摘要
目的:通过对医院电子病历的多维数据分析,探讨电子病历质量控制体系的应用价值。方法:选取医院电子病历数据,将2014年10月至2016年9月的157 814条数据纳入对照组,2016年10月至2018年9月的242 942条数据纳入观察组。对照组为电子病历系统的升级建设阶段,采用人工审核、多重线性回归及临床调研等方法进行电子病历质量控制管理;观察组为医院电子病历系统的应用完善阶段,采用德尔菲法制定电子病历质量控制管理体系;对比分析两组电子病历甲级例数、临床决策失误例数、信息安全风险例数、职业能力考核成绩和临床使用满意度5项指标的差异性。结果:观察组电子病历甲级率高于对照组,而临床决策失误率和安全风险率低于对照组,其差异有统计学意义(x^2=268.57,x^2=1207.70,x^2=13.04;P<0.05);观察组的医务人员考核成绩和临床满意度好于对照组,其差异有统计学意义(U=98.00,U=116.50;P<0.05)。结论:基于医院电子病历的多维数据分析质量控制管理体系可有效提高电子病历的规范性和临床决策的科学性,降低电子病历使用中的安全风险。
Objective:To explore the application value of quality control system of electronic medical record(EMR)through analyzing multidimensional data of EMR in hospital.Methods:The data of EMR of hospital were selected.And the 157814 data from October 2014 to September 2016 were included in control group and the 242942 data from October 2016 to September 2018 were included in observation group.The control group was in the upgrade and construction stage of EMR system,and it adopted manual review,multiple linear regression,clinical investigation and other methods to implement quality control management for EMR.The observation group was in the application and improvement stage of EMR system,and it adopted Delphi method to formulate the management system of quality control of EMR.The differences of five indicators,included the number of EMR cases with Grade A,the number of the mistakes of clinical decision-making,the risk number of information security,the results of examination of vocational ability and satisfaction of clinical application,between the two groups were compared and analyzed.Results:The rate of EMR cases with Grade A of observation group was significantly higher than that of control group,while the error rate of clinical decision-making and the risk rate of the security of the former were significantly lower than those of the latter(x^2=268.57,x^2=1207.70,x^2=13.040,P<0.05).Besides,the results of examination and clinical satisfaction of medical staffs of observation group were significantly better than those of control group(U=98.00,U=116.50,P<0.05).Conclusion:The system of quality control management,which is established on the basis of multidimensional data analysis of hospital EMR,can effectively improve the standard of EMR and the scientificity of clinical decision-making,and can reduce the risk of the security in using EMR.
作者
吴风浪
周铭
耿鹏
WU Feng-lang;ZHOU Ming;GENG Peng(Department of Network Information,The First Affiliated Hospital of Medical College of Xi'an Jiaotong University,Xi'an 710061,China)
出处
《中国医学装备》
2019年第9期132-135,共4页
China Medical Equipment
关键词
电子病历
多维数据
多重线性回归
临床路径
信息安全
Electronic medical record
Multidimensional data
Multiple linear regression
Clinical pathway
Information security
