计算机化临床实践指南的研究和实现

The Computerized Clinical Practical Guideline's Research and Implementation

目的:探讨基于本体的计算机化临床实践指南开发模式,为实现医疗信息系统中的警示/提醒、数据共享、循证医学和临床决策提供技术支持。方法:分析指南交换框架(GLIF)的结构和领域本体,根据中国脑血管病防治指南和神经疾病本体对GLIF进行扩展。结果:以急性脑梗死静脉溶栓治疗为例,建立包括版本描述元数据、药物数据项列表、证据强度说明、适应证判断步骤、禁忌证判断步骤和用药选择步骤等在内的计算机化的中文神经内科疾病治疗指南。结论:将计算机化的临床实践指南和临床信息系统以及电子病历结合在一起,对于临床路径优化和决策支持具有重要意义。

Objective： To discuss the development module of ontology-based computerized clinical practical guideline, and to supply the technology support for implement of alerm/reminding, data sharing, evidence-based medicine and clinical decision making in the medical information system. Methods： Analyse the structure and field ontology of the Guideline Interchange Format （GLIF）; expand GLIF based on the Guideline of Cerebrovascular Disease Prevention and Treatment in China and Neurology Disease Ontology. Results： A Chinese computerized guideline of intravenous thrombolytic therapy of acute cerebral infarction is constructed, which included metadata of edition describtion, list of drug data item, explanation of evidence strength, steps of indications decision, contraindication decision and drug selection. Conclusion： The computerized clinical practical guideline combined with clinical information system and Electronic Medical Records plays an important role in clinical pathways optimizing and decision making.