WO2014027661A1 - Dispositif de création de dossier médical électronique et système de création de dossier médical électronique - Google Patents

Dispositif de création de dossier médical électronique et système de création de dossier médical électronique Download PDF

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Publication number
WO2014027661A1
WO2014027661A1 PCT/JP2013/071874 JP2013071874W WO2014027661A1 WO 2014027661 A1 WO2014027661 A1 WO 2014027661A1 JP 2013071874 W JP2013071874 W JP 2013071874W WO 2014027661 A1 WO2014027661 A1 WO 2014027661A1
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WIPO (PCT)
Prior art keywords
display
confirmation
electronic medical
medical record
risk level
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PCT/JP2013/071874
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English (en)
Japanese (ja)
Inventor
真哉 杉山
池田　智
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株式会社 東芝
東芝メディカルシステムズ株式会社
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Publication of WO2014027661A1 publication Critical patent/WO2014027661A1/fr

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    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q10/00—Administration; Management
    • G06Q10/10—Office automation; Time management
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
    • G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H15/00—ICT specially adapted for medical reports, e.g. generation or transmission thereof
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H50/00—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
    • G16H50/30—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for calculating health indices; for individual health risk assessment

Definitions

  • Embodiments of the present invention relate to an electronic medical record creation apparatus and an electronic medical record creation system.
  • the present invention has been made to solve the above problems, and the object of the present invention is to determine the priority of confirmation for each displayed item when Do display is made in the creation of an electronic medical record.
  • An object of the present invention is to provide an electronic medical record creation device and an electronic medical record creation system capable of easily and reliably confirming Do display of items to be confirmed by displaying on the screen based on the priority.
  • a risk level determination unit in the electronic medical record preparation device, a risk level determination unit, a risk level determination unit, a storage unit for storing the content of an entry subject to repeated prescription or order, and a display of the content of the entry
  • a display unit for inputting, an input unit for inputting whether or not to repeatedly prescribe or order the contents of the displayed entry item, a determination unit for determining a confirmation condition based on the content of each entry item, and a confirmation
  • the display mode of the screen display for confirming the right or wrong of repeatedly prescribing or ordering the required check items is determined, and the display mode determined for the display unit for each required check item is displayed.
  • a display mode determination unit for instructing.
  • a storage unit that stores the contents of the entry items of the medical order that is the subject of repeated prescriptions or orders
  • a display unit that displays the contents of the entry items, Determined by the input section for inputting whether to repeatedly prescribe or order the contents of the displayed entry, the risk level determination section for determining the risk level of each entry, and the risk level determination section
  • a determination unit that determines the confirmation conditions based on the risk level, and a screen display mode for confirming whether or not to repeatedly prescribe or order the required confirmation items according to the confirmation conditions, as well as the required confirmation items
  • a display mode determination unit that instructs display of the display mode determined for each display unit, and the determination unit determines whether the table according to the risk level Determining a display frequency aspects as one of the confirmation conditions.
  • a server for storing the electronic medical record created so far, a medical image diagnostic apparatus for acquiring a medical image necessary for creating the electronic medical record, and repetition A storage unit that stores the contents of the entry subject to prescription or order, a display unit that displays the contents of the entry, and whether to repeatedly prescribe or order the contents of the displayed entry are entered. Display part for confirming the pros and cons of repeatedly prescribing or ordering the required confirmation item according to the confirmation condition Creating an electronic medical chart including a display mode determining unit that determines the mode and instructs the display unit to display the display mode determined for each confirmation item And a location.
  • the feature of the invention described in claim 17 is that in the electronic medical record creation system, a server for storing the electronic medical record created so far, a medical image diagnostic apparatus for acquiring a medical image necessary for creating the electronic medical record, and repetition Whether to repeat the prescription or order for the contents of the storage part that stores the contents of the entry of the medical order subject to prescription or order, the display part that displays the contents of the entry, and Input section for input, risk level determination section for determining the risk level of each entry, determination section for determining confirmation conditions based on the risk level determined by the risk level determination section, and according to the confirmation conditions Determine the display mode of the screen display for confirming the pros and cons of repeatedly prescribing or ordering the required confirmation items.
  • a display mode determination unit that instructs the display unit to display the display mode determined for each approval item, and the determination unit uses the display frequency of the display mode according to the risk level as one of the confirmation conditions.
  • an electronic medical record creation device characterized by determining.
  • FIG. 1 is a block diagram showing an overall configuration of an electronic medical record creation system including an electronic medical record creation apparatus according to an embodiment.
  • FIG. 2 is a block diagram illustrating an internal configuration of the electronic medical record creation apparatus according to the embodiment.
  • FIG. 3 is a block diagram showing an internal configuration of the Do display unit in the embodiment.
  • FIG. 4 is a flowchart showing a flow from Do display to confirmation of the display content in the embodiment.
  • FIG. 5 is a flowchart showing a flow from Do display to confirmation of the display content in the embodiment.
  • FIG. 6 is an example of a table indicating the risk level of the items to be confirmed in the embodiment.
  • FIG. 7 is an example of a table showing risk level confirmation conditions in the embodiment.
  • FIG. 1 is a block diagram showing an overall configuration of an electronic medical record creation system including an electronic medical record creation apparatus according to an embodiment.
  • FIG. 2 is a block diagram illustrating an internal configuration of the electronic medical record creation apparatus according to the embodiment.
  • FIG. 3 is a block
  • FIG. 8 is an explanatory diagram for explaining an example of the confirmation condition in the embodiment.
  • FIG. 9 is a screen example showing an example of a display screen in the embodiment.
  • FIG. 10 is a screen example illustrating an example of a display screen in the embodiment.
  • FIG. 11 is a screen example illustrating an example of a display screen in the embodiment.
  • FIG. 1 is a block diagram showing an overall configuration of an electronic medical record creation system S including an electronic medical record creation apparatus 3 in the embodiment.
  • the electronic medical record creation system S is used to create a server 1 for storing the electronic medical record created so far, a medical image diagnostic apparatus 2 for obtaining a medical image necessary for creating the electronic medical record, and an electronic medical record.
  • the electronic medical record creation system S may be configured as an independent system.
  • the server 1 is an apparatus for storing the electronic medical chart created by the electronic medical chart creating apparatus 3.
  • the server 1 may store not only the electronic medical record but also internal information (medical image) of the patient acquired by the medical image diagnostic apparatus 2 described later, for example.
  • the medical image diagnostic apparatus 2 is a medical image acquisition (imaging) apparatus that images a patient and acquires internal information thereof.
  • Examples of the medical image diagnostic apparatus 2 include an X-ray CT apparatus (computed tomography) and a magnetic resonance diagnostic apparatus (MRI).
  • the electronic medical record creation device 3 is a workstation used when, for example, a doctor or the like uses a medical image to examine a patient or interprets a medical image to create an electronic medical record.
  • an electronic medical record creation apparatus 3 itself may hold an application for creating an electronic medical record, and the electronic medical record may be created using the application.
  • the application is stored in the server 1 as a thin client system, and when creating an electronic medical record, the electronic medical record creating apparatus 3 may access the server 1 and use this application. In this case, it is sufficient for the electronic medical record creation apparatus 3 to have at least processing capability for requesting and displaying information necessary for creating the electronic medical record from the server 1.
  • a server 1, a medical image diagnostic apparatus 2, and an electronic medical record creation apparatus 3 are connected to the communication network N one by one.
  • the number of servers, medical image diagnostic apparatuses, or electronic medical record creation apparatuses connected to the communication network N may be either singular or plural, and the number is arbitrary.
  • the communication network N connects the server 1, the medical image diagnostic apparatus 2, and the electronic medical record creation apparatus 3, and enables, for example, exchange of medical image information between them.
  • Examples of the communication network N include a network such as a LAN (Local Area Network) or the Internet.
  • the standard related to information exchanged through the communication network N may be any standard such as DICOM (Digital Imaging and Communication Communication in Medical).
  • FIG. 2 is a block diagram showing an internal configuration of the electronic medical record creation apparatus 3 according to the embodiment of the present invention.
  • a CPU Central Processing Unit
  • a ROM Read Only Memory
  • a RAM Random Access Memory
  • an input / output interface 3d is connected via a bus 3e.
  • An input unit 3f, a display unit 3g, a communication control unit 3h, a storage unit 3i, and a removable disk 3j are connected to the input / output interface 3d.
  • a Do display unit 10 is also connected to perform processing necessary for Do display.
  • Do description (Do display) is a display indicating that the description is the same when the prescription or order described in the previous chart is repeated or ordered repeatedly. is there.
  • the CPU 3a reads out and executes a boot program for starting up the electronic medical record creation apparatus 3 from the ROM 3b based on an input signal from the input unit 3f, and reads out various operating systems stored in the storage unit 3i.
  • the CPU 3a controls various devices based on input signals from other external devices not shown in FIG. 3 via the input unit 3f and the input / output interface 3d.
  • the CPU 3a reads the program and data stored in the RAM 3c, the storage unit 3i, and the like, loads them into the RAM 3c, and confirms the confirmation items to be confirmed when performing Do display based on the program commands read from the RAM 3c.
  • a processing device that implements a series of processes such as calculation and processing of data.
  • the input unit 3f includes an input device such as a keyboard and a dial for an operator (for example, a doctor) of the electronic medical record creation apparatus 3 to input various operations. Based on the operation of the operator, the input unit 3f creates an input signal, and the input signal is transmitted to the CPU 3a via the bus 3e.
  • a mouse, a card reader, a barcode reader, a touch panel, a microphone, a camera, and the like can be cited as a kind of the input unit 3f.
  • the display unit 3g is a monitor such as a liquid crystal display.
  • the display unit 3g receives an output signal from the CPU 3a via the bus 3e, and displays, for example, an image necessary for setting conditions for processing an image in the electronic medical record creation apparatus 3, or a processing result of the CPU 3a. To do.
  • the display unit 3g includes a printer, a projector, a speaker, and other devices that appeal to the five senses of the person who creates the electronic medical record.
  • the communication control unit 3h is a means such as a LAN card or a modem, and is a means that enables the electronic medical record creation apparatus 3 to be connected to a communication network N such as the Internet or a LAN. Data transmitted / received to / from the communication network via the communication control unit 3h is transmitted / received to / from the CPU 3a via the input / output interface 3d and the bus 3e as an input signal or an output signal.
  • the storage unit 3i is composed of a semiconductor or a magnetic disk, and stores a program and data for executing Do display, for example, executed by the CPU 3a. Further, a table and confirmation conditions relating to risk levels, which will be described later, are also stored.
  • the removable disk 3j is an optical disk or a flexible disk.
  • a signal read / written by the disk drive is transmitted / received to / from the CPU 3a via the input / output interface 3d and the bus 3e.
  • An application necessary for Do display processing is stored in the removable disk 3i via the storage unit 3i or an external storage medium.
  • the Do display unit 10 has a function for performing Do display, which is one process when a doctor who creates an electronic medical record creates an electronic medical record. Accordingly, the function of the Do display unit 10 is executed with the trigger of the process for triggering the Do display by the person who creates the electronic medical chart.
  • FIG. 3 is a block diagram showing an internal configuration of the Do display unit 10 according to the embodiment of the present invention.
  • the Do display unit 10 includes, for example, a reception unit 11 that receives a request for executing Do from a person who creates an electronic medical record, a determination unit 12, a risk level determination unit 13, a determination unit 14, and a display mode determination.
  • the unit 15 and a transmission unit 16 that transmits a confirmation screen for the confirmation item required for confirmation of the confirmation item to the display unit 3g.
  • Do display that is, the doctor who is the person who creates the electronic medical record after selecting the item to be displayed, confirms the item, and the order until Do display is made as a result. I will explain later.
  • the case where it repeats and prescribes as an example among the Do displays regarding prescription or order performed repeatedly here is demonstrated below as an example.
  • 4 and 5 are flowcharts showing a flow from Do display to confirmation of the display content in the embodiment.
  • the person who creates the electronic medical chart reads and uses the medical chart template from the server 1 when creating the electronic medical chart.
  • the medical chart relating to the patient created so far may be read out and displayed on the display unit 3g of the electronic medical chart creation apparatus 3. Since the flow of creating these electronic medical records is known, the description thereof is omitted here.
  • Do display can be performed easily in such a situation, it is possible that the check (confirmation) of the Do display content will not be achieved while improving the convenience of creating a chart. Therefore, it is important how a doctor who creates an electronic medical record confirms the content to be displayed Do.
  • Do display When Do display is performed, first, a range (item) in which Do display is performed is selected by a person who creates the electronic medical record, so the electronic medical record creation apparatus 3 grasps the selected item (ST1). . However, at this stage, it cannot be determined whether or not Do display is actually performed. This is because, in the electronic medical record creation system S, for example, clicking a button for performing Do display requires a certain intention display from the person who creates the electronic medical record in performing Do display. Therefore, the electronic medical record creation apparatus 3 determines whether or not the selected item is a target of Do display (ST2).
  • the Do display unit 10 determines whether or not Do display is performed for the selected item. For example, when the determination is performed in the Do display unit 10, the determination unit 12 determines whether the selected item is a target of Do display. In the case where the determination is made in the electronic medical chart creation apparatus 3, for example, the determination is performed in the CPU 3a. The following description will be made on the assumption that the determination unit 12 determines whether the selected item is a target of Do display.
  • the doctor himself / herself enters the treatment and prescription in the electronic medical record. Therefore, although it is understood that the item has been selected here, the process is terminated when the Do display is not performed.
  • the Do display unit 10 acquires information about the selected item from the storage unit 3i (ST3).
  • the information related to the item includes, for example, information related to the medicine shown in the item and information about whether or not the item is to be confirmed.
  • the determination unit 12 determines whether or not the selected item (the item scheduled to be displayed in Do) is a confirmation required item (ST4).
  • “required items” are important items related to treatment, prescription, etc., among the selected items, so it is necessary to confirm the person (doctor) who creates the electronic medical record in some form before displaying Do It is an item.
  • the determination unit 12 specifies an item to be confirmed and determines a risk level for the confirmation required item. (ST5). The determination unit 12 determines a risk level for each item via the risk level determination unit 13.
  • information on items such as a name and prescription amount relating to a drug is compared with information on a drug stored in advance in the storage unit 3i and a standard prescription amount of the drug. Moreover, the characteristics of the drug are also acquired from the name of the drug. Based on these pieces of information, the risk level relating to the drug to be displayed in Do and the prescription amount thereof is grasped.
  • FIG. 6 is an example of a table indicating the risk level of the items to be confirmed in the embodiment.
  • the vertical axis shows the characteristics of the medicine, and here, three levels are shown.
  • the reason why the characteristics of a drug are grasped when determining the risk level is that the risk level varies greatly depending on the characteristics.
  • the characteristics are set using, for example, characteristics defined in NDP (National Demonstration Project).
  • NDP National Demonstration Project
  • any definition may be used to define the characteristics.
  • the level of characteristics is described in three steps in the table shown in FIG. 6, but the number of levels is arbitrary.
  • the risk level table shown in FIG. 6 does not define drugs that are unlikely to cause serious results when prescribed to patients. This is because in this embodiment, it is determined that such a medicine is not included in the confirmation required items.
  • the horizontal axis shows the appropriate range for the prescription amount of the drug.
  • centering on being in the proper range three levels are shown when the prescription amount is larger than the proper range and small.
  • the risk level is set in relation to the characteristics of the drug, so the prescription The risk level is also set when the amount is within the appropriate range.
  • the risk level is determined as “A” regardless of the prescribed amount.
  • the table shown in FIG. 6 three levels “A”, “B”, and “C” are shown as risk levels, and the risk level decreases from “A” to “C”.
  • the drug characteristic is “drug with drug interaction that can cause serious consequences” and the prescribed amount is “smaller than appropriate range”
  • the risk level is determined as “C”. The This is because this combination is judged to have a lower risk level than in the case of a “drug with strong toxicity of the component itself” having a risk level of A.
  • a risk level may be determined by defining a combination of a plurality of drugs in a table.
  • the combination of drugs in addition to the interaction, the relationship between the newly prescribed drug at the time of performing the Do display operation and the previously prescribed drug that still has an effective deadline at that time is also judged.
  • medical charts are changed when different medical departments are used, it is necessary to check the combination of medicines provided in the respective medical departments.
  • the risk level determination unit 13 determines the above risk levels. Further, as described above, since the table defining the risk level is stored in the storage unit 3i in the embodiment of the present invention, the necessary risk level is accessed by accessing the storage unit 3i from the risk level determination unit 13. decide.
  • the table defining the risk level is stored in the storage unit 3i of the electronic medical record creation apparatus 3 here, but for example, a database is provided in the Do display unit 10 and may be stored in this database. good.
  • the risk level determination unit 13 confirms whether or not it is necessary to further adjust the overall risk level with respect to the risk level related to the drug of the required confirmation item once determined (ST6).
  • the “overall risk level” means that the risk level is set not only in the medical institution where the electronic medical record creation system S is constructed, but also in a wide area including the area where the medical institution is installed. It assumes the risk level that is commonly set in medical institutions. Further, for example, a risk level set in a medical corporation group including the medical institution can be considered.
  • the risk level determination unit 13 adjusts the risk level once determined. For example, when “all risk levels are raised by one level” as the “overall risk level” (YES in ST6), the risk level is adjusted according to the specification (ST7). ). For example, if the risk level once determined is “B”, the risk level is “A” by adjustment. Further, when the risk level is already “A”, for example, it is possible to cope with the risk level “AA” or leave it as “A”.
  • This “individual risk level” is based on, for example, the attributes of a doctor who creates an electronic medical record. That is, about the doctor who produces an electronic medical record, for example, years of experience, age, etc. are each. Therefore, for example, when the doctor has little experience such as less than 3 years of experience or is elderly, the risk level is increased so as to positively confirm the Do display.
  • the risk level As to whether or not the risk level needs to be adjusted based on this “individual risk level”, for example, a doctor input when creating an electronic medical record can be uniquely specified. Judgment based on. The determination is performed by, for example, the determination unit 12 and the result is transmitted to the risk level determination unit 13. The risk level determination unit 13 adjusts individual risk levels based on the result (YES in ST8, ST9) or does not adjust (NO in ST8).
  • the risk level when it is necessary to adjust the individual risk level, it is possible to set the risk level to be increased by one. It is also possible to finely set and adjust the fluctuation of the risk level according to the attributes of the doctor. In some cases, the risk level may be lowered.
  • either process may be performed first, or both processes may be performed in parallel.
  • the determination unit 14 determines the confirmation conditions (ST10 in FIG. 5).
  • the “confirmation condition” is a condition for confirmation performed by a doctor who is a person who creates an electronic medical record based on a risk level determined for each item to be confirmed.
  • FIG. 7 is an example of a table showing risk level confirmation conditions in the embodiment.
  • “confirmation conditions” associated with “risk level” are defined.
  • the confirmation condition is “confirmation by operation”. That is, when the risk level of the confirmation required item is A, the doctor who creates the electronic medical record confirms whether or not the item to be displayed in the Do display is appropriate when performing the Do display. It is necessary to perform processing.
  • the Do display unit 10 a screen display that allows the doctor to perform an operation for confirmation in the display mode determination unit 15 is generated and displayed on the display unit 3 g.
  • the confirmation condition is “display is 3 seconds or more”. This means that the display for confirming the display on the display unit 3g is displayed for “3 seconds or more”.
  • the display time can be arbitrarily set.
  • the confirmation condition is “confirmation should be performed once every two times”.
  • the number of times here is the number of times of creating an electronic medical record. Therefore, “confirmation at a rate of once every two times” will be described by taking the case of newly creating an electronic medical record as an example.
  • confirmation items of risk level C at the time of the previous electronic medical chart creation In the case of confirmation, regarding the contents previously displayed as “Do” last time, it is necessary to confirm the necessary confirmation items again this time. On the other hand, if confirmation was made at the time of the previous electronic medical record creation, it is not necessary to confirm the current electronic medical record creation.
  • the information may be stored in the storage unit 3 i of the electronic medical record creation apparatus 3.
  • the confirmation condition may be a condition that a confirmation is always performed when a certain period of time has passed, or a plurality of confirmation conditions may be used in appropriate combination.
  • FIG. 8 is an explanatory diagram for explaining an example of the confirmation condition in the embodiment.
  • FIG. 8 shows two upper and lower number lines, the upper number line ⁇ indicates the “period in which confirmation is required for each drug”, and the lower number line ⁇ indicates “Do display”.
  • Period interval at which the patient is examined
  • the “period in which confirmation is required for each medicine” for example, it is assumed that confirmation is required every two weeks. Therefore, in the number line ⁇ , one scale represents one week, and a triangular mark is added every two weeks that need to be confirmed.
  • the interval between patient examinations, that is, the period during which Do display is performed is “5 days”. Therefore, in the number line ⁇ , 5 days of the period in which Do is displayed is represented as one scale.
  • the beginning of the number line indicates the time point when the patient is examined.
  • the patient is first prescribed a medicine for the patient, and the doctor who creates the electronic medical record newly enters the prescription for the medicine in the electronic medical chart. Accordingly, Do is displayed at the subsequent examination.
  • the “period for which confirmation is required for each drug” is set every two weeks. Therefore, there are two examinations (opportunities for Do display) during this period. However, at the time of these two examinations, since the two weeks of “the period for which confirmation is required for each drug” has not elapsed since the prescription of the drug was first prescribed, the degree of confirmation should be reduced. It is possible. On the other hand, when the third examination (the fourth examination in total) is performed from the first examination, two weeks of “a period for which confirmation is required for each drug” will elapse. The person who creates the medical chart needs sufficient confirmation. Thus, by using a combination of a plurality of confirmation conditions as appropriate, a person who creates an electronic medical record can perform more necessary and appropriate confirmation.
  • the “concentration of confirmation” for the confirmation target of the person who creates the electronic medical record can be made appropriate. . This leads to a more reliable confirmation because it makes a clear confirmation for the person who creates the electronic medical record.
  • the display mode is determined by the display mode determination unit 15 for the items to be confirmed, and the doctor is notified of the confirmation (ST12).
  • the notification in addition to a method of displaying a display for confirmation on the display unit 3g, a voice notification that the doctor reads the confirmation items as will be described later, or that the electronic medical record creation device 3 reads the confirmation items. This method is also conceivable. Therefore, the display mode determination unit 15 also supports voice notification. In FIG. 5, the flow is described on the assumption that a screen for performing a confirmation process by a doctor is displayed on the display unit 3g.
  • FIG. 9 is a screen example showing an example of the display screen in the embodiment.
  • the display mode determination unit 15 determines a display (notification) mode for confirming whether or not to perform Do display according to the confirmation condition, based on the confirmation condition determined by the determination unit 14.
  • an area for displaying information on the patient is provided in the upper stage.
  • an area for inputting a situation obtained by the examination is provided on the left side
  • an area for displaying a prescription drug or the like is provided on the right side.
  • Do is displayed about a medicine based on a past medical record.
  • Two types of drugs displayed in Do are displayed, and the screen for confirming whether or not to display Do for the doctor who is the creator of the electronic chart for “Alkeran” is the screen for creating the electronic chart. It is displayed above.
  • “alkeran”, which is an anticancer agent, is prescribed again, that is, whether or not it is described in the medical chart by Do display.
  • Whether or not the confirmation process by the doctor has been performed is determined by the determination unit 12 (ST13). For example, it is whether or not the confirmation button on the screen as shown in FIG. 9 has been clicked by the doctor.
  • confirmation by the doctor is not made (NO in ST13)
  • NO in ST14 it is confirmed whether further confirmation processing has been performed (NO in ST14).
  • whether or not to provide a standby time for determining whether or not the confirmation process has been performed can be arbitrarily set. Similarly, the standby time can be arbitrarily set.
  • the confirmation process is not performed within the predetermined waiting time (YES in ST14), it means that the doctor has not confirmed the necessary confirmation item, and the process for displaying Do itself is stopped (ST15). ). This is because the Do display without confirmation can lead to prescribing the medicine without the approval of the doctor. Specifically, processing is performed so that Do display cannot be performed by a method in which the confirmation process becomes invalid or, for example, a range selected for Do display is canceled.
  • step ST13 When the confirmation process by the doctor is performed (YES in ST13), it is confirmed whether or not there is a next confirmation required item (ST16). If the determination unit 12 determines that there is a next item to be confirmed (YES in ST16), the process returns to step ST12 and the confirmation process by the doctor is performed.
  • a doctor's confirmation process is requested for each confirmation item required, for example, depending on conditions such as the number of confirmation items, it may be considered that the confirmation items are collectively sent to the confirmation process.
  • the display mode determination unit 15 checks the size of the displayable area in the display unit 3g and determines the display mode based on the area. If the display area is large and it is determined that all the Do display targets can be displayed, including the confirmation required items, all the targets are displayed. On the other hand, if it is determined that it is difficult to display all Do display targets because the display area is small, only the confirmation items that are necessary are extracted and only the confirmation items that are necessary are displayed. Of course, it is possible to adopt a mode in which only items with a high risk level are displayed among the items requiring confirmation according to the size of the display area.
  • the display screen is automatically scrolled, and when the confirmation item is displayed, the scrolling is temporarily stopped.
  • a display method of displaying a confirmation screen for the doctor may be adopted as long as it requires a doctor's attention and prompts confirmation, such as displaying a list of items requiring confirmation separately, or displaying only the items requiring confirmation by changing the font or display color. May be.
  • FIG. 10 and FIG. 11 are other screen examples showing an example of the display screen in the embodiment. 10 and 11 show a case where the confirmation process by the doctor is performed on the screen of the portable information terminal (electronic medical record creation apparatus 3A).
  • the past treatment and prescription are entered in the areas indicated by A and B, while the current treatment and prescription are entered in the areas indicated by C and D. It will be. Further, below the middle part of the screen example Y, two tabs each having “treatment Do” and two tabs having “prescription Do” are shown. By operating this tab, the contents described in the areas indicated by A and B can be displayed Do in the areas indicated by C and D.
  • FIG. 11 shows a confirmation screen for performing Do display.
  • it is a screen related to the confirmation process regarding the prescription of the medicine (“prescription Do confirmation” is at the top of the screen).
  • the screen example Z two types of drugs are displayed, and a confirmation screen for displaying Do for the drug “bonalon” is displayed.
  • a confirmation screen for displaying Do for the drug “bonalon” is displayed.
  • the confirmation process is performed by tapping the “Do execution” part.
  • the electronic medical record creation apparatus 3A may grasp the voice read out by the doctor, perform the confirmation process, and then perform “Do execution”.
  • the risk level and the confirmation conditions corresponding to the risk level are determined depending on whether the Do display is performed to confirm various contents in advance or the confirmation process is performed so that the Do display is actually performed. It is also possible to adopt a method of changing both. In this case, the confirmation step for the person who creates the electronic medical record increases, so a method of lowering the risk level at the initial stage is also conceivable.
  • the prescription of the drug is taken as an example.
  • the present invention is not limited to the prescription (order) of the drug, and can also be applied to the case where Do display is performed for various medical orders such as an injection order, a treatment order, or a test order.
  • the “injection order” means an order for performing a treatment of performing an injection or an order of a medicine to be put into the injection.
  • the “treatment order” is an order of treatment performed after a medical examination (an electronic medical record is created).
  • the “examination order” indicates the order of the examination for the patient.
  • the present invention is used when Do display is performed in creating a record using an electronic medical record creation device and an electronic medical record creation system.

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Abstract

La présente invention comporte les éléments suivants : une unité de stockage (3i) qui stocke le contenu d'éléments d'entrée qui sera dirigé vers une ordonnance à répétition ou une commande ; une unité d'affichage (3g) qui affiche le contenu des éléments d'entrée ; une unité d'entrée (3f) pour entrer s'il faut ou non passer l'ordonnance à répétition ou la commande ; une unité de détermination (14) qui détermine des conditions de confirmation sur la base du contenu de chacun des éléments d'entrée ; et une unité de détermination de mode d'affichage (15) qui, conformément aux conditions de confirmation, détermine un mode d'affichage pour un affichage sur écran qui confirme s'il faut prescrire de manière répétée ou commander des éléments qui ont besoin d'être confirmés, et qui donne l'instruction à l'unité d'affichage d'afficher le mode d'affichage déterminé pour chaque élément qui a besoin d'être confirmé.
PCT/JP2013/071874 2012-08-13 2013-08-13 Dispositif de création de dossier médical électronique et système de création de dossier médical électronique WO2014027661A1 (fr)

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JP2012-179304 2012-08-13
JP2012179304 2012-08-13
JP2013-168018 2013-08-13
JP2013168018A JP6257953B2 (ja) 2012-08-13 2013-08-13 電子カルテ作成装置及び電子カルテ作成システム

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Citations (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
JPH10508131A (ja) * 1994-10-28 1998-08-04 アドバンスド・ヘルス・メド・イー・システムズ コーポレーション 処方箋管理システム
JP2000200316A (ja) * 1998-12-29 2000-07-18 Sanyo Electric Co Ltd 電子カルテ装置
JP2002334153A (ja) * 2001-05-08 2002-11-22 Csi Co Ltd 電子カルテシステム
JP2003022412A (ja) * 2001-07-10 2003-01-24 Hitachi Systems & Services Ltd データ入力装置およびその方法
JP2007018460A (ja) * 2005-07-11 2007-01-25 Infocom Corp 診療支援システム
JP2007037823A (ja) * 2005-08-04 2007-02-15 Matsushita Electric Ind Co Ltd 調剤支援システム
JP2010218439A (ja) * 2009-03-18 2010-09-30 Fujitsu Ltd 処方オーダ発行プログラム、処方オーダ発行装置及び方法

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* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US20100161355A1 (en) * 2008-11-20 2010-06-24 Peter Stangel Single field entry electronic clinical chart note entry system
US20120109686A1 (en) * 2010-11-01 2012-05-03 Oxbow Intellectual Property, LLC Electronic medical record system and method

Patent Citations (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
JPH10508131A (ja) * 1994-10-28 1998-08-04 アドバンスド・ヘルス・メド・イー・システムズ コーポレーション 処方箋管理システム
JP2000200316A (ja) * 1998-12-29 2000-07-18 Sanyo Electric Co Ltd 電子カルテ装置
JP2002334153A (ja) * 2001-05-08 2002-11-22 Csi Co Ltd 電子カルテシステム
JP2003022412A (ja) * 2001-07-10 2003-01-24 Hitachi Systems & Services Ltd データ入力装置およびその方法
JP2007018460A (ja) * 2005-07-11 2007-01-25 Infocom Corp 診療支援システム
JP2007037823A (ja) * 2005-08-04 2007-02-15 Matsushita Electric Ind Co Ltd 調剤支援システム
JP2010218439A (ja) * 2009-03-18 2010-09-30 Fujitsu Ltd 処方オーダ発行プログラム、処方オーダ発行装置及び方法

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