信息链视域下电子病历数据驱动临床决策的需求模型构建

Construction of a Demand Model for Clinical Decision Driven by Electronic Medical Record Data from the Perspective of Information Chain Theory

[目的/意义]在信息链视域下,提炼电子病历数据驱动临床决策的用户需求,构建需求模型,帮助弥合临床决策支持服务与现实临床工作需要的差距,为电子病历数据提供价值释放靶点,拓展信息链的应用域,助益临床决策支持系统和平台建设,进而为面向临床的情报服务提供指导。[方法/过程]以信息链为理论基础,利用模板分析的方法,通过对访谈资料的分析,提炼了7个一级需求主题、24个二级主题、54个三级主题、43个四级主题以及2个五级主题,构建了电子病历数据驱动临床决策的需求层级模型。[结果/结论]沿着信息链,可以将电子病历数据驱动临床决策的用户需求归纳为病历的智能化记录、临床关键信息的组织与提取识别、电子病历数据驱动的疾病风险预测、疾病诊疗经验与知识的提炼补充、疾病诊断辅助、病情异常原因分析、治疗方案的辅助制定与推荐。医生对电子病历数据驱动临床决策的应用采纳呈现出不同程度的积极性,表现出了对数据确权不清、信息技术成熟度不高等风险的担忧。

[Purpose/Significance]To extract user demand of clinical decision-making driven by electronic medical record data,and construct a demand model,under the perspective of information chain.To bridge the gap between clinical decision support services and actual clinical work needs,to provide value release targets for electronic medical record data,to expand the application domain of information chain,to help the construction of data-driven clinical decision support platform,and to provide guidance for clinical intelligence services.[Method/Process]Using the method of template analysis,through the analysis of interview,7 level-1 need themes,24 level-2 need themes,54 level-3 need themes,43 level-4 need themes and 2 level-5 need themes were refined,and a hierarchical model of clinical decision-making driven by electronic medical record data was constructed,based on the theory of information chain.[Result/Conclusion]The demand of users for clinical decision-making driven by electronic medical record data can be summarized along the chain of information,including(1)intelligent recording of electronic medical records,(2)organization and extract of clinical key information,(3)disease risk prediction driven by electronic medical record,(4)supplement and discovery of disease knowledge,(5)automated assistance in diagnosis driven by electronic medical record,(6)cause analysis and prompts of abnormal conditions,and(7)assist in the development and recommendation of treatment plans.Doctors showed different levels of enthusiasm for the application of electronic medical record data-driven clinical decision making,and expressed their concerns about the risks,such as unclear data rights and low information technology maturity.