以Taiwan Electronic Medical Record Template建構可攜式電子病歷文件之基礎

Building Taiwan Electronic Medical Record Template for the Basis of Portable EMR Document

傳統的電子健康紀錄是由各醫院資訊系統產生，在XML技術尚未成熟前，電子健康紀錄無法獨立於資訊系統之外。而現行健康照護機構之間的資料分享也不僅需達到資料交換功能，還需達到透通。健康資訊系統的透通性可以分為二種：資訊技術性的透通以及語意性的透通。目前為止，沒有任何單一的醫學資訊標準可以提供完全電子健康紀錄的透通。在標準方面，國際上HL7/CDA已訂定一個臨床文件的架構標準，但HL7/CDA主要並不是一個文件內容建構的標準。因此，我們建構了一組醫學文件內容的標準樣板，能同時能遵循CDA的架構標準，並達到互補的效應，命名為「Taiwan electronic Medical record Template」，簡稱為TMT標準。TMT的內容，蒐集自兩百多家醫療院所病歷單張、經過專家的整理、歸納及共同討論而成，用以規範台灣本土使用的電子病歷基本格式。TMT參考國際相關標準，考量標準的轉換，架構出Form、Components、Sections、Elements、Data Type、Code Set、Narrative Block等基礎，完成了以單張為單位的TMT電子病歷Schema。此單張即一般醫療人員所使用之病歷紙張單張，例如門診單、住院病歷摘要等。TMT並提出了四項基本的要求：(1)與國際醫學資訊標準接軌(2)對現有之醫療環境制度衝擊小(3)容易實作與執行(4)符合臺灣現行法令與常規。

A typical electronic medical record (EMR) are produced from hospital information systems, which includes HIS, LIS, NIS and from many different departments. Usually, the data of EMR is stored in a database containing many tables and can not be used and presented independently. Therefore, in this study, we used the XML technology to present and make the EMR. The interoperability of a healthcare data and system can be viewed by two directions: the functional interoperability and semantic interoperability. At the mean time, there is no single EMR standard that can provide complete EMR interoperability. In a national project that supported by the government of Taiwan, we have established a national EMR standard templates. The Taiwan Electronic Medical Record Template (TMT) is a standard that will provide an ontology and data schema to achieve semantic interoperability of EMR for different hospitals in Taiwan. Four parts are included in TMT architecture: the forms (sheets), the components, the sections, and the elements (data). Forty one code set are designed by this project and the data can be presented by data type and code set. The narrative block was also designed to contain the human readable text. Four requirements are the basic ideas of TMT: (1) being compatible with international medical information standards, such as HL7 CDA; (2) having few impacts on the existing hospital information system; (3) easy to understand and easy to be implemented and deployed, and (4) Modifying the regulations of EMR if needed.