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目的探索病案信息研究发展方向,提高病案信息对临床科研的支持力度。方法分析病案基本属性及应用价值和需求层次,探求病案信息研究的基础支撑条件。结果在医学应用(特别是临床科研)中,对病案信息利用的深广度远高于行政应用和涉法应用,需要对病案信息深度开发。病案信息研究已成为支持医院管理、循证医学和科研的基础工作之一。结论为提高病案信息研究对临床科研的支持力度,应建立规范化的病案数据库标准,并需要先进检索技术的支持。应用高维索引算法建立搜索引擎,实现病案相似性立体检索,是病案管理和病案信息研究领域的发展方向。
Objective To explore the research direction of medical record information and improve the support of medical record research to clinical research. Methods To analyze the basic attributes of medical records and their application value and hierarchy of needs, and to explore the basic support conditions for medical records information research. Results In medical applications (especially in clinical research), the extensive use of medical record information is much higher than that of administrative applications and law-related applications, and the in-depth development of medical record information is required. The study of medical record information has become one of the basic work to support hospital management, evidence-based medicine and scientific research. Conclusion In order to improve the support for clinical research in case information research, a standardized database of medical records should be established and supported by advanced retrieval techniques. The application of high-dimensional indexing algorithm to establish search engine and realize the similarity retrieval of medical records is the development direction of medical records management and medical record information research.