Tierney William M, Beck Eduard J, Gardner Reed M, Musick Beverly, Shields Mark, Shiyonga Naomi M, Spohr Mark H
Indiana University School of Medicine, Indianapolis, IN 46202, USA.
J Am Med Inform Assoc. 2006 May-Jun;13(3):253-60. doi: 10.1197/jamia.M2005. Epub 2006 Feb 24.
Providing quality health care requires access to continuous patient data that developing countries often lack. A panel of medical informatics specialists, clinical human immunodeficiency virus (HIV) specialists, and program managers suggests a minimum data set for supporting the management and monitoring of patients with HIV and their care programs in developing countries. The proposed minimum data set consists of data for registration and scheduling, monitoring and improving practice management, and describing clinical encounters and clinical care. Data should be numeric or coded using standard definitions and minimal free text. To enhance accuracy, efficiency, and availability, data should be recorded electronically by those generating them. Data elements must be sufficiently detailed to support clinical algorithms/guidelines and aggregation into broader categories for consumption by higher level users (e.g., national and international health care agencies). The proposed minimum data set will evolve over time as funding increases, care protocols change, and additional tests and treatments become available for HIV-infected patients in developing countries.
提供高质量的医疗保健需要获取持续的患者数据,而发展中国家往往缺乏这些数据。一个由医学信息学专家、临床人类免疫缺陷病毒(HIV)专家和项目管理人员组成的小组提出了一套最小数据集,以支持发展中国家对HIV患者及其护理项目的管理和监测。提议的最小数据集包括用于登记和调度、监测和改进实践管理以及描述临床会诊和临床护理的数据。数据应使用标准定义进行数字化或编码,尽量减少自由文本。为提高准确性、效率和可用性,数据应由生成数据的人员以电子方式记录。数据元素必须足够详细,以支持临床算法/指南,并汇总为更广泛的类别,供更高级别的用户(如国家和国际卫生保健机构)使用。随着资金增加、护理方案改变以及发展中国家的HIV感染患者可获得更多的检测和治疗,提议的最小数据集将随着时间的推移而不断发展。