CN102880710A - Method for creating clinical documents by medical information platform - Google Patents

Method for creating clinical documents by medical information platform Download PDF

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CN102880710A
CN102880710A CN 201210372361 CN201210372361A CN102880710A CN 102880710 A CN102880710 A CN 102880710A CN 201210372361 CN201210372361 CN 201210372361 CN 201210372361 A CN201210372361 A CN 201210372361A CN 102880710 A CN102880710 A CN 102880710A
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cda
medical
document
check
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张立勇
郑孝青
时云智
董骞
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山东浪潮齐鲁软件产业股份有限公司
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Abstract

The invention provides a method for creating clinical documents by a medical information platform and relates to the technical field of computer software. Services of a front-end computer is based on the medical information platform and mounted on various medical institutions in a manner of the front-end computer. The technical scheme includes that the method includes six steps of data acquisition, CDA (command and data acquisition) document generation, data analysis, data checkout, data transmission and data storage. The service process of the front-end computer includes acquiring various basic service data of the medical institutions, generating the CDA documents according to HL7 standards, analyzing and checking the contents of the documents, if in failure in checking, feeding back to the medical institutions, and encrypting, transmitting and storing the CDA documents passing the checking.

Description

一种利用医疗信息平台制作临床文档的方法 A method for using the medical information platform for the production of clinical documents

技术领域 FIELD

[0001] 本发明涉及计算机软件领域,具体地说是一种利用医疗信息平台制作临床文档的方法。 [0001] The present invention relates to the field of computer software, in particular to a platform for the production of clinical medical information using the method of the document.

背景技术 Background technique

[0002]目前,大部分医疗机构都拥有自己的信息管理系统、临床信息系统等,积累了大量的个人健康信息,各医疗机构在共享这些信息数据或向卫生管理部门提报数据时,都是依据自己现有系统的数据结构生成数据,传输到其他医疗机构或卫生管理部门后,需要再根据自己的实际系统将数据解析存储,受数据结构的不同和编码方式的不同,会出现很多错误,并增加工作负担。 [0002] Currently, most medical institutions have their own information management systems, clinical information systems, accumulated a great deal of personal health information, medical institutions to share this information in the data or escalation data to health authorities, are based on their existing system data structures generated data, after transfer to other medical or health authorities, according to their actual needs and then parses the data storage system, encoded by different ways and different data structures, there will be a lot of mistakes, and increased workload. 采用HL7国际标准,将业务数据生成CDA文档,可以规避数据结构和编码方式带来的问题,方便阅读。 Adopt international standards HL7, traffic data generated CDA document, you can avoid problems caused by data structure and coding for easy reading.

[0003] 但是,医疗机构自己生成CDA(Clinical Document Architecture临床文档结构)文档,需要学习HL7 (Health Level 7卫生信息交换标准)标准传输协议,对CDA文档进行合法性、有效性校验,需要花费大量的人力财力,一旦制作出的CDA文档存在错误,在被交换后对其进行解析时,接收方无法获取想要的数据,或者文档内容存在错误,影响工作效率。 [0003] However, medical institutions generate their own CDA (Clinical Document Architecture clinical document architecture) document, you need to learn HL7 (Health Level 7 Health Information Exchange Standard) standard transport protocol, for CDA documents legality, validity check, it takes a lot of human and financial resources, once to produce a CDA document there is an error, when it is parsed, the recipient can not obtain the desired data after being exchanged, or a bad document content, affect efficiency.

发明内容 SUMMARY

[0004] 本发明针对目前技术存在的不足之处,提供一种利用医疗信息平台制作临床文档的方法。 [0004] The present invention is directed to the shortcomings of existing technology to provide a method for using the medical information platform for the production of clinical documents.

[0005] 本发明的目的是按以下方式实现的,将医疗信息平台以前置机的方式安装在各医疗机构,在前置机服务中,通过HL7国际标准协议,制作CDA模板文档,通过数据采集对医疗机构系统产生的各类基础业务数据进行采集,然后调用CDA模板,将采集数据生成CDA文档,通过数据解析、数据校验对采集数据进行解析和校验,当校验不通过时,反馈给医疗机构,重新采集数据,当数据校验通过时,将校验通过的CDA文档存储到前置机磁盘目录或数据库中,对校验通过的数据进行加密传输到其他医疗机构或卫生管理信息平台,医疗信息平台将医疗机构采集的业务数据生成CDA文档,并对CDA文档进行合法性校验、解析和存储,CDA文档生成过程包括数据采集、生成CDA文档、数据解析、数据校验、数据传输及数据存储,具体步骤如下: [0005] The present invention is implemented in the following manner, the medical information platform front-end mounted in various medical institutions, in the front-end service by international standard HL7 protocol, making CDA document templates, data acquisition all kinds of basic business data generated by the system of medical institutions to collect, and then call CDA template, the collected data to generate CDA document, through data analysis, data validation on the collected data parsing and validation, when the check is not passed, the feedback to medical institutions, to re-collect the data, when the data check by the check CDA document storage through to the front-end disk directory or database, data verification by the encrypted transmission to other medical or health information management platform, medical institutions, medical information platform will gather business data generated CDA document, and verify the legitimacy of CDA documents, parsing and storage, CDA document generation process including data acquisition, generation CDA documents, data analysis, data validation, data transmission and storage of data, the following steps:

1)数据采集:对医疗机构系统产生的业务数据进行采集,以医疗机构现有系统的数据结构为依托,按照{键:值}集合的方式将业务数据组装成串形数据,这种集合数据不受数据分布存储的影响,能从不同的业务表中取出相关联的数据进行组合,并且是无序排列; 1) Data collection: medical data traffic generated by the acquisition system, the data structure of the existing systems rely on medical institutions, according to: the value of the key way} {set of traffic data assembling clusters form data, such data collection affected by the distribution of the stored data, the associated data from different tables taken out of service combination, and is disordered array;

2)生成CDA文档:前置机服务在接收到{键:值}集合数据串后,调用CDA模版,用标记语言将[值]替换在CDA模版中的[键]所对应的内容,生成CDA文档; 2) generating a CDA document: receiving {FEP service key: value} and a set of data strings, call CDA template with a markup language to [value] with the template in the CDA [key] corresponding to the content, generates CDA documents;

3)数据解析:对医疗机构的业务数据进行抽取,根据CDA模版中配置的信息,获取指定标签下对应的属性值,将数据转换成{数据元:值}的方式;4)数据校验:数据校验主要是对生成的CDA做合法性、有效性验证,根据解析出的{数据元:值}的对应关系数据,校验值的必须性、长度、数据类型,当此值为字典项时,需要校验此字典项是否存在;当校验出数据有不符合标准时,将结果反馈给医疗机构; 3) Data Analysis: the traffic data extraction medical institutions, according to CDA template configuration information acquires the attribute value corresponding to the specified label, converts the data into data elements {:} manner value; 4) Data Check: the main data check is made CDA generated legality, validation, according to the parsed data elements {:} correspondence between the data values, the necessity check value, length, data type, when this value dictionary entry , you need to check this dictionary entry exists; check out the data when there are non-compliant, the results back to medical institutions;

5)数据传输:将校验通过的CDA文档经过加密后传输到其他医疗机构或卫生管理信息平台; 5) Data transmission: The parity by the CDA document transfer to other medical or health information management platform through encrypted;

6)数据存储:数据存储包含两部分:一是校验通过的CDA文档,另一个是通过交换传输到其他医疗机构或卫生管理信息平台的CDA文档,前者以文件格式保存到前置机磁盘目录下,供交换传输调用,后者以文件和数据流的方式分别存储在磁盘目录和数据库中,增加文件安全性。 6) Data storage: Data storage consists of two parts: First, check the CDA document by the other is that the former is saved in a file format to exchange front-end disk directory by CDA document transferred to other institutions or medical health management information platform next, calling for the exchange of transport, the latter of documents and data streams are stored in the disk directory and database, increased file security.

[0006] 本发明的方法具有的有益效果是:该前置机服务采用统一标准的文档制作方法,将各医疗机构的各类数据制作成CDA文档,放到相关医疗机构或卫生管理信息平台,方便有关人员阅读,其优点为: (1)完整性 [0006] The method of the present invention has the advantages that: the front-end unified service standard document production methods, the various medical institutions of various types of data made into CDA documents into relevant medical or health information management platform, easy to read about the staff, its advantages are: (1) the integrity of the

前置机服务将医疗机构的业务信息完整规范的生成CDA文档; The front-end business information service medical institutions to generate the full specification of the CDA document;

(2)可读性 (2) readability

前置机服务将医疗机构的业务信息以一种指定结构和语义的文档标记标准组装起来,方便不同的人、不同的机器系统进行阅读查看; The front-end business information service medical institutions in a given structure and semantics of the document markup standard assembled for easy Different people, different machine systems reading View;

(3)高效性 (3) efficiency

本发明支持处理大量信息数据,并与大量文档创建系统相兼容; The present invention supports processing a lot of data, and is compatible with a large number of document creation system;

(4)简约性 (4) parsimony

本发明安装简单,允许在更多地系统中廉价的实施; The present invention is simple to install, the system allows more inexpensive embodiment;

(5)节约性 (5) saving properties

前置机服务自动将业务数据按照HL7标准转换生成CDA文档,不需要医疗机构再投入人力财力去学习HL7标准和制作CDA文档,为医疗机构降低成本。 Front-end business data services automatically generated in accordance with standard HL7 CDA document conversion does not require re-invested medical institutions, human and financial resources to study the HL7 CDA document production and reduce the cost of medical institutions.

附图说明 BRIEF DESCRIPTION

[0007] 附图I是前置机服务的工作流程图。 [0007] FIG. I is a flowchart of FEP and services.

具体实施方式 detailed description

[0008] 下面结合附图I对本发明的方法做进一步详细说明。 [0008] The accompanying drawings I described in further detail in conjunction with the method of the present invention.

[0009] 本发明所述的前置机服务,基于医疗信息平台,以前置机的方式安装在各医疗机构,将医疗机构的业务数据按照HL7标准生成CDA文档,并对CDA文档进行合法性校验、解析和存储,其解决所述技术问题采用的技术方案如下:该前置机服务由数据采集、生成CDA文档、数据解析、数据校验、数据传输及数据存储六阶段组成。 [0009] FEP service according to the present invention, based on the medical information platform, mounted in a FEP various medical institutions, medical institutions service data generated in accordance with the HL7 CDA document, and the legitimacy of the CDA document correction inspection, parsing, and storing, which solve the technical problem the technical solution adopted is as follows: the FEP served by the data collection, generates CDA document, data analysis, data validation, data transmission and data storage six stages.

[0010] 本发明所述的前置机服务,将不同医疗机构的各类基础数据,以一种指定结构和语意的文档标记标准结构组装起来,方便其它医疗机构系统或人员阅读。 [0010] FEP service according to the present invention, the different kinds of basic data of medical institutions, to the standard structure of a document markup assigned structure and semantic assembled, or to facilitate other medical personnel to read system. 该前置机服务的具体工作过程为: Specific work process of the front-end services to:

医疗机构在将业务数据提交给其他人阅读前,在前置机服务中,通过HL7国际标准协议,制作CDA模板文档,通过数据采集对医疗机构系统产生的各类基础业务数据进行采集,然后调用CDA模板,将采集数据生成CDA文档,通过数据解析、数据校验对采集数据进行解析和校验,若校验不通过,则反馈给医疗机构,重新采集数据,若数据校验通过,则被存储到前置机磁盘目录或数据库中,并将校验通过的数据CDA文档进行加密传输到其他医疗机构或卫生管理信息平台,供医疗机构系统或其它人员阅读。 Medical institutions before others will submit a business data to read, in the front-end service by international standard HL7 protocol, making CDA document templates, all kinds of basic business data generated by medical institutions through the data acquisition system to collect, and then call CDA template, the collected data to generate CDA document, through data analysis, data validation to parse data collection and verification, if the verification is not passed, then back to the medical institutions, re-acquisition data, if the data verification passes were stored to disk directory or database front-end, and the encrypted transmission to other medical or health information management platform for medical personnel to read verification system or other data through the CDA document.

[0011] 本发明基于医疗信息平台,以前置机的方式安装在各医疗机构,采集各类医疗机构相关数据,并生成符合HL7 (Health Level 7卫生信息交换标准)标准的CDA (ClinicalDocument Architecture临床文档结构)文档,放到相关医疗机构或卫生管理信息平台,方便有关人员阅读。 [0011] The present invention is based on medical information platform, front-end mounted in various medical institutions, medical institutions collect all kinds of data, and generates CDA (ClinicalDocument Architecture clinical documentation in line with HL7 (Health Level 7 Health Information Exchange Standard) Standard structure) documents into relevant medical or health information management platform to facilitate the persons concerned to read.

[0012] 本发明所述前置机服务主要由数据采集、生成CDA文档、数据解析、数据校验、数据传输及数据存储六阶段组成。 [0012] The front end processor of the present invention is mainly collected by the service data, generates CDA document, data analysis, data validation, data transmission and data storage six stages.

[0013] 对该前置机服务的各个阶段分别详细说明如下: (一)数据采集 [0013] FEP service for the various stages are described in detail as follows: (a) data collection

对医疗机构系统产生的业务数据进行采集,以医疗机构现有系统的数据结构为依托,按照{键:值}集合的方式将业务数据组装成串形数据,这种集合数据不受数据分布存储的影响,可以从不同的业务表中取出相关联的数据进行组合,并且是无序排列; Medical service data generated by the system acquisition, the data structure of the existing systems rely on medical institutions, according to: the value of the key way} {set of traffic data assembling clusters form data, which is stored a set of data from data distribution effect, associated data can be removed from different service tables are combined, and are disordered array;

(二)生成CDA文档 (B) generate a CDA document

前置机服务在接收到{键:值}集合数据串后,调用CDA模版,用标记语言将[值]替换在CDA模版中的[键]所对应的内容,从而生成CDA文档; Upon receiving the service FEP {key: value} and a set of data strings, call CDA template with a markup language to [value] with the template in the CDA [key] corresponding to the content, thereby generating a CDA document;

(三)数据解析 (Iii) data analysis

对医疗机构的业务数据进行抽取,根据CDA模版中配置的信息,获取指定标签下对应的属性值,将数据转换成{数据元:值}的方式; Service data decimation medical institutions, according to CDA template configuration information acquires the attribute value corresponding to the specified label, converts the data into data elements {:} manner values;

(四)数据校验 (Iv) Data Check

数据校验主要是对生成的CDA做合法性、有效性验证,根据解析出的{数据元:值}的对应关系数据,校验值的必须性、长度、数据类型,如果此值为字典项,需要校验此字典项是否存在。 The main data check is made CDA generated legality, validation, according to the parsed data elements {:} correspondence between the data values, the necessity check value, length, data type, if this value dictionary entry , you need to check this dictionary entry exists. 如果校验出数据有不符合标准的,则将结果反馈给医疗机构; If you check out the data have not up to standard, then the results back to the medical institutions;

(五)数据传输 (V) Data Transfer

将校验通过的CDA文档经过加密后传输到其他医疗机构或卫生管理信息平台; The check by the CDA document after the encrypted transmission to other medical or health information management platform;

(六)数据存储 (F) data storage

数据存储包含两部分:一是校验通过的CDA文档,另一个是通过交换传输到其他医疗机构或卫生管理信息平台的CDA文档。 Data storage consists of two parts: First, check the CDA document by the other CDA documents are transferred to other medical institutions or health information management platform through the exchange. 前者以文件格式保存到前置机磁盘目录下,共交换传输调用,后者分别以文件和数据流的方式分别存储在磁盘目录和数据库中,增加文件安全性。 The former saved as a file format to a disk directory under the front-end, total exchange transfer calls, which were in files and data streams are stored in the disk directory and database, increased file security.

[0014] 该前置机服务自动将业务数据按照HL7标准转换生成CDA文档,不需要医疗机构再投入人力财力去学习HL7标准和制作CDA文档,为医疗机构降低成本;由于将医疗机构的业务信息以一种指定结构和语义的文档标记标准组装起来,方便不同的人、不同的机器系统进行阅读查看。 [0014] The front-end business data service automatically generated in accordance with standard HL7 CDA document conversion does not require re-invested medical institutions, human and financial resources to study the HL7 CDA document production and reduce costs for medical facilities; business information due to medical institutions in a given structure and semantics of the document markup standard assembled for easy different people, different machine systems reading view.

[0015] 除说明书所述的技术特征外,均为本专业技术人员的已知技术。 [0015] In addition to the technical features described in the specification, it is known to those skilled in the art.

Claims (1)

  1. 1. 一种利用医疗信息平台制作临床文档的方法,其特征在于将医疗信息平台以前置机的方式安装在各医疗机构,在前置机服务中,通过HL7国际标准协议,制作CDA模板文档,通过数据采集对医疗机构系统产生的各类基础业务数据进行采集,然后调用CDA模板,将采集数据生成CDA文档,通过数据解析、数据校验对采集数据进行解析和校验,当校验不通过时,反馈给医疗机构,重新采集数据,当数据校验通过时,将校验通过的CDA文档存储到前置机磁盘目录或数据库中,对校验通过的数据进行加密传输到其他医疗机构或卫生管理信息平台,医疗信息平台将医疗机构采集的业务数据生成CDA文档,并对CDA文档进行合法性校验、解析和存储,CDA文档生成过程包括数据采集、生成CDA文档、数据解析、数据校验、数据传输及数据存储,具体步骤如下: 1)数据采集:对医 1. A method for using the medical information platform for the production of clinical documents, characterized in that the medical information platform front-end mounted in various medical institutions, in the front-end service by international standard HL7 protocol, making CDA document templates, through all kinds of basic data collection business data generated by the system of medical institutions to collect, and then call CDA template, the collected data to generate CDA document, through data analysis, data validation on the collected data parsing and validation, when the check does not pass when feedback to the medical institution, the data re-acquisition, when the data check by the check to the CDA document stored by the FEP disk directory or database, the data for verification by the encrypted transmission to other medical institutions or health management information platform, medical institutions, medical information platform will gather business data generated CDA document, and verify the legitimacy of CDA documents, parsing and storage, CDA document generation process including data acquisition, generation CDA documents, data analysis, and data correction test, data transmission and data storage, the specific steps are as follows: 1) data acquisition: on Medical 机构系统产生的业务数据进行采集,以医疗机构现有系统的数据结构为依托,按照{键:值}集合的方式将业务数据组装成串形数据,这种集合数据不受数据分布存储的影响,能从不同的业务表中取出相关联的数据进行组合,并且是无序排列; 2)生成CDA文档:前置机服务在接收到{键:值}集合数据串后,调用CDA模版,用标记语言将[值]替换在CDA模版中的[键]所对应的内容,生成CDA文档; 3)数据解析:对医疗机构的业务数据进行抽取,根据CDA模版中配置的信息,获取指定标签下对应的属性值,将数据转换成{数据元:值}的方式; 4)数据校验:数据校验主要是对生成的CDA做合法性、有效性验证,根据解析出的{数据元:值}的对应关系数据,校验值的必须性、长度、数据类型,当此值为字典项时,需要校验此字典项是否存在;当校验出数据有不符合标准时, Traffic data collection means generated by the system, the data structure of a conventional system based medical institutions, according to: Impact values ​​{} key mode of traffic data collection form data clusters assembled, this set of stored data from the data distribution , from data associated with different service combinations in the table taken out, and is disordered array; 2) generating a CDA document: receiving {FEP service key: value} and a set of data strings, call CDA template with tag language [value] with the CDA in the templates [key] content corresponding to generate a CDA document; 3) data Analysis: the traffic data for medical institutions extraction, according to the information CDA template configuration acquires the specified label under corresponding to the attribute value, converting the data into data elements {:} manner value; 4) data verification: the main data validation is done CDA generated legality, validation, according to the parsed data elements {: value } the correspondence data, necessity, length, data type check value, when the value of this dictionary entries, need to verify whether the dictionary entry is present; check out the data when there is no standard, 结果反馈给医疗机构; 5)数据传输:将校验通过的CDA文档经过加密后传输到其他医疗机构或卫生管理信息平台; 6)数据存储:数据存储包含两部分:一是校验通过的CDA文档,另一个是通过交换传输到其他医疗机构或卫生管理信息平台的CDA文档,前者以文件格式保存到前置机磁盘目录下,供交换传输调用,后者以文件和数据流的方式分别存储在磁盘目录和数据库中,增加文件安全性。 Results back to the medical institution; 5) data transmission: The CDA document check by the institution or transfer to other medical and health management information platform after encryption; 6) Data storage: Data storage consists of two parts: First, check through the CDA document, and the other is through the exchange of transport to CDA document or other medical institutions and health management information platform, the former saved as a file format to the next front-end disk directory, calls for the exchange of transport, the latter files and data are stored streamed in the disk directory and database, increased file security.
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