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        目錄
        前 言............................................................................................................................4
        第1 章 慢病管理業(yè)務功能規(guī)范..................................................................................7
        1.1 業(yè)務功能概述.................................................................................................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 個體化行為干預指導..........................................................................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 行為干預業(yè)務流程............................................................................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 標識符 identifier...............................................................................29
        慢病管理業(yè)務信息技術(shù)規(guī)范 2008 版
        2
        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 注冊機構(gòu)標識符(RAI)registration authority identifier .............30
        2.3.18 版本標識符 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)編碼擴展編碼(J1-8).............................................................37
        2.7.3 文化程度擴展編碼(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)務信息技術(shù)規(guī)范 2008 版
        3
        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)編碼細則....................................................................................45
        3.4 應用示例.......................................................................................................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....................................................................
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