Implementation of an Archetype Data Set to Reuse Electronic Health Record Data in Clinical Decision Support Systems

摘要

The efficiency and acceptance of clinical decision support systems (CDSS) can increase if they reuse medical data captured during health care delivery. High heterogeneity of the existing legacy data formats has become the main barrier for the reuse of data. Medical insurance companies perform quality assessment of medical treatment in Russia. The results of the quality control influence the payment that a clinic will get for the certain case of treatment. The quality assessment process is a well-formalized process performed by medical experts based on clinical standards and personal experience. However, different interpretation of clinical standards especially in regards of optional medical procedures add bias to the process. To avoid bias and to make the process transparent and independent the task of quality assessment can be delegated to a decision support system [1-6]. However, most of CDSSs still are standalone systems that require import-export routine with HISes. The goal of this paper is to present the development of an archetype based dataset for a CDSS-HIS data exchange.