可交換電子病歷之完整性研究

A Study on Integrity of Exchangeable Electronic Medical Record

梁煌達(Huang-Ta Liang)

指導教授 ： 梁德昭

淡江大學/管理學院/資訊管理學系碩士在職專班/碩士(2012年)

https://doi.org/10.6846/TKU.2012.00430

摘要

病歷是就醫者終其一生的健康照護紀錄，回歸病歷的真正擁有者（Owner）應該是病患本身，病歷資料的完整紀錄，能保障就醫者的權益。醫病關係是一種服務者與消費者的關係，對於醫療服務的提供不應該是有所缺少或不完整。
透過完整性的要件探討，類分出部分完整性、院內完整性及全面完整性病歷記錄。吾人以為，唯有達成全面完整性可交換電子病歷的實現，讓就醫民眾獲得更及時的醫療照顧，以及避免醫療資源的重複浪費。
本文針對現行電子病歷實現方式，從資訊不對稱的理論基礎著眼出發，去分析與檢討出現有系統流程上或設計上的不足，提出一種改良的雛形及作法。透過動態系統圖的幫助，讓現階段病歷資料發生流程，能同時產生到醫療資訊系統與電子病歷資料庫，這樣才是具有可交換電子病歷之完整性基礎。

關鍵字

電子病歷 ； 全部完整性 ； 醫病關係 ； 資訊不對稱 ； 動態系統圖

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 relationship between the doctors and patients are about medical services offering and taking. An medical services offered should be recorded completely.
Different integrity levels of EMR can be from partial integrity, to local integrity and to total integrity. 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.
In this article, we are based on the theory of asymmetric information to analyze the ways of electronic medical record fulfilling in real world. Discussing about the defects of current medical system and of imperfect design, we came out with a model and some modifications in procedures. With Dynamic System Chart helping, we are improving current procedures of medical record system and feeding data into medical system and database in electronic format. Therefore the exchangeable medical records will be based on total integrity and meet our goals.

並列關鍵字

Electronic Medical Record (EMR) ； Integrity of EMR ； Doctor-Patient Relationship ； Asymmetric infomation ； Dynamic System Chart

參考文獻

7.吳俊穎, et al., 醫療糾紛民事訴訟時代的來臨：台灣醫療糾紛民國91年至96年訴訟案件分析. 台灣醫學, 2010. 14(4): p. 359 -369.

8.吳季勳, et al., 應用Web Services建置符合HL7標準的電子病歷交換系統架構之研究. 醫療資訊雜誌, 2006. 15(2): p. 41-54.

9.林義鈜, 論醫學倫理教育. 澄清醫護管理雜誌, 2008. 4(4): p. 5.

11.林景嘉, 黃仁竑, and 郭光明, 以Web Services建構臨床文件架構(CDA)之電子病歷交換系統之研究. 醫療資訊雜誌, 2006. 15(2): p. 17-28.

12.林玉山, 導入ISO 27001 ISMS資訊安全管理系統－以醫療院所核心資料庫安全性的策略和方法為例. 電腦稽核, 2010. 53(10): p. 90-102.