Kalra Dipak, Tapuria Archana, Austin Tony, De Moor Georges
Centre for Health Informatics and Multiprofessional Education, University College London, UK.
Stud Health Technol Inform. 2012;180:48-52.
The realisation of semantic interoperability, in which any EHR data may be communicated between heterogeneous systems and fully understood by computers as well as people on receipt, is a challenging goal. Despite the use of standardised generic models for the EHR and standard terminology systems, too much optionality and variability exists in how particular clinical entries may be represented. Clinical archetypes provide a means of defining how generic models should be shaped and bound to terminology for specific kinds of clinical data. However, these will only contribute to semantic interoperability if libraries of archetypes can be built up consistently. This requires the establishment of design principles, editorial and governance policies, and further research to develop ways for archetype authors to structure clinical data and to use terminology consistently. Drawing on several years of work within communities of practice developing archetypes and implementing systems from them, this paper presents quality requirements for the development of archetypes. Clinical engagement on a wide scale is also needed to help grow libraries of good quality archetypes that can be certified. Vendor and eHealth programme engagement is needed to validate such archetypes and achieve safe, meaningful exchange of EHR data between systems.
实现语义互操作性是一个具有挑战性的目标，在这种互操作性中，任何电子健康记录（EHR）数据都可以在异构系统之间进行通信，并且在接收时计算机和人员都能完全理解。尽管使用了标准化的通用EHR模型和标准术语系统，但在特定临床条目的表示方式上仍存在过多的可选性和变异性。临床原型提供了一种定义通用模型应如何针对特定类型的临床数据进行塑造并与术语绑定的方法。然而，只有当原型库能够一致地建立起来时，这些才会有助于语义互操作性。这需要确立设计原则、编辑和管理政策，并进行进一步研究，以开发出供原型作者构建临床数据并一致使用术语的方法。基于在实践社区中开展的数年工作，这些工作涉及开发原型以及从原型实施系统，本文提出了原型开发的质量要求。还需要广泛的临床参与，以帮助建立可认证的高质量原型库。需要供应商和电子健康计划的参与来验证此类原型，并实现系统之间安全、有意义的EHR数据交换。
