深圳市宝安区居民电子健康档案相关信息分析

Analysis of electronic healthcare record(EHR)related information of residents in Baoan district of Shenzhen

目的分析深圳市宝安区居民电子健康档案相关数据,了解目前建档现状,为进一步完善健康档案提供依据。方法汇总区内各社区健康服务中心的健康档案数据库,排除了有严重缺失登记项目、存在逻辑错误、或长期没使用的废档,对2009年1月至2010年12月有效的1 088 773份档案资料数据进行统计学分析。结果共汇总1 088 773份档案资料,男性491 324份,女性597 449份,比例为1∶1.22;年龄分组:<15岁组37 902份,15～岁组587 039份,30～岁组386 980份,45～岁组53 938份,>60岁组22 914份,15～45岁组的人口最多;暂住和流动人口比例大,占全人口比例的97.25%(1 058 854/1 088 773);居民的医疗费用的支付以职工医疗保险(680 053份,占62.46%)和自费(312 097份,占28.67%)为主;疾病谱分类中,糖尿病、高血压、肺结核的患病人数分别为4176、16 588、3217例。结论宝安区居民电子健康档案结构完整,建档数量大,但健康档案里的疾病信息录入有缺失或者不够详尽,准确性和完整性有待进一步提高及完善。

Objective To analyze the EHR-related information of Bao’an residents in order to understand the present records status and provide basis for improvement of EHRs. Methods We aggregated EHR databases of each community health service centers,ruling out records with serious loss of registration information,or with logical errors,or waste records which had been unused for long.The eligible 1088773 records information in 2009—2010 was analyzed. Results Among the 1088773 cases of records,491324 were male and 597449 were female with the ratio of 1∶1.22.Age group：〈15 group of 37902 cases,15-group of 587039 cases,30-group of 386980 cases,45-group of 53938 cases,〉60 group of 22914 cases.The majority came from 15-45 age groups;the floating and temporary population accounted for 97.25%（1058854/1088773）;The medical expenses dominated by medical insurance for workers（680053 cases,62.46%）or at their own expenses（312097cases,28.67%）.As for disease spectrum,4176,16588 and 3217 cases had diabetes,hypertension,tuberculosis respectively. Conclusion The structure of EHR is complete and large number of patients have built the records.However,there is some missing or incomplete information.Therefore,the accuracy and completeness of EHRs needs to be further improved.