【作者】 张琪；

【导师】 李治柱； 徐开明； 饶若楠；

【作者基本信息】 上海交通大学 ， 软件工程， 2012， 硕士

【摘要】 电子病历系统（EMR, Electronic Medical Record），是HIS系统（Hospital InformationSystem）的一个子系统，是用电子设备（计算机、健康卡等）保存、管理、传输和重现的数字化的病人的医疗记录，取代手写纸张病历，是基于一个特定系统的电子化病人记录，该系统提供用户访问完整准确的数据、警示、提示和临床决策支持系统的能力。电子病历是随着医院计算机管理网络化、信息存储介质--光盘和IC卡等的应用及Internet的全球化而产生的，是医院病历现代化管理的必然趋势，其在临床的初步应用，极大地提高了医院的工作效率和医疗质量，但这还仅仅是电子病历应用的起步。本文所实现的电子病历系统和HIS系统的其他子系统做到无缝链接，使医务人员能在任何需要的地方书写病历并查看检验报告，大大方便和简化了医生的诊疗工作。严格执行指定的流程，从各个工作环节上进行质量控制，提高质控水平。减少医生护士重复劳动的环节，降低医护的工作强度，最大限度的减少了人为的错误，提高了工作效率，尤其是病案实现全院无纸化建设后，节省了纸张成本、降低了病人数据填写和查找比对环节的错误率，使得医生能全心投入到对病人病情的分析、诊断和治疗工作中。本文以华山医院EMR系统的项目开发为背景，分析了国内外EMR系统的现状和存在的问题，提出了EMR系统的研究目标和意义。本文主要介绍了以下内容：目前主流的数据交换语言XML语言；EMR系统的模板化设计；EMR系统界面编辑器设计以及系统的需求分析、设计和实现。本系统的开发采用了RUP（Rational Unified Process，统一软件开发过程）的方法，针对需求不断的变化进行迭代开发，同时采用了UML（Unified Modeling Language，统一建模语句）贯彻软件开发周期的每一个阶段。需求分析阶段，与华山医院各科室的医生护士以及系统所涉及到的其他部门人员进行充分的沟通，使用UML系统用例模型为系统需求建模。设计阶段，采用两层的C/S模式的系统体系结构，完成系统功能架构的设计，利用UML的静态类图、时序图等对各模块的对象、流程和功能进行了详细设计，采用Rational Rose建模，结合公司内部经验数据库的案例模型，归纳总结出一个适合华山医院自身特色的全院电子病历解决方案。本系统实现了电子病历系统模板化分类管理，使全院各个科室可以根据各自科室特点制定符合自己需求的病历模板，统一管理。结构化的编辑器界面病历书写风格，在辅助医生书写病人病历的同时，也规范了医生的输入。与HIS的无缝接口，使得医生在查阅病人各项报告和检查结果时，可以一目了然，无须切换系统，并可以方便的引用到病人的病历之中。修改痕迹、三级阅览、ICD诊断等EMR系统特殊功能也一并实现,真正意义上达到了病历电子化。本文实现的电子病历系统在华山医院上线后使用至今，运行效果良好，系统功能稳定，在实现华山医院病历无纸化的同时，显著减低了医生在书写病人病历上的时间，也规范了病历的归档保存工作，提高了医院的质控和管理水平，给医院带来了良好的经济效益和社会效率。更多还原

【Abstract】 As a subsystem of HIS system (Hospital Information System), Electronic medicalrecords system (EMR, Electronic Medical Record) replaces handwritten paper medicalrecords with digital patient medical records by using electronic equipment (computers, healthcard, etc.) to conserve, manage, transmit and reproduce the record information on the basis ofa specific system. The system provides user access to complete and accurate data, alerts, tips,and clinical decision support systems.Electronic medical records come into being along with the networking of hospitalcomputer management, information storage media-CD and IC card applications and theinternet globalization, and represent an inevitable trend of modern management of hospitalmedical records. Its preliminary clinical application has greatly improved hospital efficiencyand quality of medical care, though this is just the beginning of electronic medical recordsapplications.The electronic medical records system achieved in this paper boasts seamless links to theother subsystems of HIS system, enabling the medical staff to write and view the inspectionreports wherever needed, which greatly facilitates and simplifies the doctor’s diagnosis andtreatment. It aids to strictly implement the specified process, make quality control in all thework stages and improve quality control standards. It also helps reduce repetitive work of thedoctors and nurses, lighten the intensity of health care work, minimize the human error andimprove efficiency. Particularly, it achieves paperless hospital medical record construction and saves paper costs, while also reduces error rate in patient data filling, searching andcomparison, so that physicians can devote themselves to the analysis, diagnosis and treatmentof the patient’s condition.Taking Huashan Hospital’s EMR systems project development as an example, this paperanalyzes the status of EMR systems at home and abroad and the existing problems, and pointsout the objectives and significance of EMR systems research. The paper mainly describes thecurrent mainstream data exchange language--XML language, EMR systems template design,EMR system interface editor design and the analysis, design and realization of the system.The system is developed using the RUP (Rational Unified Process), and against changeabledemand, iterative development is adopted while employing the UML (Unified ModelingLanguage, Unified Modeling statement) into every stage of the software development cycle.During requirements analysis phase, UML case model is used in modeling, on the basis of fullcommunication with the doctors, nurses and various involved sections of Huashan Hospital.During design phase, two-tier C/S model of system architecture is taken in designing thesystem’s functional architecture, and UML static class diagram and sequence diagram arerelied on in detail design of the various modules, processes and functions. By using RationalRose modeling, combined with experience within the company database of case model, asuitable EMR solution for Huashan Hospital’s own characteristics is summarized.The system implements a template-based classification of electronic medical recordsmanagement system, so that all sections of the hospital departments can develop their ownmedical records template according to respective requirements and for unified management.Structured editor interface style of medical records helps regulate the doctor’s input whileassisting their writing of patient records. Seamless interface with HIS makes it unnecessary toswitch systems while doctors want to check the patient’s medical records and test results andquote them into the new medical records. Revision marks, three-class view, ICD diagnosisand other functions of EMR systems are all achieved, realizing a real sense of electronicmedical records.The electronic medical records system realized in this paper is running well with stableperformance of the functions since its launch in Huashan Hospital. It succeeds in achievingpaperless medical records in Huashan Hospital, markedly reduces the time of writing patients’medical records, standardizes the medical records archiving work and improves the hospital’squality control and management, increasing the economic and social efficiency to thehospital.更多还原