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[电子病历在心脏病科的实施与应用:十年经验]

[Implementation and use of an electronic medical record in a department of cardiology: ten-year experience].

作者信息

Carpeggiani Clara, Macerata Alberto, Taddei Alessandro, Benassi Antonio, Donato Luigi

机构信息

Istituto di Fisiologia Clinica del CNR, Pisa.

出版信息

G Ital Cardiol (Rome). 2008 Aug;9(8):558-65.

Abstract

The rising of healthcare and hospital efficiency has underlined the necessity of clinical information systems. Hospitals represent complex organizations requiring control of different types of data for the management of patients and resources. A project was developed at the CNR Institute of Clinical Physiology of Pisa to produce an integration system to manage healthcare in its technological, administrative and clinical aspects, in respect of high quality in healthcare and cost-effectiveness evaluation. A networked computer-based information system was implemented to integrate different heterogeneous sources of patient data, both administrative and clinical (texts, signals, images), reaching a total integration. Data are stored into a relational database, processed and presented to healthcare personnel by network-connected clinical workstations. Epidemiological components are integrated to continuously offer evaluation processes to clinical components. From 1998 to August 2007 more than 300 stations were connected. The electronic medical records of more than 20 000 patients were recorded; more than 100 000 procedures were digitally integrated and the entire health file record and cost calculation could be obtained for each patient. In conclusion, the use of electronic medical records allowed a complete clinical data integration with improvement of overall structure efficiency and healthcare quality.

摘要

医疗保健水平的提高和医院效率的提升凸显了临床信息系统的必要性。医院是复杂的组织,需要控制不同类型的数据以管理患者和资源。比萨的意大利国家研究委员会临床生理学研究所开展了一个项目,旨在开发一个集成系统,从技术、行政和临床方面管理医疗保健,同时注重医疗保健的高质量和成本效益评估。实施了一个基于网络计算机的信息系统,以整合不同的异构患者数据源,包括行政和临床数据(文本、信号、图像),实现全面整合。数据存储在关系数据库中,通过联网的临床工作站进行处理并呈现给医护人员。流行病学组件被整合,以便持续为临床组件提供评估流程。从1998年到2007年8月,连接了300多个站点。记录了2万多名患者的电子病历;10多万份医疗程序被数字化整合,并且可以获取每位患者的完整健康档案记录和成本计算。总之,电子病历的使用实现了完整的临床数据整合,提高了整体结构效率和医疗保健质量。

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