LOINC® Codes for Hospital Information Systems Documents: A Case Study
LOINC® Codes for Hospital Information Systems Documents: A Case Study
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DOI：
10.1197/jamia.m2882
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发表时间：
2009-05-01
影响因子：
6.4
通讯作者：
Heitmann, Kai U.
中科院分区：
文献类型：
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作者：
Dugas, Martin;Thun, Sylvia;Heitmann, Kai U.
医院信息系统 (HIS) 处理大量不同类型的文档。通过使用标准化代码来识别文档类型，可以促进来自不同 HIS 的数据的交换和分析。 HL7 临床文档架构 (CDA) 使用 LOINC（逻辑观察标识符名称和代码）代码来存储临床文档。作者评估了德国 HIS 中文档类型的 LOINC 代码的覆盖范围。作者分析了德国一家主要大学医院的商业 HIS 中约 130 万份文档中出现超过 10 次的文档类型。使用 Regenstrief LOINC 映射助手 (RELMA) 将文档类型手动映射到 LOINC。每种文档类型均由两名医生编码。如果存在差异，请咨询第三位专家以达成共识。对于 86 个文档类别，确定了 LOINC 代码，但对于其中 38 个类别，LOINC 代码并不具体，因为认为有必要。我们超过 93% 的本地 HIS 文档具有可以分配 LOINC 代码的本地文档类型。 J Am Med Inform 协会。 2009；16：400-403。 DOI 10.1197/jamia.M2882。
Hospital Information Systems (HIS) handle a large number of different types of documents. Exchange and analysis of data from different HIS is facilitated by the use of standardized codes to identify document types. HL7s Clinical Document Architecture (CDA) uses LOINC (logical observation identifiers names and Codes) codes for clinical documents. The authors assessed the coverage of LOINC codes for document types in a German HIS. The authors analyzed document types that occurred more than 10 times in approximately 1.3 million documents in a commercial HIS at a major German University Hospital. Document types were mapped manually to LOINC using the Regenstrief LOINC Mapping Assistant (RELMA). Each document type was coded by two physicians. In cas e of discrepancies a third expert was consulted to reach consensus. For of 86 document categories a LOINC code was identified, but for 38 of these categories, the LOINC code was not specific as deemed necessary. More than 93% of our local HIS documents had local document types that Could be assigned a LOINC code. J Am Med Inform Assoc. 2009;16:400-403. DOI 10.1197/jamia.M2882.