工作组: Orders and Observations & Clinical Genomics

标准状态: Informative

10.0 辅助诊断组件

10.0.1 简介

辅助诊断组件提供了FHIR中涉及临床诊断的医嘱和报告的相关内容与指南，包括实验室检验、影像检查和基因检测。

10.0.2 索引

辅助诊断组件包含了下列资源:

辅助诊断资源及其关系如下所示。箭头表示资源之间引用的方向（例如，诊断报告资源DiagnosticReport引用服务申请资源ServiceRequest）。 欲了解活动协作的相关信息，如辅助诊断的申请与完成，请参阅工作流组件。

实施说明：有关如何使用辅助诊断资源进行临床基因组报告和分析的更多信息，请参阅基因组学实施指南。

10.0.3 安全与隐私

辅助诊断资源通常代表特定于患者的数据，因此容易受到数据破坏的影响。在搜索和获取此信息时，必须制定必要的隐私和安全规定。 有关更一般的注意事项，请参阅安全与隐私组件。

10.0.4 常见用例

辅助诊断资源通常用于计划、推荐、下达和报告临床诊断：

• 计划一个诊断测试，见照护计划示例
• 诊断意见，如通过临床决策支持工具给出建议的诊断。有关更多信息，请参阅临床推理组件。
• 下达检验申请，如血脂全项检测
• 报告实验室检验结果，如 血脂全项报告
• 下达影像检查，如CT 检查
• 报告影像检查结果，如 CT 报告
• 下达基因检测申请，如 基因突变分析
• 报告基因检测结果，如 HLA（人类白细胞抗原）基因分析结果

有很多方法可以独立地使用这些资源。特别是观测资源，在卫生健康领域中，许多测量和事件都是围绕着它来进行的，观测资源还常用于辅助诊断医嘱和报告之外的场境。

• 记录生命体征，如 体温
• 记录患者社会史的其他观测结果，如吸烟史
• 记录患者的其他特征，如妊娠状态（注：也可用病症情况资源Condition来表示）
• 记录临床评估工具评分，如。Apgar 评分.
• 识别和描述 标本 或 身体部位

10.0.5 相关的资源与组件

在管理组件中可以找到代表患者基本信息和临床就诊信息的资源。 其他代表卫生健康提供者在患者就诊过程中产生的核心临床信息的资源在 临床摘要组件和药物组件中详细介绍。

10.0.6 开发路线图

• The Observation and Diagnostic Report resources have been tested and used in production tooling and as such have reached a maturity level FMM=4 where changes become less likely and require implementer community approval. Future work will focus on developing core profiles and clarifying use cases and boundaries and providing more domain specific examples. We anticipate Observation and Diagnostic Report reaching normative status by the end of this cycle.
• The ImagingStudy resource has had some limited testing and use. Further use of this resource in production tooling is needed for it to reach a more stable FMM level.
• The ServiceRequest resources has undergone substantial changes since DSTU2. Foremost of which is the merging of DSTU2 DiagnosticOrder and ServiceRequest into a single resource. In addition, as a result of the addition of FHIR workflow for STU3, its structure and content have been updated to align with the general FHIR workflow "request" pattern. Because of these, it remains a relatively immature resource. No more sweeping changes to its structure are expected. However, its scope and boundaries vis a vis other resources will be the topic of future workgroup efforts. We anticipate its broad use by implementers and that it will mature as a resource throughout the upcoming cycle.
• The Specimen resource will be the focus of work group efforts for the upcoming cycle. A new SpecimenDefinition resource is planned for describing specimen types vs specimen instances and will take over some of the Specimen resource's current scope. We expect to see more widespread use of this resource and future updates to its FMM level
• The MolecularSequence resource remains draft and we expect to see more widespread use of this resource and future updates to its FMM level
• The BodyStructure resource is an immature resource with a FMM level of 1. To date there has been little implementation feedback.
• The Media resource is the newest member to the Diagnostics module having undergone substantial scope and structural changes to create a specialized observation resource focused on digital media such as images and audio files. Future work will focus on developing core profiles and providing more domain specific examples.