大数据时代背景下公立医疗卫生机构病案信息管理现状及对策探讨OA

Objective To deeply explore the actual situation of medical record information management in public medical insti-tutions under the background of big data era through empirical research method,so as to provide data support and practical refer-ence for the optimization of management mode.Methods 116 public medical institutions were chosen from 6 provinces in east Chi-na,north China and southwest China using stratified cluster sampling method.Data were collected through field research,ques-tionnaires and in-depth interview.And quantitative research was conducted using statistical analysis software of SPSS 26.0.Re-sults In terms of management architecture,there were significant differences in affiliation structure of medical record management departments among different level of hospitals.The proportion of medical record management in independent departments was 40.48%in tertiary hospitals,in quality control department and information department was 35.59%and 23.73%respectively in secondary hospitals,and in medical department was 66.67%in primary hospitals.There were hierarchical differences in person-nel allocation.In tertiary hospitals,the ratio of beds to medical record staffs was 104.58:1,far exceeding the national recommen-ded standard(≤50:1).Their educational level was decreased with the hospital level.There were significant differences in edu-cational level composition of staff among different levels of hospitals(χ2=34.255,P＜0.05).In terms of quality control and in-formation security management of medical records,there were hierarchical differences.Regarding quality control,popularity rate of terminal quality control was the highest(93.10%).There was full coverage in tertiary hospitals,while the proportion was 80.00%in primary hospitals.There were significant differences in implementation rate of terminal quality control among different levels of hospitals(χ2=7.351,P＜0.05).In information security management,implementation rate of automatically recording modification traces in electronic medical records was the highest(66.38%),while the implementation rate of hierarchical access control was the lowest(59.48%).In terms of medical records archiving efficiency,3d and 7d archiving rates in tertiary hospi-tals,secondary hospitals,primary or ungraded hospitals was(92.42%,97.78%),(85.30%,94.27%)and(79.55%,90.26%),respectively.Conclusion There are problems such as insufficient architecture adaptation,unbalanced human resource load,imperfect quality control system and weak information security in medical record management of public medical institutions.It is necessary to optimize the management architecture to adapt to data governance demand,alleviate human resource contradic-tion,strengthen whole-process quality control and information security construction,and promote digitalization and professional-ization transformation of medical record management.