Kalra Dipak, Musen Mark, Smith Barry, Ceusters Werner, De Moor Georges
University College London, UK.
Stud Health Technol Inform. 2011;170:1-15.
Semantic interoperability is one of the priority themes of the ARGOS Trans-Atlantic Observatory. This topic represents a globally recognised challenge that must be addressed if electronic health records are to be shared among heterogeneous systems, and the information in them exploited to the maximum benefit of patients, professionals, health services, research, and industry. Progress in this multi-faceted challenge has been piecemeal, and valuable lessons have been learned, and approaches discovered, in Europe and in the US that can be shared and combined. Experts from both continents have met at three ARGOS workshops during 2010 and 2011 to share understanding of these issues and how they might be tackled collectively from both sides of the Atlantic. This policy brief summarises the problems and the reasons why they are important to tackle, and also why they are so difficult. It outlines the major areas of semantic innovation that exist and that are available to help address this challenge. It proposes a series of next steps that need to be championed on both sides of the Atlantic if further progress is to be made in sharing and analysing electronic health records meaningfully. Semantic interoperability requires the use of standards, not only for EHR data to be transferred and structurally mapped into a receiving repository, but also for the clinical content of the EHR to be interpreted in conformity with the original meanings intended by its authors. Wide-scale engagement with professional bodies, globally, is needed to develop these clinical information standards. Accurate and complete clinical documentation, faithful to the patient's situation, and interoperability between systems, require widespread and dependable access to published and maintained collections of coherent and quality-assured semantic resources, including models such as archetypes and templates that would (1) provide clinical context, (2) be mapped to interoperability standards for EHR data, (3) be linked to well specified multi-lingual terminology value sets, and (4) be derived from high quality ontologies. There is need to gain greater experience in how semantic resources should be defined, validated, and disseminated, how users (who increasingly will include patients) should be educated to improve the quality and consistency of EHR documentation and to make full use of it. There are urgent needs to scale up the authorship, acceptance, and adoption of clinical information standards, to leverage and harmonise the islands of standardisation optimally, to assure the quality of the artefacts produced, and to organise end-to-end governance of the development and adoption of solutions.
语义互操作性是跨大西洋观测站（ARGOS）的优先主题之一。如果要在异构系统之间共享电子健康记录，并利用其中的信息使患者、专业人员、医疗服务、研究和行业获得最大利益，那么这个主题代表了一个全球公认的必须应对的挑战。在这个多方面的挑战中取得的进展是零散的，并且在欧洲和美国已经吸取了宝贵的经验教训，发现了可以共享和结合的方法。来自两大洲的专家在2010年和2011年期间参加了三次ARGOS研讨会，以分享对这些问题的理解以及如何从大西洋两岸共同应对这些问题。本政策简报总结了问题以及解决这些问题为何重要和为何如此困难的原因。它概述了现有的以及可用于帮助应对这一挑战的语义创新的主要领域。它提出了一系列如果要在有意义地共享和分析电子健康记录方面取得进一步进展，大西洋两岸都需要倡导的后续步骤。语义互操作性不仅要求使用标准来传输电子健康记录数据并将其结构映射到接收存储库，还要求按照其作者的原意来解释电子健康记录的临床内容。需要全球范围内与专业机构广泛合作来制定这些临床信息标准。准确、完整且忠实于患者情况的临床文档以及系统之间的互操作性，需要广泛且可靠地获取已发布和维护的连贯且经过质量保证的语义资源集合，包括诸如原型和模板等模型，这些模型应（1）提供临床背景，（2）映射到电子健康记录数据的互操作性标准，（3）链接到明确指定的多语言术语值集，并且（4）源自高质量的本体。需要在如何定义、验证和传播语义资源方面积累更多经验，需要对用户（其中越来越多的将包括患者）进行教育，以提高电子健康记录文档的质量和一致性并充分利用它。迫切需要扩大临床信息标准的编写、认可和采用范围，以最佳方式利用和协调标准化孤岛，确保所产生工件的质量，并组织对解决方案开发和采用的端到端治理。
