Informatics Institute, University of Alabama at Birmingham.
AMIA Annu Symp Proc. 2024 Jan 11;2023:309-318. eCollection 2023.
Widespread adoption of electronic health records (EHR) in the U.S. has been followed by unintended consequences, overexposing clinicians to widely reported EHR limitations. As an attempt to fixing the EHR, we propose the use of a clinical context ontology (CCO), applied to turn implicit contextual statements into formally represented data in the form of concept-relationship-concept tuples. These tuples form what we call a patient specific knowledge base (PSKB), a collection of formally defined tuples containing facts about the patient's care context. We report the process to create a CCO, which guides annotation of structured and narrative patient data to produce a PSKB. We also present an application of our PSKB using real patient data displayed on a semantically oriented patient summary to improve EHR navigation. Our approach can potentially save precious time spent by clinicians using today's EHRs, by showing a chronological view of the patient's record along with contextual statements needed for care decisions with minimum effort. We propose several other applications of a PSKB to improve multiple EHR functions to guide future research.
电子健康记录 (EHR) 在 美 国 的广泛采用带来了意料之外的后果,使临床医生过度暴露于广泛报道的 EHR 局限性之下。作为对 EHR 的修复尝试,我们提出使用临床上下文本体 (CCO),将隐式上下文语句应用于正式表示的数据形式,即概念-关系-概念元组。这些元组构成了我们所谓的患者特定知识库 (PSKB),这是一个正式定义的元组集合,包含有关患者护理上下文的事实。我们报告了创建 CCO 的过程,该过程指导对结构化和叙述性患者数据进行注释,以生成 PSKB。我们还展示了使用真实患者数据在语义导向的患者摘要上显示 PSKB 的应用,以改善 EHR 导航。我们的方法可以通过以最小的努力为临床医生节省使用当今 EHR 所花费的宝贵时间,为他们提供患者记录的时间轴视图以及护理决策所需的上下文语句。我们提出了 PSKB 的其他几种应用,以改善多个 EHR 功能,指导未来的研究。