Electronic medical record management system and method

Abstract

The invention relates to the technical field of medical records, and particularly discloses an electronic medical record management system and method, and the system comprises a medical record input and management module, a privacy and safety module, a data analysis and mining module, an electronic prescription and management module, a real-time monitoring and notification module, and a remote access and communication module. The medical record input and management module is responsible for recording and managing medical record information of a patient, the privacy and security module is responsible for protecting privacy and data security of the patient and conforms to the HIPAA regulations, and the data analysis and mining module performs statistical analysis, trend analysis and predictive analysis by using medical record data; according to the method, the concept of data elements is applied, high-frequency word recommendation and a natural association mode are matched, full-structured input and storage of the medical records are achieved, the data mining process and construction of the medical knowledge graph are more convenient and faster based on full-structured medical record template configuration, then electronic medical records are better analyzed and managed, and the efficiency is improved. And clinical and hospital management departments are assisted to make medical decisions.

Description

Technical Field

[0001] The present invention belongs to the technical field of medical records, and in particular relates to an electronic medical record management system and method. Background Art

[0002] The electronic medical record database is patient-centered and integrates patient medical information and related processing processes, which promotes the optimization of work processes, the improvement of medical quality and the improvement of service levels. Developed countries have conducted in-depth research and application of electronic medical records, and have established relevant institutions to organize medical units to implement and popularize electronic medical records. Since 2009, my country has successively issued a series of policies and regulations, including "Basic Architecture and Data Standards for Electronic Medical Records (Trial)", "Functional Specifications for Electronic Medical Record Systems", "Opinions on Strengthening the Performance Appraisal of Tertiary Public Hospitals" and "Opinions on Promoting the High-Quality Development of Public Hospitals", to clarify the functional requirements of electronic medical record systems, promote the construction of hospital informatization with electronic medical records as the core, and promote the construction of smart hospitals and hospital information standardization with electronic medical records as the core, which are "three-in-one" smart medical care, smart services and smart management.

[0003] Electronic medical records have gone through three major stages of development: the first stage was the electronicization of paper medical records, the second stage was the tabulation of electronic medical records, and the third stage was the structured application and full-structured attempts of electronic medical records. At present, the development of electronic medical records in my country is in the third stage. Although the structuring of electronic medical records has been achieved, most of them are developed based on text editors, making medical record data non-standard and incomplete, unable to meet the high-standard scientific research data needs, and unable to achieve all-round and full-process quality control of electronic medical records, and thus unable to efficiently assist clinical decision-making.

[0004] Therefore, it is necessary to propose an electronic medical record management system and method to at least partially solve the problems existing in the prior art.

[0005] The above information disclosed in this background technology is only used to increase the understanding of the background technology of the present invention and therefore, it may include information that does not constitute the prior art known to ordinary technicians in this field. Summary of the invention

[0006] The purpose of the present invention is to provide an electronic medical record management system and method to solve the problems raised in the above background technology.

[0007] To achieve the above object, the present invention provides the following technical solutions:

[0008] An electronic medical record management system includes: a medical record entry and management module, a privacy and security module, a data analysis and mining module, an electronic prescription and management module, a real-time monitoring and notification module, and a remote access and communication module. The medical record entry and management module is responsible for recording and managing the patient's medical record information, the privacy and security module is responsible for protecting the patient's privacy and data security in compliance with HIPAA regulations, the data analysis and mining module uses medical record data to perform statistical analysis, trend analysis, and predictive analysis, the electronic prescription and management module is used to generate and manage electronic prescriptions and the inventory and distribution of drugs, the real-time monitoring and notification module is responsible for monitoring the patient's condition and system operating status and providing real-time notifications, and the remote access and communication module supports doctors and patients to access medical records and perform remote diagnosis through mobile devices.

[0009] Preferably, the system also includes a user management and business module and an appointment and scheduling module. The user management and business module is responsible for managing the account information and permissions of doctors, nurses, administrators and patients, and connecting with the clinical business system. The appointment and scheduling module is responsible for managing patients' appointments and connecting with the scheduling information of medical staff.

[0010] Preferably, the user management and business module uses MFA and RBAC to complete user identity verification and permission granting, realizes data exchange and interoperability between different systems through HL7 standards, and uses data compression algorithms to reduce bandwidth usage and storage requirements for data exchange.

[0011] Preferably, the medical record entry and management module realizes the entry of electronic medical records by calling standardized medical terminology, and improves the entry efficiency by combining high-frequency word recommendation and associative follow-up input, directly generates the medical record front page and discharge summary based on the medical record, and improves the efficiency and quality of medical record writing.

[0012] By using the data element form combined with actual clinical data needs, the medical record content is divided into minimal data elements with medical significance. Each data element has a unique ID. The data element value range is limited by establishing a dictionary, and the dictionary values ​​are uniformly encoded to establish a standardized medical terminology library.

[0013] The basic attributes of data elements can be divided into three categories: definition attributes, representation attributes, and management attributes. Definition attributes describe the semantics and relationships of data elements, representation attributes describe the form of their structure, and management attributes describe their management and control aspects. Therefore, the definition attributes, representation attributes, and management attributes of data elements can be applied to the hierarchical relationships, correlations, etc. between medical terms and the concepts they express.

[0014] Preferably, the data analysis and mining module processes the electronic medical records through data mining, and constructs multi-dimensional medical knowledge management based on the knowledge graph according to the analysis and mining results, and uses natural language processing to identify entities in the electronic medical records in this process.

[0015] In the construction of the medical knowledge graph, medical knowledge is represented by entities as nodes and the relationships between entities as edges. Entity recognition is to find relevant entities (existing conceptual terms) from electronic medical records, including diseases, symptoms, drugs, tests, and treatments; relationship extraction is to identify the relationships between extracted entities, including relationships between homogeneous entities (such as the relationship between drugs) and relationships between heterogeneous entities (such as the relationship between diseases and symptoms).

[0016] Preferably, the electronic prescription and management module analyzes and detects the drugs and their dosages in the electronic prescription through a drug interaction check algorithm and a drug dosage calculation algorithm to improve the quality and safety of the electronic prescription, and uses an inventory management algorithm to manage drug inventory and distribution.

[0017] Preferably, the real-time monitoring and notification module applies real-time data stream processing to ensure that data can be processed immediately when received, and uses isolation forest to construct a randomly generated tree to isolate abnormal samples, thereby quickly detecting outliers to achieve timely detection and response to electronic medical record data anomalies.

[0018] An electronic medical record management method, comprising:

[0019] Step 1: When a patient registers or visits a doctor for the first time, the system will automatically create an electronic medical record for the patient, and the staff will enter the patient's basic information into the system to ensure that the information is accurate;

[0020] Step 2: When seeing a patient, the doctor will make a diagnosis and develop a treatment plan based on the patient's symptoms and signs. The overall content will be automatically recorded in the electronic medical record to facilitate subsequent treatment and follow-up;

[0021] Step 3: After the pharmacy staff prepares the medicine according to the prescription information and confirms the dispensing through the system, the dispensing information will be automatically updated to the patient's electronic medical record to ensure the accuracy of the medicine usage information;

[0022] Step 4: Allow authorized users to view and download medical records, which is convenient for doctors to analyze the condition and make treatment decisions. It also provides medical record statistical analysis functions to help users understand the distribution of diseases and treatment effects.

[0023] Step 5. The application for modification of medical record information shall be submitted by the relevant doctor or staff, and the reason and basis for the modification shall be attached. After review and approval, the system will modify the medical record information and save the modification record.

[0024] Preferably, the method strictly controls user access rights to ensure that only authorized users can access and modify medical record data, regularly performs data backup and recovery tests to prevent data loss or damage, and supports the export and printing of medical records to meet the needs of internal management of medical institutions and patient inquiries.

[0025] Compared with the prior art, the present invention has the following beneficial effects:

[0026] The present invention applies the concept of data elements in conjunction with high-frequency word recommendations and natural association methods to achieve fully structured entry and storage of medical records. Based on the fully structured medical record template configuration, the data mining process and the construction of the medical knowledge graph are more convenient, thereby better analyzing and managing electronic medical records, assisting clinical and hospital management departments in making medical decisions, and applying real-time data stream processing to ensure that data can be processed immediately upon receipt, so that anomalies in electronic medical record data can be detected and responded to in a timely manner, thereby taking more scientific and reasonable preventive control measures.

[0027] The above summary is for illustrative purposes only and is not intended to be limiting in any way. In addition to the illustrative aspects, embodiments and features described above, further aspects, embodiments and features of the present invention will be readily apparent by reference to the accompanying drawings and the following detailed description. BRIEF DESCRIPTION OF THE DRAWINGS

[0028] Figure 1 This is a framework diagram of the electronic medical record management system of the present invention;

[0029] Figure 2 This is a flow chart of the electronic medical record management method of the present invention. DETAILED DESCRIPTION

[0030] The following will be combined with the drawings in the embodiments of the present invention to clearly and completely describe the technical solutions in the embodiments of the present invention. Obviously, the described embodiments are only part of the embodiments of the present invention, not all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by ordinary technicians in this field without creative work are within the scope of protection of the present invention.

[0031] Example:

[0032] See also Figure 1-Figure 2As shown, an electronic medical record management system includes: a medical record entry and management module, a privacy and security module, a data analysis and mining module, an electronic prescription and management module, a real-time monitoring and notification module, and a remote access and communication module. The medical record entry and management module is responsible for recording and managing the patient's medical record information. The privacy and security module is responsible for protecting patient privacy and data security in compliance with HIPAA regulations. The data analysis and mining module uses medical record data for statistical analysis, trend analysis, and predictive analysis. The electronic prescription and management module is used to generate and manage electronic prescriptions and inventory and distribution of drugs. The real-time monitoring and notification module is responsible for monitoring the patient's condition and system operation status and providing real-time notifications. The remote access and communication module supports doctors and patients to access medical records and conduct remote diagnosis through mobile devices.

[0033] The system also includes a user management and business module and an appointment and scheduling module. The user management and business module is responsible for managing the account information and permissions of doctors, nurses, administrators and patients, and connecting with the clinical business system. The appointment and scheduling module is responsible for managing patient appointments and connecting with the scheduling information of medical staff.

[0034] The user management and business modules use MFA and RBAC to complete user identity verification and permission granting, realize data exchange and interoperability between different systems through the HL7 standard, and use data compression algorithms to reduce bandwidth usage and storage requirements for data exchange.

[0035] The medical record entry and management module realizes the entry of electronic medical records by calling standardized medical terminology, and adopts a combination of high-frequency word recommendations and association follow-up input to improve entry efficiency. It directly generates the medical record front page and discharge summary based on the medical record, thereby improving the efficiency and quality of medical record writing.

[0036] The data analysis and mining module processes electronic medical records through data mining, and builds multi-dimensional medical knowledge management based on knowledge graphs according to the analysis and mining results. In this process, natural language processing is used to identify entities in electronic medical records.

[0037] The process of electronic medical record analysis and mining based on data mining: First, based on the understanding of the research problem, select the appropriate research cohort, then extract the data of the defined research cohort, clean and improve the data through data preprocessing, and have a general understanding of the data through exploratory analysis. Based on the research problem and data characteristics, select the appropriate model method for experimentation, and evaluate and improve it. After meeting the expectations, it can be verified on a large-scale real data set, and finally discover knowledge to provide support for medical practice.

[0038] The electronic prescription and management module analyzes and detects the drugs and their dosages in the electronic prescriptions through the drug interaction check algorithm and the drug dosage calculation algorithm, improves the quality and safety of the electronic prescriptions, and uses the inventory management algorithm to manage the inventory and distribution of drugs.

[0039] The drug interaction check algorithm is used to analyze the drugs contained in the electronic prescription to detect whether there are combinations that may cause adverse interactions. Based on the interaction information between drugs and clinical guidelines, it alerts doctors to potential interaction risks and helps patients avoid adverse reactions or reduced treatment effects. The drug dosage calculation algorithm is used to accurately calculate the appropriate dosage of each drug in the electronic prescription based on the patient's specific conditions (such as weight, age, renal function, etc.) and treatment needs. It is based on clinical guidelines and drug pharmacology data to ensure that each patient receives a safe and effective treatment dose to avoid problems caused by excessive or insufficient use of drugs.

[0040] The real-time monitoring and notification module applies real-time data stream processing to ensure that data can be processed immediately when it is received. It uses isolation forest to build a randomly generated tree to isolate abnormal samples, thereby quickly detecting outliers to achieve timely detection and response to electronic medical record data anomalies.

[0041] An electronic medical record management method, comprising:

[0042] Step 1: When a patient registers or visits a doctor for the first time, the system will automatically create an electronic medical record for the patient, and the staff will enter the patient's basic information into the system to ensure that the information is accurate;

[0043] Step 2: When seeing a patient, the doctor will make a diagnosis and develop a treatment plan based on the patient's symptoms and signs. The overall content will be automatically recorded in the electronic medical record to facilitate subsequent treatment and follow-up;

[0044] Step 3: After the pharmacy staff prepares the medicine according to the prescription information and confirms the dispensing through the system, the dispensing information will be automatically updated to the patient's electronic medical record to ensure the accuracy of the medicine usage information;

[0045] Step 4: Allow authorized users to view and download medical records, which is convenient for doctors to analyze the condition and make treatment decisions. It also provides medical record statistical analysis functions to help users understand the distribution of diseases and treatment effects.

[0046] Step 5. The application for modification of medical record information shall be submitted by the relevant doctor or staff, and the reason and basis for the modification shall be attached. After review and approval, the system will modify the medical record information and save the modification record.

[0047] This method strictly controls user access rights to ensure that only authorized users can access and modify medical record data, regularly performs data backup and recovery tests to prevent data loss or damage, and supports the export and printing of medical records to meet the needs of internal management of medical institutions and patient inquiries.

[0048] From the above, it can be seen that the present invention applies the concept of data elements in conjunction with high-frequency word recommendations and natural association methods to achieve fully structured entry and storage of medical records. The configuration based on the fully structured medical record template makes the data mining process and the construction of the medical knowledge graph more convenient, thereby better analyzing and managing electronic medical records, assisting clinical and hospital management departments in making medical decisions, and applying real-time data stream processing to ensure that data can be processed immediately when received, so that anomalies in electronic medical record data can be detected and responded to in a timely manner, thereby taking more scientific and reasonable preventive control measures.

[0049] In the description of this specification, the description with reference to the terms "one embodiment", "some embodiments", "examples", "specific examples" or "some examples" etc. means that the specific features, structures, materials or characteristics described in conjunction with the embodiment or example are included in at least one embodiment or example of the present invention. In this specification, the schematic representations of the above terms do not necessarily refer to the same embodiment or example. Moreover, the specific features, structures, materials or characteristics described may be combined in any one or more embodiments or examples in a suitable manner. In addition, those skilled in the art may combine and combine different embodiments or examples described in this specification and the features of different embodiments or examples, unless they are contradictory.

[0050] The present invention is described with reference to flowcharts and / or block diagrams of methods, devices (systems) and computer program products according to embodiments of the present invention. It should be understood that each process and / or block in the flowchart and / or block diagram, as well as the combination of processes and / or blocks in the flowchart and / or block diagram, can be implemented by computer program instructions. These computer program instructions can be provided to a processor of a general-purpose computer, a special-purpose computer, an embedded processor or other programmable data processing device to generate a program, so that the instructions executed by the processor of the computer or other programmable data processing device generate instructions for implementing the processes in the flowchart and / or block diagram. Figure 1 A process or multiple processes and / or boxes Figure 1 A method that specifies the functionality of a box or multiple boxes.

[0051] In the drawings of the embodiments disclosed in the present invention, only the structures involved in the embodiments disclosed in the present invention are involved, and other structures can refer to the general design. In the absence of conflict, the same embodiment and different embodiments of the present invention can be combined with each other.

[0052] Although embodiments of the present invention have been shown and described, it will be appreciated by those skilled in the art that various changes, modifications, substitutions and variations may be made to the embodiments without departing from the principles and spirit of the present invention, and that the scope of the present invention is defined by the appended claims and their equivalents.

Claims

1. An electronic medical record management system, characterized in that: include: Medical record entry and management module, privacy and security module, data analysis and mining module, electronic prescription and management module, real-time monitoring and notification module, remote access and communication module. The medical record entry and management module is responsible for recording and managing the patient's medical record information. The privacy and security module is responsible for protecting patient privacy and data security in compliance with HIPAA regulations. The data analysis and mining module uses medical record data for statistical analysis, trend analysis and predictive analysis. The electronic prescription and management module is used to generate and manage electronic prescriptions and inventory and distribution of drugs. The real-time monitoring and notification module is responsible for monitoring the patient's condition and system operating status and providing real-time notifications. The remote access and communication module supports doctors and patients to access medical records and conduct remote diagnosis through mobile devices.

2. The electronic medical record management system according to claim 1, characterized in that: The system also includes a user management and business module and an appointment and scheduling module. The user management and business module is responsible for managing the account information and permissions of doctors, nurses, administrators and patients, and connecting with the clinical business system. The appointment and scheduling module is responsible for managing patients' appointments and connecting with the scheduling information of medical staff.

3. The electronic medical record management system according to claim 2, characterized in that: The user management and business module uses MFA and RBAC to complete user identity verification and permission granting, realizes data exchange and interoperability between different systems through HL7 standards, and uses data compression algorithms to reduce bandwidth usage and storage requirements for data exchange.

4. The electronic medical record management system according to claim 3, characterized in that: The medical record entry and management module realizes the entry of electronic medical records by calling standardized medical terminology, and improves the entry efficiency by combining high-frequency word recommendation and association follow-up input, directly generates the medical record front page and discharge summary based on the medical record, and improves the efficiency and quality of medical record writing.

5. The electronic medical record management system according to claim 4, characterized in that: The data analysis and mining module processes the electronic medical records through data mining, and constructs multi-dimensional medical knowledge management based on the knowledge graph according to the analysis and mining results. In this process, natural language processing is used to identify the entities of the electronic medical records.

6. The electronic medical record management system according to claim 5, characterized in that: The electronic prescription and management module analyzes and detects the drugs and their dosages in the electronic prescription through a drug interaction check algorithm and a drug dosage calculation algorithm to improve the quality and safety of the electronic prescription, and uses an inventory management algorithm to manage drug inventory and distribution.

7. An electronic medical record management system according to claim 6, characterized in that: The real-time monitoring and notification module applies real-time data stream processing to ensure that data can be processed immediately when it is received, and uses isolation forest to construct a randomly generated tree to isolate abnormal samples, thereby quickly detecting outliers to achieve timely detection and response to electronic medical record data anomalies.

8. An electronic medical record management method, characterized in that: include: Step 1: When a patient registers or visits a doctor for the first time, the system will automatically create an electronic medical record for the patient, and the staff will enter the patient's basic information into the system to ensure that the information is accurate; Step 2: When seeing a patient, the doctor will make a diagnosis and develop a treatment plan based on the patient's symptoms and signs. The overall content will be automatically recorded in the electronic medical record to facilitate subsequent treatment and follow-up; Step 3: After the pharmacy staff prepares the medicine according to the prescription information and confirms the dispensing through the system, the dispensing information will be automatically updated to the patient's electronic medical record to ensure the accuracy of the medicine usage information; Step 4: Allow authorized users to view and download medical records, which is convenient for doctors to analyze the condition and make treatment decisions. It also provides medical record statistical analysis functions to help users understand the distribution of diseases and treatment effects. Step 5. The application for modification of medical record information shall be submitted by the relevant doctor or staff, and the reason and basis for the modification shall be attached. After review and approval, the system will modify the medical record information and save the modification record.

9. The electronic medical record management method according to claim 8, characterized in that: The method strictly controls user access rights to ensure that only authorized users can access and modify medical record data, regularly performs data backup and recovery tests to prevent data loss or damage, and supports the export and printing of medical records to meet the needs of internal management of medical institutions and patient inquiries.

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