輔仁大學

醫學資訊與創新應用學士學位學程

醫療標準及術語

Electronic Medical Records

臺北市立聯合醫院仁愛院區家庭醫學科

郭冠良

Kuan-Liang Kuo, M.D., Ph.D.

2019-04-30

1

Course

2

Date Topic (Lecture/Student representation)

Teacher

2019-04-30 EMR 郭冠良

2019-05-07 EMR 郭冠良

2019-05-14 ICD 郭冠良

2019-05-21 CDSS 郭冠良

2019-05-28 CDSS

2019-06-04 CDSS 郭冠良

2019-06-11

W3C standards applicable to Health Care / Panel discussion

郭冠良

2019-06-18 期末考 郭冠良

Reference

3

Outline

• Introduction

• Meaningful Use

• Information System Development

• Hospital Information System

• 電子病歷與電子簽章

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Introduction

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病歷 (Medical Records)

• 醫療法第67條，病歷應包括下列各款之資料：

– (1) 醫師依醫師法執行業務所製作之病歷。

– (2) 各項檢查、檢驗報告資料。

– (3) 其他各類醫事人員執行業務所製作之紀錄。

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病歷 (Medical Records)

• 醫師法第12條： – 醫師執行業務時，應製作病歷，並簽名或蓋章及加註執行年、月、日。

– 前項病歷，除應於首頁載明病人姓名、出生年、月、日、性別及住址等基本資料外，其內容至少應載明下列事項：

• (1) 就診日期。

• (2) 主訴。

• (3) 檢查項目及結果。

• (4) 診斷或病名。

• (5) 治療、處置或用藥等情形。

• (6) 其他應記載事項。

– 病歷由醫師執業之醫療機構依醫療法規定保存。 7

Why EMR

優點 缺點

紙本病歷

電子病歷

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EMR優點

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• 減少紙張文具耗費

• 容易保存

• 病歷共用

• 病歷交換*

• 整合臨床決策支援系統

• 資料庫 – 提昇病人的照護品質

– 提昇醫療行政效率

– 便於教學研究

• 符合meaningful use*要求

• …

台灣EMR發展軌跡

• 民國84年3月1日，開始實施「全民健康保險」

• 民國92年，健保局完成全民健保卡全面IC

卡化，並在每次看診時上傳伺服器

• 92年，正式營運「醫事憑證管理中心 HCA」， 8家醫療院所病歷電子化試辦

• 94年，公告實施醫療影像及報告、門診用藥紀錄、出院病摘及血液檢驗報告四張電子病歷

• 98年通過，在2年內建立電子病歷交換中心(EEC)

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名詞

• 醫療資訊系統 (Hospital Information System, or Healthcare IS, HIS) – 醫院所有資訊系統的整合，包含醫療、管理、財務等等

– 醫療部分包含醫令系統 (Computerized Physician Order Entry, CPOE)、檢驗系統(Laboratory IS, LIS)、放射科系統(Radiology IS, RIS)、影像系統( Picture Archiving and Communication System, PACS)、護理系統(Nursing IS, NIS)等等

– 非醫療部分包含企業資源規劃(Enterprise Resource Planning, ERP)各種子系統、主管支援系統 (Executive IS, EIS)等等

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名詞

• 病歷電子化

– 以電子文件方式完成之病歷。

• 電子病歷

– 依「醫療機構電子病歷製作及管理辦法」以電子文件方式製作及貯存之病歷。

• 電子簽章

– 指依附於電子文件並與其相關連，用以辨識及確認電子文件簽署人身分、資格及電子文件真偽者。

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名詞

• 臨床文件架構 (Clinical Document

Architecture, CDA)

– 由HL7組織發展，使用 XML ，產出電子病歷表單的相關文件的架構

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電子病歷內容的來源

• Front-end (by patients’ perspectives)

– Hospital Information System (HIS)

• Computerized physician order entry (CPOE)

– Picture Archiving and Communication System

(PACS)

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電子病歷內容的來源

• Back-end (by patients’ perspectives) – Hospital Information System (HIS)

– Laboratory Information System (LIS)

– Radiology Information System (RIS)

– Enterprise Resource Planning (ERP) • Business Process Reengineering (BPR)

• Supply Chain Management (SCM)

• Human Resource (HR)

• Customer Relationship Management (CRM)

• …

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電子病歷內容的來源

• 醫療事務單位

– 基本資料

• 醫療院所

• 醫師

• 病人

• 對應資訊系統

– HIS之醫事子系統

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電子病歷內容的來源

• 門診 (SOAP) – Subjective

– Objective

– Assessment • Diagnosis

– Plan • 藥品

• 檢查

• 對應資訊系統 – HIS之門診醫令系統

(CPOE)

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電子病歷內容的來源

• 出院病摘 – 主訴

– 病史

– 理學檢查

– 入院診斷

– 檢驗報告

– 治療經過

– 出院指示

– 出院診斷

• 對應資訊系統 – HIS之住院子系統

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電子病歷內容的來源

• 放射科

– 影像

– 報告

• 對應資訊系統

– PACS與RIS

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電子病歷內容的來源

• 檢驗科

– 血液檢驗報告

• 對應資訊系統

– LIS

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電子病歷內容的來源

• 健檢中心

– 健康檢查報告

• 對應資訊系統

– 健檢系統

– HIS各子系統

• LIS

• RIS

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廣義的HIS

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RIS

LIS

ERP

PACS

CPOE

Clients

HIS

產生電子病歷

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RIS

LIS

PACS

Gateway:

•XML

•Signature

ERP

CPOE

EEC

EMR

Data source

資料格式

• 病歷電子化 • 電子病歷

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國情不同

• EMR

• HIS – CPOE

– LIS

– RIS

– PACS

– NIS

– EIS

– ERP • SCM

• CRM

• HR

• 國內 vs 國外的認知的EMR

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Meaningful Use

美國EMR發展的軌跡

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Meaningful Use

• Meaningful use of health information

technology

– What does it mean for practicing physicians?

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Meaningful Use

• Using a certified EHR technology in a demonstrably meaningful way

• Using certified EHR technology that allows for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination

• Reporting on clinical quality and other measures selected by the secretary of Health and Human Services (HHS) using certified EHR technology

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Meaningful Use

• Medicare鼓勵與懲罰方案

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Meaningful Use

• Medicaid鼓勵方案

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What is Meaningful Use?

• Centers for Medicare and Medicaid

Services (CMS)

– 3階段MU要求 (2011~2015)

31

Stage 1

• focused on promoting the adoption of

certified EHR technologies.

• This initial stage established requirements

for the electronic capture of clinical data

and giving patients access to electronic

copies of their own health information.

32 Ref: https://searchhealthit.techtarget.com/definition/meaningful-use

Stage 2

• expanded upon stage 1 criteria by

encouraging the meaningful use of CEHRT.

• This stage emphasized care coordination

and the exchange of patient information.

• It increased the thresholds of criteria

compliance and introduced more clinical

decision support, care coordination

requirements and patient engagement rules.

33 CEHRT: Certified EHR Technology

Stage 3

• focused on using CEHRT to improve health

outcomes by implementing protected health

information, e-prescribing, clinical decision

support, computerized provider order entry,

patient provider access, coordinated care

through patient engagement, health

information exchange, clinical data registry

and case reporting.

34

Meaningful Use and the Shift to

the Merit-based Incentive

Payment System • With the introduction of the Medicare Access and

CHIP Reauthorization Act (MACRA), the Medicare EHR Incentive Program, commonly referred to as meaningful use, was transitioned to become one of the four components of the new Merit-Based Incentive Payment System (MIPS), which itself is part of MACRA.

• MIPS harmonizes existing CMS quality programs (including meaningful use), the Physician Quality Reporting System, and Value-Based Payment Modifiers. MIPS consolidates multiple, quality programs into a single program to improve quality care.

35

ONC: Office of the National Coordinator for Health IT

MACRA: Medicare Access and CHIP Reauthorization Act, 2015

Meaningful Use and the Shift to

the Merit-based Incentive

Payment System

36

Stage 1 MU

37

Stage 1 MU

Core Objectives • Must

38 https://www.cms.gov/eHealth/downloads/eHealthU_IntroMedicaidEHREPs.pdf

Stage 1 MU

Core Objectives

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Stage 1 MU

Menu Objectives • 5 out of 9

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45

46

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48

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50

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Stage 1 MU

Clinical Quality Measures (CQM)

• 9 CQMs for adult populations that meet all of the program requirements

• 9 CQMs for pediatric populations that meet all of the program requirements

• These recommended core sets focus on – Conditions that contribute to the morbidity and

mortality of most Medicare and Medicaid beneficiaries

– Areas that represent national public health priorities or disproportionately drive health care costs.

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64

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Things to Remember about

CMQs

• Your certified EHR does all the work—it calculates the measures and gives you the numbers you report to CMS.

• Select and Report 9 measures of a possible list of 64 approved CQMs.

• EPs are not excluded from reporting CQMs, but zero is an acceptable value.

• There are no minimum values that you must achieve for clinical quality measures. You only have to report on them, not achieve a benchmark. (不比較)

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Stage 2 MU

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Stage 2 MU

• REQUIRED for All Providers in 2015

through 2017

– Single Set of Objectives and Measures

– Alternate Exclusions and Specifications

– EHR Reporting Period

– Patient Electronic Access (VDT)

– Secure Messaging

– Public Health Reporting

68 VDT: View, download, and trasmit

Stage 2 MU

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Stage 2 MU

Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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Stage 2 MU Objective and Measure

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CEHRT: Certified EHR Technology

Stage 2 MU Objective and Measure

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CEHRT:

Certified

HER

Technology

2017

EP

Stage 2

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2017

EH

Stage 2

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2018

EP

Stage 2

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2018

EH

Stage 2

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2018

EP

Stage 3

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2018

EH

Stage 3

Thanks for your attention

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