Evaluating A Service-Oriented Architecture Based Operation Notes Implementation System

評估一個以服務導向架構為基底的手術紀錄執行系統

張怡秋(I-Chiu Chang) ； 林志育(Chih-Yu Lin) ； 陳昆輝(Kun-Hui Chen) ； 溫嘉憲(Chia-Hsien Wen)

《醫療資訊雜誌》 28卷3期 (2019/09) Pp. 11-24+26

摘要

Conventional operations notes are recorded in narrative form as a sequence of events and are not suitable for medical researches to perform advanced analysis. To computerize all the operations notes into digital format places an immense administrative burden on surgery departments and computer information centres. Therefore, we developed a web-based operation notes implementation system (ONIS) using Service-Oriented Architecture. ONIS provides three major functions: Template Designer, Content Editor, and Notes Generator to help surgeons conduct different kinds of operation notes templates. We then evaluated surgeons' acceptance of the system and found that ONIS can fit in physicians' workflow and therefore improves their intention to use ONIS. Totally 161 operation notes templates were generated using ONIS in the case hospital. These operations notes conform to the HL7 CDA R2 standard and can be easily shared among local and international healthcare institutions to further penetrate into critical problems and generate broader benefits.

關鍵字

Operations notes ； Operations notes system ； EMR

並列摘要

一般性的手術紀錄多以敘述形式記錄一系列事件，較不適合進行更進階的醫學研究分析。然而將所有手術紀錄摘要轉化成數位化格式，則帶給外科及電腦資訊中心部門巨大的行政負擔。因此，我們發展一個以網路為基底、使用服務導向為架構的手術纪錄執行系統（ONIS）。ONIS提供三個主要的功能：模板樣式設計器、內容編輯器、和記錄生成器，幫助外科醫師建構不同的類型的手術紀錄樣式。經由評估外科醫師對於該系統的接受度，我們發現該系統可符合醫師的工作流程，從而提高他們使用ONIS的意願。在個案醫院中藉由ONIS的使用，總計產生161個手術紀錄摘要樣式，這些手術紀錄摘要樣式符合HL7 CDA R2標準，可供本地和國際醫療機構之間共享，進一步解決關鍵問題並產生更廣泛的益處。

並列關鍵字

手術紀錄 ； 手術紀錄系統 ； 電子病歷