基于医学本体的电子病历系统研究

Study of Electronic Medical Record based on Medical Ontology

尽管电子病历在临床医学中已广泛应用,但传统模版生成方式的病历与临床思维逻辑存在吻合度问题,因此笔者提出基于医学本体的电子病历系统,系统地探讨了电子病历较纸质病历的优势并对本体相关知识内容进行介绍,探索建立基于医学本体的电子病历系统。在电子病历本体构建过程中,将大量的临床医学知识有机地组织并重用。系统实际应用过程表明,基于医学本体的电子病历系统能够有效缓解临床病历描述主观性强、模糊引争议等现象的发生,提高临床数据质量。

With the wide application of electronic medical records in clinical medicine, the fitness of the ones from tradition- al template generation with clinical thinking logic exists. The authors discussed systematically the advantages of EMR over the paper ones,introduced the relevant knowledge with ontology,and explored EMR on the basis of medical ontology. In EMR establishment, large amount of clinical knowledge of medicine was organically structured and applied. The systemic and practical application shows that EMR system can effectively relieve strong subjectivity and vagueness starting disputes,and improve clinical data quality.