Structured electronic medical record solution data standardization challenges (1)

2009-new health reform programme announced that concern the "four-beam eight columns" as the framework of the new health reform programme, information has become one of the eight major security system, marking the medical information on the policies and requirements, access to high speed development of fast track, "information systems hold up four-beam eight columns, medical information development new climax" of the industry consensus.

According to the new health reform "to establish practical shared medical and health information system," the overall objective, standardized electronic medical records in our country the first purpose is to meet the region-wide health care institutions to Exchange and share clinical information needs, implementation to health records and electronic medical record-based regional health cooperative. The dynamic development of informatization is catalyzing a profound reform of the wave of the medical industry.

2010 14 October, the Ministry of health published the electronic medical record pilot work programme, decided in Beijing, 22 provinces, autonomous regions and hospitals of the pilot work of electronic medical records.

Use of 1 year or so, some hospitals and part of region electronic medical record pilot and explore ways of establishing suitable for China's national conditions of electronic medical records system; and explore the hospital's existing medical information system, integrated approach, establishing a regional electronic medical record data center; gradual establishment of a regional security shared electronic medical records information management system and remote medical system. Published implementation of electronic medical records-related specifications and standards of scientific advancement and operability for demonstration and further refined to better promote and provide clinical services.

However, medical information development for 20 years, information standardization always plagued the industry's development.

Electronic medical record as the focus of the new health reform, and also the realization of the regional medical resource sharing. To achieve a new health reform proposed by the regional health collaborative goal of the standardization of electronic medical records is the most important issue to be solved. To this end, the basic structure of electronic medical records and data standards and the fundamental norms of electronic medical records (for trial implementation) "and other documents have been published. There is no doubt that the "standard" as well as the introduction of the pilot programme will promote the development of medical information. How to solve problems the industry for many years, electronic medical record data standardization challenges, but also from the structure of electronic medical record to talk ...

Structured electronic medical record solutions to problems of the "standard"

"Structured electronic medical record not only can shorten the time to complete the medical doctors, but also can improve through standardized templates, case quality in medical research statistics more important value, has been the medical information development objectives.

"Beijing ANBO-technology development co., Ltd Executive Director LU bin believes that in the new health reform is pinned, the shoulders of electronic medical records system, the smart structured data as the core, to final realization of data standardization of electronic medical records.

Taking an electronic medical record rise in China, after 10 years of development history, electronic medical records has undergone three major stages of development.

The first stage is realized in paper records to electronic enter text via text processor, changed the previous medical history of the traditional "handwriting"; the second stage is the implementation of an electronic medical record form, according to medical criterion table, set of health care professionals required fixed project. Lu bin pointed out that "in these two stages, electronic medical record just realized standardization, reduces staff workload of the medical record, electronic medical record in scientific applications, data sharing, and other aspects of value did not play. ”

Currently, the electronic medical record ushered in the third stage of development, structured the rapid development of electronic medical records.

At this stage, electronic medical record data entry interface is a standard form interface through an HTML form or WinForm form input text, and can be easily stored and data analysis capabilities. Industry experts believe that this reflects the nature of electronic medical records, a paper record of the information into the computer to recognize and understand structured data input, processing, transfer and applications, in clinical and research applications, data sharing, and so achieve a breakthrough, and standardization in the information process in steady step.

In the medical application software in touch rolls play years of climbing Lu bin, forward-looking vision will electronic medical record system structured implementation as a goal, and lead the team after many years of efforts, research and development to launch smart full structure into features "intelligent electronic medical records integration UPWAY system."

Other medical software companies can only achieve semi-structured electronic medical product development, Beijing ANBO-technology development co., Ltd. became a few home developed the complete set of all structured electronic medical products.

It is understood that the ANBO-"UPWAY intelligent electronic medical record system" has the full intelligence, flexibility and scalability features that can be used with various heterogeneous systems (HIS, LIS, PACS, EMR) about consolidation.

At the same time, the system uses comply with medical natural language full of intelligent, structured techniques to complete a language element itself, structured and able to complete the language elements in the logical relationship between structured. Current CPR full structured difficulties is the medical instrument section of all structured, "UPWAY intelligent electronic medical record adoption of the integrated system" will be part of the medical instruments "element" approach, each word is down into medical history can no longer share of medical data elements and establish all elements of the standard logical relationship can be copy of WORD and other means of record identification to structured, systematic recognition rate as high as 80 percent.

Prior to this, the Ministry of Health Ministry spokesman maoqunan has stressed the reunification of the country's standards for electronic health records, which can be one of the national retail Foundation, electronic medical records will be playing at the "three foundations, built three-level platform, enhancing business application system" as the current focus of medical information development.

"A good three Foundation", the first is the establishment of the national unified and standardized residents health records; the establishment of a national framework of electronic medical records and data standards; the third is the establishment of a national health information data dictionary.