中药临床信息数据元标准目录构建思考  

Construction and thinking of data element standard directory of traditional Chinese medicine clinical pharmacy information

作　　者：王晓霞[1] 金钟正[2] 郭桂明[3] 翟华强[1] 金世元 

机构地区：[1]北京中医药大学中药学院,北京100102 [2]北京中医药大学信息中心,北京100102 [3]首都医科大学北京中医医院,北京100010 [4]北京卫生学校,北京100875

出　　处：《中国中药杂志》2014年第9期1724-1727,共4页China Journal of Chinese Materia Medica

基　　金：国家自然科学基金项目(81373887);国家中医药管理局中医药信息化项目(ZYXX-2012)

摘　　要：该研究目的是研制《中药临床信息数据元标准目录》,为中医电子病历的应用提供中药临床药学的应用标准及模式。研究方法是通过文献分析、调查问卷、小组讨论、专家咨询4种形式制定工作路线、初步确立研究内容:从中药本草考证,中药材产地、采收、加工,性状鉴别、理化鉴别、现代研究,性味归经、功效主治、临床应用,炮制,中药调剂,中成药规格、用法用量、使用注意、功效主治等,小包装等的应用,新药研究,管理等一条线展开。包括中医药理论、应用及医院管理等信息;按照国家《卫生信息数据元标准》总则及第16部分中有关内容,数据元研究基本方法,从界定的研究内容中提取中药临床信息数据元。提出构建《中药临床信息数据元标准目录》的思路与方法,整理出中药临床信息数据元标准目录,分为基础类、临床应用类、管理类三部分,并且规范中药临床信息数据元的标识、定义、表示、允许值。讨论中药临床信息数据元的信息来源、采集标准、留接口、规范科学术语、与已有标准对接、维护管理方案等问题。The aim of this study was to develop the data element standard directory of traditional Chinese medicine （TCM） clin- ical pharmacy information, to provide application standards and models of TCM clinical pharmacy for the electronic medical record （EMR）. The developed line of work is as follows： initially establish research through four forms ： literature analysis, questionnaires, discussion groups, expert advice. The research range from the Chinese herbal medicine research, herbal origin, harvesting, processing, identification of traits, physical and chemical identification, modern research, character, taste, Indications, clinical application, pro- eessing, dispensing medicine, Chinese medicine specifications, usage, dosage, caution, efficacy indications to small packaging appli- cations, drug research, management and other related issues, including traditional Chinese medicine theory, application and hospital management information; according to the general and part 16 content of the national ＂ Health Information Data Element Standards＂, and the basic method of extracting data element to study and develop the data element of TCM clinical pharmacy information from the defining content. Correspondingly propose the ideas and methods of construction of the ＂Data Element Standard Directory of TCM Clini- cal Pharmacy Information＂, sort out medicine clinical information data element standard catalog, divided into basic categories, clinical application class, management class three parts, and set norms and standards of identifying data elements, definitions, allowable value of traditional Chinese medicine clinical information, and discuss the sources and standards of information collection, leaving the inter- face, standardized and scientific terminology, docking with the existing standards, maintenance and management program and oter issues.

关 键 词：中药临床 信息数据元 标准目录 

分 类 号：R288[医药卫生—中药学]