Chinese expert consensus on quality control and management of electronic medical records for thoracic surgery (version 2024)_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 Chinese Association of Thoracic Surgeons ,  Cross-Strait Medicine Exchange Association’s Thoracic Surgery Professional Committee , WU Jieping Medical Foundation’s Lung Cancer Professional Committee , Zhejiang Provincial Thoracic Surgeons Associations , Fujian Provincial Thoracic Surgeons Associations

Corresponding author：

Chinese Association of Thoracic Surgeons, Email: jiangjie06@126.com; Cross-Strait Medicine Exchange Association’s Thoracic Surgery Professional Committee, Email: dr_hujian@zju.edu.cn

Keywords：

Electronic medical records; thoracic surgery; quality control; artificial intelligence; expert consensus

DOI：

10.7507/1007-4848.202410041

Video：

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The application of inpatient electronic medical records (EMRs) is a crucial component of modern healthcare informatization, and also a key factor in improving medical quality and safety. Establishing standardized EMRs for thoracic surgery helps to standardize treatment processes, improve medical efficiency, enhance quality of care, and better ensure patient safety. It also facilitates the collection and use of standardized and structured data, promoting clinical decision-making, the application of artificial intelligence, and the development of specialized clinical centers. Considering relevant national policies, information standards, clinical practice challenges and latest research findings in thoracic surgery EMRs, Chinese Association of Thoracic Surgeons, Cross-Strait Medicine Exchange Association’s Thoracic Surgery Professional Committee, WU Jieping Medical Foundation’s Lung Cancer Professional Committee, Zhejiang Provincial Thoracic Surgeons Associations and Fujian Provincial Thoracic Surgeons Associations have explored innovative paths for EMRs development. Through multiple rounds of professional discussions and research, the "Chinese expert consensus on quality control and management of electronic medical records for thoracic surgery (2024 version)" was formulated. It aims to provide a reference for the construction and application of inpatient EMRs for thoracic surgeons and information professionals across China, promoting continuous improvement in the informatization and medical standards of the thoracic surgery field, and contributing to the construction of "healthy China".

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2.	国家卫生健康委办公厅. 关于进一步推进以电子病历为核心的医疗机构信息化建设工作的通知. (2018-08-22)[2024-09-26]. https://www.gov.cn/zhengce/zhengceku/2018-12/31/content_5435418.htm.General Office of the National Health Commission. Notice on further advancing the informatisation construction of medical institutions with electronic medical records as the core. https://www.gov.cn/zhengce/zhengceku/2018-12/31/content_5435418.htm. Accessed on September 26, 2024.
3.	国家卫生健康委办公厅. 关于印发电子病历系统应用水平分级评价管理办法(试行)及评价标准(试行)的通知. (2018-12-03)[2024-02-10]. http://www.nhc.gov.cn/yzygj/s7659/201812/3cae6834a65d48e9bfd783f3c7d54745.shtml.General Office of the National Health Commission. Notice on the issuance of the administrative measures for the grading evaluation of the application level of electronic medical record systems (trial) and the evaluation standards (trial). http://www.nhc.gov.cn/yzygj/s7659/201812/3cae6834a65d48e9bfd783f3c7d54745.shtml. Accessed on February 10, 2024.
4.	国家卫生健康委医院管理研究所. 关于印发电子病历系统应用水平分级评价工作规程和专家管理办法的通知. (2021-02-03)[2024-09-26]. https://niha.org.cn/prod-api/web/news/jobDetail/712.Hospital Management Research Institute of the National Health Commission. Notice on the issuance of the work procedures and expert management measures for the grading evaluation of the application level of electronic medical record systems. https://niha.org.cn/prod-api/web/news/jobDetail/712. Accessed on September 26, 2024.
5.	高春芳, 唐晓东, 罗娟. 电子病历系统应用现状及前景展望. 医疗卫生装备, 2013, 34(3): 76-78.Gao CF, Tang XD, Luo J. Current status and prospects of electronic medical record system application. Med Equipment, 2013, 34(3): 76-78.
6.	孙凤英, 于修义. 基于胸外科结构化电子病历的人工智能诊断系统构建实践. 中国数字医学, 2018, 13(11): 29-31.Sun FY, Yu XY. Practice of constructing an artificial intelligence diagnostic system based on structured electronic medical records in thoracic surgery. Chin Digit Med, 2018, 13(11): 29-31.
7.	石思恩, 于修义, 范晟, 等. 肺结节结构化电子病历在住院医师规范化培训中的应用. 中国胸心血管外科临床杂志, 2022, 29(6): 703-710.Shi SE, Yu XY, Fan Z, et al. Application of structured electronic medical records for lung nodules in standardized training of resident physicians. Chin J Clin Thorac Cardiovasc Surg, 2022, 29(6): 703-710.
8.	姜杰, 于修义. 基于标准化术语的胸外科结构化电子病历实践. 中国肺癌杂志, 2018, 21(4): 256-259.Jiang J, Yu XY. Practice of structured electronic medical records in thoracic surgery based on standardized terminology. Chin Lung Cancer J, 2018, 21(4): 256-259.
9.	王峥, 张洪, 吕军, 等. 人工智能辅助诊疗系统在肺小结节诊断中的应用—附1650例临床分析. 中华胸心血管外科杂志, 2023, 39(8): 466-471.Wang Z, Zhang H, Lü J, et al. Application of artificial intelligence-assisted diagnostic system in the diagnosis of pulmonary nodules: A clinical analysis of 1650 cases. Chin J Thorac Cardiovasc Surg, 2023, 39(8): 466-471.
10.	Zhang Y, Jiang B, Zhang L, et al. Lung nodule detectability of artificial intelligence-assisted CT image reading in lung cancer screening. Curr Med Imaging, 2022, 18(3): 327-334.
11.	冯云霞, 张润. 基于电子病历的肺癌诊断决策树算法. 计算机系统应用, 2019, 28(10): 257-263.Feng YX, Zhang R. Decision tree algorithms for lung cancer diagnosis based on electronic medical record. Comput Syst Appl, 2019, 28(10): 257-263.
12.	温麟琦, 杨盛诏, 王忠帅, 等. 基于SEER数据库的多原发肺癌临床特征分析及预后预测模型构建. 肿瘤研究与临床, 2024, 36(6): 446-453.Wen LQ, Yang SZ, Wang ZS, et al. Analysis of clinical characteristics and prognostic prediction model construction of multiple primary lung cancer based on SEER database. Tumor Res Clin, 2024, 36(6): 446-453.
13.	龙冰清, 熊曾, 刘书林, 等. 基于电子病历数据分析不同性别肺癌手术患者流行病学特征的差异. 数字医学与健康, 2024, 2(2): 98-101.Long BQ, Xiong Z, Liu SL, et al. Differences in epidemiological characteristics of lung cancer surgery patients of different sexes based on electronic medical record data analysis. Digit Med Health, 2024, 2(2): 98-101.
14.	Towe CW, Servais EL, Brown LM, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2023 update on outcomes and research. Ann Thorac Surg, 2024, 117(3): 489-496.
15.	Shukla M, Lin J, Seneviratne O. BlockIoT: Blockchain-based health data integration using IoT devices. AMIA Annu Symp Proc, 2021, 2021: 1119-28.
16.	Tang AS, Woldemariam SR, Miramontes S, et al. Harnessing EHR data for health research. Nat Med, 2024, 30(7): 1847-1855.
17.	Walsh JM, Borycki EM. A resilience model for moderating outcomes related to electronic medical record downtime. Stud Health Technol Inform, 2022, 289: 434-438.
18.	Servais EL, Towe CW, Brown LM, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2020 update on outcomes and research. Ann Thorac Surg, 2020, 110(3): 768-775.
19.	Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. BMJ Qual Saf, 2019, 28(4): 310-316.
20.	Wu KA, Boccaccio K, Buckles D, et al. Efforts to improve the billing accuracy of robotic-assisted thoracic surgery through education, updated procedure cards, and electronic medical record system changes. BMJ Open Qual, 2024, 13(2): e002710.
21.	卫生部关于印发《电子病历基本规范(试行)》的通知. (2010-03-04)[2024-09-26]. https://www.gov.cn/zwgk/2010-03/04/content_1547432.htm.Ministry of Health of the People's Republic of China notice on the issuance of the "Electronic Medical Record Basic Standards (Trial)". https://www.gov.cn/zwgk/2010-03/04/content_1547432.htm. Accessed on September 26, 2024.
22.	中华人民共和国国家卫生和计划生育委员会. 电子病历应用管理规范(试行). 中国实用乡村医师杂志, 2017, 24(6): 1-2, 6.National Health and Family Planning Commission of the People's Republic of China. Electronic medical record application management standards (Trial). Chin J Rural Pract, 2017, 24(6): 1-2, 6.
23.	胡坚, 刘伦旭, 张毅, 等. 人工智能一体化三维重建应用于胸外科的中国专家共识. 中国胸心血管外科临床杂志, 2023, 30(5): 641-646.Hu J, Liu LX, Zhang Y, et al. Chinese expert consensus on the application of integrated 3D reconstruction with artificial intelligence in thoracic surgery. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(5): 641-646.

1. 中华人民共和国卫生部. 卫生部关于印发《电子病历系统功能规范(试行)》的通知. (2011-01-04)[2024-09-26]. http://www.nhc.gov.cn/yzygj/s3585u/201012/c7e5e7d432f9417d92f52b0e7d215768.shtml.Ministry of Health of the People's Republic of China. Notice on the issuance of the "Electronic Medical Record System Functional Specifications (Trial)". http://www.nhc.gov.cn/yzygj/s3585u/201012/c7e5e7d432f9417d92f52b0e7d215768.shtml. Accessed on September 26, 2024.
2. 国家卫生健康委办公厅. 关于进一步推进以电子病历为核心的医疗机构信息化建设工作的通知. (2018-08-22)[2024-09-26]. https://www.gov.cn/zhengce/zhengceku/2018-12/31/content_5435418.htm.General Office of the National Health Commission. Notice on further advancing the informatisation construction of medical institutions with electronic medical records as the core. https://www.gov.cn/zhengce/zhengceku/2018-12/31/content_5435418.htm. Accessed on September 26, 2024.
3. 国家卫生健康委办公厅. 关于印发电子病历系统应用水平分级评价管理办法(试行)及评价标准(试行)的通知. (2018-12-03)[2024-02-10]. http://www.nhc.gov.cn/yzygj/s7659/201812/3cae6834a65d48e9bfd783f3c7d54745.shtml.General Office of the National Health Commission. Notice on the issuance of the administrative measures for the grading evaluation of the application level of electronic medical record systems (trial) and the evaluation standards (trial). http://www.nhc.gov.cn/yzygj/s7659/201812/3cae6834a65d48e9bfd783f3c7d54745.shtml. Accessed on February 10, 2024.
4. 国家卫生健康委医院管理研究所. 关于印发电子病历系统应用水平分级评价工作规程和专家管理办法的通知. (2021-02-03)[2024-09-26]. https://niha.org.cn/prod-api/web/news/jobDetail/712.Hospital Management Research Institute of the National Health Commission. Notice on the issuance of the work procedures and expert management measures for the grading evaluation of the application level of electronic medical record systems. https://niha.org.cn/prod-api/web/news/jobDetail/712. Accessed on September 26, 2024.
5. 高春芳, 唐晓东, 罗娟. 电子病历系统应用现状及前景展望. 医疗卫生装备, 2013, 34(3): 76-78.Gao CF, Tang XD, Luo J. Current status and prospects of electronic medical record system application. Med Equipment, 2013, 34(3): 76-78.
6. 孙凤英, 于修义. 基于胸外科结构化电子病历的人工智能诊断系统构建实践. 中国数字医学, 2018, 13(11): 29-31.Sun FY, Yu XY. Practice of constructing an artificial intelligence diagnostic system based on structured electronic medical records in thoracic surgery. Chin Digit Med, 2018, 13(11): 29-31.
7. 石思恩, 于修义, 范晟, 等. 肺结节结构化电子病历在住院医师规范化培训中的应用. 中国胸心血管外科临床杂志, 2022, 29(6): 703-710.Shi SE, Yu XY, Fan Z, et al. Application of structured electronic medical records for lung nodules in standardized training of resident physicians. Chin J Clin Thorac Cardiovasc Surg, 2022, 29(6): 703-710.
8. 姜杰, 于修义. 基于标准化术语的胸外科结构化电子病历实践. 中国肺癌杂志, 2018, 21(4): 256-259.Jiang J, Yu XY. Practice of structured electronic medical records in thoracic surgery based on standardized terminology. Chin Lung Cancer J, 2018, 21(4): 256-259.
9. 王峥, 张洪, 吕军, 等. 人工智能辅助诊疗系统在肺小结节诊断中的应用—附1650例临床分析. 中华胸心血管外科杂志, 2023, 39(8): 466-471.Wang Z, Zhang H, Lü J, et al. Application of artificial intelligence-assisted diagnostic system in the diagnosis of pulmonary nodules: A clinical analysis of 1650 cases. Chin J Thorac Cardiovasc Surg, 2023, 39(8): 466-471.
10. Zhang Y, Jiang B, Zhang L, et al. Lung nodule detectability of artificial intelligence-assisted CT image reading in lung cancer screening. Curr Med Imaging, 2022, 18(3): 327-334.
11. 冯云霞, 张润. 基于电子病历的肺癌诊断决策树算法. 计算机系统应用, 2019, 28(10): 257-263.Feng YX, Zhang R. Decision tree algorithms for lung cancer diagnosis based on electronic medical record. Comput Syst Appl, 2019, 28(10): 257-263.
12. 温麟琦, 杨盛诏, 王忠帅, 等. 基于SEER数据库的多原发肺癌临床特征分析及预后预测模型构建. 肿瘤研究与临床, 2024, 36(6): 446-453.Wen LQ, Yang SZ, Wang ZS, et al. Analysis of clinical characteristics and prognostic prediction model construction of multiple primary lung cancer based on SEER database. Tumor Res Clin, 2024, 36(6): 446-453.
13. 龙冰清, 熊曾, 刘书林, 等. 基于电子病历数据分析不同性别肺癌手术患者流行病学特征的差异. 数字医学与健康, 2024, 2(2): 98-101.Long BQ, Xiong Z, Liu SL, et al. Differences in epidemiological characteristics of lung cancer surgery patients of different sexes based on electronic medical record data analysis. Digit Med Health, 2024, 2(2): 98-101.
14. Towe CW, Servais EL, Brown LM, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2023 update on outcomes and research. Ann Thorac Surg, 2024, 117(3): 489-496.
15. Shukla M, Lin J, Seneviratne O. BlockIoT: Blockchain-based health data integration using IoT devices. AMIA Annu Symp Proc, 2021, 2021: 1119-28.
16. Tang AS, Woldemariam SR, Miramontes S, et al. Harnessing EHR data for health research. Nat Med, 2024, 30(7): 1847-1855.
17. Walsh JM, Borycki EM. A resilience model for moderating outcomes related to electronic medical record downtime. Stud Health Technol Inform, 2022, 289: 434-438.
18. Servais EL, Towe CW, Brown LM, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2020 update on outcomes and research. Ann Thorac Surg, 2020, 110(3): 768-775.
19. Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. BMJ Qual Saf, 2019, 28(4): 310-316.
20. Wu KA, Boccaccio K, Buckles D, et al. Efforts to improve the billing accuracy of robotic-assisted thoracic surgery through education, updated procedure cards, and electronic medical record system changes. BMJ Open Qual, 2024, 13(2): e002710.
21. 卫生部关于印发《电子病历基本规范(试行)》的通知. (2010-03-04)[2024-09-26]. https://www.gov.cn/zwgk/2010-03/04/content_1547432.htm.Ministry of Health of the People's Republic of China notice on the issuance of the "Electronic Medical Record Basic Standards (Trial)". https://www.gov.cn/zwgk/2010-03/04/content_1547432.htm. Accessed on September 26, 2024.
22. 中华人民共和国国家卫生和计划生育委员会. 电子病历应用管理规范(试行). 中国实用乡村医师杂志, 2017, 24(6): 1-2, 6.National Health and Family Planning Commission of the People's Republic of China. Electronic medical record application management standards (Trial). Chin J Rural Pract, 2017, 24(6): 1-2, 6.
23. 胡坚, 刘伦旭, 张毅, 等. 人工智能一体化三维重建应用于胸外科的中国专家共识. 中国胸心血管外科临床杂志, 2023, 30(5): 641-646.Hu J, Liu LX, Zhang Y, et al. Chinese expert consensus on the application of integrated 3D reconstruction with artificial intelligence in thoracic surgery. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(5): 641-646.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesChinese expert consensus on quality control and management of electronic medical records for thoracic surgery (version 2024)

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