Publication: Interoperabilidad semántica y normalización de la historia clínica electrónica: modelo de producción de activos semánticos basados en estándares
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Publication Date
2016-03-30
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Salvador Oliván, José Antonio
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Universidad Complutense de Madrid
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Abstract
Uno de los grandes desafíos de nuestro Sistema Nacional de Salud (SNS) es disponer de una historia clínica electrónica interoperable. En la actualidad, los sistemas de información clínica son infraestructuras aisladas unas de otras, que no interoperan entre sí. Este hecho, de especial relevancia, viene a manifestarse de forma evidente cuando un ciudadano se desplaza fuera de su centro y nivel asistencial habitual o fuera de su lugar de residencia u origen y requiere asistencia sanitaria. En tal situación, podemos observar que nuestros sistemas de información no tienen la “capacidad de comunicarse”; la información relevante para la atención de la salud de los pacientes no se encuentra disponible y el profesional sanitario que tiene que atenderlos, no puede ejercer su labor con todas las garantías y el conocimiento necesario. Esta realidad puede repercutir de una forma considerable en la calidad asistencial y en la seguridad de los pacientes. La lógica asistencial, los derechos de los pacientes y usuarios, la necesidad y responsabilidad de los profesionales y las obligaciones legales, son razones ineludibles para afrontar este reto, donde la interoperabilidad entre los sistemas es un requisito obligatorio. Pero para que la interoperabilidad sea posible hay que atender a diferentes factores: organizacionales, legales, técnicos, sintácticos y semánticos. Dentro de estos factores, la interoperabilidad semántica tiene como finalidad asegurar que el significado preciso de la información que se intercambia, pueda ser comprendido por cualquier sistema o aplicación no desarrollado inicialmente para tal fin. Este nivel de interoperabilidad, sin duda alguna, resulta ser el nivel más complejo y, alcanzarlo, requiere de un establecimiento de acuerdos entre los diferentes agentes del SNS sobre la forma de representar, describir y contextualizar la información a intercambiar. Estas acciones de consenso deben atender a políticas de normalización, con objeto de proveer un marco común de actuación basado en estándares que faciliten un intercambio eficaz de la información y su integración en los diferentes sistemas...
One of the great challenges of our National Health System (NHS) is to have an interoperable electronic health record. Currently, clinical information systems are isolated from each other infrastructures that dońt interoperable together. That fact, of particular importance, comes to manifest itself obviously when a citizen moves outside his health Centre and usual care level or outside their place of residence or origin and requires health care. In this situation, we can see that our information systems have not the "ability to communicate"; the information relevant to the health care of patients isńt available and the health professional who has to serve them cańt perform their work with all the guarantees and the necessary knowledge. This reality can affect a significant way the quality of care and safety of patients. The logic of health care, rights of patients' and users, need and responsibility of professionals and legal obligations are compelling reasons to deal with this scenario, where interoperability between different systems is a mandatory requirement. But in order that interoperability can to be possible we have to engage to different factors: organizational, legal, technical, syntactic and semantic. Within these factors, semantic interoperability is intended to ensure that the accurate meaning of the information exchanged can be understood by any system or application not initially developed for this purpose. This level of interoperability, doubtless, is the most complex level and achieve it requires establishment of agreements between the different agents of SNS regarding how to represent, describe and contextualize the information to exchanged. These actions by consensus have to meet standardization policies for the purpose to provide a common framework for action based on standards to facilitate the efficient exchange of information and integration in different systems...
One of the great challenges of our National Health System (NHS) is to have an interoperable electronic health record. Currently, clinical information systems are isolated from each other infrastructures that dońt interoperable together. That fact, of particular importance, comes to manifest itself obviously when a citizen moves outside his health Centre and usual care level or outside their place of residence or origin and requires health care. In this situation, we can see that our information systems have not the "ability to communicate"; the information relevant to the health care of patients isńt available and the health professional who has to serve them cańt perform their work with all the guarantees and the necessary knowledge. This reality can affect a significant way the quality of care and safety of patients. The logic of health care, rights of patients' and users, need and responsibility of professionals and legal obligations are compelling reasons to deal with this scenario, where interoperability between different systems is a mandatory requirement. But in order that interoperability can to be possible we have to engage to different factors: organizational, legal, technical, syntactic and semantic. Within these factors, semantic interoperability is intended to ensure that the accurate meaning of the information exchanged can be understood by any system or application not initially developed for this purpose. This level of interoperability, doubtless, is the most complex level and achieve it requires establishment of agreements between the different agents of SNS regarding how to represent, describe and contextualize the information to exchanged. These actions by consensus have to meet standardization policies for the purpose to provide a common framework for action based on standards to facilitate the efficient exchange of information and integration in different systems...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Ciencias de la Documentación, Departamento de Biblioteconomía y Documentación, leída el 27-11-2015