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PubMed2003

Implementing telemedicine services in northern Norway: barriers and facilitators.

Telemedicine is not simply a technology - it also involves processes. The use of telemedicine is influenced by many factors. Our intention was to examine what conditions promote the use of telemedicine between general practitioners (GPs) and hospitals. Qualitative interviews were undertaken with 16 GPs in northern Norway. The extent to which GPs were using the services was limited, although some used them fairly frequently. The most widely used service was teledermatology. The GPs saw advantages of the services in general and saw clear benefits for their patients. The services were considered to be time-consuming, and the lack of adequate government remuneration for the time involved in teleconsultations was seen as a barrier to their use. The GPs focused on their own ability to handle new technology and expressed a need to practise more.

Attitude of Health Personnel↗
PubMed2004

Trial of low-cost teledermatology in primary care.

We examined the feasibility of a low-cost, store-and-forward teledermatology service for general practitioners (GPs) in regional Queensland. Digital pictures and a brief case history were transmitted by email. A service coordinator carried out quality control checks and then forwarded these email messages to a consultant dermatologist. On receiving a clinical response from the dermatologist, the service coordinator returned the message to the referring GP. The aim was to provide advice to rural GPs within one working day. Over six months, 63 referrals were processed by the teledermatology service, covering a wide range of dermatological conditions. In the majority of cases the referring doctors were able to treat the condition after receipt of email advice from the dermatologist; however, in 10 cases (16%) additional images or biopsy results were requested because image quality was inadequate. The average time between a referral being received and clinical advice being provided to the referring GPs was 46 hours. The number of referrals in the present study, 1.05 per month per site, was similar to that reported in other primary care studies. While the use of low-cost digital cameras and public email is feasible, there may be other issues, for example remuneration, which will militate against the widespread introduction of primary care teledermatology in Australia.

Dermatology↗
PubMed2006

Framework for Canadian telehealth guidelines: summary of the environmental scan.

A Canadian project (the National Initiative for Telehealth Guidelines) was established to develop telehealth guidelines that would be used by health professionals, by telehealth providers as benchmarks for standards of service and by accrediting agencies for accreditation criteria. An environmental scan was conducted, which focused on organizational, human resource, clinical and technological issues. A literature review, a stakeholder survey (245 mail-outs, 84 complete responses) and 48 key informant interviews were conducted. A framework of guidelines was developed and published as a preliminary step towards pan-Canadian policies. Interim recommendations were that organizations and jurisdictions might consider formal agreements to specify: (1) organizational interoperability; (2) technical interoperability; (3) personnel requirements; (4) quality and continuity-of-care responsibilities; (5) telehealth services; (6) remuneration; and (7) quality assurance processes. An additional recommendation was that flexible mechanisms were needed to ensure that accreditation criteria will be realistic and achievable in the context of rapid changes in technology, service integration and delivery, as well as in the context of operating telehealth services in remote or underserved areas.

Canada↗
PubMed1999

The uneven diffusion of telemedicine services in Australia.

The diffusion of telemedicine services in Australia over the last four years has been uneven. Some of the major barriers to the adoption of telemedicine relate to the nature of the industry, including its immaturity, the limited telecommunications infrastructure, the lack of appropriate dialogue between vendors and buyers about solutions required, and the lack of partnerships in the industry. Remuneration is only one barrier. There are, of course, other substantial organizational, financial and attitudinal barriers to the adoption of telemedicine. Further development of telemedicine in Australia will require detailed assessment of these matters.

Australia↗
PubMed2004

Collaborative practice in health systems change: the Nova Scotia experience with the Strengthening Primary Care Initiative.

Recently attention has been focussed on the significance of primary care to the Canadian healthcare system. Nova Scotia. Like other provinces, is seeking ways to improve the healthcare that it provides within a financially constrained publicly funded system. The Strengthening Primary Care Initiative in Nova Scotia (SPCI) was a primary care demonstration project to evaluate specific goals related to primary care. Although the provincial government conceived the SPCI, the approach to its planning and implementation was participatory and consultative. Funded through the federal Health Transition Fund (HTF) (Health Canada 2002) and the government of Nova Scotia, the SPCI involved changes in four communities over a three-year period (2000-2002). These changes included the introduction of a primary healthcare nurse practitioner in collaborative practice with one or more family physicians; remuneration of the family physician(s) with methods other than a solely fee-for-service (FFS) arrangement; and the introduction and utilization of a computerized patient medical record. The SPCI was committed to a consultative process with stakeholders, and this gave rise to several challenges. Initially there was disagreement on the requirement for nurse practitioners at each of the demonstration sites. The Minister of Health confirmed that a nurse practitioner was a required component at each demonstration site. Differences in perspectives on the role of allied health professionals in the SPCI were encountered, and the significance of the role pharmacists have in primary care was not fully appreciated until after the SPCI had started. At the time the SPCI began there was no legislation for nurse practitioners in Nova Scotia; therefore, an approval mechanism for nurse practitioner practice was authorized through the provincial regulatory bodies for nursing and medicine. Malpractice and liability issues, particularly on the part of providers who had never worked with nurse practitioners before, were an initial concern. Recruitment of nurse practitioners into the three rural sites mirrored the difficulties with recruitment of healthcare providers encountered in other parts of rural Canada. The authors discuss their perspectives on the challenges related to interdisciplinary collaboration in health systems change that were encountered during the planning and implementation of the SPCI. Although nurse practitioner Legislation has existed in Ontario and Newfoundland and Labrador for several years, many provinces are grappling with the challenges associated with the introduction of nurse practitioners and collaborative practice. This paper conveys the experience of one province and will be of interest to administrators, educators and practitioners elsewhere in Canada who are engaged in primary healthcare renewal.

Cooperative Behavior↗
PubMed2002

Solutions must include the community hospitals.

The authors of this commentary acknowledge that Academic Health Sciences Centres(AHSCs) will need to change, but they assert that the need for change and urgency are even more dramatic than presented by Lozon and Fox. While the AHSCs are likely to survive, their form and fabric are likely to change dramatically in the new order. Any solutions to the problems of the AHSCs have to include the community hospital stakeholders, especially the evolving regional teaching hospitals. This applies not only to patient care but also to the potential teaching and research (clinical trials) contributions of the community/regional players. There must also be more involvement by non-medical faculties in defining the vision, mission and values of the AHSC. Federal funding should be available not only to enhance the research activity of the AHSCs and the regional partners but also to provide the informatic linkages between players. Alternative funding programs for academic physicians along with enhanced productivity measures in areas of patient care, education and research are important in order to level the playing field not only with respect to remuneration but also with respect to other incentives such as recognition and promotion.

Academic Medical Centers↗
PubMed2004

Public/private boundaries in Canadian healthcare: some clarification.

Most Canadians think that "medicare"/our healthcare system (for the differentiation is certainly not clear) is "public," meaning universal and pre-paid by their taxes. Those who have heard of the five conditions of the Canada Health Act (CHA), or at least the phrase, "public administration," are doubly confirmed in their belief. It comes as a surprise to concerned citizens to learn that, to get federal funding, a province has to set up a "single payer" for health services to fall under medicare, that is, hospitals and physicians. Then, if more information is introduced to distinguish between funding and delivery of services, and it is stated how the former is public, while the latter is mainly private, the audience starts challenging the speaker. Explaining that the delivery of services is private because doctors or nurses are not civil servants, for example, comes across as one more great Canadian fiction. "After all, they are fully remunerated by public funds--my taxes." All of this to recognize that, in Canada, discussions around the public/private divide, from whatever angle, are surrounded by preconceived, often common-sense, ideas rejected mainly by students of healthcare systems.

Canada↗
PubMedDate not supplied

The utilization of the healthcare assistant role in intensive care.

The increasing role of healthcare assistants (HCAs) in intensive care in relation to patient monitoring has raised concerns among some clinical managers, particularly where such roles are not underpinned by a sound knowledge base and critical reasoning ability. This article describes a study which was undertaken in an attempt to identify how HCAs are currently utilized within the general intensive care environment. The results show a wide variation between units in relation to the activities undertaken by HCAs, their training and the levels of remuneration. This article seeks to open up the debate as to whether or not nurses should be challenging the nursing care that is now delivered by non-nurses and makes recommendations for the way forward in this area.

Critical Care↗
PubMed1996

Between policy and practice: Japan's Silver Human Resource Centers as viewed from the inside.

The Silver Human Resource Centers (SHRC) were first established in 1980 to address the economic and psychological needs of Japan's growing numbers of senior citizens. The Centers, through which people are introduced to jobs in their locales and from which they receive remuneration for services performed, are by now well established throughout Japan. This article examines the gap between SHRC members' evaluations of the Centers and the Center guidelines, as stated in their published literature and in interviews with program administrators. The analysis is fourfold: (1) it explores the members' reasons for participating in the program; (2) it discusses their assessments of it; (3) it examines gender and social class differences in program planning and participation; and (4) it analyzes the Ministry of Labor's plan for new directions for the Centers. Although new policy directions do address many members' concerns, they do not attempt to question or change the status quo of the gendered division of labor in Japanese society.

Aged↗
PubMed2005

Obtaining an evidence-base for clinical dentistry through clinical trials.

Ideally, all clinical practice should be based on the best available evidence; however, in general dental practice even a very routine issue, such as the appropriate management of the carious primary dentition, is hampered by the lack of a sound evidence-base from high quality clinical trials run in general dental practices. Furthermore, the use of the evidence that is available may be confounded by inadequate reporting. This paper reviews the difficulties reported in successfully completing such clinical trials, and reports on the authors' own experiences. Suggestions are made for overcoming the challenge of patient recruitment in randomised controlled clinical trials in primary dental care. These include: regular contact with a principal investigator, who is viewed as a peer; ensuring the relevance of the research topic to the dentists' daily practice; appropriate remuneration; acknowledgement of the contribution made and recognition of the contribution of research activity to continuing professional development. Use of the CONSORT statement to improve planning and reporting of clinical trials is recommended.

Attitude of Health Personnel↗
PubMed2006

Informing research in primary dental care: setting priorities.

This paper suggests that priorities for research in primary dental care should follow the examples set in other areas of primary healthcare. It reviews the history of research in primary dental care, since 1990, and goes on to explain how the Delphi exercise, initiated by the Faculty of General Dental Practice (UK), has identified five priority areas for research in primary dental care. These areas are:1. Research into the application of evidence-based dentistry into practice.2. The effects of different systems of remuneration on treatment patterns in practice.3. The oral health assessment on determining recall intervals and its effect on oral health.4. Factors that influence and affect dentists' treatment modalities.5. The evaluation of the cost benefits of whole team training.

Delphi Technique↗
PubMedDate not supplied

Comparison of prescription reimbursement methodologies in Japan and the United States.

OBJECTIVES: To compare methods of prescription reimbursement in Japan and the United States. DATA SOURCES: Data were obtained through interviews and a search of the pharmacy literature using MEDLINE, International Pharmaceutical Abstracts, the Iowa Drug Information Service, and the Internet. Search terms were pharmacy, dispensing fee, reimbursement, prescriptions, Japan, United States, and average wholesale price (AWP). A comprehensive search was done (i.e., no year limits were observed). STUDY SELECTION AND DATA EXTRACTION: Performed manually by the authors. DATA SYNTHESIS: The reimbursement systems for prescriptions differ widely between Japan and the United States. The reimbursement system in the United States is fairly straightforward and easy to understand; it is generally based on product cost (e.g., AWP minus a percentage) plus a small dispensing fee. The system in Japan is extremely complex. Reimbursement formulae have four components, including fees for professional dispensing, drug cost, counseling and administration, and medication supplies and devices. Additionally, various adjustments to the final amount are made based on dosage form, length of therapy, number of prescriptions dispensed by the pharmacy per month, and when the prescription is filled (e.g., after hours, on Sundays or holidays). In Japan, each pharmacist is limited to filling 40 prescriptions per day, but each "prescription" can involve several medication orders, making it difficult to compare Japanese pharmacists' workloads with those of their counterparts in the United States. In addition, Japanese pharmacists are provided remuneration for providing various cognitive services, such as taking a patient history, counseling a patient, consulting with a physician, and identifying drug-related problems. CONCLUSION: Japan and the United States have very different methods of reimbursing pharmacists for dispensing prescriptions, each with positive and negative features. Based on the features of pharmacy reimbursement systems in each country, perhaps the optimal pharmacy practice system would have workload limits that reflect safety standards and amount of support staff available, provide a fair and standardized method for determining drug cost, are relatively straightforward, pay for cognitive services, and provide care for all of citizens through of some type of national health care system.

Costs and Cost Analysis↗
PubMed2005

Providing patient care in community pharmacies in Spain.

OBJECTIVE: To review the current status of Spanish community pharmacy, both in practice and research terms, and analyze its future trends. FINDINGS: Spain has a social security system where all citizens receive health care, social services, and pensions. All medical care and surgery are free for citizens; however, community pharmacies in Spain are privately owned. There are geographic and population standards for the establishment of new pharmacies, resulting in an average of 1 pharmacy per 2000 residents. Almost all pharmacies offer the same services: compounding, weight and blood pressure measurement, and cholesterol and glucose testing. There are also other, less-implemented services, such as methadone supply or directed observed treatments. Most of these services are freely provided, except compounding (fee for service), methadone, and directed observed treatments. University pharmacy practice departments do not exist in Spain, which leads to scarce research in this area. DISCUSSION: Efforts have been made to describe and measure the prevalence of negative clinical outcomes produced by pharmacotherapy and create an operational procedure to provide pharmacotherapy follow-up. CONCLUSIONS: Spain has many community pharmacies, but there is little pharmacy practice research. Some advanced cognitive services exist, but few are being remunerated.

Delivery of Health Care↗
PubMed2005

Providing patient care in community pharmacies in Australia.

OBJECTIVE: To describe Australia's community pharmacy network in the context of the health system and outline the provision of services. DATA SYNTHESIS: The 5000 community pharmacies form a key component of the healthcare system for Australians, for whom health expenditures represent 9% of the Gross Domestic Product. A typical community pharmacy dispenses 880 prescriptions per week. Pharmacists are key partners in the Government's National Medicines Policy and contribute to its objectives through the provision of cognitive pharmaceutical services (CPS). The Third Community Pharmacy Agreement included funding for CPS including medication review and the provision of written drug information. Funding is also provided for a quality assurance platform with which the majority of pharmacies are accredited. Fifteen million dollars (Australian) have been allocated to research in community pharmacy, which has focused on achieving quality use of medicines (QUM), as well as developing new CPS and facilitating change. Elements of the Agreements have taken into account QUM principles and are now significant drivers of practice change. Although accounting for 10% of remuneration for community pharmacy, the provision of CPS represents a significant shift in focus to view pharmacy as a service provider. Delivery of CPS through the community pharmacy network provides sustainability for primary health care due to improvement in quality presumably associated with a reduction in healthcare costs. CONCLUSIONS: Australian pharmacy practice is moving strongly in the direction of CPS provision; however, change does not occur easily. The development of a change management strategy is underway to improve the uptake of professional and business opportunities in community pharmacy.

Australia↗
PubMed2006

Pharmaceutical care in community pharmacies: practice and research in Switzerland.

OBJECTIVE: To describe the current situation and prospects for community pharmacy practice in Switzerland, a confederation of 26 cantons with a population of approximately 7 million, located in the center of Europe. FINDINGS: For the past 10 years, the Swiss Association of Pharmacists has directed an in-depth reform of the profession, with measures such as a system of remuneration based on pharmaceutical cognitive services, a quality care program named QMS-Pharmacy, a postgraduate education program (including specific titles and certificates) and obligatory continuous education, programs of public relations and health promotion, innovative services of managed care, generics substitution, and others. DISCUSSION: The implemented changes in management represent a pharmaceutical care solution for Swiss community pharmacies, which face intense competition and a very liberal policy regarding healthcare organization, relating in particular to the important cantonal autonomy, free establishment of ownership of pharmacies, pharmacy chains, dispensing physicians, chemist shops, mail order, and others. CONCLUSIONS: Community pharmacy in Switzerland is making modernization of its role in public health policy a clear orientation. Priorities for the future include reinforcement of education and academic research in pharmacy practice, demonstration of the added value of pharmacists, integration of new information technologies with pharmacies, and development of new pharmaceutical services for managed care network in collaboration with physicians and other healthcare professionals.

Community Pharmacy Services↗
PubMed2006

Pharmaceutical care in community pharmacies: practice and research in Germany.

OBJECTIVE: To discuss the provision of pharmaceutical care in community pharmacies in Germany including community pharmacy, organization and delivery of health services, pharmacy education, community pharmacy services, research in community pharmacy, and future plans for community pharmacy services. FINDINGS: In Germany, cognitive pharmaceutical services have been developed for more than 12 years. Several studies and programs have shown that pharmaceutical care and other pharmaceutical services are feasible in community pharmacy practice and that patients benefit from these services. In 2003, a nationwide contract was established between representatives of the community pharmacy owners and the largest German health insurance fund. In this so-called family pharmacy contract, remuneration of pharmacists for provision of pharmaceutical care services was successfully negotiated for the first time. In 2004, a trilateral integrated care contract was signed that additionally included general practitioners, combining the family pharmacy with the family physician. Within a few months, the vast majority (>17 000) of community pharmacies have registered to participate in this program. CONCLUSIONS: German community pharmacies are moving from the image of mainly supplying drugs toward the provision of cognitive pharmaceutical services.

Community Pharmacy Services↗
PubMedDate not supplied

Independent practice association physician groups in California.

We surveyed independent practice association (IPA) physician groups in California about their approaches to staffing, physician payment, and governance. Most IPAs desired more primary care physicians but not more specialists. Capitation was the major mode of remuneration for primary care physicians in 77 percent of IPAs, and for specialists in 30 percent of IPAs. Most IPAs also used financial incentives related to use of referral or ancillary services. Boards of directors were dominated by physicians, but governance tended to be centralized rather than highly democratic. We found that IPAs mirror many of the broader trends in physician staffing and physician payment that exist in managed care organizations.

California↗
PubMed1999

Downward trends in bronchoscopies performed between 1991 and 1997.

STUDY OBJECTIVE: To examine the frequency of bronchoscopy performance in a large tertiary medical center over a period of 8 years. DESIGN: Retrospective data analysis. SETTING: Academic medical center. MATERIALS AND METHODS: Using a computerized database of all bronchoscopies performed between 1991 and 1997, we analyzed trends in (1) the total number of bronchoscopies; and (2) the numbers of bronchoscopies performed for patients on the basis of the postbronchoscopic diagnosis in the following three main disease groups: AIDS, interstitial lung disease (ILD), and lung cancer. We measured the following outcomes in the patients of high-volume and low-volume bronchoscopists: procedure length (time to perform procedure), nondiagnostic rate, and repeat-bronchoscopy rate. In addition, we compared total admissions, outpatient visits, and insurance status of the patients during the same period. RESULTS: In total, 5,580 bronchoscopies were performed. A 17% decline in the number of procedures was noted between 1991 and 1997 (from 943 to 783, respectively; p < 0.05). The number of AIDS-related bronchoscopies fell from 235 (25% of 943) to 96 (12% of 783), a 59% decline during this period (p < 0.05). There was a corresponding 76% decrease in the number of bronchoscopies associated with a diagnosis of Pneumocystis carinii pneumonia (PCP; p < 0.05). During the same period, no similar decrease was noted in the number of bronchoscopies associated with a diagnosis of ILD or lung cancer. Moreover, no significant differences were noted in the procedure length, nondiagnostic rate, or repeat-bronchoscopy rate between high-volume and low-volume bronchoscopists. Although there was no significant change in the number of total admissions between 1991 and 1997, there was a 48% increase in the number of managed-care patients and a 25.4% increase in the number of Medicaid health insurance program for California patients between 1991 and 1997. CONCLUSIONS: We noted a significant decline in the number of bronchoscopies performed between 1991 and 1997. The significant reduction in the number of AIDS-associated bronchoscopies accounted for 87% of the decline. Other possible factors include the introduction of a management pathway for the empiric treatment of PCP in 1996, a reduction in the number of pulmonary admissions, an increase in the number of managed care patients, and a reduction in the remuneration for the performance of bronchoscopy.

Acquired Immunodeficiency Syndrome↗