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在数据表示和合规性测量中遵守数据驱动的指导方针:范围审查

Minh Trang Hoang¹, Candice Donnelly¹, Christina Igasto^1,2

¹Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, 61 401333970.

Journal of medical Internet research

|February 9, 2026

概括

衡量在医疗保健中遵守最佳实践标准是一项挑战. 本综述综合了指导方针的可计算表示和遵守测量的方法,强调了需要上下文意识的方法来确保临床相关性.

科学领域:

医疗保健信息学医疗保健信息学
临床决策支持系统临床决策支持系统
医疗保健服务研究医疗服务研究

背景情况:

最佳实践标准旨在标准化护理和改善患者的治疗结果.
临床实践存在差异,并非所有偏差都是不适当的.
由于表示和数据忠实性的限制,测量标准的遵守是具有挑战性的.

研究的目的:

调查和综合有关指南建议可计算表现的文献.
探索检测和量化偏离最佳实践标准的方法.

主要方法:

根据阿克西和奥马利框架和PRISMA-ScR指南进行范围审查.
在2025年11月搜索了五个数据库 (Ovid Medline,EMBASE,IEEE Xplore,科学网,Scopus).
包括描述可计算的标准表示或使用患者数据评估遵守标准的研究.

主要成果:

包括24项研究,其中58%测量了坚持.
心血管疾病是最常见的焦点 (54%).
标准是使用BPMN,本体学,FHIR或混合方法正式制定的;基于规则的对齐是遵守测量的常见情况.
大多数模型缺乏上下文敏感性和患者特异性因素,导致临床偏差未解决.

结论:

在计算机可解释的表示和临床上有意义的坚持测量方面,仍然存在挑战.
目前的方法侧重于技术调整而不是临床相关性,数据质量受到限制.
需要在临床工作流程中整合上下文意识的标准化建模,以区分合理的和不合理的偏差,以获得更安全的患者护理.

关键词:

最好的做法是最好的做法.临床决策支持临床决策支持临床实践指南临床实践指南计算机可解释的指导方针.电子医疗记录电子医疗记录符合指导方针的合规性.

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