Towards a national information model for medication orders in Sweden.

IF 1.3 4区 医学 Q3 COMPUTER SCIENCE, INFORMATION SYSTEMS
Sofie Holmeland, Tobias Blomberg, Andreas Mårtensson, Sabine Koch
{"title":"Towards a national information model for medication orders in Sweden.","authors":"Sofie Holmeland, Tobias Blomberg, Andreas Mårtensson, Sabine Koch","doi":"10.1055/a-2546-4092","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Semantic interoperability among health information systems (HISs), in particular electronic health records (EHRs), is crucial for informed healthcare decisions and patient access to vital health data. However, inconsistent medication information and limited health data exchange contribute to medication errors worldwide. While Sweden offers various solutions for health information exchange, there is a limitation in the exchange of medication orders and a lack of understanding the structure of medication orders among EHRs, highlighting the need for further exploration of the structure of medication orders.</p><p><strong>Objectives: </strong>This study aims to develop a common information model of medication orders for EHRs to be used in the Swedish context.</p><p><strong>Methods: </strong>An explorative qualitative design study was conducted. Documents and reference models of how medication orders are structured were collected, and semi-structured interviews were conducted with five purposefully selected participants with insight into how medication orders are structured in Swedish EHRs. The data were analyzed using information needs analysis, information structure analysis, and code systems, classifications, and terminology analysis.</p><p><strong>Results: </strong>The following information areas were identified for a medication order: medication, medication indication, way of administration, medication order details, and dosage. These information areas were conceptualized into a developed Unified Modeling Language Class Diagram information model with defined classes, attributes, and data types. The resulting information model provides a representation of how medication orders are depicted in EHRs in Sweden and is aligned with existing national information models such as the National Medication List, while still providing additional information related to medication order details.</p><p><strong>Conclusions: </strong>The developed information model could potentially provide a national standardized model for medication orders, contributing to enhance semantic interoperability and improving data exchange across various HISs. This could enhance data consistency, reducing the risk of medication errors and thereby improving patient safety.</p>","PeriodicalId":49822,"journal":{"name":"Methods of Information in Medicine","volume":" ","pages":""},"PeriodicalIF":1.3000,"publicationDate":"2025-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Methods of Information in Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1055/a-2546-4092","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"COMPUTER SCIENCE, INFORMATION SYSTEMS","Score":null,"Total":0}
引用次数: 0

Abstract

Background: Semantic interoperability among health information systems (HISs), in particular electronic health records (EHRs), is crucial for informed healthcare decisions and patient access to vital health data. However, inconsistent medication information and limited health data exchange contribute to medication errors worldwide. While Sweden offers various solutions for health information exchange, there is a limitation in the exchange of medication orders and a lack of understanding the structure of medication orders among EHRs, highlighting the need for further exploration of the structure of medication orders.

Objectives: This study aims to develop a common information model of medication orders for EHRs to be used in the Swedish context.

Methods: An explorative qualitative design study was conducted. Documents and reference models of how medication orders are structured were collected, and semi-structured interviews were conducted with five purposefully selected participants with insight into how medication orders are structured in Swedish EHRs. The data were analyzed using information needs analysis, information structure analysis, and code systems, classifications, and terminology analysis.

Results: The following information areas were identified for a medication order: medication, medication indication, way of administration, medication order details, and dosage. These information areas were conceptualized into a developed Unified Modeling Language Class Diagram information model with defined classes, attributes, and data types. The resulting information model provides a representation of how medication orders are depicted in EHRs in Sweden and is aligned with existing national information models such as the National Medication List, while still providing additional information related to medication order details.

Conclusions: The developed information model could potentially provide a national standardized model for medication orders, contributing to enhance semantic interoperability and improving data exchange across various HISs. This could enhance data consistency, reducing the risk of medication errors and thereby improving patient safety.

瑞典药品订单的国家信息模型。
背景:卫生信息系统(HISs)之间的语义互操作性,特别是电子健康记录(EHRs),对于知情的医疗保健决策和患者获取重要健康数据至关重要。然而,不一致的用药信息和有限的健康数据交换导致了世界范围内的用药错误。虽然瑞典为卫生信息交换提供了各种解决方案,但医嘱的交换存在局限性,并且对电子病历之间的医嘱结构缺乏了解,这突出表明需要进一步探索医嘱结构。目的:本研究的目的是开发一个共同的信息模型的药物订单的电子病历在瑞典的情况下使用。方法:进行探索性定性设计研究。收集了关于医嘱结构的文件和参考模型,并对五名有目的地选择的参与者进行了半结构化访谈,以深入了解瑞典电子病历中医嘱的结构。使用信息需求分析、信息结构分析、代码系统、分类和术语分析对数据进行分析。结果:在给药单中确定了以下信息区域:药物、给药指征、给药方式、给药单详细信息和剂量。这些信息区域被概念化到一个已开发的统一建模语言类图信息模型中,该模型具有已定义的类、属性和数据类型。由此产生的信息模型提供了瑞典电子病历中如何描述药物订单的表示,并与现有的国家信息模型(如国家药物清单)保持一致,同时仍然提供与药物订单详细信息相关的附加信息。结论:所建立的信息模型可为全国药品医嘱信息提供标准化模型,有助于提高医嘱信息的语义互操作性,改善医嘱信息在不同医疗机构间的数据交换。这可以增强数据一致性,减少用药错误的风险,从而提高患者安全。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
Methods of Information in Medicine
Methods of Information in Medicine 医学-计算机:信息系统
CiteScore
3.70
自引率
11.80%
发文量
33
审稿时长
6-12 weeks
期刊介绍: Good medicine and good healthcare demand good information. Since the journal''s founding in 1962, Methods of Information in Medicine has stressed the methodology and scientific fundamentals of organizing, representing and analyzing data, information and knowledge in biomedicine and health care. Covering publications in the fields of biomedical and health informatics, medical biometry, and epidemiology, the journal publishes original papers, reviews, reports, opinion papers, editorials, and letters to the editor. From time to time, the journal publishes articles on particular focus themes as part of a journal''s issue.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信