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用于中医患者会诊的电子病历信息系统。

Electronic medical record information system for patient consultations in Chinese medicine.

作者信息

Bjering Heidi, Ginige Athula, Maeder Anthony, Bensoussan Alan, Zhu Xiaoshu, Lattuca Charles

机构信息

School of Computing and Mathematics, University of Western Sydney, NSW, Australia.

出版信息

Stud Health Technol Inform. 2011;168:10-5.

Abstract

Currently there are no widely used systems to electronically record individual patient consultations with Traditional Chinese Medicine (TCM) practitioners. As TCM practice differs significantly from western medicine both in diagnosis and treatment, using information systems created for western medicine is not suitable. There is a need for information systems developed specifically for TCM practitioners to manage patient consultation and treatments. Such system should be designed to facilitate safe and effective practice by providing decision support, utilising existing knowledge such as known herb-drug interactions to signal safety risks. Utilising current and developing standards and vocabularies such as those developed by the World Health Organisation (WHO) is important to facilitate interoperability with other systems. To facilitate continued growth in consumer demand, this type of system should be compatible with the needs of the individual electronic health records and other medical systems, and provide interfaces to external systems such as Medicare, pathology and radiology systems, and insurance systems. This paper presents the high level design of a patient consultation system for TCM practitioners that addresses the individual practitioner's needs for health records entry, storage, retrieval, display and support in managing health care delivery to patients and be part of Australia's emerging e-health system.

摘要

目前,尚无广泛使用的系统可用于电子记录中医从业者与患者的个体诊疗过程。由于中医诊疗在诊断和治疗方面与西医有显著差异,因此使用为西医创建的信息系统并不合适。需要专门为中医从业者开发信息系统,以管理患者诊疗和治疗。此类系统的设计应通过提供决策支持来促进安全有效的诊疗,利用现有知识(如已知的草药-药物相互作用)来提示安全风险。采用当前和正在制定的标准及词汇表(如世界卫生组织(WHO)制定的那些)对于促进与其他系统的互操作性很重要。为了满足消费者不断增长的需求,这种系统应与个人电子健康记录和其他医疗系统的需求兼容,并提供与外部系统(如医疗保险、病理和放射系统以及保险系统)的接口。本文介绍了一种针对中医从业者的患者诊疗系统的高层设计,该系统满足个体从业者在健康记录录入、存储、检索、显示以及支持向患者提供医疗服务管理方面的需求,并成为澳大利亚新兴电子健康系统的一部分。

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