Brammen Dominik, Dewenter Heike, Thiemann Volker, Majeed Raphael W, Xu Tingyan, Heitmann Kai U, Walcher Felix, Thun Sylvia, Röhrig Rainer
Department of Trauma Surgery, Otto-von-Guericke-University Magdeburg, Germany.
Hochschule Niederrhein, University of Applied Sciences, Krefeld, Germany.
Stud Health Technol Inform. 2017;243:132-136.
A standardized medical record for the emergency department (GEDMR) was released in Germany, but only sparsely and randomly implemented by emergency department (ED) electronic health record (EHR) vendors. A reason for this may be a lacking common language between the medical and the Health Information Technology (HIT) domain. HL7 clinical document architecture (CDA) may leverage this communication gap. This paper reports on the effects of a professional medical association record standard on EHR vendors and the German ED-EHR market. Standard records and data standards are developed and published by different institutions either on governmental, healthcare agency or medical association level. There are some standard records, especially by US cardiology associations, transformed into HL7 C-CDA. GEDMR was modeled as HL7 CDA with the use of interoperable terminologies like LOINC and SNOMED CT. Being part of an emergency department data registry development project, local deployment at 15 project hospitals receiving sufficient funding was performed. Two major ED-EHR vendors adapted GEDMR within their product including CDA export. 106,868 CDAs were produced in six hospitals until now. Four local implementations with four different ED-EHRs were developed, producing 42,256 CDAs. Five additional vendors are adapting or developing an ED-EHR. The GEDMR-CDA implementation guide with funding for implementation in project hospitals had a significant impact on the German ED-EHR market. Within two years after release, a broadening and increasingly self-enforcing support by German ED-EHR vendors is notable.
德国发布了急诊科标准化病历（GEDMR），但急诊科电子健康记录（EHR）供应商只是零星且随意地采用。造成这种情况的一个原因可能是医学领域与健康信息技术（HIT）领域之间缺乏共同语言。HL7临床文档架构（CDA）可能有助于弥合这一沟通差距。本文报告了一项专业医学协会记录标准对EHR供应商和德国急诊科EHR市场的影响。标准记录和数据标准由不同机构在政府、医疗保健机构或医学协会层面制定和发布。有一些标准记录，特别是美国心脏病学协会制定的标准记录，已转化为HL7 C-CDA。GEDMR通过使用诸如LOINC和SNOMED CT等可互操作术语被建模为HL7 CDA。作为急诊科数据注册开发项目的一部分，在15家获得充足资金的项目医院进行了本地部署。两家主要的急诊科EHR供应商在其产品中采用了GEDMR，包括CDA导出功能。截至目前，六家医院共生成了106,868份CDA。开展了四个使用四种不同急诊科EHR的本地实施项目，共生成了42,256份CDA。另外还有五家供应商正在采用或开发急诊科EHR。带有项目医院实施资金的GEDMR-CDA实施指南对德国急诊科EHR市场产生了重大影响。发布后的两年内，德国急诊科EHR供应商的支持范围不断扩大且越来越具有自我强化性，这一点值得注意。
