evelopment of the Taiwan electronic Medical record Templates
Jian WS; Hsu CY; Liu MC; Chang P; Wen HC; Hao TH;Li
醫學院-生物醫學資訊研究所
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:
電子病歷是醫院資訊系統的發展趨勢，在已開發國家，如美國、日本，許多大學、研究機構
、廠商紛紛投入這一領域的研究工作。因此也成立了各種民間和政府的標準化機構來開展這
方面的標準制訂工作。政府部門也積極參與到這一過程中，採取各種行動來推動電子病歷的
發展。由於電子病歷涉及醫院電腦化，具有高度複雜性，對電子病歷也缺乏完整一致的認識
，儘管在各方面均取得了各種進展，但完整的電子病歷系統尚沒有建立起來。有鑑於電子病
歷將成為醫療機構病歷管理未來的發展趨勢，本研究協助制定及推廣電子病歷內容基本格式
，藉由規劃國內電子病歷內容基本格式、醫學詞彙標準及推廣計劃，提供全國一致性之電子
病歷內容基本格式，並應用國際醫療資訊標準，使醫療院所及產業有所遵循，以利電子病歷
分享與交換，提昇醫療照護品質。同時，藉由專家顧問會議之協商與討論，獲取電子病歷內
容基本格式的共識，再加上醫療憑證管理中心的安全機制，促進國內電子病歷健全發展。
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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