Развитие классификации клинических диагнозов в медицинских информационных системах

Бизнес-информатика. 2015. Т. 2. № 32. С. 39–47.

Neznanov A., Старичкова Ю. В.

Medical information systems are a separate class of information systems, specifically developed to improve the efficiency of health care. The purpose of the implementation of health information systems in clinical centers – a comprehensive solution of problems in information support of the delivery of health services, with emphasis on the formalization of business processes in the field of health care, the collection and secure storage of patients personal data, optimal interface solutions for clinicians and nurses, special managing of medications. The main role of the users of medical information system – heads of clinical departments, doctors and nurses. The paper is dedicated to the study of the set of coupled problems with clinical (bedside) diagnoses in medical information systems: effective input, validity and completeness checking, analysis of clinical data taking diagnoses into account. It is common in current generation of medical information systems to input diagnosis as an unstructured text field in natural language with additional selection of some classes from International Classification of Diseases or other universal disease classification. There are standardized guidelines and local conventions for input and change diagnosis text but, as a rule, these conventions are not formalized in medical information systems that leads to above-listed problems. We suggest an effective and easy variant of formalization of extended clinical diagnosis in oncology. The paper proposes a variant of formalizing additional classification of clinical diagnoses, both simple and effective, and the prototype description templates and schemes to enhance the diagnosis for certain diseases in the format JSON, optimization interface standard field "diagnosis" in medical information systems. This variant was introduced as software pilot project in the field of pediatric oncology.

Keywords: medical information systems, international classification of diseases, clinical diagnosis, diagnosis constructor, медицинская информационная система, международная классификация болезней, клинический диагноз, конструктор диагнозов