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目的:构建医学观察数据的语义模型和元数据框架,为医学观察数据的规范化表达和信息共享提供基础。方法:参照国际标准化组织ISO有关信息技术标准及SNOMED CT、LOINC等医学领域相关国际、国家标准,定义医学观察项目的属性和元数据规范,采用UML建模。结果:医学观察数据的语义模型将医学观察逐步分解,形成类的树状层次结构。第一层可分为体格检查、实验室检查等4个子类;类包含一组特定的属性;属性以数据元的形式,通过元数据进行描述;一组特定属性(数据元)的实例即为规范化的医学观察数据。结论:语义模型和元数据框架规范下的医学观察数据具有完整、清晰的语义和统一的格式。构建元数据框架有利于医学观察数据的标准化,可作为国家卫生数据字典的研发策略。
OBJECTIVE: To construct the semantic model and metadata framework of medical observation data and provide the basis for the standardization and information sharing of medical observation data. Methods: According to the International Organization for Standardization ISO standard about information technology and SNOMED CT, LOINC and other medical fields related international and national standards, the definition of medical observation project attributes and metadata specifications, the use of UML modeling. Results: The semantic model of medical observations gradually decomposed medical observation to form a dendritic hierarchy of classes. The first layer can be divided into four subcategories: physical examination, laboratory examination, etc. The class contains a specific set of attributes. The attributes are described in the form of data elements by metadata. An instance of a specific set of attributes (data elements) is Standardized medical observation data. Conclusion: The medical observation data under the semantic model and the metadata framework have a complete and clear semantic and uniform format. Building a metadata framework facilitates the standardization of medical observations and can be used as a research and development strategy for national health data dictionaries.