基于CDA的临床数据中心文档构建及XDS共享模式研究

Construction of Clinical Document for the Clinical Data Repository Based on CDA and Research of Sharing Pattern Based on IHEXDS

临床文档共享是整合医院内部异构系统、构建临床数据中心和实现信息集成的重要手段。结合HL7 CDA文档架构和国家相关数据标准以及规范,对临床文档的结构和语义进行标准化和本地化定义,支持异构系统之间临床文档的互操作,并基于IHE XDS文档共享模式进一步实现跨系统临床文档交互,提高临床质量。最后对结构化临床文档的数据可用性以及科研检索、数据安全性和保密性等进行初步讨论。

Exchange and Sharing of clinical documents is the important means of integrating the heterogeneous information system from internal hospital, constructing the Clinical Data Repository and realizing information integration. We use the HL7 CDA related with the national data standards and specifications, so the structure and semantics of clinical documents can be better defined from the specification of standardization and localization. It can then support the interoperability between clinical documents from heterogeneous systems. At this point in the IHE XDS Model, to further integrate and realize the document sharing, improving medical quality based on the construction method. Finally, we primarily discuss data availability and scientific research retrieval, data security and privacy for structured clinical documents.