Next generation terminology infrastructure to support interprofessional care planning.
Next generation terminology infrastructure to support interprofessional care planning.
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支持跨专业护理规划的下一代术语基础设施。
DOI：
10.1016/j.jbi.2017.09.007
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发表时间：
2017
影响因子：
4.5
通讯作者：
Rocha,RobertoA
中科院分区：
文献类型：
--
作者：
Collins,Sarah;Klinkenberg-Ramirez,Stephanie;Tsivkin,Kira;Mar,PerryL;Iskhakova,Dina;Nandigam,Hari;Samal,Lipika;Rocha,RobertoA
开发一个跨专业术语和信息模型基础设施的原型，使护理计划应用程序能够促进以患者为中心的护理，了解护理计划的联系和关联，提供决策支持，并实现自动化的前瞻性分析。设计研究步骤包括3步方法：（1）过程模型和临床情景开发，（2）需求分析，（3）信息和术语模型的开发和验证。结果术语模型的组成部分包括：健康问题，目标，决策，干预，评估和评价。术语基础结构应该：（A）包括离散的护理计划概念;（B）包括专业特定的关注点、决策和干预的集合;（C）在护理团队中传达通知决策的基本原理、预期指导和指南;（D）定义跨临床事件和专业的语义联系;（E）定义共享的患者目标和子目标的集合，包括患者陈述的目标;（F）为实现目标进行评价。这些要求被映射到AHRQ护理协调措施Framework.LimitationsThis研究使用了一组约束的临床医生验证的临床场景。在SNOMED CT的目标和决策的术语模型是不可用的，限制了能力来评估这些方面的建议infrastructure.ConclusionsDefining和连接子集的护理规划概念似乎是可行的，但也是必不可少的模型常见的并发症和慢性疾病的跨专业护理规划。我们建议在SNOMED CT中创建目标动态和决策概念，以进一步启用必要的模型。具有灵活术语管理基础设施的系统可以实现智能决策支持，以识别共享护理计划中相互冲突和一致的问题、目标、决策和干预措施，最终减少临床医生和患者的文档工作和认知负担。
ObjectiveDevelop a prototype of an interprofessional terminology and information model infrastructure that can enable care planning applications to facilitate patient-centered care, learn care plan linkages and associations, provide decision support, and enable automated, prospective analytics.DesignThe study steps included a 3 step approach: (1) Process model and clinical scenario development, and (2) Requirements analysis, and (3) Development and validation of information and terminology models.ResultsComponents of the terminology model include: Health Concerns, Goals, Decisions, Interventions, Assessments, and Evaluations. A terminology infrastructure should: (A) Include discrete care plan concepts; (B) Include sets of profession-specific concerns, decisions, and interventions; (C) Communicate rationales, anticipatory guidance, and guidelines that inform decisions among the care team; (D) Define semantic linkages across clinical events and professions; (E) Define sets of shared patient goals and sub-goals, including patient stated goals; (F) Capture evaluation toward achievement of goals. These requirements were mapped to AHRQ Care Coordination Measures Framework.LimitationsThis study used a constrained set of clinician-validated clinical scenarios. Terminology models for goals and decisions are unavailable in SNOMED CT, limiting the ability to evaluate these aspects of the proposed infrastructure.ConclusionsDefining and linking subsets of care planning concepts appears to be feasible, but also essential to model interprofessional care planning for common co-occurring conditions and chronic diseases. We recommend the creation of goal dynamics and decision concepts in SNOMED CT to further enable the necessary models. Systems with flexible terminology management infrastructure may enable intelligent decision support to identify conflicting and aligned concerns, goals, decisions, and interventions in shared care plans, ultimately decreasing documentation effort and cognitive burden for clinicians and patients.
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