A Standard Information Model for General Dental Records

一般牙科记录的标准信息模型

• 批准号: 8105075
• 负责人: TITUS K. SCHLEYER
• 金额: $ 21.82万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-07-06 至 2013-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8105075
• 关键词: Adopted; Adoption; Agreement; Algorithms; American; American Dental Association; Arbitration; Architecture; Back; Clinical; Clinical Data; Clinical Research; Computer software; Computerized Patient Records; Computers; Consensus; Data; Data Collection; Data Element; Data Set; Databases; Dental; Dental Care; Dental Informatics; Dental Records; Dentistry; Dentists; Electronic Health Record; Electronics; Elements; Ensure; Environment; Epidemiologic Studies; Epidemiology; Evaluation Studies; Future; General Practices; Goals; Health; Health Personnel; Health Services; Information Technology; Institutes; Marketing; Medical Care Team; Methodology; Modeling; Outcome; Outcomes Research; Paper; Participant; Patient Care; Patients; Physicians; Practice Management; Process; Publishing; Recommendation; Records; Reference Standards; Research; Research Infrastructure; Research Personnel; Resources; Retrieval; Sampling; Semantics; Source; Structure; System; Time; Translating; United States Agency for Healthcare Research and Quality; United States National Library of Medicine; Vendor; Vocabulary Test; Work; base; clinical care; clinical decision-making; data exchange; database design; design; electronic structure; evidence base; improved; information model; interest; lexical; member; practice-based research network; prevent; public health relevance; tool; web based interface

DESCRIPTION (provided by applicant): Electronic dental records (EDR) for general dentists vary widely with regard to the content and structure of the information they contain. At a time when electronic patient records are becoming increasingly essential to delivering high-quality patient care, the "Tower of Babel" that today's EDRs represent is an increasingly significant drawback. Not only does this situation currently prevent computational approaches for supporting patient care (for instance through automatic, patient-specific retrieval of evidence-based dental resources), it also will significantly hamper the exchange of patient information within the emerging National Health Information Infrastructure. Our research indicates that incomplete and fragmented EDRs force many practitioners to maintain both paper-and computer-based patient records, which situation potentially contributes to the very limited adoption of completely electronic patient records by general dentists. The objective of this project is to develop a comprehensive, consensus-based Electronic Dental Record Information Model (EDRIM) as a reference standard for the content and structure of EDRs. In Specific Aim 1, we will iterative refine the previously compiled candidate list of data elements to develop a validated, prioritized, comprehensive list of data elements for documenting patient care in general dentistry through a Delphi approach and transform this refined list of data elements into a formal information model. In Specific Aim 2, we will conduct a formal evaluation study to access the patient information coverage offered by the EDRIM developed in Specific Aim 1 by adopting a similar methodology used in the Large Scale Vocabulary Test conducted by National Library of Medicine and the Agency for Health Care Policy and Research. The goal of our project is to develop a consensus-based, comprehensive dental information model that covers at least 70- 80% of the clinical concepts recorded by general dentists in daily practice. The proposed information model will have multiple benefits. First, EDR developers will have available a ready-made template for patient information that can easily be translated into a physical database design. Second, practitioners will benefit from EDRs that represent patient information more comprehensively than is currently the case. Third, future data exchange among dentists and their colleagues, as well as other members of the healthcare team, will be facilitated by a common data infrastructure. Last, rich and comprehensive EDRs will provide a significant opportunity to support clinical, epidemiological and health outcomes research. We expect the model to have far-reaching and beneficial impact on how patient information is represented and stored, how EDRs are designed and, ultimately, how electronic systems are used in support of clinical care and research. PUBLIC HEALTH RELEVANCE: The objective of this project is to develop a comprehensive, consensus-based Electronic Dental Record Information Model (EDRIM) as a reference standard for the content and structure of electronic dental records (EDRs).

描述(由申请人提供)：普通牙科医生的电子牙科记录(EDR)在所包含的信息的内容和结构方面差别很大。在电子病历对提供高质量的患者护理越来越重要的时候，今天的EDR所代表的“巴别塔”是一个越来越严重的缺点。这种情况目前不仅阻碍了支持患者护理的计算方法(例如，通过基于证据的牙科资源的自动、特定于患者的检索)，而且还将显著阻碍在新兴的国家卫生信息基础设施内交换患者信息。我们的研究表明，不完整和零碎的EDR迫使许多从业者同时维护纸质和基于计算机的患者记录，这种情况可能导致普通牙医对完全电子患者记录的采用非常有限。该项目的目标是开发一个全面的、基于共识的电子牙科记录信息模型(EDRIM)，作为EDR内容和结构的参考标准。在具体目标1中，我们将反复细化先前编译的候选数据元素列表，以通过Delphi方法开发用于记录普通牙科患者护理的有效的、按优先顺序排列的、全面的数据元素列表，并将此细化的数据元素列表转换为正式的信息模型。在具体目标2中，我们将进行一项正式的评估研究，以获取在具体目标1中开发的EDRIM提供的患者信息覆盖范围，方法与国家医学图书馆和医疗保健政策和研究机构进行的大规模词汇测试中使用的方法类似。我们项目的目标是开发一个基于共识的、全面的牙科信息模型，覆盖普通牙医在日常实践中记录的至少70%-80%的临床概念。拟议的信息模型将有多种好处。首先，EDR开发人员将拥有一个现成的患者信息模板，该模板可以很容易地转换为物理数据库设计。其次，从业者将受益于比目前更全面地代表患者信息的EDR。第三，牙医及其同事以及医疗保健团队其他成员之间未来的数据交换将通过共同的数据基础设施来促进。最后，丰富和全面的EDR将为支持临床、流行病学和健康结果研究提供重要机会。我们预计该模型将对如何表示和存储患者信息、如何设计EDR以及最终如何使用电子系统支持临床护理和研究产生深远而有益的影响。 公共卫生相关性：该项目的目标是开发一个全面的、基于共识的电子牙科记录信息模型(EDRIM)，作为电子牙科记录(EDR)的内容和结构的参考标准。