为解决我国智慧医院发展中医疗健康数据标准不统一、医院信息部门和临床交流不充分、数据质量及应用水平待提升、信息安全防护能力不足等问题,本文提出一种基于标准化医疗术语的全结构化电子病历并进行应用和推广,完成完整的结构化病历219108份,创建标准化医疗术语131600条,病历书写病种模板69019个,形成6亿余条标准化医疗数据。实现了规范诊疗行为,提高医疗质量,统一数据归纳,服务科研管理,共享医疗信息,助推分级诊疗,推进人工智能,衍生健康产品。
<<Wisdom to solve our country hospital health data standard is not unified,developing hospital information department and clinical inadequate communication,to improve data quality and application level,such problems as insufficient information safety protection ability,this paper proposes a whole structured based on medical terminology standardization and application and popularization of electronic medical records to complete the full structured medical record,219108,131600 standardized medical terms and 69019 templates for writing medical records have been created,forming more than 600 million standardized medical data. It has achieved:standardizing diagnosis and treatment behavior,improving medical quality,unifying data induction,serving scientific research management,sharing medical information,boosting graded diagnosis and treatment,promoting artificial intelligence,and derivating health products.
<<Keywords: | Artificial IntelligenceFully Structured Electronic Medical RecordsStandardized Medical Terms |