Please use this identifier to cite or link to this item: http://hdl.handle.net/11455/19858
標題: 一個具備HL7 CDA R2簡化界接介面的電子病歷系統之設計與實作
The design and implementation of an electronic medical records system with HL7 CDA R2 interface
作者: 高飄逸
Kao, Piao-Yi
關鍵字: 醫療資訊系統
電子病歷
HL7 臨床文件架構
XML 簽章
出版社: 資訊科學與工程學系所
引用: [1] 診所層級病歷單張格式標準,http://emrstd.doh.gov.tw/strdoc/DocLib4/Forms/AllItems.aspx [2] 醫院層級病歷單張格式標準, http://emrstd.doh.gov.tw/strdoc/DocLib/Forms/AllItems.aspx [3] 醫院層級公告四類交換單張標準. http://emrstd.doh.gov.tw/strdoc/DocLib2/Forms/AllItems.aspx [4] 醫療機構電子病歷製作及管理辦法. 11 Oct 2009. http://dohlaw.doh.gov.tw/Chi/DownLoad.asp?msgid=2477 [5] 徐嫦娥、王瓊瑤(2007)。我國電子病歷之推動情形與政策發展。病歷管理期刊,7(1),32-50。 [6] 林玉玲,我國電子病歷發展現況趨勢的調查研究,台灣大學醫療機構管理研究所碩士論文,2001。 [7] 林振冬,符合臨床文件架構標準的電子病歷之研製,成功大學工程科學研究所碩士論文,2004。 [8] 行政院衛生署電子病歷推動專區. http://emr.doh.gov.tw/ [9] 行政院衛生署醫事憑證管理中心(HCA). http://hca.nat.gov.tw/ [10] 內政部憑證管理中心(MOICA). http://moica.nat.gov.tw [11] 行政院衛生署94年度醫療院所病歷電子化現況調查. http://www.doh.gov.tw/ufile/doc/%E8%A1%8C%E6%94%BF%E9%99%A2%E8%A1%9B%E7%94%9F%E7%BD%B2%E4%B9%9D%E5%8D%81%E5%9B%9B%E5%B9%B4%E5%BA%A6%E9%86%AB%E7%99%82%E9%99%A2%E6%89%80%E7%97%85%E6%AD%B7%E9%9B%BB%E5%AD%90%E5%8C%96%E7%8F%BE%E6%B3%81%E8%AA%BF%E6%9F%A5%E6%A1%88.pdf [12] CDA R2標記之應用詳論. http://hl7twtutor.wordpress.com/category/hl7%E5%85%A9%E4%B8%89%E4%BA%8B/cda-r2/ [13] A. K. Jha, C. M. DesRoches, E. G. Campbell, K. Donelan, S. R. Rao, T. G. Ferris, A. Shields, S. Rosenbaum, and D. Blumenthal, "Use of Electronic Health Records in U.S. Hospitals," New England Journal of Medicine, vol. 360, pp. 1628-1638, 2009. [14] D. Stefano and M. Paolo and M. Alessandro, HL7 Clinical Document Architecture to Share Structured Data in Wide Hospital Information Systems, http://www.tbs.ts.it/europacs2004/papers/127.pdf , 2004. [15] Kai U. Heitmann, Ralf Schweiger, Joachim Dudeck, “Discharge and referral data exchange using global standards -- the SCIPHOX project in Germany,” International Journal of Medical Informatics, vol. 70, pp. 195-203, 2003. [16] Marcel Lucas M¨uller, Frank ¨Uckert, Thomas B¨urkle, Hans-Ulrich Prokosch, “Cross-institutional data exchange using the clinical document architecture (CDA),” International Journal of Medical Informatics, vol. 74, pp. 245-256, 2005. [17] Marcel Müller, Thomas Frankewitsch, Thomas Ganslandt, Thomas Bürkle, Hans-Ulrich Prokosch, “The Clinical Document Architecture (CDA) Enables Electronic Medical Records to Wireless Mobile Computing,” MEDINFO 2004, International Medical Informatics Association, pp. 1449-1552, 2004. [18] P. David et al., Reporting Experiences from Using the HL7 Clinical Document Architecture in the PICNIC, http://www.medcom1-4.dk/picnic/deliverables/CDA-PICNIC-Berlin.pdf , 2002. [19] Robert H Dolin, LioraAlschuler, Calvin Beebe, Paul V Biron, Sandra Lee Boyer, Daniel Essin, Elliot Kimber, Tom Lincoln, John E Mattison. "The HL7 Clinical Document Architecture", the Journal of the American Medical Informatics Association, Vol 8, No 6, 2001, pp.552-569. [20] Robert H Dolin, LioraAlschuler, Sandy Boyer, Calvin Beebe, Fred M Behlen, Paul V Biron, AmnonShaboShvo. "HL7 Clinical Document Architecture, Release 2", the Journal of the American Medical Informatics Association, Vol 13, No 1, 2005, pp.30-39. [21] Smith B, Ceusters W(2006) Hl7 RIM: an incoherent standard. Studies in health technology and informatics 2006;124,pp:133-138. [22] Extensible Markup Language (XML) 1.0 (Fifth Edition). W3C Recommendation 26 November 2008. http://www.w3.org/TR/2008/REC-xml-20081126/ [23] HL7 Reference Information Model. http://www.hl7.org/implement/standards/rim.cfm [24] Java Opensource Castor Project. http://www.castor.org/ [25] Logical Observation Identifiers Names and Codes (LOINC). http://loinc.org/ [26] Robert H. Dolin et al., "HL7 Clinical Document Architecture, Release 2.0, HL7 V3 Ballot Document,". http://www.hl7.org/v3ballot/html/infrastructure/cda/cda.htm [27] Schematron. http://www.schematron.com/ [28] Web Services. http://www.w3.org/2002/ws/ [29] Wikipedia., " XML Signature". http://zh.wikipedia.org/wiki/XML_Signature [30] Wikipedia., " XSL Transformations (XSLT)". http://en.wikipedia.org/wiki/XSLT [31] XML Advanced Electronic Signatures(XAdES). http://www.w3.org/TR/XAdES [32] XML Advanced Electronic Signatures (XAdES-T) . http://www.w3.org/TR/XAdES/#Syntax_for_XAdES_T_form [33] XML Path Language (XPath) 2.0 (Second Edition). W3C Recommendation 14 December 2010. http://www.w3.org/TR/2010/REC-xpath20-20101214/ [34] XML Schema. http://www.w3.org/standards/techs/xmlschema#w3c_all [35] XML Signature Syntax and Processing (Second Edition). http://www.w3.org/TR/xmldsig-core/ [36] XSL Transformations (XSLT) Version 2.0. W3C Recommendation 23 January 2007. http://www.w3.org/TR/2007/REC-xslt20-20070123/
摘要: 目前國內的醫療院所,多已建置醫事系統,其醫療行為的記錄,幾乎都已完成e化。然而,醫療院所間多數仍無法以電子資料的方式交換病歷資料;其問題在於,醫療院所間彼此的病歷格式不一。本研究以服務導向架構與HL7 CDA R2為基礎,設計並實作了一個,具備簡化界接介面的電子病歷系統;該介面以關聯式資料表的概念,接收醫療院所的原始資料,並在參照轉換各類代碼後,將原始病歷資料,轉換成衛生署所認可的HL7電子病歷系統。除了簡化一致的界接介面,本系統也運用了衛生署醫事憑證管理中心醫事人員卡,實做了電子簽章;並實作了緊急備援及系統監控模組,讓病歷的保存更加安全嚴謹。目前已有19家醫療資訊廠商的醫事系統界接(19套不同的醫事系統),共二千多家醫療院所,使用本系統。未來,我們將持續運用累積的電子資料,實做資料挖掘的進階功能,以發揮電子化的最大效益。
At present, most medical institutions had built Hospital Information System (HIS). The medical treatment records of each medical institution are stored in its proprietary HIS. It is not easy to exchange medical records between hospitals due to different formats used in HIS. In this research, we designed and implemented an Electronic Medical Record (EMR) system based on service-oriented architecture and HL7 Clinical Document Architecture (CDA). The proposed EMR system uses a simple interface to receive medical records. After receiving records, the system transforms these records to HL7 CDA format and then makes signatures using medical certificate issued by Healthcare Certification Authority (HCA) of Taiwan. The proposed EMR system had been very successful in bridging 19 HISs from different manufacturers and connecting a total of more than 2000 clinics and hospitals.
URI: http://hdl.handle.net/11455/19858
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