Zielstorff R D
Department of Nursing, Massachusetts General Hospital, Boston 02114, USA.
J Am Med Inform Assoc. 1995 May-Jun;2(3):191-6. doi: 10.1136/jamia.1995.95338872.
There is an urgent need to capture and record data related to clinical outcomes, but there are many barriers. The range of problems includes lack of agreement on conceptualization of the term "outcome," inadequate measures of outcomes, and inadequate information systems to capture and manipulate data that would reflect outcomes. This article focuses on information system requirements to capture, store, and utilize clinical outcome data. For greatest accuracy, outcome data should be captured as close to the source as possible, including direct data capture from patients themselves and from their families. To make maximum use of outcome data, systems must be designed to 1) store data in multipurpose databases; 2) share data across different platforms; 3) link outcome data to other data that might influence or explain outcomes; 4) allow querying of the data by authorized personnel; and 5) protect patient confidentiality.
迫切需要获取和记录与临床结果相关的数据，但存在许多障碍。问题包括对“结果”一词的概念化缺乏共识、结果测量不充分以及缺乏用于获取和处理反映结果的数据的信息系统。本文重点关注获取、存储和利用临床结果数据的信息系统要求。为了获得最大的准确性，结果数据应尽可能接近源头进行获取，包括直接从患者本人及其家属那里获取数据。为了最大限度地利用结果数据，系统必须设计成能够：1）将数据存储在多用途数据库中；2）跨不同平台共享数据；3）将结果数据与可能影响或解释结果的其他数据相链接；4）允许授权人员查询数据；5）保护患者的隐私。
