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目的建立肿瘤医院电子病案的临床辅助决策系统和其他业务分析工具。方法分析肿瘤疾病和治疗过程的特点,以及临床业务分析的需要,提出与“病人—住院次”平行的“病人—治疗次”电子病案结构,设计实现这种双重结构的病历书写模版。结果在此结构基础上利用数据仓库工具建立临床辅助决策演示系统,包括治疗路径决策和治疗方案决策。结论建立临床辅助决策系统的关键是电子病案提供符合临床逻辑的结构和数据。
Objective To establish a clinical decision support system and other business analysis tools for electronic medical records in cancer hospitals. Methods To analyze the characteristics of tumor diseases and the course of treatment, and the need of clinical business analysis, put forward an electronic medical record structure that is parallel with “patient-inpatient times ” and design and implement such a dual structure of medical record writing stencil. Results Based on this structure, a data warehouse tool was used to establish clinical assistant decision presentation system, which included decision-making of treatment path decision and treatment plan. Conclusions The key to establishing a clinical decision support system is that electronic medical records provide structures and data that conform to clinical logic.