电子病历中医疗事件的动态查看器

Matsumura Y, Kuwata S, Kusuoka H, Takahashi Y, Onishi H, Kawamoto T, Takeda H

Department of Medical Information Science, Osaka University Medical School, Osaka, 565-0871, Japan.

Stud Health Technol Inform. 2001;84(Pt 1):648-52.

Medical record should enable doctors to comprehend the patient's history and select suitable medical treatment. In paper based medical records, medical events (examination, treatment etc.) are recorded successively, and problem oriented recording is difficult to be applied to patients with much information and a long history. Consequently it is not easy to understand the patient's history from paper based medical records. In order to solve this problem, we developed the flow sheet system in our electronic medical record (EMR). To make a flow sheet, we analyzed the structure of the medical event data. In this paper we introduced the medical event information model for our EMR. Furthermore, we clarified the specification of the data presentation on the flow sheet. We developed the flow sheet on the basis of these analyses. Because there are 3 layers in the vertical axis of the flow sheet, many items of the medical event can be displayed on the screen. When user clicks the cell, the corresponding detail data including images are shown. This system functions to link medical event items with a problem, and shows the bundled items on the flow sheet when the user selects the problem. We implemented this system in Osaka University Hospital. The number of the types of medical events and those of detail events in inpatients are 5.0+1.7 (mean+SD) and 60+47, respectively. The medical doctors in Osaka University Hospital evaluated this system, and concludes that the flow sheet data presentation makes comprehension of the patient's history easier than paper based records. As to the function of bundling the items relevant to the problem, they feel it is especially useful for patients with chronic disease. Thus the flow sheet data presentation in EMR is useful for medical practice.

病历应使医生能够了解患者的病史并选择合适的治疗方法。在纸质病历中，医疗事件（检查、治疗等）是依次记录的，面向问题的记录难以应用于信息量大且病史长的患者。因此，从纸质病历中了解患者病史并不容易。为了解决这个问题，我们在电子病历（EMR）中开发了流程图系统。为了制作流程图，我们分析了医疗事件数据的结构。在本文中，我们介绍了我们的电子病历的医疗事件信息模型。此外，我们阐明了流程图上数据呈现的规范。基于这些分析，我们开发了流程图。由于流程图的垂直轴有三层，许多医疗事件项目可以显示在屏幕上。当用户点击单元格时，会显示包括图像在内的相应详细数据。该系统的功能是将医疗事件项目与问题联系起来，并在用户选择问题时在流程图上显示捆绑的项目。我们在大阪大学医院实施了这个系统。住院患者的医疗事件类型数量和详细事件类型数量分别为5.0 + 1.7（均值 + 标准差）和60 + 47。大阪大学医院的医生对该系统进行了评估，并得出结论，流程图的数据呈现比纸质病历更容易理解患者的病史。至于将与问题相关的项目捆绑在一起的功能，他们认为这对慢性病患者特别有用。因此，电子病历中的流程图数据呈现对医疗实践很有用。