以Taiwan Electronic Medical Record Template建構可攜式電子病歷文件之基礎

CDA明確宣稱CDA is not deterministic for document creation。因此我們需要一組醫學文件的本土標準樣板，遵循CDA的標準，同時因應本土化的需求，發展可攜式電子健康記錄。
本研究提出一稱之為「Taiwan electronic Medical record Template」，簡稱TMT標準，以建構一個電子病歷基本格式參考架構來供台灣本土使用。經由規範應用範圍、透過資料收集、草稿擬定、專家審查、標準訂定、系統實作，參考國際相關標準，考量標準的轉換。最後結果架構出Form、Components、 Sections、Elements、Data Type、Code Set、Narrative Block基礎，完成了以單張為單位的TMT電子病歷Schema，同時也提出供參考之檔案結構、文件檔案交換路徑、測試系統評估指標與結果以及可攜式電子病歷文件簽章模式等研究結果。
本TMT標準格式有儲存資料位置明確清楚、技術實務可快速應用等特點，介面應用的可能發展包含Flash、PDF等各式主流界面，並能達到：(1)能與國際醫學資訊標準接軌；(2)對現有之醫療環境制度衝擊最小；(3)容易實作與執行；(4)符合臺灣現行法令與常規要求。未來後續的挑戰將面臨標準持續維護、使用者習慣的改變等各方面。
Traditional electronic health record (EHR) data are produced from various hospital information systems. They could not have independently existed without an information system until the XML technology had matured. The interoperability of a healthcare system can be divided into two dimensions: functional interoperability and semantic interoperability. Currently, no single EHR standard exists that provides complete EHR interoperability. In an attempt to establish a national EHR standard, we developed a set of local EHR templates. The Taiwan Electronic Medical Record Template (TMT) is a standard that aims to achieve semantic interoperability in EHR exchanges nationally. The TMT architecture is basically composed of forms, components, sections, and elements. Data stored in the elements can be referenced by the code set, data type, and narrative block. The TMT was established with the following requirements in mind: (1) being compatible with international medical information standards, such as HL7 CDA; (2) having minimal impact on the existing medical system; (3) being easy to implement and deploy, and (4) being compliant with Taiwan’s existing laws and regulations. The TMT provides a basis for building a portable, interoperable information infrastructure for EHR exchanges in Taiwan.