醫學新聞：客廳就是候診室

隨便胡言亂語的前言：

今天開始，分享一些網路上瀏覽看到的有趣玩意兒。

格式不拘、文體不拘←好比現在這樣就是BBS常用的分段方式

內容更是不拘！

各位看官就很不拘的輕鬆看，有意見請不要嚴肅

link: Medical News: Living Room Is New ED Waiting Room - in Emergency Medicine from MedPage Today  醫學新聞：客廳就是候診室

話說，急診壅塞、過長候診時間、輕症病人濫用急診…這些台灣常見的問題，美國也有！

門診可以預約，知道自己幾號大概幾點到、甚至有些醫院都有看診進度可以上網查詢；那急診可以比照辦理嗎？既然急診掛號後還要等個一兩小時才能看診(那應該是美國吧~台灣如果要等一個小時，病人早就寫好投訴單了)，那我可不可以先預約然後在家等時間到了再慢慢出門？

於是有家公司 InQuickER 官方網頁 想出了個讓民眾滿意、醫生紓解壓力、醫院又有錢賺的三贏方案－讓急診室也可以預約(只是要花錢)！

How It Works 怎麼運作？

第一步，當然是從網頁上選擇有加入這個方案的醫院。
第二步，選擇醫院提供的時間。

重點來啦！可以預約的時間，是由醫療服務供給端－醫院－提供的；而不是需求端－病人－可以指定任意時間。好處是醫院可以選擇病人數量離峰和人力相對充足時段接受預約。
第三步，輕鬆地在家看電視候診，只要在約定時間抵達急診室，保證你15分鐘內就可以看病！link 如果超過15分鐘就退你錢。

先講大家最關心的錢吧，使用這個服務要多少錢？除了原本就醫的費用，還需要額外的14.99~24.99美金！相較美國高額的醫療費用，這個價位真的是便宜又實惠啊。

那如果是重病的人咧？這樣在家等延誤了病情怎麼辦？當然如果是我很急想要立即看診的病人(只是不一定會如你所願就是了)和需要立即處理的病情，不要用這個預約，請直接去最近的急診或是打911。

＂啊我們民眾沒有醫學常識，都是健康教育課零分的白痴，怎麼知道我的症狀有沒有緊急？＂上圖的紅色框框有寫－如果你不知道自己的症狀嚴重度，就不要用這個系統！有懷疑，就請直接去醫院急診室。
(有沒有覺得跟台灣急診也很像？一堆不知道自己病情嚴重度的民眾，很緊張就掛急診…)

另外從網頁上預約時候，就需要填寫你的症狀；好比是寫＂胸痛＂(chest pain)這種的，就會接到他們的電話(不知道是InQuickER主動打還是醫院打，新聞說醫院也會持續注意預約病人的症狀描述)

One thing is certain, Song said -– the system won't let a patient schedule an appointment for later in the day if he or she needs to be seen immediately. Hospitals constantly monitor the requests coming in, and if an acute condition is sensed, a healthcare worker will follow up.
"If someone writes that they're having chest pains, they get a call," Clem said.

看起來很不錯的方案，但是如果這個方案拿來台灣實行，一定會被批評＂為什麼有錢人可以花錢先看？＂然後衛生署(雖然現在不是楊署長了)跳出來制止醫院額外跟病人收費…雖然公司發言人辯稱＂這不是插隊，只是換個地方在家候診而已＂

"Patients are just choosing where they wait," said Kathleen Clem, MD, chair of emergency medicine at Loma Linda University Medical Center in California, which recently implemented the technology. "They're waiting at home rather than our waiting room."She added that they're "not getting in line in front of someone else."

公司網頁也很強調＂這只是在家等，不是插隊＂

另外有醫療排擠和濫用的議題。雖然公司負責人說這個系統主要是給那些輕症－好比尿道感染和扭傷拉傷－或是單純因為過了門診時間只能掛急診的病人們，況且真正急重症來到急診的病人還是會優先被處理；不過反對者也認為＂既然是輕症，那就應該是去看門診，而不是跑來急診預約(可以預約的病情怎麼需要看急診咧？ link)＂

我個人是覺得這個方案不錯啦！畢竟醫療也是種服務業，額外服務當然就要額外收費。不過美國人不同意的也很多，尤其是覺得急診已經被濫用的人，應該更反對這個助長濫用的系統吧。好比底下有人回應：

"...the bookings will never take precedence over a true emergency."  "Never" is a long time. And sometime, there will start to be quiet pressure to "make sure we keep our appointments"; to "See the paying patients as soon as possible". It won't be overt; no administrator will ever say "Let the gunshot wound wait until you see the 7:15 appointment"; it'll be hints, talkarounds, subtle digs about the patient they had to pay off last week because you had a GSW, a STEMI and a CHF patient on BiPAP and the hangnail had to wait.  Systems like this one reinforce the idea that the ED is an acceptable place to come for non-emergent care. It is not. It is the place of last resort; the place where, like home in The Death of The Hired Man, when you *have* to go there, they have to take you. If you have a UTI, CALL YOUR DOCTOR, for heaven's sake. And if you're the doctor being called, *learn* how to do telephone triage, learn how to treat patients over the phone, and actually treat them, reimbursement be damned. (And at the same time, I do believe we should work to see that these types of "visits" are, in fact, reimbursed). Pediatricians have been doing this for years; why are we still sending adults to the ED when it's not an emergency? Sure, sometimes you can't tell. And when that's the case, send 'em in. But I cannot tell you how many 23 year old UTI's I've seen at 0230, who tell me their doctor either didn't answer, or told them to go to the emergency department, despite data showing that if you're 23 and say you have symptoms just like your last UTI, you have a UTI with high likelihood, and just phoning in some antibiotics and pyridium with a morning visit would save everyone much aggravation-the patient the ER doc, and you. And when I see those patients, I tell them to start shopping for a doctor who both reads the literature and cares about them, because if they read they'd know what to do, and if they cared they would avoid sending their patients to the ED unless it was, in fact, a true emergency.

美國人(應該也是醫生吧)在新聞底下留言，十分的反對這樣的服務。
另一個美國人則說：

I think this entire concept is just crazy! If they do not have an emergency, let them go to their family Dr., or an urgent care center. If they are not sure - then they should be triaged by a knowledgable nurse, and then be seen in the order of severity... I also agree that it is our duty to educate people about what truly is an emergency. This can be done with pamphlets and handout in the hospital, also by the Triage Nurse, and well as other medical professionals in the ED and in Physicians' Offices. I'm also not so sure that a fee shouldn't be charged for the non-emergent patients. It is really unfortunate how true emergency have to wait simply because of the volume of non- emergent patients!

我認為這整個概念是瘋了!!…教育病人怎樣是真正的緊急，是我們的責任…如果真正的緊急病患因為大量的非緊急病人而必須等待，那才是真正的不幸啊~~ 

不過InQuickER一直保證真正的急症患者，還是會被先看不會被延誤。不過實際上要掛保證的是醫院，保證不會因為加入這個方案，為了避免沒有達到15分鐘保證所付出的違約金，而拖延重症患者；不是InQuickER出來掛保證啊~~
目前全美只有15家醫院提供這種服務，據說15分鐘內看診這個目標達成率有95%。

公司是這麼對醫院宣揚自己的好處 link:

Benefits of Implementing InQuickER

Increase patient satisfaction Wait time is a significant component of patient satisfaction in the emergency room, and InQuickER patients spend little to no time in the waiting room; instead, they spend the wait time relaxing at home or at another location.

• 病患滿意度調查結果也是這樣，滿意度很高！其實台灣人應該也是一樣，討厭等、討厭不確定要等多久；如果你可以事先跟他們講幾點看的到，其實是會獲得好評的。不過這點對於＂我掛急診就是因為我要馬上看＂的人應該是沒有效果吧~

Increase efficiency

InQuickER shifts patients from high-utilization hours to low-utilization hours by giving patients the information necessary to plan their visits around peak usage times.

• 由於可接受預約的時間是醫院提供的，所以醫院可以選擇離峰時間接受病人預約，紓解病人的人潮…不過說實話，在台灣的離峰時間，好比凌晨兩三點的現在，有多少人願意爬起來看不急的急診??其實離峰時間也是很多人不方便的時間。話說回來，這對那些請假跑出來看急診的，應該是很有用。
• 官方說法是，民眾寧可跑到比較願且可以預約的急診，也不願意去就近還要現場等的急診。

Streamline the registration process

Patients who use the InQuickER preregistration service can enter their demographic and medical information online, before they arrive at the emergency department. With InQuickER, an emergency medical profile (including information such as current medications, allergies, and medical conditions, etc) is sent to the emergency department before the patient even walks through the front door.

• 線上預約的時候，就要求病人填寫詳細的資料，可以節省到達醫院時後再填資料的時間。