The development of clinical document standards for semantic interoperability in china.
The development of clinical document standards for semantic interoperability in china.
复制标题
中国临床文档语义互操作性标准的制定
DOI：
10.4258/hir.2011.17.4.205
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发表时间：
2011-12
影响因子：
2.9
通讯作者：
Hu J
中科院分区：
文献类型：
--
作者：
Yang P;Pan F;Liu D;Xu Y;Wan Y;Tu H;Tang X;Hu J
本研究旨在开发一组数据组(DGs)作为可重复使用的构建块，用于构建中国所在的综合医院最常用的8份临床文档，以实现其结构和语义的标准化。诊断学知识框架、卫生七级(HL7)、整合医疗企业(IHE)和医疗信息技术标准小组(HITSP)的相关方法与1,487份原始临床记录一起被考虑，以形成DG架构和数据集。然后，通过将每个DG数据集映射到相应的临床文档架构数据元素，并将每个DG数据集与中国国家卫生数据词典中的元数据进行匹配，来定义每个DG的内部结构、内容和语义。通过使用DG作为可重用的构建块，能够构建关于语义互操作的临床文档的标准化结构和语义。共开发了5个标题DG、48个节段DG和17个条目DG。关于数据组的若干问题，包括其内部结构、识别符、数据集名称、定义、长度和格式、数据类型和值集，都作了进一步界定。关于这八份临床文件的标准化结构和语义是由DGs构建的。这种使用DGS构建临床文档标准的方法是一种可行的标准驱动的解决方案，适用于在中国的不同信息系统之间准备具有语义互操作性的文档。这些标准还需要通过进一步的研究来验证和完善。
This study is aimed at developing a set of data groups (DGs) to be employed as reusable building blocks for the construction of the eight most common clinical documents used in China's general hospitals in order to achieve their structural and semantic standardization. The Diagnostics knowledge framework, the related approaches taken from the Health Level Seven (HL7), the Integrating the Healthcare Enterprise (IHE), and the Healthcare Information Technology Standards Panel (HITSP) and 1,487 original clinical records were considered together to form the DG architecture and data sets. The internal structure, content, and semantics of each DG were then defined by mapping each DG data set to a corresponding Clinical Document Architecture data element and matching each DG data set to the metadata in the Chinese National Health Data Dictionary. By using the DGs as reusable building blocks, standardized structures and semantics regarding the clinical documents for semantic interoperability were able to be constructed. Altogether, 5 header DGs, 48 section DGs, and 17 entry DGs were developed. Several issues regarding the DGs, including their internal structure, identifiers, data set names, definitions, length and format, data types, and value sets, were further defined. Standardized structures and semantics regarding the eight clinical documents were structured by the DGs. This approach of constructing clinical document standards using DGs is a feasible standard-driven solution useful in preparing documents possessing semantic interoperability among the disparate information systems in China. These standards need to be validated and refined through further study.