家庭健康档案概念数据模型及其应用研究

Conceptual Data Model for Family Health Record and Its Application

目的构建家庭健康档案概念数据模型和数据模板,为家庭健康档案的数据采集、信息共享和信息系统建设提供标准支持。方法概念框架以居民健康档案相关业务规范为依据,数据模型参照HL7参考信息模型(RIM)和HL7数据类型,数据模板参照IHE PCC已发布的标准模板,将现行的武威市居民新型电子健康档案系统中家庭电子健康档案模块的数据项与模型和模板进行对照。建模方法采用统一建模语言(UML)。结果家庭健康档案概念数据模型包含家庭标识信息和家庭健康及其影响因素2个维度,家族性疾病等14个子维度。数据模板包含标识类、一般记录项目、家族性疾病,共产生72个数据元,现有系统中尚缺30个数据元。结论家庭健康档案概念数据模型和数据模板有助于实现健康档案内容的完整性,保证信息表达的规范化和标准化。

Objective To build a conceptual data model and data templates for family health records so as to provide standards for data acquisition,information sharing and information system construction for family health records.Methods According to health record related standards of practice,a conceptual data model was designed by referring to Reference Information Model（RIM） and data types of Health Level 7（HL7）.Data templates were developed based on the standard templates from Integrating the Healthcare Enterprise（IHE） Patient Care Coordination（PCC）.The data items about family health in the electronic health record system of Wuwei were compared and mapped into the data templates.Unified Modeling Language（UML） was used for data modeling.Results The conceptual data model of family health records contained two dimensions and 14 sub-dimensions.The two dimensions included family identification data and family health condition and related risk factors.Data templates contained identification data,general data and familial disease data,covering 72 data elements.Thirty data elements were missing in the current Wuwei system.Conclusion The conceptual data model and data templates of family health records can further contribute to the comprehensiveness of health information and standardization of information display.