中文摘要：

目的：从医院信息系统中提取临床科研数据。方法．以对病毒性肝炎后肝硬化门静脉高压症患者中，脾切除对HCC（肝细胞肝癌）的发生率影响研究为例，共需收集每个病人的就诊信息106条。使用电子病历信息检索、人工筛选等方法收集从2002年至2008年出院诊断为肝炎后肝硬化患者信息。结果：共检索到符合纳入标准的病）,．5359例，因数据缺失、记录的数据不准确及排除标准等原因，最后有效病历数据为2300例。其中数据缺失及无法入组的数据约为57．08％。结论：现有HIS系统的数据尚不能很好满足临床科研对数据的需求，为收集到完整的临床科研数据，今后应加大结构化电子病历的推广和使用，并加强临床研究的科研设计。

英文摘要：

Objective： To extract clinical data for research purpose from Hospital information system （ HIS ） . Methods： 106 items should be collected for each patient in a study, in which the effects of splenectomy procedure on hepatocarcinogenesis for virus posthepatitic cirrhosis patients would be examined. We collected the data from the EMR （electronic medical record） of Xijing HIS from January 2002 to December 2008 diagnosed as posthepatitic cirrhosis. Results： According to the inclusion criteria, 5359 patients were retrieved, but only 2300 cases were qualified because of data missing, mistakes in medical record and exclusion criteria. The unqualified data was about 57.08%. Conclusions： The existing data in HIS is not good enough for clinical research. Structured EMR and pre-designed protocol should be emphasized in order to extract complete and accurate data for clinical research.