- 期刊
使用HL7 v3建置多院區個人歸戶之電子病歷－以台北市立聯合醫院爲例
Using the HL7 v3 to Create Electronic-Medical Record System for Integrated Personal Records from Various Hospital branches-Example with Taipei City Hospital
摘要
近年來，衛生署積極實作與推廣HL7(v3)電子病歷標準，各級醫院也相繼開發自身的電子病歷系統，電子化的好處除了便於儲存及減少紙張的使用外，其文字易於辨識，且經由整合後的介面能立即呈現病人相關之資料，不僅減少調閱病歷的人力及時間，也減少因放置紙本病歷所需的空間，所以隨著各醫院致力於病歷的電子化，但各醫院大多未採用HL7標準或僅以HL7(v2.x)版訊息格式爲基礎建置系統，在與醫院內部系統或其他分院的醫療資訊系統進行病歷交換的效率上顯得緩慢許多了。 隨著醫療環境的改變，醫院經營型態也逐漸形成大者恆大，各大醫院都有分院在其他行政區，各分院亦各自有獨立醫療資訊系統，病患的病歷資料並未進行歸戶，導致電子病歷中未能及時完整的呈現各病患的病史及治療情況，醫療人員在診療時可能因此而誤診或忽略藥品交互作用的情況，且也嚴重的浪費醫療資源。 因此，本研究整合HL7(v3)的方法論及現行醫療資訊系統，將所有的醫療資訊以系統與整合化的方式儲存至資料倉儲並開發個人歸戶之電子病歷系統，系統中將以時間軸呈現病患在該醫院所有院區完整的門急住看診病歷，使醫生能快速且有效的查詢病患在該醫院的就診記錄，未來我國完整訂定適用於國情的HL7(v3)標準後，醫院將能以HL7(v3)訊息達到電子交換病歷的目的。
並列摘要
Recently, the DOH (Department of Health, Executive Yuan, R.O.C. (Taiwan)) motivated the implementation and promotion on the ”HL7 V3 standard”, and so the various levels of hospitals do. There are several benefits on using the electronic-medical record system: is convenient to store the medical record, reduces the paper consuming, and is easy to read. Moreover, it can be designed to fulfill various purposes, which will reduce the time and effort to access medical record. Therefore, the electronic-medical record system will be beneficial for hospitals. However, the version 3 is not widely adapted by hospitals, which will cause problems on the electronic-medical record sharing. As the medical environment changes, the bigger gets bigger; it is common to have different sections for bigger hospitals. Each of them has separate health information system, which might cause problems of medical treatments and/or might cause the side effect among various medicines. This situation can waste the medical resources seriously. Thus, this study attends to integrate the version 3 with the currently medical information system. It stores the medical information of various systems to the data warehouse and implements the personal medical system. This personal medical system will present personal medical information against the timeframe, which enable doctors look through the medical history of patients. As a result, this system can solve the electronic-medical record sharing problems effectively.