CN102509012A - Method for mapping contents of electronic medical record into electronic medical record standard database - Google Patents
Method for mapping contents of electronic medical record into electronic medical record standard database Download PDFInfo
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Abstract
The invention relates to the field of medical data processing, in particular to a method for mapping contents of an electronic medical record into an electronic medical record standard database. The method comprises the following steps of: establishing a medical record template, wherein the medical record template stores template elements, and the template elements comprise data element IDs, data element types and data element contents; editing the medical record template, determining the data element IDs, determining data element types and the data element contents, dynamically binding the data element IDs, the data element types and the data element contents, and storing and generating the template; revising the medical record template, and importing the edited or revised medical record template into a database according to a preset criterion adapting to the electronic medical record standard database; and when the data of the electronic medical record is required to be read, reading multiple relevant data elements of the electronic medical record database according to the relevancy of the data element IDs in the medical record template. The method is used for mapping the contents of the electronic medical record into the electronic medical record standard database.
Description
Technical field
The present invention relates to electronic health record, belong to the medical data process field, relate in particular to the method for a kind of content map with electronic health record, in International Patent Classification (IPC) IPC, can belong to big type of G06F19/00 to the electronic health record standard database.
Background technology
Electronic medical record system is to realize that hospital is so that " patient is the core place of " center " as the core of medical industry medical record information system.Existing electronic health record infosystem generally adopts relational database to store and manage medical record information, and according to the business norms requirement, after the template segmentation of case history, structured storage is in the lot of data table, thus the storage and the inquiry of realization data.Domestic structuring at present all is directly directly to be saved in the node content in the case history in the XML file or in the database table; Along with case history content coverage rate is more and more wider, structurized content is more and more, the continuous refinement of structurized degree; Do like this directly causing following problem: patient's information is a lot; Like home address, unit address, birth address or the like, each information all needs a unique ID to identify, and causes the infinite expanding of patient information ID.
In addition, the Ministry of Public Health put into effect " electronic health record basic framework and data standard (trying) " on Dec 31st, 2009, specific definition electronic health record various data element information types, the form contained, formed the electronic health record standard database.The regional most case histories of China's overwhelming majority (removing nursing history, temperature chart) are still write with the free text mode that meets doctor's writing style at present.And the quotidian expression in the case history all has rigorous expression way in the predetermined data standard, like simple " name " hurdle in the case history of being in hospital, in standard, is divided into a plurality of data elements such as " patient's type ", " patient identifier "." ID card No. " in the homepage for another example is that two data tuples are closed and formed in fact in standard, i.e. " type of credential ", " number ".Similarly also having " home address ", is two data element signs " address style ", " addresses " in the standard.Similarly situation is too numerous to enumerate.When realizing this mapping, several different methods can be arranged; Like ID of every kind of address style definition, correspond on the corresponding data element, but this mode causes a large amount of off-gauge data element definitions to produce; And it expands unpredictable; Because patient information is ever-changing, the combination between type and the value is the order of magnitude and increases, and is not a good method therefore.
Therefore along with the development of electronic medical record system; Structural data is shared the active demand that more and more becomes medical informationization; Doctor's free text mode and the contradiction between Ministry of Public Health's " electronic health record basic framework and data standard (trying) " have appearred; Existing data are that its content that deposits the code of database in or store lane database into all can't satisfy the electronic health record normal data library standard of the Ministry of Public Health; Therefore how between custom structure of freely expressing and electronic health record standard database, to find a kind of good docking mode, Ministry of Public Health's data standard is really implemented, become a technical barrier.
Summary of the invention
Technical matters to be solved by this invention is; A kind of method of the content map electronic health record standard database with electronic health record is proposed; The mixed and disorderly content of original electronic health record databases storage is converted into and corresponding orderly, the regular governed data metadata of electronic health record standard database; And deposit the case history template in predetermined structure, thus to dock with the electronic health record standard database, this method comprises following process:
Process 1: set up the case history template; Said template stores template elements; Said template elements comprises data element ID, data element classification, data element content, and every group of data element is with unique data element ID sign, and said data element classification is the classification of said data element content; When said data element content has a plurality of minutes time-likes, said data element classification formats storage;
Process 2: editor's case history template; The ID of specified data unit; According to the first classification of original electronic health record data of database object specified data; According to the first content of the concrete data content specified data of original electronic health record database,, preserve and also generate template then with data element ID, data element classification, data element content dynamic binding;
Process 3: revise the case history template: case history template that at first will be to be revised resolves to revisable data object, then the data object is on-the-fly modified medical record data, preserves and generate new template;
Process 4: will edit or amended case history template imports to database according to the predetermined specifications that adapts with the electronic health record standard database, each template elements in the case history template is represented with a plurality of data elements in the electronic health record standard database;
Process 5: when needs read the electronic health record data, according to the relevance of data element ID in the case history template, read a plurality of data elements that are associated of electronic health record database, said a plurality of data elements are united the concrete implication that shows designed element in the case history.
Further, the structure of said data element ID is " STD_DE_XXX_XXXX ", and wherein, " STD_DE_ " is the fixed head of data element ID.
Further; Said template elements also comprises the ID of growth data unit, growth data unit classification, growth data unit content; Said growth data unit is the data element that does not have in the primary electron case history template; The structure of the said growth data ID of unit is " EXT_DE_XXX_XXXX ", and wherein " EXT_DE_ " is fixed head, the classification that the first classification of said growth data is the first content of said growth data.
Further, said data element classification formats storage, and its formatting method is that a plurality of data element classifications are carried out the interval with " | ".
The present invention adopts said method, compared with prior art, has the following advantages:
1. the mixed and disorderly content with original electronic health record databases storage is converted into orderly, regular governed data metadata, adapts with the electronic health record standard database simultaneously, thereby realizes docking with the electronic health record standard database;
2. use the case history template that the content of former case history is managed, revise, expand and safeguard simple and convenient.
Embodiment
Combine embodiment that the present invention is further specified at present.
The method of a kind of content map electronic health record standard database with electronic health record of the present invention, it comprises following process:
Process 1: set up the case history template; Said ATL storing template element, said template elements comprise data element ID, data element classification, data element content, the ID of growth data unit, growth data unit classification, growth data unit content, and said data element is a standard definition; Every group of data element is with unique data element ID sign; The structure of said data element ID is " STD_DE_XXX_XXXX ", and wherein, " STD_DE_ " is the fixed head of data element ID; Said growth data unit is the data element that does not have in the primary electron case history template, and the structure of the said growth data ID of unit is " EXT_DE_XXX_XXXX ", and wherein " EXT_DE_ " is fixed head; Said data element classification is the classification of said data element content; The classification that the first classification of said growth data is the first content of said growth data; The first content of perhaps said growth data has a plurality of minutes time-likes in said data element; Said data element classification or said growth data unit classification format storage, carry out the interval with " | " between a plurality of data element classifications or a plurality of growth data unit classification;
Process 2: editor's case history template; The ID of specified data unit; According to the first classification of original electronic health record data of database object specified data; According to the first content of the concrete data content specified data of original electronic health record database,, preserve and also generate template then with data element ID, data element classification, data element content dynamic binding;
Process 3: revise the case history template: case history template that at first will be to be revised resolves to revisable data object, then the data object is on-the-fly modified medical record data, preserves and generate new template;
Process 4: will edit or amended case history template imports to database according to the predetermined specifications that adapts with the electronic health record standard database, each template elements in the case history template is represented with a plurality of data elements in the electronic health record standard database;
Process 5: when needs read the electronic health record data, according to the relevance of data element ID in the case history template, read a plurality of data elements that are associated of electronic health record database, said a plurality of data elements are united the concrete implication that shows designed element in the case history.
The application of said method is described below in conjunction with instantiation:
Like original electronic health record data of database object is " number "; Then this data element ID can be expressed as " STD_DE_IDENTITY_CODE "; What in case history, represent is " ID card No. "; Like " 01 " representative " I.D. "; At this time the data element classification " STD_DE_IDENTITY_TYPE " of the correspondence of " number " data element is exactly " a certificate classification ", and " certificate classification " needs to confirm concrete value through dictionary, and the ID of " ID card No. " node in the case history is " STD_DE_IDENTITY_CODE|01| ".Expression in database is exactly:
| TEMP_ID | DE_FORMAT_DE | KEY_TYPE_DE | …… |
| 312 | STD_DE_IDENTITY_CODE|01| | STD_DE_INDENTITY_TYPE | …… |
In the last table, the part (01) that separates with " | " at place, the end of " STD_DE_IDENTITY_CODE|01| " field of DE_FORMAT_DE row is represented the value of this data element, the i.e. code of " I.D. ";
| TEMP_ID | DE_FORMAT_DE | KEY_TYPE_DE | …… |
| 312 | STD_DE_XXX|01|N2|008 | STD_DE_YYY|STD_DE_ZZZ|STD_DE_TTT | ? |
The classification of the part that separates with " | " of the field of the DE_FORMAT_DE row of KEY_TYPE_DE row, as above in the table:
" 01 " in " STD_DE_YYY " correspondence " STD_DE_XXX|01|N2|008 ", representative diagnosis sequence number,
" N2 " in " STD_DE_ZZZ " correspondence " STD_DE_XXX|01|N2|008 ", " Western medicine diagnose " of representative diagnosis traditional Chinese and western medicine classification,
" final diagnosis " of diagnostic classification represented in " 008 " in " STD_DE_TTT " correspondence " STD_DE_XXX|01|N2|008 ".
If the content of " STD_DE_XXX|01|N2|008 " place element is " chronic pneumonia " in the case history, then be resolved to theing contents are as follows in the standard scale structure:
| The diagnosis sequence number | In/Western medicine diagnose | Diagnostic-type | Diagnosis name |
| 01 | N2 | 008 | Chronic pneumonia |
In the above-mentioned instance, each template elements in the case history template then is split as a plurality of data elements in the electronic health record standard database, and these a plurality of data elements are united and expressed the concrete implication of designed element in the case history.
Although specifically show and introduced the present invention in conjunction with preferred embodiment; But the those skilled in the art should be understood that; In the spirit and scope of the present invention that do not break away from appended claims and limited; Can make various variations to the present invention in form with on the details, be protection scope of the present invention.
Claims (4)
1. method with the content map electronic health record standard database of electronic health record is characterized in that: comprise following process:
Process 1: set up the case history template; Said template stores template elements; Said template elements comprises data element ID, data element classification, data element content, and every group of data element is with unique data element ID sign, and said data element classification is the classification of said data element content; When said data element content has a plurality of minutes time-likes, said data element classification formats storage;
Process 2: editor's case history template; The ID of specified data unit; According to the first classification of original electronic health record data of database object specified data; According to the first content of the concrete data content specified data of original electronic health record database,, preserve and also generate template then with data element ID, data element classification, data element content dynamic binding;
Process 3: revise the case history template: case history template that at first will be to be revised resolves to revisable data object, then the data object is on-the-fly modified medical record data, preserves and generate new template;
Process 4: will edit or amended case history template imports to database according to the predetermined specifications that adapts with the electronic health record standard database, each template elements in the case history template is represented with a plurality of data elements in the electronic health record standard database;
Process 5: when needs read the electronic health record data, according to the relevance of data element ID in the case history template, read a plurality of data elements that are associated of electronic health record database, said a plurality of data elements are united the concrete implication that shows designed element in the case history.
2. the method for the content map electronic health record standard database with electronic health record according to claim 1, it is characterized in that: the structure of said data element ID is " STD_DE_XXX_XXXX ", wherein, " STD_DE_ " is the fixed head of data element ID.
3. the method for the content map electronic health record standard database with electronic health record according to claim 1; It is characterized in that: said template elements also comprises the ID of growth data unit, growth data unit classification, growth data unit content; Said growth data unit is the data element that does not have in the primary electron case history template; The structure of the said growth data ID of unit is " EXT_DE_XXX_XXXX "; Wherein " EXT_DE_ " is fixed head, the classification that the first classification of said growth data is the first content of said growth data.
4. the method for the content map electronic health record standard database with electronic health record according to claim 1, it is characterized in that: said data element classification formats storage, and its formatting method is that a plurality of data element classifications are carried out the interval with " | ".
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN103295176A (en) * | 2013-05-14 | 2013-09-11 | 中标软件有限公司 | Electronic medical record editing method and system |
| CN103500225A (en) * | 2013-10-21 | 2014-01-08 | 樊梦真 | Method for structural storage of medical information |
| CN103593816A (en) * | 2013-11-25 | 2014-02-19 | 方正国际软件有限公司 | Medical history document memorizing device and memorizing method |
| CN104361221A (en) * | 2014-10-31 | 2015-02-18 | 沈阳锐易特软件技术有限公司 | Heterogeneous system data mapping template-based medical data acquisition system and method |
| CN104603780A (en) * | 2013-02-06 | 2015-05-06 | 株式会社日立制作所 | Computer system, metadata management method, and recording medium |
| CN105005683A (en) * | 2015-06-17 | 2015-10-28 | 北京锐易特软件技术有限公司 | Caching system and method for solving data normalization problem of regional medical system |
| CN107563127A (en) * | 2017-10-27 | 2018-01-09 | 张川海 | The rapid generation and system of a kind of electronic health record |
| CN107818124A (en) * | 2017-03-03 | 2018-03-20 | 平安医疗健康管理股份有限公司 | Data matching method and device |
| CN107833595A (en) * | 2017-10-12 | 2018-03-23 | 山东大学 | Medical big data multicenter integration platform and method |
| CN108763365A (en) * | 2018-05-17 | 2018-11-06 | 深圳市买买提信息科技有限公司 | Case information dynamic introduction method, device, equipment and storage medium |
| CN108766513A (en) * | 2018-06-01 | 2018-11-06 | 安徽八千里科技发展股份有限公司 | A kind of wisdom health medical treatment data structured processing system |
| CN108877920A (en) * | 2018-06-15 | 2018-11-23 | 申艳莉 | Diagnosis and treatment data managing method and system |
| CN109036576A (en) * | 2018-07-23 | 2018-12-18 | 无锡慧方科技有限公司 | Electronic health record data analysis method, device, computer and readable storage medium storing program for executing |
| CN109509515A (en) * | 2018-06-29 | 2019-03-22 | 康美药业股份有限公司 | Electronic health record management method, electronic equipment, storage medium, system |
| CN109785920A (en) * | 2018-12-03 | 2019-05-21 | 南方医科大学南方医院 | A kind of medical record data input method, system, device and storage medium |
| WO2019095550A1 (en) * | 2017-11-17 | 2019-05-23 | 深圳市前海安测信息技术有限公司 | Regional healthcare system and method for sharing of electronic medical records |
| CN109935285A (en) * | 2019-01-30 | 2019-06-25 | 杭州脉兴医疗科技有限公司 | A kind of the structuring processing method and processing system of ICU nursing forms data |
| CN110322942A (en) * | 2019-07-02 | 2019-10-11 | 慕勇峰 | A kind of generation method of Nursing writs, system and computer readable storage medium |
| CN110767277A (en) * | 2019-09-09 | 2020-02-07 | 卫宁健康科技集团股份有限公司 | Management method and system of regional electronic drug calendar |
| CN112509653A (en) * | 2020-10-29 | 2021-03-16 | 望海康信(北京)科技股份公司 | Medical record data processing method and system, corresponding equipment and storage medium |
| CN113539404A (en) * | 2021-08-09 | 2021-10-22 | 郑州大学第一附属医院 | Cross-hospital electronic medical record data acquisition method, system and storage device |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN104603780A (en) * | 2013-02-06 | 2015-05-06 | 株式会社日立制作所 | Computer system, metadata management method, and recording medium |
| CN103295176A (en) * | 2013-05-14 | 2013-09-11 | 中标软件有限公司 | Electronic medical record editing method and system |
| CN103500225A (en) * | 2013-10-21 | 2014-01-08 | 樊梦真 | Method for structural storage of medical information |
| CN103593816A (en) * | 2013-11-25 | 2014-02-19 | 方正国际软件有限公司 | Medical history document memorizing device and memorizing method |
| CN104361221B (en) * | 2014-10-31 | 2017-07-14 | 沈阳锐易特软件技术有限公司 | Medical data acquisition system and method based on heterogeneous system data mapping template |
| CN104361221A (en) * | 2014-10-31 | 2015-02-18 | 沈阳锐易特软件技术有限公司 | Heterogeneous system data mapping template-based medical data acquisition system and method |
| CN105005683A (en) * | 2015-06-17 | 2015-10-28 | 北京锐易特软件技术有限公司 | Caching system and method for solving data normalization problem of regional medical system |
| CN107818124A (en) * | 2017-03-03 | 2018-03-20 | 平安医疗健康管理股份有限公司 | Data matching method and device |
| CN107833595A (en) * | 2017-10-12 | 2018-03-23 | 山东大学 | Medical big data multicenter integration platform and method |
| CN107563127A (en) * | 2017-10-27 | 2018-01-09 | 张川海 | The rapid generation and system of a kind of electronic health record |
| WO2019095550A1 (en) * | 2017-11-17 | 2019-05-23 | 深圳市前海安测信息技术有限公司 | Regional healthcare system and method for sharing of electronic medical records |
| CN108763365A (en) * | 2018-05-17 | 2018-11-06 | 深圳市买买提信息科技有限公司 | Case information dynamic introduction method, device, equipment and storage medium |
| CN108766513A (en) * | 2018-06-01 | 2018-11-06 | 安徽八千里科技发展股份有限公司 | A kind of wisdom health medical treatment data structured processing system |
| CN108766513B (en) * | 2018-06-01 | 2022-04-12 | 安徽八千里科技发展有限公司 | Intelligent health medical data structured processing system |
| CN108877920A (en) * | 2018-06-15 | 2018-11-23 | 申艳莉 | Diagnosis and treatment data managing method and system |
| CN109509515A (en) * | 2018-06-29 | 2019-03-22 | 康美药业股份有限公司 | Electronic health record management method, electronic equipment, storage medium, system |
| CN109036576A (en) * | 2018-07-23 | 2018-12-18 | 无锡慧方科技有限公司 | Electronic health record data analysis method, device, computer and readable storage medium storing program for executing |
| CN109785920A (en) * | 2018-12-03 | 2019-05-21 | 南方医科大学南方医院 | A kind of medical record data input method, system, device and storage medium |
| CN109935285A (en) * | 2019-01-30 | 2019-06-25 | 杭州脉兴医疗科技有限公司 | A kind of the structuring processing method and processing system of ICU nursing forms data |
| CN110322942A (en) * | 2019-07-02 | 2019-10-11 | 慕勇峰 | A kind of generation method of Nursing writs, system and computer readable storage medium |
| CN110767277A (en) * | 2019-09-09 | 2020-02-07 | 卫宁健康科技集团股份有限公司 | Management method and system of regional electronic drug calendar |
| CN112509653A (en) * | 2020-10-29 | 2021-03-16 | 望海康信(北京)科技股份公司 | Medical record data processing method and system, corresponding equipment and storage medium |
| CN113539404A (en) * | 2021-08-09 | 2021-10-22 | 郑州大学第一附属医院 | Cross-hospital electronic medical record data acquisition method, system and storage device |
| CN114724665A (en) * | 2022-04-21 | 2022-07-08 | 北京高灵智腾信息科技有限公司 | BS version-based electronic medical record splitting method for multi-end written medical record |
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