查詢結果分析
來源資料
頁籤選單縮合
題 名 | 電子病歷核心資料格式比較之研究=The Study of Core Data Set of Electronic Health Record in Taiwan |
---|---|
作 者 | 溫信財; 簡文山; 徐建業; 陳星助; | 書刊名 | 病歷管理期刊 |
卷 期 | 5:2 民95.04 |
頁 次 | 頁1-14 |
分類號 | 419.26 |
關鍵詞 | 電子病歷; 核心資料格式; 持續照護記錄; 健康資訊交換第七層協定; EHR; Core data set; The continuity of care record; CCR; HL7; |
語 文 | 中文(Chinese) |
中文摘要 | 內資訊環境雖然以多元化發展與快速成長,但病歷資料交換卻往往受限於異質性系統或資料庫而無法溝通或整合,若能採用共同之資料交換標準將有助於介面的統一,並降低資料交換的複雜度,而國際間巳廣泛採用HL7/XML做為醫療資訊交換傳輸標準,但衛生署目前尚未制定出一套可供大家依循之核心資料格式,所以在交換的過程中必須依照其交換的對象與內容進行特定的調整。 美國American Society for Testing and Materials (ASTM)於2003年發展了持續性照護記錄(The Continuity of Care Record, CCR),而國內「台灣健康資訊交換第七層協定協會」同年制訂了電子病歷之HL7/XML 轉診、轉檢(代檢)規範(草案),行政院衛生署亦於2005年委託「台灣醫學資訊學會」執行「制定及推動電子病歷內容基本格式」計畫。本研究針對以上「電子病歷核心資料格式」及國內特有之健保IC卡,以文件身分認定格式、病人身分認定格式、病人健康狀況格式及其他病人核心資料格式四部份列出逐一比對,研究發現: ASTM持續性照護記錄格式中,對轉出、轉入保險醫事服務機構及病人之URI/URL、Email地址,設有特定欄位,利於直接點選及聯結查詢,另 ASTM加列問題聯結(Problem Link)、評論(comment)、參考資料(reference)、資料來源(Data resource)等資料,對於醫療專業人員及醫病之間的互動,提供更方便的資料查閱和討論。在編碼標準方面,ASTM持續性照護記錄使用之疾病診斷的代碼有 CPT,ICD-9-CM,ICD-10, SNOMED等,藥品、藥物治療編碼則使用NDC; RxNorm,可做為國內的參考。台灣健康資訊交換第七層協定協會「轉診、轉檢(代檢)規範」、台灣醫學資訊學會「電子病歷內容基本格式」和國防部之「軍官健檢資料交換格式」均為國內轉診、轉檢、健檢之交換標準,若為便利國內醫療院所遵循,衛生署應協調訂定統一的基本格式。 可見的未來,電子病歷將成為醫療專業人員診治病患的重要依據,而「電子病歷核心資料格式」推行之成敗,可視為一試金石,在確保資訊的機密、隱私性的同時,醫療提供者若能有效利用數位化資訊取代紙本病歷,以整合分散於各醫療機構之病歷資料,將能有效提昇服務品質並減少資源浪費,大幅縮減儲存空間,使電子病歷之效益能夠逐步實現。 |
英文摘要 | In spite of the variety of infrastructures and rapid growth of information systems in Taiwan, there are no standadized interfaces or databases for exchanging medical information among hospitals which have increased the difficulty of comunication and intergration for patient for patient referral. To develop the core data set can help solve the present situation, and decrease the complexity of electronic data inter-change. HL7/XML has already adopted by international nations as a medical information exchange standard. However, Department of Health (DOH) has not developed a core data set for health care organizations to follow, so the contents and entities were needed adjusted during each process of healthcare information exchange. American Society for Testing and Materials (ASTM) developed "The Continuity of Care Record (CCR)" in 2003. Taiwan HL7 also developed "draft of HL7/XML referral data set" in the same year. Taiwan Medical Informatics Association was delegated by DOH to develop "HER data sets" in 2005. We compared those core data sets mentioned above and smart card issued by Taiwan National Health Insurance in four parts: document identifying information, patient identifying information, patient health status and the other information. The results were: Further information from referral, accepted health organizations and patients can be caught through the direct link to certain fields like URI/URL, Email address designed in CCR. The fields of problem link, comment, reference, data resource of CCR can help medical professionals consult and discuss with each other and interact with the patients. Regarding the coding standards, disease codes like CRT, ICD-9-CM,ICD-10, SNOMED and drug codes like NDC, RxNorm used in CCR could be our references. The purpose of Taiwan HL7's "draft of HL7/XML referral data set", Taiwan Medical Informatics Association's "HER dat sets" and Ministry of Defense's "Officers health examination data set" all are designed for referral data exchange, so the integration of these data sets should be coordinate by DOH for hospitals and clinics compliance. EHR will be one of the important sources for medical professionals to deliver the patient care in the near future. Therefore, the success or failure of core data set will be a touch stone for HER. If health providers can offer the computerized information in stead of paper records without the threat of security and privacy, it will enhance the quality of care and decrease storing space and the medical cost significantly. The information among different health care organizations could be integrated and advantages of HER could be accomplished gradually. |
本系統中英文摘要資訊取自各篇刊載內容。