可交換性電子病歷之完整性探討

梁德昭 ； 梁煌達

《電腦稽核》 25期 (2012/01) Pp. 16-29

https://doi.org/10.30007/JICTA.201201.0002

摘要

病歷是就醫者終其一生的健康照護記錄，回歸病歷的真正擁有者（Owner）應該是病患本身，病歷資料的完整記錄，能保障就醫者的權益。由於各醫療機構所公告完成的電子病歷，在臺灣地區所推動乃是屬於經過選擇的資料及業務，非真正具有可交換性電子病歷之完整記錄。透過完整性的要件探討，類分出部分完整性、局部完整性與全部完整性病歷記錄。將所有局部完整性病歷記錄，完整彙整起來，成為理想中全面完整性的病歷記錄。吾人以為，唯有能被完整彙整的電子病歷才能發揮出電子病歷可交換的最大效用。目前醫療資訊系統設計以管理與業務上的考量為主，並非以病患為中心的系統架構。因此，要實現完整性的方法，當病患的病歷記錄產生到醫療資訊系統的同時，也要另外一併產生具有可交換格式的記錄到電子病歷資料庫，且這個檔案記錄僅能被添加，不能被刪除或修改，將病患接受的所有醫療處置鉅細靡遺完整記錄，如此才是以病患為中心的完整性電子病歷記錄。唯有具完整性的可交換性的電子病歷才能確保病歷資料的可用性與可靠性。而具有全面完整性的電子病歷將提供病患更及時的醫療照顧及避免醫療資源的重複浪費，同時也是醫病糾紛仲裁的參考依據。

關鍵字

電子病歷 ； 全部完整性 ； 醫病關係

並列摘要

Medical Record is kind of documents which records a patient's health care history. To protect the rights of patient who is the owner of his/her Medical Records, the integrity of medical records have to be well maintained. The Current Electronic Medical Records (EMR) of hospitals in Taiwan are exchangeable but integrity. The integrity of EMR from various viewpoints, can be categorized into partial integrity, local integrity and total integrity. A total integrity EMR is a completely integration of all the local integrity EMRs of a given patient. An EMR, only it can be completely integrated, can play the most effective of an exchangeable EMR. The current Hospital Information System (HIS) in hospitals, are designed for management and health services but for patient's aspect. To fulfilling integrity of EMR, an exchangeable medical record has to be appended to the EMR database simultaneously when the medical record is generated from traditional HIS. Records in EMR database are not allowed to be modified or erased but appended. All the medical treatments of patient are truly recorded can thus be called a patient oriented medical records. Only with the integrity of the EMR could ensure the availability and reliability of medical records. And a EMR with total integrity will further provide more timely patient care and avoid duplication of medical resources waste, also can serve as a reference for arbitration of medical treatment disputes.

並列關鍵字

Electronic Medical Record (EMR) ； Integrity of EMR ； Doctor-Patient Relationship