設計與實作一個具有即時產生診療記錄能力的多媒體註解工具 -以健康檢查為例

Abstract

由於醫療資訊的快速發展，目前許多國際組織正致力於發展各種醫療資訊標準，例如醫療影像上的DICOM標準、HL7(Health Level Seven)是醫療資訊科技上共通性標準，在臨床病歷上定義了CDA(Clinical Document Architecture)醫療資訊系統間交換電子病歷格式的標準等。 病人在醫院進行檢查時，會需要經過許多精密的醫療設備檢查，最後產生數位化的醫療影像，醫生會根據這些檢查結果進行診斷，並簡單的在病歷上記下診斷結果，看診完後有時間才會使用醫療影像註解系統在醫療影像上進行詳細的註解。由於需要花費額外的時間去做註解工作，導致醫師使用醫療影像註解系統的意願降低。且醫師在病歷上所記錄的內容與向病患講解的內容並不一致，因此保留最完整的看診內容將可保障醫病雙方的權益。 由於目前的註解系統缺乏即時記錄的能力，為了能使醫師在看診當下便能即時將過程記錄，並在看診完後將看診過程記錄下來產生一份醫學內容，作為醫療影像上的註解或是看診過程中的完整紀錄，以替醫師省下事後註解的時間，並提升醫師使用註解工具的意願。因此特別在註解工具的功能上新增畫面錄影及錄音的能力，並於本論文中說明如何使用此工具配合醫師看診S.O.A.P.四個階段來使用，使每一次的看診都能詳實的記錄下看診過程。 醫師替病人安排檢查時，時常需要新增或刪除一些檢查項目，本論文考量此需求，亦提供樣版抽換的能力，將每個檢查項目樣版化，醫師可以利用此功能客製化病人的檢查表，快速制定出適合病人的檢查內容，以便日後評估病人的狀況。 本研究所產生的診療紀錄檔格式是依照HL7-CDA標準所制定，CDA是目前國內外臨床醫療資訊系統所通用的格式，因此本研究所產生的診療紀錄檔具有可被國內外的臨床醫療系統所共用，以提升本研究的可用性。

The rapid development of medical information leads many international organizations committed to develop a variety of medical information standards. Such as DICOM standard is developed for medical imaging. HL7 (Health Level Seven) is a standards of health information technology and CDA (Clinical Document Architecture) defines the standards of health care information systems to exchange electronic medical record in clinical medical records. Patients are examined through lots of sophisticated medical examinations in the hospital. After those procedures, the digitized medical images would be eventually produced. The doctor would diagnose the patient`s health based on these examination results and write down the diagnostic results on medical records briefly. After then, he has to spend more time to annotate on medical images in detail by using medical image annotator. Time problem described above leads the doctor to decline the willingness of using the medical image annotator, which causes the inconsistence between what the doctor writes down on medical records and what he explains to the patient. Therefore, to retain the most complete medical records would protect the rights of doctors and patients. The main purposes of this study are saving time for doctors and enhancing the willingness of doctors to use the annotator, and generate the complete medical record while seeing patients, since the annotator in present lacks of the ability of real-time recording. The medical records annotator provides the ability for doctors to record the process of seeing patients at the same time, and produce a medical content as medical image annotation or a complete record of medical records. In this study, the real-time screen recording and audio recording functions are attached in the medical records annotator, and presents about how a doctor uses it in four stages of S.O.A.P. every time to record the process of seeing patient in detail. The annotator provides templates for each medical examination for doctors to switch examination easily to generate different medical records for patients, such ability fulfill the demand for quickly arranging personalized examinations for patients. The format of medical record file produced by the annotator in this study is followed by HL7-CDA , which is a general format of clinical information system in present. Hence, the medical records produced by the annotator could be applied to the clinical medical system all over the world to enhance the usability of this study.