临床数据传输数据组和数据元标准的研究

The Standard Study of Data Groups and Data Elements in Clinical Data Transmission

目的在国家已颁布的一系列数据标准的基础上,定义临床传输数据的结构与数据元组。方法采用数据建模的方法,将散落在不同卫生信息标准中的数据元、数据元值域代码和外部术语组成有完整临床含义的数据组。结果临床信息传输数据组、数据元与元数据整体架构图;形成18个数据组,131个数据元,其中124个都已在WS363和WS364定义,并增加了7个自定义数据元。结论需要传输的数据是对电子病历核心数据的抓取,电子病历的标准化是临床传输信息标准化的基础。传输信息也可以二次录入。18个数据组和131个数据元是临床数据传输的核心数据组和数据元,可在此基础上,增加相应专科、专病的数据组和数据元。

Objective The structured and data group of clinical transmission data are de?ned based on a series of health information data standards that have been issued by the state. Method Data modeling method is used to form data groups with complete clinical meanings by data element, data element value codes and external terms scattered in different health information standards. Results An overall architecture chart including data groups, data element and metadata in clinical information transmission.There are 18 data groups and 131 data elements, of which 124 have been de?ned in WS 363 and WS 364,and added 7 custom de?ned data elements. Conclusions The data that need to be transmitted is to extract the core data from electronic medical records, and the standardization of electronic medical records is the basis of standardization of clinical transmission information. The transmission of information can also be reentered. 18 data groups and 131 data elements are the core data groups and core data elements of clinical data transmission. On this basis, some new data groups and data elements in specialties and particular diseases can be added.