|摘要: ||在知識經濟時代，透過資訊科技的蓬勃發展與知識的快速更迭，非核心的知識工作若可以外包，即能提高效率、彈性及能力，且降低成本。近年來，國內健保財務緊縮、醫療政策不穩定、同業競爭壓力及醫療人力成本高漲等情況下，醫療機構面臨經營上的困境，紛紛尋求醫療知識外包。然而，根據「醫療機構業務外包作業指引」，限定知識外包的內容。因此，本研究以高度知識密集之醫療產業為主體，利用推拉模式與醫療知識特性探討醫療知識外包的可行性。本研究採質性方法，對4名醫院經營管理者與4名不同科別且具外包經驗之醫師，共8名為對象，進行深度訪談，每次訪談歷時50~90分鐘。採紮根理論進行資料分析。結果發現，影響醫療知識外包的推力因素，在醫院方面為人力缺乏及科經營困難；在醫師方面為醫師工作負荷量、教學、研究、評鑑壓力及自行開業等；拉力因素在醫院方面為成本、經營效率、全人照護及人力需求等；而醫師方面為增加收入、工作壓力較低及自由度高等。障礙因素包含合法性、成本效益、品質、責任歸屬、資安問題及病人流失等。但這些障礙能透過合約的制定來解決病人的隱私、品質管理等。而成本、醫院人力需求、效益及品質等相關因素成為醫院將醫療知識外包的評估準則。此外，醫療知識特性中的不確定性、複雜性、隱性特質與醫療知識外包存在潛在負向關係；醫療知識特性中的具更新性不影響醫療知識外包；醫療知識特性中的高度專業性與醫療知識外包存在潛在正向關係。醫療知識外包的範疇，包含科室外包（如急診、洗腎及呼吸照護等）與醫療知識流程外包（如病理報告、醫療影像判讀等）；醫療知識外包的形式，在醫療上為醫師支援、醫療合作；在教學上為代訓制度、建教合作；在研究上產學合作、實驗室合作；利潤分配模式以分科獨立經營制度與指定醫師費制度(proportional physician fee, PPF)。知識外包為未來產業提升競爭力的重要利器，面對醫療業者的需求，政府相關對策似乎無法解決醫療委外之經營以降低資金成本及人力需求的誘因。因此，本研究建議醫療業者在現行法規下思考知識外包的內容與形式，政策制定者呼應市場需求，擬訂相關對策，或將法規予以適度鬆綁，借鏡他國。此議題值得產、官、學共同深思。|
In the knowledge economy age, operational efficiency, flexibility, capacity, and cost down can be enhanced if non-core knowledge work is outsourced. For the past few years, several hospitals have faced financial difficulties, health policy instability, competition pressures and high labor costs. Since hospitals have confronted operational challenges, they have been trying to solve the predicament through medical knowledge outsourcing. However, according to the guidelines of Department of Health (DOH), healthcare settings should establish the review mechanisms to manage and supervise knowledge outsourcing. Therefore, this study, explores the feasibility of medical knowledge outsourcing using push and pull theory. The study used qualitative methods. Four hospital managers and four physicians with outsourcing experience, totally 8 deep interviews were conducted; each lasted 50 to 90 minutes. Grounded theory was used for data analyses.The results showed that lack of manpower, operational difficulties, high workload pressure for teaching, research, and hospital accreditation are push factors of medical knowledge outsourcing. Cost, operational efficiency, holistic care, manpower demand, higher income, lower work pressures and higher degrees of freedom are pull factors. Obstacles factors included legitimacy, cost-effectiveness, quality, accountability, and patient information security issues. These obstacles can be solved by quality management through contracting. Cost, human resources, effectiveness and quality have become the assessment factors of medical knowledge outsourcing. The feasibity of medical knowledge outsourcing is negatively related to the characteristics of medical knowledge including uncertainty, complexity and recessive trait. The highly professionality of medical knowledge is positively related to medical knowledge outsourcing. The scope of knowledge of medical outsourcing includes medical departments, i.e. ER, dialysis and respiratory care, and medical knowledge process, i.e. pathology reports, medical imaging, disease coding. The forms of medical knowledge outsourcing include physician support, medical cooperation, exterior training, cooperative education, industry-university collaboration and laboratory cooperation.This study suggests that hospitals should concern the content and form of medical knowledge outsourcing in the current regulations. Policy-makers may respond to market demand, and consider the deregulation of medical knowledge outsourcing and countermeasures. These issues are worthy of concern by the government, industry and the academy.