以簡易臨床文件架構的標準為基礎建置電子病歷驗證服務平台之研究－以傳染病通報為例

Developing a Validation Service Platform Based on the Green Clinical Document Architecture Standard: -A Study of a Mandatory Communicable Disease Reporting System

王姿涵(Tz-Han Wang)黃衍文) ； Ean-Wen Huang ； 張啟明(Chi-Ming Chang)

《醫療資訊雜誌》 23卷2期 (2014/06) Pp. 25-43

摘要

衛生福利部積極推動電子病歷交換，進行患者病歷的資料交換，以利醫療資訊的流通。本研究收集行政院衛生福利部所公告之電子病歷交換標準規範書中所制定各單張之欄位，建置出一套符合簡易臨床文件架構規範之簡易臨床文件，提供本土化、輕量級、簡潔易懂的資料交換格式。根據衛生福利部所公告之電子病歷交換標準規範書中各單張欄位之驗證規則，將所使用的相關代碼進行整合，並建置為簡易臨床文件架構之檢核邏輯資料庫。檢核內容包含欄位內容值的格式，以及欄位內容值是否為有效值。撰寫程式依據檢核邏輯及相關代碼資料庫自動產生XML Schema的驗證規則，我們也提供方法，讓使用者修改驗證規則。本驗證服務平台，讓使用者可直接上傳符合簡易臨床文件架構之文件進行驗證，希望有助於提高臨床文件的完整性與正確性。

關鍵字

電子病歷 ； 臨床文件架構 ； 簡易臨床文件架構 ； 檢核邏輯

並列摘要

The Ministry of Health and Welfare of Taiwan actively promotes the exchange of data thru electronic medical records (EMR). This promotion is conducive to patient records data exchange, and also facilitates the flow of medical information. This study collected fields in the EMR exchange standards which were announced by the Ministry of Health and Welfare that compose a set for a simplified clinical document, which is in line with the Green Clinical Document Architecture (GCDA) standard. The document is an exchange format that provides features of 'localization' and being 'easy to read'. According to the fields of the EMR exchange standards, we arranged the validation rules of each individual field and integrated the relevant code to build a validation logic database for the GCDA. The validation contains the format and the effective value of the field. We wrote programs based on the validation logic database to automatically generate rules for an XML schema. We also provided a method for users to make modifications of validation rules. The validation service platform allows users to directly upload the GCDA documents for verification and hopefully improves the completeness and correctness of the document.

並列關鍵字

Electronic Medical Records (EMR) ； Clinical Document Architecture (CDA) ； Green Clinical Document Architecture (GCDA) ； Validation