以快速健康照護互操作性資源進行電子病歷交換之研究-以初診單為例

隨著資訊技術持續的發展與進步，帶來的不僅是生活上的便利，相對也逐漸影響著民眾的就醫習慣，例如：過去患者初次到醫療院所看診時，需要先到批價櫃檯填寫完初診單後才可進行掛號，而現在患者已可透過網路至醫療院所的官網中建立初診基本資料後，即可進行線上掛號。因此初診單是每位患者在看診前一定會填寫的醫療單張，但目前初診單尚未具有明確定義與規範，造成初診單中部分重複性較高的臨床訊息，無法透過資訊系統有效的進行傳遞與共享，而快速健康照護互操作性資源 (Fast Healthcare Interoperability Resources, FHIR)，是近年發展的醫療資訊交換標準，具有良好的互操作性與相容性，且對於調查項目有明確的定義與規範，保持資料的一致性與完整性。本研究將蒐集國內部分醫療院所的初診單分析調查項目後，在利用快速健康照護互操作性資源進行表單模板的建置，最終產生符合快速健康照護互操作性資源標準的交換檔，進而協助相關臨床訊息的交換，降低重複作業，提升臨床照護品質。

關鍵字

快速健康照護互操作性資源；醫療資訊交換；初診單

並列摘要

With the continuous development and progress of information technology, it is not only the convenience of life, but also gradually affects the medical habits of the people. In the past, when a patient first visited a medical institution, they had to go to the reception counter to complete the registration form before registering. Now the patient can use the Internet to establish the basic information of the First Visit Registration Form in the official website of the medical institution. They can do the registration online. First Visit Registration Form is a survey form that every patient must fill out before the visit. However, the First Visit Registration Form has not been clearly defined and standardized currently. It cannot be shared and carried out through the information system effectively because partially repetitive clinical message. Fast Healthcare Interoperability Resources (FHIR) is a medical information exchange standard developed in recent years. It has good interoperability and compatibility, and has clear definitions and specifications for survey items to keep consistency and completeness. This study collected the First Visit Registration Form from some medical institutions in Taiwan. We used the fast healthcare interoperability resources to establish the form module, which will make exchange file for FHIR to assists exchange of relevant clinical information. It reduced repetitive tasks, and improved the quality of clinical care.