電子病歷核心資料格式比較之研究

In spite of the variety of infrastructures and rapid growth of information systems in Taiwan, there are no standadized interfaces or databases for exchanging medical information among hospitals which have increased the difficulty of comunication and intergration for patient for patient referral. To develop the core data set can help solve the present situation, and decrease the complexity of electronic data inter-change. HL7/XML has already adopted by international nations as a medical information exchange standard. However, Department of Health (DOH) has not developed a core data set for health care organizations to follow, so the contents and entities were needed adjusted during each process of healthcare information exchange. American Society for Testing and Materials (ASTM) developed "The Continuity of Care Record (CCR)" in 2003. Taiwan HL7 also developed "draft of HL7/XML referral data set" in the same year. Taiwan Medical Informatics Association was delegated by DOH to develop "HER data sets" in 2005. We compared those core data sets mentioned above and smart card issued by Taiwan National Health Insurance in four parts: document identifying information, patient identifying information, patient health status and the other information. The results were: Further information from referral, accepted health organizations and patients can be caught through the direct link to certain fields like URI/URL, Email address designed in CCR. The fields of problem link, comment, reference, data resource of CCR can help medical professionals consult and discuss with each other and interact with the patients. Regarding the coding standards, disease codes like CRT, ICD-9-CM,ICD-10, SNOMED and drug codes like NDC, RxNorm used in CCR could be our references. The purpose of Taiwan HL7's "draft of HL7/XML referral data set", Taiwan Medical Informatics Association's "HER dat sets" and Ministry of Defense's "Officers health examination data set" all are designed for referral data exchange, so the integration of these data sets should be coordinate by DOH for hospitals and clinics compliance. EHR will be one of the important sources for medical professionals to deliver the patient care in the near future. Therefore, the success or failure of core data set will be a touch stone for HER. If health providers can offer the computerized information in stead of paper records without the threat of security and privacy, it will enhance the quality of care and decrease storing space and the medical cost significantly. The information among different health care organizations could be integrated and advantages of HER could be accomplished gradually.