InQuickER: See the ER doc in 15 minutes or less, or your ER visit is free
inquicker.com
inquicker.com
This is a spectacularly bad idea. I can unequivocally say without a doubt that if you pursue this service, someone will die.
Why? Because I've seen it happen.
Part of my job as an ER nurse is to triage patients that come in. Triage involves sorting through the dozens of patients that come in every night, and decide who can wait and who cannot because they have a life threatening emergency. People having symptoms of a heart attack move to the front of the line. People who ate a bad taco and have the shits get seen on a space available basis. That's the gig. I sort patients: sort_by_acuity([bad taco, bad taco, bad taco, heart attack, runny nose, cough, gun shot wound, ear infection, headache, headache, headache, stroke, headache]).
I've been doing this job for 15 years, and I have seen plenty of triage mistakes that can change people's lives for ever. I've made a few myself. You care for thousands of patients a year, you're going to drop a ball every now and then. But, I have a lot of experience doing this, and I have a lot of knowledge and very good instincts on when someone is very ill. Patients do not have that knowledge and I would never trust your customers to make that decision when life and death is on the line.
This is why ER's are almost universally abysmal at judging how long it's going to take to be seen by the doctor. The same team that is taking care of your earache at 3am or helping you get stitches after you cut your finger on your computer case, is the same team that can crack your chest open and do open heart massage on you after a thug sticks a knife in your heart. We take care of bladder infections and dying babies, sometimes right next door to each other at the same time. ER's are built for safety, not speed or even convenience. The fact that in the US, they are primarily the only type of physician that can be seen 24/7 without an appointment is an unfortunate effect of our health care system. But, we have to care for the sickest patients first, and you can never predict when the next ambulance is going to roll through the door. So, ER's suck at estimating wait times. But, you will, eventually see a doctor.
Now, I understand that you have a disclaimer that says that people should call 911 for Emergencies, and that they will not use your service for life threatening emergencies. I don't think that's not going to keep you from getting sued when Uncle Bob dies of his massive heart attack that he though was a bad burrito and put his name on your waiting list. That's also not going to help you sleep at night thinking about how you might have prevented Uncle Bob's death.
I'm not trying to flame you. I'm really not trying to be nasty. I'm just trying to communicate what a big, big, huge mistake I believe this application is. Please, shut it down.
Say your daughter has an ear infection, the appointment your HMO primary care physician gives you one week from now, is no good. So you go to the ER. There is no effective in-between option. I don't know if this website fixes that problem or exacerbates it. But that is the real problem.
This whole un- under- insured category people talk about in the US exists because people are actively being put in insurance plans where we know they will not have access to some health care services they will need. Let's not kid ourselves.
Emergency medicine in the US is in a horrible state. Overcrowding is one of the primary reasons. See: http://www.ama-assn.org/amednews/2009/01/19/prsb0119.htm
One of the primary reasons for the large influx of patients is the diversion of primary care visits into the ER for non-urgent matters. A booking system that encourages non-urgent care visits to the ER as opposed to other urgent care options does nothing to help this.
As other commenters have mentioned, the problem with overcrowded ERs from a patient perspective where they have a potentially emergent case is NOT in the middle of the night - it's during the day, where other options (including primary care and urgent care facilities) are available.
Emergency medicine should not be treated in the same convenience form-factor as other consumable goods, and applying this approach is socially irresponsible in the big picture.
If you want to solve the ER overcrowding problem, you should do it directly, by adding a surcharge (over and above the one that already exists) for nonessential ER visits. There's no rational reason to force people to sit in a crowded ER waiting room.
Meanwhile, a retail interface to the ER scheduling systems that already exist is more likely to help than hurt overcrowding, because it will route patients to the least crowded ER in their area.
[1] To the extent that emergency room overcrowding is due to people without other health care options (i.e., the un- and under-insured) using ERs as their primary care facilities, surcharges really won't help: by definition, these are people who can't pay for medical care... so adding additional surcharges probably won't have much effect on their ER utilization.
There is no reason at all that our respective agendas about how US healthcare should be run should require me to wait on-site in the hospital, as opposed to in my home at 1AM, or in my hotel room when I get violently ill on a trip.
There will always be cases when people need to use the ER, and there will never be a good reason they shouldn't be able to call ahead for a soft appointment. Everything about the system, from patient routing to triage to hospital staffing, works better with a system like InQuickER in place.
My argument was only with the idea of using surcharges to deal with overcrowding. The reason that ERs are chronically overcrowded is not (generally speaking) because of people getting ill on trips, being in car accidents, or having ear-infected kids. The reason that ERs are overcrowded is the large number of people for whom ERs serve as primary care facilities.
As you (correctly) pointed out, these people probably wouldn't be using InQuickER-like services anyway, so they're not relevant to the question of whether scheduling systems are helpful or not. I think that scheduling systems lke InQuickER definitely could be helpful to patients that use them, and maybe to the ERs themselves... but also that, depending on the specifics of a given ER's catchment area, they won't have much impact on overall crowded-ness, since that's largely due to a segment of the population that won't be using the scheduling system anyway.
Now, if one could find a way to make these people more likely to use the scheduling system, you might see more of an effect.
Of course, I could be completely wrong- IANDNAIHEOHQE (I am not a doctor nor am I a health economist or healthcare quality expert), and when it comes to health care quality interventions (which is what InQuickER basically is) it is not at all uncommon for things to behave in a counter-intuitive manner. That's why solid evaluation of system outcomes is so important. Hopefully the participating hospitals are keeping a close eye on their utilization statistics... for their sake, I hope that the InQuickER people are insisting on it- being able to show a significant change in in-ER waiting time due to their system would be the single best marketing tool that they could possibly hope for.
Adding to the list of things that I could be completely wrong about, my sense of who InQuickER's users are could be dead wrong. Tyler, what are your user demographics like? Do they mirror those of the hospitals that are using the system?
We already have all the localization code, and with more hospitals I think this would work great as a module on the site.
I sent the suggestion "upward", but I have no way to know if it'll go anywhere.
So... what was that with the socialized medicine bashing?
Socialized health care usually only means worse service for the very rich. For everyone else it's a great thing.
Here in Australia you'd generally go to a GP, a public health center or have a locum come out to visit you before heading to a hospital. There are certainly still wait times, and a system like this might be able to help, but in general I think there's a much better spread of patients to the right location.
Not always:
http://en.wikipedia.org/wiki/Free_clinic
I don't know how widespread those are, though.
Seriously, though, I hope that this startup escapes the regulatory issues and goes Big. It solves a clear problem for both patients and hospitals, will greatly increase societal welfare, and it should attract Big Bucks (TM) because of the amount of money wrapped up in the problem it solves.
This page is one of the best brief sales pitches I've ever seen, by the way:
http://inquicker.com/page/inquicker_benefits
Everything about it is great. It scans great. It directly addresses the customers' needs and makes it explicit what tangible benefits buying in will get them. I have bookmarked it so that when software vendors ask how to improve their website I'll say "Your benefits section should look like this".
Best of luck.
A) What sort of workflow do you use to exchange scheduling and appointment data between your site and the ER?
and
B) Is it the same for each participating hospital? If not, how are you planning on scaling your operation to include more than four hospitals? I'm genuinely curious, having done some work on ER workflow analysis and modeling. I think this is a great idea, but can envision some pretty significant workflow issues on your horizon depending on how you've got stuff set up currently.
We're implementing at relatively low-volume locations (in the neighborhood of 25-35k pts per year), and so far we've used the same manual workflow at all locations without any problems, but I think we need full integration for long-term growth.
I'd love to talk further by email -- can you send me a note at tyler@mystartupdomain?
1. Add some auto-suggest features to the 'add a hospital' form.
2. Use an IP address/geolocation service to guess where I'm located and pre-populate the state for the form.
3. I tried to add my local hospital, and received a very ugly error message:
====
Internal Error
There was an error processing your request. The system administrator has been notified of the problem, it will be fixed as soon as possible. Please try again later. TELEPHONE SUPPORT
For telephone assistance, call our on-duty support technician at (770)-597-9185.
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The fact of the matter is that the vast majority of the visitors to this site believe that most problems have a technical solution. I happen to believe that this technical solution has the potential to exacerbate an existing problem and that other non-technical solutions are possible. What is needed is a combination of 24 hour clinics/urgent care centers, more fast-track departments and convincing certain people that there is no need to visit a doctor for a bad cold unless certain symptoms appear or one doesn't recover in a reasonable length of time. Encouraging more people to visit the emergency department for non-emergencies does not seem prudent to me.
I don't disagree with you, and it must be said I question the need for such a service...but given the state of waiting at emergency departments today, I could see how this is useful for those people with small emergencies that for whatever reason can't be dealt with elsewhere. For now. The long term solution would obviously be to do something similar to what you suggest.
There are 5,700 hospitals in the U.S.(AHA) and ~ 4,500 emergency rooms.
Do you know how many of these clinics there are?
Of course, InQuickER (or something like it) is just going to integrate with the clinics and urgent care centers. I'm going to select "ear infection" and enter my zip code and it's going to give me a selection just like Orbitz.
For example here is the list of states which CVS operates clinics in:
http://www.minuteclinic.com/en/USA/Clinics.aspx
Here is the list of conditions they can treat:
http://www.minuteclinic.com/en/USA/Treatment-and-Cost.aspx
Note "treat and write prescriptions" in the very first sentence on the page.
Additionally, many hospitals operate onsite "fast-track" clinics which are connected to the ED, so low-acuity conditions are essentially treated in something resembling a retail clinic.
Our goal is to make the emergency medical treatment experience as efficient as possible. Parents don't want to be sitting in the waiting room half the night, potentially exposing their children to contagious diseases in the er. Professionals lose valuable time to ER visits that drag on forever. We're trying to recapture that lost time and give the patients more control of the treatment process.
Until recently, I always thought these places would triage, but my experience has been that it is just 'take a number and wait' I've been in with a broken arm, a torn nose (that required stitches) and couldn't believed we were treated exactly like a headache. So, this looks great. Try the Silicon Valley next so we can try it!
Anyone who is scared enough or in enough pain to be considering an ER visit is about as far from a 'rational actor' as possible. Helping them make good decisions not only smooths out the system, it also gives people essential help when they need it most.
Nice job. :)
If this scales, it will let me pick which of 4 local ER's I'm going to go to based on wait time. I'd pay $50 a visit for that. I'd subscribe to a service like this simply in anticipation of needing it eventually.
Good luck.
I don't understand (even after looking at the How it Works page) is how it works. Since you can't predict what types of injuries that are going to come in that are more critical than yours, how can you gaurantee an appointment time?
At this point, we have a 99.9% success rate with that guarantee: less than 1 out of every 1,000 patients has requested a write-off of the bill.
I also wonder if you could talk about the incentives you use to get hospitals to sign on to your program - while you're adding value, you're also costing them staff time. Do you pass on a portion of the $25 to them, or is the idea that they will make up the cost by having more people come to them and thus getting more volume?
Lastly, have you considered partnering with insurance companies to offer this service as part of a premium's offering?
All-in, great idea you have - this is the kind of health care innovation we need.
If you're capable of shopping around for the best appointment time then shouldn't you be seeing a GP instead?
The health system in Canada isn't ideal (or the Netherlands where I am now) but having to check emergency room wait times has never even occurred to me.
'Down a hospital hallway, a row of stretchers line the wall near the nurse's station. On one of them is an elderly woman who's in pain.
She has been waiting for four hours to get into a room with a bed, but there isn't one available.
This is happening nearly every day in hospitals across the province and the GTA," said a nurse with 22 years of on-the-job experience.'
Do you have any mechanisms in place for two-way communication between the hospital and the people booking appointments? Specifically, I'm thinking about situations where a series of individually minor symptoms may collectively indicate something major is going on, but that a layman wouldn't know.
Like let's say that I go on your site and see that I can get an appointment at an ER in three hours, so I book that because I'm feeling slightly off. My symptom description seems innocuous enough - went for a walk in the countryside, right arm is tingling a bit, small red bump on my leg, etc. - but to someone trained in medicine they indicate that I've been poisoned by some sort of tick, and I need treatment ASAP, as opposed to in three hours. Is there a way for the nurse who processes this reservation into the hospital to call me and say "screw the booking, get here now!"?
Also, I echo the calls for a map-based or local-search interface.
But even granting your point, you can still market against that experience without implying that you only schedule people for ERs.
Right now I imagine that this site gets most of its business from people who call the ER directly, and then the participating ER tells them about the site (I could be totally wrong about that, though). Going forward, though, I would think that way that this is going to be used is that a user will know they need treatment, go to the site (find it via a search engine, whatever), look for the treatment facility that satisfies some mix of 'near', 'soon', and 'perceived ability to treat my problem', and put their name down.
If there's a marketing hump to get over, I would think it would be snagging people who are coming from a search engine or via some route other than having the ER send them there directly. It seems like the perception that this is just for ERs is more a problem in this sense - I'd personally be less likely to use it if I thought it wouldn't include nearby clinics in the list of places I could sign up for.
At best, you win because the ER staff hits the right keys for your automated message. Or they agree to do a full agreement with you.
A person interested in the first can use inquicker; someone more interested in the latter can still bustle off to the ER and pace around, or something.
Oh, and one last question: where you funded by YC?
If we could find another way to keep the signal-to-noise ratio high, I would love to offer this service at a lower price point.
Awesome job, by the way.
It seems lowering the price would gut your revenue but you wouldn't increase your userbase enough to make up for it (there would be a big deadweight loss of utility that patients get, but don't have to pay for -- lost revenue for you).
Also, ER is an incredibly expensive thing to go through, so mentally your users may be more price-insensitive than usual--they'll bucket all the costs together in a 'big bath', so you can charge more.
I'm thinking of taking it a step further, though, and would like your opinion. I have a couple ideas for services, but they would take a couple weeks to build. Do you think it would be worthwhile to post an Ask HN thread, seeing if people express interest in paying for my potential products, before I build them?
Zack