基于医院信息系统的严重临床异常病例/事件监测可行性研究

Feasibility of severe clinical abnormal case/event surveillance based on hospital information system

目的通过对上海市医院信息系统(HIS)建设情况及其在传染病及症状/症候群监测情况的现况调查,为基于HIS系统的严重临床异常病例/事件监测项目开展可行性研究。方法 2012年1-6月,对上海市公立医疗机构采用自填式问卷方式,对医疗机构HIS系统概况、系统在病例、症状/症候群监测中的利用、开展严重临床异常病例/事件监测项目前景进行调查。结果上海市399家公立医疗机构HIS系统由39家软件公司开发,10个区的社区卫生服务中心系统由相同软件公司开发;各医疗机构HIS系统字段设置、筛选排序、导出构成、编码方式不同;38家医疗机构开展传染病症状/症候群监测,其中32家机构症状采集界面嵌入HIS系统;从全市医疗机构诊疗能力、HIS系统开发公司覆盖面、系统基础、监测经验以及参与项目意向进行综合评价,选取项目试点区(县)及机构。结论选取杨浦区中心医院、上海市同仁医院、闵行区吴泾医院作为基于HIS系统的严重临床异常病例/事件监测项目监测点,项目开展可行性较高。

Objective To investigate the establishment and application of hospital information system （HIS） in infectious diseases and symptom/syndrome surveillance in Shanghai medical institutions, and to study the feasibility of developing the project of severe clinical abnormal case/event surveillance based on HIS. Methods From January to June 2012, all of the public medical institutions in Shanghai were enrolled in this survey. Information about the general situation of the public medical institutions＇ HIS, the availability of HIS in case and syndrome surveillance, the chance of utilization and the foreground of the project were collected by self- administered questionnaires. Results Thirty- nine software companies developed HIS of 399 public medi- cal institutions in Shanghai City; meanwhile, HIS of community health centers of 10 districts were developed by the same compa- nies. The structures, the setting of fields, screenings, recorders, export and coding of each public medical institutions were dif- ferent. 38 medical institutions conducted symptom/syndrome surveillance of infectious diseases, of which 32 institutions developed the collection interface implanting into HIS. We comprehensively evaluated the ability of diagnosis and treatment, the coverage of HIS software developing companies, the foundation of HIS, the experience of surveillance and the aspiration of participating in the project in the public medical institutions, and then selected the district - level or county - level pilot institutions for the project. Conclusions The Central Hospital of Yangpu District, Shanghai Tongren Hospital and Wujing Hospital of Minhang District are selected as the monitoring points of the project of severe clinical abnormal case/event surveillance based on H1S with higher feasibility of implementation.