Big Data Management And Clinical Application Of Structured Ophthalmic Outpatient Electronic Medical Record

Purpose: To establish a standardized outpatient electronic medical record system(EMR),and establish a homogenized disease management system under the framework of big data for ophthalmology.Methods: We used Microsoft.NET Framework 4.0 as the supporting platform,with C#(C Sharp)as the development language,to carry out a visual,object-oriented design and programming.A structured writing framework of ophthalmic outpatient medical records was designed based on the writing standard of outpatient electronic medical records.Based on clinical diagnosis and treatment guidelines,textbooks of ophthalmology,ICD10 international standards for diagnosis and classification of diseases,international SNOMED CT nomenclature and various ophthalmology monographs,the ophthalmological disease database,specialized examination database,clinical terminology database,diagnosis database,knowledge database and quality control rules were constructed respectively.To realize the collection and homogenized management of big data in ophthalmology.Results:1)The design of structured EMR user interface was completed.It included the basic framework of history collection,routine examination,anterior and posterior segment examination,specialized examination,adjuvant examination,diagnosis and treatment.The left and right eyes were recorded separately in accordance with the physician’s recording practice.For each field,a clinical decision must be made by selecting a default value from the drop-down menu.Meanwhile,it realized the matching of patient information between various imaging examinations and laboratory examinations,and saves and transmits the results.2)A series of standardized databases were built:(I)The Ophthalmic Diseases Database contains497 clinical paths of diseases,which can be searched in three ways: by disease,by subspecialty or ICD code.(II)The Ophthalmic Specialty Examination Database contains a detailed description of the procedures for 41 types of examinations,as well as a record template designed according to these procedures.(III)The Ophthalmic Clinical Terminology Database contains over 10,000 clinical terms.(IV)The Ophthalmic Diagnostic Database contains standardized diagnostic terms covering multiple subspecialties of ophthalmology.(V)The Knowledge Database covers more than10,000 diseases and ophthalmic normal values,including monographs on general ophthalmology,subspecialties and ancillary examinations.3)A clinical decision support system(CDSS)was established based on quality control rules.The warning pop-up window is used to remind doctors the problems of incomplete filling,illogic,or non-compliance with medical standards,diagnostic criteria and surgical indications.4)The relational database was built based on Microsoft SQL.At present,more than 1.2 million patients’ medical records have been collected,including structured outpatient data of medical history collection,examination,diagnosis and treatment.Conclusion: The results of this study indicate that it is feasible to build a standardized and structured ophthalmic EMR and a series of databases to realize a homogeneous disease management system,which is of great value in hospital medical treatment,teaching,scientific research and management.