Preliminary Study on Clinical Information System of Computer Graduation Project Based on HL7

As a kind of CIS, considering the directionality of information transmission, it should be restricted. The application scope of this class is to observe the description, suggestion, treatment process and diagnosis/impression report processing of human lesions with the help of equipment, and its characteristic is that this observation needs an OBRObservationRequest. But general clinical observation (some of which also use simple equipment, such as thermometers and sphygmomanometers) such as vital signs, course records, nursing records and physical examinations are not in this category. The main properties of this base class are: UniversalServiceIdentifier, Priority, RequestedDate/Time, ObservationDate/Time, ObservationEndDate/Time, CollectionVolume, CollectorIdentifier, SpecimenActionCode, DangerCode, RelevantClinicalInfo. , date/time of sample receipt, sample source, ordering supplier, result status, transportation mode, research reason, technicians, scheduled date/time, program code, etc. The observation report will be used as the main basic class of auxiliary diagnosis such as radiation information system and laboratory information system. 3.4. As a base class, patient care provides a problem-oriented rule for medical records and helps to improve medical quality. It is also a measure (method) to help us change our thinking mode from empirical medicine to evidence-based medicine. The course records written by doctors and the nursing records of nurses reflect a patient-centered medical process, which will be derived and expanded on this basis. As a standard, the abstraction and the difference from China medical culture are the difficulties to realize this standard. Copying foreign standards will encounter various obstacles, which must be inherited and carried forward, combined with actual localization. 3.5. Scheduling hospitals need to use various resources to provide services for patients. However, resources are limited and need to be arranged reasonably. Therefore, the use of any resource requires an appointment. Taking reservation as a base class of CIS alone has its special significance and function, which strengthens the concept of resources and clarifies the management objects. During the medical treatment in China, many services need to be reserved. However, most services do not require an appointment. This phenomenon often misleads inexperienced system analysts. Actually, you need to make an appointment, but for some reason, the relevant data is temporarily defaulted. Once these factors change, this potential demand will appear. 3.6. Management of medical records, including file establishment, completion status, storage status, availability and security. It is the most basic attribute of medical literature, including encounter, process record and observation report. 4. The division of the main domain ApplicationSystem refers to the previous base class. Many foreign CIS suppliers classify or name the software products in this way, which obviously inherits the results of relevant chapters of HL7. There are some differences in the application classification of clinical information systems in China, such as outpatient registration reservation subsystem, outpatient doctor workstation, outpatient charging subsystem, LIS, RIS, ultrasonic workstation, drug distribution subsystem, admission and exit management and settlement subsystem, resident workstation and nurse workstation. Classification is divided according to the DepartmentApplicationSystem, which has the advantage that it conforms to the organization and function setting of most hospitals in China at present, but the disadvantage is the future. This way of thinking is often limited. With the reform and development of hospital management, many businesses will gradually be in line with international standards. In order to meet the ever-changing business needs, the foundation of building CIS must be solid. Building a department application system based on domain application is an important step to establish a clinical information system that meets the application needs of hospitals in China, but it must have the concept of domain application. The characteristic of these application systems is that they can run independently from other systems and complete certain clinical services. At the same time, they can communicate with other systems conveniently according to the standard interface of HL7, so as to integrate all systems organically and complete more complicated clinical work. 4.1.1.ADT & Patient management The main functions of this system include outpatient or emergency patient registration, outpatient and hospitalization management (including bed management during hospitalization). In addition, the system will provide patients and their access information and master index service (MPI service) for other related systems to keep patient ID consistent. 4.1.2. OrderEntryandManagement The main function of this system is to handle doctor's advice, including the transaction communication between requester (placer) and filler. It is a complicated system in CIS, and it can only be used by other departments after secondary development according to different types of orders. A more appropriate classification will determine their respective attributes and methods according to the type of patient's visit (PV 1-2PatientClass) and the order (drug/treatment, observation, diet, etc.). ) .4.1.3. Computerized electronic PATIENTRECORD mainly includes medical history (medical treatment), physical examination, stage summary, discharge or transfer records, consultation records, etc. 4. 1.4. Patient course records and nursing records are also important components of electronic medical records, which emphasize the process of patient care, while electronic medical records emphasize the recording and coding of information, which is not closely related to the process. 4.1.5. Observation Reporting System This system includes processing observation requests and related transactions, inputting and storing reports, and sending reports. 4. 1.6. scheduling system appointment In clinical affairs, new appointment requests are often triggered by doctor's orders, and the resource manager is responsible for confirming the appointment. 5. Results/Results RadiologyInformationSystem(RIS) is the first HL7-based application software system (departmental application system) in our company, which integrates applications in registration (ADT), observation report system (core part), order entry and scheduling system. Because the data of RIS, that is, image information, is provided by PACS, its integration with PACS is unique. Laboratory Information System (LIS) is a departmental application system integrated on the basis of existing field application systems (basic fields similar to RIS), which emphasizes specimen tracking (contents in observation reports) and realizes information exchange and data collection with laboratory automation equipment. 6. Discussion The application of computers in Chinese hospitals is gradually developing towards clinical business. How to design a clinical information system suitable for hospitals in China is a topic of concern to many people in the industry. The formulation of HL7 standard provides an interface for information exchange between systems, which enables different application systems to establish connections and achieve the purpose of integrating software products provided by different suppliers. In other words, HL7 does not tell us how to design a clinical information system. Www.bfblw.com is a 100% paper network, which will not tell you how to establish a clinical information system that meets the requirements of China hospital. However, HL7 is an application-level standard protocol based on clinical services. It is a comprehensive result of clinical work induction, summary and abstraction, which completely conforms to the top-down design principle. This is also the main reason why this paper puts forward HL7 as the basis of CIS design. We can compare HL7 to a building with a solid foundation and frame, while DomainApplication is an empty building without decoration. Departmental applications are rooms delivered to customers for immediate use. Customers can buy floor tiles and ask professional companies or themselves to space and decorate them to meet different functional needs. CIS is a very complex system, which is difficult to design and has complex functions. This paper only expounds the author's point of view from the overall framework. Due to the limitation of space, many core issues such as electronic medical record and its coding and structured report cannot be discussed here, and we will publish them in future articles. In view of the author's limited level, I hope this article can play a role in attracting jade.