電子カルテデータ二次利用の現状と課題

抄録

In hospitals that introduced electronic medical records (EMRs), the data on EMR database was transferred to the analytical database and has been used for the analysis such as the clinical research. As the standardization of the medical data by the Ministry of Health, Labour and Welfare (SS-MIX:Standard Structured-Medical Information eXchange) has advanced, the clinical research using not only the data from single facility but also the data from plural facilities can be carried out. On the other hand, the structure of the EMR database is not suitable for clinical research, because the EMR database was designed only for the duties purpose. For this reason, the clinical study only with the data accumulated in the EMR database passively is limited. It is necessary to accumulate the data actively. For example, the usage of the template with required items for clinical research is helpful. The Health Insurance Claims (receipt) data and the Diagnosis Procedure Combination (DPC) data are the clinical data that standardization has been achieved. However, these data were designed for medical service fees request use and does not have the result information. For the secondary use of clinical data, it is necessary to capture the characteristic of EMR data, receipt data and DPC data, and to select which data should be used. The clinical research using EMR data is focused on observational research. The high quality findings could be achieved by handling the loss data appropriately and by adjusting the patient background factor. In this report, we discuss the outline of the current situation and issues of the secondary use of electronic medical record data.