基于CDR的临床决策支持系统设计及应用初探

Initial Exploration of Design and Application of Clinical Decision Support System Based on CDR

目的:通过临床决策支持系统建设,充分发掘临床数据应用价值,降低医疗差错,提升医疗质量和保障患者安全。方法:研究和学习国际、国内临床决策支持系统相关标准和建设经验,结合专科的临床需求,实现临床指南的结构化表达,基于临床数据中心提供的患者临床数据,实时给予医生提醒和警告。结果:临床决策支持系统可以辅助专科医生进行病情危重评分、制定治疗方案、推荐成套医嘱等。结论:基于CDR的临床决策支持系统是建设智慧医院的核心,可以避免部分人为差错,是医生践行循证医学的有力工具。

Objective： To fully explore the application value of clinical data, reduce medical errors, improve medical quality and ensure patient safety through the construction clinical decision support system. Methods： Related standards and construction experience of domestic and international clinical decision support system are studied and learned. Combined with specialized clinical demand, the structured expression of clinical guidelines is realized. Based on the clinical data of patients provided by the clinical data center, remind and warning is given to the doctor in real time. Results： The clinical decision support system can assist specialist physician in rating critical conditions, making treatment plan, recommending a complete set of doctor＆#39;s advice, etc. Conclusion： The CDR-based clinical decision support system is the core of the construction of intelligent hospital. It can avoid some artificial errors. It is a powerful tool of practice and evidence-based medicine for doctors.