ISO 27269:2021 健康信息学 国际患者摘要

标准编号：ISO 27269:2021

中文名称：健康信息学 国际患者摘要

英文名称：Health informatics — International patient summary

发布日期：2021-04

标准范围

本文档定义了患者摘要文档的核心数据集，该文档支持患者护理的连续性和医疗保健的协调。它专门用于支持“计划外跨境护理”的“用例”场景，旨在成为国际患者摘要（IPS）。虽然数据集是最小且非穷尽的，但它提供了一组健壮、定义良好的核心数据项。对该用例的密切关注也使IPS能够用于计划性护理。这意味着在地方和国家范围内，该数据集可以支持计划外和计划内护理，从而提高其效用和价值。它使用欧洲eHN指南作为患者总结要求的初始来源，然后考虑其他国际患者总结项目，以提供具有全球应用的可互操作数据集规范。本文档提供了患者总结的抽象定义，从中可以实现派生模型。因此，由于其性质，读者应意识到，遵守本文件并不意味着自动技术互操作性；本文件实现的这一结果可以通过符合相关技术规范和实施指南中所示的标准来实现。本文件不包括数据输入、数据收集、数据汇总、后续数据展示、同化或汇总的工作流程。此外，本文件不包括汇总行为本身，即导致数据汇总工作流的智力/技能/能力。它不是一个与应用层下面的各个技术层有关的实现指南。具体管辖问题的实施指南，例如指令、术语、格式等，相关技术规范中规定了一个示例。特别是，各种编码方案、附加结构和术语的表示不属于本文件的一部分。参考文献[3]阐述了术语及其约束。药品标识标准（缩写为IDMP）是与本文件相关的药物总结的建议目标，但在IDMP全面实施之前，本IPS标准目前不能坚持使用，并承认在IDMP成为规范之前，可能需要临时方案。

This document defines the core data set for a patient summary document that supports continuity of care for a person and coordination of their healthcare. It is specifically aimed at supporting the use case’ scenario for ‘unplanned, cross border care’ and is intended to be an international patient summary (IPS). Whilst the data set is minimal and non-exhaustive, it provides a robust, well-defined core set of data items. The tight focus on this use case also enables the IPS to be used in planned care. This means that both unplanned and planned care can be supported by this data set within local and national contexts, thereby increasing its utility and value.It uses the European Guideline from the eHN as the initial source for the patient summary requirements, then takes into consideration other international patient summary projects to provide an interoperable data set specification that has global application.This document provides an abstract definition of a Patient Summary from which derived models are implementable. Due to its nature therefore, readers should be aware that the compliance with this document does not imply automatic technical interoperability; this result, enabled by this document, can be reached with the conformity to standards indicated in the associated technical specification and implementation guides.This document does not cover the workflow processes of data entry, data collection, data summarization, subsequent data presentation, assimilation, or aggregation. Furthermore, this document does not cover the summarization act itself, i.e. the intelligence/skill/competence that results in the data summarization workflow.It is not an implementation guide that is concerned with the various technical layers beneath the application layer. Implementation guidance for specifically jurisdictional concerns, e.g. Directives, terminologies, formats, etc., an example is specified in the associated Technical Specification^[3].In particular, representation by various coding schemes, additional structures and terminologies are not part of this document. Terminology and its binding are addressed in Reference [3]. The Identification of Medicinal Products standards (abbreviated to IDMP) are the recommended target for the Medication Summary related to this document but, prior to IDMP’s full implementation in practice, this IPS standard cannot insist in its use at this point in time and recognizes that interim schemes might be necessary until IDMP becomes established as a norm.

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