电子病历(文档模板形式、结构化形式、半结构化形式)的应用有一个难题，就是客户化。特别在中国目前没有统一的病历书写标准，卫生部有一个书写规范却没有成为国家标准，各地有各地的书写规范，而且这些书写规范是针对手工书写制定的，明显不适应电子病历的要求，现在除好像除了word或类似Word的病历模板，其它客户化工作很难在开发商这里进行。

客户化工作还有其它问题，不同医院管理要求不同，按教科书做的模板(包括各种输入选项)等，可能一线医生很难接受。比如一套体格检查下来就是一大段，但实际上不同科室、不同医院要求却不同。

还就有时现有的公司的技术人员，很少可能同时还是医学行业的专家，所以能够总结的东西也很少。

那电子病历应该如何客户化？还是不需要在生产商那里进行客户化，直接在实施时进行客户化？

呵呵，我就是从临床医师转到电子病历等临床信息化研究上的，虽然我称不上医疗行业的专家，也称不上医疗信息化方面的专家，但我想我的这段经历也许能对临床信息化的公司有所帮助，欢迎一起讨论电子病历的问题！

其实国内有不少信息科主任都是由医师转过来的，包括不少国内著名医院，上次跟人聊天，甚至说他现在还有上门诊的班，佩服他们！

现在的客户化是不是把手工的作业流程再电脑复现一次?

不妨看看openEHR（http://www.openEHR.org）【wikiMIForum】所做的工作，如原始型(Archetype) 和模板(Template)。

在没有大家公认的病种模版出现前，最好的办法是教会医生自己做模版。这个话题在CHIMA论坛上讨论过。嘉和公司的电子病历系统和广总的都能做到这一点。即用陈联忠的书写器就能做到。

回楼上：嘉和公司的电子病历系统和广州军区总医院的系统实际上是一套系统。

但我的想法是电子病历的内涵绝对不是一个编辑器就能解决的。

最近嘉和的广告贴似乎有点太多了，嘿嘿

楼上的，你认为不是一个编辑器能够解决，那么到底电子病历的【内涵】是什么？这个内涵在当前的技术和法律条件下，应该着重实现的重点又是什么呢？愿闻其详。

问题关键是谁来做？

做的模板能否得到使用者-医生的认可？

随着电子病历的普及，医学会可发展一个模版委员会来发表指导性模版，这样开发商的工作量就小一些，医院也不担心自己的模版是否完善。当然，这只能解决一般问题，书写器本身还允许医生发挥自由描述和自建节点的需要，以满足个性化的需求。

我有一篇英文的关于电子病历里功能的英文文章很全面，可能对理解内涵有用，但文章是PDF的，很长，我不会上传，可上HIMMS查找。电子病历的内涵不是讨论出来的，而是由无数功能体现出来的，核心是记录--record.主观记录和客观记录，这里采集是一切的出发点。在中国，如果我们的采集都无法很好的实现，如果我们的采集的文档无法满足医政管理的要求，一切就无从谈起。

电子病历系统帮助医护人员加快工作流是通过集成来完成的，他的跨系统跨医疗机构的交换是通过信息标准化来实现的。对目前到中国医院来讲，完成结构化采集存储，能调用医技科室报告，能实现院内医护人员间的交流，病历能网上流转，完成这些可能就要3-5年。但这些确实能对医院的效率有帮助。

至于诊疗决策支持，这是需要医学专家先完成知识库建设，任何厂家提供的专家系统都是难于被广泛接受的。万一有医疗纠纷，厂家还可能担责任。.

此帖由 claude 在 2006-08-30 11:27 进行编辑...

引用大肚能容 @ 2006-08-30 09:48)

楼上的，你认为不是一个编辑器能够解决，那么到底电子病历的【内涵】是什么？这个内涵在当前的技术和法律条件下，应该着重实现的重点又是什么呢？愿闻其详。

看来跟我较上真了！

我个人的体会是电子病历首先就是记录，如果局限EMR，那记录的内容是就诊过程中医疗过程的信息集合及相关的信息集合。这些信息可以是目前临床医疗文书（也就是目前所指的病历），也包括由挂号、药房、PACS、LIS、重症监护、麻醉系统、手术系统、心电系统等产生的信息，也包括患者自己提供的病情信息，也许以上还说的不全，但大概就是这么个意思。

将以上信息以集中的，连贯的、友好的方式展现给医护人员，就是电子病历要做的内容。这里强调几点、一是单点登录即可浏览所有病情有关的信息，二是对问题的跟踪功能等。

至于什么临床决策支持，CPOE等，由于与其它知识库等密切相关，大概就属于外延了。

以上纯属胡言乱语，没有细想，有不同意见者欢迎提出来。

模板应该是医生来做，或者是代表医生的专业协会等组织来做，因为那是专业问题

但是模板的基本模型则需要HIT方面的专家的帮助

关键是将这些专业领域的知识从信息系统的模型中分离出来，这样才好让医生们来更好地借助信息系统，利用自己的知识，依据自身专业的实际需要，构建原始型和模板（源于对openEHR的理解，不知对否，请各位老师指正）

archetype
    openEHR-EHR-OBSERVATION.blood_film.v1
concept
    [at0000]

description
    original_author = <
        ["email"] = <"sam.heard@oceaninformatics.biz">
        ["date"] = <"9/03/2005">
        ["name"] = <"Sam Heard">
        ["organisation"] = <"Ocean Informatics">
    >
    lifecycle_state = <"AuthorDraft">
    details = <
        ["en"] = <
            language = <"en">
            purpose = <"To record observations on a blood film including microscopic findings and cell counts.">
            copyright = <"test">
            use = <"This archetype can be used for one or all of the elements recorded, such as a haemaglobin alone or a complete blood picture.">
            misuse = <"This archetype is not a full laboratory report and requires diagnosis and other assessments to be recorded using other archetypes">
        >
        ["zh-cn"] = <
            language = <"zh-cn">
            purpose = <"旨在记录对血液涂片的观察结果，包括显微镜下的所见以及细胞计数。">
            copyright = <"test">
            use = <"本原始型可用于所记录的一个或所有元素，如单纯的血红蛋白或者一份完整的血液图片（血常规）">
            misuse = <"本原始型并不是一份完整的实验室报告，还需要使用其他原始型来记录诊断及其他评估">
        >
    >

definition
    OBSERVATION[at0000] matches {
        data matches {
            HISTORY[at0001] matches {
                events cardinality matches {0..*; unordered} matches {
                    EVENT[at0002] occurrences matches {0..*} matches {
                        data matches {
                            ITEM_TREE[at0003] matches {
                                items cardinality matches {1..*; ordered} matches {
                                    ELEMENT[at0004] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0005] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0006] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0007] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0008] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0009] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0010] occurrences matches {0..1} matches {
                                        value matches {
                                            QUANTITY_RATIO matches {
                                                numerator matches {
                                                    COUNT matches {*}
                                                }
                                                denominator matches {
                                                    COUNT matches {*}
                                                }
                                            }
                                        }
                                    }
                                    ELEMENT[at0011] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0012] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0013] occurrences matches {0..1} matches {*}
                                    CLUSTER[at0014] occurrences matches {0..1} matches {
                                        items cardinality matches {1..5; ordered} matches {
                                            ELEMENT[at0015] occurrences matches {0..1} matches {*}
                                            ELEMENT[at0016] occurrences matches {0..1} matches {*}
                                            ELEMENT[at0017] occurrences matches {0..1} matches {*}
                                            ELEMENT[at0018] occurrences matches {0..1} matches {*}
                                            ELEMENT[at0019] occurrences matches {0..1} matches {*}
                                        }
                                    }
                                    ELEMENT[at0020] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0021] occurrences matches {0..1} matches {
                                        value matches {
                                            QUANTITY_RATIO matches {
                                                numerator matches {
                                                    COUNT matches {*}
                                                }
                                                denominator matches {
                                                    COUNT matches {*}
                                                }
                                            }
                                        }
                                    }
                                    ELEMENT[at0022] occurrences matches {0..1} matches {*}
                                    ELEMENT[at0024] occurrences matches {0..1} matches {
                                        value matches {
                                            TEXT matches {*}
                                        }
                                    }
                                    ELEMENT[at0023] occurrences matches {0..1} matches {
                                        value matches {
                                            TEXT matches {*}
                                        }
                                    }
                                }
                            }
                        }
                    }
                }
            }
        }
        protocol matches {
            ITEM_TREE[at0025] matches {
                items cardinality matches {0..*; unordered} matches {
                    CLUSTER[at0026] occurrences matches {0..1} matches {
                        items cardinality matches {0..*; unordered} matches {
                            ELEMENT[at0027] occurrences matches {0..1} matches {
                                value matches {
                                    TEXT matches {*}
                                }
                            }
                            ELEMENT[at0028] occurrences matches {0..1} matches {
                                value matches {
                                    CODED_TEXT matches {*}
                                }
                            }
                        }
                    }
                    CLUSTER[at0029] occurrences matches {0..1} matches {
                        items cardinality matches {0..*; unordered} matches {
                            ELEMENT[at0030] occurrences matches {0..1} matches {
                                value matches {yyyy-??-?? ??:??:??}
                            }
                            ELEMENT[at0031] occurrences matches {0..1} matches {
                                value matches {yyyy-??-?? ??:??:??}
                            }
                        }
                    }
                    CLUSTER[at0032] occurrences matches {0..1} matches {
                        items cardinality matches {0..*; unordered} matches {
                            ELEMENT[at0033] occurrences matches {0..1} matches {
                                value matches {
                                    TEXT matches {*}
                                }
                            }
                            ELEMENT[at0034] occurrences matches {0..1} matches {
                                value matches {
                                    TEXT matches {*}
                                }
                            }
                        }
                    }
                }
            }
        }
    }

ontology
    primary_language = <"en">
    languages_available = <"en", "zh-cn", ...>
    term_definitions = <
        ["en"] = <
            items = <
                ["at0000"] = <
                    text = <"Complete blood picture">
                    description = <"The full blood count or examination normally reported by a haematology laboratory">
                >
                ["at0001"] = <
                    text = <"history">
                    description = <"@ internal @">
                >
                ["at0002"] = <
                    text = <"any event">
                    description = <"*">
                >
                ["at0003"] = <
                    text = <"structure">
                    description = <"@ internal @">
                >
                ["at0004"] = <
                    text = <"Haemaglobin">
                    description = <"The mass concentration of haemaglobin">
                >
                ["at0005"] = <
                    text = <"Red cell count (RCC)">
                    description = <"The number of red blood cells per litre">
                >
                ["at0006"] = <
                    text = <"Packed cell volume (PCV)">
                    description = <"The proportion of the volume of blood taken up by red blood cells">
                >
                ["at0007"] = <
                    text = <"Mean cell haemaglobin concentration (MCHC)">
                    description = <"The average haemaglobin concentration in the red blood cells">
                >
                ["at0008"] = <
                    text = <"Mean cell volume (MCV)">
                    description = <"The average volume of the red blood cells (PCV/RCC)">
                >
                ["at0009"] = <
                    text = <"Mean cell haemaglobin (MCH)">
                    description = <"The average haemaglobin content of red blood cells">
                >
                ["at0010"] = <
                    text = <"Red cell distribution width (RDW)">
                    description = <"The variation in red cell volume">
                >
                ["at0011"] = <
                    text = <"Erythrocyte sedimentation rate (ESR)">
                    description = <"The velocity of sedimentation of red cells in the first hour">
                >
                ["at0012"] = <
                    text = <"Platelet count">
                    description = <"The number of platelets per litre">
                >
                ["at0013"] = <
                    text = <"White cell count">
                    description = <"The number of white cells per litre">
                >
                ["at0014"] = <
                    text = <"White cell differential">
                    description = <"The differential count of white cells or leukocytes">
                >
                ["at0015"] = <
                    text = <"Neutrophils">
                    description = <"The number of neutrophils per litre">
                >
                ["at0016"] = <
                    text = <"Lymphocytes">
                    description = <"The number of lymphocytes per litre">
                >
                ["at0017"] = <
                    text = <"Basophils">
                    description = <"The number of basophils per litre">
                >
                ["at0018"] = <
                    text = <"Monocytes">
                    description = <"The number of monocytes per litre">
                >
                ["at0019"] = <
                    text = <"Eosinophils">
                    description = <"The number of eosinophils per litre">
                >
                ["at0020"] = <
                    text = <"Mean platelet volume">
                    description = <"The average platelet volume">
                >
                ["at0021"] = <
                    text = <"Platelet distribution width">
                    description = <"The variation in platelet volume">
                >
                ["at0022"] = <
                    text = <"Plateletcrit">
                    description = <"The proportion of the volume of blood taken up by platelets">
                >
                ["at0023"] = <
                    text = <"Microscopic features">
                    description = <"The features of the blood film on microscopy">
                >
                ["at0024"] = <
                    text = <"Comment">
                    description = <"Comment on the findings">
                >
                ["at0025"] = <
                    text = <"Tree">
                    description = <"@ internal @">
                >
                ["at0026"] = <
                    text = <"Identification">
                    description = <"Information identifying the laboratory and specimen">
                >
                ["at0027"] = <
                    text = <"Specimen identification">
                    description = <"Indentifying information about the specimen">
                >
                ["at0028"] = <
                    text = <"Laboratory identification">
                    description = <"Information identifying the laboratory">
                >
                ["at0029"] = <
                    text = <"Specimen details">
                    description = <"Information about the specimen">
                >
                ["at0030"] = <
                    text = <"DateTime received">
                    description = <"The date and time the specimen was received">
                >
                ["at0031"] = <
                    text = <"DateTime processed">
                    description = <"The date and time the specimen was processed">
                >
                ["at0032"] = <
                    text = <"Methods">
                    description = <"*">
                >
                ["at0033"] = <
                    text = <"Processing details">
                    description = <"Information about the process followed to generate the report">
                >
                ["at0034"] = <
                    text = <"Device">
                    description = <"Information about the device used">
                >
            >
        >

        ["zh-cn"] = <
            items = <
                ["at0000"] = <
                    text = <"全血图片（血常规）">
                    description = <"血液学实验室通常所报告的全血细胞计数或检查结果">
                >
                ["at0001"] = <
                    text = <"history">
                    description = <"@ internal @">
                >
                ["at0002"] = <
                    text = <"any event">
                    description = <"*">
                >
                ["at0003"] = <
                    text = <"structure">
                    description = <"@ internal @">
                >
                ["at0004"] = <
                    text = <"血红蛋白">
                    description = <"血红蛋白的质量浓度">
                >
                ["at0005"] = <
                    text = <"红细胞计数(RCC)">
                    description = <"每升中红细胞的数量">
                >
                ["at0006"] = <
                    text = <"红细胞比积 (PCV)">
                    description = <"红细胞占据血液体积的比例">
                >
                ["at0007"] = <
                    text = <"平均红细胞血红蛋白浓度 (MCHC)">
                    description = <"红细胞中血红蛋白的平均浓度">
                >
                ["at0008"] = <
                    text = <"平均红细胞体积">
                    description = <"红细胞的平均体积 (PCV/RCC)">
                >
                ["at0009"] = <
                    text = <"平均红细胞血红蛋白 (MCH)">
                    description = <"红细胞中血红蛋白的平均含量">
                >
                ["at0010"] = <
                    text = <"红细胞分布宽度 (RDW)">
                    description = <"红细胞体积的变异程度">
                >
                ["at0011"] = <
                    text = <"红细胞沉降率 (ESR)">
                    description = <"红细胞在第一小时中的沉降速度">
                >
                ["at0012"] = <
                    text = <"血小板计数">
                    description = <"每升中血小板的数量">
                >
                ["at0013"] = <
                    text = <"白细胞计数">
                    description = <"每升中白细胞的数量">
                >
                ["at0014"] = <
                    text = <"白细胞分类">
                    description = <"白细胞的分类计数">
                >
                ["at0015"] = <
                    text = <"嗜中性粒细胞">
                    description = <"每升中嗜中性粒细胞的数量">
                >
                ["at0016"] = <
                    text = <"淋巴细胞">
                    description = <"每升中淋巴细胞的数量">
                >
                ["at0017"] = <
                    text = <"嗜碱性粒细胞">
                    description = <"每升中嗜碱性粒细胞的数量">
                >
                ["at0018"] = <
                    text = <"单核细胞">
                    description = <"每升中单核细胞的数量">
                >
                ["at0019"] = <
                    text = <"嗜酸性粒细胞">
                    description = <"每升中嗜酸性粒细胞的数量">
                >
                ["at0020"] = <
                    text = <"平均血小板体积">
                    description = <"血小板的平均体积">
                >
                ["at0021"] = <
                    text = <"血小板分布宽度">
                    description = <"血小板体积的变异程度">
                >
                ["at0022"] = <
                    text = <"血小板比积">
                    description = <"血小板占据血液体积的比例">
                >
                ["at0023"] = <
                    text = <"显微特征">
                    description = <"血液涂片在显微镜下的特征">
                >
                ["at0024"] = <
                    text = <"注释">
                    description = <"关于所见的注释">
                >
                ["at0025"] = <
                    text = <"Tree">
                    description = <"@ internal @">
                >
                ["at0026"] = <
                    text = <"标识">
                    description = <"标识实验室和标本的信息">
                >
                ["at0027"] = <
                    text = <"标本标识">
                    description = <"关于标本的标识信息">
                >
                ["at0028"] = <
                    text = <"实验室标识">
                    description = <"标识实验室的信息">
                >
                ["at0029"] = <
                    text = <"标本详情">
                    description = <"关于标本的信息">
                >
                ["at0030"] = <
                    text = <"收到日期与时间">
                    description = <"标本的收到日期与时间">
                >
                ["at0031"] = <
                    text = <"处理日期与时间">
                    description = <"标本的处理日期与时间">
                >
                ["at0032"] = <
                    text = <"方法">
                    description = <"*">
                >
                ["at0033"] = <
                    text = <"处理详情">
                    description = <"关于为产生报告所遵循的过程的信息">
                >
                ["at0034"] = <
                    text = <"设备">
                    description = <"关于所用设备的信息">
                >
            >
        >
    >
    constraint_definitions = <
        ["en"] = <
            items = <
            >
        >

        ["zh-cn"] = <
            items = <
            >
        >
    >

此帖由 linforest 在 2006-08-30 19:33 进行编辑...

同意楼上的，模板只是辅助快速输入的工具，客户需要的是一个可以方便的自定义模板的工具。

至于什么规范，我想还用不到模板上。深层次上的电子病历模型，元素的规范，才是重点吧

电子病历问题不是电子病历文档问题，从文档角度解决电子病历问题注定会出问题。

电子病历 目前要解决的问题应该包括：

1、时间属性问题。

2、组织协作问题。

3、元素粒度及其进一步利用问题。

4、树型结构及其本质问题。

5、与滞后法规之间的协调问题。

6、信息标准问题。