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

A typical electronic medical record (EMR) are produced from hospital information systems, which includes HIS, LIS, NIS and from many different departments. Usually, the data of EMR is stored in a database containing many tables and can not be used and presented independently. Therefore, in this study, we used the XML technology to present and make the EMR. The interoperability of a healthcare data and system can be viewed by two directions: the functional interoperability and semantic interoperability. At the mean time, there is no single EMR standard that can provide complete EMR interoperability. In a national project that supported by the government of Taiwan, we have established a national EMR standard templates. The Taiwan Electronic Medical Record Template (TMT) is a standard that will provide an ontology and data schema to achieve semantic interoperability of EMR for different hospitals in Taiwan. Four parts are included in TMT architecture: the forms (sheets), the components, the sections, and the elements (data). Forty one code set are designed by this project and the data can be presented by data type and code set. The narrative block was also designed to contain the human readable text. Four requirements are the basic ideas of TMT: (1) being compatible with international medical information standards, such as HL7 CDA; (2) having few impacts on the existing hospital information system; (3) easy to understand and easy to be implemented and deployed, and (4) Modifying the regulations of EMR if needed.