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本文引用的文献

1
Health information technology: initial set of standards, implementation specifications, and certification criteria for electronic health record technology. Interim final rule.健康信息技术:电子健康记录技术的初始标准集、实施规范和认证标准。暂行最终规则。
Fed Regist. 2010 Jan 13;75(8):2013-47.
2
Using digrams to map controlled medical vocabularies.使用双词组合来映射受控医学词汇表。
Proc Annu Symp Comput Appl Med Care. 1994:172-6.

自动化质量报告的发展:使地方工作与国家标准保持一致。

Development of automated quality reporting: aligning local efforts with national standards.

作者信息

Dykes Patricia C, Caligtan Christine, Novack Andrew, Thomas Debra, Winfield Linda, Zuccotti Gianna, Rocha Roberto A

机构信息

Partners Healthcare System, Boston, MA, USA.

出版信息

AMIA Annu Symp Proc. 2010 Nov 13;2010:187-91.

PMID:21346966
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC3041414/
Abstract

As providers and systems move towards meaningful use of electronic health records, the once distant vision of data reuse for automated quality reporting may soon become a reality. To facilitate consistent and reliable reporting and benchmarking beyond the local level, standardization of both electronic health record content and quality measures is needed at the concept level. This degree of standardization requires local and national advancement and coordination. The purpose of this paper is to review national efforts that can be leveraged to guide local information modeling and terminology work to support automated quality reporting. Moreover, efforts at Partners HealthCare to map electronic health record content to inpatient quality metrics, terminology standards and to align local efforts with national initiatives are reported. We found that forty-one percent (41%) of the elements needed to populate the inpatient quality measures are represented within the draft documentation content and an additional 29.5% are represented within other Partners HealthCare (PHS) electronic applications. Recommendations are made to support data reuse based on established national standards and identified gaps. Our work indicates that value exists in individual healthcare systems engaging in local standardization work by adopting established methods and standards where they exist. A process is needed, however, to ensure that local work is shared and available to inform national standards.

摘要

随着医疗服务提供者和系统朝着有意义地使用电子健康记录迈进,曾经遥不可及的数据再利用以实现自动化质量报告的愿景可能很快成为现实。为了促进超越地方层面的一致且可靠的报告和基准测试,需要在概念层面实现电子健康记录内容和质量指标的标准化。这种标准化程度需要地方和国家层面的推进与协调。本文的目的是回顾可用于指导地方信息建模和术语工作以支持自动化质量报告的国家层面的努力。此外,还报告了合作医疗保健机构为将电子健康记录内容映射到住院患者质量指标、术语标准以及使地方努力与国家倡议保持一致所做的工作。我们发现,填充住院患者质量指标所需的元素中有41%在文档内容草案中有所体现,另外29.5%在合作医疗保健机构(PHS)的其他电子应用程序中有所体现。基于既定的国家标准和已识别的差距,我们提出了支持数据再利用的建议。我们的工作表明,各个医疗系统通过采用现有的既定方法和标准开展地方标准化工作是有价值的。然而,需要一个流程来确保地方工作能够共享并为国家标准提供参考依据。