Yasini Mobin, Duclos Catherine, Venot Alain, Lepage Eric, Lamy Jean-Baptiste
LIM&BIO (Laboratoire d'informatique médicale et bioinformatique), UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny, France.
Stud Health Technol Inform. 2013;192:719-23.
The culture of evidence-based practice includes also the field of laboratory medicine. Clinical laboratory expenditure is growing rapidly for various reasons including increased utilization. Delivering decision support to requesters at the point of care is one of the main incentives for implementing laboratory guidelines. Laboratory guidelines were analyzed to extract test-ordering rules. Each rule was explicated in at least one clinical situation with triggers that launch the execution of the implemented rule. The Unified Modeling Language was used to represent the categories of information elements found in the guidelines and underline the information elements that need to be structured and coded in the EHR. These information elements are related to conditions including clinical conditions, habits, family history, demographic information, medical treatments, laboratory tests, and non-laboratory test procedures. Timestamping of each event is also important for implementing laboratory prescription rules. A linkage between the conditions of this model and HL7 RIM was feasible. Use of this model facilitates the implementation of evidence-based test-ordering rules and clarifies the EHR requirements for successful implementation of guidelines.
循证实践文化也涵盖检验医学领域。由于包括利用率提高在内的各种原因，临床检验支出正在迅速增长。在医疗点为请求者提供决策支持是实施检验指南的主要动机之一。对检验指南进行分析以提取检验医嘱规则。每条规则都在至少一种临床情况下进行了阐述，并带有触发已实施规则执行的触发因素。统一建模语言用于表示指南中发现的信息元素类别，并强调需要在电子健康记录（EHR）中进行结构化和编码的信息元素。这些信息元素与多种状况相关，包括临床状况、习惯、家族史、人口统计学信息、医疗治疗、实验室检验以及非实验室检验程序。对每个事件进行时间戳记对于实施检验处方规则也很重要。该模型的状况与HL7参考信息模型（RIM）之间建立联系是可行的。使用此模型有助于实施循证检验医嘱规则，并阐明成功实施指南所需的电子健康记录要求。
