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互通性電子病歷之辭彚標準-臨床醫學術語系統(SNOMED CT)之現狀與發展
Interoperable Electronic Health Record Terminology Standard - The Current
Status and Development of Systematic Nomenclature of Medicine-Clinical Term
(SNOMED CT)
溫信財
a*、簡文山
a、李友專
b、陳筱如
a a臺北醫學大學醫務管理研究所 b陽明大學生物醫學資訊研究所 E-mail:溫信財，[email protected] 摘要背景與目的：臨床資訊透過互通性電子病歷(Interoperable Electronic Health Record, iEHR)之交換與分享，可達成 醫療機構提升經營效率與促進病人照護品質的目的，近來我國及歐美先進國家均投入巨資發展，而電子病歷的 臨床辭彙標準中，最受各國重視及普遍採用的為臨床醫學術語系統(Systematic Nomenclature of Medicine-Clinical Term, SNOMED CT)。
方法：本研究除採用文獻分析法，整理 SNOMED CT 七個版本之演進及內容外，並以個案研究國內醫院發展現 況，且以訪談方式了解臨床醫師及醫院資訊專業人員在作業內容系統建置上初步之需求。
結果：SNOMED CT 是一強大的臨床醫學術語(reference terminology)系統，它包含超過 344,000 概念(concepts) 、 913,000 描述(descriptions)及 1,360,000 關係 (relationships)，由概念、描述及關係三個可交換互通的資料表(tables) 組成。SNOMED CT 明確的定義醫學概念、同義字(synonyms)及概念之間的語義關聯，注重語義相互操作，並 用類似關聯式資料庫方式，以階層式和關聯性組合概念間的多種關係，於是各類醫事專業人員可在不同照護地 點查閱(index)、儲存(store)、回溯(retrieve)及累總(aggregate)病人臨床資訊，確保其可靠性和連貫性，並減少內 容的變異(variability)，若應用其資訊編碼與參考術語於臨床資料上，除醫事專業人員記載病人病情及癌症登記 外，資訊人員可用於發展電子病歷系統，醫療照護機構可做為支援決策、費用分析和臨床研究之工具，目前已 有美、加拿大、英國等三十多個國家採用。 結論：展望未來，建構 SNOMED CT 辭彙標準將是醫療機構營運之重要競爭利器，亦為醫院資訊建設之必然趨 勢，而此標準之制訂需要政府、醫療機構及臨床、資訊等相關專業人員的積極合作，以建置符合國際之全國性 臨床辭彙標準，使醫療院所及產業有所遵循，達到資料分享、交換及醫療照護品質提昇的目的。 關鍵字：互通性電子病歷、臨床醫學術語系統 Abstract
Background: Exchange and sharing clinical information through Interoperable Electronic Health Record (iEHR) have
improved healthcare organizations efficiency and enhance patient quality care. Taiwan also has invested million dollars in health information technology following US and many Europe countries steps. Systematic Nomenclature of Medicine-Clinical Term (SNOMED CT) has become the most important and adopted clinical terminology standard by these countries which keep developing EHR.
Methods: The development of 7 different versions of SNOMED CT was explored by literature review. The current
application of SNOMED in domestic hospital and the need of clinical and information departments have also approached by case study and individual interview.
Results: SNOMED CT is a powerful reference terminology which contains more than 344,000 concepts,
13,000 descriptions and 1,360,000 relationships. Clinical data are exchanged and interoperated by concept, descriptions and relationship tables. SNOMED CT is comprised of definite medical concepts, synonyms and semantic relationship. The hierarchal and correlated multiple concepts were operated by semantic connection as similar as correlative databases used in information system. The various clinicians could index, store, retrieve and aggregate patient clinical data in different places. Therefore, the data reliability and consistency were assured and the variability was also reduced. The codes and terms of SNOMED CT were applied in clinical data not only for documentation and cancer registry but also applied in developing EHR systems, decision supporting, cost analysis and used as research tool. More than 30 countries has adopted SNOMED CT such as US, UK and Canada.
Conclusions: SNOMED CT could be a sound competitive tool for hospital management and an essential part for future
information system development. The national clinical terminology standard should be followed by medical care industry which needs the collaboration of government, healthcare organizations, clinical and IT experts. Then the goals of information exchange and enhance of quality care could be achieved.
Keywords：Interoperable Electronic Health Record, SNOMED CT
