醫師使用電子病歷交換的影響因素及效益評估─以健保雲端藥歷系統為例

莊秋華

doi:10.6342/NTU201803078

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医师使用电子病历交换的影响因素及效益评估─以健保云端药历系统为例

Influential factors and benefits of physicians using health information exchange – using National Health Insurance PharmaCloud System as an example

庄秋华 , 博士　　导师：杨铭钦　　

繁体中文 DOI： 10.6342/NTU201803078

云端药历；电子病历交换；电子病历；科技持续理论；科技接受模式；云端资讯系统；医疗资讯系统； PharmaCloud ； Health Information Exchange (HIE) ； Electronic Medical Records ； Technology Continuance Theory (TCT) ； Technology Acceptance Model (TAM) ； MediCloud System, Health Information Systems (HIS)

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摘要 │ 参考文献 (161) │ 国际计量

摘要〈TOP〉

目的：本研究欲分析影响医师使用电子病历交换的因素及效益评估，以健保云端药历系统为例，采用科技持续理论 (Technology Continuance Theory, TCT)，了解医师使用健保云端药历系统的影响因素及其效益，即是否能降低病人的药品项数、药费及增加被发现重复用药机率、用药交互作用机率之情形，以作为健保署及医疗机构推动持续使用的参考。方法：依据研究目的，将研究分为两部分，第一部分以科技持续理论为基础，设计结构式问卷，调查台湾某医疗体系的医师，该体系包括一家医学中心、两家区域医院及三家地区医院等，针对门诊主治医师在使用健保云端药历系统，采用预载比对云端药历和手动查询云端药历两种方式，在「与期待相符」、「知觉有用性」、「知觉易用性」、「态度」、「满意度」、「持续使用意向」等变项，使用结构方程模式(SEM)分析以验证各变项间的因果关系。第二部分探讨医师使用健保云端药历系统的效益评估，采用差异中之差异模型(DID)来分析，有签署同意预载比对云端药历病人是否能让就诊门诊成年病人的每年每次药品项数、每人每次的药费有效降低及增加被发现重复用药、用药交互作用机率。结果：本研究共发出775份问卷，回收有效问卷528份(回收率68%)。根据医师基本特质对变项的影响，本研究发现医师基本特质对於预载比对云端药历系统的看法，不同医院层级填答者对预载比对云端药历的「知觉易用性」的看法有显着差异与不同性别填答者对预载比对云端药历的「态度」的看法有显着差异。另，医师年龄越低、服务年资越短，其对手动查询云端药历的「与期望相符」、「知觉有用性」、「知觉易用性」、「态度」、「满意度」、「持续使用意向」的得分越高，且不同医院层级对手动查询云端药历的「与期望相符」、「知觉有用性」「知觉易用性」、「态度」、「满意度」、「持续使用意向」的看法会有显着差异；而每次平均门诊人数较少的医师，其对手动查询云端药历的「知觉有用性」、「知觉易用性」、「态度」的看法和平均门诊人数较多的医师不同，且「满意度」和「持续使用意向」得分越高。路径分析之结果显示，会影响医师对预载比对云端药历的「持续使用意向」的因素包括「认知有用性」(p<0.0001)、「满意度」(p<0.001)、「态度」(p<0.001)；但影响医师手动查询云端药历「持续使用意向」的因素只有「满意度」(p<0.001)和「态度」(p<0.001)。「与期望相符」与「知觉易用性」在预载比对云端药历和手动查询云端药历上，都会正向影响「知觉有用性」(p<0.001, p<0.001)；「知觉有用性」和「知觉易用性」两变项在预载比对和手动查询云端药历上，也都会正向影响「态度」(p<0.001, p<0.001)；但「知觉有用性」对「满意度」的影响只有在预载比对云端药历上显着。健保云端药历查询效益评估分析上，在控制性别、年龄、三高及思觉失调等疾病病人特质後，病人有签署同意预载比对云端药历同意书之後测发现平均每人每次药品项次减少7.0%（p<0.001）、平均每人药费则未显着增加。另外，被发现有重复用药的机率显着较高，是未签署者的1.83倍（p<0.0001）；被发现有用药交互作用的机率和未签署者之差异则未达统计显着。结论：当医师对健保云端药历系统的「期望」与实际使用的相符性越接近，则其对健保云端药历系统的「知觉有用性」越高，自然而然地对该系统的「满意度」和「态度」就越良好，且对「持续使用」健保云端药历系统所造成的正向影响则会越强，持续使用健保云端药历系统的时间则会越久。病人有签署同意预载比对云端药历之後，显着的影响病人门诊的药品项数降低，但门诊药费却没有减少。另外，被发现有重复用药的机率显着较高，但被发现有用药交互作用之机率则没有差异。

并列摘要〈TOP〉

Objectives: This research aims to use Technology Continuance Theory (TCT) to investigate the factors influence physicians using pharmaCloud system and to evaluate its benefits, which includes whether the number and cost of prescribed medications are redueced and the probability of discovering repetitive medication and medication interaction are increased. Method: According to the research objective, the research consists of two parts: the first part is to construct a structured questionnaire that was based on the TCT, which was used in order to investigate physicians in a medical system, which consists of a medical center, two regional hospitals, and three district hospitals in Taiwan. The research focuses on investigating the “confirmation”, “perceived usefulness“, “perceived ease of use“, “attitude“, “satisfaction“ and “continuance usage intention“ towards preload-based comparison and manual search in pharmaCloud for attending physicians during their outpatient clinics. The research uses path analysis to analyze the cause and effect relationship between variables. The second part of the research evaluated the benefits of physicians using the Healthcare pharmaCloud system. The research uses Difference in Differences (DID) to analyze whether patients who signed the consent form to use preload-based comparison pharmaCloud experienced reduced numbers and cost of prescribed medication and an increase of the probability of discovering repetitive medication and medication interaction than those who did not sign the consent form. Results: The research sent out 775 copies of questionnaires, and collected 528 copies, with a response rate of 68%. In terms of the effects of physicians’ characteristic on using preload-based pharmaCloud, the research found that physicians from different levels of hospitals have significantly different opinions toward the “perceived ease of use” in preload-based comparison in pharmaCloud. Gender of the physicians also significantly affected their attitude towards preload-based comparison in pharmaCloud. In terms of manual search in pharmaCloud, the research found that in regards to “perceived ease of use”, “attitude”, “satisfaction” and “continuance usage intention”, physicians who are younger and have fewer years of service, scored higher in “confirmation”, “perceived usefulness”, “perceived ease of use”, “attitude”, “satisfaction” and “continuance usage intention” towards manual search in pharmaCloud. In addition, levels of hospitals also significantly affect physicians’ opinions toward “confirmation”, “perceived usefulness”, “perceived ease of use”, “attitude”, “satisfaction” and “continuance usage intention” towards manual search in pharmaCloud. Physicians who had less average number of outpatients seen per clinic session scored higher in “satisfaction” and “continuance usage intention” and their opinions in “perceived usefulness”, “perceived ease of use” and “attitude” towards manual search in pharmaCloud is significantly different from that of physicians who had more average number of outpatients seen per clinic session. The results of path analysis show that factors affect physicians continue to use preload-based comparison in pharmaCloud included “perceived usefulness” (p<0.001), “satisfaction” (p<0.001), and “attitude” (p<0.001). However, factors that influence physicians’ continue to use manual search in pharmaCloud are only “satisfaction” (p<0.001) and “attitude” (p<0.001). “Confirmation“ and “perceived ease of use“ both affect physicians’ “perceived usefulness“ towards preload-based comparison in pharmaCloud (p<0.001, p<0.001, respectively), and both “perceived usefulness” and “perceived ease of use” positively affect “attitude” (p<0.001, p<0.001, respectively) on both preload-based comparison and manual search in pharmaCloud. However, the effects of “perceived usefulness” and “perceived ease of use” on “satisfaction” can only be seen in preload-based comparison in pharmaCloud. In terms of the benefits of the healthcare pharmaCloud system, the research has controlled patients’ gender, age, triple H (hypertension, hyperglycemia, and hyperlipidemia) and Schizophrenia and found that by signing consent for preload-based comparison in pharmaCloud, the number of prescribed medications has decreased by 7% (p<0.001) per visit per person, but the costs of prescribed medication per visit per person did not increase significantly. The probability of discovering repetitive medication was 1.83 times higher than that of outpatients who did not sign the consent form while the probability of discovering medication interaction was not significantly different.
Conclusion: When physicians’ actual use of pharmaCloud has met their expectation, they will have higher levels of confirmation, better perceived usefulness, and it will naturally increase their satisfaction and attitude towards pharmaCloud and positively affect them to continue to use pharmaCloud. After outpatients have signed the consent form for preload-based comparison on pharmaCloud, the number of prescribed medications decreased significantly while the change of cost of prescribed medication was not significant. In addition, the probability of discovering repetitive medication increased significantly while the probability of discovering medication interaction did not change significantly.

参考文献 ( 161 ) 〈TOP〉

Davis, F. D. (1989). Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology. MIS Quarterly, 13(3), 319-340. doi:10.2307/249008
连结：
陈福基, 萧世荣, 陈启元, & 杜素珍. (2005). 影响医院接受行动护理站因素之研究-以南部某区域教学医院为例. 资讯管理学报, 12(S), 67-89.
连结：
Abdekhoda, M., Ahmadi, M., Gohari, M., & Noruzi, A. (2015). The effects of organizational contextual factors on physicians' attitude toward adoption of Electronic Medical Records. J Biomed Inform, 53, 174-179. doi:10.1016/j.jbi.2014.10.008
Abramson, E. L., McGinnis, S., Edwards, A., Maniccia, D. M., Moore, J., Kaushal, R., & Investigators, H. (2012). Electronic health record adoption and health information exchange among hospitals in New York State. J Eval Clin Pract, 18(6), 1156-1162. doi:10.1111/j.1365-2753.2011.01755.x
Adler-Milstein, J., Bates, D. W., & Jha, A. K. (2011). A survey of health information exchange organizations in the United States: implications for meaningful use. Ann Intern Med, 154(10), 666-671. doi:10.7326/0003-4819-154-10-201105170-00006

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