以結構化表單建置整合性照會系統落實病歷結構化與電子化

Build An Integrated Consult System With Structured Forms To Implement The Structuring And Electronicization Of Medical Records

【目的】
為促進本院的智慧醫療的基礎建設及日後照會資料結構化與電子化，將以結構化表單(含插入圖片功能)來重新建置整合版的照會系統落實病歷結構化，並導入電子病歷來實現照會資料電子化與減少列印的耗費。
【方法】
一、資料整合與架構重整：新版照會系統的架構將改用主/從資料表的方式建立，主要資料表記錄照會申請的相關資訊，包含病人資訊、申請者、申請時間、回覆者、回覆時間、此筆照會狀態等等，從屬資料表則記錄照會的申請內容、回覆內容、異動時間等明細資料。
二、使用介面調整與設計：新版的照會系統將以Web平台來設計，可獨立於瀏覽器運作，並新增了許多欄位收合的功能，讓使用者的編輯區域能夠最大化的呈現，並改善清單的顯示方式，讓使用者能快速辨識目前所點選的病患資訊，並同步顯示該病患的主治醫師、住院醫師、專科護理師的姓名及聯絡方式，並導入表單系統與插入圖片的模組，同時協助臨床科建立常用的表單格式。
【結果】
一、減少列印照會回覆單紙本病歷：照會系統尚未導入電子病歷時，紙本病歷仍需列印下來與病人病歷夾帶存放，平均一年下來需列印5萬多份的紙本病歷。因此導入電子病歷之後，即可減少列印次數省下需列印紙張之費用，與列印時產生的排碳量。
二、增加照會內容的完整性：新版的照會系統提供了圖片、表單等多樣的工具協助醫師在撰寫照會時能增加內容的完整性，未來將會再新增醫師片語、帶入檢查檢驗資料等擴充功能。
三、依照病人的病情狀況與相關臨床數據自動發送照會：因應病人的病情多元，若於特定病情滿足需照會的條件，則系統會主動發送照會至相關的臨床單位，另外也可與其他系統介接，依照醫師的判斷可立即啟動照會申請。
【結論】
透過表單與插入圖片功能的導入，讓照會醫師明確的知道申請照會時需準備什麼資料，勾選哪些選項，並明確的表達照會的原因，更進一步可用圖片來說明病情進而更加完善內容的完整度，反之，會診醫師完成會診後也可以用圖片來回覆並附上所做的處置或建議，使回覆的內容更加完整之外同時也落實了病歷結構化與電子化。

Purpose
In order to promote the basic construction of smart medical care at our hospital and the structurization and electronization (the latter can also be called electronicization, document digitalization, or computerization) of future consult data, a structured form (including the function of inserting pictures) will be used to rebuild the integrated version of the consult system to implement the structuring of medical records, import electronic medical records to realize electronic consult data, and reduce the cost of documentation.
Method
1. Using C# as the principle language, along with developing tools provided by Microsoft Visual Studio and the MVC framework of Web (Model-View-Controller) to proceed the development; as the mentioned two added together, the resulted program structure became more intuitive, the system management more convenient, which is a plus for group developments.
2. Data integration and structure reorganization: The structure of the new version of the consult system will be established by the master/slave data table. The main data table records the relevant information of the consult application, including the patient information, name of the applicant, time of application, responder, reply time, the status of the consult, etc., also the subordinate data table records of the details of the consult's application content, reply content, and timing modification if any
3. Using interface adjustment and design: The new version of the consult system will be designed on the Web platform, which can be operated independently by the browser, and a number of column collapsing functions have been added, so that the user's editing area can be maximized and improved. The display of method list allows the user to quickly identify the information of the currently selected patient, and simultaneously display the name and contact information of the attending physician, resident physician, and specialist nurse of the patient, and import the form system and insert the picture module, and assist the clinical department to establish a common form format.
Results
1. Reducing the number of paper-based medical records that are printed and replied to: When the electronic medical record has not been imported into the consult system, the paper-based medical records still need to be printed and stored with the patient’s medical records. On average, more than 50,000 paper-based medical records need to be printed in a year. Therefore, after importing the electronic medical record, the number of times of printing can be reduced, the cost of printing paper and the amount of carbon emissions generated during printing can be saved.
2. Increasing the integrity of the content of the consult: The new version of the consult system provides various tools such as pictures and forms to help doctors increase the integrity of the content when writing the reply. In the future, the doctor's phrase and the examination and lab data will be added.
3. The system automatically sent consult according to the patient's condition and relevant clinical data: In response to the diverse conditions of the patient, if the conditions for a specific condition were met, the system would actively send the consult to the relevant clinical unit, and it could also interface with other systems. At the discretion of the physician, a consult application could be initiated immediately.
Conclusion
Through the import of the form and the function of inserting pictures, the physician who is in the consult can clearly know what materials to prepare when applying for a consult, which options to check, and clearly express the reason for the consult. Further, pictures can be used to illustrate the condition to further improve the integrity of the content. On the contrary, the consulting physician can also use pictures to reply after completing the consultation and attach the treatment or suggestion, which makes the content of the reply more complete, and also implements the structuring and electronization of medical records.