医疗健康大数据视角下医院病案统计及管理研究

Research on statistics and management of hospital medical records under the perspective of medical health big data

病案信息是建设医疗健康大数据的核心和基础。医疗健康大数据的运用前景非常广泛,将在辅助卫生政策制定、临床决策支持、药物研发和评价、疫情监测与疾病预防等方面发挥重要作用。分析了在医疗健康大数据视角下,当前病案管理存在病案信息孤岛普遍存在、原有病案管理标准不适应大数据要求、病案隐私和权利保护不够、病案信息的收集统计方法落后、缺乏病案管理复合型人才等方面的不足,并提出建设全国性病案信息共享平台、制定符合大数据要求的病案标准、加强隐私保护、积极采用现代信息技术记录病案材料、调整优化病案管理人员等5个方面的建议。

Medical record information is the core and foundation of building health care big data.The application future of medical and health big data has wide range,and will play an important role in assisting health policy formulation,clinical decision support,drug research and development and evaluation,epidemic monitoring and disease prevention.However,from the perspective of large medical and health data,there are many shortcomings in current medical record management,such as isolated island of medical record information,inadequate protection of privacy and rights of medical record,backward collection and statistics methods of medical record information,lack of composite personnel in medical record management,etc.To this end,five suggestions were put forward,including building a national medical record information sharing platform,formulating medical record standards that meet the requirements of large data,strengthening privacy protection,actively using modern information technology to record medical record materials,and adjusting and optimizing medical record managers.