某省三家DRG试点医院病案管理系统住院病案首页功能现状及改进建议

Function Status and Improvement of Home Page of Medical Record Management System in Three DRG Pilot Hospitals in a Province

目的调研某省DRG省市级试点的省、市、县三家医院病案管理系统住院病案首页功能现状,作为改进依据.方法2019年12月11日-2019年12月20日对病案管理人员、编码员、信息工程师、医保管理人员和临床医师77人进行问卷调查,发放调查问卷77份,有效问卷77份.采用EpiData 3.1进行调查问卷录入,采用Excel 2007进行数据分析,运用描述性统计方法进行资料分析.结果调查显示三家医院病案系统均为外采取得,使用年限3年以上的2家,使用年限5年以上的1家;电子病历系统功能规范推荐的6项质控和管理功能,三家医院总体功能缺陷率为50%,地市级和县级医院功能缺陷较省级医院更多;49.4%的调查对象对现行病案系统住院病案首页功能不满意,54.5%的调查对象认为现行系统不能满足DRG支付需要,28.6%的调查对象说不清现行系统能否满足DRG支付需要.结论三家医院现行病案系统功能已不能满足管理需要;提高住院病案首页数据质量,短期办法是改造升级现行系统建立住院病案首页数据管控平台,长远计划是自主研发新病案系统;强化对相关人员DRG培训,以明确病案系统改造升级或研发的方向定位.

Objective To investigate the present situation of the function of the first page of inpatient medical records in the medical record management system of provincial,municipal and county hospitals in a province,city and county,and put forward some suggestions for improvement.Methods From December 11,2019 to December 20,2019,a total of 77 professionals,including medical record administrators,medical record coders,information engineers,medical insurance administrators and clinical doctors,were surveyed by questionnaires.77 questionnaires were distributed and 77 questionnaires were valid.EpiData 3.1 was used to input the questionnaire,Excel 2007 was used to analyze the data,and descriptive statistical method was used to analyze the data.Results The medical record systems were all taken from outside,two hospitals with more than 3 years of service,one hospital with more than 5 years.6 quality control and management functions,and the overall functional defect rate of the three hospitals was 50%,there were more functional defects in municipal and county hospitals than provincial hospitals;49.4%were dissatisfied with the function and 54.5%felt that system could not meet the needs of the work,28.6%were unsure whether the current system would meet DRG payment requirements.Conclusions The functions of the current medical records system in the three hospitals can not meet the needs of current and future management;to improve the quality of the first page data of the medical records of inpatients,short-term measures are to reform and upgrade the current system to establish the first page data management and control platform of the medical records of inpatients,the long-term plan is to develop a new medical record system independently;to intensify DRG training for related personnel to define the direction of medical record system reform,upgrade or research and development.