A brief analysis of the connotation and development trend of medical information construction

Digital healthcare refers to the digitization, networking and informatization of medical services. It refers to the collection, storage, processing, extraction and data exchange of patient and management information for various departments of the hospital through computer science, modern network communication technology and database technology, and meets the functional requirements of all authorized users. Establishing a complete hospital information system is a requirement of the government or health authorities and relevant departments such as price and insurance for hospitals, a requirement of the increasingly competitive medical industry for hospitals, and a demand of patients for hospitals.

Hospital Information System (HIS)

Hospital information system (HIS) is a comprehensive system that uses computer technology, network technology, and database technology to modernize and digitize hospital management, and provides reliable reference data and decision support for leaders and departments at all levels. HIS plays an important role in hospital management, clinical medicine, nursing, finance, logistics, medical insurance and other multi-level and multi-departmental areas, and can promote major changes in hospital management models. Hospital information is characterized by large amounts of information, rapid growth and complexity, and the need to share and exchange data between departments (including outside the hospital, such as medical insurance).

The application of hospital management information system in my country began in the late 1980s. It has generally gone through three development stages: the application of computers to charging and pricing; the application of computer network technology to various aspects of hospital management; and digitalization. The whole process is consistent with the pace of my country's overall information construction. After 2000, with the development of communication technology and optical fiber technology, as well as the improvement of storage capacity, the transmission and storage of image information has become more and more convenient, which has provided an opportunity for the formation of electronic medical records in the true sense. At the same time, the development of fingerprint recognition and digital signature technology also provides a guarantee for the legitimacy of medical record storage and transmission. During this stage, PACS (medical image storage and transmission system) and I.IS (clinical trial information system) began to be embedded in HIS, making it possible to comprehensively improve the functions of HIS.

The premise of comprehensively improving the hospital management information system is to set up a doctor information system workstation, so that HIS data collection can be realized in the process of doctor-patient communication, so as to comprehensively improve the medical process, meet the various needs of medical insurance and medical system reform, and realize cross-hospital and cross-regional medical treatment for patients. On another level, it will also realize paperless hospital office and filmless diagnosis. However, the current digitalization of medical care in my country is still facing problems such as insufficient investment, weak information infrastructure, lack of unified standards and advanced management concepts, and the medical management information system needs further development.

Electronic Medical Records

Electronic Medical Record (EMR) refers to the electronic, networked and informationized management of medical records. It is the inevitable product of the application and development of information technology and network technology in the medical field, and is the inevitable trend of modern management of hospital medical records. In developed countries, such as the United States and Japan, many universities, research institutions and manufacturers have invested in research in this field. At present, the goal and significance of electronic medical records are not to replace paper medical records. Its development goal is mainly to strengthen the information flow between doctors and patients, improve the functional service of health information from a deeper level, and thus improve the quality of medical care and the benefits of health information.

Medical records are a person's health history. They contain a variety of information such as home page information, doctor's orders, medical records, various examination and test results, operation records, nursing conditions, etc., and are an important basis for doctors to make scientific diagnoses of patients. Scientific management of medical records is very important, and the emergence and development of electronic medical records has made it possible. Electronic medical records have advantages that traditional paper cases cannot match. First, electronic medical records include all the functions of traditional medical records, but patients do not need to bring medical records when seeing a doctor. They only need to provide their own name, medical record number or other information. Doctors can get all the patient's information (including diagnosis of various departments, medication history, various medical data, special examination reports, etc.) through computers, which shortens the time for consulting medical records. Second, electronic medical records in computers will not have the problems of loss, defect, mold, and water immersion of traditional medical records. They are highly reliable and can be preserved permanently. When patients need their own medical records, computers can output a complete medical record for patients. Electronic medical records can also selectively print part of a patient's information or all medical record information. Third, the storage capacity of electronic medical records is large. A CD can store 325,000 Chinese characters or about 50,000 A4 sheets of paper, which is equivalent to the capacity of 500 ordinary patient records. It reduces the waste of human and material resources and greatly reduces management costs. In short, electronic management of medical records and the formulation of unified medical record templates through computers make medical record management more standardized, greatly improving the convenience and efficiency of patients' medical treatment, and also greatly improving the service efficiency and quality of medical staff.

However, computers cannot completely replace people. For electronic medical records to really play a role, it is necessary to establish standardized electronic medical record templates, improve the medical record data collection system, doctor workstation system, electronic medical record quality monitoring system, storage system and backup plan, etc. Electronic medical records in my country have developed rapidly, but they need further development in terms of technology, application, and law. The "Regulations on Medical Record Management of Medical Institutions" issued by the Ministry of Health in 2002 did not clarify the legal effect of electronic medical records, so electronic medical records still expect relevant national laws and regulations to further clarify their legal effect. Moreover, the future electronic medical records will collect all health-related information throughout a person's life. In terms of development trends, electronic medical records not only belong to hospitals and are used by doctors, but also have close ties with scientific research units, government management departments, insurance institutions, etc., to present data materials to them and provide decision-making references in order to better serve the society.

City Citizen Health Information Card

The urban citizen health information card refers to a health service system software established by the urban health service system specifically for citizens, which is centered on the residents' health records and covers many aspects of the residents' basic health records, such as preventive immunization, medical records, health examination records, family planning, etc. It realizes the "multi-file integration" management of citizens' health information files, so as to provide citizens with better prevention-oriented health services.

The construction of community health service information system should emphasize "people-oriented", based on the construction of regional central database in the future, based on information sharing between different hospitals in the region, and provide residents with round-the-clock health record information services. After completing the regional resident health record database, it will be provided to different age groups, especially health information cards, and each hospital will realize health card information sharing.

Telemedicine

Telemedicine originated from the global information superhighway craze set off by the NII plan in 1993. An American scholar defined it as the application of communication technology, interactive transmission of information, and the development of remote medical services [1] (Nagy K. Telemedicine creeping into use, despite obstacles [J]. J Natl Cancer Inst, 1994, 86 (21): 1576-1578). In 1995, Dr. Lee of the University of Hong Kong diagnosed Yang Xiaoxia with "necrotizing meningitis caused by mixed infection" through the global information superhighway, and the Internet diagnosed Zhu Ling, a student at Tsinghua University, with "thallium poisoning". This kind of medical service is actually the implementation of telemedicine. Telemedicine is mainly used for remote communication for clinical purposes. Most telemedicine is used in remote areas or areas with a small population because the medical level in these areas is relatively backward. The fundamental purpose of telemedicine is for areas with higher medical levels to provide medical assistance to areas with relatively backward medical levels. This is also the premise and foundation for the existence and development of telemedicine.

Telemedicine has been gaining more and more attention since it first appeared on the medical stage. With the maturity of satellite communications and the improvement of computer technology, telemedicine has developed rapidly. Initially, telemedicine had a very low ability to process data and was limited to transmitting still images and some text files. With the development of communication technology, frozen section images of surgical patients can be transmitted over long distances to diagnose diseases. Now, telemedicine equipment can not only transmit data in a timely manner, but also transmit television images. The application of multimedia makes telemedicine more vivid and vivid, and the real-time, interactive, professional guidance and automation of telemedicine have been greatly improved.

However, telemedicine is not widely used in China at present. On the one hand, it is because my country still lacks a complete operating mechanism, the equipment is expensive, and many medical workers do not pay much attention to this technology; on the other hand, the charging problem has not been solved. This is also the most important reason. Therefore, to promote the rapid development of telemedicine, it is necessary to establish an operating mechanism for telemedicine, clarify responsibilities, and improve management. At the same time, it is necessary to pay attention to economic benefits and clarify charging standards so that teleconsultation can bring economic benefits to the units that organize the consultation to promote the in-depth development of telemedicine.

Urban Medical Imaging Data Center

At present, a major trend in the development of urban hospital management information systems is the widespread establishment of medical image transmission systems (PACS).

The medical image transmission system (PACS) is an important part of the hospital clinical information system and is the product of the development and application of information technology in the hospital information management system. However, the medical image transmission system (PACS) must combine medical records, medical records, relevant examination reports and relevant treatment records to conduct a comprehensive ICI analysis of medical images in order to make a clear diagnosis and formulate an appropriate treatment plan. On the other hand, the use of the (DICOM3.0) standard has the advantages of universality and interface standardization. It is necessary to formulate specifications for the combination of medical image information and text information in medical records according to clinical needs, and determine the accuracy and quality of medical image digitization, and the way and method of acquisition and re-display.

The purpose of establishing a city medical imaging data center is to improve the utilization rate of hospital resources, speed up the diagnosis of patients, and formulate treatment plans in a timely manner. It completely solves the exclusivity of traditional medical imaging resources, allowing many users to read the same medical image at the same time, share these medical imaging resources, and greatly reduce the cost of film management, reduce the storage space required for film preservation and the manpower required for film management, and realize permanent lossless archiving of medical image information. It makes important preparations for the establishment of the "filmless radiology" system and provides convenient scientific research and learning conditions for medical personnel and researchers engaged in medical imaging.