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。在电子病历对提供高质量的患者护理变得越来越重要的时候，今天的EDR所代表的“巴别塔”是一个越来越明显的缺点。这种情况目前不仅阻碍了支持患者护理的计算方法（例如，通过自动的、针对患者的循证牙科资源检索），而且还将严重阻碍新兴的国家卫生信息基础设施内的患者信息交换。我们的研究表明，不完整和分散的EDR迫使许多从业者保持纸质和计算机为基础的患者记录，这种情况可能导致非常有限的采用完全电子病历的一般牙医。本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，我们将迭代细化先前编制的候选数据元素列表，以通过德尔菲方法开发一个经过验证的、优先级排序的、全面的数据元素列表，用于记录普通牙科中的患者护理，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，通过采用美国国家医学图书馆和医疗保健机构进行的大规模词汇测试中使用的类似方法，访问具体目标1中开发的EDRIM提供的患者信息覆盖范围。政策和研究。我们项目的目标是开发一个基于共识的综合牙科信息模型，该模型至少涵盖普通牙医在日常实践中记录的70- 80%的临床概念。拟议的信息模型将有多方面的好处。首先，EDR开发人员将有一个现成的患者信息模板，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EDR，它比目前的情况更全面地代表了患者信息。第三，未来牙医及其同事以及医疗团队其他成员之间的数据交换将通过通用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。我们希望该模型对患者信息的表示和存储方式、EDR的设计方式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。 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（EDRs）内容和结构的参考标准。

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).