HL7/CDA醫療資訊交換系統

An Exchange System for Medical Information Based on HL7/CDA

洪尚棓(Shang-Pei Hong)

指導教授 ： 林耀仁 ； 張璞曾

國立臺灣大學/電機資訊學院/電機工程學研究所/碩士(2004年)

https://doi.org/10.6342/NTU.2004.00308

摘要

資訊電子化，這個名詞在近年來十分盛行，釵h醫療機構也搭上這股風潮，把院內相關資訊電子化，大幅提昇整體的醫療效率。但由於每個醫院的資訊系統格式迥異，造成醫療資訊難以流通，尤其是病歷相關資料，更間接造成病患轉診的不便，也浪費了寶貴的醫療資源。因此世界各國都投入相當的心力，推展相關的醫療資訊交換標準。

針對醫療資訊交換的需求，本研究採用HL7/CDA標準來架構整個系統。CDA標準是由美國HL7組織所發佈，是為了達到資訊交換的目的，所訂定的一個描述臨床文件架構的標準，加上CDA文件是採用XML語言來編寫，更增加了整份文件的實用性。

醫院內部的資訊系統都十分地龐大，若要修改整個系統來達到交換的目的，勢必窒礙難行。故本研究和恩主公醫院腸胃內科合作，提出一個架構在醫院資訊系統外的交換系統，由交換系統負責處理交換的工作，免去修改原有系統的困擾。藉由Web Service，交換系統可以從醫院端取得病患的資訊，提昇整體資料的流通性；而交換系統依據醫療流程所產生的CDA文件，可以供醫院交換上的使用。在醫療行為中，醫學影像一直是醫師判斷上的主要根據，故系統中增加了影像瀏覽的部分，讓整個弁鄑韞[地完善。經由在恩主公醫院實際測試的結果，符合我們對於系統的要求，加上瀏覽器介面的使用，讓系統有更大的彈性和延展性。最後希望此系統的建構，可以爲未來醫院系統的改造，提供一個參考的範例。

關鍵字

臨床文件架構 ； 網路服務 ； 可延伸標籤語言

並列摘要

Electronic – information, this conception is in vogue recently, and many hospitals adhere this trend to switch their material to digital information. This raises their efficiency substantially. Because frameworks of information system in every hospital are different, exchange of data between hospitals, clinical documents is very difficult. This is a waste of patients time and precious medical resources indirectly. Thus, many countries are striving for developing electronic medical record standard.

In light of the need of medical record exchange, we used the HL7/CDA standard to develop our system. CDA is a standard adopted by HL7 that specifies the structure and semantics of clinical documents for the purpose of exchange. The documents are coded in XML and can include multimedia data (like image, sound…).

Information system in hospital is very huge, so it is difficult to change the entire old system for the purpose of exchanging medical record. By cooperating with the E.C.K.(En Chu Kong) Hospital, we design an exchange system parallel to the hospital information system and is responsible for the exchange. By using the Web Service, the proposed system can access with the mother system and obtain up to date circulation of medical data. Besides text, the exchange system provides the medical image so that doctors can obtain more information on patients' condition. Clinical test is conducted for 30 patients and find it is workable.

並列關鍵字

CDA ； Web Service ； XML

參考文獻

[1]行政院衛生署，“ 我國醫療資訊發展的政策 ”，2003

[9]Health Level Seven，“ HL7 Clinical Document Architecture Release1.0 ”，2000

[4]Andrew Hutchison、Matthias Kaiserswerth、Michael Moser and Andreas Schade “ Electronic Data Interchange for Health Care ” IEEE Communication Magazine 1996

[5]Health Level Seven，“ HL7 Reference Information Model Version：V 01-10 ”，2001

[6]Grace I. Paterson、Michael Shepherd、Xiaoli Wang、Carolyn Watters、David Zitner “ Using the XML-based Clinical Document Architecture for Exchange of Structured Discharge Summaries ” Proceedings of the 35th Hawaii International Conference on System Sciences – 2002