Vreeman Daniel J, McDonald Clement J, Huff Stanley M
Regenstrief Institute, Inc and Indiana University School of Medicine, Indianapolis, IN;
AMIA Annu Symp Proc. 2010 Nov 13;2010:832-6.
Without being included in accepted vocabulary standards, the results of completed patient assessment instruments cannot be easily shared in health information exchanges. To address this important barrier, we have developed a robust model to represent assessments in LOINC through iterative refinement and collaborative development. To capture the essential aspects of the assessment, the LOINC model represents the hierarchical panel structure, global item attributes, panel-specific item attributes, and structured answer lists. All assessments are available in a uniform format within the freely available LOINC distribution. We have successfully added many assessments to LOINC in this model, including several federally required assessments that contain functioning and disability content. We continue adding to this "master question file" to further enable interoperable exchange, storage, and processing of assessment data.
由于未被纳入公认的词汇标准，已完成的患者评估工具的结果难以在健康信息交换中轻松共享。为解决这一重要障碍，我们通过迭代优化和协作开发，构建了一个强大的模型，用于在LOINC中表示评估。为了捕捉评估的关键方面，LOINC模型体现了分层面板结构、全局项目属性、特定面板项目属性和结构化答案列表。所有评估在免费提供的LOINC发行版中均采用统一格式。我们已通过此模型成功将多项评估添加到LOINC中，并添加了多项包含功能和残疾内容的联邦要求评估。我们将继续扩充这个“主问题文件”，以进一步实现评估数据的可互操作交换、存储和处理。
