臺灣博碩士論文加值系統

疾病管制局在幾次抽查結核病用藥處方的計畫中，發現不正確或是不依循現行結核病治療指引處方的比例並不低，因結核病治療指引內容較為複雜，衛生所公衛護士或是結核病承辦人在評估處方的適切性時，亦不易僅靠閱讀指引即可完成。緣此，本研究目的在依用藥指引建立一結核病用藥處方異常之電腦決策支援系統，以方便查核工作的進行。

在本研究中，我們採用疾管局於2008年出版之結核病診治指引第三版，開發了一個針對公衛人員進行處方異常查核使用之Web-based的決策支援系統。透過知識工程的方法，先將標準化的處方指引，轉化成決策表及IF-THEN邏輯，同時設計一輸入介面以便取得分析所需參數，輸入完畢，使用者即可取得決策支援系統的處方異常分析結果。系統也內含一警示模組，可將嚴重錯誤的處方即時回報給相關人員。

我們使用18本特意挑選之健保抽審後疑似有問題之住院病例，共62個處方以評估系統的表現，合計開立200種不同的藥。本系統找出48%的藥物組合、21%的藥物劑量及6%的藥物頻次的異常，其中，藥物組合檢核的敏感度為0.93，特異度為0.59；藥物劑量檢核的敏感度為0.95，特異度為0.91，藥物頻次的檢核的敏感度為1.00，特異度為0.98。
因本用藥查核系統具有高敏感度，對結核病防治公衛人員在進行處方異常查核工作將是一有用的輔助工具，而藥物組合檢核特異度偏低的情形，因所選擇抽樣病歷之處方多於特殊情況時開立，將可在補足特殊情況使用之開藥規則後改善。本決策系統著眼於處方異常的查核，並希望經由本系統減少非標準的處方，能達到增加結核病的治癒率，並提昇病人安全。

High prevalence of prescription errors in treatment of pulmonary tuberculosis (TB) in Taiwan has been reported in previous studies. Due to the complexity of treatment guideline for TB, frontline health workers for TB control often find difficulties in determining the appropriateness of anti-TB regimens. The aim of this study was to build a guideline-based computerized decision support system (DSS) for screening prescription errors in anti-TB regimens.

To facilitate the screening work for prescription errors, we’ve created a web-based DSS implementing the paper-based “Taiwan Guidelines for TB Diagnosis & Treatment, 3rd edition”. By means of knowledge engineering, standardized prescription guidelines were transformed into computerized decision table and if-then rules. An ease-to-use user interface was designed for collecting required parameters. With a single click, users are allowed to obtain the analytic results by the DSS immediately. An alert module for reporting severe or harmful errors to relevant medical officers was also embedded.

For system performance test, we used 62 regimens with 200 different drugs prescribed from 18 pre-selected in-patient medical charts. This DSS detected errors in 48% of drug combination, 21% in dosages and 6% in frequencies. Sensitivity and specificity were, respectively, 0.93 and 0.59 in combination check, 0.95 and 0.91 in dosage check, and 1.00 and 0.98 in frequency check.

With the characteristics of high sensitivity of this DSS, frontline health workers for TB control may find it useful as a screening tool for anti-TB prescription errors. The low specificity in drug combination check can be improved after amending rules used in special considerations. Aside from the purpose of surveillance for non-standardized prescriptions, this system may have the potential for increasing TB treatment success rate and improving patient safety by improving the compliance to TB treatment guidelines.

第一章 緒論
1.1 台灣結核病流行現況 1
1.2 台灣結核病處方異常現況 1
1.3 研究目的及主要目標 2
第二章 文獻查證
2.1 用藥錯誤之分類 3
2.2 知識工程 3
2.2.1 知識分類 4
2.2.2 以知識分基礎的系統 4
2.2.3 專家系統的組成 5
2.3 決策支援系統 5
2.4 決策支援系統 6
第三章 研究材料與方法
3.1 系統開發環境 8
3.1.1 系統介面程式 8
3.1.2 後端分析程式 8
3.2 系統檢核資料來源 8
3.3 系統架構 14
3.3.1 知識工程 14
3.3.1.1 用藥組合知識 14
3.3.1.2 用藥劑量知識 34
3.3.1.3 用藥頻次知識 44
3.3.1.4 程式開發過程知識 46
3.3.2 系統運作流程 47
3.3.3 結核病用藥查核輔助系統 47
3.3.3.1 事實庫與知識庫 47
3.3.3.2 推論引擎 47
3.3.4 系統功能與介面 55
3.3.4.1 基本資料 56
3.3.4.2 就診表單 58
3.3.4.3 就診歷程分析 58
3.3.4.4 修正功能 60
3.3.4.5 二線用藥病患查（含SM）及異常用藥快速查詢清單 60
3.3.4.6 E-mail 警示 72
第四章 分析與結果
4.1 中央傳染病追蹤管理系統串接評估測試 73
4.1.1 轉檔方法 73
4.2 中央傳染病追蹤管理系統TB用藥組合評估 77
4.2.1 快速列表清單的統計 79
4.2.2 知識庫藥物組合規則分析 79

第五章 討論
5.1 臨床指引使用的困難與改善方式 85
5.2 研究進行方式 85
5.3 系統評估討論 86
5.4 電子病歷整合 87
5.5 系統限制 87
第六章 結論與建議
6.1 結論結論 88
6.2 研究建議 88
參考資料
中文文獻 89
英文文獻 89
電子資料 91

表1、病患基本資訊表單資料欄位 9
表2、病患用藥組合表單資料欄位 9
表3、藥物感受性試驗表單資料欄位 11
表4、藥物副作用表單資料欄位 11
表5、相關醫事檢查表單資料欄位 12
表6、中央傳染病追蹤管理系統系統總紀錄表 77
表7、中央傳染病追蹤管理系統系統無用藥日誌紀錄 77
表8、中央傳染病追蹤管理系統系統有用藥日誌紀錄 77
表9、各項有用藥日誌紀錄快進選單統計表 78
表10、開藥紀錄與有無藥敏結果統計表 79
表11、藥物服用頻率異常偵測敏感度及特異度分析 82
表12、藥物劑量異常偵測敏感度及特異度分析 82
表13、藥物組合異常偵測敏感度及特異度分析 83

圖1、系統架構圖 14
圖2、決策表範例圖 29
圖3、藥物劑量及頻次知識整理範例 35
圖4、結核病治療用藥查核輔助系統運作意示圖 47
圖5、系統程式流程圖圖 47
圖6、TB就診手冊 55
圖7、中央傳染病監視系統表單輸入畫面 56
圖8、結核病患用藥查核輔助系統功能 56
圖9、系統帳號登錄畫面 57
圖10、基本資料參數輸入介面 57
圖11、就診資料參數輸入介面 58
圖12、藥物組合檢核結果 59
圖13、藥物劑量、頻次檢核結果 59
圖14、修正檢核參數介面 60
圖15、本系統使用到「中央傳染病監視系統資料庫」之資料表欄位關聯圖 61
圖16、二線藥物使用情況快速統計功能 63
圖17、二線藥物使用統計圖 64
圖18、在案非多重抗藥性結核病人使用二線藥物列表 65
圖19、同類藥物併用之病人列表 66
圖20、PAS及CS併用之病人列表 67
圖21、Levofloxacin及moxifloxacin併用之病人列表 68
圖22、Rifater及rifinah併用之病人列表 69
圖23、新病人但未使用一線藥物之病人列表 70
圖24、新病人使用二線藥fluoroquinolone之病人列表 71
圖25、用藥劑量填寫情況查核選單 72
圖26、E-mail警示功能 72
圖27、用藥記錄與藥敏報告藥物品項關聯圖 74
圖28、藥物組合異常（不考慮藥物敏感紀錄） 80
圖29、藥物組合異常（考慮藥物敏感紀錄） 81

中文文獻

1.陸坤泰等，結核病診治指引 第三版，台北：衛生署疾病管制局，民97.5。
英文文獻
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電子資料
29.台灣電子病歷交換基本格式. Available at http://emr.doh.gov.tw/. Accessed Mar 20, 2009
30.TB Treatment Guidelines in PDA Format. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/tb/pubs/PDA_TBGuidelines/. Accessed Mar 20, 2009
31.Stanford Medical Informatics. Stanford University. Available at http://protege.stanford.edu/ Accessed Mar 20, 2009.