- 學位論文
應用健保IC卡建置門診病人跨院用藥安全提示系統之研究
Using NHI IC Cards to Design a Reminding System for Outpatients
摘要
動機：台灣的醫療照護十分便利，病人可以利用健保IC卡到大部分的醫院就醫。但是，病人的醫療資訊在各個醫療院所之間並不相互流通。而不同的醫療院所開立的處方可能導致醫療錯誤的發生。 目的：本研究利用健保IC卡來建置用藥安全提示系統並且與醫令系統結合，根據FDA(Food and Drug Administration)藥物的懷孕用藥分級與依照ATC (The Anatomical Therapeutic Chemical) CODE制定的藥品資料庫，當病人的健保IC卡中仍有服用中的藥品紀錄並且醫師開立的處方有跨院重複用藥、跨院藥物交互作用、懷孕用藥分級C、D、X級的藥品、小兒疫苗重複時，提供醫師跨院重複用藥提示、跨院藥物交互作用提示、懷孕用藥提示、小兒疫苗重複提示。 方法：利用健保IC卡建立跨院重複用藥提示、跨院藥物交互作用提示、懷孕用藥提示、小兒疫苗重複提示系統，架構在電腦醫令系統中，於醫師開立檢查時，在讀取病人健保IC卡且發現，病人目前仍有服用中藥物的情況下，自動檢核跨院藥物交互作用、跨院藥物交互作用、懷孕用藥提示、小兒疫苗重複，並跳出提示畫面提供相關資訊，供醫師開立處方時的參考。透過單組前後測實驗來評估，希望可以透過系統的介入減少醫師開立給病人的處方與其他醫療院所所開立的處方產生重複用藥或是藥物交互作用，也減少開立給孕婦FDA(Food and Drug Administration)懷孕用藥等級C、D、X的藥品，並且減少對病人重複施打疫苗。另一方面，檢視醫師是否接受提示系統的提示而修改本次的處方。 結果：本研究於北市某醫學中心進行實驗。跨院重複用藥與跨院藥物交互作用及疫苗重複的介入實驗期間為2007年3月至6月，而2007年1月至2007年3月為無介入的對照期間。跨院懷孕用藥分級的介入實驗期間為2006年1月至3月，而2005年10月至2005年12月為無介入的對照期間。 實驗組的三個月中，提示系統分別提示跨院重複用藥146筆與跨院藥物交互作用3筆、懷孕用藥分級9筆及小兒疫苗重複提示5筆，與前測資料利用無母數統計的兩個相關分析發現，重複用藥的前後測相關顯著性為0.337；藥物交互作用的前後測相關顯著性為0.2965；懷孕用藥分級的前後測相關顯著性為0.034；疫苗重複的前後測相關顯著性為0.0215，除懷孕用藥分級與疫苗重複的顯著性<0.05顯示前後有差異外，其餘兩項提示的顯著性皆>0.05，顯示系統介入後醫師仍不會主動讀取病人健保IC卡的資料，重複用藥與藥物交互作用的提示比例不因系統介入而下降。醫師在被提示系統提示後，在重複用藥方面，146筆處方被提示，其中有36張處方的藥品被刪除，修改率為24.66%；在跨院藥物交互作用方面，一共有3張處方被提示，其中有1張處方醫師接受提示刪除本次藥品修改率為33.33%；在懷孕用藥提示系統提示方面，9張處方受到提示系統的提示，其中有3張處方被修改，修改率為33.33%。小兒疫苗重複部分， 5張處方被提示，有4張處方醫師在受到提示後，刪除了被提示為已施打過的疫苗，修改的比例為80%。 結論：在系統介入後，提供了醫師更多病人的用藥資訊，加上主動式的提示，提高了病人的用藥安全。許多情況下，雖然醫師並未因提示系統而修改處方，但醫師會因此重新檢視處方，例如重複用藥的部分就有23.64% (26/110)是醫師重新檢視處方後仍決定不修改的，這在病人安全上已是相當有意義的行為，當然對病人安全，也有一定的助益。
並列摘要
CONTEXT Medication care is very convenient in Taiwan. Patients can go to most of hospitals with NHI IC card; meanwhile, the information of patients can not be circulated among hospitals. However, the prescription prescripted by different hospitals may result in medication error. OBJECTIVES We take advantages of National Health Insurance (NHI) IC cards where medical care records are required to be written in there when the card holders receive their medical care. We have enhanced a CPOE system by adding interface modules to communicate with NHI IC card readers, a pregnancy drug database based on the FDA pregnancy categorization, a NHI medicines database decoded by The Anatomical Therapeutic Chemical (ATC) classification systematc based on the NHI website, a drug-drug interaction database, and an alerting module to generate alerts when a doctor prescribes medicines. The alerting module includes duplicate medications reminder, drug-drug interaction reminder, pregnant patients’ prescriptions fall into FDA pregnancy category C, D and X or repeat inoculation. INTERVENTION We have developed a CPOE system that provides alerts online to the doctors when the system detects the prescription had duplicate medicine or drug-drug interaction or their patients are pregnant and the prescribed medicines that fall into FDA pregnancy category C, D and X or repeat inoculation. METHOD: Duplicate medication reminder, drug-drug interaction reminder and repeat inoculation reminder was activated on the CPOE in one medical center for a 3-month intervention period from April to June 2007. Pregnant medication reminder was activated on the CPOE in one medical center for a 3-month intervention period from January to March 2007. RESULTS There were 146 duplicated medication had been reminder. Doctors’ responses to the reminder can be categorized into ignored (75.34%) ,alerted with deletion of the drugs (24.66%). There were 3 drug drug interaction had been reminder. Doctors’ responses to the reminder can be categorized into ignored (66.67%) ,alerted with deletion of the drugs (33.33%). There were 9 pregnant prescription fall into FDA pregnancy category C, D and X had been reminder. Doctors’ responses to the reminder can be categorized into ignored (66.67) ,alerted with deletion of the drugs (33.33%). There were 5 repeat inoculation had been reminder. Doctors’ responses to the reminder can be categorized into ignored (20.00) ,alerted with deletion of the drugs (80.00%). CONCLUSIONS Our finding showed that most prescriptions that had been modified after reminder interventions. The CPOE system that provides alerts to the doctors whose prescriptions containing drugs that may potentially harm patients can reduce medication risks for patients. Although most of alerts were ignored, it is desirable to provide drug use information to healthcare providers to avoid prescription mistakes.