建立具有中国特色医疗信息系统的构想

张建春，李昌青，刘卫华，吴永胜，李婉珺

建立具有中国特色医疗信息系统的构想

张建春，李昌青，刘卫华，吴永胜，李婉珺

目的：分析国内外医疗信息系统发展与应用的现实状况，探索适合中国特色的医疗信息系统发展的最佳模式。方法：通过分析医疗信息系统的功能架构与发展历程，总结了发达国家医疗信息化建设的成功经验，找出国内医疗信息化发展应用面临的问题与差距，研究相应对策。结果：借鉴美国医疗信息化建设“互操作”的经验，大力推进国内医疗信息化的发展。结论：通过“互操作”实现不同医疗机构信息系统间的数据交换与分享，并最终形成可自我持续发展的医疗信息网络的最佳模式。

医疗信息系统；功能架构；互操作；电子病历

AbstractObjectiveTo analyze present situation of development and application of medical information system at home and abroad and explore the optimal developmental style of medical information system with Chinese characteristics.Methods Problems and differences which would be faced with in the development of medical informatization of China were expected to be found out,and corresponding strategy were studied,by analyzing function structure and development of medical information system and by summarizing successful experience in the development of medical informatization of developed countries.Results By mirroring interoperability experience in the construction of American medical information,the development of medical informatization of China was advanced greatly.ConclusionBy interoperability,the data interchange and sharing among the information systems of different medical services were implemented.The optimal style of medical information network which can keep on developing itself will come into reality.[Chinese Medical Equipment Journal，2011，32（1）：99-100，104]

Key wordsmedical information system;function structure;interoperability;electronic medical record

1 引言

多年来，医疗信息化及其应用一直是卫生界关注的热点。提高医疗质量和效率的要求，改善医疗服务的驱动，特别是公共财政领域医疗卫生体制改革和社会福利、医疗保险制度的深入开展，更进一步推动了医疗信息化的建设与应用，医疗信息系统已成为医疗卫生单位不可缺少的基础设施与技术支持环境。

首先，从功能特性来分析。通常将针对医院使用的一些院内共用功能的程序，如患者的个人信息、费用信息、物资信息、人员信息等归入HIS范围，它们是医院信息管理的基础，这是学术界所公认的。而将针对某一专业或专业科室内部专用功能的程序，如PACS、LIS、EHR-S、临床决策支持系统（clinical decision support system，CDSS） 等这样一些庞大、复杂、专业性突出又自成一体的信息系统是否归入HIS则持有质疑。……