摘要
目的通过试验性地进行白求恩国际和平医院核医学科实验室检验项目与观测指标标识符逻辑命名与编码系统(Log-icalObservationIdentifierNamesandCodes,LOINC)标准术语的对照,探索中文本地临床观测指标与LOINC标准术语对照的原则与方法。方法核医学科实验室检验项目来自本院实验室信息系统(LIS)的检验项目字典;中文LOINC数据库依据2.14版英文LOINC数据库编制;基于VisualBasic的自编辅助对照程序用来搜索相关LOINC术语,并将合适的LOINC代码对照至本地检验项目。结果完成了核医学科实验室检验项目与LOINC数据库的计算机辅助对照,并且获得核医学科实验室检验项目本地术语与LOINC术语的对照关系表。结论结果表明,采用中文LOINC数据库作为英文LOINC数据库的语言接口,借助计算机辅助对照程序,能够有效地将检验项目字典中的本地术语与LOINC术语关联对照起来。该研究不失为一次有益的尝试,其实践经验、指导原则和实现方法,在一定程度上将为今后实现我国医院、疾病预防与控制中心等医疗卫生机构信息系统中实验室及临床观测指标命名与编码的标准化奠定工作基础。
Objective To perform a pilot mapping project to standardize the local nuclear medicine laboratory test names to Logical Observation Identifier Names and Codes （LOINC） at the Bethune International Peace Hospital, and explore the guidelines and methodology to map local clinical observations in Chinese to standard LOINC terms. Methods The local terms were extracted from the Laboratory Test Dictionary of the Laboratory Information System（LIS）at the hospital.The Chinese LOINC Database was derived from English LOINC Database （version 2.14）. An automated mapping tool based on Visual Basic was developed in-house to search related LOINC terms and assign relevant LOINC codes manually to the local tests. Results Achieved was the mapping of the local nuclear medicine laboratory tests to LOINC Terms. The results were achieved in a form of a database table containing the cross-referencing relationship between the codes of the local tests and LOINC Terms. Conclusions These results suggest that the local nuclear medicine laboratory tests can be effectively mapped to LOINC terms with the aid of the Chinese LOINC Database, as an linguistic interface of the original English LOINC Database, and the computer-aided mapping program; thereby the experience, guidelines and methodology will serve as a beneficial tentative model for future standardization practice of names and codes for laboratory tests and clinical observations in various information systems at various healthcare institutions, such as hospitals and centers of disease prevention and control in China.
关键词
医学信息学
卫生信息标准化
受控词表
临床观测指标
核医学
检验项目
medical informatics
health information standardization
controlled vocabulary
clinical observations
nuclear medicine
laboratory tests
