Research On Establishing An Indicator System For Evaluating The Quality Of Electronic Medical Records Through The Network

Backgrounds:With the continuous development of hospital information system construction, electronic medical records are increasingly used for hospitals at all levels. Compared to traditional medical writing, the electronic medical record has great advantages such as clearly documented, well-formed, easy access to read, reducing the transfer costs, improve medical efficiency. EMR is the future development trend of history records.With the use of electronic medical records, electronic medical records network quality control has emerged. Electronic medical record network control make up a few defects of medical record quality control mode. Network quality control not only can improve the comprehensiveness of history monitor, can monitor all of the medical records, but also can improve the efficiency of the monitoring and real-time monitoring, to avoid the existence of important indicators to monitor the quality of the lag and omissions.Medical institutions at all levels are not the same degree of electronic medical records. The medical establishment is insufficient to the electronic medical record quality control attention. There is not a set of electronic medical record quality control measures of domestic network.Aim:The purpose is to construct the electronic medical record quality control index system of network.This study collected the more generally accepted indicators of quality control of medical record management, medical quality management indicators, such as including the medical security, the antibiotic use, the courtyard inner sense controlled and so on the targets, then screening to determine the history of the network quality control principles, building a preliminary electronic medical records network quality control frameworks and indicators, consults the law using the expert, and ultimately, to establishing medical history network quality control indicators and indicators of the authentication.Method:Literature analysis:through the collection published literature, studies,2 the information, access to electronic medical records, medical history network quality control situation, as well as medical history quality control of various indicators. This research mainly take medical history quality, electronic medical record, electronic medical record network control as autograph or key word retrieval literature.Delphi method:the present research applications Delphi law expert advice, based on 18 experts in the field of medical, computer experts consultation. After this research determination medical history network nature controls the target screening principle, this research according to the scientific nature, the data may result in the nature, the importance, the versatility, the systematic principle, after two rounds of expert consultation network electronic medical records quality control index system is established.Results:Electronic medical records receiving more and more attention, but with the quality of network monitor are rare. This research through the investigation, discovered the current electronic medical record the quality question main performance is that the data is not complete, failure timeframe, information errors and inconsistencies, history records are not standardized. Current electronic history of quality management mainly taken manually.This study constructed a network indicator of quality management system of electronic medical records. First, the researchers through access to a large number of documents and literature, as well as expert advice, reference quality of medical history and medical quality evaluation index system, combining the existing electronic medical record use the actual, defined the principles of network monitoring index system of electronic medical records, purpose. Then establishes the medical history network nature to control the target system initially the frame, finally through expert advice, filter out specific indicators, and after a round of expert advice to determine each of the indicators, established 5 first class indexes,17 second class indexes,57 third class indexes in all. Because all levels of medical establishment electron medical record function is different, the electronic medical record network nature controls the target to be different. In this study, a history of writing specifications and medical quality management practices as well as the status of EHR quality research design, so this set of index system has strong value and practicality.This research carries on the research design in view of the medical history writing standard as well as the medical service quality control standard as well as electronic medical record quality present situation, after 2 rounds of expert advice, and further improve the index, and utilizes this set of target system to carry on present situation investigation and the comparison research. The research shows that:this index system has better reliability and distinction degree, stronger applicability directional and operative. Since the electronic patient record system features are not consistent and do not complete, in the actual movement, the partial natures control the target to be unable to realize. However, as his system features the continuous improvement, the evaluation index system of perfection can be further enriched. It will become a powerful tool for assessment of quality of medical history and medical quality, provide a reliable basis for improving the level of medical quality in hospital.