创建针对不同护理时刻的开放式电子病历内容:产科急诊方案

G. Bacelar-Silva, R. Sousa-Santos, R. Correia
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引用次数: 3

摘要

如果卫生信息系统使用一个通用的参考模型来存储患者数据,它将简化卫生数据交换和实现语义互操作性。目的:描述与开发开放电子病历内容相关的过程和问题,这些内容将在产科场景的不同时刻使用,即检索患者数据。方法:在两个主要数据库(openEHR和国家电子卫生过渡管理局(NEHTA))上进行搜索,寻找代表先前研究(产科场景)中定义的临床概念的原型。选择更合适的原型来设计模板。结果:共识别出22个临床概念,其中21个可被原型所涵盖。需要28个原型(23个openEHR / 5个NEHTA)来代表它们(13个openEHR / 8个NEHTA)。讨论与结论:本文证明了创建一个openEHR模板来描述产科场景中不同时刻的信息需求是可能的。一个可能的应用是使用它们从外部系统检索患者的数据。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Creating openEHR content to different moments of care: Obstetrics emergency scenario
Introduction: If health information systems used a common reference model to store patient data it would ease health data exchange and achievement of semantic interoperability. Aim: To describe the process and the issues related to developing openEHR content to be used during different moments in the Obstetrics scenario, namely to retrieve patient's data. Methods: It was conducted a search on two major repositories - openEHR and National E-Health Transition Authority (NEHTA) - for archetypes to represent clinical concepts defined in a previous study (Obstetrics Scenario). The better-suited archetypes were chosen to design the templates. Results: 22 clinical concepts were identified and 21 of them could be covered by the archetypes. It was necessary 28 archetypes (23 openEHR / 5 NEHTA) to represent them (13 openEHR / 8 NEHTA). Discussion and Conclusion: This paper demonstrates that it was possible to create an openEHR template to describe the information needs during different moments of an Obstetrics scenario. A possible application is to use them to retrieve patient's data from external systems.
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