電子病歷資訊儲存平台的未來

Abstract

病歷是紀錄病患病情的重要文件，病歷的功能除了以醫療人員的專業將病情詳實紀錄之外，還具有教學傳承的意義，因為病歷的內容是年輕醫療人員參考前輩醫師及相關醫療團隊治療病患的依據，因為治療疾病的經驗法則是最有意義的教學資料。此外，現代醫學的發展與法律人文偶有交集，所以病歷本身也可以成為法律上的重要憑證，因此近代醫療的法律事件中，病歷的記載是保護病患及優秀醫療人員的利器。過去的紙本病歷的紀錄具有歷史文獻的價值，也有人文史觀的意義，但是如何妥善的保存，始終是醫療單位空間上，最具爭議性的考量。目前我國的醫療法規上的規範，是將病歷的保存年限定為七年，所以在醫療院所停止執業後，或是病歷滿七年後，病患的過往病歷即可能永久的銷燬，其實是人類壽命大幅延長後的一大困擾，因之，電子化病歷的革命是全球電腦化後的必然趨勢，因為保存病歷的空間問題，得以順利解決。再者，電子病歷的保存介面可以分為文字及影像的紀錄，透過網路的運作，病歷可以在安全的防護機制下，流通於相關的醫療院所，這種方便性考慮的深層具有兩種意義，其一在於病歷流通的便捷性，可以簡化病患的求醫難度，減少醫療浪費及強化醫療資訊的即時性；其二在於過去的病歷在人文方面的缺失，就是病歷代表醫療資訊的不對稱及不透明化，但是病歷電子化的過程，解決了保存病歷的問題，所以病歷的擁有權將逐步回歸到病患本身。這些病歷紀錄及保存的相關議題，將在未來的若干年內，實質的改變醫療的型態，也會讓醫療人員更注重病歷的詳實記載。近年來，許多的資訊產業界開始注意到健康產業的前景，所以未來如何妥善的規劃病歷，乃至於個人健康資訊的方式，將成為重要的課題。本研究的目的，在於回顧過去的電子病歷發展歷史軌跡，希望能發展出電子病歷化的產業經濟用途，特別是當電子病歷流通平台建立後，建立醫療資源稽核機制，以及病患處置用藥安全的管理，進一步在區域或跨國醫療中，看到電子病歷的有效應用。

Anamnesis (medical record) is an important document for recording disease progression for certain patient and diagnostic procedure for medical practitioners. Therefore, anamnesis is also meaningful for medical students in education, because anamnesis recorded therapeutic strategies or pathways used by experienced medical staffs. Meanwhile, medical record could be the certification, and may play a pivotal role in medical legal issues. The correct recording from anamnesis would be a useful tool in protecting not only excellent medical practitioners but human right of patients. Conventional medical anamnesis was recorded in papers, and such documents could be emphasized their value in humanism and art. However, the difficult issue for preserving such precious documents was still unresolved. In Taiwan, the medical anamnesis was regulated to be destroyed by burning after preserving for seven years. Thereafter, the medical record will be lost forever. In 21th century, electronic anamnesis could be expected a newer preserving pathway for medical record in various forms, including literalness and images. Information-storing platform for anamnesis should be considered to be the media between different clinics or hospitals. Such platforms could be expected to be more convenient for medical practitioners to obtain immediate information of certain patients, and such platform will decrease the information imbalance between physicians and patients. In our research, we reviewed the development of electronic anamnesis in departed decades, and we hope to establish the concept of electronic anamnesis in localized or even in multinational medical systems for establishing individual medical records via specification in such information-storing platforms.