Moreno-Conde Alberto, Moner David, Cruz Wellington Dimas da, Santos Marcelo R, Maldonado José Alberto, Robles Montserrat, Kalra Dipak
Centre for Health Informatics and Multiprofessional Education, University College London, London, UK Hospital Universitario Virgen del Rocío, Sevilla, Spain
Instituto de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas, Universitat Politècnica de València, Valencia, Spain.
J Am Med Inform Assoc. 2015 Jul;22(4):925-34. doi: 10.1093/jamia/ocv008. Epub 2015 Mar 21.
This systematic review aims to identify and compare the existing processes and methodologies that have been published in the literature for defining clinical information models (CIMs) that support the semantic interoperability of electronic health record (EHR) systems.
Following the preferred reporting items for systematic reviews and meta-analyses systematic review methodology, the authors reviewed published papers between 2000 and 2013 that covered that semantic interoperability of EHRs, found by searching the PubMed, IEEE Xplore, and ScienceDirect databases. Additionally, after selection of a final group of articles, an inductive content analysis was done to summarize the steps and methodologies followed in order to build CIMs described in those articles.
Three hundred and seventy-eight articles were screened and thirty six were selected for full review. The articles selected for full review were analyzed to extract relevant information for the analysis and characterized according to the steps the authors had followed for clinical information modeling.
Most of the reviewed papers lack a detailed description of the modeling methodologies used to create CIMs. A representative example is the lack of description related to the definition of terminology bindings and the publication of the generated models. However, this systematic review confirms that most clinical information modeling activities follow very similar steps for the definition of CIMs. Having a robust and shared methodology could improve their correctness, reliability, and quality.
Independently of implementation technologies and standards, it is possible to find common patterns in methods for developing CIMs, suggesting the viability of defining a unified good practice methodology to be used by any clinical information modeler.
本系统综述旨在识别和比较文献中已发表的用于定义支持电子健康记录（EHR）系统语义互操作性的临床信息模型（CIM）的现有流程和方法。
按照系统综述和荟萃分析的首选报告项目系统综述方法，作者检索了PubMed、IEEE Xplore和ScienceDirect数据库，对2000年至2013年间发表的涵盖EHR语义互操作性的论文进行了综述。此外，在选定最终的一组文章后，进行了归纳内容分析，以总结构建这些文章中描述的CIM所遵循的步骤和方法。
筛选了378篇文章，选择了36篇进行全面综述。对选定进行全面综述的文章进行分析，以提取分析所需的相关信息，并根据作者在临床信息建模中遵循的步骤进行特征描述。
大多数综述论文缺乏对用于创建CIM的建模方法的详细描述。一个典型的例子是缺乏与术语绑定定义和生成模型的发布相关的描述。然而，本系统综述证实，大多数临床信息建模活动在定义CIM时遵循非常相似的步骤。拥有一个强大且共享的方法可以提高其正确性、可靠性和质量。
无论实施技术和标准如何，在开发CIM的方法中都可以找到共同模式，这表明定义一种统一的良好实践方法供任何临床信息建模人员使用是可行的。
