A Standard Information Model for General Dental Records

一般牙科记录的标准信息模型

• 批准号: 8105075
• 负责人: TITUS K. SCHLEYER
• 金额: $ 21.82万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-07-06 至 2013-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8105075
• 关键词: Adopted; Adoption; Agreement; Algorithms; American; American Dental Association; Arbitration; Architecture; Back; Clinical; Clinical Data; Clinical Research; Computer software; Computerized Patient Records; Computers; Consensus; Data; Data Collection; Data Element; Data Set; Databases; Dental; Dental Care; Dental Informatics; Dental Records; Dentistry; Dentists; Electronic Health Record; Electronics; Elements; Ensure; Environment; Epidemiologic Studies; Epidemiology; Evaluation Studies; Future; General Practices; Goals; Health; Health Personnel; Health Services; Information Technology; Institutes; Marketing; Medical Care Team; Methodology; Modeling; Outcome; Outcomes Research; Paper; Participant; Patient Care; Patients; Physicians; Practice Management; Process; Publishing; Recommendation; Records; Reference Standards; Research; Research Infrastructure; Research Personnel; Resources; Retrieval; Sampling; Semantics; Source; Structure; System; Time; Translating; United States Agency for Healthcare Research and Quality; United States National Library of Medicine; Vendor; Vocabulary Test; Work; base; clinical care; clinical decision-making; data exchange; database design; design; electronic structure; evidence base; improved; information model; interest; lexical; member; practice-based research network; prevent; public health relevance; tool; web based interface

DESCRIPTION (provided by applicant): Electronic dental records (EDR) for general dentists vary widely with regard to the content and structure of the information they contain. At a time when electronic patient records are becoming increasingly essential to delivering high-quality patient care, the "Tower of Babel" that today's EDRs represent is an increasingly significant drawback. Not only does this situation currently prevent computational approaches for supporting patient care (for instance through automatic, patient-specific retrieval of evidence-based dental resources), it also will significantly hamper the exchange of patient information within the emerging National Health Information Infrastructure. Our research indicates that incomplete and fragmented EDRs force many practitioners to maintain both paper-and computer-based patient records, which situation potentially contributes to the very limited adoption of completely electronic patient records by general dentists. The objective of this project is to develop a comprehensive, consensus-based Electronic Dental Record Information Model (EDRIM) as a reference standard for the content and structure of EDRs. In Specific Aim 1, we will iterative refine the previously compiled candidate list of data elements to develop a validated, prioritized, comprehensive list of data elements for documenting patient care in general dentistry through a Delphi approach and transform this refined list of data elements into a formal information model. In Specific Aim 2, we will conduct a formal evaluation study to access the patient information coverage offered by the EDRIM developed in Specific Aim 1 by adopting a similar methodology used in the Large Scale Vocabulary Test conducted by National Library of Medicine and the Agency for Health Care Policy and Research. The goal of our project is to develop a consensus-based, comprehensive dental information model that covers at least 70- 80% of the clinical concepts recorded by general dentists in daily practice. The proposed information model will have multiple benefits. First, EDR developers will have available a ready-made template for patient information that can easily be translated into a physical database design. Second, practitioners will benefit from EDRs that represent patient information more comprehensively than is currently the case. Third, future data exchange among dentists and their colleagues, as well as other members of the healthcare team, will be facilitated by a common data infrastructure. Last, rich and comprehensive EDRs will provide a significant opportunity to support clinical, epidemiological and health outcomes research. We expect the model to have far-reaching and beneficial impact on how patient information is represented and stored, how EDRs are designed and, ultimately, how electronic systems are used in support of clinical care and research. PUBLIC HEALTH RELEVANCE: The objective of this project is to develop a comprehensive, consensus-based Electronic Dental Record Information Model (EDRIM) as a reference standard for the content and structure of electronic dental records (EDRs).

描述（申请人提供）：普通牙医的电子牙科记录（EDR）在其包含的信息的内容和结构方面差异很大。在电子患者记录对提供高质量的患者护理至关重要的时候，今天的EDRS代表的“ Babel塔”是一个越来越重要的缺点。当前，这种情况不仅可以阻止支持患者护理的计算方法（例如，通过自动，特定于患者的循证牙科资源检索），还将大大阻碍新兴国家健康信息基础设施中的患者信息的交换。我们的研究表明，不完整和零散的EDRS迫使许多从业人员保持基于纸张和计算机的患者记录，这种情况有可能导致一般牙医对完全电子患者记录的采用非常有限。该项目的目的是开发一个基于共识的电子牙科记录信息模型（EDRIM），作为EDRS内容和结构的参考标准。在特定目标1中，我们将迭代完善先前编制的数据元素列表，以开发经过验证的，优先的，全面的数据元素列表，以通过Delphi方法记录一般牙科患者护理的数据元素，并将此精制的数据元素列表转换为正式信息模型。在特定目标2中，我们将进行正式的评估研究，以访问特定目标1中开发的Edrim提供的患者信息覆盖范围，该方法采用了国家医学图书馆和医疗保健政策和研究机构进行的大规模词汇测试中使用的类似方法。我们项目的目的是开发一个基于共识的，全面的牙科信息模型，涵盖一般牙医在日常实践中记录的临床概念的至少70-80％。提出的信息模型将具有多个好处。首先，EDR开发人员将提供一个现成的模板，以获取可以轻松转化为物理数据库设计的患者信息。其次，从业人员将从EDR中受益，而EDR比目前更全面地代表患者信息。第三，牙医及其同事以及医疗团队的其他成员之间的未来数据交流将由共同的数据基础设施促进。最后，丰富而全面的EDR将为支持临床，流行病学和健康成果研究提供重要的机会。我们希望该模型对如何代表和存储患者信息，EDRS的设计以及最终如何使用电子系统来支持临床护理和研究。 公共卫生相关性：该项目的目的是开发一个基于共识的电子牙科记录信息模型（EDRIM）作为电子牙科记录（EDRS）内容和结构的参考标准。