在临床医学中怎样用药

1Chapter1:HealthCareDeliverySystemsFeipeiLaiNationalTaiwanUniversity2HealthCareDeliverySystemsHistoryofMedicineandHealthcareDeliveryContinuumofCareHealthCareFacilityOwnershipHealthCareFacilityOrganizationalStructureLicensure,Regulation,andAccreditation3IntroductionHealthcaredeliveryhasbeengreatlyimpactedbyescalatingcosts,resultinginmedicalnecessityrequirements,reviewofappropriatenessofadmissions,andrequirementforadministrationofqualityandeffectivetreatments.4MRXO在臨床醫學中，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(MR)、Ｘ光及電腦斷層掃描(CT)系統，大幅減少病患危險並簡化醫師的手續，可望提高手術成功率。這項由日本東海大學、飛利浦醫療系統事業部合力推動的「未來手術室」，已經由日本東海大學的松前教授、津具醫師、山本醫師共同在手術室同時使用MR(磁振造影)和X光影像技術，來進行神經外科手術。5MRXO在「未來手術室」中執行手術，可依執刀醫師與病患狀況，在數分鐘內將病患從手術台搬移到磁振造影、電腦斷層掃描或Ｘ光診斷系統，增加手術精密度與成功率。在磁振造影和電腦斷層掃描區域有拉門。6HistoryofMedicine&HealthCareDeliveryHistoryofmedicineEvolutionofhealthcaredeliveryintheUnitedStates7HistoryofmedicineIn1994,scientistsdiscoveredthegenesresponsibleformanycasesofhereditarycoloncancer,inheritedbreastcancer,andthemostcommontypeofkidneycancer.8EvolutionofhealthcaredeliveryintheUnitedStates1991TheWorkgrouponElectronicDataInterchange(WEDI)wascreatedtoreducehealthcareadministrativecoststhroughimplementationoftheelectronicdatainterchange(EDI),whichusesnationalstandardstotransmitdataforreimbursementpurposes.9EvolutionofhealthcaredeliveryintheUnitedStates1996TheHealthInsurancePortabilityandAccountabilityAct(HIPAA)waspassed.Itmandatesadministrativesimplificationregulationsthatgovernprivacy,security,andelectronictransactionstandardsforhealthcareinformation.10EvolutionofhealthcaredeliveryintheUnitedStates1996TheHealthcareIntegrityandProtectionDataBank(HIPDB)wascreatedwhichcombatsfraudandabuseinhealthinsuranceandhealthcaredeliverybyalertinguserstoconductacomprehensivereviewofapractitioner’s,provider’s,orsupplier’spastactions.11HealthcareIntegrityandProtectionDataBankAccesstoinformationintheHIPDBisavailabletoentitiesthatmeettheeligibilityrequirementsdefinedinSection1128EoftheSocialSecurityActandtheHIPDBregulations.Inordertoaccessinformation,eligibleentitiesmustfirstregisterwiththeDataBank.HIPDBinformationisnotavailabletothegeneralpublic.However,informationinaformthatdoesnotidentifyanyparticularentityorpractitionerisavailable.12HealthcareIntegrityandProtectionDataBankEstimatesofannuallossesduetohealthcarefraudrangefrom3to10percentofallhealthcareexpenditures--between$30billionand$100billionbasedonestimated1997expendituresofover$1trillionand2.5trillionfor2009.13ContinuumofCareAcompleterangeofprogramsandservicesiscalledacontinuumofcare,withthetypeofhealthcareindicatingthehealthcareservicesprovided.PrimarycareSecondarycareTertiarycare14PrimarycareservicesIncludepreventiveandacutecare,arereferredtoasthepointoffirstcare,andareprovidedbyageneralpractitionerorotherhealthprofessionalwhohasthefirstcontactwithapatientseekingmedicaltreatment,includinggeneraldental,ophthalmic眼科的,andpharmaceuticalservices.15PrimarycareservicesAnnualphysicalexaminationsEarlydetectionofdiseaseFamilyplanningHealtheducationImmunizationsTreatmentofminorillnessesandinjuriesVisionandhearingscreening16SecondarycareservicesProvidedbymedicalspecialistsorhospitalstaffmemberstoapatientwhoseprimarycarewasprovidedbyageneralpractitionerwhofirstdiagnosedortreatedthepatient.17TertiarycareservicesProvidedbyspecializedhospitalsequippedwithdiagnosticandtreatmentfacilitiesnotgenerallyavailableathospitalsotherthanprimaryteachinghospitalorLevelI,II,IIIorIVtraumacenters.18TraumacentersLevelI:providesthehighestlevelofcomprehensivecareforseverelyinjuredadultandpediatricpatientswithcomplex,multi-systemtrauma.LevelII:broadrangeofsub-specialistsareon-callandpromptlyavailabletoprovideconsultationorcare.19TraumacentersLevelIII:physiciansareadvancedtraumalifesupport(ATLS)trainedandexperiencedincaringfortraumaticallyinjuredpatients;nursesandancillarystaffarein-houseandimmediatelyavailabletoinitiateresuscitativemeasures.20TraumacentersLevelIV:criticallyinjuredpatientswhorequirespecialtycarearetransferredtoahigherleveltraumasystemhospitalinaccordancewithpre-establishedcriteria.21TertiarycareBurncentertreatmentCardiothoracicandvascularsurgeryInpatientcareforAIDSpatientsMagneticresonanceimaging(MRI)NeonatologylevelIIIunitservicesNeurosurgeryOrgantransplant22TertiarycarePediatricsurgeryPositronemissionstomography(PET)RadiationoncologyServicesprovidedtoapersonwithahigh-riskpregnancyServicesprovidedtoapersonwithcancerState-designatedtraumacentersTraumasurgery23Positronemissionstomography(PET)buildsimagesbydetectingenergygivenoffbydecayingradioactiveisotopes.Isotopesareatomsofanelementwiththesamenumberofprotons(positivelychargedparticles)inthenucleus,butadifferentnumberofneutrons(neutralparticles).Becauseradioactiveisotopesareunstable,astheydecay,theythrowoffpositronsthatcollidewithelectronsandproducegammaraysthatshootoffinnearlyoppositedirections.24PETPETsystemsusethep