A framework for capturing clinical data sets from computerized sources
A framework for capturing clinical data sets from computerized sources
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DOI：
10.7326/0003-4819-127-8_part_2-199710151-00049
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发表时间：
1997-10-15
影响因子：
39.2
通讯作者：
Dwyer, DM
中科院分区：
文献类型：
--
作者：
McDonald, CJ;Overhage, JM;Dwyer, DM
改善医疗保健和以较低成本提供更好护理的压力产生了有效捕获临床数据的需求。许多数据集现在被定义为分析医疗保健。从历史上看，审查和研究组织只是确定他们想要收集的数据，开发表格，然后通过图表审查收集信息，而不考虑计算机化数据库中已经存在的信息。如今，许多电子患者信息在操作数据系统（例如，实验室系统、药房系统和手术调度系统）中可用，并且可由机构和组织通过消息、代码和加密电子邮件的标准来访问。这些机构和组织应根据标准化业务数据界定其数据集的要素，数据制作者应充分采用这些编码和信息标准。健康计划雇主数据和信息集以及州和地区流行病学家理事会与疾病控制和预防中心以及州和地区公共卫生实验室主任协会合作，提供了如何做到这一点的例子。
The pressure to improve health care and provide better care at a lower cost has generated the need for efficient capture of clinical data. Many data sets are now being defined to analyze health care. Historically, review and research organizations have simply determined what data they wanted to collect, developed forms, and then gathered the information through chart review without regard to what is already available institutionally in computerized databases. Today, much electronic patient information is available in operational data systems (for example, laboratory systems, pharmacy systems, and surgical scheduling systems) and is accessible by agencies and organizations through standards for messages, codes, and encrypted electronic mail. Such agencies and organizations should define the elements of their data sets in terms of standardized operational data, and data producers should fully adopt these code and message standards. The Health Plan Employer Data and Information Set and the Council of State and Territorial Epidemiologists in collaboration with the Centers for Disease Control and Prevention and the Association of State and Territorial Public Health Laboratory Directors provide examples of how this can be done.