Garcia Diego, Moro Claudia Maria Cabral, Cicogna Paulo Eduardo, Carvalho Deborah Ribeiro
Health Technology Post-graduate Program - Pontifical Catholic University of Paraná, Brazil.
Stud Health Technol Inform. 2013;192:871-5.
Clinical guidelines are documents that assist healthcare professionals, facilitating and standardizing diagnosis, management, and treatment in specific areas. Computerized guidelines as decision support systems (DSS) attempt to increase the performance of tasks and facilitate the use of guidelines. Most DSS are not integrated into the electronic health record (EHR), ordering some degree of rework especially related to data collection. This study's objective was to present a method for integrating clinical guidelines into the EHR. The study developed first a way to identify data and rules contained in the guidelines, and then incorporate rules into an archetype-based EHR. The proposed method tested was anemia treatment in the Chronic Kidney Disease Guideline. The phases of the method are: data and rules identification; archetypes elaboration; rules definition and inclusion in inference engine; and DSS-EHR integration and validation. The main feature of the proposed method is that it is generic and can be applied toany type of guideline.
临床指南是辅助医疗保健专业人员的文件,有助于特定领域的诊断、管理和治疗的便利化与标准化。作为决策支持系统(DSS)的计算机化指南试图提高任务执行效率并促进指南的使用。大多数决策支持系统并未集成到电子健康记录(EHR)中,这就需要进行一定程度的返工,尤其是在数据收集方面。本研究的目的是提出一种将临床指南集成到电子健康记录中的方法。该研究首先开发了一种识别指南中包含的数据和规则的方法,然后将规则纳入基于原型的电子健康记录中。所测试的方法是慢性肾脏病指南中的贫血治疗。该方法的阶段包括:数据和规则识别;原型构建;规则定义并纳入推理引擎;以及决策支持系统与电子健康记录的集成和验证。所提出方法的主要特点是具有通用性,可应用于任何类型的指南。