Bernstein Knut, Bruun-Rasmussen Morten, Vingtoft Søren
MEDIQ - Medical Informatics and Quality Management, Copenhagen, Demark.
Stud Health Technol Inform. 2006;124:515-21.
The Copenhagen County is using clinical guidelines in the electronic health record development to provide documentation support, process support and decision support for the healthcare professionals. The electronic health record development is based on three main components: The first component is a national information model. The second component is a common classification system (SNOMED). The third key component is the so-called "clinical content". This paper describes the structured "clinical content", how it is linked to the clinical process, and how it is used to create clinical guidelines in the form of standard care plans. The Copenhagen County and MEDIQ has developed a methodology for identifying and specifying structured "clinical content" to be used in electronic health records. The method combines analyses of national clinical guidelines with local experience and practices and it heavily involves healthcare professionals. The method includes four main steps: Analyses of background material, analyses of clinical process-flow, mapping to standards (the national information model and the common classification system), and specification of the structured clinical content itself. Three secondary steps may be added to specify the clinical content in more detail: Workflow analyses, analyses of quality indicators, and decision analyses. This paper reports the experiences using the method and stresses the demand for a common exchange format and IT-tools for documenting clinical content in a formalised way.
哥本哈根郡在电子健康记录开发中使用临床指南，为医疗专业人员提供文档支持、流程支持和决策支持。电子健康记录开发基于三个主要组件：第一个组件是国家信息模型。第二个组件是通用分类系统（SNOMED）。第三个关键组件是所谓的“临床内容”。本文描述了结构化的“临床内容”、它如何与临床流程相联系，以及如何用于以标准护理计划的形式创建临床指南。哥本哈根郡和MEDIQ开发了一种方法，用于识别和指定电子健康记录中使用的结构化“临床内容”。该方法将对国家临床指南的分析与当地经验和实践相结合，并且大量涉及医疗专业人员。该方法包括四个主要步骤：背景材料分析、临床流程分析、映射到标准（国家信息模型和通用分类系统）以及结构化临床内容本身的规范。可能会添加三个次要步骤以更详细地指定临床内容：工作流程分析、质量指标分析和决策分析。本文报告了使用该方法的经验，并强调需要一种通用的交换格式和信息技术工具，以便以形式化的方式记录临床内容。
