Development of a Medical Terminology Coding System for Electronic Medical Records Platform

[[abstract]]由於臺灣各醫院機構所自行發展的電子病歷系統架構中，系統規格、資料欄位及院內代碼不盡相同，而且醫院針對電子病歷標準建置所需的詞彙代碼與各醫院所使用代碼也不完全相同，因此在進行病歷資料交換時就會有代碼資訊不一致的問題發生。 本研究建置一套符合國內的電子病歷交換標準之詞彙代碼系統平台，利用健康資訊交換第七層協定所提出的通用術語服務概念，並以現行衛生署所公告四類交換單張標準、診所層級單張及電子健康記錄摘要單張共計13個單張，將收集的詞彙代碼類別資訊建置於資料庫中，藉此達到電子病歷交換時的醫學詞彙代碼一致性。系統功能包括：詞彙代碼查詢與Web Services代碼服務及資料庫管理等功能，透過系統所提供的服務取得符合臨床文件架構中的編碼資訊，讓各醫療院所在製作電子病歷文件都能有一致性的代碼資訊，促進醫療資訊交換標準的發展。 The Electronic Medical Records (EMR) systems in Taiwan hospitals are different between their self-built systems of specifications, data fields, coding architecture, and also medical vocabulary, making it inconsistent during the code information exchange of medical records. In this study, we use the Health Level Seven’s (HL7) Common Terminology Services (CTS) concept to design a set of electronic medical records exchange standard vocabulary code system platform. Referring to the Department of Health standard documents, a total of thirteen documents were used to achieve the exchange of electronic medical records medical vocabulary code with consistency. The database contains all of the vocabulary code class information. The system functions include the medical vocabulary words query/database management With Web Services. The encoding information of words is provided by the system in accordance with Clinical Document Architecture (CDA). Therefore, the hospitals create EMR files with a consistent code, improving the development of medical information exchange