中文摘要 當前精神醫療過程中，存在若干矛盾的現象，尤其是生物－生理的以及社會文化的病因解釋與治療手法被交互運用。由於治療方法都是從診斷而來，因此精神治療意義的闡明指向診斷依據的釐清。本研究的目的在於探討當前的臨床精神醫療團隊拿什麼標準對於瘋狂的現象進行觀察，這個觀察的客觀標準的基礎又是什麼。研究方法使用田野觀察和質性訪談。資料分析則採用現象學的方法。 主要研究發現指出，正規臨床精神醫療的診斷標準，其實是社會文化生活中的常識。雖然常識作為衡量瘋狂是否存在的標準是客觀的，但也是不精確的。面對這個難題，臨床精神醫療的診斷採用了一種特殊的技術，亦即在一個已經設定好的時間中進行觀察，並且為這段時間設定好治療的目標。於是瘋狂的差異性就有了被規定出來的邊界，被觀察到的瘋狂將只是在一段治療時間中所觀察到的瘋狂，而且治療的目標也被設定為在這段時間中達成穩定的狀態的維持，以及讓精神病患養成一個不斷連結或憶起這段治療時間所學會的種種「儀式」的習慣。 因此，當今的精神醫療採用生物─心理─社會的社區精神醫療的模式，入院治療只是一種回歸社會的技術。現今的精神科醫療團隊，以治療計劃來為病人擬定「回歸社會」或「復原」的目標，進而提昇病人適應社會的功能，醫療在其中所扮演的角色就是控制瘋狂的差異相，讓它保持「穩定」。 然而，臨床精神醫療的深層結構其實是較不為人意識到的時間結構。透過這個可以被理性所限定與規劃的時鐘時間，形成一套將非理性時間納入理性時間的規範，這種時間的規範才是臨床精神醫療的時間結構的核心現象。時間因此成了一種技術，透過這種技術就能將瘋狂圈圍起來，在這個被限定的範圍內，瘋狂終於得以被認識，進而被有效地控制。 關鍵詞：臨床精神醫療、技術結構、時間結構、慢性病房、復原 / Abstract This study aims to explore the criterion of observation in modern psychiatric team’s madness observing, and to explore what is the basis of the criterion of observation. The research methods involved field observation and qualitative interviews. The data analyses were phenomenological methods. The major findings suggested that the clinical psychiatric team use a special technology in diagnosis which they observe madness phenomena in a schedule, and they set the target of curing for the time of observation and treatment. The target of curing is being setted to maintain a stable situation of symptom.To achieve the goal of recovery, modern psychiatry would place emphasis on one’s ability of adapting to norms of the society. In the beginning of recovering, medication would be used to keep patients' condition in a stable situation. Secondly, the whole team of treatment needs a comprehensive plan to guide themselves. In a way of "location", "orientation" and "connection", doctors and nurses ask patients to pass through a "threshold", and turn the process of treatment into the process of passing through. To find out a "breakthrough point " will be the first important thing in recovering, it is the roadmap of teaching a patient to form new habits by making an appointments, punishing and keeping a watchful eye on her or him. Once the patient has really proved herself or himself the ability of adapting to the society , it is the time for her or him to leave the hospital and go home. The results of the study may help psychiatric team members to rethink the strategies of treatment and to the possible benefits of understanding the modern culture which belongs to us. Key words: Clinical Psychiatry, Technical Structure, temporal structure

健康相關生活品質越來越重視病人主觀的感受，然而將這個部分納入測量之後，許多研究結果卻出現殘疾悖論(disability paradox)的現象，也就是重度疾病病人的自評生活品質並不比程度輕微或甚至健康的人差。反應轉移理論認為，造成這個現象的原因在於個人的自評生活品質會受到個體對於生活品質定義的改變（重新構念）、內在測量尺度標準的改變（重新校準）、以及價值的改變（重新權重）的影響，到目前為止，反應轉移尚未發展出合適的測量工具。 SEIQoL-DW (Schedule for the Evaluation of Individual Quality of Life- direct weighting)做為一個生活品質測量個人化的代表，其評估分成三個步驟，分別是提名重要的生活領域、評估提名領域的滿意程度、以及評估提名領域的相對權重，許多研究者嘗試用SEIQoL-DW在兩點間的領域變化做為重新構念，權重變化做為重新權重，重新校準則需要搭配then test來測量，then test是在第二個測量點時邀請受試重新對第一個時間點的提名領域進行評估，然而這三個成分指標的操作型定義不一，then test也有使用上的不便，同時過去這些指標對生活品質的效用檢驗也都未達顯著。本研究分認為，若能解決上述的問題，將有助於解釋殘疾悖論，同時可以區辨不同類別病人的反應轉移模式，並運用在臨床來幫助病人進行調適。 本研究以立意取樣招募3期以上之慢性腎臟病患者、以及血液透析、腹膜透析未滿一年以上之三組病患共85名，除了背景和臨床資料外，在間隔三個月的兩點分別填寫SEIQoL-DW、ideal scale（評估期待）、生活滿意問卷、正負向情緒問卷，並在後測時填寫then test。研究結果顯示，三組病人的生活品質符合殘疾悖論，並無顯著差別。重新構念、重新校準、和重新權重當中，僅重新校準有助於生活品質的提升，並能夠顯著解釋生活品質的改變。 對腎臟病患者來說，期待越高，生活品質提升得越多，進一步的分析顯示，受試會捨棄相對權重較低的領域，新提名領域的滿意程度、期待、和相對權重都顯著高於捨棄的舊領域，這可以作為臨床上協助病人調適的策略。雖然then test的結果顯著，但實證結果和理論卻相當混亂，尚待未來研究釐清。 / Health-related quality of life (HRQoL) is increasingly recognized as being subjective, which emphasized patient-reported outcomes. Many HRQoL studies reported that people with serious illness perceived no less quality of life (QoL) than those without such illness. This phenomenon is labeled as disability paradox. Response shift theory provides an explanation for it and refers to a change in the meaning of one’s self-evaluation of QoL as a result of changes in internal standards (recalibration), values (reprioritization), and reconceptualization of QoL. It is these changes that will influenced perceived QoL. Current methods to detect Response Shift are still evolving. SEIQoL-DW (Schedule for the Evaluation of Individual Quality of Life- direct weighting) is one of individualized QoL instruments and measures three elements of QoL, including five important aspects of life, current satisfaction with each aspect, and relative importance of each aspect. Many researchers tried to use SEIQoL-DW to detect response shift. Changes in the content of aspects of life between two time points reflect reconceptualization. Changes in the relative weighting between two time points reflect reprioritization. Recalibration is measured by then test, which is a method by asking respondents at time two to provide a renewed rating of their aspects of life given at time one. However, there are no consensus operational definition of indices of reconceptualization , reprioritization, and recalibration. The examination between indices and improvements in QoL was not significant, either. Besides, then test with SEIQoL-DW has a disadvantage when aspects nominated between time one and two are different. This study tried to resolve issues above. If these issues are resolved, disability paradox will be explained. Response Shift will possibly differentiate patients of various disease, and provide ideas to help patients adjust to illness. 85 patients were recruited, including those with renal disease stage 3-5, and those undergoing hemodialysis or peritoneal dialysis within one year. All patients completed SEIQoL-DW, ideal scale, Satisfaction with Life Scale, the Positive And Negative Affect Scale at time one and three months after , except questionnaire on personal background and biological information (at time one) and then test (at time two). Results indicated that the QoLs of these three groups of patients showed no different, which confirmed disability paradox. Only recalibration showed helpful. Regression analyses also showed that recalibration indices were better predictors in QoLs. For End-stage Renal Disease patients, higher expectation suggested higher QoL improvement. Further analysis showed that patients would abandon lower-weighted aspect of life. Compared to the abandoned aspects, higher satisfaction, expectation and weighting were seen in new-nominated aspect. This finding could be useful in helping patients adjust. Although then test also reached significance, evidences was contradicted to its prediction. More research is needed in the future.

本論文研究專注於研究穿戴科技對於銀髮族遠距照護服務創新的可能性，利用系統思維與設計思維的研究方法來進行服務設計。研究問題設定為”一個罹患慢性病並獨自在家生活的銀髮族,如何自主健康生活，並能讓家人感到安心呢” 。透過顧客驅動價值共創的服務設計模型，確認利害關係人，並實際訪談利害關係人後深入分析使用者潛在問題及需求，以不同視角來找出創新的洞見。依據此洞見來發展可行的方案，並展開成為完整的服務系統，再將此服務系統雛型具體化產出後進行風險分析。最終的研究結果以商業模式草圖來呈現完整的商業模式。 / The aim of this thesis is to study the possibility of the wearable technology and to create a service innovation toward the tele-health for elders. The research method of the service design is based on the design thinking and the system thinking.We set up a hypothetical situation as follows: A solitary elder who has chronic diseases knows to how to manage her/ his life well without making the family worry. Through the service design models from the co-creation of the customer empowerment, we affirm the stakeholder at the beginning and then interview her/ him to get to know more about the needs and some main details. The purpose is to look for the insight into the innovation in different aspects. Based on this insight, we start a feasible plan and develop the integrity of the service design. Next thing we externalize the service design prototype and provide the follow-up risk assessment.As the final result, we use business model canvas to bring out the coherence and the integrity to our business models.

全球遠端醫療產業蓬勃發展，各國家的法規也越來越明朗化，未來醫療需求將隨人口老化而大幅上升，如何利用新型態的醫療方式來解決醫療問題，便成為國際上討論的趨勢。本文以遠端藥事做為研究目標，透過「iHealth政昇處方宅配藥局」服務全台的經營模式，以及「春森藥局」服務社區式的經營模式，比較兩家藥局的施行歷程，如何以不同的形態達成遠端藥事。 本研究以Osterwalder提出之經營模式圖(Business Model Canvas)做為基礎，論文以商業畫布、市場機會的發掘與辨識、興業的商業概念、興業的執行、興業的成果呈現，探討機構的獲利方式、民眾的營收方式、藥事服務的形式、慢性病照護，以及政策性的醫療網絡建構等…議題，皆可做為政府規劃醫療政策之參考，本研究有別於其他遠端醫療研究多半選擇科技之論述，以藥局經營做為研究對象，探討產業商機所在。 研究結果顯示，台灣遠端藥事可以符合在現有的法規之上，藥局經由的通訊科技聯繫到病患，提供連續處方箋獲利，不需要依靠業外收入，達成藥事服務營利。比較特別的事，不同藥局要施行遠端藥事的動機不同，分別有企業藥局的經營導向，協助機構評鑑、提供民眾的宅配，此模式下的遠端藥事僅為企業願景的一部分，最終以平台建製作為目標；另一種模式為個人藥局的經營導向，藥師透過政策接觸到社區病患，提供居家服務、甚至安寧服務，實現全人照護之目標。 本研究認為，台灣的遠端藥事尚有發展之潛能。企業經營的方向，需要以機構做為穩定現金流的基礎；個人經營的方向，依然以自身的使命感為主，然而配合「遠端醫療法案」鬆綁、「居家照護政策」的補助，建製完善的社區醫療網絡，將有助於提升社區藥局參與遠端藥事服務之意願，形成新型的產業模式。 / As the telemedicine industry flourishing, the regulations became clear among the countries, the medical needs will also increase in the future. As the goal of the research, this dissertation focused on telepharmacy, the research compared two pharmacies with two different models: serves-the-entire-Taiwan bussiness model from 「iHealth政昇處方宅配藥局」, and serves-the-community bussiness model from 「春森藥局」, hoping to be able to present the telepharmacy with different forms and conditions. This research used the Business Model Canvas which was presented by Osterwalder as the foundation, Unlike other telemedicine researches, this research explored the industry opportunities, and focused on the pharmacy management perspective, instead of the science perspective. The result shows that the telepharmacy in Taiwan can be consistent with the existing regulations. What is more special is that, different pharmacies have different motivations for telepharmacy, and the telepharmacy under this model is only part of the enterprise vision, and creates Platform as the final goal; another model is the business directoin of personal pharmacy, pharmacist contacts patients in the communities through policies, provide home services, and hospice home care to achieve the goal of holistic care. This study considers that telepharmacy still has the potential for development. The direction of enterprise management needs to be based on institutions as the basis of stable cash flow; the direction of personal management sill based on their sense of mission. However, with the help of telepharmacy laws and home care policies, through building the well rounded community medical network, can help increasing the wills of the community pharmacies to participate in telepharmacy.