Moidu K, Singh A K, Boström K, Chowdhury S, Trell E, Wigertz O, Kjessler B
Department of Medical Informatics, Faculty of Health Sciences, University of Linköping, Sweden.
Methods Inf Med. 1992 Sep;31(3):182-92.
There is a need for consensus on the quantity of data that must be available in a computer-based information system of a health care organization. In this paper we take up the issue of defining the data content of an information system and introduce the concept of Essential Data Sets with an explicit methodology which was applied to define a data set for the Maternal Health Services program. A key step in the method was a recognized technique used in systems development process called data modelling, in this case infological modelling, by an interdisciplinary group. A preliminary set of 86 data elements was identified and it provided the foundation for development of an application software for discussion and a real-world testing framework. The acceptability of the data set was tested in a laboratory perspective by retrospective data entry from records of 94 pregnant women registered at a maternal health care center in Sweden. Data from a total of 1,318 prenatal visits, an outcome visit, and a postnatal visit for each woman was entered into a computer using the software, with no loss of information. Thus, in a short-term perspective the acceptability of the data set was demonstrated. The software has since been implemented for pilot prospective studies at sites in India and Sweden. The use of a common data protocol is an essential foundation for patient outcome research, especially as the trend of health care management has changed from a "process of care" orientation to an "outcome of care" orientation.
对于医疗保健机构基于计算机的信息系统中必须具备的数据量,需要达成共识。在本文中,我们探讨了定义信息系统数据内容的问题,并引入了基本数据集的概念,同时介绍了一种明确的方法,该方法被用于为孕产妇保健服务项目定义一个数据集。该方法的一个关键步骤是系统开发过程中使用的一种公认技术,即数据建模,在这种情况下是由一个跨学科团队进行的信息学建模。确定了一组初步的86个数据元素,它为开发用于讨论的应用软件和一个实际测试框架奠定了基础。从瑞典一家孕产妇保健中心登记的94名孕妇的记录中进行回顾性数据录入,从实验室角度测试了数据集的可接受性。使用该软件将每位女性总共1318次产前检查、一次结果检查和一次产后检查的数据录入计算机,没有信息丢失。因此,从短期来看,证明了数据集的可接受性。此后,该软件已在印度和瑞典的一些地点用于试点前瞻性研究。使用通用数据协议是患者结局研究的重要基础,特别是随着医疗保健管理的趋势已从“护理过程”导向转变为“护理结局”导向。