在日本,临床进展记录的标准化与FHIR合作
Eizen Kimura1, Katsuhiko Nishino2, Masahiko Kimura3
1Medical School of Ehime University.
Studies in health technology and informatics
|May 17, 2025
概括
这项研究创建了电子健康记录进度说明的标准格式,用于训练大语言模型 (LLM). 在日本EMR和C-CDA的FHIR标准之间发现了显著的差异,突出了需要全供应商标准化努力的需要.
科学领域:
- 医疗信息学 医疗信息学
- 自然语言处理自然语言处理.
- 医疗保健标准 医疗保健标准
背景情况:
- 电子医疗记录 (EMR) 对于临床文档至关重要.
- 标准化进展说明对于互操作性和人工智能培训至关重要.
- 现有的EMR结构可能与国际医疗保健数据标准不一致.
研究的目的:
- 建立一个标准化格式的进度笔记作为LLMs的培训数据集.
- 分析日本EMR与快速医疗互操作资源 (FHIR) 的综合临床文档架构 (C-CDA) 的兼容性.
- 为了确定在日本实现标准化的进展中存在的挑战,请注意.
主要方法:
- 审查了现有的临床文档指南.
- 在埃希梅大学医学院分析了EMR系统的结构.
- 将主观,目标,评估和计划 (SOAP) 部分映射到C-CDA部分.
- 引入了一个DocumentReference扩展,用于处理DICOM图像等附件.
主要成果:
- 成功地将EMR SOAP段与C-CDA段进行映射.
- 一个DocumentReference扩展用于附件.
- 在FHIR上的日本EMR和C-CDA之间发现了实质性的差异.
- 该研究强调了需要多供应商分析的必要性.
结论:
- 从EMR中创建LLM培训数据是迈出了基础的一步.
- 目前日本的EMR实践与基于FHIR标准的C-CDA之间存在重大差距.
- 涉及多个供应商的进一步研究对于推动日本的进展说明标准化至关重要.
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