基于“互联网+”的医院病案管理新模式研究

Research on new mode of hospital medical record management based on “Internet +”

传统的病案管理以纸质病案和手工操作为主,病案利用的难度大、可及性不足、利用水平不高等现象普遍存在,无法满足人民群众对自身就诊病案信息越来越重视的需求。因此,本研究设计了全新的、全流程的"互联网+"医院病案管理新模式,该模式将"互联网+"技术全面融入病案管理全过程,包括:基于OCR技术的病案回收、基于微信小程序的病案质控、基于大数据技术的病案智能编码、基于二维码的病案自动归档、基于云数据的病案远程利用。为实现"互联网+"病案管理新模式,还需做好完善结构化病案的顶层设计、构建医院信息系统与病案的互联互通平台、实现病案信息资源的深度应用、强化病案的法制化监管、提高病案管理人才的专业素养等保障措施。

Traditional medical record management is mainly based on paper medical record and manual operation,which is difficult to use,inadequate accessibility,and low level of utilization.It can't meet people's increasing attention to their own medical record information needs.Therefore,this research has designed new and full process Internet + hospital medical record management mode,which integrates Internet and technology into whole process of medical record management.It includes recovery of medical records based on OCR technology,quality control of medical records based on WeChat small program,intelligent coding of medical records based on big data technology,auto-arching of medical records based on QR code,and long-distance utilization of medical records based on cloud data.In order to achieve new mode of “Internet +” medical record management,we need to improve the top-level design of structuralization medical records,build interconnection platform for hospital information systems and medical records,realize depth application of medical records information resources,strengthen the legal supervision of medical records,and improve the professional quality of medical records management personnel.