Vittorini Pierpaolo, Tarquinio Antonietta, di Orio Ferdinando
Department of Internal Medicine and Public Health, University of L'Aquila, Via S. Salvatore 1, 67010 L'Aquila, Italy.
Comput Methods Programs Biomed. 2009 Mar;93(3):297-312. doi: 10.1016/j.cmpb.2008.10.009. Epub 2008 Dec 13.
The eXtensible markup language (XML) is a metalanguage which is useful to represent and exchange data between heterogeneous systems. XML may enable healthcare practitioners to document, monitor, evaluate, and archive medical information and services into distributed computer environments. Therefore, the most recent proposals on electronic health records (EHRs) are usually based on XML documents. Since none of the existing nomenclatures were specifically developed for use in automated clinical information systems, but were adapted to such use, numerous current EHRs are organized as a sequence of events, each represented through codes taken from international classification systems. In nursing, a hierarchically organized problem-solving approach is followed, which hardly couples with the sequential organization of such EHRs. Therefore, the paper presents an XML data model for the Omaha System taxonomy, which is one of the most important international nomenclatures used in the home healthcare nursing context. Such a data model represents the formal definition of EHRs specifically developed for nursing practice. Furthermore, the paper delineates a Java application prototype which is able to manage such documents, shows the possibility to transform such documents into readable web pages, and reports several case studies, one currently managed by the home care service of a Health Center in Central Italy.
可扩展标记语言（XML）是一种元语言，有助于在异构系统之间表示和交换数据。XML 可使医疗从业者将医疗信息和服务记录、监控、评估并存档到分布式计算机环境中。因此，关于电子健康记录（EHR）的最新提议通常基于 XML 文档。由于现有的命名法都不是专门为在自动化临床信息系统中使用而开发的，而是经过改编用于此类用途，所以当前许多电子健康记录都是按照事件序列进行组织的，每个事件都通过取自国际分类系统的代码来表示。在护理领域，采用的是分层组织的问题解决方法，这与此类电子健康记录的顺序组织方式很难结合。因此，本文提出了一种针对奥马哈系统分类法的 XML 数据模型，奥马哈系统分类法是家庭医疗护理环境中使用的最重要的国际命名法之一。这样的数据模型代表了专门为护理实践开发的电子健康记录的形式化定义。此外，本文还描述了一个能够管理此类文档的 Java 应用程序原型，展示了将此类文档转换为可读网页的可能性，并报告了几个案例研究，其中一个案例目前由意大利中部一家健康中心的家庭护理服务部门管理。
