政府對於弱勢族群之長期照顧，除了高齡化問題之外，許多地區另有獨居老人、隔代教養、外籍配偶等嚴重現象。因此，本研究以個人健康記錄（Personal Health Records, PHR）之觀念為基礎，以旗津地區為研究範圍，並與高雄市立旗津醫院之慢性病照護小組（Chronic Care Unit, CCU）合作，發展社區健康照護雛型系統，協助醫療照護人員針對旗津地區慢性病患者與弱勢團體之整合性與跨專業的相關照護之資訊化管理作業，包含糖尿病、高血壓、失能與孩童早期療育等。研究結果顯示，整體使用者對本系統具有正面之滿意度，然而資訊呈現方式是否方便、操作介面之友善及易用程度與系統安全措施等部份，醫師之滿意度則相對較低。最後，本研究對於政府、醫療機構、病患、廠商等，亦有相關建議，期許能提供各領域發展社區健康照護系統之參考。 Besides taking care of the problem of advanced age, the government also pays attention to serious phenomena for disadvantaged minorities including old people living alone, generation education, and spouses from another country. Due to these problems and referring to Personal Health Record (PHR) concept, we cooperated with Kaohsiung Municipal Cijin Hospital of Chronic Care Unit (CCU) and developed a community healthcare system prototype to assist healthcare staffs of using management information to combine their specialized field for helping chronic patients in Cijin and disadvantaged minorities including diabetes, hypertension, and disability. Furthermore, this system also provided some specific functions for the support of early intervention service. The results showed that the users are satisfied with this system and have positive attitude, but it is not convenient, easy, safe, and friendly to operate from doctors’ opinions. In conclusion, this study has some discussions and suggestions which may provide some methods of developing about community health care system for government, medical institutions, patients, system providers.