整合多套放射腫瘤與醫療資訊系統以實現病歷電子化

INTEGRATION OF MULTIPLE RADIATION ONCOLOGY AND HEALTH INFORMATION SYSTEMS TO IMPLEMENT COMPUTERIZATION OF MEDICAL RECORDS

林思廷(Shih-Ting Lin) ； 王帝皓(Ti-Hao Wang) ； 蕭正英(Cheng-Ying Shiau) ； 劉裕明(Yu-Ming Liu) ； 陳曾基(Tzeng-Ji Chen) ； 胡育文(Yu-Wen Hu)

《放射治療與腫瘤學》 25卷1期 (2018/03) Pp. 21-32

https://doi.org/10.6316/TRO/201825(1)21

摘要

目的：以取代紙本病歷為目標，建構整合式放射治療電子病歷系統（Radiation Therapy Electronic Medical Record，RTEMR），並分別與本科來自三家供應商、高異質性的三套放射腫瘤資訊系統（Radiation Oncology Information Systems, ROIS）：ARIA/VARiS、MOSAIQ、Tomotherapy連結，以即時取得治療紀錄；亦與全院醫療資訊系統交流資料，可取得病人基本資料與最新門住院動向，亦提供最新治療進度供其他部門參考，不受治療設備廠牌的限制。材料與方法：對ROIS之資料庫進行剖析，並召開會議，討論各組工作人員需求後，繼承本科舊有之單一使用者、單機版之管理軟體，進行開發。RTEMR使用網頁介面，免安裝，易更新，可跨平台使用。即時治療進度的查詢，可同時以治療計畫參考點之累積劑量、及醫師標靶部位處方等兩種方式呈現。結果：RTEMR可依登入身分顯示不同功能，另有病人自助報到系統，工作人員可掌握病人動態。醫師與治療機病人名單可顯示病人是否已報到、已治療，以及交班注意事項。放射治療摘要自動完成以及產出各式行政報表，亦為RTEMR的重要應用。結論：RTEMR已明顯增加放射治療部門的作業效率，降低疏漏的風險；未來與全院醫療資訊系統與癌症資訊系統更緊密的整合，將更顯著提升放射治療品質。

關鍵字

放射腫瘤資訊系統 ； 電子病歷 ； 治療品質與安全

並列摘要

Purpose: To replace paper medical records, we constructed an integrated Radiation Therapy Electronic Medical Record (RTEMR) system, and connected it to heterogeneous Radiation Oncology Information Systems (ROIS) from three independent vendors in our department - ARIA/VARiS, MOSAIQ and Tomotherapy - to acquire real-time treatment records. In addition, data exchange between RTEMR and Health Information System (HIS) allowed RTEMR to get patients' basic data and inpatient/outpatient status from HIS, and medical personnel in other departments can access the most updated information about radiotherapy progress, regardless of treatment unit. Materials and Methods: After analyzing the database structure of ROIS, and meeting with multidisciplinary staff in our department, RTEMR underwent development, as a successor of our original single-user standalone management software. The web-based interface of RTEMR has several advantages: installation-free, ease-of-update and cross-platform. The system provides the real-time treatment progress in terms of cumulative dose and fractions to plans' reference points or physician prescribed target volume. Results: RTEMR can display different functions according to user's login identity. Self-serve checkin system can help our staff to keep track of patients' current state. Patient lists for doctors and treatment machine can show check-in status, treatment status, and special notes. Other important applications of RTEMR are auto-generation of radiation therapy treatment summary and several routine reports for administrative purpose. Conclusion: RTEMR can increase the efficiency and decrease the risk of near miss in clinical work. Further integration with health information system and cancer information system will improve the quality of radiation therapy.

並列關鍵字

Radiation Oncology Information Systems (ROIS) ； Electronic medical records ； Treatment quality and safety