临床信息模型与数据结构化的研究探讨

The study of Clinical Information Model and Structured Clinical Data

临床信息模型是实现临床数据在异构信息系统中传递而保持语义准确性和完整性的基础,是计算机准确识别和处理临床信息的前提。目前国际上已有的临床信息模型主要有openEHR原型和原型模型、临床元素模型以及ISO 13972详细临床模型等。基于临床信息模型构建结构化临床文档,不仅保证了信息传输中临床数据在语义上的唯一性、一致性和完整性,而且极大地方便了临床信息在医疗服务过程中的首次利用以及在医学科学和政策研究中的二次利用。

Clinical information model is the foundation of achieving clinical data transmission in heterogeneous information systems while keeping the accuracy and completeness of semantics as well as the premise of computers identifying and dealing with clinical information. At present, the relevant abroad studies on clinical information model and other international standards are openEHR archetype and archetype models, Clinical Element Model and ISO 13972 Detailed Clinical Models, etc. In the application level, we want to build clinical structured documents based on clinical information model supporting for user-computer communications. By this method, we not only ensure the uniqueness, consistency and integrity of clinical data semantics, but also greatly facilitate the primary use of clinical information during the process of medical service and secondary use in medical science and decision-making research.