论文标题
健康信息标准化作为学习卫生系统的基础
Health Information Standardisation as a basis for Learning Health Systems
论文作者
论文摘要
自1990年代以来，医疗保健的标准化一直是医院管理和临床医生的重点。电子健康记录已经旨在为临床医生提供实时访问临床知识和护理计划的机会，同时还记录和存储大量患者数据。电子健康记录花了三十多年的时间在医疗保健的各个方面开始变得无处不在。学习卫生系统是健康信息系统中的下一阶段，其潜在的好处已促进了十多年，但在临床实践中很少见。临床护理过程规格是医疗保健各个方面使用的临床文档的主要形式，但它们缺乏标准化。这篇论文认为，缺乏标准化是通过电子健康记录继承的，这是一个重大问题，阻碍了学习卫生系统的发展和采用。临床文件的标准化用于减轻电子健康记录中的问题，以此作为实现学习卫生系统的基础。为了实现有效的资源和确保一致性和质量的有效方法，一种临床文档，即Caremap。这不仅导致了临床医生对临床文件的理解和接受，而且还减少了使用临床专家的输入建立的复杂学习卫生系统所花费的时间。
Standardisation of healthcare has been the focus of hospital management and clinicians since the 1990's. Electronic health records were already intended to provide clinicians with real-time access to clinical knowledge and care plans while also recording and storing vast amounts of patient data. It took more than three decades for electronic health records to start to become ubiquitous in all aspects of healthcare. Learning health systems are the next stage in health information systems whose potential benefits have been promoted for more than a decade - yet few are seen in clinical practice. Clinical care process specifications are a primary form of clinical documentation used in all aspects of healthcare, but they lack standardisation. This thesis contends that this lack of standardisation was inherited by electronic health records and that this is a significant issue holding back the development and adoption of learning health systems. Standardisation of clinical documents is used to mitigate issues in electronic health records as a basis for enabling learning health systems. One type of clinical document, the caremap, is standardised in order to achieve an effective approach to containing resources and ensuring consistency and quality. This led not only to improved clinicians' comprehension and acceptance of the clinical document, but also to reduced time expended in developing complicated learning health systems built using the input of clinical experts.
