CN101034410A - Medical treatment case index cast and electronic medical record system based on same - Google Patents
Medical treatment case index cast and electronic medical record system based on same Download PDFInfo
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Abstract
The invention opens a index model of medical event, to the incident as the core, in accordance with the relationship between the incidents to express the whole medical process; The invention also opens a integrated view system of electronic medical records based on the above medical events index model, mainly according to organization of data of medical events index model, establish a comprehensive medical data center with standard and structure covering the entire medical field, of the patients with, to realize indexing on the various types of medical information of the patients, for all types of clinical applications provide a convenient, speedy service, at the same time integrated view of electronic medical records software, patients with outpatient, medical detailed view software of inpatient medical records information integrated integrated with data center integration of medical data collation, analysis, from different perspectives, different levels formating intuitive, and visual expression of information.
Description
Technical field
The present invention relates to a kind of electronic medical record system, be particularly related to a kind of patient's general practice data center that sets up based on the medical events index model of having contained, and can reflect the patient disease development track, with patient's outpatient service, the fully-integrated electronic medical record system of hospitalization information.
Background technology
The modern medical service technology can be various from the information category that human body obtains, come in every shape, and numerical value, literal, image, waveform etc. are arranged, and the relation between information is numerous and diverse and uncertain.Correctly make diagnosis, treatment, the preventive measure of disease clinically, must rely on the mutual support and the confirmation of various information, farthest utilize the complementarity of information.But existing all kinds of clinic information system is often independently of one another, and same patient's all kinds of medical datas disperse to be stored in these systems, and they are carried out orderly tissue, and setting up patient's general practice data center is the prerequisite that guarantee information is efficiently utilized.On this basis, for medical personnel provide one can reflect the patient disease development track, with patient's outpatient service, the fully-integrated electronic medical record system of hospitalization information, make its overall understanding patient's general practice information, medical assistance work carries out more effectively.
Foundation contain the complete medical data collection of patient data model, make up aspect patient's general practice data center, does not still have the method for maturation both at home and abroad at present.Generally adopting with patient is the center, sets up data model based on the associating information that information flow is set up each other.Up-to-date external 6W1H (Who, Whom, When, Where, What, Why, the How) model of serving as theme based on medical events of researching and proposing promptly writes down the key element of each medical events, and is associated with all data with this; HL7 3.0 editions (HL7 V3) has also proposed reference information model, and (Reference Information Model RIM), is a hinge with medical events (ACT) object, to the modeling of whole medical data collection.
Aspect the medical record data visualization technique, the system of existing clinical practice only provides the function that patient's part medical information is browsed, part also can be implemented on same the computing machine and browses various medical informations by linking other clinical department infosystem, but the visual of these information all is dispersion, uncorrelated, and fail real realize the orderly integration of massive medical information and carry out visually, offer the only Data View of medical worker.
HL7 is the standard of being formulated by the Health Level Seven normal structure of the U.S. that is found in 1987, is the agreement of electric transmission between the medical field different application.Can make standardization such as data that each medical profession system need exchange such as sufferer essential information, medical information, cost information, Transaction Information based on the interface routine of HL7 international standard exploitation, in the transmission of realization information between each autonomous system under the same standard.HL7 organizes the last demonstration of just actively developing latest edition HL7 V3 at present.The body design of HL7 V3 has adopted the OO executing model drive structure based on UML, uses reference information model, data type and vocabulary statement to derive from the information assembly of message statement.(eXtensible Markup Language XML) as the expression way of message, makes it can utilize XML instrument and up-to-date Web service technology to carry out the establishment and the parsing of message to adopt extend markup language.
Reference information model is the basis of HL7 V3 message data content, is the core and the key member of HL7 V3 message exploitation.RIM is static health information model, and it comprises class figure and constitutional diagram, and is furnished with use-case model, interaction models, data type model, term model and other models, and the view of a demand and standard design is provided.It is a coherent sharing information model, can guarantee the consistance of notion.It focuses on the description of HL7 message, and information exists with the form of class, and class has attribute, and certain relation is arranged between the class.RIM is made up of 6 core classes: Act, Entity, Role, Participation, ActRelationship, RoleLink.It synthesizes each working group of HL7 and international member's the unainimous viewpoint about information, and as common reference, it is all the most basic sources of HL7V3 protocol specification standard.
Summary of the invention
On reference HL7 RIM thought and 6W1H model based, actual conditions in conjunction with China, the invention provides a kind of is core with the incident, expresses the medical events index model that is used for all kinds of medical datas of index of whole medical procedure according to the relation between incident and the incident.
Each incident all has a series of attributes, and determinant attribute wherein comprises incident main body, incident object, Time To Event, incident scene, event type, state-event, event data index information etc.Index information in the raw data source of the data source of all incidents of taking place in the whole medical procedure, the corresponding medical data of each incident and access mode, the corresponding medical data of each incident, the incidence relation between a plurality of incident etc. have been write down in the mode of 6W1H index in the model.
A kind of medical events index model is a core with the incident, and according to the whole medical procedure of the relationship expression between incident and the incident, its ingredient comprises:
The event category dictionary, the classification situation of definition medical events;
The incident dictionary, in every class medical events, the particular type information of definition incident;
Case index is gathered all medical events, writes down the attribute and the corresponding index information of medical data in the raw data source of each incident, and all incidents must define in advance at event category dictionary and incident dictionary;
The event data source dictionary, the raw data source information of definition all kinds medical events correspondence;
Event data source index, to every kind of data source, how definition passes through the medical data of the form visit physical store of index, binding events data source dictionary and incident dictionary, unique access mode of determining every type of medical events corresponding data source;
The event relation dictionary, the various incidence relations between the definition incident.
Event relation is described the incidence relation between two medical events;
Described medical data is organized according to the mode that with the incident is core, and the index information of medical data in the raw data source of every class incident correspondence is by the concrete file layout decision of medical data.
Described medical events adopts hierarchy to classify.
The data source of the medical data of the medical events correspondence of same type is identical, and is identical by the mode of index accesses.
Based on above-mentioned medical events index model, the present invention also provides a kind of can reflect the patient disease development track, with patient's outpatient service, the fully-integrated electronic medical record system of hospitalization information, with a series of medical events relevant in the whole medical procedure, all previous outpatient service, hospitalization information with the patient, form directly perceived, visual information representation through arrangement, analysis back, intactly reproduce.
A kind of electronic health record integrated view system based on above-mentioned medical events index model comprises:
Patient's general practice data center, data organization mode based on the definition of medical events index model is set up, with the patient medical data that are dispersed in each clinic information system is that core is carried out centralized integration with the medical events, supports to realize all medical datas are conducted interviews by index;
Electronic health record integrated view software, be used for concentrating visual through all medical events of medical data central integration, the common time attribute of all kinds of incidents based on the definition of medical events index model, represent patient's all kinds of medical datas according to the relation of " incident-time ", reflect the development track of patient disease on the whole;
Case history detailed view software, be used for all previous outpatient service of patient, hospitalization information through the medical data central integration, based on the medical events index model is index organization's form of core with the medical events to all data, and the incidence relation between the incident of wherein definition, concentrate reproduction according to time sequencing.
Described electronic health record integrated view software, by the medical events index model, obtain original medical data from the actual storage locations of medical data, the common time attribute of all kinds of incidents based on the definition of medical events index model, and the incidence relation between the incident of wherein definition, carry out visual according to the time sequencing tissue to all medical events that patient's general practice data center integrates, the relation of concentrated reflection " incident-time ", on an interface, show current each vital sign of patient, check check, doctor's advice, observation index such as all kinds of clinical discoveries, and the situation of can the time mode inquiring about observation index, mutual relationship and trend.System provides predefined integrated view template according to the difference of the medical data of required demonstration, allows the needs customization different integrated view of user according to different medical professions.
Described case history detailed view software, based on the medical events index model is index organization's form of core with the medical events to all data, arrive all diagnosis information of patient by the search index of concentrating, generate patient's all previous prescription on individual diagnosis tabulation, to all previous outpatient service of the patient of medical data central integration, hospitalization information, based on the incidence relation between the incident of medical events index model definition, be that preface is concentrated reproduction with time.
The invention has the beneficial effects as follows:
At first, based on the medical events index model, whole medical field is contained in foundation, patient's general practice data center of standardized structuralization, realization is to the centralized indexes of all kinds of medical informations of patient, for all kinds of clinical practices are provided convenience, quick service, these data comprise the diagnosis records in the HIS database, diagnosis, prescription, check application, metacheirisis, information such as operation and hygienic material, inspection request in the LIS database, assay information, structuring in the multimedia file storehouse, semi-structured, the electronic health record document of forms such as free text, audit report etc., all kinds of medical imaging object informations at image data center etc.
Secondly, electronic health record integrated view software with patient's all kinds of changes of vital signs, check medical events such as assay, clinical discovery according to time sequencing organize carry out visual; Simultaneously, be presented in intuitively under the continuous situation about changing of conditions of patients, the various disposal nursing situations that medical personnel carried out, the formulation of diagnosis and treatment plan, implementation status and clinical effectiveness thereof etc., make medical personnel hold the development track of patient disease on the whole from different view, analysis patient's all kinds of medical datas.
At last, patient's outpatient service, the integrated case history detailed view software of hospitalization information are preface with time, concentrate and reproduced all previous outpatient service of patient, hospitalization information, can between difference is gone to a doctor, position, switch easily, for medical personnel provide complete, patient information service timely.
Description of drawings
Fig. 1 is a medical events index model general structure synoptic diagram;
Fig. 2 is the overall frame structure synoptic diagram of electronic medical record system of the present invention;
Fig. 3 is the structural representation of electronic health record integrated view software;
Fig. 4 is the structural representation of the integrated case history detailed view software of patient's outpatient service, hospitalization information.
Embodiment
As shown in Figure 1, a kind of medical events index model is a core with the incident, expresses whole medical procedure according to the relation between incident and the incident, comprising:
(1) event category dictionary: the classification situation of definition medical events, as sign parameter class, doctor's advice class, inspection class, check class, case history document class etc., hierarchy is adopted in the classification of all medical events, is convenient in visualization process to carry out browsing of incident and expand from different levels;
(2) incident dictionary: the particular type information of definition incident, each type comprise the information such as data source of type coding, title, correspondence.The data source of the medical data of the medical events correspondence of same type is identical, mode by index accesses is also identical, every class incident must at first define in the incident dictionary, otherwise can't discern in the case index model and use, every class incident has its specific visual representing form;
(3) case index: the set of all medical events, to each incident, write down its each attribute and the corresponding index information of medical data in the raw data source, look the difference of every class data storage form, index information also can be different, and all incidents must define in advance at event category dictionary and incident dictionary;
(4) event data source dictionary: the raw data source information of definition all kinds medical events correspondence, as relational database, ftp file server, DICOM image center etc.
(5) event data source index: to every kind of data source, how definition passes through the medical data of the form visit physical store of index, binding events data source dictionary and incident dictionary, unique access mode of determining every type of medical events corresponding data source;
(6) event relation dictionary: the various incidence relations between the definition incident, as comprise, follow-up, prerequisite, result, relevant etc., event relation must at first define in the event relation dictionary, otherwise can't discern and use in the case index model.
(7) event relation: describe the incidence relation between two medical events, make whole diagnosis and treatment activity become an associated with each other process similar with real world from the set of a plurality of incidents;
Incident is the core texture of medical events index model, and a medical events comprises following determinant attribute usually: incident main body, incident visitor, Time To Event, incident scene, event type, state-event, data access index etc.According to actual conditions, can have specific contact between the different medical events.
In implementation process, the medical events index model can realize that each ingredient of model all is designed to a table based on relational database.When carrying out the heterogeneous data source integration based on the medical events index model, in order correctly to set up case index, set up patient's general practice data center for the medical data that is stored in wherein, need carry out following several steps:
(1) all kinds of medical events of handling as required define, register the classified information of medical events respectively in event category dictionary, incident dictionary;
(2) the predefined event correlation relation of registration in the event relation dictionary;
(3) according to the type of the data source of definition incident and the storage mode of data, corresponding data source information of registration and access mode thereof in event data source and event data source index;
(4) needs are set up the medical data of case index, extracted its 6W1H index information, be written in the case index table according to the ACT structure of index model definition;
(5) set up the incident of incidence relation for needs, relevant information is written in the event relation table.
In system's operational process, in event type, event relation type, when data source changes, upgrade corresponding dictionary table according to the method described above; Content in case index table, the event relation table except that the disposable index of finishing data with existing when the system deployment, also need be carried out the extraction and the record of index information along with the generation of new medical data to each event synchronization.
A kind of electronic medical record system based on above-mentioned index model, main data organization mode according to the medical events index model, whole medical field is contained in foundation, patient's general practice data center of standardized structuralization, realization is to the centralized indexes of all kinds of medical informations of patient, for all kinds of clinical practices are provided convenience, quick service, electronic health record integrated view software and patient's outpatient service, the integrated case history detailed view software of hospitalization information is put in order at all kinds of medical datas that patient's general practice data center is integrated, after the analysis, from different perspectives, form directly perceived on the different aspects, visual information representation.Its structure comprises as shown in Figure 2:
(1) patient's general practice data center based on the data organization mode of medical events index model definition, carries out centralized integration with the patient medical data that are dispersed in each clinic information system, supports to realize all data are conducted interviews by index;
(2) electronic health record integrated view software, for any one medical events through the medical data central integration, the integrated various medical datas that represent its time of origin point and produced before reflect the inner link between them;
(3) patient's outpatient service, the integrated case history detailed view software of hospitalization information for all previous outpatient service of patient, the hospitalization information through the medical data central integration, are that preface is concentrated reproduction with time, and complete, patient information service timely is provided.
As shown in Figure 3, electronic health record integrated view software, the common time attribute of all kinds of incidents based on the definition of medical events index model, and the incidence relation between the incident of wherein definition, according to time sequencing tissue visual to all medical events of medical data central integration, the relation of concentrated reflection " incident-time ", on an interface, show current each the vital sign (body temperature of patient, pulse, blood pressure, breathe), check check, doctor's advice, the observation index that patients such as all kinds of clinical discoveries are important, and can inquire about before this situation of These parameters arbitrarily in the time mode, mutual relationship and trend.Electronic health record integrated view software obtains original medical data by the medical events index model from the actual storage data source of medical data, for dissimilar medical events, provide different visual forms to represent to the user:
(1) for vital sign parameter class incident, at every turn be in hospital incident of sign data recording of each type of the corresponding patient of system, the user can select the part or all of sign parameter of needs demonstration according to actual conditions, integrated view can find all such sign data that this time of patient is in hospital in data center, and further inquire more detailed sign numerical information by index according to patient ID, the ID that is in hospital, sign parameter type.In integrated view, go out every class sign parameter trend over time with chart plot.
(2) for doctor's advice class incident, every doctor's advice that system carries out reality is recorded as an incident in the case index table, the user can select the part or all of doctor's advice of needs demonstration according to actual conditions, integrated view finds all execution information of this doctor's advice according to the doctor's advice content in data center, and further inquires more detailed information by index.For long-term doctor's advice, integrated view is indicated with lines in start time of this doctor's advice, stand-by time scope; For interim doctor's advice, integrated view is indicated on doctor's advice execution time point.For medication, on behalf of the size of dosage, the length of lines, the width of usefulness lines represent the time that continues, thereby depicts dosage relative situation of change in time.
(3) for check, check class incident, system is corresponding to be checked at every turn, inspection request is recorded as an incident in the case index table, integrated view retrieves all images that this time produce in checking, report, assay value etc. according to application number.In integrated view, apply for leaving on the time point at every turn and indicate with the icon form at it.
(4) for case history document class incident, the corresponding every part of case history document of system is recorded as an incident in the case index table, and writes down this part document and describe patient's keyword of state of an illness state at that time.Every part of document adopts the index of unique ID as access data sources, and integrated view is visited this part case history document according to document id.In integrated view, every part of case history document is indicated with the icon form on its rise time point, and shows the keyword of this part document with mark.
In the electronic health record integrated view software shown in Figure 3, according to mentioned above principle all kinds of medical events (comprising sign parameter, doctor's advice, inspection, check, case history letter) are being carried out respectively on the visual basis, for every class incident provides its development trend view in time, as the situation of change of sign parameter, doctor's advice implementation status in time etc.; Simultaneously, software has also represented the mutual relationship between all kinds of medical events.As shown in the figure, the integrated view software description a typical diagnosis and treatment process: patient's sign parameter occurs unusual, the doctor with reference to before case history document record after, assigned long-term doctor's advice, sign parameter, two incidents of case history document have constituted the prerequisite of this doctor's advice incident; According to doctor's advice, patient needs to carry out inspection and check respectively, has promptly comprised inspection incident, check incident in the doctor's advice incident; Along with the execution of doctor's advice, the result of its generation is that the sign parameter is recovered normally, and the doctor stops original long-term doctor's advice, has assigned interim doctor's advice again; All above-mentioned incidents are all recorded faithfully in the case history document, and the medical document incident is the successor of these incidents; Many parts of case history documents of different time record exist correlationship each other.
In addition, electronic health record integrated view software provides predefined integrated view template according to the difference of the medical data of different section office needs demonstration; On this basis, allow the needs customization different integrated view of user according to different medical professions.
As shown in Figure 4, the integrated case history detailed view software of patient's outpatient service, hospitalization information is that preface is concentrated reproduction to all previous outpatient service of the patient of medical data central integration, hospitalization information with time.Is index organization's form of core based on the medical events index model with the medical events to all data, arrives all prescription on individual diagnosis event informations of patient by the search index of concentrating, and generates patient's all previous prescription on individual diagnosis tabulation; Incidence relation based between the incident of medical events index model definition inquires all kinds of medical events (as sign parameter, doctor's advice, inspection, check, case history letter) that each prescription on individual diagnosis incident is comprised; For each class incident, based on the data source information of medical events index model definition, software further is indexed in the actual storage data source of medical data, obtains original medical data, and the detailed function of browse to such data is provided.
Claims (8)
1. medical events index model, it is characterized in that: be core with the incident, according to the whole medical procedure of the relationship expression between incident and the incident, its ingredient comprises:
The event category dictionary, the classification situation of definition medical events;
The incident dictionary, in every class medical events, the particular type information of definition incident;
Case index is gathered all medical events, writes down the attribute and the corresponding index information of medical data in the raw data source of each incident;
The event data source dictionary, the raw data source information of definition all kinds medical events correspondence;
Event data source index, to every kind of data source, how definition passes through the medical data of the form visit physical store of index;
The event relation dictionary, the various incidence relations between the definition incident;
Event relation is described the incidence relation between two medical events.
2. medical events index model as claimed in claim 1, it is characterized in that: described medical data is organized according to the mode that with the incident is core, and the index information of medical data in the raw data source of every class incident correspondence is by the concrete file layout decision of medical data.
3. medical events index model as claimed in claim 1 is characterized in that: described medical events adopts hierarchy to classify.
4. medical events index model as claimed in claim 1 is characterized in that: the data source of the medical data of the medical events correspondence of same type is identical, and is identical by the mode of index accesses.
5. one kind based on the electronic medical record system as the arbitrary described medical events index model of claim 1-4, it is characterized in that comprising:
Patient's general practice data center, data organization mode based on the definition of medical events index model is set up, with the patient medical data that are dispersed in each clinic information system is that core is carried out centralized integration with the medical events, supports to realize all medical datas are conducted interviews by index;
Electronic health record integrated view software, be used for concentrating visual through all medical events of medical data central integration, the common time attribute of all kinds of incidents based on the definition of medical events index model, represent patient's all kinds of medical datas according to the relation of " incident-time ", reflect the development track of patient disease on the whole;
Case history detailed view software, be used for all previous outpatient service of patient, hospitalization information through the medical data central integration, based on the medical events index model is index organization's form of core with the medical events to all data, and the incidence relation between the incident of wherein definition, be that preface is concentrated reproduction according to the time.
6. electronic medical record system as claimed in claim 5, it is characterized in that: described electronic health record integrated view software is by the medical events index model, obtain original medical data from the actual storage locations of medical data, the common time attribute of all kinds of incidents based on the definition of medical events index model, and the incidence relation between the incident of wherein definition, carry out visual according to the time sequencing tissue to all medical events that patient's general practice data center integrates, the relation of concentrated reflection " incident-time ", on an interface, show current each vital sign of patient, check check, doctor's advice, observation index such as all kinds of clinical discoveries, and the situation of can the time mode inquiring about observation index, mutual relationship and trend.
7. electronic medical record system as claimed in claim 5 is characterized in that: system provides predefined integrated view template according to the difference of the medical data of required demonstration, allows the needs customization different integrated view of user according to different medical professions.
8. electronic medical record system as claimed in claim 5, it is characterized in that: described case history detailed view software is index organization's form of core with the medical events to all data based on the medical events index model, arrive all diagnosis information of patient by the search index of concentrating, generate patient's all previous prescription on individual diagnosis tabulation, to all previous outpatient service of the patient of medical data central integration, hospitalization information, based on the incidence relation between the incident of medical events index model definition, be that preface is concentrated reproduction with time.
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