在臨床醫(yī)學中怎樣用藥

1、Chapter 1: Health Care Delivery SystemsFeipei LaiNational Taiwan University 1Health Care Delivery SystemsHistory of Medicine and Health care DeliveryContinuum of CareHealth Care Facility OwnershipHealth Care Facility Organizational StructureLicensure, Regulation, and Accreditation2IntroductionHealth

2、 care delivery has been greatly impacted by escalating costs, resulting in medical necessity requirements, review of appropriateness of admissions, and requirement for administration of quality and effective treatments.3MRXO在臨床醫(yī)學中，進行手術時同時使用磁振造影並整合各種影像技術是目前最熱門的醫(yī)療概念。新式的未來手術室中，安裝有全球首套MRXO解決方案，即完全整合磁振造影

3、(MR)、光及電腦斷層掃描(CT)系統(tǒng)，大幅減少病患危險並簡化醫(yī)師的手續(xù)，可望提高手術成功率。這項由日本東海大學、飛利浦醫(yī)療系統(tǒng)事業(yè)部合力推動的未來手術室，已經(jīng)由日本東海大學的松前教授、津具醫(yī)師、山本醫(yī)師共同在手術室同時使用MR(磁振造影)和X光影像技術，來進行神經(jīng)外科手術。4MRXO在未來手術室中執(zhí)行手術，可依執(zhí)刀醫(yī)師與病患狀況，在數(shù)分鐘內(nèi)將病患從手術臺搬移到磁振造影、電腦斷層掃描或光診斷系統(tǒng)，增加手術精密度與成功率。在磁振造影和電腦斷層掃描區(qū)域有拉門。5History of Medicine & Health Care DeliveryHistory of medicineEvolutio

4、n of health care delivery in the United States6History of medicineIn 1994, scientists discovered the genes responsible for many cases of hereditary colon cancer, inherited breast cancer, and the most common type of kidney cancer.7Evolution of health care delivery in the United States1991 The Workgro

5、up on Electronic Data Interchange (WEDI) was created to reduce health care administrative costs through implementation of the electronic data interchange (EDI), which uses national standards to transmit data for reimbursement purposes.8Evolution of health care delivery in the United States1996 The H

6、ealth Insurance Portability and Accountability Act (HIPAA) was passed.It mandates administrative simplification regulations that govern privacy, security, and electronic transaction standards for health care information.9Evolution of health care delivery in the United States1996 The Healthcare Integ

7、rity and Protection Data Bank (HIPDB) was created which combats fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioners, providers, or suppliers past actions.10Healthcare Integrity and Protection Data BankAccess to informati

8、on in the HIPDB is available to entities that meet the eligibility requirements defined in Section 1128E of the Social Security Act and the HIPDB regulations. In order to access information, eligible entities must first register with the Data Bank.HIPDB information is not available to the general pu

9、blic. However, information in a form that does not identify any particular entity or practitioner is available.11Healthcare Integrity and Protection Data BankEstimates of annual losses due to health care fraud range from 3 to 10percent of all health care expenditures-between $30billion and $100billi

10、on based on estimated 1997 expenditures of over $1 trillion and 2.5 trillion for 2009.12Continuum of CareA complete range of programs and services is called a continuum of care, with the type of health care indicating the health care services provided.Primary careSecondary careTertiary care13Primary

11、 care servicesInclude preventive and acute care, are referred to as the point of first care, and are provided by a general practitioner or other health professional who has the first contact with a patient seeking medical treatment, including general dental, ophthalmic 眼科的, and pharmaceutical servic

12、es.14Primary care servicesAnnual physical examinationsEarly detection of diseaseFamily planningHealth educationImmunizationsTreatment of minor illnesses and injuriesVision and hearing screening15Secondary care servicesProvided by medical specialists or hospital staff members to a patient whose prima

13、ry care was provided by a general practitioner who first diagnosed or treated the patient.16Tertiary care servicesProvided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospital or Level I, II, III or IV tr

14、auma centers.17Trauma centersLevel I: provides the highest level of comprehensive care for severely injured adult and pediatric patients with complex, multi-system trauma.Level II: broad range of sub-specialists are on-call and promptly available to provide consultation or care.18Trauma centersLevel

15、 III: physicians are advanced trauma life support (ATLS) trained and experienced in caring for traumatically injured patients; nurses and ancillary staff are in-house and immediately available to initiate resuscitative measures.19Trauma centersLevel IV: critically injured patients who require specia

16、lty care are transferred to a higher level trauma system hospital in accordance with pre-established criteria.20Tertiary careBurn center treatmentCardiothoracic and vascular surgeryInpatient care for AIDS patientsMagnetic resonance imaging (MRI)Neonatology level III unit servicesNeurosurgeryOrgan tr

17、ansplant21Tertiary carePediatric surgeryPositron emissions tomography (PET)Radiation oncologyServices provided to a person with a high-risk pregnancyServices provided to a person with cancerState-designated trauma centersTrauma surgery22Positron emissions tomography (PET)builds images by detecting e

18、nergy given off by decaying radioactive isotopes.Isotopes are atoms of an element with the same number of protons (positively charged particles) in the nucleus, but a different number of neutrons (neutral particles).Because radioactive isotopes are unstable, as they decay, they throw off positrons t

19、hat collide with electrons and produce gamma rays that shoot off in nearly opposite directions. 23PET PET systems use the paths of the two detected gamma rays to determine the originating collision point, a process called electronic collimation (瞄準).The scanners use a circular series of gamma ray-de

20、tectors to envelope the patient so both gammas can be detected so the instrument can use electronic collimation to predict where the energy signal originated.This signal is then converted into a three-dimensional image slice. 24臺灣醫(yī)院分類診所地區(qū)醫(yī)院 (497/2005)區(qū)域醫(yī)院 (80/2005, 65/2006, 64/2007)醫(yī)學中心 (23/2005, 18

21、/2006, 19/2007, 14/2009)25醫(yī)學中心在衛(wèi)生局登記開放的急性一般病床與急性精神病床合計須達五百床以上至少應能提供 家庭醫(yī)學、內(nèi)、外、婦產(chǎn)、兒、骨、神經(jīng)外、泌尿、耳鼻喉、眼、皮膚、神經(jīng)、精神、復健、麻醉、放射線、病理、核醫(yī)、牙 等十九科之診療服務。 26醫(yī)學中心專任主治醫(yī)師人數(shù) (包括主任在內(nèi)) 每八床應有一名。專任護理人員每2床至少1名。加護病房：每床2.5名。手術室：每班每臺2.5名。手術恢復室：每班每床0.5名。產(chǎn)房及待產(chǎn)室：每床2名。嬰兒室：每床0.4名。急診室：觀察室每床0.5名；診療室每12人次1名。門診：每班每診療室0.5名。血液透析室：每4人次1名。行政、教

22、學、研究及其他護理人員 (如院內(nèi)感染控制、公衛(wèi)、供應中心等護理人員) 另計，應佔總人數(shù)百分之六。應有受過感染控制訓練之專任護理人員，每300床應設1名。27醫(yī)學中心藥事人員每40床至少1名。每60張門診處方至少1名。特殊藥品處方每15張至少1名。藥事人員總數(shù)至少四分之三為藥師。藥事人員至少有4名負責藥品管理諮詢及臨床等工作。28區(qū)域醫(yī)院應設置250床位以上急性病病床數(shù)每床所擁有的樓地板面積應在50平方公尺以上每9床至少應擁有一名主治醫(yī)師每2.5床至少應擁有一名護理人員等。至少應能提供 家庭醫(yī)學、內(nèi)、外、婦產(chǎn)、兒、骨、耳鼻喉、眼、精神、復健、麻醉、放射線、病理、牙 等十四科之診療服務。 29區(qū)域

23、醫(yī)院 Nurse加護病房：每床2名。手術室：每班每臺2名。手術恢復室：每班每床0.5名。產(chǎn)房及待產(chǎn)室：每床1.2名。嬰兒室：每床0.4名。急診室：觀察室每床0.5名；診療室每12人次1名。門診：每班每診療室0.5名。血液透析室：每4人次1名。行政、教學、研究及其他護理人員 (如院內(nèi)感染控制、公衛(wèi)、供應中心等護理人員) 另計，應佔總人數(shù)百分之四。應有受過感染控制訓練之專任護理人員，每300床應設1名。30區(qū)域醫(yī)院藥事人員每50床至少1名。每70張門診處方至少1名。特殊藥品處方每15張至少1名。藥事人員總數(shù)至少四分之三為藥師。藥事人員中，至少有2名負責藥品管理諮詢及臨床等工作。 31地區(qū)醫(yī)院在衛(wèi)生

24、局登記開放的急性一般病床需20床以上，急性一般病床及急性精神病床合計249床（含）以下。32地區(qū)醫(yī)院專任員工總人數(shù)每床應有1名。專任主治醫(yī)師人數(shù)以及專任護理人員應符合醫(yī)療機構設置標準。藥事人員每50床至少1名。每80張門診處方至少1名。每增加100張?zhí)幏綉黾?名。應有藥師1人以上。 33評鑑分級設施總樓地板面積病房設施安全設備及一般設備保險病床比率34評鑑分級人員員工總人數(shù) 醫(yī)師總數(shù)麻醉科醫(yī)師 放射線科醫(yī)師核醫(yī)科醫(yī)師 病理科醫(yī)師復健科醫(yī)師 精神科醫(yī)師護理 藥事醫(yī)事檢驗 醫(yī)用放射線技術復健技術 精神科社會工作 營養(yǎng)師病歷管理35評鑑分級醫(yī)療業(yè)務及設備醫(yī)療業(yè)務 急性病床數(shù)診療科別 急診業(yè)務手術及

25、麻醉作業(yè) 產(chǎn)房嬰兒室 加護病房藥事作業(yè) 檢驗作業(yè)輸血作業(yè) 放射線診療作業(yè)病理作業(yè) 復健醫(yī)療作業(yè)精神科 核子醫(yī)學牙科 特殊醫(yī)療服務醫(yī)務社會服務工作 營養(yǎng)部門病歷部門 社區(qū)衛(wèi)生服務員工健康檢查36評鑑分級品質保證醫(yī)療品質審查感染控制人體試驗藥事作業(yè)品質護理服務品質檢驗作業(yè)品質管制輸血作業(yè)品質管制病理作業(yè)品質管制放射線診療品質管制核子醫(yī)學品質管制病歷管理醫(yī)院管理業(yè)務醫(yī)病關係之促進37評鑑分級指定項目評估住院 診斷 處置 用藥 手術 病歷寫作38評鑑分級教學訓練教學師資 教學訓練與研究設備 教學訓練活動 與其他醫(yī)院(醫(yī)學院)交流合作情形 研究情形及論文發(fā)表 教學進修研究經(jīng)費39新制教學醫(yī)院評鑑基準教學

26、資源教學訓練計畫與成果研究執(zhí)行與成果臨床師資培育及繼續(xù)教育學術交流與社區(qū)功能及角色管理行政40財團法人醫(yī)院評鑑暨醫(yī)療品質策進會41Health Care Facility OwnershipGovernment (not-for-profit) 25%Proprietary (for-profit) 15%Voluntary (not-for-profit) 60%42Medical StaffIntern: a physician in the first year of graduate medical education, which ordinarily immediately fol

27、lows completion of the four-year medical curriculum.Resident: a physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of medicine, surgery, or any of the other special fields that provide advanced train

28、ing in preparation for the practice of a specialty.43Medical StaffChief resident: a physician who is in his final year of residency or in the year after the residency has been completed.Visiting Staff (VS): 主治醫(yī)師44Health Care Facility Organizational StructureGoverning boardAdministrationMedical staff

29、Departments, services, and committeesContracted services45Governing boardThe governing board (board of trustees, board of governors, board of directors) serves without pay, and its membership is represented by professionals from the business community.46Administration Serves as liaison between the m

30、edical staff and governing board and is responsible for developing a strategic plan for supporting the mission and goals of the organization.CEO: chief executive officeCFO: chief financial officerCIO: chief information officerCOO: chief operating officer47Medical staffConsists of licensed physicians

31、 and other licensed providers as permitted by law (e.g., nurse practitioners and physician assistants) who are granted clinical privileges.48physician assistantsExamine, diagnose, and treat patients under the direct supervision of a physician.49Medical staff membership categoriesActive: delivers mos

32、t hospital medical services, performs significant organizational and administrative medical staff dutiesAssociate: advancement to active category is being consideredConsultingCourtesy: admits an occasional patient to the hospitalHonorary5051Hospital departments, Services, and Committees52NTUH Depart

33、ments秘書室 總務室 企劃管理室病歷資訊管理室醫(yī)療事務室 社會工作室 公共事務室工務室 資訊室 圖書室 安全衛(wèi)生室警衛(wèi)隊 會計室 人事室 教學部醫(yī)學工程部53NTUH Departments內(nèi)科部外科部 骨科部 婦產(chǎn)部 小兒部神經(jīng)部 精神部 耳鼻喉部 眼科部 泌尿部皮膚部 牙科部 復健部家庭醫(yī)學部麻醉部影像醫(yī)學部 核子醫(yī)學部檢驗醫(yī)學部病理部 藥劑部 護理部營養(yǎng)部 綜合診療部醫(yī)學研究部基因醫(yī)學部 門診部 急診醫(yī)學部 腫瘤醫(yī)學部創(chuàng)傷醫(yī)學部 老年醫(yī)學部 環(huán)境及職業(yè)醫(yī)學部54NTUH Departments品質管理中心資財管理中心健康管理中心 肝炎研究中心形體美容醫(yī)學研究中心國家級卓越臨床驗與研究

34、中心55抗老及健康諮詢中心 心臟衰竭中心乳房醫(yī)學中心感染控制中心運動醫(yī)學中心過敏免疫中心臨床心理中心健康教育中心睡眠中心國際醫(yī)療中心56The Johns Hopkins HospitalAllergy and Clinical ImmunologyAnesthesiology/Critical Care MedicineCardiologyDermatology (Skin)Emergency MedicineEndocrinology 內(nèi)分泌學Gastroenterology 胃腸病學 Gynecology & Obstetrics 婦產(chǎn)Hematology 血液學 Infectious

35、DiseasesInternal Medicine Nephrology 腎病學 Neurology & Neurosurgery57The Johns Hopkins HospitalOncology (Cancer)Ophthamology (Eyes)Orthopedic Surgery 整形外科 Otolaryngology (ENT)Pediatrics 兒科 Physical Medicine/RehabilitationPsychiatry/Behavioral SciencesPulmonary/Critical Care Medicine 肺 RadiologySurgery

36、Urology 泌尿科58Internal MedicineAdolescent medicineCardiovascular medicine 心血管 Critical care medicineElectrophysiology 電生理學 Endocrinology 內(nèi)分泌學 Gastroenterology 胃腸病學 Geriatrics 老年醫(yī)學 Hematology 血液學 ImmunologyInfectious diseaseNephrology 腎病學 OncologyPulmonary medicine 肺 Rheumatology 風濕病學 Sports medicine5

37、9Hospital DepartmentsAdmitting (Patient Registration)Biomedical EngineeringBusiness OfficeCase Management (Discharge Planning)Central Sterilizing ServiceChaplainClinical LaboratoryCommunity Relations (Public Relations)60Hospital DepartmentsComplianceComputingDurable Medical EquipmentElectroneurodiag

38、nostic TestingEmergency RoomEmployee Assistance Program (EAP)Employee Health ServicesEnvironmental ServicesHealth Information Management Services61Hospital DepartmentsHospice CareHuman ResourcesMedical EducationMedical LibraryMedical StaffNursingNutrition and Food ServiceOccupational Therapy62Hospit

39、al DepartmentsOperating Room SuitePatient AdvocacyPatient EducationPerformance ImprovementPharmacyPhysical TherapyPlant Operations and MaintenancePreadmission Testing (PAT)63Hospital DepartmentsPurchasingRadiation OncologyRadiologyRecreation TherapyRehabilitative ServicesRespiratory TherapyRespite C

40、areRisk ManagementSafety Management64Hospital DepartmentsSocial ServicesSpeech and Language PathologyTelemedicineUtilization ManagementVolunteer65Hospital CommitteesDisaster ControlDrug Utilization ReviewEducationFinanceFormsHealth InformationInfection ControlQuality ManagementRisk ManagementTissue

41、ReviewTransfusionUtilization Management662009/11/1967Health Information DepartmentDepartment administrationCancer registryCoding and abstractingImage processingIncomplete record processingMedical transcriptionRecord circulationRelease of information processing6869CodingInvolves assigning numeric and

42、 alphanumeric codes to diagnoses, procedures, and services; this function is usually performed by credentialed individuals.Coders assign ICD-9-CM codes to inpatient cases and Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS) Level II (National), and ICD-9-CM codes to

43、outpatient, emergency department, and physician office cases.70Cancer registryPerformed by individuals who are credentialed as certified tumor registrars and include using computerized registry software to conduct lifetime follow-up on each cancer patient, electronically transmit data to state and n

44、ational agencies for use at local, regional, state, and national levels, and generate reports and information for requesting entities.71Current Procedural Terminology (CPT)Published annually by the American Medical Association and codes are 5-digit numbers assigned to ambulatory procedures and servi

45、ces.E.g. 90663 Influenza virus vaccine, pandemic formulation72ICD-9-CMThe International Classification of Diseases, Ninth revision, Clinical Modification is used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures.National Center for Healt

46、h Statistics (NCHS).731. INFECTIOUS AND PARASITIC DISEASES (001-139)TUBERCULOSIS (010-018)Includes:infection by Mycobacterium 分枝桿菌 tuberculosis (human) (bovine 牛)Excludes:congenital tuberculosis (771.2)late effects of tuberculosis (137.0-137.4)The following fifth-digit subclassification is for use w

47、ith categories 010-018:0 unspecified1 bacteriological or histological 組織學的 examination not done2 bacteriological or histological examination unknown (at present)3 tubercle bacilli 結核桿菌 found (in sputum) by microscopy4 tubercle bacilli not found (in sputum) by microscopy, but found by bacterial cultu

48、re5 tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically6 tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods inoculation 預防接種 of animals74010 Primary tuberculous infectionRequires fift

49、h digit. See beginning of section 010-018 for codes and definitions.011 Pulmonary tuberculosisRequires fifth digit. See beginning of section 010-018 for codes and definitions.Use additional code to identify any associated silicosis矽肺病 (502)012 Other respiratory tuberculosisRequires fifth digit. See

50、beginning of section 010-018 for codes and definitions.Excludes:respiratory tuberculosis, unspecified (011.9)013 Tuberculosis of meninges 腦脊膜 and central nervous systemRequires fifth digit. See beginning of section 010-018 for codes and definitions.75014 Tuberculosis of intestines 腸, peritoneum 腹膜,

51、and mesenteric glands 腸系膜腺Requires fifth digit. See beginning of section 010-018 for codes and definitions.015 Tuberculosis of bones and jointsRequires fifth digit. See beginning of section 010-018 for codes and definitions.Use additional code to identify manifestation, as:tuberculous:Arthropathy 關節(jié)

52、病(711.4)Necrosis 壞死of bone (730.8)Osteitis 骨炎(730.8)Osteomyelitis 骨髓炎(730.8)Synovitis 滑膜炎(727.01)Tenosynovitis 腱鞘炎(727.01)76016 Tuberculosis of genitourinary 泌尿生殖器的 systemRequires fifth digit. See beginning of section 010-018 for codes and definitions.017 Tuberculosis of other organsRequires fifth d

53、igit. See beginning of section 010-018 for codes and definitions.018 Miliary 粟粒狀的 tuberculosis Includes:tuberculosis:Disseminated 彌散性Generalized 全身性的miliary, whether of a single specified site, multiple sites, or unspecified sitePolyserositis 漿膜炎77HCPCSThe Health Care Procedure Coding System is comp

54、rised of Level I (CPT) and Level II (National) codes.Level II HCPCS codes are developed by the Centers for Medicare & Medicaid Services (CMS) and used to classify report procedures and services.78CPT (Current Procedural Terminology)a numeric coding system maintained by the American Medical Associati

55、on (AMA).The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. 79Level I of the HCPCS, the CPT codes, does not include codes needed to s

56、eparately report medical items or services that are regularly billed by suppliers other than physicians.80Level II HCPCSCodes are reported to third-party payers (e.g., insurance companies) for reimbursement purposes.81Level II of the HCPCS is a standardized coding system that is used primarily to id

57、entify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics 假體, orthotics 矯形器, and supplies (DMEPOS) when used outside a physicians office 82Level II alphanumeric HCPCS procedure and modifier codes, their long and short

58、 descriptions, and applicable Medicare administrative, coverage, and pricing data.The Level II HCPCS codes, which are established by CMSs Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Associations Current Procedur

59、al Terminology-4 (CPT-4) codes;Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing.83A1001007DRESSING FOR ONE WOUND Dressing for one wound C 20701 N A2001007DRESSING FOR TWO WOUNDS Dressing for two wounds C 020701 N A3001007DRESSING FOR THREE

60、WOUNDS Dressing for three wounds C 020701 N84Abstracting Performed to enter codes and other pertinent information utilizing computer software.To generate statistical reports and disease/procedure indexes, which are used for administrative decision-making and quality-management purposes.85Incomplete