慢病管理業(yè)務(wù)信息技術(shù)規(guī)范
（2008 版）
衛(wèi)生部疾病預(yù)防控制局
中國疾病預(yù)防控制中心
二〇〇八年四月
慢病管理業(yè)務(wù)信息技術(shù)規(guī)范 2008 版
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目錄
前 言............................................................................................................................4
第1 章 慢病管理業(yè)務(wù)功能規(guī)范..................................................................................7
1.1 業(yè)務(wù)功能概述.................................................................................................7
1.1.1 人群分類..............................................................................................8
1.1.2 管理對象危險因素水平評估..............................................................8
1.1.3 個體化行為干預(yù)指導(dǎo)..........................................................................9
1.1.4 管理效果評價....................................................................................12
1.2 信息管理.......................................................................................................12
1.2.1 人群分類所需信息............................................................................12
1.2.2 管理對象危險因素水平評估所需信息............................................13
1.2.3 管理效果評價所需信息....................................................................18
1.2.4 群體信息分析....................................................................................18
1.3 業(yè)務(wù)流程.......................................................................................................18
1.3.1 人群分類流程....................................................................................18
1.3.2 慢病高危人群和患者管理流程........................................................19
1.3.3 行為干預(yù)業(yè)務(wù)流程............................................................................20
1.4 規(guī)范性引用文件...........................................................................................25
第2 章 慢病管理基本數(shù)據(jù)集....................................................................................27
2.1 適用范圍.......................................................................................................27
2.2 規(guī)范性引用文件...........................................................................................27
2.3 術(shù)語...............................................................................................................28
2.3.1 數(shù)據(jù)元 data element .........................................................................28
2.3.2 數(shù)據(jù)元概念 data element concept....................................................28
2.3.3 數(shù)據(jù)元目錄 data element dictionary ................................................28
2.3.4 數(shù)據(jù)集 Data Set................................................................................28
2.3.5 數(shù)據(jù)元名稱 data element name........................................................29
2.3.6 標(biāo)識符 identifier...............................................................................29
慢病管理業(yè)務(wù)信息技術(shù)規(guī)范 2008 版
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2.3.7 版本 version......................................................................................29
2.3.8 數(shù)據(jù)元注冊系統(tǒng) data element registry ............................................29
2.3.9 實體 entity ........................................................................................29
2.3.10 對象 object......................................................................................29
2.3.11 對象類 object class .........................................................................29
2.3.12 屬性 attribute ..................................................................................29
2.3.13 屬性值 attribute value.....................................................................30
2.3.14 定義 definition................................................................................30
2.3.15 相關(guān)環(huán)境 context............................................................................30
2.3.16 表示 representation.........................................................................30
2.3.17 注冊機(jī)構(gòu)標(biāo)識符（RAI）registration authority identifier .............30
2.3.18 版本標(biāo)識符 version identifier ........................................................30
2.4 慢病管理基本數(shù)據(jù)集數(shù)據(jù)元的提取方法...................................................30
2.5 慢病管理基本數(shù)據(jù)集元數(shù)據(jù)描述...............................................................32
2.6 慢病管理基本數(shù)據(jù)集...................................................................................32
2.6.1 管理信息類........................................................................................32
2.6.2 基本人口特征信息類........................................................................33
2.6.3 知識、態(tài)度和行為因素類................................................................33
2.6.4 體格檢查和實驗室檢測類................................................................35
2.6.5 分類分級............................................................................................36
2.7 慢病管理數(shù)據(jù)元代碼集...............................................................................37
2.7.1 居民唯一編碼（J1-1）.....................................................................37
2.7.2 職業(yè)編碼擴(kuò)展編碼（J1-8）.............................................................37
2.7.3 文化程度擴(kuò)展編碼（J1-9）.............................................................38
2.7.4 血壓知曉情況代碼（J1-10）...........................................................38
2.7.5 2 周內(nèi)是否服用降壓藥代碼（J1-11）.............................................38
2.7.6 血糖知曉情況代碼（J1-12）...........................................................39
2.7.7 糖尿病藥物治療編碼（J1-13）.......................................................39
2.7.8 現(xiàn)在吸煙者代碼（J1-14）...............................................................39
慢病管理業(yè)務(wù)信息技術(shù)規(guī)范 2008 版
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2.7.9 戒煙者代碼（J1-15）.......................................................................39
2.7.10 被動吸煙者程度代碼（J1-16）.....................................................40
2.7.11 身體活動水平代碼（J1-23）.........................................................40
2.7.12 人群分類代碼（J1-33）.................................................................40
2.7.13 高血壓危險分層代碼（J1-34）.....................................................40
2.7.14 尼古丁依賴分級代碼（J1-35）.....................................................41
第3 章 慢病管理基本數(shù)據(jù)集數(shù)據(jù)交換接口規(guī)范....................................................42
3.1 適用范圍.......................................................................................................42
3.2 規(guī)范性引用文件...........................................................................................42
3.3 數(shù)據(jù)交換接口規(guī)范.......................................................................................42
3.3.1 數(shù)據(jù)交換接口規(guī)范設(shè)計原則............................................................42
3.3.2 功能設(shè)置............................................................................................43
3.3.3 數(shù)據(jù)表示方式....................................................................................43
3.3.4 數(shù)據(jù)文件編碼方式............................................................................44
3.3.5 數(shù)據(jù)類型............................................................................................45
3.3.6 數(shù)據(jù)編碼細(xì)則....................................................................................45
3.4 應(yīng)用示例.......................................................................................................46
3.4.1 接口說明............................................................................................46
3.4.2 接口設(shè)置............................................................................................46
3.4.3 接口細(xì)則............................................................................................47
3.4.4 數(shù)據(jù)交換測試接口相關(guān)附表............................................................49
3.4.5 交換數(shù)據(jù)樣例....................................................................................56
附 錄..........................................................................................................................57
附錄1：信息采集參考用表...............................................................................57
附錄2：膳食相關(guān)指標(biāo)計算方法.......................................................................65
附錄3：群體信息統(tǒng)計分析規(guī)則及人群信息統(tǒng)計匯總參考用表...................66
附錄4：基于Web services 的數(shù)據(jù)交換技術(shù)...................................................78
附錄5：縮略語...................................................................................................81
慢病管理業(yè)務(wù)信息技術(shù)規(guī)范 2008 版
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前言
近年來，隨著社會經(jīng)濟(jì)的快速發(fā)展、人民生活水平的迅速提高及生活方式的
巨大轉(zhuǎn)變，我國人群的主要疾病模式及死因構(gòu)成已由原來以傳染性疾病和營養(yǎng)缺
乏病為主，轉(zhuǎn)變?yōu)橐月苑莻魅拘约膊。ㄒ韵潞喎Q慢病）為主，以心血管病（包
括高血壓、冠心病、中風(fēng)等）、癌癥、糖尿病、慢性阻塞性肺部疾病等為代表的
慢病的發(fā)病、死亡以及相關(guān)危險因素的流行日益上升。慢病正在嚴(yán)重威脅我國人
民的健康和生命，并給個人、家庭和社會帶來巨大的經(jīng)濟(jì)損失和負(fù)擔(dān)。 |
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