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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Acknowledgments
This research was supported by National Science and Technology Support Project Grant (No. 2008BAI52B01) from the Ministry of Science and Technology of the People’s Republic of China. Special thanks are extended to the hospitals that participated in the collection of the sheets, providing valuable material. We wish to acknowledge the support of Dr. Haijing Tu and editors of American Journal Experts for their assistance in the writing.
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Tu, H., Yu, Y., Yang, P. et al. Building Clinical Data Groups for Electronic Medical Record in China. J Med Syst 36, 723–736 (2012). https://doi.org/10.1007/s10916-010-9540-x
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DOI: https://doi.org/10.1007/s10916-010-9540-x