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研究生:簡銘男
研究生(外文):Chien, Ming-Nan
論文名稱:運用安全憑證建構糖尿病人自主管理之網路健康服務系統
論文名稱(外文):Building a Certificate-Based Secure Telemedical Health-Care and Self-Management System for Diabetic Patients
指導教授:劉 立
指導教授(外文):Liu,Li
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:醫學資訊研究所
學門:醫藥衛生學門
學類:醫學技術及檢驗學類
論文種類:學術論文
論文出版年:2005
畢業學年度:93
語文別:中文
論文頁數:109
中文關鍵詞:糖尿病安全憑證網路健康服務糖化血色素空腹血糖
外文關鍵詞:diabetescertificate-basedtelemedical health-careHbA1cFasting glucose levels
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論文名稱:運用安全憑證建構糖尿病人自主管理之網路健康服務系統
臺北醫學大學醫學資訊研究所
研究生姓名:簡銘男
畢業時間:九十三學年度第二學期
指導教授:劉 立 臺北醫學大學醫學資訊研究所 副教授
關鍵詞: 糖尿病,安全憑證,網路健康服務,糖化血色素,空腹血糖

目的
目前,病人安全的觀念日益受到重視。然而現行健保政策為減少民眾就醫次數,鼓勵慢性病患者,使用長達三個月的慢性病連續處方簽。其立意甚佳,惟國人普遍對健康自主管理和糖尿病正確照護觀念尚不足時,若無一個即時警示互動機制提醒病患做好血糖控制,不免讓人憂心是否會因醫病互動減少,導致合併症發生率增加,因而危及病人生命安全?有鑑於此,我們導入一套促進醫病之間更密切互動的糖尿病網路健康服務系統,以填補因門診就醫間隔拉長而產生可能延宕診治的漏洞,並且在確定網路與病人安全及隱私無虞的前提下,協助病患養成正確健康自主管理的能力。若以經濟觀點來看,爰此當可掌握即時有效治療,為政府節省醫療開銷,消弭健保赤字,提昇病患生活品質。

方法

針對在台北醫學大學附設醫院及馬偕紀念醫院門診就醫的糖尿病患,我們架設了一個健康自主管理之服務網站,病患可以透過自然人憑證加入會員,與醫事人員進行網路互動或取得衛生教育相關資訊。並隨時都可以上傳居家血糖機測試值或其他相關資料。而醫事人員得以使用醫事人員卡進行網路健康諮詢服務。並運用公開金鑰( Public key infrastructure)的安全憑證機制,確保資料傳輸安全及隱私性。針對此家族134名會員,我們隨機分組為實驗組(上網登錄血糖) 67名及對照組(未上網登錄血糖) 67名,做為期六個月的網路健康服務對空腹血糖控制及糖化血色素(HbA1c)的影響評估。

結果

這134位會員中,實驗組及對照組其在初次登錄時與三個月後及6個月後之最後一次登記時之空腹血糖平均AC Sugar (mg/dl±SD)變化,我們採用One-way analysis of variance (ANOVA) 分析比較同組前後及Parallel student’s t-test分析比較實驗組與對照組間之差異,在初次登錄時,實驗組(241±77mg/dl)與對照組(252±57mg/dl)比較,並無明顯統計學上的差異。而三個月後追蹤空腹血糖平均值,實驗組(194±57 mg/dl)與對照組(233 ±54 mg/dl)比較,則有明顯統計學上的差異( p=0.034 )。但就三個月後血糖值下降的改變幅度來看,控制組並無明顯統計學上的差異。再看六個月後最後一次追蹤飯前血糖平均值時,實驗組(179±61mg/dl)與對照組(221±64mg/dl)兩組仍有明顯統計學上的差異(p=0.038)。而就六個月後血糖值下降的改變幅度來看,皆各有明顯血糖值下降的統計學改變意義。實驗組的改變幅度(-63±86 mg/dl)要比對照組(-32±85 mg/dl)的改變幅度來得大( p<0.001 v.s. p=0.008) 。

就比較實驗組及對照組個別在初次登錄時、三個月後及六個月後的糖化血色素值HbA1C (% ±SD)改變而言,我們採用One-way analysis of variance (ANOVA) 分析比較其前後及Parallel student’s t-test分析比較實驗組與對照組間之差異,在初次登錄時,實驗組(11.3±1.9 %)與對照組(10.9 ±2.0%) 比較,並無明顯統計學上的差異。而三個月後追蹤糖化血色素值,實驗組(10.0±1.7%)與對照組(11.6±1.9%) 比較,則有明顯統計學上的差異( p<0.001)。六個月後最後一次追蹤糖化血色素值時,實驗組(8.4 ±2.0%)與對照組(10.8 ±2.2%)兩組之間亦仍有明顯統計學上的差異(p<0.001)。而就六個月後糖化血色素值改變的幅度來看,只有實驗組(-2.9 ±1.7%)與初次登錄時相較,呈統計學上有意義的下降( p<0.001 )。但對照組(-0.1 ±2.1%)則與初次登錄時相較,並無明顯統計學上的差異。

結論

由研究結果可以看出,透過網路健康服務系統,糖尿病患有較佳的血糖控制表現,此有利於合併症的防治。終究,我們當以病人為中心來整合醫療資源,以網路安全為基礎,病患安全及隱私為前提,建構糖尿病網路健康加值服務。由醫療專業團隊的介入,積極參與醫病互動機制,並給予即時的行為鞭策、提醒、支持及鼓勵,俾能提昇糖尿病人健康自主管理的能力及生活品質。進而獲致身、心、靈的完整醫治。
Building a Certificate-Based Secure Telemedical Health-Care and Self-Management System for Diabetic Patients

Author:Chien, Ming-Nan
Thesis advised by :Liu, Li
Taipei Medical University,
Graduate Institute of Medical Informatics

The prevalence of diabetes continues to rise worldwide. It is the 4th leading cause of death in Taiwan. Persons with diabetes often struggle to keep their blood glucose level in a normal range or close to normal to prevent or delay complications caused by the disease. Though we realize to treat diabetes with diet, exercise, and medicine control, and there have been many update methods to upgrade our ability, there are still many patients suffered from diabetic complications resulting into mortality or disability. The epidemiological burden of diabetes is changing the classical model of diabetes management, in which a specialist center delivers care based on registration, recall and regular review.
The internet is used worldwide as a communication tool. To improve the quality of diabetes control, we show a program which allows patients with diabetes to transmit their self-monitored blood glucose data directly from their personal glucometer device to their diabetes care provider over the internet. No customized software is necessary on the patient’s computer, only a web browser , MOICA and active Internet connection. We use this example to highlight public key infrastructure and security measures that should be considered for devices that transmit healthcare data to remote locations. The Internet continues to grow at an accelerating pace, and it is clear that it will serve as an increasingly central role in the healthcare process. With these advances, authentication, non-repudiation, security, confidentiality, and data integrity concerns have been raised.
目 錄
表目錄---------------------------------------------------------------------------------------------------- x
圖目錄---------------------------------------------------------------------------------------------------- x

第一章 緒論
第一節 研究背景------------------------------------------------------------------------------------01
第二節 研究動機------------------------------------------------------------------------------------07
第三節 研究問題------------------------------------------------------------------------------------09
第四節 研究問題的重要性----------------------------------------------------------------------- 11
第五節 糖尿病健康自主管理教育---------------------------------------------------------------12
第六節 研究目的------------------------------------------------------------------------------------13

第二章 文獻查證
第一節 糖尿病簡介---------------------------------------------------------------------------------14
第二節 糖尿病的定義------------------------------------------------------------------------------16
第三節 糖尿病的分類------------------------------------------------------------------------------17
第四節 糖尿病的併發症---------------------------------------------------------------------------20
第五節 糖尿病的五個階段------------------------------------------------------------------------26
第六節 糖尿病預防---------------------------------------------------------------------------------26
第七節 影響糖尿病的相關因子------------------------------------------------------------------28
第八節 血糖控制與糖尿病併發症關聯的文獻回顧------------------------------------------30
第九節 糖尿病合併症的防治---------------------------------------------------------------------33
第十節 認識糖化血色素(HbA1c)---------------------------------------------------------------- 33
第十一節 血糖控制的目標---------------------------------------------------------------------------35
第十二節 網際網路在糖尿病的自我血糖控制管理及應用------------------------------------36
第十三節 遠距醫療在糖尿病健康自主管理養成教育的應用---------------------------------37
第十四節 納入網路安全機制的糖尿病社區健康照護系統------------------------------------39
第十五節 提昇病人的自我處理能力及生活品質------------------------------------------------42

第三章 研究材料與方法
第一節 研究設計------------------------------------------------------------------------------------44
第二節 研究方法------------------------------------------------------------------------------------46
第三節 統計及分析---------------------------------------------------------------------------------48
第四節 導入上線之策略及實施方式------------------------------------------------------------48
第五節 社區健康代理人系統---------------------------------------------------------------------53
第六節 健康資訊交換平台------------------------------------------------------------------------54
第七節 健康自主管理系統------------------------------------------------------------------------54
第八節 健康資料倉儲系統------------------------------------------------------------------------55
第九節 健康資訊探勘工具------------------------------------------------------------------------55
第十節 系統畫面展示------------------------------------------------------------------------------56

第四章 研究結果
第一節 實驗組之最終HbA1c值與年齡及性別跟上網登錄次數的關係 ----------------67
第二節 實驗組之不同年齡層其初次與最終登錄時之空腹血糖變化--------------------- 69
第三節 實驗組之不同年齡層其初次與最終登錄時之HbA1c變化------------------------71
第四節 實驗組之不同性別其初次與最終登錄時之空腹血糖變化------------------------ 72
第五節 對照組之不同年齡其初次與最終登錄時之空腹血糖變化------------------------ 74
第六節 對照組之不同性別其初次與六個月後之空腹血糖變化--------------------------- 76
第七節 比較實驗組及對照組在初、三及六個月後的空腹血糖變化----------------------77
第八節 比較實驗組及對照組在初、三及六個月後的HbA1c變化------------------------81

第五章 討論
第一節 安全憑證與網路健康服務系------------------------------------------------------------85
第二節 智慧型健康代理人機制的建立---------------------------------------------------------87
第三節 糖尿病人健康自主管理能力的養成---------------------------------------------------89
第四節 增加醫病關係的互動與激發積極控制血糖的意圖心------------------------------89
第五節 傳統的糖尿病健康照護模式仍有其存在的必要------------------------------------92
第六節 整合資訊科技及團隊合作模式構築健康共同照護網------------------------------94

第六章 結論與建議
第一節 結論------------------------------------------------------------------------------------------96
第二節 建議------------------------------------------------------------------------------------------97

第七章 參考資料
中文文獻------------------------------------------------------------------------------------------------101
英文文獻------------------------------------------------------------------------------------------------102
電子資料------------------------------------------------------------------------------------------------108











表目錄

表3-1 自我血糖監測記錄表-------------------------------------------------------------------------51
表4-1 實驗組之最終HbA1c值與年齡及性別跟上網登錄次數的關係---------------------68
表4-2 實驗組之不同年齡層其初次與最後一次登錄時之空腹血糖值變化--------------- 70
表4-3 實驗組之不同年齡層其初次登錄時與最後一次登錄時之HbA1c變化------------34
表4-4 實驗組之不同性別其初次與六個月最後一次登錄空腹血糖之變化--- ------------73
表4-5 對照組之不同年齡層其初次登錄與六個月後空腹血糖之變化----------------------75
表4-6 對照組之不同性別其初次登錄與六個月後之空腹血糖-------------------------------76
表4-7 實驗組及對照組在初、三及六個月後的空腹血糖改變之比較----------------------78
表4-8 實驗組及對照組在初、三及六個月後的空腹血糖改變之比較----------------------79
表4-9 實驗組及對照組六個月前後的HbA1c改變之比較------------------------------------81
表4-10 實驗組及對照組在初、三及六個月後的HbA1c改變之比較------------------------60

圖目錄
圖3-1 基本資料及個人病史-----------------------------------------------------------------------50
圖3-2 社區健康代理人系統架構圖------------------------------------------------------------- 53
圖3-3 社區健康代理人服務流程-----------------------------------------------------------------56
圖3-4 健康自主管理系統網站--------------------------------------------------------------------56
圖3-5 HCA憑證選擇-------------------------------------------------------------------------------57
圖3-6 HCA驗章成功-------------------------------------------------------------------------------57圖3-7 LOGIN畫面----------------------------------------------------------------------------------58
圖3-8 MOICA輸入PIN----------------------------------------------------------------------------58
圖3-9 MOICA簽章完成----------------------------------------------------------------------------59圖3-10 MOICA驗章成功----------------------------------------------------------------------------59
圖3-11 醫師主動關懷(醫師端)---------------------------------------------------------------------60
圖3-12 醫師主動關懷(病患端)---------------------------------------------------------------------61
圖3-13 健康自主管理計畫建議套餐維護--------------------------------------------------------61
圖3-14 健康代理人健康自主管理計畫建議確認-----------------------------------------------62
圖3-15 填寫健康自主管理計畫指引建議--------------------------------------------------------62
圖3-16 填寫健康自主管理計畫指引建議--------------------------------------------------------63
圖3-17 填寫健康自主管理計畫指引建議--------------------------------------------------------63
圖3-18 填寫健康自主管理計畫指引建議--------------------------------------------------------64
圖3-19 填寫健康自主管理計畫指引建議--------------------------------------------------------64
圖3-20 甜蜜家族健康管理量值趨勢分析--------------------------------------------------------65
圖3-21 甜蜜家族健康管理量值趨勢分析--------------------------------------------------------65
圖3-22 健康資料倉儲線上趨勢分析--------------------------------------------------------------66
圖4-1 實驗組之不同年齡層其初次與最後一次登錄時之空腹血糖變化-------------------70
圖4-2 實驗組之不同年齡層其初次與最後一次登錄時之HbA1c變化---------------------72
圖4-3 實驗組之不同性別其初次與六個月最後一次登錄空腹血糖之變化----------------73
圖4-4 對照組之不同年齡層其初次與最後一次登錄之空腹血糖變化----------------------75
圖4-5 對照組之不同性別其初次與六個月後之空腹血糖變化-------------------------------77
圖4-6 實驗組及對照組在初次與最後一次登錄時之空腹血糖改變之比較---------------78
圖4-7 實驗組及對照組在初次、三及六個月後的空腹血糖改變之比較------------------79
圖4-8 實驗組及對照組在初次、三及六個月後的空腹血糖改變之比較------------------80
圖4-9 實驗組及對照組在初次、三及六個月後的空腹血糖改變之比較------------------80
圖4-10 實驗組及對照組六個月前後的HbA1c改變之比較-----------------------------------82
圖4-11 實驗組及對照組在初次、三及六個月後的HbA1c改變之比較--------------------83
圖4-12 實驗組及對照組在初次、三及六個月後的HbA1c改變之比較--------------------84
圖4-13 實驗組及對照組在初次、三及六個月後的HbA1c改變之比較--------------------84
參考資料


中文文獻
1.林宏達,〈糖尿病的診斷與分類〉,中華民國內分泌暨糖尿病學會會訊,11卷,頁1-8,民77.4。
2.林文德,張睿詒,楊志良,〈不同醫師專科別間糖尿病門診照護品質之差異〉,醫學教育,7卷,頁271-281,民92。
3.蔡世澤,〈台灣糖尿病照護現況與省思〉,臨床醫學,45卷5期,頁316-320,民89.5。
4.蔡世澤,〈最新糖尿病診斷與分類〉,中華民國內分泌暨糖尿病學會會訊,12卷,頁53-54,民88.5。
5.蔡世澤,〈國人糖尿病照護概況〉,於中華民國糖尿病衛教學會年會暨學術研討會‧台北:台北國醫中心,民93.7。
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8.傅振宗,〈糖尿病患血糖控制的指標-糖化血色素、空腹血糖與飯後血糖〉中華民國糖尿病衛教學會會訊,頁23-30,民94.4。
9.吳至中,〈 糖尿病診治的最新技術與市場商機〉,工研院生醫中心,民91。
10.林宏達,〈論述血糖控制與糖尿病合併症〉,中華民國內分泌暨糖尿病學會會訊,12卷,頁1-4,民88.5。
11.謝昌勳、洪乙仁,〈糖尿病最新診斷標準與分類〉,國防醫學,30卷,頁468-473 頁,民89.6。
12.陳建宇,《台灣十大死因與防治》,台北:聯經出版,民88。
13.林文元,劉文俊,〈妊娠糖尿病〉,基礎醫學,15卷第7期,頁149-153,民89.7。
14.戴在松,〈糖尿病的慢性併發症及血糖控制的重要性〉,嘉基院訊,民89。
15.曾慶孝,〈糖尿病的大血管病變〉,中華民國內分泌暨糖尿病學會會訊,13 卷第2 期,頁8-18,民89.1。
16.陳慕師,〈糖尿病視網膜病變〉,中華民國內分泌暨糖尿病學會會訊,13 卷第4 期,2000 年7 月,頁3-8,民89.7。
17.陳建宇,《台灣十大死因與防治》,台北:聯經出版,民88。

英文文獻

18.Charles M.C., Judith E.F., Roland G.H., Rodney A.L., Frank V., Elizabeth W.B.. Promoting Early Diagnosis and Treatment of Type 2 Diabetes. Journal of American Medical Association 2000; 284(3):363-365.
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電子資料

65.行政院研究發展考核委員會網站:2005健康臺灣實施方案 http://www.rdec.gov.tw/public/Data/561616412171.doc Accessed June 1, 2005
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