【作者】 王海波；

【导师】 郑明春；

【作者基本信息】 山东师范大学 ， 电子政务， 2010， 硕士

【摘要】 深化医药卫生体制改革,发展信息化医疗服务新模式,推行公众健康疾病全程管理是我国医疗改革发展的必然趋势。随着医疗卫生事业的发展,对医院信息化的要求越来越高,传统的医院信息系统已经不能满足我国医疗改革发展的需要,而作为医学信息原始数据的电子病历,是这场变革中重要一环,电子病历系统作为医院信息系统的核心,是一个重要的研究课题。我国目前使用电子病历的大部分医院把其当成一个快速书写病历、实现医院信息共享的手段,做到的只是对时间和书写格式的规范化管理,并没有发挥电子病历强大的功能。较国外电子病历的发展,我国电子病历的开发应用起步较晚,整体应用水平仍处于初级阶段。电子病历系统在加强医院的质量监控,减少医疗差错,提高医疗服务质量;同时创新社会新型医疗服务模式,提高全民医疗健康水平方面是一个不可或缺的基础环节。本论文对电子病历的内涵与功能进行了全面阐述,说明了电子病历系统对新型医疗服务模式的重大意义及新型医疗服务模式对电子病历系统发展的推动作用。对电子病历应用中的法律效力、安全性、标准化问题进行了分析。又从电子病历管理的关键问题入手,对电子病历信息系统和应用环境的建设、系统的实施、身份认证与信息安全方面进行了研究。接下来,本文讨论了电子病历系统的发展趋势,认为随着新型医疗服务模式的发展,电子病历建设必然走向区域化,并最终形成全民健康信息档案系统,在此基础上,论文深入探讨了完善我国电子病历系统的对策,从树立新的服务理念,优化服务流程,电子病理实施和运行等若干方面提出了相应的建议。电子病历是我国医院信息管理系统发展的重要方向,是深化社会医药卫生体制改革的基础任务之一。本文工作对于发展我国新型医疗服务模式,促进全社会健康信息系统建设是一个有益的探索。更多还原

【Abstract】 Deepening medical and health system,developing the new model of informationized medical service,implementing full management of public health represent the main trends of China’s medical reform. The new development of medical service calls for higher standard of informationization ; traditional information system can not meet the demands of the development of medical reform any longer. As original data,electrical medical record (EMR) is the key link of the transformation. And therefore,it has become a very important area of study and research.EMR was not introduced to China until recently,so,compared with other countries,its application is at elementary level. It is regarded as a time-saving tool of medical record writing and an information-sharing means. It can only guarantee the standardization of time and writing form of medical record. However, EMR’s functions are far from being fully realized.EMR plays an indispensible role in quality monitoring,medical errors reduction,medical service improvement,and creating a new model of medical service.This dissertation elaborates the meaning and function of EMR in detail. In addition,it analyzes law effect,security as well as standardization in EMR application. Meanwhile,it examines the construction of EMR system and application environment , identity authentication,and information security.Then this dissertation discusses the development trend of EMR, and believes EMR will definitely develop toward regionalization and finally construct Personal Health File. Based on this, strategies for perfecting China’s EMR are thoroughly probed. Suggestion and strategies are also presented in terms of the construction,implementation and operation of EMR system.EMR is the important direction of China’s hospital information management system; is one of the basic tasks of deepening medical and health system reform. This dissertation is viewed as a beneficial investigation of the trends of EMR system and citizen health information system.更多还原