Zhou Li, Collins Sarah, Morgan Stephen J, Zafar Neelam, Gesner Emily J, Fehrenbach Martin, Rocha Roberto A
Clinical Informatics, Partners HealthCare System, Boston, MA; Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
Clinical Informatics, Partners HealthCare System, Boston, MA.
AMIA Annu Symp Proc. 2017 Feb 10;2016:1293-1302. eCollection 2016.
Structured clinical documentation is an important component of electronic health records (EHRs) and plays an important role in clinical care, administrative functions, and research activities. Clinical data elements serve as basic building blocks for composing the templates used for generating clinical documents (such as notes and forms). We present our experience in creating and maintaining data elements for three different EHRs (one home-grown and two commercial systems) across different clinical settings, using flowsheet data elements as examples in our case studies. We identified basic but important challenges (including naming convention, links to standard terminologies, and versioning and change management) and possible solutions to address them. We also discussed more complicated challenges regarding governance, documentation vs. structured data capture, pre-coordination vs. post-coordination, reference information models, as well as monitoring, communication and training.
结构化临床文档是电子健康记录(EHR)的重要组成部分,在临床护理、行政职能和研究活动中发挥着重要作用。临床数据元素是构成用于生成临床文档(如笔记和表格)的模板的基本构建块。我们介绍了在不同临床环境中为三个不同的电子健康记录系统(一个自主开发的和两个商业系统)创建和维护数据元素的经验,在案例研究中以流程图数据元素为例。我们识别了基本但重要的挑战(包括命名规范、与标准术语的链接以及版本控制和变更管理)以及应对这些挑战的可能解决方案。我们还讨论了有关治理、文档与结构化数据捕获、预协调与后协调、参考信息模型以及监测、沟通和培训等更复杂的挑战。