临床路径核心元数据体系的语义结构

Development of Semantic Structure of Clinical Pathway Core Metadata System

首先将我国《标准临床路径》与国际上较完善的临床路径进行比较分析,找出我国《标准临床路径》存在的问题,然后采用openEHR两层法来构建医学临床路径核心元数据体系的语义结构,其中参考信息模型层采用《中国电子病历标准》)的数据结构,原型模型层以《标准临床路径》中的核心元数据为数据来源,结果发现:我国现有《标准临床路径》在语义框架结构上存在分类笼统、内容模糊,缺少清晰明确的逻辑层次的问题;在语义属性结构上存在元数据类型和属性值单一的问题。从语义框架结构和语义属性结构两个方面对临床路径元数据体系进行结构重建,在所设计的临床路径语义框架结构中,将在我国标准临床路径中的三个文档"主要诊疗工作"、"重点医嘱"、"主要护理工作"下增加一级数据组,以便更好地将三个文档的细节项目进行合理归类;在语义属性结构中,设计4种数据元类型,包括"判定数据元"、"赋值数据元"、"条件数据元"和"引用数据元",从而为建立规范的、模块化的、适于计算机操作的临床路径提供具体思路。

In order to develop semantic structure of clinical pathway （CP） core metadata system. , we compared Chinese Standard CPs with advanced CPs in other countries, and found the deficiencies of current Chinese CPs. Then we developed semantic structure of clinical pathway core metadata system based on the Electronic Health Record （EHR） Architecture and Data Standard （Chinese EHR Standard ）. The results show that China ＂s current standard CPs are ambiguous in classification and structure and simple in properties. We developed semantic framework structure and semantic property structure, and added datagroups under three documents of ＂main care activities＂, ＂main orders＂, and ＂main nursing activities＂ in developing semantic framework structure. We designed four types of metadata including ＂decision metadata＂, ＂value metadata＂, ＂ condition metadata＂, and ＂ reference metadata＂. We developed semantic framework structure and semantic property structure of CP core metadata system and we believe the building block structure of CPs facilitates computer and Web processing.