Zhou Li, Hongsermeier Tonya, Boxwala Aziz, Lewis Janet, Kawamoto Kensaku, Maviglia Saverio, Gentile Douglas, Teich Jonathan M, Rocha Roberto, Bell Douglas, Middleton Blackford
Clinical Informatics Research & Development, Partners HealthCare System, Inc., Wellesley, MA, USA.
Stud Health Technol Inform. 2013;192:195-9.
At present, there are no widely accepted, standard approaches for representing computer-based clinical decision support (CDS) intervention types and their structural components. This study aimed to identify key requirements for the representation of five widely utilized CDS intervention types: alerts and reminders, order sets, infobuttons, documentation templates/forms, and relevant data presentation. An XML schema was proposed for representing these interventions and their core structural elements (e.g., general metadata, applicable clinical scenarios, CDS inputs, CDS outputs, and CDS logic) in a shareable manner. The schema was validated by building CDS artifacts for 22 different interventions, targeted toward guidelines and clinical conditions called for in the 2011 Meaningful Use criteria. Custom style sheets were developed to render the XML files in human-readable form. The CDS knowledge artifacts were shared via a public web portal. Our experience also identifies gaps in existing standards and informs future development of standards for CDS knowledge representation and sharing.
目前，对于基于计算机的临床决策支持（CDS）干预类型及其结构组件，尚无被广泛接受的标准表示方法。本研究旨在确定对五种广泛使用的CDS干预类型进行表示的关键要求：警报与提醒、医嘱集、信息按钮、文档模板/表单以及相关数据呈现。提出了一种XML模式，用于以可共享的方式表示这些干预措施及其核心结构元素（例如，一般元数据、适用的临床场景、CDS输入、CDS输出和CDS逻辑）。通过针对2011年有意义使用标准中要求的指南和临床状况构建22种不同干预措施的CDS工件，对该模式进行了验证。开发了自定义样式表，以将XML文件呈现为人类可读的形式。CDS知识工件通过公共门户网站进行共享。我们的经验还识别了现有标准中的差距，并为CDS知识表示和共享标准的未来发展提供了参考。
