脑血管疾病半结构化专病病历及智慧医疗系统建立

Establishment of semi-structured disease-specific electronic medical record and intelligent health care system for cerebrovascular diseases

急性脑血管病作为神经内科常见疾病,具有高致残率及高致死率的特点。目前我国脑血管疾病电子病历记录尚无统一模板,各医疗机构病历质量参差不齐。通过结构化收集脑血管疾病患者临床病历数据,建立脑血管疾病半结构化专病病历,为开展高质量临床科研和制定医疗政策奠定了基础。建立包括电子病历、检查化验、影像数据等资料在内的智慧医疗系统,使用计算机辅助临床诊治是医疗事业发展的必然趋势。半结构化专病病历及智慧医疗系统的建立为实现医疗信息的高效有序收集、整合与共享,提高医护人员工作效率以及医疗服务质量奠定了基础。

Cerebrovascular disease is a common disease,with the high morbidity and mortality.There is no unified template for electronic medical records of acute stroke in China and the quality of medical records varies greatly among medical institutions.Structured collection of clinical data and the establishment of semi-structured disease-specific electronic medical record for patients with cerebrovascular diseases will lay the foundation for high-quality clinical research and medical policy-making.The establishment of an intelligent health care system includes semi-structured electronic medical records,physical examination and lab tests and image data.Intelligence-assisted diagnosis and treatment is an inevitable trend for the future development of medical care.Creation of the disease-specific medical records and intelligent health care system facilitates efficient collection,integration and sharing of medical information,strengthening the workflow.It lays the basis for future improvement of quality of medical care service.