Building clinical data groups for electronic medical record in China

Area of Science:

• Health Informatics
• Medical Informatics
• Clinical Data Standards

Background:

• Electronic Medical Record Systems (EMRS) require standardized data structures for effective implementation in China.
• Existing medical sheets in Chinese hospitals contain valuable clinical information that needs categorization.
• International standards like HL7 CDA R2 Model provide a framework for structuring clinical data.

Purpose of the Study:

• To develop reusable clinical data groups for Electronic Medical Records (EMR) in China.
• To create a guideline for building EMRS by defining basic information units.
• To adapt international health informatics standards to Chinese national regulations and health system characteristics.

Main Methods:

• Adopted the Health Level 7 Clinical Document Architecture Release 2 Model (HL7 CDA R2 Model) for data categorization.
• Collected and analyzed medical sheets from Chinese hospitals.
• Integrated international standards with Chinese health informatics regulations and legal documents.

Main Results:

• Created a set of 75 data groups comprising 452 data elements.
• Developed 12 data groups (87 elements) for EMR headers and 63 data groups (405 elements) for the EMR body.
• Established a two-level structure for data groups, enhancing reusability as templates for clinical records.

Conclusions:

• The developed EMR data groups serve as essential reusable information units and implementation guidelines for EMRS in China.
• Localizing international health standards through abstraction and categorization of Chinese medical data is critical for future sharing and EMRS implementation.
• This pilot study successfully combined international standards with Chinese national regulations, paving the way for standardized health information systems.