【作者】 黄箭；

【导师】 权光日；

【作者基本信息】 哈尔滨工业大学 ， 计算机科学与技术， 2009， 硕士

【摘要】 随着计算机技术的飞速发展,国际医学信息标准化、电子化的推进,利用计算机进行医院病历现代化管理已是时代发展的必然趋势。在医院的现代化管理中,电子病历EMR(Electronic Medical Record)是医疗活动信息的主要载体,为了实现电子病历的共享和利用,必须实现电子病历的标准化。美国卫生信息传输标准HL7(Health Level Seven)规范了临床医学和管理信息格式,降低医院信息系统互连的成本,提高医院信息系统之间数据信息共享的程度,因此构建和实现基于HL7的电子病历模型,并实现基于国际标准HL7的电子病历子系统具有较大意义。本文首先在对电子病历系统特点以及HL7信息参考模型进行深入分析的基础上,构建出基于HL7的电子病历模型。该模型由表示临床数据的基础类和基础类之间的关联组成,基础类包括实体、角色、参与和活动四个类别。本文结合当前国内病历的实际结构,抽象出了满足HL7标准的所有属性字段,基础类中的功能属性和基础类之间的关联关系能良好支持HL7状态机的运转和HL7消息的构建。此外,为优化存储结构,本文采用继承消除的策略,将常用类型从父类中独立出来,降低了实体之间的复杂性。并按照医疗信息数据类型对存储所有数据结果的观察类进行拆分,从而使得观察活动具体化。其次,采用ER-EAV混合模型将电子病历模型映射到物理数据库。拆分后的观察类采用ER-EAV混合模型,而其他类采用ER模型,通过这种方式建立HL7消息到数据库的映射。最后,本文在上述研究的基础上设计并实现了基于HL7的电子病历子系统。该系统实现了多种对电子病历数据库查询和基本的医院管理功能,满足当前对电子病历的需求,且能通过HL7消息的方式与符合HL7标准的电子病历系统进行交互、共享病人临床数据,达到本文设计的初衷,实现了整个系统的标准化、规范化。更多还原

【Abstract】 With the rapid development of computer technology, standardization of medical information, the promotion of electronic, it is the inevitable trend today for the hospitals to manage the medical records effectively by using computer. During the modernization management of hospital, EMR (Electronic Medical Record) is the main carriers of health care information, In order to share and use EMR, it is necessary to achieve the standardization of EMR. As the transmission standard of the United States Department Health information, HL7 (Health Level 7) has standardized clinical and formats of management information, reduces costs of interconnection and improves data information sharing between hospitals. Therefore, it is greatly significant to research an HL7-based EMR model and implement HL7-based EMR subsystem.In this paper, firstly, based on in-depth analysis to characteristics of EMR and HL7 reference information model (RIM), a HL7-based model of EMR is proposed. This model is consisted with clinical data basic classes and their connections. Entity, Role, participation and act are included in basic classes. Combining with current actual medical records structures of China, in this paper, all property fields which is consistent with HL7 is abstracted. The basic functional properties and connections of basic classes can support operation of HL7 state machine well and HL7 message’s construction. In addition, in order to optimize the storage structure, in this paper, elimination of the inheritance is used, which abstracts common classes from basic classes and eliminates the complexity between entities. Observation classes which store all data results are spitted in accordance with medical information data type so as to make medical information more specific.Secondly, using ER-EAV mixed model map EMR model to physical database. Observation classes which are disconnected use ER-EAV model, but other classes use ER model, in this way, it is convenient to map HL7 information to database.Finally, after research above, an HL7-based EMR subsystem is designed and implemented. This system achieves many inquiries for EMR database and basic hospital management function. It can meet the current demand for EMR system; furthermore, it can interact and share clinical data with HL7-based EMR system by using HL7 message. So, it meets the original intention of this paper ensuring whole system to achieve standardized.更多还原