基于XML-CDA规范快速构建弹性结构健康档案

摘要

Objective: Under the direction of new healthcare reform policy about national electronic health records,according to Chinese present standard GB and GB/T, this paper develops a technology solution supported clinical document architecture ( CDA ) specification which could achieve electronic health records (EHRs)rapidly. Methods:1.Adhering to relevant specifications promulgated by the Ministry of Health and State Administration of Traditional Chinese Medicine recently, since health records involved with particular column and text, we established self-explain metadata of CDA with Extensible Markup Language (XML) and integrated CDA resources. 2. XML documents with CDA that were composed and filled fast from resources to relevant CDA structure through flexible structured electronic health records (FS-EHR). 3. DES algorithm and X.509 protocol were be used in CDA to protect non repudiation from operation of the third party, and make information safety. Results: Information collection templates of EHR carrying out standard and specification with shortcut combination could be built including electronic medical records (EMR). FS-EHR has data entry freedom with "get what you see", an attribute of signature and encryption, extend personalize structure elastically;generate XML documents integrated by CDA automatically. Conclusion: This technology solution supports region hygiene information exchange and processing safely between different health information systems.%目的:根据新医改政策及卫生部关于电子健康档案的建设方案和相关标准,提出支持标准和可扩展标记语言(Extensible Markup Language,XML)标准、符合临床文档结构(Clinical Document Architecture,CDA)规范原则、能快捷建档的技术方案.方法:1.遵照现行中国标准GB、GB/T、卫生部和国家中医药管理局近期发布政策标准规范,采用XML和CDA规范,针对健康档案涉及栏目及其填写内容,建立具有自解释能力和符合XML标准的CDA元数据,并集储于CDA资源库:2.通过弹性结构式电子健康档案(Flexible Structured Electronic Health Records,FS-EHRs)系统,从CDA资源库导入相关结构的CDA,系统的文体为多个CDA构成的XML文档;3.采用DES算法和X.509协议处理CDA数据加密和抗抵赖的信息安全.结果:执行标准和规范的同时能快速组合构建包括电子病历在内的健康档案信息采集模板: FS-HERs为"即见所得"式自由文本录入界面,可供现场实时导入或直接编辑CDA文档,能快捷地在CDA规范下弹性扩展个性化结构,统一了模板规范化与个性化和实时性的矛盾;FS-HER生成的由CDA集仍属于XML,并自含加密或签名属性.结论:本技术方案有助于区域卫生跨平台互联互通的信息交换和安全保障.