健康檢察報告單之HL7/CDA標準格式轉換服務系統建置

Design and Implementation of an HL7/CDA Standard Document Format Transfer Service System for Physical Examination Reports

健康檢查報告是個人健康歷的一部分，和電子病歷一樣都有交換的需求，必須要遵循標準的格式才能進行交換。我國目前使用的電子病歷資料交換標準是以臨床文件架構(CDA)為主，之前雖曾經制定過健康檢查報告的單張和交換標準格式的規範書草案，但是各醫院所製作的健檢報告，卻很少看到實際採用 CDA 格式，究其原因在於健康檢查報告的項目繁多，有些項目不容易找到標準代碼，增加標準編碼系統開發的困難度，另一方面也因為代碼不一致的情形，而無法進行交換。為了解決健康檢查報告資料互通的問題，本研究探討國內外現有健康檢查報告標準的文獻，並收集國內常見的健康檢查報告之檢查項目，找出每一種檢查項目的標準代碼，並且將產生標準文件所需的資料，如檢查項目的方法和參考值等，都建立到資料庫中，然後撰寫CDA 的編碼程式，開發健康檢查報告標準編碼系統雛型。使用者可以使用編碼範例產生工具，選擇某一種檢查項目，輸入一個檢驗值後，產生該檢驗的CDA區段編碼，也可以將全部的健康檢查結果值上傳到系統後，自動產生完整的檢驗報告標準文件。為了方便使用者閱讀健檢報告文件，本系統也採用可擴充性樣式語言(XSL)的技術，製作健檢報告資料呈現模板，提供使用者選擇所需的樣式，並呈現在適合的終端設備。雛型系統建置完成後，相信對於檢驗報告的交換及個人健康歷的推動將會有幫助。

Physical examination reports are included in the personal health records. Similar to medical records, physical examination reports also have an exchange requirement and need to follow a standard format. The Ministry of Health and Welfare proposed the Clinical Document Architecture (CDA) as the standard format for medical information exchange in the country. The standard profile of physical examination reports has been defined and declared for several years, but has not been followed by any institution given the complexity of physical examination items and the difficulty in finding a consistent code for CDA encoding of such items. In order to solve the interoperability problems of physical examination reports and determine the deficiencies, we reviewed related literatures, discussed with experts, gathered local and common physical examination reports, and tried to redefine a new standard profile that satisfies the requirements of most medical institutions. We aimed at determining the standard code for each examination item such as method and reference value while establishing a physical examination item database. We implemented a CDA encoding prototyping system that could allow users to generate CDA section sample code by entering an examination value. Users could also transfer examination results to the system to automatically generate a complete examination document in CDA format. To help a user read a medical document easily; we would provide a presentation format with an extensible style-sheet language (XSL). The prototyping system is under development and would significantly help promote the exchange of physical examination reports and personal health records in the near future.