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  • 學位論文

SNOMED CT應用於醫療機構之研究

The Study of SNOMED CT Applies to the Medical Facilities

指導教授 : 黃麗玲
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摘要


臨床醫學術語系統(Systematized Nomenclature of Medicine - Clinical Terms,SNOMED CT)在國外已使用多年,諸如美國、英國等先進國家都已使用SNOMED CT來統一臨床診斷描述。隨著SNOMED CT不斷更新,使用輸入端的醫生甚至可以直接按圖索驥(mapping)ICD碼,所以可將SNOMED CT視為電子病歷的「輸入碼」,而ICD碼是電子病歷的「輸出碼」。美國健康資訊管理協會(AHIMA)亦擬於2016年將ICD-11與SNOMED CT兩者合併上路,屆時美國的電子病歷整合、申報將出現新的面貌。而台灣的健保申報技術亦朝電子化方向發展,國內SNOMED CT之使用必然成為未來的發展方向,所以本研究目的在介紹SNOMED CT之內涵與應用,並訪談相關專業人士以了解SNOMED CT其應用於台灣醫療機構之可行性。 本研究採立意抽樣,深度訪問國內中區某醫學中心二位醫療資訊有關之專業人士。本研究結果得知台灣想要與國際間接軌,SNOMED CT的使用已變成不可避免的趨勢,但目前台灣的醫院對於SNOMED CT仍感陌生,雖有醫學中心正致力於SNOMED CT之使用,但目前病歷電子化未臻完整,且現有電子病歷部分仍不適合導入使用。再者,使用SNOMED CT,需建立在資訊統整之前提下,對於病歷室人力需求之質與量也會有影響,實務上會有阻力。因此短期內台灣可能無法應用SNOMED CT上線,但在國際醫療發展趨勢下,勢必仍須面對。

並列摘要


SNOMED CT has been used abroad for many years, such as the United States, England and the others countries. It could unify the description of the clinical diagnosis, and help doctors to key some ICD code with its mapping. So, we can call SNOMED CT as the "input code" of electronic medical records, and ICD code be the "output code" of electronic medical records. American Health Information Management Association (AHIMA) will combined ICD-11 and SNOMED CT in 2016. At that time, electronic medical record will integrated to be a new style. Taiwan''s NHI developed to EMR, and SNOMED CT should be the future direction. So the purpose of this study are try to introduce SNOMED CT, by interviewing with relevant experts to realize the possibility of SNOMED CT could be applied in Taiwan’s medical institutions. In this study, we used the purposive sampling of one central Taiwan’s medical center in depth-interview method. The results showed that SNOMED CT might become an inevitable trend, but Taiwan’s hospitals still unfamiliar of SNOMED CT now. So, SNOMED CT seems not to suit of electronic medical record process in this moment. Before apply SNOMED CT, model it need to establish information system the whole premises. And it will also influence the quality and quantity of the manpower structure in medical records department. It may not be able to apply on-line SNOMED CT in short term, but we could not ignore its international medical trend.

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