Generation, Storing and Management System for Electronic Discharge Summaries Using HL7 Clinical Document Architecture

HL7 표준임상문서구조를 사용한 전자퇴원요약의 생성, 저장, 관리 시스템

  • 김화선 (경북대학교 의료정보학교실) ;
  • 김일곤 (경북대학교 컴퓨터과학과) ;
  • 조훈 (경북대학교 의과대학 의료정보학교실)
  • Published : 2006.04.01

Abstract

Interoperability has been deemphasized from the hospital information system in general, because it is operated independently of other hospital information systems. This study proposes a future-oriented hospital information system through the design and actualization of the HL7 clinical document architecture. A clinical document is generated using the hospital information system by analysis and designing the clinical document architecture, after we defined the item regulations and the templates for the release form and radiation interpretation form. The schema is analyzed based on the HL7 reference information model, and HL7 interface engine ver.2.4 was used as the transmission protocol. This study has the following significance. First, an expansion and redefining process conducted, founded on the HL7 clinical document architecture and reference information model, to apply international standards to Korean contexts. Second, we propose a next-generation web based hospital information system that is based on the clinical document architecture. In conclusion, the study of the clinical document architecture will include an electronic health record (EHR) and a clinical data repository (CDR), and also make possible medical information-sharing among various healthcare institutions.

병원정보시스템(Hospital Information System)은 다른 병원정보시스템과 서로 독립적으로 운영되므로 상호운영성(Interoperability)이 배제되어 왔다. 이 연구는 HL7 표준임상문서구조(Health Level 7, Clinical Document Architecture)와 XML 스키마의 분석과 설계를 통하여 새로운 패러다임의 병원정보시스템을 제안한다. 퇴원요약지로부터 필수 항목을 규정하여 템플릿을 정의한 후 임상문서구조를 설계하여 자동적으로 임상문서를 생성되도록 하였다. XML 스키마는 HL7에서 정의한 참조정보모델(Reference Information Model)을 기반으로 분석하였고, 전송 프로토콜은 HL7 V2.4를 사용하였다. 본 연구가 가지는 의의는 첫째, 국제 표준인 HL7 표준임상문서구조를 사용하기 위한 확장과 정제과정의 연구를 했으며, 둘째, 표준임상문서구조를 사용할 수 있는 웹 기반의 차세대 병원정보시스템의 구조를 제안하였다. 결론적으로, 한국의 퇴원요약 표준임상문서구조에 대한 본 연구로 말미암아 평생전자의무기록(Electronic Health Record)과 임상데이타저장소(Clinical Data Repository)를 포함하여 다양한 보건의료기관 간 의료정보 공유의 기반이 될 것이다.

Keywords

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