Reiner Bruce
Department of Radiology, Baltimore VA Medical Center, 10 North Greene Street, Baltimore, MD, 21201, USA,
J Digit Imaging. 2015 Jun;28(3):249-55. doi: 10.1007/s10278-015-9794-4.
One of the greatest challenges facing healthcare professionals is the ability to directly and efficiently access relevant data from the patient's healthcare record at the point of care; specific to both the context of the task being performed and the specific needs and preferences of the individual end-user. In radiology practice, the relative inefficiency of imaging data organization and manual workflow requirements serves as an impediment to historical imaging data review. At the same time, clinical data retrieval is even more problematic due to the quality and quantity of data recorded at the time of order entry, along with the relative lack of information system integration. One approach to address these data deficiencies is to create a multi-disciplinary patient referenceable database which consists of high-priority, actionable data within the cumulative patient healthcare record; in which predefined criteria are used to categorize and classify imaging and clinical data in accordance with anatomy, technology, pathology, and time. The population of this referenceable database can be performed through a combination of manual and automated methods, with an additional step of data verification introduced for data quality control. Once created, these referenceable databases can be filtered at the point of care to provide context and user-specific data specific to the task being performed and individual end-user requirements.
医疗保健专业人员面临的最大挑战之一是能否在护理点直接且高效地从患者的医疗记录中获取相关数据,这既与正在执行的任务背景相关,也与个体终端用户的特定需求和偏好有关。在放射学实践中,成像数据组织的相对低效和手动工作流程要求阻碍了对历史成像数据的审查。与此同时,由于医嘱录入时记录的数据质量和数量,以及信息系统集成相对不足,临床数据检索问题更大。解决这些数据缺陷的一种方法是创建一个多学科的患者可参考数据库,该数据库由累积患者医疗记录中的高优先级、可操作数据组成;其中使用预定义标准根据解剖学、技术、病理学和时间对成像和临床数据进行分类。这个可参考数据库的填充可以通过手动和自动方法相结合来完成,并引入额外的数据验证步骤以进行数据质量控制。一旦创建,这些可参考数据库可以在护理点进行筛选,以提供与正在执行的任务和个体终端用户需求相关的背景信息和特定于用户的数据。