The standard differs Connect and hinder Can the electronic case history get through the enclosure of hospital

The standard differs Connect and hinder Can the electronic case history get through the enclosure of hospital
The standard differs Connect and hinder Can the electronic case history get through the enclosure of hospital
Because 5 -year-old Xiao Ling is burnt carelessly, goes to Shanghai Communications University medical college subsidiary Rui Jin hospital to seek medical advice, after surgery treatment, enter the stage of recovering in hospital. In the intersection of ward and nurse station, click electronic case history of Xiao Ling, from make a diagnosis for the first time and the intersection of operation and situation, doctor diagnose to every daily medicine situation, various case history records are very clear. In Shanghai, like such an electronic case history system has already been pursued in more than 20 hospitals. The intersection of hospital and information construction of Shanghai start, early, spread all over Shanghai at present the whole city 24 medical organizations at city level " medicine unite the project " ,Have already enlisted 16 million patients' medical information, include some electronic case histories. Two major factors hinder the information sharing as the hospital that built informationization first, Shanghai Rui Jin hospital began to explore since 1995. In April of this year, the hospital realized emergency call system HIS2.0 operates formally on the door, the patient diagnoses the illness and basically realizes with no paper at all. Have dealings with information the intersection of Rui Jin and the intersection of hospital and Vice President for many years frugal to it seems Yuan gram have, advance the main difficulty of the electronic case history to two: First the affirmation question of the law, it is second standard reunification. When because the medical dispute takes place, the evidence about asserting in the department is accurate by having paper text that doctors signed. If the electronic case history replaces the paper case history, it is rather thorny to meet the legal dispute in the future and deal with. "If each doctor signs electronically, the cost is very high. The electronic case history should need the third party to confirm or keep and encrypt as legislative authority. " Deputy Director of Shanghai Yueyang hospital information center Wei Hong �S says. "Though it is a development trend of the future to sign electronically, confirm the question to the law of the electronic case history at present, can only rely on ' two legs ' to walk: The concrete method of the general hospital is, besides the electronic case history, doctors will also print the electronic case history out, both sides save the case history of the paper quality after signing. " Yuan KeJian reveals. Meanwhile, because the business procedure of the hospital, shared data,etc. have not sought unity of standard, the information between every medical organization can't be connected and become the greatest obstacle shared. Yuan KeJian thinks, in addition, channel, quality,etc. factor that transmit, tele-medicine, picture may produce the phenomenon with distorted information and decaying to interchange etc., this will give a great discount, even will present the malpractice for therapeutic effect. The use of the electronic case history has already had several years, but it is burst to be each among the hospitals, it is quite difficult so as to realize the medical information sharing. "Realize the information sharing, should strengthen the overall planning, should break the enclosure of hospital, so must be prospective. " Yuan KeJian says, the hospital will regard electronic case history as the breakthrough point while describing management and developing direction of the hospital, regard rules and regulations as foreshadowing, regard quality as and catch hands, this is " digital hospital " in the future Basic frame. The electronic case history nowadays needs employing deeply, with the further popularization of the electronic case history, the patient's right can get more easy to safeguard too. Ministry of Public Health released a few days ago <>,The electronic case history system can be set up and consulted the authority, the patient information whom the doctor of different ranks can see is different. At the same time in order to prevent distorting information, the system will carry on the identity and discern, it is all previous to keep and revise the traces, marks to revise time and revise people's information. This year, Rui Jin hospital signs the information-based project cooperative agreement of digital hospital with Shanghai telecommunications. Before the end of the year, the medical personnel only needs to pass the palmtop computer in the hand, can carry on the intersection of life and the intersection of physical sign and data, the intersection of doctors and nurses and inquiry of data, attend to, call out communication, the intersection of medicine and the intersection of person who provide and deliver and medical treatment, work by the bed by the bed in patient, and convey the data to the information system of the hospital through the wireless network. Meanwhile, Yueyang hospital has already realized the intact electronic case history produces the system, the doctor can produce the case history by different methods with building block system of the term, template type of the segment, whole case history template type, medical information transmission type,etc., not only reduce the doctor's input but also raised the efficiency and information accuracy. "Through backstage supporter, hospital can also manage side behavior of making a diagnosis of doctor and performance examine link up, make the hospital more scientific and more normal in management. " Yuan KeJian reveals, in the future, the hospital will also strengthen " employ deeply " of the electronic case history ,Utilize mass memory of the electronic case history, characteristic and function dealt with fast, organize the relevant department to strengthen analysis on materials, arrangement and study, in order to improve scientific research and educational function of the hospital. (Responsible editor: Zhao JingHan)


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