Resident Electronic Medical Record Opens

The reporter learned from the second plenary session of the First Medical Committee held yesterday (16th) that the city will launch an electronic medical record pilot in 9 hospitals on January 1, 2011, and complete the electronic medical records and residents for all residents within five years. Health file construction. In the future, the phenomenon of patients seeking treatment, waiting in line, and waiting with a pile of inspection data will become history.

Nine hospitals took the lead in piloting the city's first pilot electronic medical records in nine hospitals. The so-called electronic medical record refers to the doctor's basic information in the computer system to record the patient's information, the situation of the surgery, the results of the test, the status of medication, etc., to generate digital information, able to store, manage, transfer and reproduce.

Compared with the current paper medical records, electronic medical records are more easily retrieved. Whether the patient is in the outpatient clinic or in the ward, as long as the patient's name or medical record number is entered, the patient's medical record and medical history can be retrieved in less than one minute.

The city’s electronic medical records work to be launched on January 1 next year will be led by the Municipal Health Bureau and the Municipal Human Resources and Social Security Bureau. The Municipal Economic and Information Committee, the Municipal Bureau of Finance, and the Municipal Development and Reform Commission will jointly participate in the work.

"Implicit Coding Code" to collect non-medical health information to achieve in the community hospitals and other major hospitals can call for the patient's medical records, it is not enough to simply establish an electronic medical record, but also need to unite the city's patient information into a database. This requires that patient information in each hospital be recorded and transmitted using the same standard. At present, all hospitals have visiting cards. The card stores information about patient visits. However, the data in these visit cards cannot be communicated due to different standards.

In January 2011, the city will start the collection of emergency medical information. It plans to issue “Medical Link Codes” at 50 tertiary hospitals and 11 central hospitals in remote suburban counties. The "Imperative Coding Code" is a series of barcodes that hospitals place on the patient's visit card. Through the "medical linkage code" on the visit card, the basic information, diagnosis and changes of each patient in Beijing will be displayed on the public health information platform of the health department, real-time collection, real-time monitoring and real-time analysis.

The "IDC code" is mainly used to collect information of non-medical insurance treatment personnel, and the information of the medical insurance group is collected through the medical insurance card.

The hospital information system urgently needs to be transformed. “Beijing hospitals have established their own information systems for 20 years in succession. The developers of information systems for each hospital are different. The system standards are not uniform, and the patient information of each hospital cannot be connected.” said the person in charge of the Municipal Health Bureau. .

To transform the system requires input from all parties, the average cost of each hospital's information system transformation, network transformation, and hardware equipment procurement is about 5.5 million yuan, and this fund needs to be solved by all departments.

The health department also mentioned that many patients currently attend military hospitals stationed in the Beijing Armed Police Hospital. The information of these patients needs to be provided in a timely manner by the Armed Police Hospital in Beijing.

The community may make appointments for referral next year. In addition, an integrated management information system covering the municipal community health management agencies, district and county community health service management agencies, more than 300 community health service centers, and more than 2,000 community health service stations was launched in 2008. At present, there are 8 districts and counties, 30 community health service centers and 101 community health service stations in Chaoyang, Shunyi, Xicheng, Haidian and Shijingshan.

With this network system, the community can update residents' health records in real time and make two-way referral appointments with major hospitals at any time, facilitating the transfer of patients from the community to the major hospitals. At the same time with the medical insurance docking, can be real reimbursement.

As of November 19, the system has established 2.878 million residents' health records. Appointment referral from the community to the hospital was achieved.

This set of community information system plans to be fully applied in the city by the end of 2011. (Reporter Fang Fang)

Doubt 1 How to ensure that electronic medical record information will not be disclosed?

The health department stated that it will continue to increase the safety factor by strengthening cyber security construction, and strictly stipulates that medical personnel are not allowed to disclose personal information of residents in the electronic medical record and private information concerning the health of residents.

2 When a medical dispute occurs, is the electronic medical record easier to be changed?

The Ministry of Health recently released the "Basic Regulations for Electronic Medical Records (Trial)", and the electronic medical record system can set access rights. Different levels of doctors can see different patient information. At the same time, in order to prevent tampering with the information, the system will perform identification, save the traces of previous revisions, mark modification time, and modify the information.

3 What are the sources of life cycle health record information for residents?

The information of residents' health records in this Municipality comes from outpatient emergencies, discharge medical records, community health records, physical examination information, mental illness reporting systems, child and woman health care, planned immunization, blood management information, and disease prevention and control systems.