摘要
电子病历以语言数据为主体,极少部分以语言数据为阐释工具,可被称为病历语言数据。病历语言数据从依靠手写生成,到数字时代依靠信息系统电写生成,主要呈现出以下时代特征:媒介物从书面语言拓展至机器语言;使用拉丁语、图形等多类符号来建构新意义,超语化趋势进一步增强;保管主体从患者转移拓展至医院。当前病历语言数据面临以下现实挑战:数据生成规则面临“黑箱”、数据共享范围存在“壁垒”、数据开发应用场景的“窄化”。为激发病历语言数据的潜力,应从以下几方面积极探索对策,助力电子病历数据的善治:以处方代码规则普及破除规则“黑箱”,以区块链技术赋能电子病历数据共享,以激发电子病历数据“乘数效应”助力健康中国建设。
Abstract
Electronic Medical Records (EMRs), primarily composed of language data with a smaller portion serving as interpretive tool, can be conceptualized as medical record language data. The transformation of these records—from handwritten documentation to electronic generation via information systems in the digital era—reflects several distinct characteristics: an expansion of medium from written language to machine-readable language; the incorporation of multimodal symbols such as Latin scripts and graphic elements to construct new layers of meanings, thereby intensifying translanguaging trends; and a shift of custodianship from patients to hospitals. However, medical record language data face several practical challenges: the “black box” nature of data generation rules, restrictive “barriers” in data-sharing framework, and the “narrowing” scenarios of data development and application. To fully realize the potential of medical record language data and promote their effective governance, the following strategies are proposed: the widespread adoption of prescription coding rules to enhance transparency in rule generation, the utilization of blockchain technology to facilitate secure and efficient data sharing, and the activation of a “multiplier effect” through innovative application to contribute to the construction of a Healthy China.
关键词
病历语言数据 /
时代特征 /
现实问题 /
治理路径
Key words
medical record language data /
era characteristics /
current issues /
governance path
梁京涛, 张志平.
数字时代病历语言数据的特征、挑战与治理[J]. 语言战略研究. 2025, 10(4): 44-53 https://doi.org/10.19689/j.cnki.cn10-1361/h.20250405
Liang Jingtao and Zhang Zhiping.
Characteristics, Challenges and Governance of Medical Record Language Data in the Digital Era[J]. Chinese Journal of Language Policy and Planning. 2025, 10(4): 44-53 https://doi.org/10.19689/j.cnki.cn10-1361/h.20250405
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基金
国家语委“十四五”科研规划2021年度重大项目“我国语言文字治理体系现状及创新研究”(ZDA145‒1),河北省高等学校科学研究项目2025年度青年项目“文化视域下《黄帝内经》数据建设与应用研究”(QN2025499)。