Chen Elizabeth S, Manaktala Sharad, Sarkar Indra Neil, Melton Genevieve B
Center for Clinical & Translational Science, University of Vermont, Burlington, VT, USA.
AMIA Annu Symp Proc. 2011;2011:227-36. Epub 2011 Oct 22.
Within Electronic Health Records (EHRs), the social history section contains information relevant to social, behavioral, and environmental determinants of health. While social history is playing an increasingly important role in patient care, biomedical research, and public health, little analysis has been done to describe content in the EHR or the adequacy of existing standards for representing this information. In this study, social history sections from 260 clinical notes containing 989 sentences and 1,439 statements were analyzed from three sources. In total, 35 statement types were identified along with categories of information within statements for each type. For the 8 most common types, HL7 CDA and openEHR were found to provide different representations capable of capturing the breadth and granularity of information to some extent. The results of this study provide valuable insights for guiding efforts in the enhanced collection, standardization, and use of social history information in the EHR.
在电子健康记录（EHR）中，社会史部分包含与健康的社会、行为和环境决定因素相关的信息。虽然社会史在患者护理、生物医学研究和公共卫生中发挥着越来越重要的作用，但针对电子健康记录中的内容或用于表示此信息的现有标准的充分性所做的分析却很少。在本研究中，从三个来源分析了260份临床记录中的社会史部分，这些记录包含989个句子和1439条陈述。总共识别出35种陈述类型以及每种类型陈述中的信息类别。对于8种最常见的类型，发现HL7 CDA和openEHR能够在一定程度上提供不同的表示方式来捕捉信息的广度和粒度。本研究结果为指导在电子健康记录中加强社会史信息的收集、标准化和使用方面的工作提供了有价值的见解。
