Building Clinical Data Groups for Electronic Medical Record in China |
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Authors: | Haibo Tu Yingtao Yu Peng Yang Xuejun Tang Jianping Hu Keqin Rao Feng Pan Yongyong Xu Danhong Liu |
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Institution: | (1) Institute for Health Informatics, Fourth Military Medical University, Changle West Road 17#, Xi’an, 710032, China;(2) Division of Medical Service, TangDu Hospital, Fourth Military Medical University, XinShi Road 1#, Xi’an, 710038, China;(3) Center of Health Statistics and Information, Ministry of Health, XiZhiMenWaiNan Road 1#, Beijing, 100044, China; |
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Abstract: | 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. |
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