電子病例資料採集

Data Capture in Electronic Medical Records

資料採集 （Data capturing） 在設計電子病歷（EMR） 是一個很重要的考慮因素之一。資料設計主要是依據臨床醫生的工作流程和所有涉及電子病歷作業參與者的業務需求而定。結構化資料輸入非常適合於電腦化的紀錄，但不能充分獲取很細部的病歷和管理資訊，並且有其他的缺點。而以自由書寫的文字輸 入 （Free text） 很適合臨床工作流程，又可提供更多的彈性來記錄臨床病史、檢查和治療，但是，電腦卻很不容易處理其資料。為了解決上述問題，目前已投入的很多研究，使自由書寫的文字輸入同時可以被人們了解和機器處理。電子病歷必須支援從輸入裝置採集資料的功能以滿足用戶的工作環境和個人喜好，此外，電子病歷也須支援從各種醫療儀器採集資料。無論如何資料採集應該儘量自動化，並提供有效性檢查。雖然大部分的資料輸入由臨床醫師來完成，但是病人本身在資料收集上也可以作出有意義的貢獻。

The capture of data is probably the single most important consideration when designing an EMR. Data design must be based on a thorough understanding of the workflow of clinicians and the business requirements of all stakeholders. Structured data entry is highly suited to computer based records but is inadequate for capturing the fine details of patient history and management, and has other drawbacks. Free text fits in well with clinical workflow and provides full flexibility for recording clinical history, examination and treatment, but the data can not easily be processed by computers. To address this issue efforts are being made to enable free text to be both human readable and machine processable. An EMR must support data capture from several input devices to suit a user’s work environment and personal preferences. In addition it must also support data capture from a variety of medical devices. Whenever possible data entry capture should be automated and there should be validity checks. Although most data entry will be done by clinicians, patients themselves can make a significant contribution to data collection.