evelopment of the Taiwan electronic Medical record Templates
Jian WS; Hsu CY; Liu MC; Chang P; Wen HC; Hao TH;Li
醫(yī)學(xué)院-生物醫(yī)學(xué)資訊研究所
期刊名稱(journal):
The Journal of Taiwan Association for Medical Informatics
卷(vol.):
vol.14
期(issue.):
Issue. 4
年代(year.):
2005
摘要:
電子病歷是醫(yī)院資訊系統(tǒng)的發(fā)展趨勢(shì)，在已開發(fā)國(guó)家，如美國(guó)、日本，許多大學(xué)、研究機(jī)構(gòu)
、廠商紛紛投入這一領(lǐng)域的研究工作。因此也成立了各種民間和政府的標(biāo)準(zhǔn)化機(jī)構(gòu)來(lái)開展這
方面的標(biāo)準(zhǔn)制訂工作。政府部門也積極參與到這一過(guò)程中，採(cǎi)取各種行動(dòng)來(lái)推動(dòng)電子病歷的
發(fā)展。由於電子病歷涉及醫(yī)院電腦化，具有高度複雜性，對(duì)電子病歷也缺乏完整一致的認(rèn)識(shí)
，儘管在各方面均取得了各種進(jìn)展，但完整的電子病歷系統(tǒng)尚沒有建立起來(lái)。有鑑於電子病
歷將成為醫(yī)療機(jī)構(gòu)病歷管理未來(lái)的發(fā)展趨勢(shì)，本研究協(xié)助制定及推廣電子病歷內(nèi)容基本格式
，藉由規(guī)劃國(guó)內(nèi)電子病歷內(nèi)容基本格式、醫(yī)學(xué)詞彙標(biāo)準(zhǔn)及推廣計(jì)劃，提供全國(guó)一致性之電子
病歷內(nèi)容基本格式，並應(yīng)用國(guó)際醫(yī)療資訊標(biāo)準(zhǔn)，使醫(yī)療院所及產(chǎn)業(yè)有所遵循，以利電子病歷
分享與交換，提昇醫(yī)療照護(hù)品質(zhì)。同時(shí)，藉由專家顧問(wèn)會(huì)議之協(xié)商與討論，獲取電子病歷內(nèi)
容基本格式的共識(shí)，再加上醫(yī)療憑證管理中心的安全機(jī)制，促進(jìn)國(guó)內(nèi)電子病歷健全發(fā)展。
Abstract:
The Department of Health in Taiwan has been promoting the development of electronic medical records
with much of efforts on the adoption of HL7 and DICOM, the accredited communication syntax and
standards for sharing of medical information, as well as the standard for information exchange among
electronic medical records. Currently, electronic medical records adopted by different hospitals are filled with
copious contents invarious formats; therefore, the Department decided to build a fundamental template,
which can be used by medical services for the purpose of the exchange the electronic medical records.
Experts have involved in the convention and evaluation for building the templates. The template is
conformed with HL7 Clinical Document Architecture and is given the name, Taiwan electronic Medical
record templates, abbreviated as TMT. By the end of 2005, and 48 electronic medical style sheets have been
created and verified and a prototype system for electronic medical records has been developed. The results
will then be transferred to the healthcare providers for the adoption in the future and served as the basis of
standard for the electronic medical records in Taiwan.
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