肝病结构化中医电子病历的设计及应用

Design and Applications of Structured Electronic Medical Records of Traditional Chinese Medicine of Liver Disease

目前医疗资源信息化已成为发展趋势,中医电子病历对于中医学的发展及中医信息化建设非常重要。本文从中医电子病历的研究现状着手,提出了我院肝病结构化中医电子病历系统的设计思路,即中医电子病历要体现中医的特点,以整体观和辨证论治的思想为指导;要实现结构化、标准化和规范化,这是对病案信息进行挖掘和利用的前提和基础;能够实现数据挖掘的功能,分析总结疾病的发生发展规律以及疾病之间的各种关系,使之成为科研工作的有力工具。文章对该系统实现过程中的难点及对策进行了分析,解决了术语不规范、诊断不统一等问题,实现了一个比较完善的肝病结构化中医电子病历系统。

Currently, medical resources information technology has become a trend. The electronic medical record of traditional Chinese medicine is very important for the development of traditional Chinese medicine and information construction TCM medicine. This article summarized the current status of TCM EMR, showed the design ideas of structured electronic traditional Chinese medical science records of liver disease in our hospital. Electronic medical records of TCM should reflect the characteristics of TCM, guided by the overall view and thought of differentiation. It should be structured, standard and specification. This is the foundation of mining and use. Electronic medical records of TCM should realize the function of data mining, analysis the rule of disease and the relationships between different diseases. This paper analyzed the difficulties and the countermeasures of this system. A more complete structured electronic traditional Chinese medical science records system of liver disease had been achieved.