我院规范处方开具行为的信息化实践

Informatization Practice of Regularizing Prescribing Behavior in Our Hospital

目的:通过信息化手段有效规范医师处方开具行为,提高处方质量,促进药品安全合理使用。方法:介绍我院根据相关药事法规等要求,依托医院信息系统(HIS)建立的具有智能化、精细化管理特点的"处方信息管理系统"(PIMS)的各项功能及实践情况。结果:PIMS能通过特定药品处方开具资质权限设定、药品处方限定(超品种数、超剂量、超频次、超给药途径)、专病专科用药限定、重复用药限定、禁忌用药限定、皮肤过敏试验用药流程规范、血液生物制品智能化开具等措施规范处方开具流程,实现药品的分级管理、药品专用、用药安全、按需使用和提高用药水平等。处方不合理率由2010年的24.70%逐渐下降到2013年的14.21%,抗菌药物占全部药品金额比例由11.96%下降到10.24%,药品收入占医疗收入比由44.6%下降到39.5%。结论:PIMS的建立和使用从源头上规范了处方开具,使处方质量得到提高,不合理用药得到有效干预,药事管理工作得到加强,药物使用趋于合理。

ABSTRACT OBJECTIVE： To effectively regularize the doctors＇ behavior of prescribing, improve the quality of prescription and promote safe and rational use of drugs by means of informatization. METHODS： According to the requirements of relevant pharmaceutical affairs law and regulation laws and regulations, based on hospital information system （HIS）, intelligent and delicacy ＂Prescription Information Management System＂（PIMS） was established and introduced in terms of function and practice. RESULTS： PIMS could achieve level administration, special use, the safety of drug use and drug use according to one＇ s needs, and improvement of drug use through setting the limit of doctors＇ authority to prescribe the specific drugs, the limit of drug prescription （excessive varieties, overdose, ultrahigh frequent and off-label route of administration）, the limit of drugs for special disease, the limit of repeated drug use and the limit of contraindications, and regularizing the prescribing procedure of skin allergy test drugs, blood biological products, etc. The unreasonable rate of prescriptions decreased from 24.70% in 2010 to 14.21% in 2013; the proportion of the consumption sum of antibiotics decreased from 11.96% to 10.24%; and drug ratio decreased from 44.6% to 39.5%. CONCLUSIONS： Due to practice of PIMS, the behavior of prescribing has been regulated; the quality of prescription has been improved; the irrational drug use has been effectively intervened; pharmacy administration has been enhanced, and the drug use tends to be more reasonable.