| Summary: | 博士 === 國立臺灣大學 === 生醫電子與資訊學研究所 === 102 === 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.
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