电子病案与临床决策支持

Electronic Medical Records and the Clinical Decision Support

非结构化电子病案在临床数据的利用和临床医疗决策系统的应用方面,存在临床数据共享性差等问题,指出实现电子病案临床决策支持,必须统一电子病案结构标准、保护病案信息安全、做好数据存储及备份、建立电子病案多维结构。实现电子病案系统临床数据信息共享,通过智能化与知识化的临床决策支持,在确保合理安全用药、规范临床路径治疗、提升病案信息记录质量等方面发挥了重要作用,实现了降低医疗差错、提高医疗质量的目标。

In utilization of clinical data and application of clinical medical decision system, unstructured EMR can not share dinical data very well. This paper points out to realize EMR clinical decision support need to unify EMR structure standard, ensure the medical records information safety, backup of data storage and construction of EMR multi -dimension. It elaborates EMR system achieving clinical data information sharing. Through in- telligent and knowledgeable clinical decision support, it plays vital role in ensuring reasonable safety medication, standard of clinical pathway treatment and medical records quality improvement, which achieves medical error reduction and medical quality improvement.