以資通訊技術強化健康照護的連續性--以糖尿病照護為例

Facilitating the Continuity of Healthcare with Information Communication Technology --- an Empirical Study Applied in Diabetes Care

陳俐瑾(Lichin Chen)

指導教授 ： 賴飛羆

國立臺灣大學/電機資訊學院/生醫電子與資訊學研究所/博士(2014年)

https://doi.org/10.6342/NTU.2014.01797

摘要

近年來隨著疾病型態的改變，不同於以往的急性治療，慢性疾病已經成為民眾主要的健康問題。治療的型態同樣不再以單一事件的治療、看診為基礎，漸漸的需要將病人於不同時間的狀態予以綜合評估，且整合不同的醫療專業，提供更為連續性的健康照護。我國國民健康局於民國90年10月起陸續推出子宮頸癌、乳癌、肺結核、糖尿病、氣喘等五種疾病的個案管理加成給付及疾病套裝組合方案，提升個案管理的推行誘因，顯示醫療服務的轉型與整合性醫療的重要性。研究發現，透過資訊技術的輔助，可以強化照護的連續性，近年來更成為各家醫院面對醫療型態轉變的重要工具。
觀察照護的連續性主要可區分為病患的觀點與照護者觀點。以病患的觀點而言，照護的提供是以人為中心，提供衛教且增加病患的健康意識以及自我健康照護的能力。在衛教的過程中提供醫療專業的輔助、生活型態改變的建議，並且於平時與病患保持聯繫，定時追蹤且瞭解病人的健康狀況。以醫療照護者的觀點而言，照護的連續性代表著醫療團隊之間達到跨領域的合作，整合不同專業的人員的知識，提供病人整合型的照護。過程中每位成員與成員之間的合作、溝通與訊息分享皆是重要的環節，並且透過妥當的流程設計達到無縫式 (Seamless)的醫療照護。同時，不同於過去定點式的照護 (Point of care)，連續性照護強調以長時間的觀點觀察醫療照護的品質與過程，透過整合與跨時間的追蹤與接軌，以瞭解整體照護過程的品質與病患照顧的結果。
糖尿病是一種慢性疾病，且已經成為國人的十大死因之一，糖尿病的照護大量的仰賴病患的自我健康照護以及生活型態改變。糖尿病併發症的預防需要整合多重專業的醫療人員之間的合作、溝通與訊息分享，進行疾病的篩檢、檢驗、衛教，同時需要跨時間的追蹤病患狀態。本研究利用資訊技術，針對連續性照護的四大特性，強化糖尿病照護中的連續性。本研究利用資通訊技術分別針對連續性照護中，病患與醫療照護人員的觀點進行輔助，並且最後透過一臨床試驗以及資料倉儲的相關技術進行整合性、長時間的病患照護觀察與評估，呈現出病患於自我健康照護的行為改變與血糖的控制情形。
整體而言，研究結果顯示資訊技術運用於糖尿病照護，不論是輔助病患或是醫療照護人員，皆可獲得正向的輔助結果。對於病患而言，病患的血糖、血壓變化皆漸趨穩定、自我健康意識提升、有效的強化自我健康照護的相關知識；個管師與衛教師之作業流程獲得改善，輔助人員之間的溝通、訊息分享以及臨床指引的遵循；同時，整合性的分析顯示病患於院外輸入的資料的可信度，並且可以進階的分析衛教師面對病患問題時所進行的照護策略，長期而言可以作為發展臨床指引、現行照護行為的檢討、以及未來發展臨床決策支援系統的基礎。

關鍵字

糖尿病 ； 連續性照護 ； 健康資訊技術 ； 自我健康管理 ； 疾病管理 ； 遠距照護 ； 資料倉儲

並列摘要

Patients nowadays are increasingly seen by healthcare providers in a wide variety of organizations and places, which raises the concerns about fragmentation of care. Many believe that the fragmentation can be elaborated through greater integration of healthcare delivery and higher continuity of care. The continuity of care is advocated as a cornerstone or an essential element of general medical practice. It is defined as the coordination of patients and care providers in the care process and work together throughout the course of illness across settings. The discussions of the continuity of care are many. Two main perspectives can be defined, one is from the view point of patients and the other is from the perspective of care providers. From the perspective of patients, the continuity of care was viewed as a continuous caring relationship. The care is tailored into individual needs and the disease is managed in the content of the patients’ life based on the long-term relationship and the knowledge of patient’s condition and personal contents. From the perspective of healthcare professionals, the continuity of care is a process of seamless care delivery. It is a team-based approach, and involves in the coordination, communication, and information sharing among multidisciplinary providers. Meanwhile, the healthcare settings nowadays were usually lack of integration. When it comes to evaluate patient’s performances and outcomes, it is commonly done individually and rarely considered other healthcare services that the patients received. This study aimed to facilitate the two perspectives of continuity of care with technologies, empowering patients’ ability in self-management and enhancing the team work of disease management. Also, this study offers an opportunity to observe patient conditions and evaluate patient outcomes across settings through the integration of data, and was initially applied the care of diabetes.
The proposed architecture framework in this study has generally a positive outcome in supporting the care of diabetes. Patients have shown more stabilized in the variation of blood pressure and blood glucose control. The program raises the self-awareness of patients and increases the ability of patients in self-management. The workflows of the case managers and the certificated diabetes educators have been reform, the communication and information sharing among providers had been supported, and that the system acts as a guideline to support the educators during education. The investigation of the education strategies of certified diabetes educators (CDE) is potential in the development of clinical guidelines and the validation of the effectiveness of current strategies. The analysis of longitudinal data and patient outcomes reveals patterns and phenomenon that was not previously noticed. The result shows that implementing information communication technology in diabetes care has a positive outcome and provides more insight and opportunities in observing patient outcomes.

並列關鍵字

Diabetes mellitus ； continuity of care ； health information technology ； self-management ； disease management ； telehealthcare ； data warehouse

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