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识别临床和公共卫生表格中标准数据元素的方法。

Methods to identify standard data elements in clinical and public health forms.

作者信息

Abernethy Neil F, DeRimer Kathy, Small Peter M

机构信息

University of Washington, Seattle, WA, USA.

出版信息

AMIA Annu Symp Proc. 2011;2011:19-27. Epub 2011 Oct 22.

Abstract

The fragmentation of clinical and public health systems results in divergent information collection practices, presenting challenges to standardization and EHR certification efforts. Data forms employed in public health jurisdictions nationwide reflect these differences in patient treatment, monitoring and evaluation, and follow-up, presenting challenges for data integration. To study these variations, we surveyed tuberculosis contact investigation forms from all fifty states, three municipalities and two countries. We apply statistics and cluster analysis to analyze the divergent content of contact investigation forms with the goal of characterizing normative practices and identifying a common core of data fields. We found widespread variation in data elements between states in the study, with the "Name" field being the only ubiquitous data element. Our method reveals distinct groupings of data fields employed in certain regions, allowing the simultaneous identification of core standard data fields as well as variations in practice.

摘要

临床和公共卫生系统的碎片化导致信息收集做法各异,给标准化和电子健康记录认证工作带来挑战。全国公共卫生辖区使用的数据表格反映了患者治疗、监测、评估及随访方面的这些差异,给数据整合带来挑战。为研究这些差异,我们调查了来自美国所有50个州、三个直辖市和两个地区的结核病接触者调查表格。我们运用统计学和聚类分析来分析接触者调查表格内容的差异,目的是描述规范做法并确定数据字段的共同核心。我们发现,研究中的各州之间的数据元素存在广泛差异,“姓名”字段是唯一普遍存在的数据元素。我们的方法揭示了某些地区使用的数据字段的不同分组,能够同时识别核心标准数据字段以及实际做法中的差异。

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