The Design And Evaluation Of Active Electronic Medical Records System

Nowadays,the Medical and health industry in China is faced with a lot of problems.For example,it is difficult and expensive to see a doctor,and the service quality of medical institutions is not quite satisfactory.From the perspective of medical information technology,the thesis brought forward the concept of Active Electronic Medical Record and designed the corresponding system in order to provide technical means to solve these problems. It can normalize clinical practice through technical means,improve the efficiency of clinical work,effectively avoid medical errors,and realize active clinical treatment mode.Firstly,all items in the HL7 functional model of electronic medical records are fully analyzed.On this basis,considering business processes and function requirements of the People's Liberation Army General Hospital,this article inspected each item of the HL7 standard,and made some adjustments and improvements to build the Active Electronic Medical Record functional model. This model adopts international practices and is in line with China's national conditions.Secondly,according to this model,this article designed an electronic medical records system incorporating a clinical decision support system.Now this system is being used by the PLA General Hospital.Thirdly,the system was assessed by a scientific method of both qualitative and quantitative approaches.The integrated information platform was assessed with qualitative methods,mainly based on the evaluation conclusions from clinical medical staff,hospital management staff and medical information technology experts.The assessment of clinical decision support system used a quantitative method.The performance of clinical decision support system is evaluated by the statistical results of a randomized controlled experiment. The assessment result indicates that the application of Electronic Medical Record system can significantly improve the efficiency of clinical work, effectively regulate clinical practices,and reduce the clinical misdiagnosis rate to a certain degree.The assessment result meets the initial design purpose and requirement.