CN102819656B - Generate the system and method for electronic health record - Google Patents
Generate the system and method for electronic health record Download PDFInfo
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Abstract
The invention provides a kind of system generating electronic health record, this system comprises: standard management device, there is provided the logical relation between data element and described data element specified electronic health record data standard to carry out the software module of visual typing, editor, the information according to typing generates data element document; Electronic health record template generation unit, read data elements document, generates edit model interface visually according to data element document, receives user and inputs generation electronic health record template; Electronic health record generation unit, selects according to training classification and/or patient information and loads described electronic health record template, according to the user interface of electronic health record template dynamic creation for medical personnel's typing electronic health record data, receives user instruction and generates electronic health record.Adopt said system, make medical personnel can carry out visualized operation to natural language, and the electronic health record generated meets the computing machine semantic expressiveness that electronic health record standard specifies.In addition, a kind of method generating electronic health record is additionally provided.
Description
[technical field]
The present invention relates to electronic health record technical field, more particularly, relate to a kind of system and method generating electronic health record.
[background technology]
Electronic health record is the major way that sufferer medical information is preserved and safeguarded, is also the important means that sufferer health status information is shared in whole medical system.The medical information system that current various big hospital uses adopts data inputting template privately owned separately and typing structure mostly, and the electronic health record therefore generated is difficult to share.
Due to the clinical needs of complexity, electronic health record template often with professional section office (as division of endocrinology, liver and gall surgical department etc.), clinical business procedure (as head examine, postoperative, health examination etc.), the difference of hospital (as City Hospitals, District hospital, community hospital etc.) and disease specific and different, need to create electronic health record template targetedly, and this process needs clinician to participate in usually.For privately owned data inputting template, clinician only need carry out typing by natural language drawing template establishment content.But in order to make electronic health record and the electronic health record operating such of generation, also require that electronic health record template and electronic health record comprise term, the information such as coding and logical relation of electronic health record prescribed by standard on the basis of natural language.Because doctor is uncomfortable to these number languages for computing machine semantic understanding, the difficulty of simultaneously editing the natural language in electronic health record template and electronic health record and number language content is larger.Therefore a kind of system and method is needed, the computing machine semantic information in electronic health record template and electronic health record can be hidden to doctor, doctor only can generate and editing electronic medical record templates and electronic health record according to the operation of natural language, and the electronic health record produced meets the requirement of electronic health record standard in term, coding, structure etc. automatically.
[summary of the invention]
Based on this, be necessary to provide a kind of system generating electronic health record, make medical personnel only need carry out visualized operation to natural language and can produce electronic health record, and the electronic health record generated meets the computing machine semantic representation method that electronic health record standard specifies.
A kind of system generating electronic health record, described system comprises: standard management device, there is provided the logical relation between data element and described data element specified electronic health record data standard to carry out the software module of visual typing, editor, the information according to typing generates data element document; Electronic health record template generation unit, reads described data element document, generates edit model interface visually according to described data element document, receives user and inputs generation electronic health record template; Electronic health record generation unit, select according to training classification and/or patient information and load described electronic health record template, according to the user interface of described electronic health record template dynamic creation for medical personnel's typing electronic health record data, receive user instruction and generate electronic health record.
Preferably, described standard management device be further used for described data element and between the computer representation of logical relation expand, increase the context relation information of data element, comprise the option scope representing the semanteme of data element, the information of logical relation and optional daughter element.
Preferably, described electronic health record template generation unit comprises one for generating the user interface of electronic health record template, this interface by data element document graphical display portion and graphical display portion two parts of electronic health record template form; Natural language information in data element document and institutional framework thereof are that each data element creates a visual back end, the corresponding relation between service data node and respective data element at the graphical display portion of described data element document; The graphical display portion of electronic health record template is that each data element in template creates a visual natural language back end, and the corresponding relation between service data node and respective data element; Described electronic health record template generation unit receives the operational order of user further, by described back end from data element document graphic software platform interface copy to the graphic software platform interface of described electronic health record template, data element corresponding for copied back end is copied to the correct position of electronic health record template simultaneously.
Preferably, described electronic health record generation unit comprises: template selector, selects according to selected user or the training classification of doctor and/or the disease information of patient and loads electronic health record template; Patient management module, for selecting patient, management and acquisition patient information; User management module, for selecting user, management and acquisition user profile; Input interface generates engine, supply the natural language user interface element of medical personnel's typing electronic health record data according to the natural language information in selected electronic health record template and institutional framework dynamic creation, and set up the corresponding relation of the data element in described interface element and electronic health record template.Electronic health record generates engine, is combined by data element corresponding with interface element for user's input information, generates the electronic health record data element comprising the instantiation of given patient information, and copies to the relevant position of electronic health record; Display interface, for showing electronic health record user input interface.
Preferably, described electronic health record generation unit comprises: data element service condition record analysis unit, for the frequency to data element appearance in electronic health record use procedure, sequentially, the probability simultaneously occurred, and the conditional probability of above-mentioned statistic under specific main suit, doctor's training, season, regional context carries out calculating, record; The automatic adjustment unit of electronic health record template, for the statistics according to described record analysis unit, adjusts the position of the data element in electronic health record template and data element automatically; The automatic adjustment unit in visual electronic health record interface, according to the statistics of described record analysis unit, the position of back end in visualization interface automatically in adjustment electronic health record template.
In addition, there is a need to provide a kind of method generating electronic health record, make medical personnel can carry out visualized operation to natural language, and the electronic health record generated meets the computing machine semantic representation method that electronic health record standard specifies.
A kind of method generating electronic health record, said method comprising the steps of: the logical relation between the data element specified electronic health record data standard by software module and described data element carries out visual typing, editor, and the information according to typing generates data element document; Read described data element document, generate edit model interface visually according to described data element document, receive user and input generation electronic health record template; Select according to training classification and/or patient information and load described electronic health record template, according to the user interface of described electronic health record template dynamic creation for medical personnel's typing electronic health record data, receiving user instruction and generate electronic health record.
Preferably, the step of described generation data element document specifically comprises: further to described data element and between the computer representation of logical relation expand, increase the context relation information of data element, comprise the option scope representing the semanteme of data element, the information of logical relation and optional daughter element.
Preferably, the step of described structure electronic health record template specifically comprises: read data elements document, be that each data element creates a visual back end according to the natural language information in data element document and institutional framework thereof at data element document graphical display portion, and the corresponding relation between service data node and respective data element; Reading electronic health record template, is that each data element in electronic health record template creates a visual back end in the electronic health record template graphics display section of graphical interfaces according to the natural language information in electronic health record template and institutional framework thereof; Receive the operational order of user, by back end from data element document graphic software platform interface copy to the graphic software platform interface of described electronic health record template, data element corresponding for copied back end is copied to the correct position of electronic health record template simultaneously.
Preferably, the concrete steps of described generation electronic health record comprise: select patient obtain patient medical information and/or select user or doctor's training classification; Disease information according to selected user or doctor's training classification and/or patient is selected and loads electronic health record template; Supply the natural language user interface element of medical personnel's typing electronic health record data according to the natural language information in selected electronic health record template and institutional framework dynamic creation, set up the corresponding relation of the data element in described interface element and electronic health record template; Electronic health record user input interface is used to receive user's input; Data element corresponding with interface element for user's input information is combined, generates the electronic health record data element comprising the instantiation of given patient information, and copy to the relevant position of electronic health record.
Preferably, described method also comprises: the frequency, sequentially occurred data element in electronic health record use procedure, the statistical informations such as the probability simultaneously occurred, and the conditional probability of above-mentioned statistic under specific main suit, doctor's training, season, regional context carries out calculating, record; According to described statistics, automatically the position of the data element in electronic health record template and data element is adjusted; According to described statistics, the position of back end in visualization interface automatically in adjustment electronic health record template.
The system and method for above-mentioned generation electronic health record, logical relation between the data element specified electronic health record data standard by software module and data element carries out visual typing, editor, information according to typing generates data element document, according to the visual generation edit model interface of data element document energy, user, by edit model interface input information, produces electronic health record template.In the electronic health record template generation stage, because used electronic health record template dependant is in concrete hospital business, user's training, disease etc., need user to participate in customization process.Make medical personnel only need carry out visualized operation to natural language and can produce electronic health record, and the electronic health record generated meets the computing machine semantic representation method that electronic health record standard specifies.
By using visual natural language back end to the data element in user's display data element document, and allow the unnatural language information such as coding and structured message to user transparent.User the method for visualizing such as can to pull by mouse and from all data elements, selects different subsets and reconfigure according to certain order, produce the electronic health record template being applicable to user's practical business, the data element in template meets the regulation of electronic health record standard; At electronic health record generation phase, user uses the electronic health record template of customization dynamically to generate natural language interface element for electronic health record typing, medical personnel can use this interface typing electronic health record data, the data element that the electronic health record data of medical personnel's typing are corresponding with natural language information on user's input interface combines, the electronic health record data element comprising particular data can be generated, this electronic health record data element is copied to the relevant position of electronic health record, generate electronic health record.Because electronic health record template have employed the data element of term, coding and the structural information structure meeting electronic health record standard, the electronic health record thus using said system and method to produce has the feature with electronic health record operating such.On the other hand, because doctor can use natural language to create electronic health record template and electronic health record by visualization method for specified disease or clinical business, make medical personnel can carry out visualized operation to natural language, the electronic health record generated has the good computing machine feature of semanteme, has good dirigibility, practicality and extensibility.
[accompanying drawing explanation]
Fig. 1 is the structural representation generating the system of electronic health record in an embodiment;
Fig. 2 A is the interface schematic diagram of data element document management in the first embodiment;
Fig. 2 B is the interface schematic diagram of data element document management in the second embodiment;
Fig. 2 C is the interface schematic diagram of data element document management in the 3rd embodiment;
Fig. 2 D is the interface schematic diagram of data element document management in the 4th embodiment;
Fig. 2 E is another interface schematic diagram of data element document management in the 4th embodiment;
Fig. 3 is the user interface schematic diagram building electronic health record template in an embodiment;
Fig. 4 is the structural representation of electronic health record generation unit in an embodiment;
Fig. 5 is the process flow diagram generating the method for electronic health record in an embodiment;
Fig. 6 is the process flow diagram generating the method for electronic health record in an embodiment.
[embodiment]
Fig. 1 shows the system generating electronic health record in an embodiment, and this system comprises standard management device 100, electronic health record template generation unit 200 and electronic health record generation unit 300, wherein:
The software module of standard management device 100 for providing the logical relation between data element and data element specified electronic health record data standard to carry out visual typing, editor, and generate data element document according to the information of typing.In one embodiment, electronic health record data standard can be the various electronic health record standards specified, such as health ministry has issued " electronic health record basic framework and data standard (exposure draft) " August in this year, has wherein made regulation to term, coding and storage organization that electronic health record should be followed.
In one embodiment, standard management device 100 be also further used for data element and between the computer representation of logical relation expand, increase the context relation information of data element, comprise the option scope representing the semanteme of data element, the information of logical relation and optional daughter element.Under the prerequisite meeting electronic health record standard, electronic health record is made to have better medical information ability to express and medical profession tenability.
In one embodiment, the data element of standard management device 100 also for being specified by described user interface typing electronic health record data standard, by the logical relation between data element described in the structure of data and coded representation.In addition, also the data element that electronic health record data standard specifies can be expanded, comprise and increase self-defining metadata and computing machine semantic information.
Fig. 2 A shows user and clicks in standard management device and add the user interface after top mode, dynamically generates in right panel the data element that corresponding data element input interface specifies for typing electronic health record standard.Click ACK button after user's typing corresponding information, interface shown in Fig. 2 B will be produced.The data element information of typing from Fig. 2 B, Fig. 2 A creates a new node (being designated as red node) at Left-Hand Panel.Fig. 2 C shows the interface that user adds subdata node element in standard management device.User selects a back end (red node represent current choose node) at template manager Left-Hand Panel, then clicks and adds child node button, dynamically will produce interface shown in Fig. 2 C right panel.When user selects " floating number " option in the combo box that Fig. 2 C right panel " Value Types " label is corresponding, interface shown in Fig. 2 D right panel dynamically will be produced.As shown in the mark in Fig. 2 D, the entry item dynamically produced both had comprised electronic health record standard-required " floating number " data element of type requires the information (as unit) of typing also to comprise the information of system extension, as upper limits of normal, normal limits etc.When user's typing corresponding information click confirming button in the interface of Fig. 2 D, template manager will show interface shown in Fig. 2 E, the data element of typing as can be seen from Fig. 2 E, Fig. 2 C and Fig. 2 D creates a new node (being designated as red node) at the Left-Hand Panel of Fig. 2 E.
Electronic health record template generation unit 200, for read data elements document, builds electronic health record template according to data element document.In one embodiment, electronic health record template generation unit 200 comprises one for generating the user interface of electronic health record template, and this interface is made up of the graphical display portion of data element document and graphical display portion two parts of electronic health record template.Natural language information in data element document and institutional framework thereof are that each data element creates a visual back end, the corresponding relation between service data node and respective data element at the graphical display portion of described data element document.The graphical display portion of electronic health record template is that each data element in template creates a visual natural language back end, and the corresponding relation between service data node and respective data element.Electronic health record template generation unit 200 is further used for the operational order receiving user, by described back end from data element document graphic software platform interface copy to the graphic software platform interface of described electronic health record template, data element corresponding for copied back end is copied to the correct position of electronic health record template simultaneously.
Fig. 4 shows the user interface building electronic health record template in an embodiment, wherein, is represented by the data element that electronic health record standard specifies by form that is tree-shaped or list.In panel on the left of Fig. 4, the corresponding data element (comprising corresponding medical terminology, coding, metadata etc.) of the back end of each natural language, the institutional framework of the node tree formed has reacted the logical relation between the different pieces of information element of electronic health record prescribed by standard; In the panel on right side, the visual structure presenting electronic health record template, wherein each visual back end still corresponds to a data element, but data element subset choose and institutional framework has reacted logical relation between the data element relevant to specified disease or clinical business.
As shown in Fig. 4 Left-Hand Panel, electronic health record template generation unit 200 presents by this graphical interfaces the natural language information comprised in data element according to the institutional framework meeting medical logic, and user is concealed to the coding and computing machine semantic information that comprise in data element.User pulls by carrying out mouse to back end and/or copies stickup, visual this back end is inserted into relevant position in right panel, meanwhile, the data element that this visual back end is corresponding copies to position suitable in electronic health record template document.User, by controlling the position of the selection of visualizes nodes, the order pulled and placement, can generate the electronic health record template for various disease and training.In one embodiment, user carries out mouse to the back end for specified disease or clinical business in Fig. 4 Left-Hand Panel and pulls or copy stickup, the data element causing visualizes nodes corresponding is dissolved in electronic health record template document corresponding to right panel by this process, thus the electronic health record template that can create for specified disease or clinical business, the electronic health record template generated remains the full detail of selected data subset of elements, and add the logical relation relevant to specified disease and/or clinical business, be structurized medical files.
Electronic health record generation unit 300 is for selecting according to training classification and/or patient information and loading described electronic health record template, according to the electronic health record user input interface of described electronic health record template dynamic creation for medical personnel's typing electronic health record data, receive user instruction and generate electronic health record.In one embodiment, electronic health record generation unit 300 also receives the electronic health record data of medical personnel's typing by user's input interface, and the data element corresponding with interface element combines, generate the electronic health record data element comprising the instantiation of given patient information, electronic health record data element is copied to the relevant position of electronic health record, realize generation and the editor of electronic health record.
Fig. 5 shows the electronic health record generation unit 300 in an embodiment, and it comprises template selector 301, patient management module 302, input interface generation engine 3 02, user management module 304 and display interface 305, wherein:
Template selector 301 is for selecting according to the training classification of selected user or doctor and/or patient information and load electronic health record template; Patient management module 302, for managing patient information, comprise the essential information (as name, age etc.) of patient, hospital information of registering (as patient the training classification, kinds of Diseases etc. of hanging); Input interface generates the data in the electronic health record template that engine 3 03 loads according to template selector 301, dynamic creation is for the electronic health record user input interface of medical personnel's typing electronic health record data, this electronic health record user input interface shows the natural language information comprised in electronic health record template, and hides computing machine semantic information to user; User management module 304, for managing user information, comprises medical personnel place section office, affiliated training classification etc.; Display interface 305 is for showing described electronic health record user input interface.
In one embodiment, input interface generates engine 3 03 and resolves selection electronic health record template, according to natural language information dynamic creation electronic health record user input interface wherein, received the electronic health record data of medical personnel's typing by this user's input interface.Quantitative typing (as numerical value check result), sxemiquantitative typing (as negative, positive etc.), template or Select input (as selected symptom, sign, medication, drug effect, complication, spinoff etc. from limited option) and free typing (by medical personnel oneself fill message etc.) is comprised for the form of typing.The data element that the electronic health record data of typing are corresponding with natural language information on interface combines, and produces electronic health record data element and copies in the electronic health record of generation.Medical personnel also can carry out mark strengthening (such as illustrate some symptoms are difficult to explain, significant etc.) to certain some medical record information.
In one embodiment, electronic health record generation unit 300 comprises data element service condition record analysis unit, the automatic adjustment unit (not shown) of the automatic adjustment unit of electronic health record template and visual electronic health record interface.Wherein: data element service condition record analysis unit, for the frequency to data element appearance in electronic health record use procedure, sequentially, the probability simultaneously occurred, and the conditional probability of above-mentioned statistic under specific main suit, doctor's training, season, regional context carries out calculating, record; The automatic adjustment unit of electronic health record template is used for the statistics according to described record analysis unit, automatically adjusts the position of the data element in electronic health record template and data element; The automatic adjustment unit in visual electronic health record interface, according to the statistics of described record analysis unit, the position of back end in visualization interface automatically in adjustment electronic health record template.。Like this, electronic health record template automatically can adjust according to the service condition of user after deployment, makes user more easily access the content oneself often used, and strengthens the ease for use of template.
Fig. 5 shows the method flow generating electronic health record in an embodiment, and detailed process is as follows:
In the step s 100, the logical relation between the data element specified electronic health record data standard by software module and described data element carries out visual typing, editor, generates data element document.As previously mentioned, electronic health record data standard can be the various electronic health record standards specified.Such as health ministry has issued " electronic health record basic framework and data standard (exposure draft) " August in this year, has wherein made regulation to term, coding and storage organization that electronic health record should be followed.
In a way of example, step S100 is specially: to described data element and between the computer representation of logical relation expand, increase the context relation information of data element, comprise the option scope representing the semanteme of data element, the information of logical relation and optional daughter element.Fig. 2 A shows user and clicks in standard management device and add the user interface after top mode, dynamically generates in right panel the data element that corresponding data element input interface specifies for typing electronic health record standard.Click ACK button after user's typing corresponding information, interface shown in Fig. 2 B will be produced.The data element information of typing from Fig. 2 B, Fig. 2 A creates a new node (being designated as red node) at Left-Hand Panel.Fig. 2 C shows the interface that user adds subdata node element in standard management device.User selects a back end (red node represent current choose node) at template manager Left-Hand Panel, then clicks and adds child node button, dynamically will produce interface shown in Fig. 2 C right panel.When user selects " floating number " option in the combo box that Fig. 2 C right panel " Value Types " label is corresponding, interface shown in Fig. 2 D right panel dynamically will be produced.As shown in the mark in Fig. 2 D, the entry item dynamically produced both had comprised electronic health record standard-required " floating number " data element of type requires the information (as unit) of typing also to comprise the information of system extension, as upper limits of normal, normal limits etc.When user's typing corresponding information click confirming button in the interface of Fig. 2 D, template manager will show interface shown in Fig. 2 E, the data element of typing as can be seen from Fig. 2 E, Fig. 2 C and Fig. 2 D creates a new node (being designated as red node) at the Left-Hand Panel of Fig. 2 E.In step s 102, the corresponding relation between natural language and computing machine semanteme is set up by structurized organizational form.In the electronic health record generated, constraint and scope, the correlation properties etc. of data in the position (having reacted between different pieces of information unit in the classificatory logical relation of medical terminology) that should occur and medical terminology corresponding to each data element, coding, case history, are inputted owing to defining basic terms collection (data element set), the different pieces of information unit that should use in Electronic Medical Record in electronic health record standard.In these information, a part is the natural language information (as medical terminology) for doctor's read-write, another partial information (as coding) carries out analysis retrieval for helping computing machine to the semanteme of electronic health record, corresponding relation between both has done clear and definite regulation in electronic health record standard, thus safeguards this corresponding relation by structurized computer representation.
In step s 200, read data elements document, generates edit model interface visually according to described data element document, receives user and inputs generation electronic health record template.In one embodiment, the detailed process of step S200 is:
Read data elements document, be that each data element creates a visual back end according to the natural language information in data element document and institutional framework thereof at data element document graphical display portion, and the corresponding relation between service data node and respective data element.
Reading electronic health record template, is that each data element in electronic health record template creates a visual back end in the electronic health record template graphics display section of graphical interfaces according to the natural language information in electronic health record template and institutional framework thereof.
Receive the operational order of user, by back end from data element document graphic software platform interface copy to the graphic software platform interface of described electronic health record template, data element corresponding for copied back end is copied to the correct position of electronic health record template simultaneously.
Although the basic terms doctor collection in electronic health record data standard covers during electronic health record generates most of term that may run into, but because data volume is too huge, medical personnel will therefrom select the term subset relevant to given patient very difficult, therefore need to concentrate from basic terms according to doctor's training and disease to select the typing of a subset for electronic health record.Although often the disease kind of process is very limited in diagnosis and treatment business for most doctor, with the difference of the factors such as area, training, hospital size and condition, doctor may be variant to the terminology that same disease is conventional.In addition, doctor waits the information-organization style being used for computing machine semantic understanding uncomfortable to coding, therefore needs to hide these computing machine semantic informations to doctor.In one embodiment, build the interface of electronic health record template as shown in Figure 3, its form by tree-shaped or list is with the logical relation between natural language demonstrating data element and element.
As previously described, in one embodiment, pull by carrying out mouse to back end and/or copy stickup, visually corresponding data element is copied to position suitable in template document, user can for specified disease or back end corresponding to clinical service selection, the data element that the back end pulling and/or copy is corresponding is automatically inserted into the relevant position of the electronic health record template of generation, by producing the visual display of the electronic health record template of renewal on a user interface.The electronic health record template generated remains the full detail of selected data subset of elements, and adds the logical relation relevant to specified disease and/or clinical business, is structurized medical files.
In one embodiment, build in the process of electronic health record template, also can the frequency of utilization of data element in recorded electronic medical record templates, according to the display position of frequency of utilization adjustment back end on graphical interfaces of described data element, and data element the putting in order in the data store organisation of electronic health record template that adjustment back end is corresponding.User is facilitated again to select these back end.
In step S300, select according to training classification and/or patient information and load electronic health record template, create the electronic health record user input interface for medical personnel's typing electronic health record data according to the Data Dynamic in electronic health record template, receive user instruction and generate electronic health record.
When user uses electronic health record template, can select according to training classification (section office as medical personnel place), patient information (a certain class disease as patient) etc. and load corresponding electronic health record template.Input interface generates engine 3 03 and resolves the electronic health record template selected, and create electronic health record user input interface according to the Data Dynamic in electronic health record template, interface content can comprise check box, option list etc.As implied above, the typing form that electronic health record user input interface provides comprises quantitative typing, sxemiquantitative typing, Select input and free typing etc.Electronic health record template due to employing comprises the data element that electronic health record data standard specifies, thus by the data of user's typing are merged mutually with respective data element, the semantic information (as coding, structure, metadata) that respective data element can be comprised copies in the electronic health record of generation, make the electronic health record generated automatically meet electronic health record standard, and there is the intelligible semanteme of computing machine.
As shown in Figure 6, in one embodiment, the detailed process of step S300 is:
Step S301, selects patient obtain patient medical information and/or select user or doctor's training classification.
Step S302, the disease information according to selected user or doctor's training classification and/or patient is selected and loads electronic health record template.
Step S303, supply the natural language user interface element of medical personnel's typing electronic health record data according to the natural language information in selected electronic health record template and institutional framework dynamic creation, set up the corresponding relation of the data element in described interface element and electronic health record template.
Step S304, uses electronic health record user input interface to receive user's input.
Step S305, combines data element corresponding with interface element for user's input information, generates the electronic health record data element comprising the instantiation of given patient information, and copies to the relevant position of electronic health record.
In another embodiment, said method also comprises:
To the frequency that data element in electronic health record use procedure occurs, sequentially, the statistical informations such as joint probability, and the conditional probability of above-mentioned statistic under the contexts such as specific main suit, doctor's training, season, area carries out calculating, record.According to the statistics of above-noted, automatically the position of the data element in electronic health record template and data element is adjusted.According to the statistics of record, the position of back end in visualization interface automatically in adjustment electronic health record template.Like this, electronic health record template automatically can adjust according to the service condition of user after deployment, makes user more easily access the content often used, and strengthens the ease for use of template.
The above embodiment only have expressed several embodiment of the present invention, and it describes comparatively concrete and detailed, but therefore can not be interpreted as the restriction to the scope of the claims of the present invention.It should be pointed out that for the person of ordinary skill of the art, without departing from the inventive concept of the premise, can also make some distortion and improvement, these all belong to protection scope of the present invention.Therefore, the protection domain of patent of the present invention should be as the criterion with claims.
Claims (8)
1. generate a system for electronic health record, it is characterized in that, described system comprises:
Standard management device, provide the logical relation between data element and described data element specified electronic health record data standard to carry out the software module of visual typing, editor, the information according to typing generates data element document;
Electronic health record template generation unit, read described data element document, edit model interface is generated visually according to described data element document, by using visual natural language back end to user's display data element document, allow coding and these unnatural language information of structured message to user transparent, receive user and input generation electronic health record template;
Electronic health record generation unit, select according to training classification and/or patient information and load described electronic health record template, according to the user interface of described electronic health record template dynamic creation for medical personnel's typing electronic health record data, receive user instruction and generate electronic health record;
Described electronic health record template generation unit comprises one for generating the user interface of electronic health record template, and this interface is made up of the graphical display portion of data element document and graphical display portion two parts of electronic health record template;
Natural language information in data element document and institutional framework thereof are that each data element creates a visual back end, the corresponding relation between service data node and respective data element at the graphical display portion of described data element document;
The graphical display portion of electronic health record template is that each data element in template creates a visual natural language back end, and the corresponding relation between service data node and respective data element;
Described electronic health record template generation unit receives the operational order of user further, by described back end from data element document graphic software platform interface copy to the graphic software platform interface of described electronic health record template, data element corresponding for copied back end is copied to the correct position of electronic health record template simultaneously.
2. the system of generation electronic health record according to claim 1, it is characterized in that, described standard management device be further used for described data element and between the computer representation of logical relation expand, increase the context relation information of data element, comprise the option scope representing the semanteme of data element, the information of logical relation and optional daughter element.
3. the system of generation electronic health record according to claim 1, is characterized in that, described electronic health record generation unit comprises:
Template selector, selects according to selected user or the training classification of doctor and/or the disease information of patient and loads electronic health record template;
Patient management module, for selecting patient, management and acquisition patient information;
User management module, for selecting user, management and acquisition user profile;
Input interface generates engine, supply the natural language user interface element of medical personnel's typing electronic health record data according to the natural language information in selected electronic health record template and institutional framework dynamic creation, and set up the corresponding relation of the data element in described interface element and electronic health record template;
Electronic health record generates engine, is combined by data element corresponding with interface element for user's input information, generates the electronic health record data element comprising the instantiation of given patient information, and copies to the relevant position of electronic health record;
Display interface, for showing electronic health record user input interface.
4. the system of generation electronic health record according to claim 1, is characterized in that, described electronic health record generation unit comprises:
Data element service condition record analysis unit, for the frequency to data element appearance in electronic health record use procedure, sequentially, the probability simultaneously occurred, and the frequency, sequentially that above-mentioned data element occurs, the conditional probability of the probability simultaneously occurred under specific main suit, doctor's training, season, regional context carries out calculating, record;
The automatic adjustment unit of electronic health record template, for the statistics according to described data element service condition record analysis unit, adjusts the position of the data element in electronic health record template and data element automatically;
The automatic adjustment unit in visual electronic health record interface, according to the statistics of described data element service condition record analysis unit, the position of back end in visualization interface automatically in adjustment electronic health record template.
5. generate a method for electronic health record, it is characterized in that, said method comprising the steps of:
Logical relation between the data element specified electronic health record data standard by software module and described data element carries out visual typing, editor, and the information according to typing generates data element document;
Read described data element document, edit model interface is generated visually according to described data element document, by using visual natural language back end to user's display data element document, allow coding and these unnatural language information of structured message to user transparent, receive user and input generation electronic health record template, the step generating electronic health record template specifically comprises:
Read data elements document, be that each data element creates a visual back end according to the natural language information in data element document and institutional framework thereof at data element document graphical display portion, and the corresponding relation between service data node and respective data element;
Reading electronic health record template, is that each data element in electronic health record template creates a visual back end in the electronic health record template graphics display section of graphical interfaces according to the natural language information in electronic health record template and institutional framework thereof;
Receive the operational order of user, back end is copied to the graphic software platform interface of described electronic health record template from the graphic software platform interface of data element document, data element corresponding for copied back end is copied to the correct position of electronic health record template simultaneously;
Select according to training classification and/or patient information and load described electronic health record template, according to the user interface of described electronic health record template dynamic creation for medical personnel's typing electronic health record data, receiving user instruction and generate electronic health record.
6. the method for generation electronic health record according to claim 5, is characterized in that, the step of described generation data element document specifically comprises:
Further to described data element and between the computer representation of logical relation expand, increase the context relation information of data element, comprise the option scope representing the semanteme of data element, the information of logical relation and optional daughter element.
7. the method for generation electronic health record according to claim 5, is characterized in that, the concrete steps of described generation electronic health record comprise:
Patient is selected to obtain patient medical information and/or select user or doctor's training classification;
Disease information according to selected user or doctor's training classification and/or patient is selected and loads electronic health record template;
Supply the natural language user interface element of medical personnel's typing electronic health record data according to the natural language information in selected electronic health record template and institutional framework dynamic creation, set up the corresponding relation of the data element in described interface element and electronic health record template;
Electronic health record user input interface is used to receive user's input;
Data element corresponding with interface element for user's input information is combined, generates the electronic health record data element comprising the instantiation of given patient information, and copy to the relevant position of electronic health record.
8. the method for generation electronic health record according to claim 5, is characterized in that, described method also comprises:
To the frequency, sequentially that data element in electronic health record use procedure occurs, the probability simultaneously occurred, and the frequency, sequentially that above-mentioned data element occurs, the conditional probability of the probability simultaneously occurred under specific main suit, doctor's training, season, regional context carries out calculating, record;
According to the statistics of record, automatically the position of the data element in electronic health record template and data element is adjusted;
According to the statistics of record, the position of back end in visualization interface automatically in adjustment electronic health record template.
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