[1]徐帆舒婷.高级别医院电子病历系统数据质量评价及对策研究[J].中国卫生质量管理,2022,29(12):006-9.[doi:10.13912/j.cnki.chqm.2022.29.12.02 ]
　XU Fan,SHU Ting.Data Quality Evaluation and Countermeasures of Electronic Medical Record System in High-Level Hospital[J].Chinese Health Quality Management,2022,29(12):006-9.[doi:10.13912/j.cnki.chqm.2022.29.12.02 ]
点击复制

高级别医院电子病历系统数据质量评价及对策研究
分享到：

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第29卷
期数:
2022年12期
页码:
006-9
栏目:
特别关注
出版日期:
2022-12-28

文章信息/Info

Title:
Data Quality Evaluation and Countermeasures of Electronic Medical Record System in High-Level Hospital
作者:
徐帆舒婷
国家卫生健康委医院管理研究所
Author(s):
XU Fan; SHU Ting
National Institution of Hospital Administration,National Health Commission
关键词:
电子病历系统; 应用水平分级评价; 数据质量; 完整性; 一致性; 整合性; 及时性
Keywords:
Electronic Medical Record;  Hierarchical Evaluation of Application Level;  Data Quality;  Integrity;  Consistency;  Integrated;  Timeliness
分类号:
R197.3
DOI:
10.13912/j.cnki.chqm.2022.29.12.02
文献标志码:
A
摘要:
目的 了解高级别医院电子病历系统数据质量情况，分析问题并提出针对性改进建议，以提高医院数据挖掘和再利用能力。方法收集2018年-2020年的电子病历评级为高级别（5级及以上）的31家医院数据质量实证材料，梳理并总结医院数据质量状况。结果31家高级别医院分布在11个省（自治区、直辖市）。电子病历系统数据质量的完整性、一致性、整合性、及时性等方面均存在问题：完整性方面存在数据记录缺失（90.32%）、系统应用不规范（54.84%）、数据字符数不符合要求（12.90%）等问题；一致性方面存在数据字典缺失（83.87%）、数据字典管理不规范（74.19%）等问题；整合性方面存在关联性数据缺失（87.10%）、业务系统孤岛建设（48.39%）等问题；及时性方面存在时间节点缺失（22.58%）、时间逻辑不合理（16.13%）等问题。结论数据质量意识薄弱以及医院信息系统建设缺乏连通性是主要原因。应提高医院管理者的数据质量意识，定期对数据录入人员进行培训，连通医院各系统以保证关联数据完整性，并建立数据监测系统，以达到数据可用、好用、够用的目的。
Abstract:
ObjectiveTo investigate the data quality of electronic medical record (EMR) in high-level hospitals, analyze the problems and put forward targeted improvement suggestions, so as to improve the ability of hospital data mining and reuse.MethodsThe empirical data quality materials of 31 hospitals EMR with high rating (level 5 and above) from 2018 to 2020 were collected, and data quality status were sorted out and summarized.ResultsThere were 31 high-level hospitals in 11 provinces (autonomous regions and municipalities). There were problems in the integrity, consistency, integration and timeliness of the data quality of the EMR . In the integrity, there were problems such as missing data records (90.32%), non-standard system application (54.84%), and non-conforming data word count (12.90%). In terms of consistency, there were problems such as missing data dictionary (83.87%) and non-standard data dictionary management (74.19%). In terms of integration, there were problems such as missing correlation data (87.10%) and island construction of business system (48.39%). In terms of timeliness, there were problems such as missing time nodes (22.58%) and unreasonable time logic (16.13%).Conclusion Weak data quality awareness and lack of connectivity in hospital information system construction were the main reasons. It was necessary to improve the awareness of data quality of hospital managers, train data entry personnel regularly, connect all hospital systems to ensure the integrity of related data, and establish a data monitoring system to achieve the purpose of data availability, ease of use and adequacy.

参考文献/References:

［1］国务院办公厅.关于促进和规范健康医疗大数据应用发展的指导意见：国办发〔2016〕47号［EB/OL］.（2016-06-21）［2022-04-14］.http://www.gov.cn/zhengce/content/2016-06/24/content_5085091.htm. ［2］国家卫生计生委.关于印发“十三五”全国人口健康信息化发展规划的通知：国卫规划发〔2017〕6号［EB/OL］.（2017-02-21）［2022-04-14］.http://www.nhc.gov.cn/guihuaxxs/s10741/201702/ef9ba6fbe2ef 46a49c333de32275074f.shtml. ［3］刘 丁，陈 萍，方清永.重庆地区67所医院感染监测基本数据及质量控制指标调查研究［J］.重庆医学，2016，45（36）：5145-5147，5178. ［4］徐 乐，陈 飞，苏 皖.大数据在医疗质量管理中的应用研究［J］.中国卫生质量管理，2020，27（2）：78-80，83. ［5］周 彬，赵雪飞，刘 炜，等.医院数据质量改进措施研究［J］.医学与社会，2020，33（12）：32-36. ［6］熊昊祾，路 伟，许 昌，等.病案首页数据质控的实践［J］.中国卫生质量管理，2019，26（4）：5-8. ［7］丁光霞，陈珍初，马丽娟.某省三级公立医院住院病案首页数据质量分析［J］.中国病案，2020，21（4）：9-13. ［8］张 晨，计 虹，金昌晓.医疗数据质量分析与治理对策探讨［J］.中华医院管理杂志，2020，36（9）：747-750. ［9］董冲亚，姚 晨，高 嵩，等.加强医院临床研究源数据管理提高我国临床研究数据质量［J］.中国循证医学杂志，2019，19（11）：1255-1261. ［10］张焕荣，张海燕，于建军，等.应用PDCA循环模式提高医院电子病历首页的手术分级数据质量［J］.中国卫生统计，2017，34（6）：956-958.

相似文献/References:

[1]舒婷赵韡刘海一.2020年我国医院电子病历系统应用水平分析[J].中国卫生质量管理,2022,29(01):008.[doi:10.13912/j.cnki.chqm.2022.29.1.03 ]
　SHU Ting,ZHAO Hua,LIU Haiyi.Analysis on the Application Level of Electronic Medical Record System in Chinese Hospitals in 2020[J].Chinese Health Quality Management,2022,29(12):008.[doi:10.13912/j.cnki.chqm.2022.29.1.03 ]
[2]霍添琪徐帆李红霞张蕾.基于SE-SBM模型的贵州省三级医院电子病历系统建设效率评价[J].中国卫生质量管理,2022,29(01):016.[doi:10.13912/j.cnki.chqm.2022.29.1.05 ]
　HUO Tianqi,XU Fan,LI Hongxia.Efficiency Evaluation of Electronic Medical Record System Construction in Tertiary Hospitals in Guizhou Province Based on SE-SBM Model[J].Chinese Health Quality Management,2022,29(12):016.[doi:10.13912/j.cnki.chqm.2022.29.1.05 ]
[3]徐帆张蕾李红霞舒婷.基于DEA－Malmquist 指数的浙江省三级公立医院电子病历系统建设效率评价[J].中国卫生质量管理,2022,29(01):021.[doi:10.13912/j.cnki.chqm.2022.29.1.06 ]
　XU Fan,ZHANG Lei,LI Hongxia.Efficiency Evaluation of Electronic Medical Record System Construction in Tertiary Public Hospitals of Zhejiang Province Based on DEA-Malmquist Index[J].Chinese Health Quality Management,2022,29(12):021.[doi:10.13912/j.cnki.chqm.2022.29.1.06 ]

更新日期/Last Update: 2022-12-28