With the rapid development of day surgery mode in China, day surgery management has shifted from extensive to refined, but there are still many problems in the information system of day surgery in Chinese hospitals. The Second Affiliated Hospital Zhejiang University School of Medicine has developed a day surgery information management system since 2018, established a pre-hospital and in-hospital day surgery ecological management, and integrated daily management concepts and management rules into the system through the whole-process information management. It realized the whole process, full data, closed-loop and path-based information management of day surgery. This paper introduces the day surgery information management system of the Second Affiliated Hospital Zhejiang University School of Medicine, and aims to share the experience of building the day surgery information management function module.
According to system reform of the current medical insurance diagnosis related groups, quality control of rehabilitation medicine and requirements of information management, this paper constructs a rehabilitation information system by using the theoretical framework and core sets of International Classification of Functioning, Disability and Health (ICF). Then, the constructed system is embedded into the work of rehabilitation medicine team. By the four processes of ICF items evaluation, rehabilitation goal setting, team cooperation scheme formulation and reevaluation, the operation process of rehabilitation information management based on ICF is formed, which strengthens comprehensively the rehabilitation diagnosis and treatment standards and improves the efficiency of quality control management. The big data mining and multi-dimensional analysis in this platform can provide support of medical insurance payment, achieve exchanging and sharing rehabilitation medical quality control data among hospitals at different levels in different regions, assist tertiary referral and remote rehabilitation, improve the rehabilitation medical service system, and enhance the level of rehabilitation medical care. This paper will summarize the application experience of constructing ICF rehabilitation information management system.
Objective To examine the feasibility and efficacy of narcotic drugs and the first psychotropic drugs of category handover procedures, which based on CA certification electronic signature technology in the anesthesia information management system. Methods The handover of narcotic drugs and the first class psychotropic drugs in 30 operating rooms of the Department of Anesthesiology at West China Tianfu Hospital of Sichuan University between June and July 2023 was selected as the research object. According to the handover of narcotic drugs and the first class psychotropic drugs, the 30 operating rooms that were handed over using paper-based system in June 2023 were designated as the traditional handover group, the 30 operating rooms that were handed over using CA certification electronic signature technology in July 2023 were designated as the paperless handover group. The time spent on quality control of management of narcotic and psychoactive drugs, the time spent on the handover of narcotic and psychiatric drugs, and the users’ effort degree and satisfaction by anesthesiologists and nurses were compared between the two groups. Results The traditional handover group completed 3027 surgeries, while the paperless handover group completed 3022 surgeries. There were no statistically significant difference in the daily average number of surgeries completed in the operating rooms [(137.59±10.81) vs.(137.36±11.98) cases] and usage of narcotics drugs and the first class psychotropic drugs [(713.91 ± 7.24) vs. (716.64 ± 6.53) pills] between the TPH and paperless handover groups. The time of checking drug handover records [(35.80±3.07) vs. (3.89±0.43）min] and the cost time of drugs handover [(6.07±0.55) vs. (3.57±0.39）min] in the traditional handover group were higher than those in the paperless handover group (P<0.001). The average laborious degres [(3.17±1.17) vs. (4.34±0.70)] and the satisfaction [(3.75±1.09) vs. (4.64±0.52)] of the traditional handover group are lower than those of the paperless handover group (P<0.001). Conclusions CA certification electronic signature technology significantly enhances management efficiency, reduces non-technical workload, optimizes the healthcare experience, and enables permanent storage and real-time retrieval of electronic records. It complies with data security and ecological healthcare requirements, making it highly worthy of application.
A mobile operating room information management system with electronic medical record (EMR) is designed to improve work efficiency and to enhance the patient information sharing. In the operating room, this system acquires the information from various medical devices through the Client/Server (C/S) pattern, and automatically generates XML-based EMR. Outside the operating room, this system provides information access service by using the Browser/Server (B/S) pattern. Software test shows that this system can correctly collect medical information from equipment and clearly display the real-time waveform. By achieving surgery records with higher quality and sharing the information among mobile medical units, this system can effectively reduce doctors' workload and promote the information construction of the field hospital.