臺灣博碩士論文加值系統

隨著新冠肺炎（COVID-19）引發的全球大流行疫情，加上全球皆因城鄉差距問題引發醫師分配不均問題，遠距醫療在全球大量被採用，包含遠距皮膚科、遠距耳鼻喉科與遠距眼科等，然而臺灣目前仍未有統一交換規格提供遠距醫療進行互通。2021年台灣衛生福利部宣布臺灣電子病歷交換中心將改用基於 Health Level 7（HL7）上的快速健康照護互通資源（FHIR），成為遠距醫療互通的轉機。
皮膚科和耳鼻喉科所使用的五官鏡包含皮膚鏡、耳鏡、口腔鏡及鼻咽內視鏡，成為皮膚科、耳鼻喉科診斷上一個不可或缺的工具。皮膚鏡協助診斷包含痣、脂漏性角化症、皮膚腫瘤等；耳鏡可協助診斷包含外耳道與耳內疾病，如耳膜，耳道炎等疾病，亦可協助評估耳內術後傷口狀況；口腔鏡及鼻咽內視鏡則可協助診斷透過黏膜、聲帶、下咽部、口咽部肌肉等病症。本研究為實現應用FHIR於遠距皮膚科與耳鼻喉科，打通台灣現行遠距偏鄉會診之醫療資訊傳輸，解決未來轉診或跨院會診時資訊交換難度較高之問題，應用FHIR於遠距專科會診之皮膚科和耳鼻喉科與協助五官鏡影像之交換，並以某台北市醫學中心級醫院做為互通場域，實踐遠距皮膚科與遠距耳鼻喉科基於FHIR的應用。研究方法分為三個階段，一、應用FHIR於遠距皮膚科與遠距耳鼻喉科與數位五官鏡影像傳輸。二、進行遠距FHIR互通平臺與FHIR 伺服器互通。三、醫院系統與FHIR 伺服器互通，透過與某台北市醫學中心級醫院做為互通場域實踐互通性，並以正確性與一致性評估互通結果。
研究結果如下: 本研究實際應用15個FHIR資源、架設FHIR伺服器，並開發遠距FHIR互通平臺提供未來遠距醫療的遠距端和在地端醫療院所與其他合作醫療院所可即時查閱病患的就醫資料及會診紀錄，提升醫療資訊互通性。再者，於某台北市醫學中心級醫院實際透過FHIR進行資料互通，並顯示在該院OnePage 病患資訊查詢系統中，且雙方資料確實符合正確性與一致性，顯示FHIR實際應用於遠距醫療的可行性。
綜觀上述結果，隨著醫療資訊交換和FHIR在國際醫療資訊互通領域的重要性提升，加上台灣開始發展與訂定FHIR相關標準，本研究提供了FHIR應用於遠距皮膚科及耳鼻喉科數位五官鏡影像及會診紀錄交換一個良好的示範，並且在過程中發現FHIR標準的制定需要多方討論才能達到符合臨床流程之共識，在資料存儲上仍須考量資料量及網路傳輸等問題選擇較好的存取方式，以上結果皆有助於未來台灣訂定遠距醫療相關FHIR標準和應用發展。

With the global pandemic caused by the new crown pneumonia (COVID-19) and the uneven distribution of doctors caused by the gap between urban and rural areas around the world, telemedicine is widely adopted, including tele-otolaryngology and tele-dermatology. However, there is still no formal and consistent format for telemedicine data exchange in Taiwan. In 2021, it has been announced that the National Electronic Medical Record Exchange Center (EEC) should follow Fast Health Care Interoperability Resources (FHIR) based on Health Level 7 (HL7).
Otoscope, nasopharyngoscope and dermoscope have become significant tools for diagnosis in otolaryngology and dermatology. Otoscope assists in the diagnosis of external auditory canal and inner ear diseases, it also can assist in the evaluation of wounds after surgery. Nasopharyngoscope used in diagnosing such as mucous membrane (or mucosa), vocal cords, hypopharynx, oropharyngeal muscles diseases. Dermatoscope used in diagnosing moles, seborrheic keratosis and skin tumors, etc. The research focused on applying FHIR for the interoperability of otoscope, nasopharyngoscope and dermoscope (“scopes” for short) images in telemedicine, implemented in the medical center in Taipei City. There were three stages: (1) Applying FHIR for scopes images in telemedicine. (2) Sharing images between telemedicine system and the FHIR server. (3) Sharing images between FHIR server and the hospital system. We use two indicators, correctness and consistency, to evaluate the performance of data exchanging.
Among them, we applied 15 FHIR Resources, set up FHIR server, and built a telemedicine system. telemedicine system provides the medical institutions in urban area and the medical institutions in rural area can instantly access patients' medical information. Furthermore, a medical center in Taipei City accessed the data from FHIR server and displayed in their OnePage system, and we achieved the requirement of two indicators, correctness and consistency. These showed the feasibility of FHIR for telemedicine.
In conclusion, with the increasing importance of FHIR and the medical information exchange, Taiwan has begun to set up FHIR. We provide good examples of FHIR in tele-dermatology and tele-otorhinolaryngology. Also, we found that setting up FHIR requires multi-party discussions, and it is necessary to consider the data volume and network transmission. It is helpful for Taiwan to set up FHIR in the future.

應用 FHIR 於遠距皮膚科與耳鼻喉科： 實現數位五官鏡傳輸與互通 i
審定書 ii
學位考試保密同意書暨簽到表 iii
誌謝 v
目 錄 vi
表目錄 viii
圖目錄 ix
中文摘要 x
英文摘要 xii
第一章 緒論 1
1.1 研究背景 1
1.2 研究目的與動機 2
第二章 文獻查證 4
2.1 數位五官鏡概述 4
2.2 遠距醫療狀況概述 6
2.3 臺灣醫療互通現況 8
2.4 FHIR與互通性實踐案例 9
第三章 研究材料與方法 13
3.1 研究架構 13
3.2看診流程與數位五官鏡後設研究 15
3.3 FHIR標準應用 17
3.4 FHIR伺服器 22
3.5 遠距FHIR互通平臺 25
3.6 系統與互通性評估 26
第四章 分析與結果 28
4.1 FHIR標準 28
4.2 FHIR伺服器互通實踐 30
4.3 遠距FHIR互通平臺成果 33
4.4 互通性實踐結果 37
第五章 討論 42
5.1 實踐遠距醫療資訊互通 42
5.2 研究效益與優勢 42
5.3 研究準備與發現 44
5.4 研究限制 45
第六章 結論與建議 46
參考資料 48
中文文獻 48
英文文獻 49
附錄 52
附錄一 實際情境Encounter資源內容 52
附錄二 實際情境Conditiony 資源內容 55
附錄三 實際情境Observation資源內容 57
附錄四 實際情境MedicationRequest資源內容 59

表目錄
表 1 2021年癌症預估新病例人數與死亡人數 5
表 2 台灣CDA R2 與 FHIR的比較 9
表 3 衛生福利部遠距醫療試辦計畫執行醫院之數位五官檢查鏡組規格 17
表 4 Media 規範內容 20
表 5 API設計 32
表 6 遠距端欄位與FHIR伺服器之映射 38

圖目錄
圖 1 研究架構圖 14
圖2 FHIR系統架構圖 15
圖 3 遠距會診流程圖 16
圖 4 FHIR R4版本提供之Resource列表 18
圖 5 FHIR R4版本Patient Resource詳細內容 19
圖 6 HAPI FHIR伺服器架構 23
圖 7 HAPI FHIR初始畫面 24
圖 8 稽核日誌功能展示 25
圖 9 會診和相關基本資料FHIR Resource關聯圖 28
圖 10 臨床與診斷FHIR Resource關聯圖 29
圖 11 診療計畫與藥物FHIR Resource關聯圖 29
圖 12 Postman測試Restful API 31
圖 13 病患資訊系統部分後端程式碼 35
圖 14 病患資訊系統查詢頁面 35
圖 15 病患資訊檢視頁面 36
圖 16 FHIR伺服器Patient和Observation資源資料 36
圖 17 會診資訊檢視頁面 37
圖 18 實際互通結果-顯示於OnePage 病患資訊查詢系統 40
圖 19 實際於FHIR伺服器上的抓取稽核紀錄 40
圖 20 實際OnePage 病患資訊查詢系統與FHIR內容映射結果 41

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