Construction And Application Of Electronic Medical Record Information Exchange Model

Electronic medical records is not only a necessary business support systems to carry out the clinical work in modern medical institutions, but also the main sources of information and an integral part of the health records of residents. It is the digital medical services records of clinical treatment and intervention in medical institutions for outpatient, inpatient (or health-care objects). An electronics record is a complete and detailed clinical information resource that produced and recorded during treatment of residents in medical institutions. Electronic medical records are not equal to "hospital information system", it is a data integration system that focuses on the information of clinical treatment generated in the process of the activities of various types of medical services for individuals in medical institutions. Construction of standardized electronic medical records is the basis of achieving clinical information sharing in region-wide and collaboration services among medical and health institutions.However, it is not easy to organize medical data into a logical complete electronic medical record database. The medical data are scattered in different agencies with different format and different historical periods, involving everyone, it is complicated and in large volume. In order to realize the integration and sharing of electronic medical records, first to do is to solve the interoperability between systems based on the electronic medical record information model and data model.The study took the information model in "the basic architecture and data standards of electronic medical record ", data sets and data element, basic templates and data sets as the research object; took XML-technical as means; did through the definition of the semantic model of electronic medical records document (Schema) to improve the accurately understand of information sharing between systems and to realize the semantics interoperability among electronic medical records systems.The main methods used in this study were:the use of W3C XML Schema Definition Language (XML Schema Definition Language, XSDL), structure and semantic definitions and constraints of electronic medical records document by construction of modular electronic medical records management system information model and data standards for XML Schema documents, and verify document for each data item is consistent with the data standards (validity validation).Mapping XML Schema of electronic medical records with hospital information system, generating electronic medical records documentation by mapping relationship.Using eXtensible Stylesheet Transformation Language (eXtensible Stylesheet Transformation Language, XSLT) recommended by W3C, designing style sheet based on XML Schema of electronic medical records for the browser display of electronic medical record documents.Mapping effectively the Electronic Medical Record XML Schema with Relational Database Schema, completing the structured storage of electronic medical records documentation, meanwhile preserving the entire document.The main findings of this study:An electronic medical records XML Schema document based on information model of electronic medical records and data standards.Electronic medical record documentation based on the electronic medical records XML Schema (documents of first page of hospital medical record).A style sheet based on electronic medical records XML Schema (document-style table of first page of hospital medical record).A set of relational database stored program based on electronic medical records XML Schema.Through the application of this study, it is easy to facilitate the formation of uniform components, unified information structure, semantics explicit electronic medical record documents for the exchange and sharing of data between systems. Electronic medical records system can provide timely and accurate decision-making information for all participants in the medical health field, including patients, doctors, managers, policy makers and researchers, give play to improve health care quality and reduce medical costs and improve the performance of health systems. At the same time it can also help to standardize the clinical path, and achieve the medical treatment process supervision, to avoid the deadly medical errors, to promote the ability of emergency medical treatment. However, to achieve the integration and sharing of electronic medical records, in addition to the necessary information technologies, there should be supported by policy, legal and other non-technical framework. The experience of electronic medical records in many developed countries has shown that the main obstacle to the implementation of electronic medical records is from the people and institutions, rather than technical.