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.





Similar content being viewed by others
References
Jha, Ashish K., DesRoches, Catherine M., Campbell, Eric G., Donelan, Karen, Rao, Sowmya R., Ferris, Timothy G., Shields, Alexandra, Rosenbaum, Sara, and Blumenthal, David, Use of Electronic Health Records in U.S. Hospitals. The New England Journal of Medicine 360:1628–1638, 2009.
Zhang, Yuhai, Xu, Yongyong, Shang, Lei, and Rao, Keqin, An investigation into health informatics and related standards in China. International Journal of Medical Informatics 76:614–620, 2007.
HL7 Health Level Seven. Available on World Wide Web at: http://www.hl7.org/, Last date visited:2010-01-12.
Dolin, R. H., Alschuler, L., Boyer, S., Beebe, C., Behlen, F. M., Biron, P. V., and Shabo, S. A., HL7 Clinical Document Architecture, Release 2. J. Am. Med. Inform. Assoc. 13:30–39, 2006.
ASTM Committee E31 on Healthcare Informatics develops standards. Available on World Wide Web at: http://www.astm.org/cgi-bin/SoftCart.exe/COMMIT/COMMITTEE/E31.htm?L+mystore+fdxl9438, Last date visited: 2010-01-12.
Kibbe, D. C., Phillips, J., and Green, L. A., The continuity of care record. Am. Fam. Physician 70:1220–1223, 2004.
IHE IT Infrastructure Technical Framework, Volume 2a (ITI TF-2a), Transactions Part A—Sections 3.1–3.28, Revision 6.0, Final Text, August 10, 2009. Available on World Wide Web at: http://www.ihe.net/Technical_Framework/upload/IHE_ITI_TF_6-0_Vol2a_FT_2009-08-10-2.pdf. Last date visited: 2010-01-12.
Jian, Wen-Shan, Hsu, Chien-Yeh, Hao, Te-Hui, Wen, Hsyien-Chia, Hsu, Min-Huei, Lee, Yen-Liang, Li, Yu-Chuan, and Chang, Polun, Building a portable data and information interoperability infrastructure—framework for a standard Taiwan Electronic Medical Record Template. Computer Methods and Programs in Biomedicine 88:102–111, 2007.
Interviewing Keqin Rao, the director of statistic department of Ministry of Health. 2009. Available on the World Wide Web at : http://www.h-ceo.com/doc/2009/04/15749.shtml. Last date visited: 2010-1-12(Chinese).
Use of Hospital Information System in China. Available on World Wide Web at: http://www.cio360.net/Page/1806/InfoID/294896/SourceId/13718/PubDate/2009-04-16/Default.aspx. Last date visited: 2010-01-12(Chinese).
The HIS functional guideline. Available on World Wide Web at: http://wsj.maoming.gov.cn/new_page_1.htm. Last date visited: 2010-01-12(Chinese).
Chen, Wenbin, and Pan, Xianglin, Diagnostics. Version 7. People Health Press, BeiJing, pp. 6–551, 2008.
Medical Document Rule, Ministry of Health. Available on World Wide Web at: http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohyzs/s3585/200904/40299.htm. Last date visited: 2010-01-15.
The basic Architecture and Data Standard of EHR, Ministry of Health. Available on World Wide Web at: http://www.chima.org.cn/pe/Article/ShowArticle.asp?ArticleID=763. Last date visited: 2010-01-12(Chinese).
The Draft of Construction Guidelines for Health Information Platform basing on EHR, Ministry of Health. Available on World Wide Web at: http://www.chima.org.cn/pe/Article/ShowArticle.asp?ArticleID=764. Last date visited: 2010-01-12(Chinese).
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.
Author information
Authors and Affiliations
Corresponding authors
Appendix I
Appendix I
Rights and permissions
About this article
Cite this article
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
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10916-010-9540-x