Sass Julian, Zabka Susanne, Essenwanger Andrea, Schepers Josef, Boeker Martin, Thun Sylvia
Berlin Institute of Health (BIH), Germany.
Institute for Medical Biometry and Medical Informatics, University of Freiburg, Freiburg, Germany.
Stud Health Technol Inform. 2021 May 24;278:231-236. doi: 10.3233/SHTI210074.
Electronic documentation of medication data is one of the biggest challenges associated with digital clinical documentation. Despite its importance, it has not been consistently implemented in German university hospitals. In this paper we describe the approach of the German Medical Informatics Initiative (MII) towards the modelling of a medication core dataset using FHIR® profiles and standard-compliant terminologies. The FHIR profiles for Medication and MedicationStatement were adapted to the core dataset of the MIl. The terminologies to be used were selected based on the criteria of the ISO-standard for the Identification of Medicinal Products (IDMP). For a first use case with a minimal medication dataset, the entries in the medication chapter of the German Procedure Classification (OPS codes) were analyzed and mapped to IDMP-compliant medication terminology. OPS data are available at all German hospitals as they are mandatory for reimbursement purposes. Reimbursement-relevant encounter data containing OPS medication procedures were used to create a FHIR representation based on the FHIR profiles MedicationStatement and Medication. This minimal solution includes - besides the details on patient and start-/end-dates - the active ingredients identified by the IDMP-compliant codes and - if specified in the OPS code - the route of administration and the range of the amount of substance administered to the patient, using the appropriate unit of measurement code. With FHIR, the medication data can be represented in the data integration centers of the MII to provide a standardized format for data analysis across the MII sites.
药物数据的电子记录是数字临床文档面临的最大挑战之一。尽管其很重要，但在德国大学医院中尚未得到一致实施。在本文中，我们描述了德国医学信息学倡议（MII）使用FHIR® 简档和符合标准的术语对药物核心数据集进行建模的方法。药物和药物声明的FHIR简档已根据MIl的核心数据集进行了调整。所使用的术语是根据《药品识别ISO标准》（IDMP）的标准选定的。对于第一个使用最小药物数据集的用例，分析了德国程序分类（OPS代码）药物章节中的条目，并将其映射到符合IDMP的药物术语。所有德国医院都可获取OPS数据，因为出于报销目的这些数据是强制性的。包含OPS药物程序的与报销相关的会诊数据被用于基于FHIR简档“药物声明”和“药物”创建FHIR表示形式。这个最小化解决方案除了包含患者详细信息和开始/结束日期外，还包括由符合IDMP的代码识别的活性成分，以及——如果在OPS代码中指定——给药途径和使用适当计量单位代码向患者给药的物质数量范围。借助FHIR，药物数据可以在MII的数据集成中心中表示，以便为跨MII各站点的数据分析提供标准化格式。
