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PubMed1995

Modeling shared health and social care information.

The article describes an analysis of the detailed data used by different groups of health care professionals and their requirements to share data as part of an integrated information systems design project. This systematic recording of their data usage and sharing requirements led to the development of a novel analysis technique: the complex object grid. The use of the complex object grid facilitates the description of information usage and needs at several levels of detail.

Aged↗
PubMed2000

Responses of Canada's health care management education programs to health care reform initiatives.

Canada's provincial health care systems have been experiencing significant changes, mostly through horizontal integration achieved by merging hospitals, and, in a few cases, through vertical integration of public health, long term care, home care and hospital services. The government motivation for forcing these changes seems to have been primarily financial. In a few cases, the integration seems to have resulted in a stable and successful outcome, but, in most others, there has been destabilization, and in some, there has been chaos. The question posed in this research was how the five accredited Canadian graduate programs in health care management were responding to these changes. Two of the programs have recently made major changes in structure and/or delivery processes, following careful examination of their perceived environments. One has rationalized by subdividing courses. Another is repatriating courses from the business school in order to achieve more health-related content. Four of the five programs have added a number of courses in the last few years, or plan to do so in the next year or two, either because of accreditation criteria or student or faculty interest. The program directors viewed the educational requirements for clinicians and non-clinicians as being identical. In spite of the major structural changes, and the resulting destabilization of the health care organizations (and even governments), none of the programs emphasized the changes as factors in their plans for program changes. They expressed some concern about the possibility of fads as opposed to significant changes. It may be that these changes are dealt with in the content of individual courses. This aspect was not examined by the survey nor by interviews with the directors. Each of the programs has emphasized its own niche, with no consensus about changes required.

Canada↗
PubMed1994

The case against using the APACHE system to predict intensive care unit outcome in trauma patients.

The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. In our opinion, however, it is unlikely that any single system will be developed that can accurately estimate more than 50% of ICU deaths. The intention of the APACHE III system to include 78 diagnostic categories seems unrealistic. Furthermore, the number of data needed to document outcomes for both low- and high-risk admissions is impractical. We are evaluating APACHE III to determine whether the revisions to the definition for head trauma will represent a significant improvement in predicting outcomes for trauma patients. In the interim, the financial investment in the APACHE III automated bedside data collection system cannot be justified for trauma patients. Neither should it be used in ICUs that admit a large number of trauma patients as a tool for monitoring unit efficiency, guiding triage decisions, allocating staff and ICU beds, identifying risks of iatrogenic or other potential complications, or assessing quality of life, in spite of marketing efforts by the APACHE Corporation. We believe that using any of the APACHE systems for these purposes, at best, is premature, and potentially misrepresents the trauma patient population. Standards for patient classification already are in place for use in making determinations for institutional reimbursement from governmental and insurance agencies. The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology.(ABSTRACT TRUNCATED AT 400 WORDS)

Bias↗
PubMed1994

Building a children's health network: city-wide computer linkages among heterogeneous sites for pediatric primary care.

For many infants and children in our cities, quality of care and health status outcomes suffer due to poor continuity and coordination among ambulatory care sites. Despite proximity to technologically-advanced secondary and tertiary institutions, primary care services for children are fragmented, multiple-site use is common, and data flow among providers serving the same patients is primitive. Preventive and acute health care is often incomplete or redundant, and aggregate information for public health purposes is insufficient. This paper focuses on the development of a city-wide computer-based pediatric health care network to improve provider decision-making and follow-through, parent role in their children's care, and community-wide data. A process of building consensus for a regional system is presented, addressing issues of establishing a uniform data base, coordination among heterogeneous institutions, system development, confidentiality, and integration with public health reporting and planning functions.

Child↗
PubMed1997

The integration of two health systems: social stratification, work and health in East and West Germany.

This is an analysis of system integration, social stratification and work for health status and health care in East and West Germany. It is based on aggregate data and representative survey data of random samples of 2554 adults in both subsystems. Findings show that there were marked differences in life-expectancy prior to unification. The integration of the two systems, which occurred almost totally with regard to terms of West German health care organization, shows adjustment problems in the East for the public Health-Care-Funds and few if any for ambulatory care. The work situation has an impact on health, but there are no significant differences for East versus West. Social stratification variables show an influence on subjective health status for education (East) and for income, social status (West), while physician utilization (despite a preference of specialists by those with higher status) is not significantly determined by stratification variables in either East or West Germany. Beyond the central focus on work and stratification determinants a major finding pertains to a comparatively worse health situation for the aged and for women in what was the former East Germany. System models of Capitalism versus Socialism fit the results and recent history of the two systems to only a limited degree, as the West German corporate health system shows clear limits in following free market principles. The East German system, regardless of its centralized organization and move towards a socialist system, never fully abandoned the traditional model of German health care. Unlike the East German health system, that of West Germany, with its general expansion to 92% of the population, shows an increasing effect for social redistribution. The latter may be a reason why standard indicators of social stratification show less of an impact on health and health care than expected, while conditions at work clearly determine the health of people-the latter being the case in both the former East and West Germany.

Adult↗
PubMedDate not supplied

Model-based methodology for analyzing incomplete quality-of-life data and integrating them into the Q-TWiST framework.

BACKGROUND: The standard Q-TWiST approach defines a series of health states and weights each state's duration according to its quality of life (QOL) to calculate quality-adjusted lifetimes. However, a fixed weight may not adequately reflect time variations in QOL. METHODS: To account for measurements derived from irregular visits and informative missing data, the authors estimated the mean QOL profile using a mixed-effect growth curve model for the response, combined with a logistic regression model for the drop-out process. RESULTS: Using data from a clinical study of lymphoma patients, the authors demonstrated better readaptation to normal life for patients younger than 30. Sensitivity analyses and computer simulations demonstrated that modeling the drop-out probability as a function of the QOL measurements is necessary if conditioning by health state is not possible. CONCLUSION: Our model-based approach is useful to analyze studies with incomplete QOL data, especially when approximate QOL assessment by health state is not possible.

Adult↗
PubMed1994

Technology assessment in Catalonia: integrating economic appraisal.

A brief description of the evolution and role of the Catalan Office for Health Technology Assessment (COHTA) into the framework of the Catalan Health Care Service are presented. Methodological approaches used by COHTA range from synthesis of scientific evidence to the collection of primary data. Regarding the integration of economic appraisal into technology assessment, the main approaches are the following: integration into clinical trials funded by the COHTA and in the reimbursement policies of the Catalan Health Service. COHTA participates in the process of purchasing medical technologies, especially expensive ones, and in the establishment of reimbursement policies of medical technologies. The particular characteristics of COHTA as a regional agency for Technology Assessment and its position into the framework of the Department of Health are discussed. Among the advantages of this position are the knowledge of the relevant questions for policy makers and the potential influence in the process. Among the disadvantages are the possibility of losing autonomy. Regional agencies that are closely related to the regional health services could provide a better understanding of the real problems in clinical practice and in the utilization of health technologies.

Clinical Trials as Topic↗
PubMed1999

Strategic planning for research use in nursing practice.

BACKGROUND/OBJECTIVE: To prepare for a culture change to integrate research utilization into daily nursing practice, the authors conducted a descriptive survey of all registered nurses (RNs) in an integrated healthcare delivery system. The purposes of this study were to assess RNs' knowledge, attitudes, and practices (KAP) of nursing research activities, assess factors that support a research environment, and determine facilitating and challenging factors related to conducting regional nursing research. METHODS: A 33-item survey based on the Iowa Model for Evidence-Based Practice was developed, validated, and determined to be reliable by the authors. Site coordinators organized and managed the orientation, administration, and collection of data from the 2,736 registered nurses who worked in 6 hospitals, 65 affiliated clinics, and 3 business units. Narrative notes taken by study investigators were analyzed for themes to determine challenging and facilitating factors for conducting regional research. RESULTS: Education and job title significantly predicted knowledge and ability to perform research activities but was not related to willingness to engage in research activities. Several environmental factors were associated with knowledge of, willingness to engage in, and ability to perform research utilization activities. Challenging and facilitating factors to conducting regional research were identified. CONCLUSIONS/IMPLICATIONS: Our research environment is changing to value research as shown in the philosophy, conceptual framework, and bylaws for the professional nursing staff. Novice-to-expert research utilization expectations are included in the promotional model for nursing. All RN job descriptions and the annual performance tool were revised to include responsibilities related to research activities. The Iowa Model for Evidence-Based Practice was adopted as the method for creating practice validation and change. Train-the-trainer educational and experiential sessions are being designed for nurse leaders; all new RN employees complete a self-assessment tool of research utilization knowledge and the nursing division strategic goals incorporate research utilization expectations. The elements of this plan may be useful for nurse executives. Healthcare systems are restructuring throughout the world and within the United States. These changes are occurring to better meet the evolving healthcare needs of the population through cost-effective approaches. Within the United States, emerging organized healthcare systems require research related to patient care outcomes and the health systems that can best address them.

Adult↗
PubMed2003

Integrated breast diseases research and cancer registry in Turkey.

A system we call BDRS is implemented as an integrated disease specific system for breast diseases in order to obtain and use patient health data for clinical research, cancer registry and clinical care. It is an open, flexible and modular system that supports multi-institutional and multi-viewed utilization of health data. Three-tier web based architecture, and object oriented technologies have been employed to ensure its extendibility. Exchange and sharing of health data have been implemented with XML.

Biomedical Research↗
PubMed2005

The use of routinely collected computer data for research in primary care: opportunities and challenges.

INTRODUCTION: Routinely collected primary care data has underpinned research that has helped define primary care as a specialty. In the early years of the discipline, data were collected manually, but digital data collection now makes large volumes of data readily available. Primary care informatics is emerging as an academic discipline for the scientific study of how to harness these data. This paper reviews how data are stored in primary care computer systems; current use of large primary care research databases; and, the opportunities and challenges for using routinely collected primary care data in research. OPPORTUNITIES: (1) Growing volumes of routinely recorded data. (2) Improving data quality. (3) Technological progress enabling large datasets to be processed. (4) The potential to link clinical data in family practice with other data including genetic databases. (5) An established body of know-how within the international health informatics community. CHALLENGES: (1) Research methods for working with large primary care datasets are limited. (2) How to infer meaning from data. (3) Pace of change in medicine and technology. (4) Integrating systems where there is often no reliable unique identifier and between health (person-based records) and social care (care-based records-e.g. child protection). (5) Achieving appropriate levels of information security, confidentiality, and privacy. CONCLUSION: Routinely collected primary care computer data, aggregated into large databases, is used for audit, quality improvement, health service planning, epidemiological study and research. However, gaps exist in the literature about how to find relevant data, select appropriate research methods and ensure that the correct inferences are drawn.

Biomedical Research↗
PubMed2001

Age variations in personal agency and self-esteem: the context of physical disability.

OBJECTIVES: This study examines how age patterns in health control, self-efficacy, and self-esteem are influenced by age-correlated social status, health, personality, and social integration variables. METHODS: Ordinary least squares regression documents age patterns in data from a 1985 community sample of 1,549 physically disabled and nondisabled individuals from southwestern Ontario, Canada. RESULTS: Older respondents report lower health control, self-efficacy, and self-esteem. Less education, more physical impairment, poorer global health, less empathy, and less introspectiveness explain about 43% of age's negative association with health control and more than half of its negative association with self-esteem. In addition, age is associated more negatively with self-efficacy among the disabled. Social status variables conceal the strength of the age-by-disability interaction coefficient, while health accounts for almost an equal amount. DISCUSSION: The findings describe how age-correlated personal and social factors contribute to, or statistically conceal, older adults' sense of health control, self-efficacy, and self-esteem.

Age Factors↗
PubMed1999

Information systems integration in radiology.

Advances in information systems and technology in conjunction with outside forces requiring improved reporting are driving sweeping changes in the practice of radiology. In most academic radiology departments, there can be at least five separate information systems in daily use, a clinical picture archiving and communication system (PACS), a hospital information system (HIS), a radiology information system (RIS), a voice-recognition dictation system, and an electronic teaching/research file system. A PACS will have incomplete, incorrect, and inconsistent data if manual data entry is used. Correct routing of studies for diagnostic reporting and clinical review requires accurate information about the study type and the referring physician or service, often not easily entered manually. An HIS is a hospital-wide information system used to access patient information, reports from various services, and billing information. The RIS is typically a system specifically designed to place radiology orders, to receive interpretations, and to prepare bills for patients. Voice-recognition systems automatically transcribe the radiologist's dictation, eliminating transcription delays. Another system that is needed in a teaching hospital holds images and data for research and education. Integration of diverse systems must be performed to provide the functionality required by an electronic radiology department and the services it supports. Health Level 7 (HL7) and Digital Imaging and Communications in Medicine (DICOM) have enabled sharing of data among systems and can be used as the building blocks for truly integrated systems, but the user community and manufacturers need to specify the types of functionality needed to build clinically useful systems. Although technology development has produced the tools for interoperability for clinical and research/educational use, more work needs to be done to define the types of interaction that needs to be performed to realize the potential of these systems.

Computer Communication Networks↗
PubMedDate not supplied

A framework for an institutional high level security policy for the processing of medical data and their transmission through the Internet.

BACKGROUND: The Internet provides many advantages when used for interaction and data sharing among health care providers, patients, and researchers. However, the advantages provided by the Internet come with a significantly greater element of risk to the confidentiality, integrity, and availability of information. It is therefore essential that Health Care Establishments processing and exchanging medical data use an appropriate security policy. OBJECTIVE: To develop a High Level Security Policy for the processing of medical data and their transmission through the Internet, which is a set of high-level statements intended to guide Health Care Establishment personnel who process and manage sensitive health care information. METHODS: We developed the policy based on a detailed study of the existing framework in the EU countries, USA, and Canada, and on consultations with users in the context of the Intranet Health Clinic project. More specifically, this paper has taken into account the major directives, technical reports, law, and recommendations that are related to the protection of individuals with regard to the processing of personal data, and the protection of privacy and medical data on the Internet. RESULTS: We present a High Level Security Policy for Health Care Establishments, which includes a set of 7 principles and 45 guidelines detailed in this paper. The proposed principles and guidelines have been made as generic and open to specific implementations as possible, to provide for maximum flexibility and adaptability to local environments. The High Level Security Policy establishes the basic security requirements that must be addressed to use the Internet to safely transmit patient and other sensitive health care information. CONCLUSIONS: The High Level Security Policy is primarily intended for large Health Care Establishments in Europe, USA, and Canada. It is clear however that the general framework presented here can only serve as reference material for developing an appropriate High Level Security Policy in a specific implementation environment. When implemented in specific environments, these principles and guidelines must also be complemented by measures, which are more specific. Even when a High Level Security Policy already exists in an institution, it is advisable that the management of the Health Care Establishment periodically revisits it to see whether it should be modified or augmented.

Access to Information↗
PubMed2002

Health care in the information society. A prognosis for the year 2013.

Our society is increasingly influenced by modern information and communication technology (ICT). Health care has profited greatly by this development. How could health care provision look in the near future, in 10 years, or more precisely, in the year 2013? What measures must be undertaken by political and self-governing health institutions, and by medical informatics research, to ensure an efficient, medically advanced and yet affordable future health care system? Three factors will greatly influence the further development of information processing in health care within the near future: the development of the population, medical advances, and advances in informatics. These factors have motivated us to set up 30 theses for health care provision in the year 2013. The theses cover areas of health care, such as its people, its information systems, and its ICT tools. Three major goals requiring achievement have been identified: patient-centered recording and use of medical data for cooperative care, process-integrated decision support through current medical knowledge, comprehensive use of patient data for research and health care reporting. In consequence, political institutions should provide a framework for networked, patient-centered health care. They are called on to regulate the storage and exchange of health care data and of appropriate information system architectures. Finally, the health care institutions themselves must emphasize professional information management more strongly. Relevant research topics in medical informatics are: comprehensive electronic patient records, modern health information system architectures, architectures for medical knowledge centers, specific data processing methods ('medical data mining'), and multi-functional, mobile ICT tools.

Adolescent↗
PubMed1995

Working towards a national health information system in Australia.

One of the major administrative dilemmas facing the Australian national health care system is the need to reform practices associated with massive data-information overload. The current system is burdened with paper-based administrative forms, patient record files, referral notes and other manual methods of data organisation. An integrated computer-based information system may be perceived as an attractive solution to such burdens. However, computerisation must not be seen as a panacea with the possibility of exacerbating information overload and accentuating privacy concerns. Recent surveys in Australia [1] and the US [2] indicate a perceived causal link between computers and privacy invasion. Any moves toward a national health information system must counter this perception through macro-level education schemes of affected parties and micro-level mechanisms such as the establishment of hospital privacy officers. Such concerns may be viewed as a subset of the wider privacy debate, and information policy development should address such considerations to develop policies to prevent unauthorized access to personal information and to avoid the extraction and sale of sensitive health data. Conservative in nature and slow to change the health care sector may be forced to adopt more efficient work practices through the increasing proliferation of information technology (IT) in health care delivery and an escalating emphasis upon accountability and efficiency of the public health care dollar. The economic rationalist stance taken by governments in Australia and other nations generally will also force health care workers to adopt and develop more efficient information management practices, health indicators and best practice care methods than presently employed by this sector The benefits of a national health information system are far reaching, particularly in developing a more effective health care system through better identifying and understanding community health care trends and in applying IT to the efficient collection of data for the development of more appropriate performance measures and statistical indicators. A coherent and integrated approach is called for in the design of a national health information system which incorporates the necessary and requisite security features to meet privacy concerns. Protecting information privacy poses complex political, economic, technological, legal and social problems for systems developers and health care providers alike [2]. According to Brannigan [3] there are three components involved in the formulation and implementation of privacy: public policy (What level of privacy does society want?); legal structure (Does the law adequately provide for society's privacy requirements?); and technical (how much privacy can technical tools provide, at what cost, and with what effects on the system?). Examining technical tools alone, it is apparent that the necessary technologies are available in Australia to provide the security of medical records required by public policy. Such tools may include encryption, user and data authentication methods, authorisation schemes and mechanisms for the prevention of data inference. While none of these available measures are infallible, it is suitable for most applications where the encryption mechanism can provide protection for a given length of time. Australia needs to develop a coherent national health information infrastructure policy to ultimately avoid fragmented, duplicated and incompatible systems that rely on different standards and protocols. Such a policy will only work by addressing the key issue of patient privacy within a technological framework. The application of IT to health care systems is a sensitive social experiment affecting many professions including general practitioners, medical administrators, politicians, lawyers, computer specialists, privacy advocates and patients whose records will ultimately reside in the system. (abstract trun

Australia↗
PubMed2000

Validity of rapid estimates of household wealth and income for health surveys in rural Africa.

STUDY OBJECTIVE: To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa. DESIGN: Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population. SETTING: Rural areas of Mali, Malawi, and Côte d'Ivoire (two national surveys). PARTICIPANTS: Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively). MAIN RESULTS: In both Mali and Malawi, the wealth proxy correlated highly (r>/=0.74) with the more complex monetary value method. For rural areas of Côte d'Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset, r=0. 72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings. CONCLUSIONS: It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.

Africa↗
PubMed2005

Patterns of care, outcomes, and direct health plan costs of antiepileptic therapy: a pharmacoeconomic analysis of the available carbamazepine formulations.

BACKGROUND: Although generic formulations of immediate-release carbamazepine (IR-CBZ) are available, extended-release delivery systems may offer important advantages, including the convenience of less-frequent administration and smaller peak-to-trough serum carbamazepine (CBZ) fluctuations. OBJECTIVE: The aim of this study was to compare the patterns of pharmacotherapy, rates of adverse events, and the utilization costs among patients treated with the available CBZ formulations (ie, generic and branded IR-CBZ, and extended-release CBZ (ER-CBZ) capsules [Carbatrol, Shire US Inc., Wayne, Pennsylvania] and tablets [Tegretol-XR, Novartis Pharmaccuticals Corporation, East Hanover, New Jersey]). METHODS: Data were retrieved from the PharMetrics patient-centric database (which contains integrated claims data for almost 36 million unique patients from 61 US health plans) for patients who were diagnosed with epilepsy and initiated CBZ between July 1999 and June 2001. Patient demographic and clinical characteristics, adverse events, discontinuations, CBZ therapy switches, and utilization and costs for related care subsequent to treatment initiation were recorded. Annual rates of adverse events and discontinuations were calculated, and the risks of these events were compared across treatment groups. RESULTS: Data were gathered for 1737 patients. The branded CBZ group was demographically and clinically different than the other groups (ie, migraine and cerebral palsy prevalence) and therefore was excluded from event-risk analyses. Results of the proportional hazards regression analysis indicated that Tegretol-XR patients were more likely to experience common central nervous system (CNS)-related adverse events relative to Carbatrol (hazard ratio, 1.67; P = 0.043). A lower percentage of subjects switched off ER-CBZ relative to IR-CBZ (Carbatrol, 5.2%; Tegretol-XR, 5.7%; generic IR-CBZ, 13.0%; branded IR-CBZ, 16.7%). Differences in mean payments for epilepsy-related health care services at 1 year among Carbatrol, Tegretol-XR, and branded or generic CBZ did not reach statistical significance. CONCLUSIONS: Among the available CBZ formulations, Carbatrol was associated with a lower incidence of common CNS adverse events. ER-CBZ formulations were also associated with reduced likelihood of therapy discontinuation or switching CBZ medications, relative to patients taking generic IR-CBZ, in this retrospective data analysis.

Adolescent↗