

InQuickER: See the ER doc in 15 minutes or less, or your ER visit is free - tkiley
http://inquicker.com/

======
iamelgringo
So, I've been an ER nurse for the last 15 years. I run the Hackers and
Founders Silicon Valley meetup, and I love to support startup ideas. It's
extremely rare that I don't support a startup idea or give it a fair shake.

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.

~~~
mustpax
The need for such a website also points to a larger problem: a lot of people
in the US, including most insured people, do not have access to timely primary
care for non-life threatening problems.

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.

~~~
csbrooks
I guess it depends on your doctor, but we usually get an appointment the same
day if someone is actually sick. Also, the in-between option is "urgent care",
which is open at least 8 hours or so on Saturday and Sunday.

------
cscott
Talk about contributing to the public health problem in our ERs.

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.

~~~
tptacek
Your argument is that on-site ER wait times are an effective deterrant for
frivolous ER visits. They aren't: they impose costs on both legitimate and
illegitimate visits. That cost is also imposed randomly: currently, your ER
wait is luck-of-the-draw.

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.

~~~
stevenbedrick
The problem with the surcharge idea (and lots of other market-oriented
solutions to health care problems) is that, under our current system, market
forces don't really apply in the same way that they apply to, say, items in
the grocery store. Very few people going to an ER are paying out of pocket:
many don't have insurance[1], and will either not pay for their visit or will
negotiate some sort of payment plan at a reduced rate with the hospital. And,
of course, those visitors with insurance don't care what the hospital ends up
charging their insurance company- that's the whole point of insurance. This
is, of course, especially true during emergency or urgent care situations.

[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.

~~~
tptacek
The people who are using the ER because they have no other option and who
cannot pay out-of-pocket are not at all germane to this startup idea, which is
part of my point.

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.

~~~
stevenbedrick
Oh, I absolutely agree with the usefulness of InQuickER!

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?

------
tkiley
This is my startup. 100% bootstrapped and ramen profitable. Questions and
comments encouraged. Thanks for checking it out!

~~~
prakash
fantastic idea. The first ER experience I had in the US, I waited for 5 hours
-- completely baffled that it was called ER.

~~~
kirse
Just wait until we get socialized health-care... the wait times are going to
be absolutely phenomenal.

~~~
ews
Never waited more than 10 minutes in Spain, Italy, Portugal, Germany or UK
(and lived on all those countries for a while), had to wait 4.5 hours on San
Francisco just few months ago.

~~~
wheels
While I'm a fan of the German healthcare system, under 10 minutes is an
overstatement. Honestly, the only time I've gotten treatment that fast was
when I was covered in blood. I'd say my usual (non-critical) ER waits are
closer to an hour, but still shorter in general than I had when in the US.
(I've lived in Germany for 7 years now.)

------
stevenbedrick
Great idea! Which EHR/scheduling systems do you currently interoperate with?
EmStat, Epic, etc. Alternatively, if you're not directly hooking into the ER's
systems:

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.

~~~
tkiley
Right now, we're use a manual workflow; we provide patients' preregistration
data to nurses and registration staff through a web interface. Direct EHR
integration is my next priority.

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?

------
invisible
Just for a note as to my experience, there should be a "relinquish" or
"Cancel" when setting up an appointment. I clicked next step and it booked my
time temporarily. Ten minutes later it'll be open, but if you're releasing
this you're going to want to allow us curious folks to cancel out.

~~~
invisible
Also, it looks like it booked the SOONEST appointment rather than the one I
requested. In the "When" row I selected 10:30PM and it said on the next page
11:15AM was what I had selected.

------
Adrenalist
Sounds like a neat idea. You obviously have to get hospital permission/buy-in
before this idea could really take off. This is a similar idea to OpenTable,
the dining reservation system. Perhaps you could do (or already have done)
some research to find out how that company has succeeded/failed and apply
those lessons to your efforts. Online based reservation systems are a great
idea, but seems like a lot of leg work is required to get it really rolling.
Classic chicken/egg problem here with early adopters.

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.

====

~~~
tkiley
Thanks for reporting this, it's been fixed, and we did receive your hospital
suggestion. :)

------
Feynman
Nifty idea -- I work for a Hospital with California's largest ER, and several
ERs in other hospitals owned by the same company. Unfortunately, I'm having a
hard time seeing something like this working in our environment (for a variety
of reasons). However, I CAN see how this could be killer for small Urgent Care
clinics. I can't tell you how many times I'd love to just go on a website and
see what the wait times are for all my local urgent cares -- and then
reserve/travel to the one I can get in quickest. Nice idea, clean design...
really cool. Best of luck with it.

------
absconditus
If you can afford to wait do you actually have an emergency? There are many
other options, including clinics in drugstores, which don't burden emergency
departments.

~~~
tkiley
This is a very good question, and a very complicated one. In many markets,
retail clinics and urgent care centers are open 60 hours per week at best;
nights and weekends, treatment options are scarce.

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.

~~~
bestes
As yet another parent, this looks promising. My ER visits are usually in the
5-7 hour range. I also don't really care what the place is called: if I have
an issue, I want to go to the closest place that can help me. If it happens to
be the Walgreens three blocks away (it isn't), fine. Urgent Care, ER, trauma
center or whatever.

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!

------
tptacek
A killer idea. Every friend of mine that has had kids echoes my experience,
which is that you end up going to the ER way more than you expect to --- your
primary care pediatrician sends you there any time the answer to an "is it
serious" phone call is "maybe".

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.

------
matt1
What an ambitious, innovative idea--nice work.

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?

~~~
tkiley
The short answer: we can't. Sometimes, we miss the guaranteed appointment
time. However, we do everything we can to ensure that our predictions are
accurate, and we do everything we can to ensure that the patient experience is
still as smooth as possible if we're wrong.

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.

~~~
JimmyL
Can you expand on this a bit - for example, do you come up with the
appointment times based on your own models, or does the hospital update your
system to say "well, we're having a light day, so most people can get in two
hours after they send us their triage info, regardless of what comes up."

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.

------
danw
I'm not sure I comprehend this. Isn't it the role of the emergency services to
prioritise your visit? If you're critical you'll get seen, otherwise you wait.

If you're capable of shopping around for the best appointment time then
shouldn't you be seeing a GP instead?

~~~
tptacek
This service doesn't bypass triage. It just puts your name and info on the
triage list and allows you to wait from home instead of taking up space in the
waiting room. The hospitals are (apparently) intensely involved in this
process.

~~~
tkiley
Bingo. Most patients fall into the general "low-acuity" category, which means
that they are essentially seen in the order in which they arrive at the ER;
this is the default case in our system. However, the ED caregivers do have the
ability to change it.

------
jacoblyles
Awesome, meaningful, useful startup. Congratulations. I hope you are
successful and expand to my area. My friend spent 4 hours in the ER on his
birthday to get some stitches. This would have been a huge help.

------
delano
This is a great service but it seems unfortunate that it has to exist at all.

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.

~~~
jdminhbg
[http://www.torontosun.com/news/canada/2009/05/03/9330606-sun...](http://www.torontosun.com/news/canada/2009/05/03/9330606-sun.html)

'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.'

~~~
delano
That's fair. I should have been more accurate since Canada is a gigantic
country. My experience is based on living in Vancouver and Montreal (although
I went to a hospital in Toronto on one occasion and waited only 30 minutes).

------
JimmyL
What this service does, if I'm reading this right, is bypass the stage where
you talk to a triage nurse - you're triaged based on what you report is wrong
with you, as opposed to what a nurse sees is wrong with you.

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!"?

~~~
tkiley
Yes, we do have the capacity to reprioritize patients based on symptoms.
Patients who reserve a treatment time online are responsible for their own
health until they arrive at the ED, but we do give the ED caregivers the
capacity to communicate with the patient early on if they deem it prudent;
this feature is generally used in the sort of situations you describe, where
the patient's condition may be more serious than he or she realizes.

------
calambrac
Great idea, but why focus on the ER in your branding? The question that the
end user has is "How can I get treatment for this health problem as soon as
possible, without having to wait around in a waiting room"? It seems like the
way that you're answering this could easily be extended to clinics and urgent
care centers, couldn't it?

Also, I echo the calls for a map-based or local-search interface.

~~~
tptacek
Because from a pure marketing perspective very few people have the problem of
having horrendous waits at clinics, but tens of millions of people have had
the experience of waiting 3-5 hours in an ER waiting room.

~~~
calambrac
I've personally had horrendous waits in clinics, urgent care centers, and ERs.
I've also had really quick experiences with an ER. I'm not saying I'm typical,
I'm just saying that my personal experience is such that your point never
would have occurred to me.

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.

------
edw519
Nice. You may want to consider a Google maps mashup centered on my location.
If the hospital(s) I know aren't participating, this would be easier to use
than a drop down box.

~~~
tkiley
Great idea! Right now we have a fairly small network of participating
hospitals (3, to be exact), and engaging visitors who aren't in our current
service area is a bit of a trick. I'll pass this one along to the designer for
our next revision.

~~~
thorax
From what I understand, there are a number of hospitals that can do some
measure of call-ahead scheduling for ERs. What would prevent you from asking
about each hospital policy and at worst doing a Twilio automated call to the
number if they choose that one? At worst your automated message would get hung
up on, and you'd tell them that it could not be processed and tell them to go
there directly.

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.

------
byrneseyeview
Interesting. Actually, this is a good way to separate two of the crucial
functions of health care: actually fixing medical problems, or demonstrating
serious concern and sympathy for someone's medical problems.

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.

------
tptacek
Real quick: SIFR for typography not a win. I'm not some crazy paranoid, but I
block Flash by default because it kills my browser.

------
cadalac
Wow I think you have a great idea. We really need something like this in
Canada. What are your rates? I couldn't find them on the site.

Oh, and one last question: where you funded by YC?

~~~
matt1
To answer one of your questions... From the registration page: "Your credit
card will be charged a fee of $24.99 to complete the registration process."

~~~
tkiley
Exactly. Originally, we experimented with offering this service to patients
for free or for $2.99, but the hospitals were experiencing significant numbers
of no-shows and bogus registrations; the $24.99 price point was actually
requested by our pilot hospital as a form of data validation.

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.

~~~
mediaman
I say don't lower your price. What you want to do is segment the demand curve
for ER services and slice out those who are willing to pay more to avoid
wasting hours of their time.

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.

------
nerdburn
Awesome :) Glad to see this taking off Tyler. Nice to see my new design on
there. PS. Center the layout ;)

~~~
rickharrison
I liked this design. I've been looking for a designer for some work. Could we
get in touch? Email is in my profile

------
ivankirigin
Emergency services: there in minutes when seconds matter.

------
eries
Very cool.

~~~
zackattack
Are you Eric Ries?

~~~
matt1
Look at his submissions. I'm seeing a trend... :)

~~~
eries
brilliant deduction :)

