Design And Implementation Of Electronic Consultation Record Base On Electronic Medical Records

In recent years,the frequency of consultation in the hospital is becoming higher and higher because of the clinical disciplines getting more detailed and a variety of difficult miscellaneous diseases.Electronic medical records as the focus of the study of medical information,is gradually to the direction of the development of the platform,which can be integrated into the patient's diagnosis and treatment process.Many hospitals abroad have successfully combined consultation with electronic medical records and improved the work efficiency and quality of medical care greatly.But many domestic hospitals are still using the manual consultation model which has been inherited for many years: the application department fill out a manual consultation,and then to the manual transmission to the department,the department received a visit to the consultation,and complete a joint written consultation records together finally.This traditional consultation process has the following obvious shortcomings: first,it is easier to make mistake of passing the consultation bill.Because the handwriting of doctors is difficult to identify,so consultation bill may be delivered to the wrong department even be lost in the transfer process.Secondly,the consultation is low time efficiency.Manual transmission is bound to take a long time,not only affects the patient treatment,but also reduces the work efficiency of the doctor.Thirdly,the consultation record is not standardized.Today,“Medical record writing standard” produced by the Ministry of health has clearly defined the need of the format for consultation bills and consultation records,so the manual bills of the traditional model will inevitably occur the problem such as format omission or incorrect writing.Fourthly,the writing efficiency of consultation records is inefficient.When doctors are writing a consultation record,they not only need to type the word one by one,but also to open the system respectively such as HIS,LIS when they need the data.Fifthly,it's hard to regulate the consultation.The management departments are difficult to do a whole control for the consultation,and after the event,it is also difficult to make a correct assessment.In view of the above problems,this paper designs and implements a consultation system based on electronic medical record.Firstly,the electronic medical record platform is established,which is based on the traditional three layer structure.In the middle layer,the interaction between the client and the database is realized by WEB SERVICE.In addition,the client can call WEB SERVICE from the HIS,LIS and other external systems to achieve the data sharing.In the underlying database,the relational database is taken as the main,supplemented by XML,HTML and other key special fields.The XML field is mainly used to store some medical terms,elements,rules in the structured consultation document,and html is mainly used to store and represent the specific content of the consultation document.The implementation of the electronic medical record platform not only solves the problem of writing incorrectly,but also improves the efficiency of writing consultation document greatly by the structure of input and data sharing.Then on this basis,this paper also joined the electronic consultation bill and SMS platform.The electronic consultation bill will be in series with the whole consultation process by realizing the bill building,sending,auditing,completing.It's not only to avoid the mistakes of the manual consultation,but also make the clinical departments and management departments can readily grasp the progress of the consultation.At the same time,the short message platform,which is based on EMPP and Mlink protocol,is to construct the corresponding uplink and downlink message body and send messages to remind the users of China mobile,Unicom and telecom.It greatly improving the timeliness of consultation.According to the function,the system can be divided into four sub modules: electronic medical records writing device,electronic consultation bill,platform of sharing HIS,LIS,RIS data and SMS platform.In the end,this paper design the functional test case for the four sub modules,and also explain how to deploy and configure the system.At present,the consultation system has been running in Ruijin Hospital,Shanghai Jiao Tong University School of Medicine.Compared with the traditional consultation mode,the current consultation process can save about 48 minutes and basically reach the effect of real-time alert through electronic consultation bill and SMS platform;the time of writing has been controlled in 6 minutes by realizing sharing the data of HIS,and it improves about 5 times compared with the previous.Finally,for the hospital's management department,they also can carry on the strict monitoring and control of the entire process in the background.If some part has problem,they can immediately inform and warn the relevant responsible person.And also can add up all the information through multidimensional inquire in the end.