| 摘要: | 現今病患的求醫行為已不是只在醫院的機構限制裡，過去以醫院為主的專業權威醫療形已開始出現以病人為中心的整合式健康照護，反映出一種求醫行為及醫療保健服務模式的新典範轉變。醫療服務商品化作為發展的必然趨勢，自費醫療照護服務也以商品化的形式開始轉變，以遠距健康照護服務來說，?僅是一套臨床上病情監測與疾病照護的需要，也已成為病患視需要而自掏腰包的商業行為。本研究從社會文化的角度（Social-Cultural Perspective）檢視現行遠距健康照護服務以用活動理論作為分析架構，探索服務提供者與病患在互動歷程中突現的衝突與價值，再以此作為分析並探討服務改進的遠距健康照護服務遞送內涵。本研究以南部某醫學中心的遠距健康照護中心之服務推廣歷程（亦稱潛客收案活動）作為研究場域，研究訪談對象的為接觸過外勤護理師潛客收案活動的病患與家屬，觀察時間為2013年08月至2014年03月（共計8個月），其中包含加入遠距健康照護服務之民眾、拒絕加入遠距健康照護服務之民眾，實際完訪人數共計26人。透過活動理論之矛盾分析，本研究發現現有潛客收案活動下的服務遞送模式中有幾個矛盾，導致收案容易出現失敗的現象。（一）矛盾一：異於常規治療計劃之活動─病患與家屬將推廣活動視為陌生的醫療照護服務，使得病患與家屬將遠距健康照護服務與醫師所安排的醫療照護服務分割獨立一二，且將推廣活動視為外於常規治療計劃的活動。（二）矛盾二：有缺漏的自費推銷活動經驗─過去與現在依然存在著託付式順從的醫病關係，病患與家屬既定的認為病房裡的治療計劃應透過醫師所安排，而外勤護理師的「主動推銷」方式，使得病患與過去所接受的醫療照護服務產生了認知衝突。（三）矛盾三：為難的服務訊息傳遞─在潛客收案活動中發現，病患與家屬對於使用醫療照護服務的決策行為頗吻合行為經濟學典範Kahneman & Tversky所提出的展望理論，在特定推銷情境下當病患知覺其疾病嚴重度、疾病復發風險程度高時，相較於自行照顧與使用傳統醫療服務可能的風險，其傾向於選擇使用自費遠距健康照護服務。本研究所採用之活動理論除了提供完整的架構協助分析服務推廣歷程，更進一步增進理解服務遞送活動的文化脈絡。潛客收案活動鑲嵌於醫療社會文化之中，產生的矛盾衝突隨著文化脈絡與歷程不斷地變動與發展。為使現行遠距健康照護服務遞送模式中，所產生於動態歷程矛盾衝突更易於掌握修正，本研究有以下建議，包括醫療院所組織層面由上而下加以重整，強化推展以病人為中心的整合式健康照護服務模式；加強宣導遠距健康照護服務效益；常規鼓勵發展由下而上（bottom up）的服務創新整合；並將遠距健康照護服務納入常規門診/住院診療計劃；以及強化外勤護理人員的服務與專業訓練。
Nowadays, health care seeking behaviors no longer restrict its performing in healthcare organizations. This reflects the paradigm shift of service delivery model from the perspective of patriarchy on medicine to its patient centered. Meanwhile, it also emphasizes the inevitable growth of commercialization on medical services. Under the circumstance, the emergence of telehealthcare services represents not only the emphasis of clinical need on it technology enabled seamless health status monitoring, but also the individual demand on the self-paid medicine. From the social-cultural perspective, this research applies activity theory to construct the activity systems of the telehealthcare delivery model. With the findings through the contradictions of interactions in the activity systems, it provides the researchers insights of improving the services design.We aim our research on the customers and their major care-givers for the perspective of service promotion process in the center for telehealthcare in a medical center in southern Taiwan. Of the 26 participants, we finished the interview from the observing phase of 2013/08 to 2014/04 (totally 8 months). Under the analysis of the activity system consisted from activity theory, we find three contradictions in service promotion process of telehealthcare lead to failed interaction. First of the contradictions, the “perceived weird promoting behavior from the routine treatments program”. Patients and their major care-givers tend to treat the formal telehealthcare promoting behaviors as the unfamiliar experience in the medical treatment activities. It makes patients separates the telehealthcare services out of the clinical treatment procedures and concludes to the purely commercial behavior. The second contradiction, the “incomplete experience of telehealthcare service promoting procedure”. The existence of medical compliance behaviors from subjugated to the professional opinion makes patients and their major care-givers hard to accept the clinical suggestions of promoting nurses from the service promotion. The third contradiction, the “embarrassing message delivery in the service promotion”. The decision making of patients and their major care-givers under the service promotion is likely to be explained by the Perspective theory from the Tversky and Kahneman. That means a individual’s decision making behavior may be influenced through the message priming, while one who is primed to perceived highly risk to get worse tends to accept to use the self-paid medicine.This research apply activity theory reflecting the social cultural perspective to provide a full analog to analyze the self-paid service promoting process. It enhances the understanding of services design through a higher perspective. In conclusion, we provide some suggestions to help to improve the efficacy of services design of the telehealthcare. It is summarized including the restructuring of organizational design, the promotion of patient-centered health delivery redesign in the clinical departments, the forced promotion of the importance of telehealthcare, the service innovation and integration within the cross departments, apply the telehealthcare into the formal clinical treatment, and improve the professional training of service providers. |
