管理式照護為基礎之新一代醫療資訊系統-以論質計酬為例
A New Medical Information System Based On Managed Care- A
Case Study of Fee-For-Quality
中文摘要
管理式照護在美國行之多年，全民健康保險局自民國九十年十一月一日起推行醫
療給付改善方案，以降低醫療浪費與提昇醫療品質。醫療給付改善方案之試辦計
劃包括子宮頸癌、乳癌、肺結核、糖尿病、氣喘等，本研究以乳癌為例，將有限
狀態機原理應用於乳癌之個案管理中，藉此解決論質計酬對醫院資訊系統申報作
業問題與追蹤個案之困難。
本研究所建立之新系統效益乃利用有限狀態機管理系統提昇對個案管理的績效
與改善醫療品質，同時可整合各類不同之申報制度。無論在論量計酬或論質計酬
之下皆能藉由有限狀態機之機轉解決傳統醫院資訊系統橫跨不同系統如門急
診、住院、居家照護申報上的困難。對於存在個案相關的醫療資訊，也可有系統
的收集、監控、儲存、傳遞、分享、和利用的過程與管理。更加入品質之概念如
管理式照顧與臨床路徑於新系統中。因此不但可降低疾病復發的醫療成本，更可
提高癌症存活率。
本研究同時利用管理式照護為基礎之系統，將論質計酬所支付的點數作為依據與
過去及現在之醫療費用做比較，以作為醫療費用之參考與依據並達到費用控制的
目的。
英文摘要
Managed care has been practiced in the United States of America for years. Since 1989, the Bureau of National Health Insurance has also launched this program to reduce medical expenses and to increase medical quality. This trial program includes cervical cancer, breast cancer, diabetes and asthma. The purpose of this case study is to apply the theory of Finite State Machine (FSM) into the management of Breast Cancer''s patients and solve the problems arose in the preparation of Fee-For-Quality declaration reports and case-tracking.
In this study, the new system was to incorporated the FSM system in order to improve the efficacy of managed care and the medical quality. Moreover, this system also integrated all kinds of declaration policies. No matter of what kind of policies, Fee-For-Service or Fee-For-Quality, the FSM is capable of solveing the problems occurred in the traditional hospital information system including
emergency patients, inpatients, outpatients, and home-care patients. The health information of individual cases was collected, stored, transported and shared. All the related procedures of using those information were also monitored. The
conception of quality, i.e., Managed care and Clinical Path were well incorporated into the new system. In conclusion, the new system no only effectively reduced the cost of recurrence, but also increased the survival rate of cancer patients.
The system was based on managed care. According to the account of
Fee-For-Quality payment, we tried to compare the current cost with that in the past, and finally to reach the purpose of cost control.
