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对轻度创伤性脑损伤患者管理的EHR数据的建模和标准化

Julia Hernández-Sánchez¹, Paula Rubio-Mayo^1,2, Javier de la Cruz-Bertolo³

¹Digital Health Group, Research Institute Hospital 12 de Octubre, Madrid, Spain.

Studies in health technology and informatics

|May 17, 2025

概括

这项研究标准化了电子健康记录中的创伤性脑损伤 (TBI) 数据,减少了计算机断层扫描 (CT) 扫描的过度使用. 该方法提高了数据管理效率和实时监控,以改善TBI护理和研究.

科学领域:

神经学神经学
医疗信息学医疗信息学

背景情况:

创伤性脑损伤 (TBI) 是致病率和死亡率的主要原因,急诊室的利用率很高.
在内病变的诊断测试方面缺乏共识,导致过度使用计算机断层扫描 (CT) 扫描.

研究的目的:

改进电子健康记录 (EHR) 中创伤性脑损伤 (TBI) 信息的结构和标准化.
减少在TBI病例中过度使用诊断成像,特别是CT扫描.

主要方法:

在EHR中统一的TBI诊断编码.
开发了一个结构化临床观察收集的表单.
创建了一个Power Business Intelligence (PowerBI) 仪表板,用于数据可视化和监控.

主要成果:

成功确定了442个TBI病例的队列.
显著减少数据搜索时间,提高管理效率.
启用了对TBI患者管理的关键指标的实时监测.

结论:

在EHR中标准化TBI数据可以增强临床护理,并促进数据的互操作性.
开发的系统通过提供结构化和可访问的数据来支持TBI研究.
这种方法为改善TBI的管理提供了一个模型.

关键词:

电子健康记录电子健康记录在PowerBI中使用PowerBI.这就是SNOMED CT.标准标准标准标准术语学术语术语学术语的使用创伤性脑损伤创伤性脑损伤

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Traumatic Brain Injury l: Introduction

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