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研究生:林哲如
研究生(外文):Che-Ju Lin
論文名稱:設計與實作符合臨床文件架構的臨床文件產生器
論文名稱(外文):Design and Implement a Generator with Clinical Document Architecture standard
指導教授:劉德明劉德明引用關係劉德明劉德明引用關係
指導教授(外文):Der-Ming LiouDer-Ming Liou
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:生物醫學資訊研究所
學門:工程學門
學類:生醫工程學類
論文種類:學術論文
論文出版年:2010
畢業學年度:98
語文別:英文
論文頁數:58
中文關鍵詞:電子病歷臨床文件架構網路服務健康資訊第七層交換協定
外文關鍵詞:Electronic Health Records (EHR)Clinical Document Architecture (CDA)Web ServicesHealth Level 7
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病歷電子化的推動,解決醫院紙本病歷擺放空間不足的問題,也讓病歷便於管理。更重要的一點,利用電子病歷讓病人的病歷更容易整合並讓各醫院的病歷能夠做互通,進而達成連續性照護的理想。而在此方面,醫療資訊標準的採用與推廣扮演著相當重要的角色,目前已有不少研究投入於此。但是,各家醫院之資訊系統大不相同,所以造成電子病歷之格式亦不相同,目前也無一標準可供遵循,因此,在互通的過程中必須要依照互通的對象與內容特別進行調整,而增加了互通的困難度。另外醫療院所的資訊系統,大部分都不注重國際編碼標準,不是採用院內自訂碼就是遵循健保碼。成為互通病歷的一大阻礙。
本研究以臨床文件架構 (Clinical Document Architecture, CDA) 作為電子病歷互通的標準,希望建置一個平台,此平台提供一個友善的介面,直接提供一套符合編碼規範之電子病歷編輯系統,讓各醫院能夠依照需求增減需要的欄位來建立專屬的病歷格式,使用者利用此平台可直接產生電子病歷內容,讓電子病歷能夠轉換成符合臨床文件架構之標準,進而可以與其他醫療機構彼此做互通。

Electronic Health Records (EHR) allows health records to be easily integrated, shared, and inter-operates between health institutions. However, the system heterogeneity and the lack of standards present current challenges which hinder efficient inter-operate of medical information between institutions.
Health Level 7 (HL7) Clinical Document Architecture (CDA) is a renowned exchange standard. Presently, there are many studies regarding CDA to resolve the problems discussed above. This paper implements a tool to simplify the CDA generation and provide a friendly user interface. It is divided into three main parts: Template Designer, Mapping engine and CDA Generator. The CDA tool helps users to create the template (e.g. discharge summary) through an efficient user interface.
In addition, it maps the CDA elements to the field of the legacy information table. Ultimately, the CDA tool generates the CDA documents and saves them as XML files. The application of CDA as a promising standard in the hospital environment ensures the efficient exchange of health records.

Keywords: Electronic Health Records (EHR), Clinical Document Architecture (CDA), Health Level 7, Web Services

誌謝 I
中文摘要 II
Abstract III
Table of Contents IV
List of Tables VII
List of Figures VIII
List of Abbreviations X
Chapter Ⅰ Introduction 1
1.1 Background 1
1.2 Clinical Document Architecture (CDA) 3
1.2.1 CDA R-MIM 4
1.2.2 CDA R2 Header 6
1.2.3 CDA R2 Body 6
1.2.4 Application of CDA 7
1.3 Motivation 8
1.4 Specific Aims 10
1.5 Organization of this Thesis 10
Chapter Ⅱ Literature Review 11
2.1 Health Level-7 Compliant Clinical Patient Records System 11
2.2 CDA Authoring Tool: CDA Studio 13
Chapter Ⅲ System Design 17
3.1 System Scope 17
3.2 Related Technology 18
3.3 System Architecture 19
3.3.1  Template Designer 20
3.3.2  Template Designer and CDA Generator 21
Chapter Ⅳ System Implementation 24
4.1 System Implementation 24
4.1.1 System Implementation Process 24
4.1.2 Preliminary Work 25
4.1.3 Testing Data Mapping 26
4.2 Development Environment 28
4.3 System Results 29
4.4 Evaluation 35
Chapter Ⅴ Discussion and Conclusion 37
5.1 Discussions 37
5.2 Limitations 38
5.3 Conclusions 38
5.4 Future Works 39
Bibliography 40
Appendix 1: The form fields information of Provider Order 41
Appendix 2: The CDA tool code 47


[1] HIMSS: http://www.himss.org/
[2] A. Atreja, et al., "Opportunities and challenges in utilizing electronic health records for infection surveillance, prevention, and control," Am J Infect Control, vol. 36, pp. S37-46, Apr 2008.
[3] 行政院衛生署電子病歷推動專區: http://emr.doh.gov.tw/index.aspx
[4] R. H. Dolin, et al., "HL7 Clinical Document Architecture, Release 2," J Am Med Inform Assoc, vol. 13, pp. 30-9, Jan-Feb 2006.
[5] HL7 Taiwan: http://www.hl7.org.tw/
[6] N. Saranummi, "PICNIC Architecture," Stud Health Technol Inform, vol. 115, pp. 37-60, 2005.
[7] Arbeitsgemeinschaft SCIPHOX GbR mbH, SCIPHOX—standardisation of communication between information systems in physician’s offices and hospitals using XML: http://www.sciphox.de/
[8] M. L. Muller, et al., "Cross-institutional data exchange using the clinical document architecture (CDA)," International journal of Medical informatics, vol. 74, pp. 245-256, 2005.
[9] SCIPHOX project: http://sciphox.hl7.de/
[10] G. I. Paterson, et al., "Using the XML-based Clinical Document Architecture for Exchange of Structured Discharge Summaries," Proceedings of the 35th Hawaii International Conference on System Science, 2002.
[11] M. Muller, et al., "The Clinical Document Architecture (CDA) enables electronic medical records to wireless mobile computing," Stud Health Technol Inform, vol. 107, pp. 1448-52, 2004.
[12] J. J. Lin, et al., "A study on web services based CDA for medical information exchange system," The Journal of Taiwan Association for Medical Informatics, vol. 15, pp. 17-28, June 2006.
[13] J. H. Yun, et al., "Processing HL7-CDA Entry for Semantic interoperability," International Conference on Convergence Information Technology, 2007.
[14] J. S. Hooda, et al., "Health Level-7 Compliant Clinical Patient Records System," ACM Symposium on Applied Computing, 2004.
[15] S. Jung, et al., "Development of CDA Authoring Tool: CDA Studio," Enterprise networking and Computing in Healthcare Industry, 2005

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