临床指南模型构建中医学知识的规范化表达方法

目的：探索和研究计算机化临床指南模型构建中医学知识规范化表达的方法,为基于疾病防治指南的计算机决策支持（CDS）系统及其在个人健康管理中的应用提供借鉴。方法：以高血压为例,分析防治指南文本,构建规则、提炼出节点和医学概念;形成类的层次结构;利用protege进行本体建模,参考openEHR原型表达医学概念。结果：建立了高血压评估诊疗管理全过程的流程图。以“测量血压”为例,描述了“行为”节点类的属性;以“医学概念”中的“血压”类为例,定义其描述结构和内容：通过“行为”类的属性将实例“测量血压”关联至概念类中定义的“血压”。结论：疾病防治过程中涉及的医学概念能以结构化的形式嵌入指南模型,在此基础上构建CDS有助于减少理解分歧导致的诊疗行为变异,促进慢性病管理中各参与方的知识共享。     

基于HL7 CDA的中草药处方文档规范构建

目的：参照HL7 CDA文档规范的表示方法,对中医处方中中草药处方的数据进行建模,并建立中草药处方的CDA文档规范,使其能够完整地表示中草药处方的信息。方法：通过研究中医电子病历处方信息特征及组成结构,将中医电子处方信息抽象提取相应的信息元素,参照HL7 CDA模板构建中草药处方文档规范,使其能够充分表达中草药处方信息的概念与属性。结果：通过将中草药处方数据元素与CDA模板进行映射来完成中草药处方的数据表达具有可行性,为中医处方信息规范化研究提供了新的指导方法。     

基于语义关系的高血压临床指南知识库构建

随着“循证医学”的发展,临床指南的出现对于医生的临床实践活动具有重要的指导意义。临床指南可以适时准确地为医生的临床实践活动提供科学权威的诊疗建议,对于减小医生的误诊率,提高诊疗效率具有重要意义。目前临床指南的重要性得到医生的普遍认可,但是临床指南在实际临床实践活动中使用率很低。为了解决临床指南发展过程中遇到的瓶颈,提高临床指南的利用率,结合本体的方法将文本临床指南转变成临床指南知识库,具有非常重要的研究意义。以高血压临床指南为例,结合语义本体的方法构建高血压临床指南知识库。     

中医针刺处方临床文档信息模型及其与HL7V3R-MIM的映射

本研究目的是验证应用HL7V3R-MIM模型表示中医针刺处方信息元素的适用性。根据中医临床信息采集的需求，建立了中医针刺处方信息内容描述模板；提取了中医特征信息属性，并进一步抽取共性特征，建立了中医针刺处方信息概念模型。通过与HL7R-MIM进行信息元素映射，研究结果表明：基于HL7V3R-MIM建立中医针刺处方信息模型是具有可行性的。     

临床实践指南实施性促进研究之六：临床实践指南知识图谱构建中关于基本信息、背景和方法的建模表征研究

在计算机辅助临床决策和实践中,现行临床实践指南的可读性和可操作性存在诸多不足。通过对指南的结构、知识及知识间的关系进行规范化的表示,发掘指南通用性的结构框架;通过建模表证,促进指南知识的标准化、规范化表达,构建便于共享和可移植的标准化指南知识库,有利于满足临床决策支持系统发展的需要,推动临床实践指南的实施和临床诊疗服务质量的提升。知识图谱的引入为指南数字智能化提供了坚实的基础,然而目前介绍指南知识图谱构建的方法学研究较为罕有。本研究以《中国非肌层浸润性膀胱癌治疗与监测循证临床实践指南(2018年标准版)》的知识图谱构建为例,通过梳理指南模块,解析指南基本信息、背景和方法内容范围,结合专家意见设置各概念间的层级关系,根据多级概念层及概念实例设计概念结构表,调整概念间的关系结构,并改进实体与实体间的关系。本文旨在探讨指南中基本信息、背景和方法部分的建模和表征方法,以期为今后其他临床实践指南的知识图谱构建提供参考。     

《中国高血压防治指南》在西部贫困农村推广应用的现状及对策

1999年发布的《中国高血压防治指南》已指导临床工作5年余，为高血压的防治起到了重要的作用。中国高血压防治指南起草委员会依据我国近5年来高血压和心血管病的发病趋势。参考JNC-7、2003年欧洲高血压指南和2002WHO/ISH关于高血压处理建议，以循征医学和国内外专家的临床实践经验为依据，完成了对（2004年中国高血压防治指南》的修订（以下简称为《新指南》）。随着我国经济的快速发展，人口老龄化和城市化进程的加快，高血压患病率出现较快的增长趋势。为了防止本世纪心血管疾病发病高峰的到来，《新指南》的修订是非常及时的，《新指南》采用加强健康教育、改善生活方式等措施。立足于疾病防治的上游，将预防战线前移，把高血压全面阻击在一级预防的前沿阵地，这样有助于防患于未然。《新指南》还以“心血管总危险”取代单纯追求降压。也重视了亚临床靶器官损害的检出，有利于对各种危险因素实施综合治疗，在治疗方面主要提倡以低剂量复方药作为初始或维持用药方法之一。以降低药品费用，提高患者的依从性。符合发展中国家的国情，更符合我国众多贫困农村高血压人群的需求。     

面向分类统计的传统医学疾病本体构建研究

目的：构建传统医学疾病本体,促进中医疾病分类统计的规范化与标准化,推动我国传统医学名词与国际医学术语标准的融合与创新发展。方法：通过借鉴国际疾病本体建设模式,提出复用已有资源构建传统医学疾病本体的新方法。利用精确、向上、向下和相关4种匹配方式,研究新建本体与ICD-11中文版的语义映射。结果：通过复用已有标准中的中医病名、定义、结构体系等资源,完成了传统医学疾病本体构建,并实现了新构建本体与ICD-11中文版的语义关联。结论：新构建的传统医学疾病本体为中医疾病分类统计的规范化和标准化奠定了基础。     

利用医院信息标准规范电子病案

目的探讨利用医院信息标准化,指导电子病案标准化。方法文献查阅法结合个人总结。结果归纳出与电子病案发展相关的标准如HL7医院电子信息交换标准、医学数字化影像通信标准DICOM、SNOMED编码、国际疾病分类、ASTM制定的有关医疗标准、NDC国家药品编码、统一的医学语言系统等,对电子病案发展提供了规范化和标准化依据。结论我国医院信息标准化可借鉴发达国家医院信息标准化,在相对成熟的医院信息标准的基础上结合本国医院信息的现状制定出适合我国医院信息标准,加快电子病案的发展,解决电子病案在标准化方面的瓶颈问题,更有效地为临床、教学、研究、管理服务。     

临床决策支持与HL7研讨会在上海召开

2014年1月11日,由HL7 China和国家卫生信息共享技术及应用工程技术研究中心联合主办,《中国数字医学》杂志社和HIT专家网协办的临床决策支持与HL7研讨会在上海召开,     

老年高血压临床指南现状分析及质量评价

背景 高血压多发于老年人群;随人口老龄化程度的日益加深,老年高血压患病率呈上升趋势。老年高血压的早期预防和诊疗至关重要,而开发高质量的临床实践指南是提升老年高血压预防及诊治水平的重要途径。 目的 分析国内外老年高血压诊疗与管理指南的现状,并对其进行方法学质量评价。 方法 于2021年12月,计算机检索中国知网、维普中文科技期刊全文数据库、万方数据知识服务平台、中国生物医学文献服务系统、PubMed、EmBase、医脉通,以及美国国立临床实践指南文库（NGC）、国际指南协作网（GIN）、英国国家卫生与临床优化研究所（NICE）等网站,获取老年高血压临床指南。检索时限均为建库至2021年12月。由2名研究者独立筛选文献、提取资料后,由4名研究者采用AGREEⅡ对纳入指南的方法学质量进行评价,并汇总指南的推荐意见。 结果 共纳入11部指南,其中7部来源于中国,2部来源于美国,2部来源于欧洲。11部指南在范围和目的、参与人员、制定的严谨性、表达的清晰性、应用性和编辑独立性6个领域的平均标准化百分比分别为50.13%、24.24%、18.51%、54.03%、11.36%、30.30%;5部指南推荐级别为B,6部指南推荐级别为C。主要推荐意见涉及3个方面,分别为老年高血压的药物治疗、非药物治疗与持续性健康管理。 结论 老年高血压临床指南总体质量不高。未来,在开发老年高血压临床指南时,应提升对参与人员、制定的严谨性、应用性三大领域的关注度和重视程度,以使指南能更好地服务于临床。     

Analysis of the process of representing clinical statements for decision-support applications: a comparison of openEHR archetypes and HL7 virtual medical record

Delivering patient-specific decision-support based on computer-interpretable guidelines (CIGs) requires mapping CIG clinical statements (data items, clinical recommendations) into patients’ data. This is most effectively done via intermediate data schemas, which enable querying the data according to the semantics of a shared standard intermediate schema. This study aims to evaluate the use of HL7 virtual medical record (vMR) and openEHR archetypes as intermediate schemas for capturing clinical statements from CIGs that are mappable to electronic health records (EHRs) containing patient data and patient-specific recommendations. Using qualitative research methods, we analyzed the encoding of ten representative clinical statements taken from two CIGs used in real decision-support systems into two health information models (openEHR archetypes and HL7 vMR instances) by four experienced informaticians. Discussion among the modelers about each case study example greatly increased our understanding of the capabilities of these standards, which we share in this educational paper. Differing in content and structure, the openEHR archetypes were found to contain a greater level of representational detail and structure while the vMR representations took fewer steps to complete. The use of openEHR in the encoding of CIG clinical statements could potentially facilitate applications other than decision-support, including intelligent data analysis and integration of additional properties of data items from existing EHRs. On the other hand, due to their smaller size and fewer details, the use of vMR potentially supports quicker mapping of EHR data into clinical statements.     

Building Clinical Data Groups for Electronic Medical Record in China

This article aims at building clinical data groups for Electronic Medical Records (EMR) in China. These data groups can be reused as basic information units in building the medical sheets of Electronic Medical Record Systems (EMRS) and serve as part of its implementation guideline. The results were based on medical sheets, the forms that are used in hospitals, which were collected from hospitals. To categorize the information in these sheets into data groups, we adopted the Health Level 7 Clinical Document Architecture Release 2 Model (HL7 CDA R2 Model). The regulations and legal documents concerning health informatics and related standards in China were implemented. A set of 75 data groups with 452 data elements was created. These data elements were atomic items that comprised the data groups. Medical sheet items contained clinical records information and could be described by standard data elements that exist in current health document protocols. These data groups match different units of the CDA model. Twelve data groups with 87 standardized data elements described EMR headers, and 63 data groups with 405 standardized data elements constituted the body. The later 63 data groups in fact formed the sections of the model. The data groups had two levels. Those at the first level contained both the second level data groups and the standardized data elements. The data groups were basically reusable information units that served as guidelines for building EMRS and that were used to rebuild a medical sheet and serve as templates for the clinical records. As a pilot study of health information standards in China, the development of EMR data groups combined international standards with Chinese national regulations and standards, and this was the most critical part of the research. The original medical sheets from hospitals contain first hand medical information, and some of their items reveal the data types characteristic of the Chinese socialist national health system. It is possible and critical to localize and stabilize the adopted international health standards through abstracting and categorizing those items for future sharing and for the implementation of EMRS in China.     

患者转诊信息及其结构化与标准化

根据我国医疗文书管理相关规定，遵循有关国际组织的健康文档标准化技术和方法，探讨了患者转诊时需要携带的个人健康信息的内容、文档结构以及数据标准化问题。转诊信息包括基本信息、转诊事件信息和临床信息三个方面，按照文档段／子文档段、数据组／子数据组、数据元等三个层次划分，形成包括10个文档段（子文档段）、18个数据组（子数据组）、123个数据元的转诊文档基本框架结构。文档段限定了所包含数据产生的背景和语境，数据组由一系列数据元组成。通过数据元属性描述进行标准化。研究表明，结构化和标准化的转诊文档可促进医疗信息传递中数据的准确、一致性理解。但有赖于共享范围内标准制定和应用的协调一致，目前我国还有大量的临床概念、术语和数据元有待标准化。     

随机对照试验评价的语义模型研究

目的：将随机对照试验评价的基本理论和知识整合为计算机可识别的语义模型、属性和元数据,为语义网计算机推理提供知识本体.方法：知识本体的建立以国际上公认的随机对照试验评价规范为依据,采用本体编辑工具Protégé构建语义模型的层级结构,定义类、属性及其关系和其他元数据的规范描述.结果：构建了包含一般信息、分类与分级信息和具体评价项目的语义模型,创建了51个语义属性和元数据,13个随机对照研究的评价实例.结论：构建计算机可识别和处理的随机对照试验评价本体,是网络医学文献信息逻辑推理操作的基础,也为医学研究过程提供了随机对照试验文献质量评价的形式化表达和结果推论的参考.     

Evaluation of family history information within clinical documents and adequacy of HL7 clinical statement and clinical genomics family history models for its representation: a case report

Family history information has emerged as an increasingly important tool for clinical care and research. While recent standards provide for structured entry of family history, many clinicians record family history data in text. The authors sought to characterize family history information within clinical documents to assess the adequacy of existing models and create a more comprehensive model for its representation. Models were evaluated on 100 documents containing 238 sentences and 410 statements relevant to family history. Most statements were of family member plus disease or of disease only. Statement coverage was 91%, 77%, and 95% for HL7 Clinical Genomics Family History Model, HL7 Clinical Statement Model, and the newly created Merged Family History Model, respectively. Negation (18%) and inexact family member specification (9.5%) occurred commonly. Overall, both HL7 models could represent most family history statements in clinical reports; however, refinements are needed to represent the full breadth of family history data.     

基于HL7标准的PACS/RIS与HIS集成设计与应用

目的：设计基于HL7标准PAcs／RIS与HIS之间的集成接口,解决两个系统之间数据共享的问题,优化业务流程。方法：介绍了HL7标准的消息格式,分析了PACS／RIS与HIS之间的数据交换流程,在此基础之上,设计了HL7接口引擎,实现了数据共享。结果：通过MIRTH平台,实现了PACS／RIS与HIS2之间基于HL7标准的集成。结论：基于HL7标准的PACS／RIS与HIS之间集成,符合国际标准,扩展性好,大大提高了医院的工作效率,避免了资源浪费。     

建设基于XML技术电子病历系统的核心价值

介绍了电子病历的基本问题和HL7 CDA临床文档标准;提出XML电子病历编辑器是完成数据类型复杂医疗文档的重要工具;认为在医院建设基于XML技术电子病历系统的核心价值体现在方便快捷的医疗信息采集、医疗质量实时监控、医疗管理决策支持和医疗科研应用等方面。     

The Clinical Document Architecture and the Continuity of Care Record: A Critical Analysis

Health care provides many opportunities in which the sharing of data between independent sites is highly desirable. Several standards are required to produce the functional and semantic interoperability necessary to support the exchange of such data: a common reference information model, a common set of data elements, a common terminology, common data structures, and a common transport standard. This paper addresses one component of that set of standards: the ability to create a document that supports the exchange of structured data components. Unfortunately, two different standards development organizations have produced similar standards for that purpose based on different information models: Health Level 7 (HL7)'s Clinical Document Architecture (CDA) and The American Society for Testing and Materials (ASTM International) Continuity of Care Record (CCR). The coexistence of both standards might require mapping from one standard to the other, which could be accompanied by a loss of information and functionality. This paper examines and compares the two standards, emphasizes the strengths and weaknesses of each, and proposes a strategy of harmonization to enhance future progress. While some of the authors are members of HL7 and/or ASTM International, the authors stress that the viewpoints represented in this paper are those of the authors and do not represent the official viewpoints of either HL7 or of ASTM International.