個案管理資訊整合與成效評估—以糖尿病為例

A Research for Information Integration in Case Management Systems of Diabetes Mellitus

由於醫療環境的快速變遷及醫療政策的不斷變革，各醫療機構莫不尋求一套有效的管理方法，來降低成本及改善醫療品質，其中個案管理之照護模式即是醫療產業積極推動之方案。然而在推展個案管理模式中，如何進行資料的整合與優化，一直是個案管理相當大的挑戰，因此本研究目的即運用資訊科技之輔助，建構一套資訊系統來整合臨床路徑、病歷、檢驗檢查、用藥、衛教等相關資訊，以利醫師與個案管理師進行分析及決策之需求，並提供個案管理及相關照護品質之各項指標，以作為品質改善之依據。透過現有資料分析發掘出高危險群、高成本、多發性併發症等適合納入個案管理的潛在病例，以提供健康照護策略規劃之決策依據。個案管理資訊系統發展分成參階段：第一為規劃階段，主要是蒐集相關文獻，整理出系統應該具備的功能，並確立系統功能架構與可行性分析。第二為系統分析階段，根據使用者需求及個案管理作業流程擬訂系統規格。第三為系統開發與評值階段，包括進行系統程式撰寫、系統測試及評估。系統之整體效益經評估發現，個案管理系統可整合各專科醫療活動，並延續社區健康照護之進行，增加醫療照護的有效性與持續性，提昇追蹤病患回診的完整率及滿意度。

Owing to the quick evolution of medical environment and the continued changes in medical politics, the healthcare organizations need to develop an efficient management system to cut down the cost and to improve the medical care quality. Among all the efforts, the case management systems were the care model that the medical industry carried on with enthusiasm. While implicating, to integrate and to tune up the information system was the greatest challenge the case management systems. The object of this study is to construct an information system to integrate clinical path, medical records, laboratory data, medications, and the health care education with the help of information techniques to helps the doctors and the case manager to analyze and to make decisions, to provide the indicators for case management and care quality and the foundation for quality improvement. By analyzing the data collected the high risk group, high cost and multiple complicated cases which were suitable adapted to the case management systems, could be explored to provide the bases for the strategy in health care planning decision. The development of case management information systems included three stages：stage one is planning, aimed to collect relevant references to integrate the functions that the system should hold and to make sure the framework and viability of the system. Stage two is system analysis, to certify the spectrum of the system according to the needs of the users and the processes of the case management. Stage three is system development and evaluation, which included the programming, testing and evaluation of the system. As the efficiency evaluation of the system had revealed that the case management system could integrate the medical activities in all the specialties, and lasting the communities health care processes, adding the efficiency and continuity in health care, and promoting the integration and satisfaction of clinical follow-up.