Faculty of Applied Health and Social Sciences, University of Applied Sciences Rosenheim, Rosenheim, Germany.
Human Functioning Unit, Swiss Paraplegic Research, Nottwil, Switzerland.
Appl Clin Inform. 2018 Apr;9(2):348-365. doi: 10.1055/s-0038-1649488. Epub 2018 May 23.
Specifying the content in electronic health records (EHRs) through standardized headings based on international reference classifications will facilitate their semantic interoperability. The objective of this study was to specify potential chapter headings for EHRs aligned with the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICF) based on the perspectives of people living with chronic health conditions, carers, and professionals.
A multistage process was established including (1) a patient workshop, (2) an online survey of both patients and carers, and (3) an online consultation with patient and professional bodies. The ICF served as a starting point. Based on the first stage, a first draft of the headings was developed and further refined based on the feedback at each stage. We examined in a fourth step whether items from existing assessment tools support the operationalization of the identified headings. Therefore, we used the WHO Disability Assessment Schedule 2.0 (WHODAS2.0), a patient-reported instrument, and interRAI, a clinician-administered instrument.
The first workshop was attended by eight people, the survey was completed by 250 persons, and the online consultation received detailed feedback by 18 professional bodies. This study resulted in 16 potential chapter headings for EHRs which capture aspects related to the body, such as emotions, motivation, sleep, and memory or thoughts, to being involved in social life, such as mobility, social activities, and finances, as well as to the care process, such as understanding of health issues and treatment or care priorities and goals. When using the WHODAS2.0 and interRAI together, they capture all except one of the proposed headings.
The identified headings provide a high level structure for the standardized recording, use, and sharing of information. Once implemented, these headings have the potential to facilitate the delivery of personalized care planning for patients with long-term health problems.
通过基于国际参考分类的标准化标题来指定电子健康记录（EHR）中的内容，将促进其语义互操作性。本研究的目的是根据患有慢性健康状况的患者、护理人员和专业人员的观点，基于世界卫生组织（WHO）的《国际功能、残疾和健康分类》（ICF）指定与 EHR 一致的潜在章节标题。
建立了一个多阶段的过程，包括（1）患者研讨会，（2）患者和护理人员的在线调查，以及（3）与患者和专业机构的在线咨询。ICF 作为起点。基于第一阶段，制定了标题的初稿，并根据每个阶段的反馈进行了进一步的细化。我们在第四步检查了来自现有评估工具的项目是否支持所确定标题的操作化。因此，我们使用了世界卫生组织残疾评估表 2.0（WHODAS2.0），这是一种患者报告的工具，以及 interRAI，这是一种临床医生管理的工具。
第一次研讨会有八人参加，共有 250 人完成了调查，18 个专业机构详细反馈了在线咨询。这项研究产生了 16 个潜在的 EHR 章节标题，这些标题涵盖了与身体相关的方面，例如情绪、动机、睡眠和记忆或想法，以及参与社会生活的方面，例如移动性、社会活动和财务，以及护理过程方面，例如对健康问题的理解以及治疗或护理重点和目标。当同时使用 WHODAS2.0 和 interRAI 时，它们涵盖了除一个建议标题外的所有标题。
所确定的标题为标准化记录、使用和共享信息提供了高级结构。一旦实施，这些标题有可能为患有长期健康问题的患者提供个性化的护理计划。
