醫療雲飄進復興鄉

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2013 / 2月

文‧朱立群 圖‧莊坤儒


從山地偏鄉的角度觀看台灣,180度不一樣。

 

政府打造醫療雲,建構電子病歷交換平台,選在醫療與數位資源雙重落差的桃園縣復興鄉試辦,需要很大的勇氣與膽識。

 

平步瞬間難成青雲,醫療雲也非一蹴可幾。復興鄉從醫療資訊化的基礎出發,4年前已先在桃園山上、山下之間搭起小型的雲端,開山地與離島地區之先,成效令人刮目相看。


在山區樹蔭底下看病、體檢、開藥、打針,一次搞定─以醫院的標準作業流程來看,這樣的就醫環境粗糙得讓人捏把冷汗,但對資源較平地都會地區匱乏的偏遠地區,卻可能是殘酷現實下的最適安排。

根據衛生署統計,全國共有48個山地離島鄉,一鄉設有一間衛生所,共服務近37萬名居民,其中原住民老人居多,最需受到健康照護。

然而,按照每間衛生所平均僅兩名醫師的編制,偏鄉地區根本無法做到平地醫院分科詳盡、專科醫師看診的服務。不過,正因為如此,山地離島衛生所發展出特殊的巡迴醫療服務模式,醫護人員主動走入村落幫人看病,病人即便在樹下看診,也能得到跟醫院診間一樣的醫療照護。

醫療資訊透過網路傳輸與雲端分享,正是山地離島之所以能化腐朽為神奇,扭轉資源劣勢的關鍵。政府打造醫療資訊化,起步就在網路及醫療資源最貧乏的山地離島地區。幅員占全縣面積三分之一的桃園縣復興鄉,去年起被衛生署指定為「醫療雲」的試辦點,哪裡最困難,就從哪裡開始。

山中傳奇

元旦假期前的禮拜一,桃園縣復興鄉拉拉山清晨氣溫只有9度,家住華陵村的泰雅族楊小弟在睡夢中被搖醒,媽媽提醒他上學記得要看醫生。

已有咳嗽症狀的楊小弟就讀巴岭國小,該校標高海拔1,200公尺,全縣最高,有「雲端上的小學」浪漫稱號。這一天,從半山腰衛生所來的醫師會到校看診,楊媽媽已事先同意讓孩子在校接受診療。

時鐘剛過8點,復興鄉衛生所已忙碌了起來,職員們將巡迴門診所需的物品搬上公務車,包括兩個藥櫃與檢驗器材,以及三台筆記型電腦,各供掛號、看診、包藥使用,就醫流程完全與大醫院一樣。

衛生所兩位醫生排班,周一至周五,一位在所裡門診,另一位則到村裡巡診。復興鄉10個村、約1萬5,000名居民(近七成是泰雅族原住民),看病、拿藥、新生兒預防接種、老人注射流感疫苗,最方便的地方就是位在角板山蔣公行館附近的衛生所。如果捨近求遠到山下就醫,車程至少兩小時。

內科醫師、復興鄉衛生所主任林德文是當天的巡診醫師。八點半不到,他與兩位護理師及一位替代役藥師已上車就位,準備開始一整天的工作。當天的巡診點包括三光村的爺亨部落,以及華陵村的光華部落,是復興鄉最偏遠的兩個巡診角落。

進到村裡,一旦筆電連上網路,即便海拔高度差了六、七百公尺,也能即時讀取衛生所伺服器裡的病歷,並允許醫生同步寫入當天的診斷及開藥記錄。

「這是我們的『小雲』,」出身台中梨山泰雅族的林德文說。他指的是巡診時,筆電端與衛生所端的病歷資料傳輸與共享。

同樣是利用「小雲」的服務,元旦假期剛過,林德文開車載著同事及藥箱上山巡診。車子一到村裡,立刻放送原住民歌曲與開診廣播,請有需要的民眾,立刻攜帶健保卡前往看診。

在奎輝村的衛生室裡,林小姐幫4歲的兒子預約施打流感疫苗,患有糖尿病的77歲簡李阿美奶奶則來驗血糖兼拿藥。

下一站,在離衛生所約50分鐘車程的長興村高遶部落裡,醫護團隊在大樹下看診,80歲的曾奶奶來看抽血檢查報告;7年前搬回部落居住的黃太太,懷裏抱著流鼻水的外孫來看感冒,自己順便量血壓。藉由「小雲」的幫忙,所有診斷及開藥紀錄,都一一被林德文用3G網卡上網輸進筆電裡。

林德文所說的「小雲」,就是復興鄉衛生所已實施4年的遠距醫療資訊系統。

大雲、小雲,能數位傳輸的都是好雲

為了提升偏遠地區醫療照護品質,衛生署自2006年起,推動48個山地離島衛生所建置共用醫療資訊系統(HIS)及醫療影像傳輸系統(PACS),透過網路,把平地醫院的服務品質帶入偏鄉。

復興鄉衛生所在2009年完成HIS/PACS的建置,其中又以PACS實施迄今的效益最顯著。就以X光片來說,林德文表示,病人的片子照完後,製作成數位檔,經系統傳至市區設於署立桃園醫院的影像判讀中心,由放射科醫師判讀並撰寫報告回傳。之後,衛生所第一線醫師根據該報告,綜合山上病人實際的傷病狀況,做出是否需下山轉診治療的評估。

相較之下,以往X光片只要不是照得很清楚,衛生所醫師基於謹慎,通常直接就請病人下山就醫。由此可見,對通常由內科、家醫科、耳鼻喉科、皮膚科等醫師看診的衛生所而言,欲做出更準確的醫療判斷,參考放射科的專業意見非常重要。

因為實施PACS系統,X光片判讀的精準度得以大幅提昇,讓病況嚴重者得以把握下山治療的黃金時間,也讓病情輕微者省去舟車勞頓,以及避免不必要的重複醫療。

鑒於山地離島居民在衛生所就醫全額免費,復興鄉衛生所估算,2009~2012年HIS/PACS實施期間,已幫輕症病人省下台幣近400萬元的鄉外就醫交通費、掛號費及健保部分負擔費用,以及近3,000個需請假看病的工作天,相當於8年時間。

林德文強調,醫療資訊化為山地離島帶來更經濟、更省時、更便利的醫療照護服務,但「不只是X光片數位化或洗片藥水與紙張的節省,PACS的C代表Communication,傳輸才是重點。」

然而,山地離島人煙稀少、山巒層疊,對於網路傳輸的強調,卻也狠狠打中它的痛處。林德文表示,特別是在外出巡診部分,有些地方如爺亨部落與高遶部落,網路訊號非常差,醫療團隊只好將就「做半套」,只開兩台筆電「勉強」供掛號與看診用,不但處方籤需用紙筆書寫,就連看診紀錄也無法立即輸進電腦,只因螢幕切換太快就會當機。

「我們已有不錯的上層(醫療資訊系統)服務,但在寬頻基礎建設方面,還需政府多幫忙。」林德文強調:「網路品質,決定我們的服務品質。」

電子病歷,雲端交換

然而,就算網路通訊通暢無阻,復興鄉的醫護人員還得面臨另一個重要的課題:必須到平地醫院接受治療的民眾,回到山上後,如何取得他的治療情況、用藥紀錄等資訊,以協助其後續復健及健康管理?難道只能依照傳統方式,請他向原醫院申請病歷影印後,帶回山上?

衛生署去年3月啟動的跨醫院電子病歷交換中心,提供政府醫療雲的核心服務─在病人同意下,醫療院所可跨院提取其醫療影像報告、出院病歷摘要、血液檢查報告,以及門診用藥紀錄資料。衛生署按美國實施病歷電子化一年可省一成醫療支出的經驗推估,透過這朵雲,我國一年可省下台幣500億元的健保支出。

有了HIS/PACS醫療資訊化的成功經驗後,復興鄉在衛生署的指定下,創全國衛生所首例,去年12月開始登上電子病歷跨院交換的雲端,醫師因而更能掌握病人的病史及治療狀況。林德文表示,在此之前,對於在山下就醫的慢性病患希望改在衛生所拿藥,醫師只能從病人提供的藥袋或口頭陳述藥品外觀,粗略得知病人的用藥狀況,缺乏更進一步的評估依據,使得醫療及照護品質打了折扣。

根據衛生署統計,包括台大醫院、成大醫院、國泰醫院等19家醫學中心在內,全國目前已有142家醫院完成聯網介接,經當事人出具健保卡、簽署同意書,即可透過雲端調閱存在其他醫院的病歷資料;對跨院看病的民眾來說,可以確保治療的延續性。

然而,由於雲端病歷交換還在試辦階段,且無法源的強制約束,林德文察覺到,即便大型醫院參與者眾,但院方實際釋出的病歷內容卻極為有限,讓外界有「靠病歷綁客戶(病人)」的疑慮。

如此看來,歷經10年推動電子病歷的打底,政府推出的第一朵醫療雲已經踏出第一步,但能否具體成形,讓平地與山地離島醫療機構在病人的同意下,都能共享病歷資源,提升對病人的服務品質,還有很長的路要走。

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近期文章

EN

Blue Skies Ahead? The Medical Cloud Blows Through Fuxing Township

Sam Ju /photos courtesy of Chuang Kung-ju /tr. by Scott Williams

Taiwan’s government last year began work on a “medical cloud,” creating a platform for the exchange of medical records and selecting Fu­xing Township, Tao­yuan County, for its pilot program. Considering the relative underdevelopment of Fu­xing’s computer and medical systems, it was a bold choice for the program.

 

On the other hand, Fu­xing already had some experience integrating computer systems into medical care. In fact, it had seen quite good results from a four-year-old Tao­yuan County initiative that linked medical systems in the county’s mountainous areas to those in its more developed plains.


Forty-eight of Taiwan’s townships and municipal districts are located in mountainous areas or on outlying islands, and each has its own public health center (PHC). According to the Department of Health (DOH), these PHCs collectively provide services to some 370,000 people, many of whom are elderly Aborigines in great need of healthcare.

However, such centers have only limited staff (they average only two doctors each), which prevents them from offering the kind of comprehensive specialist care available on Taiwan’s plains. In an effort to provide more comprehensive service to township residents, PHCs utilize a system that sends medical personnel on rounds of the villages under their care.

The transmission of medical data over the Internet and the sharing of that data via the cloud are turning out to be crucial to providing better care in remote areas. The DOH chose Fu­xing Township, which accounts for one-third of Tao­yuan’s geographic area, as a pilot location for its cloud-medicine program in part on the principle that it should begin the rollout where problems are the most pressing.

A mountain miracle

It is a chilly 9° Celsius on Fu­xing’s Mt. Lala in the early morning of New Year’s Eve. Mrs. Yang, an Atayal woman, awakens her son in their Hua­ling Village home, and reminds him he needs to see the doctor at school today. It’s important that he remember because today is the day the doctor from the PHC halfway down the mountain will be at the school.

For roughly 15,000 Fu­xing resi­dents, nearly 70% of whom are Atayal, the PHC is the most convenient place to see a doctor, pick up medications, have their infants inoculated, and get flu vaccines for the elderly. A trip down to the plains for care means a drive of at least two hours. To make it a bit easier for township residents to receive care, one of the PHC’s doctors makes rounds of its 10 villages while the other holds down the fort at the PHC itself.

At just past 8 a.m., the PHC is already busy. Employees are loading the supplies they’ll need for their “rounds” into the center’s service vehicle. These include several boxes of pharmaceuticals and examination equipment, and three notebook computers, one each for registrations, examinations, and prescriptions. All of this gear enables examinations to be carried out just as they would be at a major hospital.

Today, Dr. Lin De­wen, an internist and the director of the Fu­xing PHC, will be making the rounds. On the road by 8:30 with two nurses and a pharmacist, the team will be visiting Ye­heng, a hamlet under the jurisdiction of San­guang Village, and Guang­hua, a hamlet administered by Hu­ling Village, the two most remote sites on the Fu­xing Township medical circuit.

Once they enter a hamlet and get connected to the network, the remoteness and 600 or 700-meter difference in altitude cease to be hindrances to care. Instead, the network provides the doctor with instant access to patient records on the center’s servers, and the ability to update them with any diagnoses and prescriptions made today.

“This is our ‘little cloud,’” says Dr. Lin, himself an Atayal from Li­shan, Tai­chung. His “little cloud” is a system that enables the laptops making the rounds to share medical records with the center’s servers.

Lin and his colleagues continue their rounds of Fu­xing’s mountain hamlets after the New Year’s holidays are over, again making use of their “little cloud.”

In the examining room in Kui­hui Village, a Ms. Lin makes an appointment for her four-year-old son to get a vaccination, while Li A-mei, a 77-year-old diabetic, drops in to have her blood tested and pick up her medications.

The medical team’s next stop is Gao­rao, a Chang­xing Village hamlet that’s about 50 minutes by car from the PHC. Here they see the 80-year-old Grandma Ceng, who has come in for the results of a blood test, and a Mrs. ­Huang, who moved back to the hamlet seven years ago and has come to have her grandson, who has a runny nose, looked at. Since she’s already here, Mrs. ­Huang also plans to have her blood pressure checked. With the help of a 3G network card and the “little cloud,” Dr. Lin enters all of his notes directly into his patients’ records.

Dr. Lin’s “little cloud” has now been in operation for about four years.

A cloud for all seasons

Aiming to improve the quality of care in remote areas, in 2006 the DOH began promoting the construction of Hospital Information Systems (HIS) and Picture Archiving and Communication Systems (PACS) in the 48 townships and districts in Taiwan’s mountainous areas and on its outlying islands. These systems are helping to raise the quality of care in these localities towards those of hospitals in Taiwan’s more developed areas.

The Fu­xing PHC completed its HIS/PACS in 2009, and has achieved especially good results with its PACS. Dr. Lin explains that the system allows you to send digital X-ray images straight to the Image Reading Center at Tao­yuan General Hospital with a request to have a radiologist there examine them and send back a report immediately. The frontline doctor can then use this report in conjunction with the patient’s current condition to determine whether the patient needs to travel to the plains for further treatment.

In other words, the PACS has enabled more accurate interpretation of X-rays, allowing patients whose condition is serious to seek treatment in the plains within the so-called “golden hour,” patients whose condition is less severe to save themselves a long and unnecessary trip, and the system to avoid redundant care.

Given that residents of Taiwan’s mountain areas and outlying islands receive free medical care at their local PHCs, the Fu­xing PHC estimates that from 2009 to 2012, its HIS/PACS program saved its patients nearly NT$4 million in expenditures on registration fees, National Health Insurance co-pays, and transportation to and treatment outside the township, not to mention nearly 3,000 days of sick leave that would otherwise have been used seeking care at more distant locations.

Lin stresses that medical information systems bring convenience, as well as savings in time and money, to Taiwan’s remote areas. The key, he says, is communication.

“We already have a good superstructure [the HIS], but we could still use some help with broadband infrastructure.” He adds: “The quality of our connection determines the quality of our service.”

Electronic medical records

But even a perfect Internet connection doesn’t eliminate every problem. For example, when mountain residents have to seek treatment down on the plains, how do they get the reports on their condition and medications back to their local PHC to facilitate follow-on care and health management? Is there no alternative to requesting the hospital that treated them to make physical copies for them to hand carry back to the PHC?

In March 2012, the Department of Health established an inter-hospital electronic medical records exchange mechanism that operates via a government-created medical cloud. With a patient’s consent, the system enables hospitals and clinics to exchange the patient’s discharge summary, blood-test and medical-imaging reports, and treatment and pharmaceutical-use records. Given that the United States was able to reduce its medical costs by 10% through the use of electronic medical records, the DOH estimates that its medical cloud will save Taiwan some NT$50 billion per year in healthcare expenditures.

One of the reasons that the DOH chose Fu­xing for the pilot study of its cloud-based electronic medical records exchange system was Fu­xing’s success with HIS/PACS. Fu­xing began its rollout of the new cloud system, the first by a township PHC, in December 2012.

Lin says that prior to the system’s introduction, PHC doctors had a hard time providing medications to patients who had received treatment for a chronic condition in the plains. Patients often weren’t familiar with their medications, requiring PHC doctors to guess at their pharmaceutical use based on either what was printed on the bag in which medicines had previously been dispensed (if the patient had happened to bring it in) or on the patient’s descriptions of the medication’s appearance. Patient care suffered as a result.

Fortunately, the DOH says that 142 hospitals across Taiwan are currently connected to the records system, including 19 major medical centers. Now, when a patient presents an NHI card and signs a consent form, care providers can use the system to review the patient’s medical records from other hospitals. This ensures continuity of care for patients receiving treatment at more than one facility.

However, Lin observes that with cloud-based exchanges of medical records just entering the pilot stage and without a legal basis for compelling compliance, large hospitals that participate can choose to exchange only very limited information. That is, they can use their possession of patients’ medical records to hold patients hostage.

After 10 years laying the groundwork for electronic medical records, the government has now rolled out phase one of the medical cloud. But we still have a long way to go before we discover how much sharing of medical records and resources will actually occur and whether this sharing will ultimately improve patient care.

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