HIS (LIS, PACS, RIS, EMR) system solution
I. Definition descriptionHospital Information System,HIS), using electronic computers and communication equipment, to provide the hospital departments with the ability to collect, store, process, extract and exchange patient diagnosis and treatment information and administrative information, and meet the functional requirements of all authorized users. Laboratory Information Management System (LMIS)LIS), is a set of information management system designed for the hospital laboratory, can be the experimental instrument and computer network, so that the patient sample login, experimental data access, report review, print distribution, statistical analysis of experimental data and other complex operation process to achieve intelligent, automated and standardized management. It helps to improve the overall management level of the laboratory, reduce loopholes and improve the quality of testing. Picture Archiving and Communication Systems,PACSIn recent years, with the rapid development of digital imaging technology, computer technology and network technology, medical image acquisition, display, storage, transmission and management of a comprehensive system. Radioiogy Information System,RIS) is a software system for optimizing the workflow management of hospital radiology department. A typical workflow includes registration, appointment, treatment, image generation, film production, report, audit, film distribution and other links. Electronic Medical RecordEMR), refers to the traditional paper medical record fully electronic, and provide electronic storage, query, statistics, data exchange, such as management mode, it is information technology and network technology, the inevitable outcome of the application in the medical field is the inevitable trend in the hospital computer network management, at present this field research application has become a new research hotspot.Second, the overviewHospital Information System (HIS) is a huge and complex modern information management system, which includes financial, personnel, inpatient, outpatient, registration, medical technology, billing, triage, drug management and other subsystems. After years of development, HIS system has been endowed with more functions: With the continuous sorting and integration of the hospital’s internal business processes, HIS and LIS,PACS,RIS,EMR and other peripheral modules are constantly integrated. With the continuous expansion of the connotation and extension of health informatization, the business and data exchanges between HIS and social security, medical insurance and even banking systems are more and more frequent. HIS system has become the core engine system for business driving, process integration and service capability improvement in the medical industry. 1. Construction Objective V To build an advanced and comprehensive modern digital hospital with patients as the center, electronic medical records as the core, comprehensive integration as the means and the goal of improving hospital management level and operating efficiency. Digital hospital construction is to build a comprehensive management information system and clinical information system, the most advanced IT technology to the floor with the latest information resources (people, goods, content, medical information) to conduct a comprehensive digital, comprehensive optimization and integration of the hospital internal resources and external information resource of the whole society to the hospital clinical, management services, Use all information resources to provide advanced, convenient and humanized medical services for patients; V Humanization: People-oriented, patient-centered principle, humanistic care should be reflected in every detail of the system, considering how to be more convenient for patients, more convenient for business personnel, more humanized. V Integration: Hospital information system construction will be formed by a large number of different systems, and form an organic unified whole, to avoid medical information island. V Intelligence: through the intelligent processing of the system, reduce manual links, enhance the degree of automation, increase the function of auxiliary support. V paperless: gradually go paperless through the application of electronic prescription, electronic medical record, electronic application form, electronic report, etc. V Film-free: Through the implementation of medical imaging system, the establishment of digital film reading center and diagnostic workstation in radiology Department, digital film reading room in clinical center, doctor image browsing workstation, digital film reading center in the whole hospital, consultation center, teaching center and so on to achieve film-free clinical mode and management mode of the whole hospital. V Wireless network: through the establishment of wireless network, the use of notebook, tablet computer, PDA, wireless disease tracker and other wireless devices to achieve doctors and nurses ward rounds, warehouse management, patient tracking and so on, so that some businesses are not limited by space, everywhere. 2. The features of Jingqi HIS system V are designed based on an integrated public basic data platform, which establishes a complete working platform for medical workers. V Realized the integration of accounting, clinical, decision-making and service information. V realized the integration of LIS, PACS, RIS, EMR and other systems. V Comprehensive introduction of clinical pathway management. V Support medical research and clinical quality control. V integrated design, simplify the software and hardware structure of the system, reduce the cost of system development, implementation and maintenance, improve the efficiency of the system, easy to upgrade. V Seamless integration with regional health information systems.Iii. General construction ideas1. Patient-centered, medical information as the main line. V Adopt medical card technology, simplify the patient’s medical treatment process, convenient for doctors and patients; The PACS system and LIS system combine the imaging and laboratory results with the basic information of the patient, so that various vital indicators of the patient can be obtained timely and accurately on the doctor workstation. The design idea of V system is to integrate all kinds of medical information through the recording of clinical information, and on this basis generate information accumulation of cost, until the clinical information system with medical, teaching and research as the core is formed in medical treatment. 2. Data management service V system with strict authority control mechanism, so that the information and data is safe and reliable, work role to determine the work authority of each person; Adopt unified drug management mode, and control the purchase, warehousing, warehousing, price adjustment and inventory of drugs in the management of drug storehouse and pharmacy; Prescription and medical advice integration, doctor workstation to issue prescription and medical advice, using a unified price system; Dean query system, dynamic query for dean to provide decision-making basis.Fourth, the overall framework of the systemThe functional analysis of the framework is described as follows:(1) Hospital information system ****1. Outpatient management system, medicine management systemV Basic components: outpatient and emergency registration, outpatient and emergency charging, doctor workstation, outpatient and emergency electronic medical record. V Support appointment registration, follow-up registration, doctor registration. V Support automatic charging, manual charging, refund, etc. V Support medical insurance, self-funded patients and other types of patients, and flexibly set the patient type. V Support electronic prescription directly written by doctors and electronic prescription input by specially-assigned persons in the clinic, and support a variety of input schemes. The use of electronic prescription can effectively control the abnormal consumption of drugs, realize the electronization of outpatient treatment sheet, laboratory sheet and examination sheet, simplify the patient’s treatment procedure, and effectively solve the phenomenon of “three long and one short” in outpatient and emergency department.(1) Outpatient and emergency registrationV Outpatient registration: support different types of registration, different types of fees, first visit and return visit, same-day and appointment, number limit management, etc. V Registration information inquiry: hold the combination inquiry according to the patient’s name, medical record number, registration time, registration department, etc. V registrar personal statistics: according to the time period or the receipt of the charge and workload statistics V registrar personal query: according to the time period or the receipt of the query of the current registrar hanging registration information V receipt of the query: query the current registrar receipt of the use of v reconciliation statistics: Count the use, charge and return of a registered clerk’s receipt in a specified time period, and print it.(2) Outpatient feesV window charging: automatically check the charging items information such as prescription, treatment sheet, examination sheet and inspection sheet from the clinic and medical technology department, and allow the cashier to manually input the charging items that are not connected to the network, and maintain the drug inventory of the pharmacy after charging. V Window refund: Handle the front desk refund business. V Receipt inquiry: the cashier can inquire personal charge information at any time, including the use of the receipt, the number of invalid tickets, the amount of charges. V Invalid receipt processing: this function is used to process invalid receipts. V statistical delivery: after a receipt is used up, the cashier classifies and summarizes the charging information of the receipt for delivery with the background.(3) Outpatient doctor workstationDoctor V completed the input and editing of prescriptions, the generation of examination sheets and treatment sheets and other relevant medical information processing. V Information configuration: The configuration information includes the corresponding relationship between various prescriptions and pharmacies, toll office, patient information source, prescription issuing place, prescription fee category, and whether to print prescriptions. V Prescription entry and editing: complete the entry and modification of prescription and narcotic prescription, and provide a variety of drug entry schemes. Agreement prescription maintenance: according to the medication characteristics of specialized diseases and the medication habits of specialized doctors, some customary formulations can be made into agreement prescriptions. Treatment list: according to the prescribed medication and implementation plan to generate treatment list. Examination and laboratory test list: request for examination or laboratory test according to the condition(4) Outpatient electronic medical recordsV Basic information of outpatients, outpatient and emergency medical records, blood transfusion records, special examination and treatment consent, outpatient surgery consent, notification of critical illness, nosocomial infection investigation report 2. Basic components of inpatient management subsystem V: inpatient discharge management, ward bed management, doctor workstation, accounting management, inpatient electronic medical record management. V Adopt electronic medical advice to provide multiple input methods and support real-time drug inventory retrieval. V will automatically classify the medical advice into long-term medical advice and short-term medical advice, and can automatically decompose and print oral single, muscle injection single, intravenous single, nursing single and infusion card, improve work efficiency. V According to the doctor’s order process, can be automatically generated by the doctor’s order and various detailed cost information, effectively reduce human error. V Support automatic and manual charging. V Support cost accounting by single section and provide real-time analysis and statistics.(1) Entry and discharge managementV Admission registration: complete the entry of patients’ basic information and support different charging types. V Admission modification: Modify the information of registered patients. If the patient already has a bed number, the department and department information cannot be changed. V Discharge management: Transfer of patient information from the current database to the discharge database. Include patient basic information form, advance payment, bookkeeping, invoice and so on. V Discharged patient regression: The discharged patient’s information is transferred back to the current database from the history database. V Bookkeeping: record the use of the patient’s expenses and reduce the patient’s expense balance. Able to receive fees generated by medical orders in the ward (unchangeable information).(2) Doctor’s workstationV Medical advice book: input, proofread, modify and delete medical advice. V Medical order sheet: print the patient’s long-term and short-term medical order sheet, and classify the medication list and nursing list. V Four orders: break down the medical order into four orders: oral, intramuscular, intravenous and nursing. V Doctor’s order transmission: calculate the quantity and cost of medicine for the patient, inform the pharmacy to prepare for dispensing medicine. V Automatic charges: charges are made for long-term non-medical orders and fixed daily charges. V Transfer management: transfer patients to other departments. V Infusion card printing: patient infusion card printing.(3) Electronic medical record management in hospitalV patients basic information, temperature nursing records, long-term orders, temporary orders, medical record home page, admission, discharge records records, hospital records, general treatment disposal records, operation records, special nursing, special nursing records, operation records, general nursing record, hospitalization duration, record, for the first time duration of the consultation, etc. V daily course record, preoperative summary, the information presented, outside experts consultation application of hospitalized patients, the hospital go out leave application form, became very ill (crisis) notice, invasive diagnosis, treatment, operation agreement, special examination and treatment of consent agreement, blood transfusion, automatic discharge, discharge notice or transfer agreement, operation agreement , special examination and treatment consent, blood transfusion consent, surgical consent, notice of serious illness (critical condition), anesthesia consent v other medical informed consent, infectious disease report, nosocomial infection survey form, v summary of medical history.3.Basic components of drug management subsystem V: drug storehouse management, outpatient pharmacy management, inpatient pharmacy management, preparation management, narcotic drug management, drug standard data maintenance. V Adopt modular design idea, can flexibly configure medicine storehouse and pharmacy according to different hospitals. V The inpatient pharmacy automatically monitors the information of medication orders in the ward. V Support the pharmacy department and hospital leaders to inquire about the purchase, sale and storage of drugs in each warehouse. V supports more than one medicine, and the index is simple and fast, which provides a guarantee for the realization of electronic prescription and electronic medical advice. V Unified management, release drug information at any time.(1) Drug storehouse managementV Drug storage: support planned storage and unplanned storage, change inventory and record profit and loss. Including the preparation and audit of warehouse receipt. V Please take out of the warehouse: the handover relationship between the pharmacy transferring drugs from the warehouse is called please take out of the warehouse. For the warehouse, it is called please take out of the warehouse. The inventory of the warehouse decreases while the inventory of the pharmacy increases. V. Drugstore withdrawal: drugstore returns drugs to drugstore, drugstore inventory increases while drugstore inventory decreases, and drugstore fulfills the right of audit. V Loss report of drug storehouse: measures taken by the drug storehouse to deal with expired or damaged drugs that can no longer be used, reducing the stock of the drug storehouse. Including the preparation and audit of loss report. V Drug warehouse inventory: including accounting inventory, firm inventory and audit of firm inventory.(2) Pharmacy managementV Please take in storage: the handover relationship of drugs transferred from the pharmacy is called please take in storage. For the pharmacy, it is called Please take in storage. The inventory of the pharmacy decreases while the inventory of the pharmacy increases. Transfer out: transfer of drugs from pharmacy to another store by transfer. The stock in this pharmacy is reduced and the stock in another warehouse is increased. V Pharmacy return: return drugs not suitable for the pharmacy to the pharmacy. Inventory in pharmacies decreased, and inventory in drug warehouses increased. V Reported loss of drugs: the measures taken by the pharmacy to deal with a small amount of damaged, expired and other drugs that cannot be used again reduce the inventory of the pharmacy. Including the preparation and audit of loss report. V Patient return: Return unnecessary or unsuitable drugs to patients. According to the release of drugs, the increase of pharmacy inventory. V Prescription dispensing: including prescription review, prescription and dispensing. To deal with unqualified prescriptions for doctors to modify. V Doctor’s Order drug delivery: automatically receive the doctor’s order drug delivery from the ward, and according to the temporary doctor’s order, long-term doctor’s order, oral medicine, non-oral medicine, preparation, etc., generate drug delivery list for the pharmacy.(2) Medical Image Storage and Transmission System (PACS)V Through the implementation of hospital-wide PACS, image data can be shared in all clinical departments. Realize the whole process control and management from patient information registration – image data acquisition – transmission – storage – query – soft reading – diagnosis/electronic report – storage and other application levels.(1) Image collection**(2) storage and management ****(3) call and post-processing function ****(4) communication function **(3) Hospital laboratory System (LIS)****(1) Examination of medical ordersTests prescribed and required by doctor V for the treatment of patients’ diseases, such as blood routine, urine routine, liver function, two-fifty, glucose tolerance, etc., may be individual items or combination items, and the doctor’s orders are written in the patient’s medical history book.(2) Electronic examination of medical ordersV In order to realize the charge of patients, nurses through the computer system input medical records in the examination of medical advice, thus formed, according to the charging unit standard, stored in the computer system, electronic examination of medical advice. For example, in the medical record book, the examination medical advice is written as “liver function plus blood sugar”, and after the electronic is two electronic medical advice “liver function” and “blood sugar”.(3) Inspection application formDr. V wrote the voucher issued by the nurse as a result of the sample, and finally provided to the laboratory technician for the test operation. There is a unique serial number on the inspection request form. It contains information about the patient and the tests that the patient will undergo.(4) Electronic inspection application formV Inspection application forms stored in LIS or HIS system. It forms in a number of ways:A)It is done by LIS system alone.B)It is completed by HIS system alone. The nurse will input the test order into HIS system, and then HIS system will automatically transform the electronic test order (allowing manual adjustment) into the electronic test application form according to the set rules, or the nurse will input the test application form into HIS system.C)LIS system and HIS system cooperate to complete this task, and then LIS system will automatically transform the electronic test orders in HIS system into electronic test application forms according to the set rules (manual adjustment is allowed).(5) Test samplesV The nurse collects patient samples provided to the clinical laboratory for examination, such as blood, urine, stool, cerebrospinal fluid, etc. One sample corresponds to one test application form, and the two are one-to-one correspondence.(6) Inspection reportV Written reports containing test results issued to clinical departments after the laboratory departments accept test applications, complete sample tests and review results.(7) Electronic inspection reportV provides unified inspection reports through LIS system, which can be easily queried for reading and printing.(8) Inspection chargesV Test charges are calculated based on the doctor’s order. If the hospital has HIS system, HIS system will calculate the charges based on the electronic test order. When will HIS system start charging? There are generally three situations:A)After the electronic examination of medical advice, immediately charge;B)The inspection Department is charged after receiving the inspection application form or electronic inspection application;C)The clinical laboratory department charges only after releasing the test report or electronic test report to the clinical department.(9) Patient informationV Obtain natural attributes of patients, such as medical record number, name, gender, date of birth, etc., and obtain patient-related information in LIS system through medical record number stored in HIS system.