建立加護病房護理電子病歷標準與相關知識定義系統之試作

Building an ICU Nursing Electronic Record Standard and Practicing Knowledge Definition System

王淑靜(Chu-Ching Wang)

指導教授 ： 徐建業

臺北醫學大學/醫學院/醫學資訊研究所/碩士(2007年)

https://doi.org/10.6831/TMU.2007.00136

摘要

病歷是醫療重要的一環，發展電子化病歷的優點有，降低醫院行政管理作業成本與空間、提升醫師醫療決策的效率與正確、提供完善整合的病人資料等。目前，政府正積極推動無紙化病歷的法源成立，將輔導醫療院所推動電子病歷，建立醫療電子認證機制，並配合醫療資訊標準列入國家標準，同時推動醫院間的病歷交換，亦公開徵求醫療資訊電子化應用的相關計畫。

本研究將我國醫院加護病房(ICU)臨床照護情境中，以某大教學醫院ICU特殊護理單張為主軸，參考TMT(Taiwan electronic Medical-record Templates)，並收集整理多家大型醫院單張，利用專家會議，由臨床與學術界的醫學、護理、呼吸治療等領域專家建構加護病房特殊護理紀錄單張的內容。依照各臨床專家的專業判斷，提供並分享各家醫院的經驗，同時參考國際護理用詞研究標準，訂定欄位格式，且對格式內容加以定義。以臨床文件架構(Clinical Document Architecture, CDA)作為病歷資料交換的準則，使用延伸標示語言（XML, Extensible Markup Language）的電子資料交換機制則用來作為病歷資料的發展格式，以期達到加速醫療資訊流通，並減少醫療資源浪費的目的。

將單張內容細分為八個部份：住院基本資料、照護基本資料、生命徵象、生理監測、呼吸功能數值、生化電解質、輸出輸入、給藥，由此八大模組建立成一大表單的護理電子病歷格式。

並且依照病歷格式內容，訂定符合需求的知識，包含名稱、英文全文、中文名稱、簡體中文名稱、同義字、參考值、說明與介紹，並實作Web-based相關知識定義查詢系統，提供相關知識查詢、相關網站連結及XML格式下載。

以專家系統測試及滿意度調查為評值指標，臨床人員滿意度平均4，資訊人員滿意度平均 4.15，滿意度平均為4.08。滿意度最低之項目為對於查詢系統網頁所提供的多項功能滿意，為3.83，滿意度最高之項目為護理記錄電子化是一種未來趨勢，為4.65。達滿意之百分比為96.73%。

關鍵字

電子病歷 ； 臨床文件架構 ； 臺灣電子病歷內容基本格式 ； 加護病房 ； 延伸標示語言

並列摘要

Medical record plays an important role in health care. The advantages of using electronic medical records are numerous; it can be summarized into many folds: Like reduction of hospital administrative cost and space maintenance; improve efficiency and accuracy of medical decision making; provide fully-integrated patient information.

Currently, Taiwan government has been actively promoting “paperless” medical records. To achieve this goal, the government will assist health care facilities in the use of electronic medical records with electronic authentication as additional security measures to protect private records. There will be a national standard with all medical records. Exchange medical records among hospitals are encouraged. Projects for electronic medical information applications are welcome as well.

This research study follows the ICU care settings in Taiwan. Special intervention sheets from a major teaching hospital are adopted as the main reference. We also evaluate special sheets from several other hospitals. TMT (Taiwan electronic Medical-record Template) structure is also reviewed and referenced. Expert meetings, which specialists from several disciplines including medicine, nursing, respiratory therapy were involved, were held to formulate the electronic special intervention sheet. Terminologies from several international nursing standards and HL7 protocol definition are reviewed and used for building data fields. The architecture of our protocol is based on CDA (Clinical Document Architecture), which is used as a data exchange vehicle. The tool to implement the protocol is by use of XML (Extensible Markup Language), which exchanges information with high efficiency and hence reduces health care costs.

The ICU Nursing Electronic Record system has 8 categories:
1. Admission profiles
2. Nursing care profiles
3. Vital sign
4. Physiologic monitoring
5. Respiratory parameters
6. Laboratory data
7. Medication module
8. Intake output records

The design principles behind this ICU Nursing Electronic Record include, Chinese-to-English as well as traditional-to-simplified Chinese ICU medical terminology, synonyms and reference values. A web-based knowledge definition query system was built using the electronic medical record template that we defined. This system will facilitate the work of related knowledge inquiry and links to related websites as well as provide downloads of our medical record template in XML format.

Regarding expert's system testing and satisfaction investigation as the commenting value index, clinical personnel's satisfaction is average 4, personnel's satisfaction of information is average 4.15, satisfaction is 4.08 on average. The lowest project of satisfaction, for being satisfied for inquiring about the multiple functions that the query system offers, it is 3.83. The project with supreme satisfaction is nursing electronic medical record is a future trend, it is 4.65. It is 96.73% to reach satisfactory percentage.

並列關鍵字

Electronic medical record ； CDA ； TMT ； ICU ； XML

參考文獻

1. 王桂芸(2005)，病患結果在臨床護理上之分類與應用，護理雜誌，47(2)，27-32。

3. 行政院衛生署，《95年版衛生資訊年報》，民95。

4. 佘明玲, 薛亞聖, 黃興進 (2005)，影響醫院資訊系統績效評估之關鍵因素：高階主管觀點之實證研究，台灣公共衛生雜誌，24(1), 22-32.。

11. 林景嘉、黃仁竑、郭光明(2006)，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，15(2)，17-27。

13. 邱瑞科、王永興、林寬治(2006)，Agent-Based 數位影像醫療資訊整合及交換共通服務閘道-以轉診系統為例，，醫療資訊雜誌，15(1)，35-54。