利用作業研究規劃探討病人連續處方箋領藥方式 以改善醫藥分業現況

Abstract

研究動機：面對政府醫藥分業及全民健保的實施，政府鼓勵各級醫療院所之處方箋釋出，醫院面對連續處方箋釋出造成營收及利潤流失的困境；另一方面對藥局通路來說相對比一般零售業之經營門檻更高，高價藥品庫存成本高，市面上藥局林立競爭激烈，藥師除了必須具備藥學相關專業，又必須面對商業面盈虧的挑戰。另一方面由於社會經濟結構的變化，民眾對於就醫及用藥保健相關常識也隨資訊透明化而容易取得，故對個人及家庭之健康維護日漸重視，進而對於選擇自主權亦大幅提高。上面種種因素導致政府推行醫藥分業之制度無法順利開展。在醫藥分業政策下而形成的市場競爭中，醫院和藥局如何進行多元資源整合，形成良性的競合關係，「分工」後還是要「合作」進而達到互利共生的雙贏，同時如能滿足病人的需求必是現在就要面對的重要課題。 研究目的：本研究以新北市中、永和地區某大型教學醫院之資料為統計分析基礎，醫院於民國108年3月共開立100,4935張一般處方箋、49,306張連續處方箋。其中利用連處回醫院領藥者僅有12,984(26.3%)張，另有36,322張(73.7%)連續處方箋由病人於社區藥局領藥。此時如果單一藥局要備齊所有鄰近大型醫院所開立之藥品品項，勢必大幅增加庫存成本及資金壓力。這也解釋了本研究問卷調查結果，病人至社區藥局領藥時最常發生的困擾為:藥品數目、品項不正確或是領到替代藥品。如要解決這個問題，我們考慮建議藥品由原醫院備齊，備齊後運送至病人方便或就近藥局領藥。如此同時解決大型醫院營收減少，藥局備藥壓力及病人領用藥物正確性的問題。 研究方法：接下來的問題是以新北市中、永和地區為例總共有195家社區藥局；新北市中、永和地區未回醫院領藥計有26,377張張處方箋，經以「人」為單位統計後共有21,710位病人。此時大型醫院該如何選擇哪幾家藥局合作(195家社區藥局如何和21,710位病人配對)，以達最小運輸及管理成本而能涵蓋最多病人領藥方便性？本研究使用 Google 地圖的路線規劃功能，將1家醫院、195家藥局與21,710位病患的地址資訊透過Geocoding API（Application Programming Interface）取得地理經緯座標；接著將上述座標透過Directions API取得步行或乘車路線距離，以利後續作業研究分析之用。 研究結果：經分析結果，我們發現只須與中、永和地區27家社區藥局合作(較小經營管理成本)，即可在這27家藥局所在地點1.0公里範圍內，服務中、永和地區22,381位病人(涵蓋率為22,381/21,710=97.9%)，更重要的是當由醫院出發，將配製好的病人藥物運送至這27家藥局之最短運送距離，每日只要一趟車即可送完27家藥局(最小運輸成本)。 研究結論與延伸：利用上述研究結果建立中、永和地區1間大型醫院及27家社區藥局之合作，形成醫藥聯盟，服務97.9%長期於社區藥局領用慢性處方用藥的病人，史期能在就近距離方便下‚正確領到原開立醫院用藥。另外依據問卷調查結果一般民眾於社區藥局領藥時除了擔心藥品與原開立醫院不一致外還擔心社區藥局藥師專業能力是否足夠？目前各縣市藥師公會都有定期舉辦進修課程，然而此類教育訓練其量能及對現有工作幫忙可能有限，結盟醫院反而能定期針對領取長期處方病人的需求提供更為精準方向之教育訓練，如此無疑是針對病人及社區藥師工作需要‚更能提供加值服務。至於其他之2.1%位於1.0公里範圍以外之中、永和地區病人並不是不適用此服務，在這些病人居住地點1.0公里內雖無合作藥局‚在此第一階段‚需要稍微遠一點的距離即可得到同樣之服務，然而只要第一階段成功導入快速達到規模經濟，就能擴大合作藥局甚或於沒有藥局服務之地區開立新藥局以提供服務。日後亦可導入APP提供掛號回醫院看診開立處方、用藥提醒、整合他院用藥衝突或禁忌監測….等服務。聯盟一旦建立也可結合長照，提供整合性全人醫療服務。

Research motivation: Facing the implementation of the government's medical policies: national health insurance and separation of pharmaceutical practice and medical practice, the government encourages the release of continuous medical prescriptions at all levels of medical institutions. The hospital faces the dilemma of revenue and profit loss caused by the release of continuous prescriptions. For the community pharmacies management also faces higher operating cost than that of the other retail business, higher inventory cost of high-price drugs and more fierce competitions in the pharmacy market. In addition to having professional knowledge, for the community pharmacist, they need a pharmacy-related management challenges of business profit and loss. On the other hand, due to changes in the socio-economic structure, people’s common knowledge about health and medical care is also easily available as information becomes transparent. Therefore, they pay more and more attention to the health maintenance for individuals and families, and thus greatly increase their autonomy in choice. The above factors have led to the government's inefficiency to implement the policy of separation of pharmaceutical practice and medical practice. In the market competition formed under above mentioned changes, how do hospitals and pharmacies integrate multiple resources to form a benign competitive partnership? After the 'division of labor', we still need to 'cooperation' to achieve a win-win situation for mutual benefit and symbiosis. If we can meet the demand for the patients’ need at the same time, this is an urgent issue facing us now. Research purpose: This research is based on statistical analysis of a large teaching hospital in Zhonghe and Yonghe districts in New Taipei City. The hospital prescribes a total of 100,4935 general prescriptions and 49,306 continuous prescriptions in March 2019. Among 49,306 continuous prescriptions, only 12,984 (26.3%) received medicines from the hospital, and 36,322 (73.7%) continuous prescriptions were received by patients at the community pharmacy. At this time, if a single pharmacy wants to prepare all the medicine, especially high-cost ones, opened by the neighboring large hospitals, it will inevitably increase the inventory cost and capital pressure. This also explains the results of the questionnaire survey in this study, the most common troubles that patients faced when they go to the community pharmacy to receive medicines are : the number of medicines, incorrect items, or alternative medicines. To solve this problem, we consider recommending that the medicines were prepared by the original hospital, and then transported to the community pharmacies for patient’s convenient or nearest location. At the same time, it solves the problems of reduced revenue in large hospitals, pressure of drug preparation by pharmacies and correctness of patients receiving drugs. Research method: The next question is to take Zhonghe and Yonghe districts in New Taipei City as an example. There are 195 community pharmacies: 26,377 prescription in Zhonghe and Yonghe districts in New Taipei City. Because some patients maybe have more than 2 continuous prescriptions there were only 21,710 people need to use these 26,377 prescriptions in Zhonghe and Yonghe districts. At this time, how many or which pharmacies should hospitals choose to cooperate with (how can 195 community pharmacies pair with 21,710 patients) to achieve the minimum transportation and management costs while covering the most of the patients in Zhonghe and Yonghe districts for the convenience of receiving medicines? In this study, the route planning function of Google Maps was used to obtain the geographic latitude and longitude coordinates of the address information of 1 hospital, 195 pharmacies, and 21,710 patients through the Geocoding API (Application Programming Interface); then the above coordinates were transformed through the Directions API into walk or drive distance of the route to facilitate the following analysis of operation research. Research results: After analyzing the results, we found that hospital only need to cooperate with 27 community pharmacies in Zhonghe and Yonghe (less operating and management costs) to serve 22,381 patients (the coverage rate is 22,381/21,710=97.9%) in Zhonghe and Yonghe districts within 1.0 km range around these 27 pharmacies. And more importantly, the shortest delivery route for these all 27 pharmacies was also identified from this analysis, hospital can deliver well prepared medicine for all 22,381 patients in Zhonghe and Yonghe with one trip per day (minimum shipping cost). Research conclusions and extensions: Use the above research results to establish a cooperation between 1 hospital in Zhonghe and Yonghe District and 27 community pharmacies to form a medical-pharmaceutical alliance, to serve 97.9% of local patients having received continuous prescription medications from the community pharmacies, and correctly to receive the identical medicine as the original prescribed hospital.According to the results of the questionnaire survey, besides worrying about the inconsistency between the drug and the original hospital, the patient is worried that the professional ability of the pharmacist of the community pharmacy is modest? At present, each county and city pharmacists' association have regular continuous education courses. However, the quality and quantity of such education and training may not help the current work. The alliance hospitals can regularly provide more precise education and training for the needs of patients receiving long-term prescriptions. This is undoubtedly aimed at providing value-added services for patients and community pharmacists. As for the other 2.1% located outside the 1.0 km range, this service is also applicable to patients in Zhonghe and Yonghe area. Although there is no cooperative pharmacy in the nearby place where these patients live, it is only a little longer walking distance in this first phase project to get the same Services, however, as long as the first phase project is successfully introduced and quickly reaches economies scale, it will be possible to expand cooperative pharmacies or even open new pharmacies in areas where pharmacy services are not available. In the future, APP can also be imported to provide extra services; such as registration to return to the hospital for prescriptions, medication reminders, and integration of monitoring of medication conflicts or taboos from other hospitals. Once the alliance is established, it can be combined with long-term care system to provide integrated whole-person medical services.