A Standard Information Model for General Dental Records

描述（由申请人提供）：普通牙医的电子牙科记录（EDR）在其包含的信息的内容和结构方面差异很大。当电子病历对于提供高质量的患者护理变得越来越重要的时候，今天的电子病历所代表的“巴别塔”是一个越来越明显的缺点。目前，这种情况不仅阻碍了支持患者护理的计算方法（例如，通过自动、针对患者的基于证据的牙科资源检索），而且还将严重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，不完整和碎片化的电子病历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。该项目的目的是建立一个全面的、基于共识的电子牙科病历信息模型（EDRIM），作为电子病历内容和结构的参考标准。在具体目标1中，我们将迭代改进先前编译的候选数据元素列表，以通过Delphi方法开发一个经过验证的、优先的、全面的数据元素列表，用于记录普通牙科患者的护理，并将此改进的数据元素列表转换为正式的信息模型。在具体目标2中，我们将采用与国家医学图书馆和卫生保健政策与研究机构进行的大规模词汇测试类似的方法，对具体目标1中开发的EDRIM提供的患者信息覆盖率进行正式的评估研究。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，该模型至少涵盖了普通牙医在日常实践中记录的70- 80%的临床概念。所建议的信息模型将有多种好处。首先，EDR开发人员将有现成的患者信息模板，可以很容易地将其转换为物理数据库设计。第二，从业者将受益于比目前更全面地代表患者信息的电子病历。第三，未来牙医和他们的同事以及医疗团队的其他成员之间的数据交换将通过一个共同的数据基础设施来促进。最后，丰富和全面的电子病历将为支持临床、流行病学和卫生结果研究提供重要机会。我们期望该模型对如何表示和存储患者信息、如何设计电子病历以及最终如何使用电子系统来支持临床护理和研究产生深远而有益的影响。

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).