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电子病历:围产医学领域消息信息模型

Electronic patient records: domain message information model perinatology.

作者信息

Goossen William T F, Jonker Marcel J, Heitmann Kai U, Jongeneel-de Haas Irma C, de Jong Tom, van der Slikke Johannes W, Kabbes Bert L

机构信息

Acquest R&D, Koudekerk aan den Rijn, Netherlands.

出版信息

Int J Med Inform. 2003 Jul;70(2-3):265-76. doi: 10.1016/s1386-5056(03)00054-6.

Abstract

PURPOSE

The Netherlands is developing a set of national domain information models to support electronic information exchange and electronic patient records (EPR). These domain information models aim to support the development, adoption, implementation and maintenance of the EPR in Dutch healthcare practice. This article describes the modelling for a pilot for mother- and childcare (perinatology).

METHODOLOGY

Cases' from perinatology are modelled using the Health Level 7 version 3 Reference Information Model (HL7 RIM) as the methodology and tools.

RESULTS

Results include descriptions of care processes, communication and information that are broken down into interaction tables and tables with information. Next several domain information models for perinatology are drawn up. These models allow healthcare professionals to recognise their communication, content and work. Currently, the models facilitate discussion and critique by clinician and informaticians.

CONCLUSION

The perinatology domain information models facilitate in building implementations because they contain sufficient details for EPR developers and for developers of messages for information exchange. The first results of the project are useful, despite the fact that HL7 RIM modelling methodology is still not finalized. The approach bridges professional content, technical implementation of messages, and future EPR development.

摘要

目的

荷兰正在开发一套国家领域信息模型,以支持电子信息交换和电子病历(EPR)。这些领域信息模型旨在支持荷兰医疗实践中电子病历的开发、采用、实施和维护。本文描述了母婴保健(围产医学)试点项目的建模情况。

方法

使用卫生信息标准化组织(HL7)第3版参考信息模型(HL7 RIM)作为方法和工具,对围产医学案例进行建模。

结果

结果包括对护理流程、沟通和信息的描述,这些内容被分解为交互表和信息表。接下来制定了几个围产医学领域信息模型。这些模型使医疗专业人员能够识别他们的沟通、内容和工作。目前,这些模型有助于临床医生和信息专家进行讨论和批评。

结论

围产医学领域信息模型有助于构建实施方案,因为它们为电子病历开发者和信息交换消息开发者提供了足够的细节。尽管HL7 RIM建模方法仍未最终确定,但该项目的初步结果是有用的。这种方法连接了专业内容、消息的技术实施和未来的电子病历开发。

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