國內電子轉診病歷交換HL7標準之研究

An Approach to Exchange Patient Referral Information Based on HL7 Standard for Taiwan

高源忠(Yuan-Chong Kao)

指導教授 ： 劉建財

臺北醫學大學/醫學院/醫學資訊研究所/碩士(2002年)

摘要

我國現行醫療相關法令中，對於轉診行為的鼓勵與規範相當地完備，但是醫療機構及臨床醫師基於創造服務量及避免病患流失等財務考量，並且礙於依法仍需保持病歷之書面形式，造成轉診作業相關的文件處理繁雜，例如除手寫病歷或電子化醫令輸入外，尚需另行填寫轉診表單，且需等待轉診結果回覆再將轉診表單歸回病歷內，因此多數院所的資訊化便僅止於電子表單，並未能於醫療資訊系統與電子轉診單間作資料整合，影響醫療服務提供者落實轉診制度的意願。而後，在降低經營成本並提高醫療服務品質的共同目的下，各類的醫療聯盟體系出現，一方面病患之互相轉介獲得重視，另一方面則推動服務資訊化。但是由於我國醫療資訊化過程中，缺乏資訊標準之發展，也限制了電子病歷在院所間之交換與流通。 因此，本研究將藉由對現行轉診制度的瞭解，分析轉診病歷結構，並導入HL7轉診標準，以使用關聯式資料庫（Relational Database）系統之醫療院所為對象，研擬轉診HL7 Interface資料庫整合介面，以定義轉診病歷結構與HL7訊息間的介面規格，再藉由電子轉診作業模式的建立，便可以透過網際網路或全國醫療資訊網（HIN）為載具，交換或傳遞電子轉診病歷。 本研究成果產生之HL7 Referral Message，已通過由陽明大學劉德明博士所建置之「HL7 Validation System」檢測，並已在台北市立萬芳醫院及台北縣大仲診所，進行電子化轉診病歷交換HL7標準之實機測試，達到正確且即時地轉診電子病歷交換成果，足以說明醫療資訊系統使用HL7標準運作轉診作業在技術上是完全可行的。 所以，本研究已經就國內轉診電子病歷資訊交換提出一確實可行的方法，以解決目前國內轉診病歷記錄不完整，及轉診作業缺乏時效性的問題，將提供醫療院所建置HL7轉診病歷系統與其醫院內部醫療資訊系統整合之參考。

關鍵字

健康資訊交換第七層協定 ； 轉診 ； 電子化轉診 ； 病歷交換 ； 電子病歷

並列摘要

The regulation/law of medical practice regarding patient referral in Taiwan is complete and encouraging. However, it is not implemented effectively. Later on, to lower down the operation cost and to enhance the quality of medical service, various medical associations emerge. Patient Referral was noticed which also push improving the capacity of computerized healthcare service. Because the medical records are in written form, only some electronic sheets are computerized in most clinics/hospitals during patient referral. The data for referral is not integrated with clinic/hospital information system. Besides, we did not develop a standard during our medical information system process, which also limits the exchange and transference of medical records. Thus, the research is based on our understanding of the current patient referral system to analyze the structure of medical record to introduce and employ the HL7 Standard. Our subjects are the clinics/hospitals that apply Relational Database System, and we formulate HL7 Interface, which defines the interface specifications for the information of referral medical records and HL7. Thus we establish the electronic operation system for patient referral and then we are able to exchange or communicate the electronic medical records through Internet or HIN. HL7 Referral Message, the product of this research, has passed the HL7 Validation System test established by Dr. Der-Ming Liou of National Yang-Ming University. HL7 Referral Message is also tested at Taipei Municipal Wan Fang Hospital and Da Chung Clinic at Taipei County to proceed the medical records exchange. The result of the exchange is correct and immediate. It illustrates that applying HL7 standard of patient referral in clinic/hospital information system is feasible. This research provides a practical way for Taiwan electronic medical record exchange regarding patient referral to solve the incomplete of medical records and timing problem when patient referral. It also serves as a reference to integration of HL7 medical records referring system in the clinic and hospital medical information systems.

並列關鍵字

HL7 ； Referral ； Patient Referral ； Exchange of Medical Record ； Health Level Seven

參考文獻

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