电子病历受控术语结构与质量的评价  

Evaluation of Structure and Quality of Controlled Terminology Applied for Electronic Medical Records

作　　者：张林[1] 刘丹红[2] 徐勇勇[2] 刘运成[3] 葛义[3] 胡建平[4] 孟群[4] 

机构地区：[1]白求恩国际和平医院核医学科,石家庄市050082 [2]第四军医大学卫生信息研究所,西安市710032 [3]中国人民解放军总后卫生部信息中心,北京市100842 [4]卫生部统计信息中心,北京市100044

出　　处：《中国卫生信息管理杂志》2014年第1期21-25,共5页Chinese Journal of Health Informatics and Management

基　　金：国家高技术研究发展计划(863计划)课题<医疗信息化体系与信息标准研究>(课题编号:2012AA02A617)

摘　　要：电子病历是数字化医疗的基础。虽然我国关于电子病历文档类型和文档段标识已有相关标准和规范,但仍缺乏电子病历文档内容和术语的标准和规范,难以纠正不同级别的医疗机构同一文档段的记录内容在结构和术语使用上的巨大差异,也无法利用大数据信息挖掘、知识发现等IT新技术,对我国丰富的电子病历数据资源库进行有效的二次利用。本文介绍了电子病历中单词、术语与受控术语的相关概念、用途和重要性,列举了患者主诉与临床检查结果表达的术语结构的概念框架,通过受控医学词汇结构与质量评价的12条评价要点,强调了电子病历内容结构与受控术语结构的标准化,在我国电子病历标准化工作中的重要性和紧迫性。Digital healthcare is based on Electronic Medical Records （EMRs）. In China, standards and specifications have been developed for document types and sections in EMRs. However, document contents and terms in EMRs are still lack of relevant standards and specifications; therefore, substantial differences in record structures and related term usage cannot be addressed, and effective re-use of rich EMR repositories in our country can hardly be realized with new technologies such as big data mining or knowledge discovery. In this article, authors outlined basic components, and concepts, usages and importance related to terms, terminology and controlled terminology; then a terminological framework for representation of patient’s chief complaints and clinical test results, and twelve essential evaluations for structure and quality of controlled terminologies were analyzed; finally, the authors emphasized the importance and urgency of standardization of EMR content structure and controlled terminology structure in China＆#39;s EMR standardization.

关 键 词：电子病历 语义互操作性 受控医学词表 标准 

分 类 号：R-34[医药卫生] R197.323.1