Liu C T, Long A G, Li Y C, Tsai K C, Kuo H S
Graduate Institute of Medical Informatics, Taipei Medical University, Taipei, Taiwan.
Int J Med Inform. 2001 May;61(2-3):189-205. doi: 10.1016/s1386-5056(01)00141-1.
In order to obtain appropriate medical care, patients can be referred or transported from one hospital to another based on the capacity, capability and quality of medical care provided by hospitals. Therefore, enabling patient care records to be shared among hospitals is essential not only in delivering the quality of medical care services but also in saving medical expenses. Currently, most patient care records are paper-based and not well organized. Hence, they are usually incomplete and can hardly be accessed in time. The authors in this paper present methods to structure and represent patient care records, design mechanisms for interpreting and integrating the XML-based patient care records into the existing hospital information systems. More importantly, in our approach, each significant piece of medical record is associated with a tag based on the syntax and semantics of the XML. The XML-based medical records enable a computer to capture the meaning and structure of the document on the web. The authors have developed a unified referral information system in which patient care records can be shared among hospitals over the Internet. It can not only facilitate the referral process but also maintain the integrity of a patient's medical record from distributed hospitals. The workflow of the system basically follows the existing manual system and can easily be adapted. The working group on integration of municipal hospital information systems, Department of Health, Taipei City Government, has decided to adapt this system for referral practice among the municipal hospitals.
为了获得适当的医疗护理，患者可以根据医院提供医疗护理的能力、水平和质量，从一家医院转诊或转送至另一家医院。因此，实现患者护理记录在医院之间共享不仅对于提供高质量的医疗护理服务至关重要，而且对于节省医疗费用也很关键。目前，大多数患者护理记录都是纸质的，而且整理得不好。因此，它们通常不完整，而且很难及时获取。本文的作者提出了构建和表示患者护理记录的方法，设计了将基于XML的患者护理记录解释并集成到现有医院信息系统中的机制。更重要的是，在我们的方法中，每一份重要的医疗记录都根据XML的语法和语义与一个标签相关联。基于XML的医疗记录使计算机能够在网络上捕捉文档的含义和结构。作者开发了一个统一的转诊信息系统，患者护理记录可以在医院之间通过互联网共享。它不仅可以促进转诊过程，还可以维护来自不同医院的患者医疗记录的完整性。该系统的工作流程基本遵循现有的手工系统，并且很容易进行调整。台北市政府卫生局市立医院信息系统整合工作小组已决定采用该系统用于市立医院之间的转诊实践。
