评估语义互操作性:关于芬兰护理文档和LEP护理干预分类的初步研究
Mikael Helenius1,2, Hanna von Gerich2, Glorianna Jagfeld3
1Turku University Hospital, Finland.
Studies in health technology and informatics
|August 8, 2025
概括
在国际上分享健康数据至关重要. 这项研究发现,使用多个护理分类系统,如芬兰护理分类系统 (FinCC) 和LEP护理3,由于不一致性和不同的临床用途,会带来文档挑战.
科学领域:
- 医疗信息学 医疗信息学
- 护理信息学 护理信息学
- 数据标准 数据标准
背景情况:
- 像欧洲健康数据空间这样的国际倡议旨在加强健康数据的共享,以改善访问和利用.
- 标准化护理干预措施对于互操作性和电子健康记录中的数据表示一致至关重要.
研究的目的:
- 探索使用多种分类系统编码护理干预的挑战和影响.
- 评估将LEP护理3分类应用于芬兰护理分类系统 (FinCC) 中最初记录的数据的可行性.
主要方法:
- 最初用FinCC编码的电子健康记录被追溯编码使用LEP护理3干预分类.
- 在2594个护理数据条目中分析了2807个注释.
主要成果:
- 其中很大一部分 (85.6%) 涉及监测干预措施.
- 在FinCC组件层面观察到不一致性,很少使用结构化标题和子类别.
- 单个文档条目通常包含多个干预,使分类系统之间的直接映射复杂化.
结论:
- 实施各种数据标准的健康数据交换平台带来了重大挑战.
- 协调健康数据标准的临床应用可能与其预期的设计不同.
- 在芬兰电子健康记录中编码LEP护理干预可能是基于FinCC数据的特定领域 (移动,治疗,安全) 的可行,这需要在所有护理领域进行进一步调查.
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