醫療服務提供者觀點下的門、急診轉診問題與挑戰

Exploring the challenges of outpatient and emergency department referral from the perspective of the health-care provider

目標：有鑑於臺灣就醫自由度高造成雙向轉診成效不彰，又國內尚未有以醫療服務提供者角度所進行的相關研究，故本研究欲以醫療服務提供者觀點探討與分析執行轉診所遭遇之困難及障礙。方法：本質性研究採半結構式深度訪談，透過立意取樣，以北、中、南部地區各層級醫療機構為主要取樣地區，並以有轉診經驗之醫師、護理師與行政管理人員為研究對象。首先透過網路視訊會議一對一訪談進行資料蒐集，將訪談內容建立逐字稿，再利用主題分析法，進行編碼及尋找初步主題，接著將主題精緻化、主題界定與命名。結果：本研究樣本有15位，包含醫師5位、護理師6位與行政管理人員4位，本研究結果發現轉診時主要的障礙可分為四個層面：成本、過程、品質以及制度。成本面問題包含病人流失與自我轉診、系統與行政作業成本、轉診財務誘因不足與醫師轉診獎金、人力配置等；過程面所發現的挑戰包含資訊系統與平台操作、雙向溝通有效性、病人因素、提供者因素等；品質面上則包括照護連續性、提供者照護品質等問題；以及制度面存在轉診績效指標制定、就醫可近性與部分負擔等問題。結論：本研究發現，在進行轉診時，醫療服務提供者面臨著眾多困難，這些問題涵蓋成本、流程、品質及制度層面，且不同層級醫療院所皆有不同的障礙與考量。本研究結果可作為國內全民健保未來落實分級醫療雙向轉診政策之參考。

Objectives: Owing to patients’great freedom in choosing their health care in Taiwan, the effectiveness of bilateral referral policy is limited in the country. Research on referral policies from the viewpoint of the health-care provider is currently lacking. Therefore, this study identified and analyzed the challenges faced by health-care service providers during their implementation of the referral policy instituted by Taiwan’s health-care system. Methods: The present qualitative study conducted semistructured, in-depth interviews of individuals recruited through purposeful sampling. Health-care facilities in the northern, central, and southern regions of Taiwan were the primary sampling sites, and the recruited participants were clinicians, nurses, and health-care administrators who had experience with the referral process. Data were collected through one-on-one online interviews. Thematic analysis was employed to code and identify initial themes, and this was followed by theme refinement, definition, and coding. Results: Fifteen participants were recruited: five clinicians, six nurses, and four administrators. The results uncovered four main categories of barrier to implementation of the referral policy: cost, process, quality, and system barriers. The primary care providers mainly mentioned cost-related problems, including patient loss and self-referral, system and administrative costs, insufficient financial incentives for referrals by health-care providers, and personnel allocation. Process-related problems included operation of the information system and platform, ineffective bilateral communication, patient factors, and provider factors. Quality-related problems included continuity of care and provider service quality. System-related problems included referral performance indicators, accessibility of care and copayment standards. Conclusions: The findings of this study revealed that health-care service providers continue to face many challenges during the referral process, which can be classified as cost, procedural, quality, and systemic issues. Different considerations and barriers emerged at differing levels of health-care facilities.