JP3074536B2 - Input / output control method of electronic medical record system - Google Patents

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION The present invention is, in the medical information system, electronic medical record sheet that electronic clinical information physicians handle
Relates to the stem, in particular, high electronic medical record system reliability that can prevent tampering of the medical information entered by the doctor
On-time.

[0002]

2. Description of the Related Art In recent years, digitization and integration of medical information have been advocated, and digitization of slip processing has been embodied based on the rise of a conventional medical accounting system. This manifestation is the electronic input of various orders by the doctor, which has already been constructed as a hospital information network, and medication orders, examination orders, and the like are being used by doctor input.
Against this background, the electronic medical record system, which aims to increase the efficiency of operations by computerizing and increasing the efficiency of business by converting the increasing number of paper medical records year by year into digital medical records, and to enhance the efficiency of medical treatment research and medical research by computers. Research is being done.
However, what is specifically studied among them is related to an input means such as a tool for constructing an expert system for medical diagnosis, which aims to efficiently classify and manage medical information by doctors with a computer. . For example, input means of chart information is mainly used, such as that relating to the input of findings described in JP-A-1-136277 and that relating to the input of a diagnostic report described in JP-A-1-320049. It is not a specific technology for content management and operation. Also, “Nikkei Computer 1991. 3.25 (no. 24)” published by Nikkei BP
The electronic medical record system described on page 46 of “9)” (1991) manages a paper medical record handwritten by a doctor by accumulating it as image information in an optical disk device.
Doctors do not directly enter and manage medical information using a computer.

FIG. 7 is an explanatory diagram showing one embodiment of the information described in a conventional paper chart. The entry format of the paper chart 55 is not standardized at present, and is often left to the discretion of each hospital, medical department, and doctor. For example, in some medical charts, which are mainly inspected, an inspection table or a sketch is printed in advance so that the inspection result can be easily entered. However, the contents as shown in FIG. 7 can be given as a general chart entry. The patient basic information 49 is the basic social attributes of the patient and the management information in the hospital, which are input when the consultation is accepted. The contents include a patient recognition ID (index), patient name, gender, date of birth, and the like. Although not included in the chart information, information such as the patient's insurance type, contact information, etc., is also uniformly managed as patient basic information.
The current medical history / allergy 50 is a description of the medical treatment content and constitution of the patient that has been received so far. The main complaint 51 mainly includes the contents of the medical interview and the explanation of the patient's condition. Some doctors ask questions directly, while some hospitals ask
In some cases, it is completed by a physician who performs a pre-examination. The finding 52 describes a medical finding. The prescription / treatment 53 is a description of medication and treatment contents.
Regarding the prescription / treatment 53, there is an order input system that electronically performs a request procedure using a slip that is performed simultaneously with the entry online via a network. The other 54 is a part for transferring and pasting test data such as blood pressure, ultrasound photograph, biochemical test, etc., and writing a comment on the test result.

[0004]

As described above, the information described on the paper chart includes the basic information of the patient such as the patient's name, serial number, gender, age, etc., the contents of the order such as examination and treatment, and the like. There are medical treatment contents such as, results, current symptoms and findings. Even if these descriptions are replaced with electronic medical records, the expressions are changed but the contents are the same. This chart information has the characteristic that when it is spread out on paper, it can be freely added and changed in a form that allows its progress to be understood.If it is intentionally falsified by anyone other than the attending physician, it will be falsified from the handwriting. Can be determined. That is, the content once entered cannot be erased (the chart information cannot be erased), and at the same time the time progress can be clarified. Another major feature of the paper chart is that the amount of information that can be entered into the chart sheet can be made arbitrary by changing the size of characters or using sketches. In medical practice, the results of various treatments and examinations arrive at the doctor with a delay in time, so the medical record information is often not completed at once but is completed after a lapse of time. In such a background, if the medical record information is digitized and most of the medical information is converted into code information, it is necessary to prevent the information from being tampered with and to be able to add and change the medical information similar to the paper medical record. No.

[0005] The problem to be solved is that in the conventional electronic medical record system , the description operation and operation corresponding to the current paper medical record cannot be performed efficiently using a computer. An object of the present invention is to solve the problems of the prior art, and to enable the input of the contents of a medical record, such as postscript information, performed over time by the same procedure as when handling a paper medical record. It is an object of the present invention to provide a highly reliable electronic medical record system capable of preventing the contents from being falsified.

[0006]

In order to achieve the above object, an electronic medical record system according to the present invention comprises: (1) an input device for inputting diagnostic information relating to a patient;
A storage device for registering diagnostic information as an electronic medical record;
A display device for displaying the electronic medical record is provided to the patient.
To create electronic medical charts using computers
In the chart system, the newly input diagnostic information
Update prohibited area that prohibits input other than addition to the information storage area
And register the diagnostic information in the storage device
It is characterized by the following. Further, (2) an electronic medical record system smell according to the above (1)
Storing the diagnostic information additionally input to the update prohibited area.
Specify an area as the update prohibited area and register it in the storage device.
It is characterized by that. (3) In the electronic medical record system according to (2) above
In the additional input diagnostic information,
An attribute different from the diagnostic information
Is displayed on a display device. Further, (4) an electronic medical record system smell according to the above (3)
The attribute is one of display density, display color, and display brightness.
It is characterized by the following. Also, (5) an electronic medical record system smell according to the above (2)
In the diagnostic information that has been additionally input,
An attribute different from the diagnostic information
It has a printing device that prints out child charts.
I do. Further, (6) electronic medical according to any one of (1) to (5)
In a telecommunication system, data using the diagnostic information for input / output
Other data of the medical information system to which the data processing device is connected
Outputting the electronic medical record by a data processing device.
You. Furthermore, (7) electronic medical according to any one of (1) to (6)
In the tele-system, identification of an operator for inputting the diagnostic information
The date and time when the input operation was performed is given to the
Storage area for the identifier with the date and time appended
Registered in the storage device by designating the
And features.

[0007]

In the present invention, a doctor in charge inputs medical information of a patient to a predetermined field of an electronic medical record screen displayed on a display device. Here, whether or not the input person is in charge is determined by comparing an identifier such as a name input by a doctor with an identifier registered in advance corresponding to the electronic medical record being displayed. When the input of the diagnostic information is completed and the registration is made in the storage device, the storage area of the newly input medical information is
Register as an update prohibited area that prohibits input other than addition by insertion. As a result, the medical information once input becomes non-rewritable, thereby preventing falsification of the electronic medical record. When the doctor in charge makes a change to the diagnostic information in the update prohibited area, only the additional input by insertion is possible, and the additionally input diagnostic information is the same as the already entered medical information. Are displayed with different display expressions, for example, with different brightness. As a result, the medical chart can be easily viewed, and the medical chart reference at the time of medical treatment can be efficiently performed. In this way, the diagnosis information conventionally described on the paper chart is digitized, and even when operated by the medical information system, the input of the information in the chart performed over time is performed by the paper chart. It can be performed in the same procedure as when handling.

[0008]

Embodiments of the present invention will be described below in detail with reference to the drawings. FIG. 1 shows the entrance and exit of the electronic medical record system of the present invention.
5 is a flowchart illustrating an example of a processing operation related to force control . FIG. 4 shows an input / output control operation at a doctor workstation in the medical information system shown in FIG.
First, the current date and time are added to an identifier, for example, a doctor's name, input in a predetermined column of the displayed electronic medical record and displayed (step 101). Note that this date and time is given based on the clock function of the doctor's workstation. next,
It is determined whether this identifier is the doctor in charge who has permitted the operation of the electronic medical record (step 102). If the identifier is correct (step 103), the doctor performs the input processing of the medical information input through the keyboard, mouse, and handwritten tablet (step 104) as follows. If the area to be input is an area in which medical information has not been input yet (step 10).
5) Display the input medical information (step 106),
If the area to be input is an update-prohibited area in which medical information has already been input before this display reading, the input medical information is added (added) and registered. It is displayed in a display state different from certain medical information, for example, in a different color, brightness, density, or the like (step 10).
7). Next, when the medical treatment is completed and a registration instruction of the medical information is issued (step 108), the recording area of the input or added medical information is designated as the update prohibited area (step 109) and registered in the storage device (step 109). Step 110). If it is determined in step 103 that the identifier is an invalid identifier (for example, not the doctor in charge), an identifier input error is displayed (step 111), and the flow advances to step 109. Along with the data such as the date and time assigned in step 101, it is designated as an update prohibited area and registered in the storage device (step 11).
0). In this way, by making it impossible to update the medical information input to the electronic medical record, falsification of the medical information can be prevented. In addition, it is possible to additionally record the medical treatment information, and it is possible to clearly indicate that the additional information is added, and the doctor uses the same procedure as the conventional handwritten medical chart,
Medical information can be input and output. Regarding the method of designating the update prohibited area in step 109, that is, the method of protecting the data of the computer, various storage protection methods are known technologies, and the description thereof is omitted here.

Next, a medical information system that actually operates such an electronic medical record will be described. FIG. 2 is a block diagram showing one embodiment of a medical information system using a doctor's workstation for performing input / output control of the electronic medical record in FIG. 1 is an overall configuration diagram of a medical information system that operates an electronic medical record of the present invention, and has the following configuration. The medical information system according to the present embodiment includes a medical service network 1 for accounting services and the like, which is currently widely used, and a file such as an electronic medical record of the present invention, such as a medical result input by a doctor while facing a patient. A medical department network 2 and B medical department network 3 for registration and transfer, a laboratory network 4 for an examination specified based on the medical results, and a radiology network 5 for handling high-definition images such as X-ray images. And a nursing service support network 6 in the ward are connected by a high-speed local area network 7 for large-capacity images such as high-definition images and a local area network 8 for code information. In this way, a doctor's instruction (order) from the A medical department network 2 or the B medical department network 3 is transmitted via the local area network 8 to the pharmacy department in the medical business network 1 or the laboratory network 4. By transmitting to the inspection department etc. in the so-called ordering system,
By transmitting medical image information, such as X-rays and CT scans, which are centrally managed by the radiology network 5, via the high-speed local area network 7, a so-called medical image information system is constructed. Further, by transmitting the electronic medical record to the nursing service support network 6 in the ward via the local area network 8, the electronic medical record can be referred to, for example, at a bedside terminal, thereby providing an efficient nursing system. Is building.

A medical department network 2 includes a doctor's workstation 9 (denoted by WS in the figure) for inputting and outputting an electronic medical record according to the present invention, which is used when a doctor does not perform diagnosis of a high-definition image. A high-definition image doctor's workstation 10 (W in the figure), which has a display device for high-definition images, and in which a doctor similarly inputs an electronic medical record of the present invention.
S) and an internal file device 1 as a storage device for registering an electronic medical record input at the doctor's workstation 9 or the high-definition image doctor's workstation 10.
1 (indicated as F in the figure) and a doctor's workstation 9
And a file server 12 (denoted by S in the figure) for controlling the input and output of electronic medical records of the in-facility file device 11 by the high-definition image doctor's workstation 10 and the like. Although not shown, the medical department network 3 has the same configuration. With such a configuration, in the medical information system according to the present embodiment, the medical care information centering on the contents of the medical chart input at the doctor's workstation 9 or the high-definition image doctor's workstation 10 is stored in the in-house file device 11. The order of inspection, treatment, etc. is transferred to a predetermined department,
Processing corresponding to each is performed. Then, the electronic medical record registered in the in-facility file device 11 is displayed and output to the doctor's workstation 9 or the high-definition image doctor's workstation 10 when the patient returns or when examination data is generated, and is referred to. . Then, when referring to the inspection data, a comment on the inspection result is added to the electronic medical record as needed to complete the electronic medical record. Further, the electronic medical record created in this way can be displayed and output on a workstation or the like in the network for nursing service support via the local area network 8 for reference.

Hereinafter, the doctor's workstation 9 for performing the processing operation according to the present invention will be described in more detail. FIG. 3 is a substantive view showing one embodiment of the configuration of the doctor's workstation for performing the input / output control operation of the electronic medical record in FIG. FIG. 2 shows the appearance of a doctor's workstation 9 and a high-definition image doctor's workstation 10 shown in FIG. 2. The doctor's workstation 9 shown in FIG. 2 performs various data processing including input / output control of an electronic medical record according to the present invention. Workstation body 13 that performs
A display device 14 for displaying the processing results, etc .; a mouse 15 for operating a cursor at the time of inputting coordinates; and a handwriting tablet 16 used for inputting sketches and handwritten characters.
The high-definition image doctor's workstation 10 is provided with a high-definition image referencing display device 18. The doctor arranges these devices on a desk, faces the patient, and places the mouse 15, the handwriting tablet 16, and the electronic medical record displayed on the display device 14 or the high-definition image reference display device 18 on the display device 14. ,
Using the keyboard 17 or the like, medical information can be directly input.

FIG. 4 is an explanatory diagram showing one embodiment of a process of creating an electronic medical record by the doctor's workstation in FIG. FIG. 4 shows the timing of entry into the electronic medical record 19 by the doctor's workstation in the medical care process in the medical information system of FIG. 2, and the entry timing occurs on a month-to-day basis or over time. First, at the time of the examination 20, an inquiry is made, and for example, patient basic information such as a patient's name, allergy, medical history, gender, date of birth, and the results of the examination are entered. And treatment 2
At time point 1, a treatment order such as an inspection order or a radiation order is entered. Each order entered here is transmitted to the examination department network 4 and the radiology department network 5 via the local network 8 in FIG. 2, and each examination (1) 22 to (n) 24 is performed. Then, if the test result is obtained in a short time, the doctor visits at 25:00, and if the test result takes a long time, the second visit 2
At 6:00, a comment such as a finding is input.

FIG. 5 is an explanatory diagram showing one embodiment of an electronic medical record display screen of the doctor's workstation in FIG. The entry columns of the screen 27 on the display device 14 of the workstation for digitizing the chart information shown in FIG. 3 are shown, and the entry columns 28 and 29 are filled with the names of the doctors in charge of the information input. By referring to this field, it is determined whether or not the doctor has the authority of the input, and thereafter, the input of only the doctor having the medical treatment permission to the corresponding patient is permitted. Normally, only the doctor in charge is allowed to make an input, but after a predetermined procedure, a doctor in the same medical department can also make an input. In the entry column 30, the contents of the interview are entered by a doctor who is permitted to enter the information. A patient name is entered in the entry field 31 and also becomes a file name of the electronic medical record. In the entry column 32, the current medical history of the conventional paper chart shown in FIG.
Allergy 50, and the entry column 33, gender,
Part of the patient's basic information such as date of birth is entered and displayed. The entry field 34 corresponds to the chief complaint 51 and the finding 52 of the conventional paper chart shown in FIG. 7, and is filled with the chief complaint and the finding. The entry column 35 is a portion corresponding to the other 54 in FIG. 7, in which examination data, handwritten information 36, comments 37 and the like input by the doctor are entered. Inspection result data by an automatic inspection device or the like is provided in a treatment / problem entry column 38.
Are displayed in the respective entry fields 39 to 43. That is, the entry column 39 contains the inspection order, the entry column 40 contains the radiation order, the entry column 41 contains the prescription order, and the entry column 42
, The treatment order is entered, and the entry column 43 is filled with the hospitalization order.

It should be noted that the allergy information in the entry column 32 is always displayed, and a part of the medical history is displayed. Further, a new window for displaying a medical history is opened by referring to by scrolling or by clicking. You may do it. Similarly, reference to the overall information and actual data input to each entry field are performed by opening a data entry screen window by clicking each entry field (object item display area) on the screen 27. For order items that cannot be displayed in the action / problem entry field 38, the action / problem entry field 38 may be used.
Can be realized by scrolling the area. Such display control can be performed using a so-called multi-window technique, and a description thereof is omitted here. The medical information input in the respective entry fields of the electronic medical record displayed in this manner is once registered in a storage device such as the in-facility file device 11 in FIG. From the next time, only additional writing by insertion is permitted for this area. Thus, falsification of the medical care information can be prevented.

FIG. 6 is an explanatory diagram showing one embodiment of the display area of the electronic medical record by the doctor's workstation in FIG. Display device 14 of the workstation of FIG.
FIG. 3 is a diagram in which the electronic medical record file registered in the in-facility file device 11 of FIG. 2 is developed in paper specification. The workstation display screen 44 is, for example, a screen on the display device 14 of the workstation in FIG. The electronic medical record file 45 is an image when the text part of the electronic medical record file registered in the intra-facility file device 11 of FIG. 2 is developed with the same display specifications as paper. In addition, the input prohibition area 46
Is a display screen portion of the already input portion which has been input by the time of this medical examination, and is controlled as an update prohibited area which cannot be erased or rewritten. The new input area 47 is a part where a new input is permitted, and is a part for newly inputting a medical record by the present examination. As shown in FIG. 4, the entry of the medical record into the electronic medical record is performed at various timings depending on the contents of the medical treatment, and the entry position is set in the new input area 4.
There are many cases where it is desired to fill in not only the area 7 but also the input prohibited area 46 which is an already input area. For this reason, in the present embodiment, an already input portion such as the input prohibition region 46 is provided with an editing function that can only be added, and the added portion 48 is changed in density, color, or luminance. This makes it possible to provide not only reliable falsification prevention but also an environment for creating a chart similar to the entry on a paper chart. Furthermore, by scrolling the other input portions of the electronic medical record file 45 on the display screen of the workstation display screen 44, it is possible to provide an efficient medical chart reference operation environment. it can.

As described above with reference to FIGS. 1 to 6, according to the present embodiment, the input of the contents of a medical record performed over time, such as postscript information, is performed in the same procedure as in the case of handling a paper medical record. By preventing the contents of the medical chart from being tampered with, a highly reliable electronic medical chart system with high operation efficiency can be constructed. And
As described above, by digitizing the medical chart, the medical information can be sequentially input without worrying about the capacity of the medical chart, and the medical chart can be referred to by a simple scroll operation, thereby improving the operability. In addition, since one disease can be added to one file, it is not necessary to generate a new file every time a medical record is entered, and it is possible to prevent an increase in the number of file directories. Further, by connecting this electronic medical record system to an existing medical information system, the performance of the medical information system can be improved.

[0017]

According to the present invention, falsification of the contents of the electronic medical record is prevented by permitting only additional writing to the previously input medical information, and reference to the electronic medical record is made possible by clearly displaying the added part. And a highly reliable and highly efficient electronic medical record system can be constructed.

[0018]

[Brief description of the drawings]

FIG. 1 is a flowchart showing one embodiment of a processing operation related to input / output control of an electronic medical record system of the present invention.

FIG. 2 is a block diagram showing one embodiment of a medical information system using a doctor's workstation for performing input / output control of the electronic medical record in FIG. 1;

3 is a substantive view showing one embodiment of a configuration of a doctor's workstation for performing input / output control operation of the electronic medical record in FIG. 1;

FIG. 4 is an explanatory diagram showing one embodiment of a process of creating an electronic medical record by the doctor's workstation in FIG. 3;

FIG. 5 is an explanatory diagram showing one embodiment of an electronic medical record display screen of the doctor's workstation in FIG. 3;

FIG. 6 is an explanatory diagram showing one embodiment of a display area of an electronic medical record screen by the doctor workstation in FIG. 3;

FIG. 7 is an explanatory diagram showing one embodiment of information described in a conventional paper chart.

[Explanation of symbols]

 DESCRIPTION OF SYMBOLS 1 Medical business network 2 A medical department network 3 B medical department network 4 Laboratory network 5 Radiology network 6 Nursing business support network 7 High-speed local area network 8 Local area network 9 Doctor workstation 10 High-definition image doctor work Station 11 Internal file device 12 File server 13 Workstation body 14 Display device 15 Mouse 16 Handwritten tablet 17 Keyboard 18 High-definition image reference display device 19 Electronic medical record 20 Examination 21 Treatment 22 Examination (1) 23 Examination (2) 24 Examination (n) 25 Examination 26 Return visit 27 Screen 28-35 Entry column 36 Inspection data / handwritten information 37 Comment 38 Treatment / problem entry column 39-43 Entry column 44 Workstation示画 surface 45 electronic chart file 46 input prohibition region 47 new input region 48 postscript 49 basic patient information 50 Other 55 paper medical chart Present illness Allergy 51 complained 52 Findings 53 prescription and treatment 54

Continuation of the front page (56) References JP-A-58-169627 (JP, A) JP-A-1-255954 (JP, A) JP-A-1-169567 (JP, A) Ohashi, Guo After one year of outpatient clinic operation, ”Medical Informatics, Vol. 10, No. 8, p. 227-242, 1990 (Heisei 2-12-31) (58) Fields investigated (Int. Cl. ⁷ , DB name) G06F 19/00 A61B 5/00 G06F 17/60 JICST file (JOIS)

Claims (2)

(57) [Claims] 1. An input device for inputting diagnostic information on a patient, a storage device for registering the diagnostic information as an electronic medical record of the patient, and a display device for displaying the electronic medical record, An input / output control method for an electronic medical record system created using a computer, wherein the diagnostic information of the electronic medical record displayed on the display device is provided.
Enter the diagnostic information from the input device in the blank fields.
To enter the information in the above storage device.
Setting an update-prohibited area that prohibits rewriting and deletion of the information entered in the entry field; and setting the updated area to be read from the storage device and displayed on the display device.
The input device to the entry field set in the update prohibited area
With the input operation of the diagnostic information by the
Steps to add only to the entry field set in the update prohibited area
Input of an electronic medical record system, characterized in that to have a and-flops
Output control method . 2. An input device for inputting diagnostic information relating to a patient.
To register the diagnostic information as an electronic medical record of the patient.
A storage device, and a display device for displaying the electronic medical record, wherein the patient
An input / output control method of an electronic medical record system for creating an electronic medical record using a computer , wherein an identifier of a writer entered from the input device is used for the electronic medical record system.
Whether it is an identifier of a person who has authority to enter the medical record
Discriminating, and if the identifier of the one having the input authority matches,
Permitting the entry to the electronic medical record; and
Output control how the electronic medical record system, which comprises organic and registering in the storage device with the date
Law .