立体化电子病历与循证医学研究

The stereo computer-based record and the evidence-based medicine

近年来,出现了许多电子病历系统,但是其组成仍摆脱不了传统纸张式病历的方式,病人的临床信息分散在不同的页面。我们提出了建设全新的立体化电子病历的思想,把分散的信息进行重新组织,全程收集病人的临床信息,以一种时间相关的立体模式显示病人的所有资料,最终得到病人从发病到预后的全程信息。由于是病人全程信息的追踪而且数据可以用计算机进行处理。可以在临床研究中得到更加接近疾病规律的结果。本文就电子病历在循证医学研究中的作用进行了阐述。

In recent years, a growing number of computer-based patient record (CPR) systems have come into existence. But the format is still no more than just the paper medical record: The information about the patients is placed in different sections of pages, such as case history, surgery record and laboratory examination etc. We had been trying to create a new kind of CPR system that can show the information to the doctor in a time related stereo way. We call it stereo CPR. In this system, the information from the normal medical practice record including symptoms, physical signs, laboratory examinations, treatments and drugs, is estimated with the standard dictionary of medical glossary, finding out which is abnormity and then show them and alarm automatically to the doctor. All this runs through the whole process of inpatients and outpatients. What we get at last is the time related stereo impression about what happens to the patient and what is going on. Because of continuing patient data collecting and all the data capable of being processed on computer, we can get the result that is close to the real fact of the disease in the medical research. It is a powerful tool for the practice of evidence-based medicine.