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PubMed1995

The nursing minimum data set, standardized language, and health care quality.

Providers and consumers of health care have been attempting to define quality for the past several decades. The article describes one of nursing's contributions to the multidisciplinary health care quality revolution: its ability to provide a more complete and holistic picture of the consumer (patients/clients). Nursing's focus on responses to health care problems, not just illness events in isolation, provides insight into causes and effective management strategies for health problems. The Nursing Minimum Data Set (NMDS) documents patient/client responses, interventions, patient-sensitive outcomes, and resource consumption. By implementing the NMDS, nursing collaborates with other health care professionals to identify the needs of patient populations as well as the needs of individual patients. The article examines the relationship of the NMDS to other health care databases used in quality measurement, describes the integral role of standardized language in implementing the NMDS, provides examples of NMDS data analyses to address specific aspects of quality measurement, and outlines a methodology for using nonstandardized data.

Humans↗
PubMed2001

National Electronic Disease Surveillance System (NEDSS): a standards-based approach to connect public health and clinical medicine.

The National Electronic Disease Surveillance System is a broad initiative focused on the use of data and information systems standards to advance the development of efficient, integrated, and interoperable surveillance systems at the state and local levels facilitating sharing of appropriate data across jurisdictions. This initiative is designed to facilitate the electronic transfer of information needed for public health from clinical information systems in the health care industry, to reduce provider burden in the provision of information, and to enhance both the timeliness and quality of information provided.

Centers for Disease Control and Prevention, U.S.↗
PubMed2002

Misoprostol for women's health: a review.

OBJECTIVE: To review published literature on misoprostol for women's health indications to provide a synthesis of available information and highlight areas in need of additional research. DATA SOURCES: Studies were identified through searches of medical literature databases including MEDLINE, Cochrane Database, and Popline, in addition to a review of references from identified articles. STUDY SELECTION: We included all studies reported in English and published before March 31, 2001, which evaluated the efficacy of misoprostol alone for labor and delivery, evacuation of the uterus after pregnancy failure and induced abortion. Studies were not excluded based on quality or sample size. TABULATION, INTEGRATION, AND RESULTS: Misoprostol shows promise for all of the women's health indications addressed. Currently available data, though, are often hard to interpret because of variations in regimen, dose, and outcome measures. The low cost, ease of administration and storage, and widespread availability of misoprostol make it particularly appealing for developing countries. Because many of the women's health problems for which misoprostol could be prescribed currently cause significant mortality and morbidity, increased access to and information on use of misoprostol could help improve women's health especially where these problems are most severe. CONCLUSION: Further research is needed to identify optimal regimens for misoprostol for obstetric and gynecologic health indications. Registering misoprostol with national drug regulatory authorities for any of several women's health indications could help increase access to and safe use of this drug. Provider training would be a logical subsequent step.

Abortifacient Agents↗
PubMed1990

[Model of an information system for veterinary fertility monitoring as part of an integrated herd management system].

The requirements of the veterinarian's work are changing by reason of an increasing intensity of dairy industry. The model of an information system for monitoring and managing dairy herd health and management system is described. General and special requirements are illustrated. The program requires urgent development for the use of veterinarians and herd owners, including the provision of a data communication link to a veterinary-agricultural information system. The system should integrate the veterinarians into the animal production in order to improve herd health and to secure the veterinarian's role in, and facilitate the development of novel scientific approaches to, dairy herd health and management.

Animal Husbandry↗
PubMed2006

Linkage of patient records to support continuity of care: Issues and future directions.

Continuity of care depends on the availability of complete health care information on which current and future care can be planned and implemented. Consumers however, may have multiple records--even within single institutions--often unknown by the institution or the individual care provider. One of the first challenges to health care informatics professionals is to establish a means of identifying individual patients across care delivery systems. The ability to create an integrated record system depends on the development of a "universal person index" as well as considerations for standardizing and integrating other aspects of the electronic record. Many individual health facilities are working to create a "master person index" (MPI) and some integrated delivery systems are attempting to combine these MPIs into a single "enterprise person index" (EPI). Even more difficult is the task of establishing a means of identifying and linking patient records across all health care settings. Primary efforts to establish these linkages will depend on standardization across multiple MPI files, linkage protocols, data protection and patient consent. The nurse informatics specialist will be important to the planning, implementation, application and evaluation process necessary to the integration of health information records to support patient care.

Continuity of Patient Care↗
PubMed1976

[Secondary prevention of alcoholism in an urban area. An evaluation of 3 models: asylum, integration and incorporation into mental health].

Three models for the secondary prevention of alcoholism were considered: Asylum or Institution, Mental Health Unit and Comprehensive Program. All three were carried out using similar resources, at the same urban area, in succesion. Data were gathered from two sources: daily registers of Outpatient Services and clinical records, being the former of better quality. The Comprehensive Program, whose main characteristic is the integration of the community in the effort to solve its mental health problems, proved to have the greatest efficacity, according to the items selected for evaluation. The detection of new alcoholic patients was three or fourfold the two other models had; the detection was produced at much earlier stages, and the therapeutic performance and results were significantly higher. The costs, global as well as per capita, were much lower, and the use of institutional resources much more rational. The Mental Health Unit model meant a good professional performance at the specialized Psychiatric Services but showed rather poor results in detecting new cases, and costs much higher than those of the Comprehensive Program. The Asylum or Institution model showed the poorest levels of efficacity in all items, and the higher costs. The paper also analyzes some possible biases stemming from the general assumptions at the basis of the chosen evaluation system. It emphasizes the importance of general community leaders in primary prevention in reducing secondary prevention needs through education of the general population.

Alcoholism↗
PubMed2005

Current status of integrating information technologies into the clinical research enterprise within US academic health centers: strategic value and opportunities for investment.

Little information exists about the incorporation of information technologies (ITs) into clinical research processes within US academic health centers (AHCs). Therefore, we queried a group of 37 leading AHCs regarding their current status and future plans in clinical research IT. The survey specifically inquired about the presence or absence of basic infrastructure and IT support requirements; individual applications needed to support study preparation, study conduct, and its administrative support; and integration of data from basic research, clinical trials, and the clinical information systems increasingly used in health care delivery. Of the 37 AHCs, 78% responded. All strongly agreed that a "state-of-the-art" clinical research IT program would be ideal today and will be essential tomorrow. Nonetheless, no AHC currently has an IT solution that even approached this ideal. No AHC reported having all of the essential management foundations (ie, a coherent vision, an overall strategy, a governance structure, and a dedicated budget) necessary to launch and sustain a truly successful implementation of a cohesive clinical research IT platform. Many had achieved breakthroughs in individual aspects of clinical research IT, for example, adverse event reporting systems or consent form templates. However, overall implementation of IT to support clinical research is uneven and insufficient. These data document a substantial gap in clinical research IT investments in leading US AHCs. Linking the clinical research IT enterprise with its clinical operations in a meaningful fashion remains a crucial strategic goal of AHCs. If they are to continue to serve as the "translational research engines" that our society expects, AHCs must recognize this gap and allocate substantial resource deployment to remedying this situation.

Academic Medical Centers↗
PubMed1998

Influenza immunization in a managed care organization.

OBJECTIVE: To compare the effects of different types of computer-generated, mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders. DESIGN: Randomized controlled trial. SETTING: Multispecialty group practice. PATIENTS: We studied 24,743 high-risk adult patients aligned with a primary care physician. INTERVENTION: Patients were randomized to one of four interventions: (1) no reminder, which served as control; (2) a generic postcard; (3) a personalized postcard from their physician; and (4) a personalized letter from their physician, tailored to their health risk. MEASUREMENTS: The immunization rate was measured using billing data. A telephone survey was conducted in a subgroup of patients to measure reactions to the mailed reminders. To evaluate the cost-effectiveness, a model was constructed that integrated the observed effect of the interventions with published data on the effect of immunization on future inpatient health care costs. MAIN RESULTS: All three of the reminders studied increased the influenza vaccination rate when compared with the control group. The vaccination rate was 40.6% in the control group, 43.5% in the generic postcard group, 44.7% in the personalized postcard group, and 45.2% in the tailored letter group. The rates of immunization increased as the intensity of the intervention increased (p < .0001). Seventy-eight percent of patients in the letter group deemed the intervention useful, and 86% reported that they would like to get reminders in the future. The cost-effectiveness analysis estimated that in a nonepidemic year, the net savings per 100 reminders sent would be $659 for the personalized postcard intervention and $735 for the tailored letter intervention. When these net cost-savings rates were each applied to the entire high-risk cohort of 24,743 patients, the estimated total net savings was $162,940 for the postcard and $181,858 for the tailored letter. CONCLUSIONS: Although the absolute increase in immunization rates with the use of reminders appeared small, the increases translated into substantial cost savings when applied to a large high-risk population. Personalized reminders were somewhat more effective in increasing immunization, and personalized letters tailored to the patients' condition were deemed useful and important by the individuals who received them and had a beneficial indirect effect on patient satisfaction.

Adult↗
PubMed2006

Complex causal process diagrams for analyzing the health impacts of policy interventions.

Causal diagrams are rigorous tools for controlling confounding. They also can be used to describe complex causal systems, which is done routinely in communicable disease epidemiology. The use of change diagrams has advantages over static diagrams, because change diagrams are more tractable, relate better to interventions, and have clearer interpretations. Causal diagrams are a useful basis for modeling. They make assumptions explicit, provide a framework for analysis, generate testable predictions, explore the effects of interventions, and identify data gaps. Causal diagrams can be used to integrate different types of information and to facilitate communication both among public health experts and between public health experts and experts in other fields. Causal diagrams allow the use of instrumental variables, which can help control confounding and reverse causation.

Audiovisual Aids↗
PubMed1998

Building health plan databases to risk adjust outcomes and payments.

OBJECTIVES: To highlight the types and sources of data on medical risk and outcomes routinely collected by managed care organizations over time; to summarize the quality and consistency of these data; and to describe some of the difficulties that arise in collecting, pooling, and using these data. DESIGN: Synthesis of the experiences of two risk-adjustment modeling projects in assembling large volumes of demographic, diagnostic, and expense data from several health maintenance organizations (HMOs) over multiple years. SETTING: Six large HMOs from the Northwest, North Central, and Northeast regions of the USA. INTERVENTIONS: Health plans were approached to participate in a risk-adjustment study, presented with an extensive variable-by-variable data request, and, if willing to participate, asked to specify a desired process for extracting, copying, and transferring selected variables to the study site for purposes of research. Depending on local circumstances, three different approaches were used: (i) health plan staff obtained the data and organized them into the requested study format; (ii) study staff were provided access to health plan data systems to perform the extractions directly; and (iii) health plans hired contract programmers to perform the extractions under the direction of the study team. Key measures of risk and cost were extracted and merged into analysis files. MAIN OUTCOME MEASURES: Complete and consistent eligibility maps, demographic information, inpatient and outpatient diagnoses, and total health plan expense for each enrollee. RESULTS: We have been successful in collecting and integrating complete utilization, morbidity, demographic, and cost data on total memberships of five large HMOs as well as a subset from a sixth HMO, all for multiple years. CONCLUSION: While HMOs vary greatly in the quality and comprehensiveness of their data systems, these attributes have been improving across the board over time. Automated health plan data systems represent potentially valuable sources of data on health risks and outcomes and can be used to benchmark disease management programs and risk adjust capitation payments and medical outcomes.

Databases, Factual↗
PubMed1999

Episodes of care: theoretical frameworks versus current operational realities.

BACKGROUND: Fundamental changes in the structure of the health care industry have stimulated the need for improved definitions of output and for better methods of organizing utilization data into appropriate units. Although the "episode of care" concept has existed since the 1960s, its recognition as integral to the management of health care cost and utilization is relatively recent. Conceptually, episodes of care represent a meaningful unit of analysis for assessing the full range of primary and specialty services provided in treating a particular health problem. Proprietary episode software grouper products are currently being used by health care organizations for the purposes of provider profiling, clinical benchmarking, disease management, and quality measurement. DESCRIPTION OF EPISODE GROUPER SOFTWARE PRODUCTS: Four episode grouper products are described that use a computerized approach for developing episodes of care from administrative data. They are compared on several characteristics, including purpose, case-mix adjustment, comprehensiveness, and clinical flexibility. Their differences in episode construction, such as how the start points and endpoints of an episode are defined, are also delineated. CONCLUSIONS: Episode groupers are critical to the analysis of health care delivery, since they focus on the entire process of care. Although all the groupers reviewed have many strengths, much developmental work still needs to occur in order to standardize the measurement and operationalization of episodes of care as units of analysis. Furthermore, until the data sources used are more valid and reliable, they will at best remain gross screening measures of quality.

Benchmarking↗
PubMed1994

An integrated health care model in medical education: interviews with faculty and administrators.

PURPOSE: To broaden the understanding of how medical schools can help students learn an approach to health care that reflects the integration of psychosocial and biomedical factors in health and illness. METHOD: A qualitative research design was used, with data collected through document review and semi-structured interviews conducted in the spring and summer of 1992 with 22 faculty and administrators from 17 U.S. and Canadian medical schools. The interviewees represented the following disciplines: internal medicine, family medicine, pediatrics, psychiatry, and preventive/behavioral medicine. An analytic framework was developed, within which the constant comparative method was used on a continuous basis during and after data collection. Category development focused on (1) defining the scope and character of an integrated perspective, (2) delineating various ways to incorporate such a perspective in medical education, and (3) identifying barriers to and facilitative factors for incorporating such a perspective in medical education. Validity was assessed by having the interviewees and three other faculty members review the analyses and preliminary results. RESULTS: The interviewees' conceptions of an integrated perspective on health care focused on the theoretical need for a broader scientific model and on the practical need for more inclusive approaches to medical practice. The interviewees described patient-level and community-level approaches as equally important. The ideal curricula envisioned by the interviewees were patient-centered, integrated, developmental, and population-based. In addition to naming many barriers to integration (e.g., negative attitudes of faculty and administrators, diffuse organization of medical schools, ignorance of appropriate curriculum design and implementation), the interviewees identified certain facilitative factors (e.g., strong leaders, faculty development programs, and reform of the faculty reward system). CONCLUSION: The interviewees envisioned an integrated model of health care that suggests that medical curricula should address the development of physicians' knowledge, attitudes, and skills regarding physicians' relationships with both patients and community.

Administrative Personnel↗
PubMed2004

Integrated analysis of genetic, genomic and proteomic data.

The rapid expansion of methods for measuring biological data ranging from DNA sequence variations to mRNA expression and protein abundance presents the opportunity to utilize multiple types of information jointly in the study of human health and disease. Organisms are complex systems that integrate inputs at myriad levels to arrive at an observable phenotype. Therefore, it is essential that questions concerning the etiology of phenotypes as complex as common human diseases take the systemic nature of biology into account, and integrate the information provided by each data type in a manner analogous to the operation of the body itself. While limited in scope, the initial forays into the joint analysis of multiple data types have yielded interesting results that would not have been reached had only one type of data been considered. These early successes, along with the aforementioned theoretical appeal of data integration, provide impetus for the development of methods for the parallel, high-throughput analysis of multiple data types. The idea that the integrated analysis of multiple data types will improve the identification of biomarkers of clinical endpoints, such as disease susceptibility, is presented as a working hypothesis.

Animals↗
PubMed1996

Conflict, enactment, empowerment: conditions of independent therapeutic nursing intervention.

The purpose of this qualitative study was to describe the use of independent therapeutic nursing interventions by registered nurses in a variety of health care delivery agencies. The process used to integrate nursing interventions into the daily routines of agencies that did not formally require their use, the conditions in which they were implemented, and the consequences of their use, were examined. Data collection methods include observations and interviews of 36 participant nurses, employed in five health care agencies, for 1 year. The organizational culture of each environment was observed and its impact on the enactment of independent therapeutic nursing interventions was evaluated. Data analysis, done by using the constant comparative method, generated a proposal of a substantive theory that integrates conditions and consequences of therapeutic nursing intervention. Intra-role conflict, the product of incompatible expectations of the professional conception of nursing and task oriented/medically controlled work environments, served as the motivating force behind strategies of enactment utilized to overcome barriers to implement therapeutic nursing interventions. As a consequence of using therapeutic nursing interventions, participants perceived empowerment in relation to clients, peers and other health care professionals.

Choice Behavior↗
PubMed2006

[Integrated Health Care in cardiology at Essen].

This paper reports in detail on a project of Integrated Health Care in cardiology at Essen, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

Cardiology↗