Cimino J J
Center for Medical Informatics, Columbia University, Columbia Presbyterian Medical Center, New York, NY 10032.
Int J Biomed Comput. 1994 Jan;34(1-4):185-94. doi: 10.1016/0020-7101(94)90021-3.
The representation of patient information for use in clinical workstations is a complex problem. Ideally, it should be addressed in a way that allows multiple uses of the data, including simple manual review, sharing and pooling across institutions, and as input to knowledge-based decision support systems. To a great extent, this means coding information with controlled medical vocabularies, but it does not mean that all information must be codable before workstations are feasible. This paper defines some of the choices, both current and future, that are available to address the needs of controlled medical vocabularies for representing data and knowledge in clinical workstations and explores some of the implications of those choices.
用于临床工作站的患者信息表示是一个复杂的问题。理想情况下，应以一种允许对数据进行多种用途的方式来解决，包括简单的人工审查、跨机构共享和汇总，以及作为基于知识的决策支持系统的输入。在很大程度上，这意味着使用受控医学词汇对信息进行编码，但这并不意味着在工作站可行之前所有信息都必须是可编码的。本文定义了一些当前和未来可用于满足临床工作站中表示数据和知识的受控医学词汇需求的选择，并探讨了这些选择的一些影响。
