Electronic medical records is not our ultimate goal, the formation of a continuous time, content integrity, the public health records available to share our life and health is the master key password.
One life, from birth to death, all the conditions on his body are in electronic form will be recorded in the Computer Information System: 1 length at age, body weight; 5 years of age suffer from several cold; 13 years of age ride falls the leg, stitches; 25 years of age fixed once appendicitis; 50 years of age with high blood pressure a little bit ... .... No matter which hospital he was in no need to repeat asked, doctors can see through the network all his health information to carry out rapid diagnosis, detection and treatment.
This is the future of the hospital to give our services, now being referred to as public health information systems, electronic medical records is the next target. Years later, the medical information technology will be tailored to each of us life and health of the password.
The future of electronic medical records
Today, the people of the electronic medical records generally understood yes, the patient electronic medical records generated during the treatment process of all medical Jilu electronic, and digital technology these records, Jiegou of Chulicunchu, and then store the data for Xiang Ying Tigong on the query, search, statistics, research services. Written medical records electronic medical record is set, medical quality control, sharing, services in an integrated clinical information system. However, this is only a narrow electronic medical records.
In fact, the generalized electronic medical record is the continuation of people throughout the life of all records generated in the process of information, including not only medical records, but also include other vital signs information, eventually forming a continuous, comprehensive personal health record can also be call public health information, it covers the life from the birth until the end of the life of all relevant health information, is a continuous time in space on the full coverage of all involved in the life and health-related information, so the electronic medical record system development trends will be of public health information systems
Currently, electronic medical records systems have been implemented in some medical institutions, and achieved good results, not only improve the quality of writing records, but also improve health care institutions the degree of clinical information, but these electronic medical records systems are basically the medical institutions units, medical history, the basic limit information sharing within the medical information in medical institutions, and only records the treatment of patients in the medical unit of information, records of content restrictions on out-patient medical records, medical records, etc., between different medical institutions can not be sharing, which also limits the application of medical records. Therefore, the same person spread of electronic medical records stored in different medical institutions, can not form a complete record of the life and health.
Therefore, it is foreseeable that the future of electronic medical records will be the development of the following two aspects:
* Content of a more complete electronic medical records include not only the patient's outpatient medical institutions, hospital information, but also including birth information, immunization records, medical information, health care and other information as well as spouses, children, parents, health related information, in addition to maternal and child specific health information. Through the collection of information, the contents of electronic medical records will be more complete, and can be extended in time and space covering the entire life.
* More extensive exchange of information based on current national health plan, medical institutions will develop in two directions, one large integrated health care institutions, and second, the medical community. This event may lead to a treatment different medical institutions, and different medical institutions to form their own characteristics, different diseases will choose a different medical institutions. All information exchange electronic medical records will put a higher demand.
Electronic medical records include a variety of health information, not only information but also clinics and other related information, the information from different systems and different architectures and even different agencies. Put this information together to form a complete health records must provide an "electronic medical record data warehouse" system, the system collects from various structures of health information, and provide external information sharing services, the system must have the corresponding interfaces, and different systems can exchange information and exchange format to General. Across multiple operating systems, programming languages and hardware platforms and integrated software applications which can not be a specialized environment to solve, for now, Web services technology and XML technology to better meet the information exchange of electronic medical records needs.
Key Technologies
Completion of this electronic medical record system is critical that the Web services technology. Web services allow applications to be platform and programming language-independent way to communicate with each other a technical. Web service is a software interface that describes a group on the network through standardized XML messaging access operation. It uses protocols based on XML language to describe the action to perform or to exchange with another Web service data.
Web service uses the XML can be truly platform-independent way to describe any (all) data in order to exchange data across systems, so turned to loosely coupled applications. Moreover, Web services can be more abstract level, a more abstract level can be dynamically re-evaluate as needed, modify or handle data types. So, speaking from a technical level, Web services can more easily process the data, and allows software to communicate more freely.
The concept of a higher level of speaking, Web services as we can some work units, each dealing with specific functions and duties. Web services attempt to resolve the main problem is the data and the application program was incorporated in the problem, is a technical function conversion into the calculation of Ren Wu Oriented problem. So Web services for different medical institutions providing technical support information exchange.
Ecological composition
Public health system is a system of information collection, exchange and services to the system, wants to different sources of information systems and information systems integration of consumer interaction, these systems directly affect the application of degrees of efficacy in application level of the whole system, include:
Only identifies public health community to continuously record the information, every citizen must provide a unique identity logo. For now, the public can be used for Medicare medical insurance card, health insurance for non-members of the public can adopt a unified social security card issued, in addition to vital signs of identification can be used, such as fingerprints.
Hospital information system (HIS) HIS system is the first medical institutions throughout the information technology foundation, HIS system provides the basic information of all medical events, including events (outpatient, inpatient) occurred at a time, clinical departments, clinics and doctors, in addition to including medical consultation during the processing of prescriptions, medical advice, diagnosis and other information, such information is summarized from the overall state of describing an event.
Electronic medical records system (EMR) electronic medical records system to produce the most important medical information, it records in detail through the entire treatment process, including patient records, hospital records, hospital records, surgical records and death records, the information content of health major components, which not only describes an incident handling process, but also statistics and an important source of external data services.
Laboratory system (LIS) inspection system disease information on the patient's body to analyze the quantitative data, which doctors diagnose and treatment plan an important basis for life in patients with physical disease but also a detailed description.
Medical Imaging Systems (PACS) medical imaging system on the patient provides the most intuitive image description, these images are also diagnosed and an important basis for development of information programs.
Medical system generated in the process of testing physical examination, laboratory data, and the medical section and the total inspection findings is also one of the elements of information exchange.
Maternal and child health systems for women (especially pregnant women), children's health-care system to produce birth, birth, immunization and physical examination of the health information is the beginning part of the lives and health information.
Community Health Systems community health system include general health information community residents registration records, and chronic disease, disability management.
The system basically includes all the life processes of health record information generated. These systems are being implemented in our country, for the public health system, laid the foundation for the exchange of information.
Exchange Language
These systems form a regular health information data, and only when these data can be generated between the exchange and sharing of time, can become useful information, it is necessary to consider the exchange interface. In general, the public health system needs to exchange interfaces include the following:
User interface, including basic information on the registration of the public unique identity, the public basic information such as registration and public search.
The interface application data submitted to the health system to information exchange as a one-time event, each case must provide basic general information, an event the event Caiyong a global unique identification number Jinxing, Suoyouzheci occurring health events are both sent Zhege number as the basis for action.
Public health system, including information collection and information dissemination interface, which interface through Web services, dissemination, and transfer content used in all XML 鏍煎紡, Ke Yi ensure that all information interactive system of Tiaoyong He Shujujiaohuan.
Health information to the interface to health information created for each event to develop a different directory specification, the health of these directories for different events can be expanded flexibly. To regulate all health XHTML format and XML format using the definition of different health information content can be expanded flexibly.
External data access interface provides data access services, including public health information, the public health profile index of public health information and detailed public health information. These message formats using XHTML and XML format, you can use the browser, etc. to facilitate the view.
Security control
Privacy protection of public health content is the scope of legal protection by the state, so the public health system must provide secure and reliable data transfer mechanism to ensure the security data storage, transmission and viewing. Security includes two aspects:
1. Authentication and Authorization Authentication is the process of identification, which is a layer of security controls.
The application to grant access to the public health information before, it must confirm the identity of the requester. Requester by providing some form of credentials to establish an identity, only the requester of the identity and authentication host know. In some cases, the requester may want to validate the identity of the host authentication, this is called mutual authentication.
Authority is to verify whether an authenticated party has permission to access specific resources the process, it is the authentication of security control layer after, not only because of the authentication host has confirmed the identity of the requester, would necessarily mean that the requester authenticated have the correct permissions to access specific resources.
For example, the public must provide the public card and verify the PIN to verify the identity of the user, but users have access only to view information on the operation of their privileges.
Visitors must be members of the public health information through legitimate authentication and authorization to access specific resources, information, identity and authority to strictly control the resources, and resolutely put an end to the illegal access of public health information.
2. Data security
Data storage security and transport security, including security, data encryption, while the use of encryption algorithms and encryption keys to render the data, neither for the proper algorithm to decrypt the data and no keys were meaningless. Encryption key is an additional variable used in the algorithm. By the key encryption key that contains restrictions contained in the median value. Encryption key to allow multi-use does not endanger a public algorithm and encrypted data with the algorithm.
Public health system is based on the Internet or virtual private network to transmit data, these networks may be unsafe, so use at least 128-bit encryption key way ciphertext transmission. Each data exchange organizations have made in the public health system, a public private key pair, all members of the public health information asymmetry in the transmission have been encrypted before, and then to network transmission, which ensures the transmission of information to public health security.
In short, the electronic medical records system into the public health system, not only do the various medical institutions to share information, and each time the public can form a continuous, full content of the health information record.
Electronic Medical Record Research Committee
In order to study China's electronic medical record standards and international standards, in May 2006, the Ministry of Health Information Center and the Intel Research Council set up an electronic medical record, the agency's goal is to study the processes related to electronic medical records, standards, platforms and other infrastructure issues to jointly promote the development of domestic electronic medical records.
Link
The scope of electronic medical records
1. The patient basic information: name, date of birth and other information, blood type, allergies, family history and other information;
2. Course records: admission diagnosis, medical advice, discharge diagnosis, course information, etc.;
3. Nursing records: three single measurements such as text graphics information;
4. Check the inspection records: the inspection report sheet, computed tomography (CT or CAT) images, magnetic resonance images, DR images, DSA video, X-rays, ultrasound images and photos;
5. Operation record: Before, during and after the recording and video.
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