肿瘤专科医院个案管理信息系统的构建与实施

Construction and implementation of an information system for case management in cancer special hospital

目的基于医院嘉和电子病历系统以及医院信息系统(HIS)、实验室信息管理系统(LIS)以及医学影像存档与通讯系统(PACS),构建个案管理信息系统并实施。方法依托医院信息系统资源,根据肿瘤患者的诊疗特点及个案管理工作的全流程信息管理的需求,由护理部与信息中心共同设计研发以个案全程管理为主线的信息管理系统;并由个案管理师应用于临床实践。结果构建了包括患者的收案、诊断期、治疗期、随访期及结案在内的全流程个案管理信息系统;2018年1-12月应用于对肿瘤患者的个案管理,共收案3901例,结案2396例,组织多学科会诊(MDT)讨论2744例;通过个案管理的实施,既定治疗方案遵循率为96.85%(3756/3878),随访及时率95.60%(4501/4708)。结论个案管理信息系统的构建实现了对肿瘤患者从就诊到随访期的全流程管理,为个案管理师岗位工作的顺利开展提供了便捷实用的信息管理,也为个案管理师岗位工作质量的督导提供了量化依据。

Objective To establish and implement an information system for case management based on the Jiahe Electronic Patient Record System,Hospital Information System(HIS),Laboratory Information System(LIS)and Picture Archiving and Communication Systems(PACS).Methods Relying on the hospital information system resources,an information system for case management was developed by nursing department and information department according to the clinical characteristics of cancer patients and the needs of the completely informative case management.Case managers were put in charge of the system in clinical practice.Results The information system for case management was established which provides the whole-process including taking the case,diagnosis,treatment,follow-up and closing the case.The study consisted of 3901 patients in case management,in which 2396 cases closed,2744 cases received multi-disciplinary team discuss from January to December 2018.The planning treatments implementation rate was 96.85%(3756/3878)and the timely follow-up rate was 95.60%(4501/4708)through the implementation of case management.Conclusion The information system for case management can realize the whole-process management from taking case stage until the end of follow-up,provide a convenient and practical information management for post duty of the case manager,and also a quantitative basis for the supervision of the quality of the case management.