浙江省电子健康档案质量控制体系构建与应用研究

Study on the Construction and Application of Quality Control System of Electronic Health Records in Zhejiang Province

目的 实现对电子健康档案质量的规范化评价,提高国家基本公共卫生服务居民电子健康档案数据质量。方法 基于浙江省电子健康档案质控规范和省级电子健康档案信息系统,结合多学科应用模型进行构建和展示。结果 基于完整性、有效性、规范性、一致性4个评价维度,形成了10大类重点人群和重点疾病居民电子健康档案的2 470个评价指标,达到对电子健康档案单维度或综合性规范化评价的目的。结论 浙江省电子健康档案质量控制体系的构建,适应了对电子健康档案的综合性质量控制和绩效评价工作需求,推进了电子健康档案规范化、标准化的高质量发展。

Objective To realize the standardized evaluation of the quality of electronic health records and improve the quality of electronic health records for residents national basic public health service. Methods Based on the Zhejiang provincial electronic health records quality control specification, the quality control information system was constructed and demoed by multidisciplinary application model. Results Based on the four quality evaluation dimensions of completeness, effectiveness, standardization and consistency, 2470evaluation indicators of residents electronic health records for 10 major population groups and diseases were formed to achievethe purpose of single-dimension or comprehensive standardized evaluation of electronic health records. Conclusion The construction of Zhejiang provincial electronic health records quality control system has adapted to the demand for comprehensive quality control and performance-based evaluation of electronic health records, and promotes the standardized and high-quality development of electronic health records.