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".

Citation： 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. 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, 2024, 31(12): 1703-1712. doi: 10.7507/1007-4848.202410041 Copy

1.	中華人民共和國衛生部. 衛生部關于印發《電子病歷系統功能規范(試行)》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.	國家衛生健康委辦公廳. 關于進一步推進以電子病歷為核心的醫療機構信息化建設工作的通知. (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.	國家衛生健康委辦公廳. 關于印發電子病歷系統應用水平分級評價管理辦法(試行)及評價標準(試行)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.	國家衛生健康委醫院管理研究所. 關于印發電子病歷系統應用水平分級評價工作規程和專家管理辦法的通知. (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, 唐曉東, 羅娟. 電子病歷系統應用現狀及前景展望. 醫療衛生裝備, 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.	孫鳳英, 于修義. 基于胸外科結構化電子病歷的人工智能診斷系統構建實踐. 中國數字醫學, 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, 于修義, 范晟, 等. 肺結節結構化電子病歷在住院醫師規范化培訓中的應用. 中國胸心血管外科臨床雜志, 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, 于修義. 基于標準化術語的胸外科結構化電子病歷實踐. 中國肺癌雜志, 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.	王崢, 張洪, 呂軍, 等. 人工智能輔助診療系統在肺小結節診斷中的應用—附1650例臨床分析. 中華胸心血管外科雜志, 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.	馮云霞, 張潤. 基于電子病歷的肺癌診斷決策樹算法. 計算機系統應用, 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.	溫麟琦, 楊盛詔, 王忠帥, 等. 基于SEER數據庫的多原發肺癌臨床特征分析及預后預測模型構建. 腫瘤研究與臨床, 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.	龍冰清, 熊曾, 劉書林, 等. 基于電子病歷數據分析不同性別肺癌手術患者流行病學特征的差異. 數字醫學與健康, 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.	衛生部關于印發《電子病歷基本規范(試行)》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.	中華人民共和國國家衛生和計劃生育委員會. 電子病歷應用管理規范(試行). 中國實用鄉村醫師雜志, 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.	胡堅, 劉倫旭, 張毅, 等. 人工智能一體化三維重建應用于胸外科的中國專家共識. 中國胸心血管外科臨床雜志, 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. 中華人民共和國衛生部. 衛生部關于印發《電子病歷系統功能規范(試行)》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. 國家衛生健康委辦公廳. 關于進一步推進以電子病歷為核心的醫療機構信息化建設工作的通知. (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. 國家衛生健康委辦公廳. 關于印發電子病歷系統應用水平分級評價管理辦法(試行)及評價標準(試行)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. 國家衛生健康委醫院管理研究所. 關于印發電子病歷系統應用水平分級評價工作規程和專家管理辦法的通知. (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, 唐曉東, 羅娟. 電子病歷系統應用現狀及前景展望. 醫療衛生裝備, 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. 孫鳳英, 于修義. 基于胸外科結構化電子病歷的人工智能診斷系統構建實踐. 中國數字醫學, 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, 于修義, 范晟, 等. 肺結節結構化電子病歷在住院醫師規范化培訓中的應用. 中國胸心血管外科臨床雜志, 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, 于修義. 基于標準化術語的胸外科結構化電子病歷實踐. 中國肺癌雜志, 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. 王崢, 張洪, 呂軍, 等. 人工智能輔助診療系統在肺小結節診斷中的應用—附1650例臨床分析. 中華胸心血管外科雜志, 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. 馮云霞, 張潤. 基于電子病歷的肺癌診斷決策樹算法. 計算機系統應用, 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. 溫麟琦, 楊盛詔, 王忠帥, 等. 基于SEER數據庫的多原發肺癌臨床特征分析及預后預測模型構建. 腫瘤研究與臨床, 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. 龍冰清, 熊曾, 劉書林, 等. 基于電子病歷數據分析不同性別肺癌手術患者流行病學特征的差異. 數字醫學與健康, 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. 衛生部關于印發《電子病歷基本規范(試行)》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. 中華人民共和國國家衛生和計劃生育委員會. 電子病歷應用管理規范(試行). 中國實用鄉村醫師雜志, 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. 胡堅, 劉倫旭, 張毅, 等. 人工智能一體化三維重建應用于胸外科的中國專家共識. 中國胸心血管外科臨床雜志, 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.

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

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