建置醫學詞彙代碼系統協助電子病歷交換之研究

A Study of Developing a Medical Terminology Coding System for Electronic Medical Records Exchange

林建羽(Chien-Yu Lin) ； 黃衍文(Ean-Wen Huang) ； 邱淑芬(Shwu-Fen Chiou)

《醫療資訊雜誌》 22卷3期 (2013/09) Pp. 25-42

摘要

近年來衛生主管機關積極推動電子病歷交換，但是符合標準的臨床文件的資料轉換程序複雜，至今成果並不顯著，特別是在醫學詞彙編碼系統方面的轉換，如果能夠在網路上維護一套完整的醫學代碼系統，並且提供轉換服務，相信對於電子病歷交換會有很大的幫助。本研究參考國際醫療資訊標準的臨床文件架構（CDA）及標準的轉換工具，提供醫學詞彙的編碼和轉換服務。依據國際HL7協會所建議的通用術語服務（CTS）的概念，分析符合臨床文件架構標準的病歷資料交換的欄位，建立詞彙代碼系統的網路服務轉換工具。本系統的資料庫收集了電子病歷交換所需的完整中英文醫學詞彙及代碼資料，並提供線上查詢、轉換和管理的功能，透過網路服務製作電子病歷文件可以獲得一致性的臨床文件架構的編碼資訊，促進醫療資訊交換標準的發展與提升健康照護品質。

關鍵字

醫療資訊標準 ； 電子病歷 ； 臨床文件架構 ； 醫學詞彙代碼系統 ； 網路服務

並列摘要

Electronic medical record (EMR) exchange has been promoted by Ministry of Health and Welfare for several years, but the accomplishment so far can be further improved. The primary issue to be improved is that medical records difficultly conform to the medical information standards especially in the medical terminology coding system. In this study, we adopt the international standard of Clinical Document Architecture (CDA) and provide standard conversion tools to present and translate medical vocabulary and coding system. We use the concept of Health Level Seven's Common Terminology Services (CTS) to analyze the data fields of the EMR system mapped to the CDA document and implement web service tools to translate medical vocabulary and coding system. The database contains all of the vocabulary code class information. The system functions include online medical vocabulary code query, translation and management services. Therefore, users may create electronic medical record files with a consistent code to improving the development of medical record exchange and enhancing the overall healthcare quality.

並列關鍵字

Health Information Standards ； Electronic Medical Record ； Clinical Document Architecture ； Medical Terminology Coding System ； Web Services