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    數字證書在醫療衛生系統中的應用

    2016-2-29 16:41:28

        ◇根據國家衛生計生委辦公廳的局面健康卡規劃和我國信息化程度的不斷推進,醫療衛生信息化,特別是電子病歷EMR的發展大趨勢來看,推行居民健康卡勢在必行。鑒于醫患雙方醫療糾紛的普遍性及其社會關注度,需要建立有效的身份認證及責任認定機制。因此,遼寧省衛計委依據《中華人民共和國電子簽名法》、《衛生系統電子認證服務管理辦法》及相關標準規范要求等要求,引入了醫療衛生平臺電子認證體系。
        ◇居民健康卡將銀行支付系統與醫院的診斷HIS系統相結合,簡化了掛號、劃價、付費、看病等診療支付流程手續。無論是門診患者,還是住院患者,持有居民健康卡可代替醫院就醫卡,通過自助設備實現繳費、查詢、打印甚至是訂餐等服務,為患者帶來了極大的便利。并實現與子病歷EMR系統知情文書的無紙化,將患者的數字證書、電子簽名與居民健康卡相結合,能夠隨時查閱就診記錄、病歷、處方等,滿足電子病歷發展的大趨勢。
        ◇雖然,基于PKI體系的數字簽名,能夠實現對電子病歷EMR部署權威可信時間源設備,實現了基于時間戳服務系統對醫療數據電文的時間戳認證,保證了電子數據的合法性和有效性,滿足身份真實性、合法性和安全存儲的需求,而且以數字證書服務和數字簽名應用為核心的電子認證服務,也有效解決了醫囑、處方、檢查單等電子病歷項中醫生簽名的需求。
        ◇然而,目前居民健康卡在推行的過程中,也存在兩種情況。早期發放的數萬張居民健康卡不具備PKI體系的數字證書功能,合法的知情文書簽名功能未能最終實現無紙化,依然需要將電子病歷中的信息打印出來,讓患者手動簽名留檔,而后發放的居民健康卡已經加載了數字證書,但如何讓不同類型的居民健康卡通過統一流程,成為了亟待解決的重點問題。

         一、需求分析:
        1、通過數字證書確認患者信息。從而實現醫療衛生系統信息化需求;
        2、通過數字證書確保醫院在醫療系統中的各項流程實現,簡化傳統就醫流程。從而實現醫療資源的高效利用,并且實現無紙化辦公節省社會資源;
        3、通過數字證書對知情文書、手術簽字等醫療流程賦予法律效益,從而減少醫患矛盾;

         二、設計思路:
        1、遼寧省衛生計生委醫療衛生平臺電子認證體系的建設
        按照遼寧省衛計委醫療衛生平臺電子認證體系的建設,在衛生專網中,構建統一認證服務器,實現了對數據的匯集,使患者可以通過移動終端的客戶端訪問個人的就診信息、知情文書等。而認證體系由遼寧省衛生計生委建設,保證了權威性的同時,需要對安全性進行考慮。方案準備讓智能終端的客戶端上,使用實名申請的帳號,通過驗證后,下載數字證書綁定智能終端,鏈路使用VPN保護,保證數據的完整性和安全性。

    (流程示意圖)

        2、統一認證平臺的建設
        由遼寧省衛計委醫療衛生平臺建設,實現一個能夠全省公眾統一的安全接入平臺,實現跨平臺的對移動終端和證書的認證,保證安全性的同時,極大提高使用的便利性。智能終端需要下載客戶端,在實名注冊后,下載數字證書,并通過VPN訪問醫療衛生平臺內網,實現基于Internet的跨平臺的電子認證服務。如圖2所示,統一認證平臺可以跨越兩個網絡提供認證接入。

        ◆ 患者在互聯網環境下使用智能終端,下載安裝客戶端。使用實名注冊的賬號密碼登錄客戶端。
        ◆ 患者的首次登錄信息通過VPN加密發送到互聯網統一認證平臺,在通過認證后,向CA申請數字證書。
        智能終端在加載數字證書后,可以訪問醫療衛生信息平臺中醫生開具的醫囑、處方、檢查單等知情文書進行電子簽名或查看個人信息HIS、PACS等信息
        3、實現在智能終端上對知情文書簽名確認
        在智能終端接入互聯網后,使用客戶端進行登錄,首次登陸獲取數字證書后,可對綁定了數字證書的客戶端接收到醫生發來的知情文書,在確認內容后可進行電子簽名,簽名后發送回醫生,醫生簽名后歸檔,對知情文書確認和電子簽名如下圖。

        ◆ 醫生使用電腦將病歷、處方、診斷報告等知情文書發送給持有居民健康卡的患者。
        ◆ 患者的首次登錄信息通過VPN加密發送到互聯網統一認證平臺,在通過認證后,向CA申請數字證書。

        ◆ 智能終端在加載數字證書后,可以訪問醫療衛生信息平臺中醫生發送的知情文書,在對內容進行確認后,進行電子簽名,簽名后的知情文書會發送回醫生電腦。

        ◆ 醫生使用USB-KEY進行電子簽名。
        ◆ 歸檔到EMR系統中。

        4、患者查看自己簽名過的知情文書
        患者可在互聯網環境下,隨時登陸客戶端,在經過實名注冊的賬號登陸后,通過智能終端查看自己簽名后的知情文書和PACS中的超聲、放射影像等信息。通過智能終端訪問簽名后的知情文書,流程如下圖:


         三、成功案例:
          ⇒中國醫科大學附屬盛京醫院
          ⇒中國醫科大學附屬第四醫院
          ⇒沈陽精神衛生醫院
          ⇒大連醫科大學附屬第一醫院
          ⇒大連醫科大學附屬第二醫院
          ⇒大連市中心醫院
          ⇒大連市第三人民醫院
          ⇒大連市皮膚病醫院
          ⇒大連中山醫院
          ⇒大連新華醫院
          ⇒瓦房店中心醫院
          ⇒阜新礦業集團公司總醫院
          ⇒撫順市礦務局總醫院
          ⇒撫順市第四醫院
          ⇒撫順市中心醫院
          ⇒本溪鋼鐵(集團)總醫院
          ⇒本溪市中心醫院
          ⇒鞍山鐵西醫院中國醫科大學附屬盛京醫院
          ⇒中國醫科大學附屬第四醫院
          ⇒沈陽精神衛生醫院
          ⇒大連醫科大學附屬第一醫院
          ⇒大連醫科大學附屬第二醫院
          ⇒大連市中心醫院
          ⇒大連市第三人民醫院
          ⇒大連市皮膚病醫院
          ⇒大連中山醫院
          ⇒大連新華醫院
          ⇒瓦房店中心醫院
          ⇒中國醫科大學附屬第一醫院鞍山醫院
          ⇒鞍山中心醫院
          ⇒鞍鋼總醫院
          ⇒鞍山市第四醫院
          ⇒海城市中心醫院
          ⇒鞍山市曙光醫院
          ⇒鞍山鐵西醫院
          ⇒撫順市中心醫院
          ⇒撫順市第四醫院
          ⇒撫順市礦務局總醫院
          ⇒本溪市中心醫院
          ⇒本溪鋼鐵(集團)總醫院
          ⇒桓仁醫院
          ⇒丹東市中心醫院
          ⇒丹東市人民醫院
          ⇒阜新礦業集團公司總醫院
          ⇒阜新市第二人民醫院
          ⇒遼陽市中心醫院
          ⇒盤錦市中心醫院
          ⇒遼河油田總醫院
          ⇒葫蘆島中心醫院

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