The Design And Realization Of Structured Electronic Medical Record

By applying Hospital Information System (HIS) in the past 2 decades, Chinese hospitals greatly improved their management in financial and goods flow fields.In recent years, more attention of medical treatment quality improvement was drawn by China. For this purpose, more and more Clinical Information Systems (CIS) appear. Among them, Electronic Medical Record (EMR) system is the core one.Normally, Medical Record is composed of writings, symbols, charts, images to record clinical facts. It can be divided into 3 parts, which are outpatient, emergency and inpatient. In the past, medical records are completed on paper and just by handwork every day. It obviously has many shortcomings such as low working efficiency, high mistaking rate, difficulty of data analysis. EMR system is a patient-centered information system which builds on the real clinical workflow and regulates it. It can help hospital to eliminate the defects of hand-worked Medical Record.This project was to establish an EMR System and integrated with a Hospital Information System platform. The EMR system was developed by PowerBuilder and Oracle 8i, with C/S structure. It was designed to store structured EMR data, and supported EMR template development. After requirement analysis, system designing, system coding, system test, and implementation, the EMR system was shaped. The whole period covers 18 months. Now, the EMR system had being an organic part of the hospital that applying it and it had been helping the hospital improve its medical treatment quality.