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PubMed1998

How healthcare organizations can achieve true integration.

Of the many organizations that have attempted to become integrated delivery systems (IDSs), only a few have actually achieved this goal. Achieving true integration requires commitment to an ongoing process that consists of a series of increasingly challenging phases: development of the organization's unifying concept and culture, specification of the organizational and administrative structure, integration of funds and other assets, development of synergistic operations, and ongoing commitment to ensuring organizational responsiveness to market forces. In addition, including physicians in the integration process is essential for achieving true integration. To effectively integrate physician practices into the larger organization, IDSs need to overcome physician resistance to losing perceived autonomy and control. Physicians are most likely to accept integration into an IDS if they recognize the advantages they gain from allowing the IDS to assume administrative control of their practices.

Delivery of Health Care, Integrated↗
PubMedDate not supplied

Incentives for vertical integration in healthcare: the effect of reimbursement systems.

In the United States, many healthcare organizations are being transformed into large integrated delivery systems, even though currently available empirical evidence does not provide strong or unequivocal support for or against vertical integration. Unfortunately, the manager cannot delay organizational changes until further research has been completed, especially when further research is not likely to reveal a single, correct solution for the diverse healthcare systems in existence. Managers must therefore carefully evaluate the expected effects of integration on their individual organizations. Vertical integration may be appropriate if conditions facing the healthcare organization provide opportunities for efficiency gains through reorganization strategies. Managers must consider (1) how changes in the healthcare market have affected the dynamics of production efficiency and transaction costs; (2) the likelihood that integration strategies will achieve increases in efficiency or reductions in transaction costs; and (3) how vertical integration will affect other costs, and whether the benefits gained will outweigh additional costs and efficiency losses. This article presents reimbursement systems as an example of how recent changes in the industry may have changed the dynamics and efficiency of production. Evaluation of the effects of vertical integration should allow for reasonable adjustment time, but obviously unsuccessful strategies should not be followed or maintained.

Decision Making, Organizational↗
PubMed1999

Integrating healthcare for older populations.

The complex array of needs posed by older adults has frequently produced fragmentation of care in traditional fee-for-service systems. Integration of care components in newer health systems will maximize patient benefits and organizational efficiency. This article outlines the major issues involved in integration of care for older populations. A health system must integrate its care of older adults in many ways: among providers, both in primary care and specialty services; with community-based sources of care; and across sites of care (clinic, hospital, emergency department, and nursing home). Integrating reimbursement structures for various services will serve to create a client-oriented system, as opposed to a finance-centered system, thereby enhancing coordination of care. The extent to which two experimental comprehensive systems, PACE (Program of All-inclusive Care of the Elderly) and SHMO II (Social Health Maintenance Organization), have achieved clinical and financial integration are discussed in detail. Healthcare organizations are encouraged to create integrated models of care and to study the effects of integration on patient outcomes.

Aged↗
PubMed1999

General practice integration in Australia. Primary health services provider and consumer perceptions of barriers and solutions.

OBJECTIVE: To identify practical examples of barriers and possible solutions to improve general practice integration with other health service providers. METHOD: Twelve focus groups, including one conducted by teleconference, were held across Australia with GPs and non GP primary health service providers between May and September, 1996. Focus groups were embedded within concept mapping sessions, which were used to conceptually explore the meaning of integration in general practice. Data coding, organising and analysis were based on the techniques documented by Huberman and Miles. RESULTS: Barriers to integration were perceived to be principally due to the role and territory disputes between the different levels of government and their services, the manner in which the GP's role is currently defined, and the system of GP remuneration. Suggestions on ways to improve integration involved two types of strategies. The first involves initiatives implemented 'top down' through major government reform to service structures, including the expansion of the role of divisions of general practice, and structural changes to the GP remuneration systems. The second type of strategy suggested involves initiatives implemented from the 'bottom up' involving services such as hospitals (e.g. additional GP liaison positions) and the use of information technology to link services and share appropriate patient data. CONCLUSION: The findings support the need for further research and evaluation of initiatives aimed at achieving general practice integration at a systems level. There is little evidence to suggest which types of initiatives improve integration. However, general practice has been placed in the centre of the health care debate and is likely to remain central to the success of such initiatives. Clarification of the future role and authority of general practice will therefore be required if such integrative strategies are to be successful at a wider health system level.

Australia↗
PubMed2000

Duck hepatitis B virus DNA integration induced by oxidative radicals and its transmission from parent cells to offspring ones.

OBJECTIVE: To investigate the role of oxidative radicals in duck hepatitis B virus DNA (DHBV DNA) integration and the transmission of integrated DHBV DNA from parent cells to their offspring cells. METHODS: TUNEL assay and Southern blot hybridization were used to detect the cellular DNA strand breaks and the incidence of new type of DHBV DNA integration into cellular DNA of LMHD(21-6) cell line after the cells treated by low dose of hydrogen peroxide (10.0 micromol/L) during its growth from one cell to 3 +/- 10(7) to 5 +/- 10(7) cells. RESULTS: The rate of cell death induced by low dose of H(2)O(2) (10.0 micromol/L) was 32.0%, but that induced by high dose (>10.0 micromol/L) was more than 50.0%. At the same time, the incidence of new DHBV DNA integration into cellular DNA induced by 10.0 micromol/L of H(2)O(2) was 50.0% (6/12) and that in control group was 8.33% (1/12). There was a significant difference between the two groups (P<0.05). Besides, the new integrated DHBV-DNA in the parent cells could be found in the DNA of their offspring cells with the same size of base pair. CONCLUSION: Oxidative radicals is one of the important inducing factors in DHBV-DNA integration into cellular DNA and the integrated DHBV-DNA is able to transmit from the parent cells to their offspring cells stably.

Animals↗
PubMedDate not supplied

Integrating your radiology information system in a complex computing environment.

Radiology departments are a major source of important information regarding patient care. Such information is valuable in its own right but also provides significant added value when correlated with other information, including other clinical diagnoses, therapies, utilization, costs of care and outcomes. In the past, hospitals/imaging centers have typically sought the "best" RIS to meet the needs of the department and its user constituencies (physicians, nurses, medical records, etc.). Function and feature drove the RIS selection process. "Best of breed" was the rallying cry. Having multiple systems and vendors requires information systems and departmental staff to maintain expertise and support in each system and to interact with each vendor. The best-of-breed approach has a number of hidden costs. Before buying, ask "Is the best-of-breed RIS so much better than a more integrated solution that the support and integration efforts are worth it?" This is a complex question involving true needs, perceived needs, wants (justifiable or not), ego, politics, institutional future plans and more. Effective integration in a complex computing environment involves both technical processes and people processes. A cooperative, team-oriented process with the appropriate allocation of staff functions based on expertise and experience is needed. In general, the radiology department is best able to manage operations of the RIS. The information systems department should retain responsibility for housing the RIS computer and performing routine backup procedures as well as monitoring RIS performance. Both organizations can contribute to a highly successful integrated system operation based on their respective knowledge and experience. The IHE (Integrating the Healthcare Enterprise) is a joint initiative of the RSNA and HIMSS (Healthcare Information Systems Society) to stimulate the integration of information and imaging systems. The initiative will promote enterprise-wide sharing of data via established standards. The organizations, at their annual national meetings, will provide a visible forum and showcase of integration capabilities (most recently at HIMSS 2000).

Computer Systems↗
PubMed2001

Integration from the Australian GP's perspective.

OBJECTIVE: To report on what general practitioners' perceptions are about their role in relation to activities that support integration and what they are doing. METHOD: General practitioner perceived integrative behaviour was measured using a survey containing 114 statements about, 'what constitutes a well integrated GP'. Four hundred and forty-eight GPs were randomly sampled from the Health Insurance Commission (HIC) Medicare billing database in 1996. A response rate of 47% was obtained, yielding 208 surveys for analysis. RESULTS: General practitioners reported integrative activities such as being accessible to patients and working within a multidisciplinary team as currently occurring optimally. Not occurring optimally were: hospital and community involvement; participation in local projects; student education; and payment for working with others. Rural practitioners reported significantly more hospital and community involvement compared with metropolitan practitioners. Less than one-third of GPs reported that they were linked to other services by computer and used a computer for storage/communication of patient information. DISCUSSION: There are many obstacles preventing integrative activities in daily general practice. Policy and attitudinal changes as well as financial incentives are required to enable GPs to practise in an integrated manner. Infrastructure support to encourage GP education, training and information technology are essential to improve GP integration. Many such initiatives are currently in progress, and will require future evaluation. Findings from this 1996 survey will provide some useful baseline information assisting with future evaluation studies.

Australia↗
PubMedDate not supplied

Strengthening your ties to referring physicians through RIS/PACS integration.

Many imaging centers are turning to technology solutions to increase refering physician satisfaction, implementing such enhancements as automated report distribution, picture archiving and communications system (PACS), radiology information systems (RIS), and web-based results access. However, without seamless integration, these technology investments don't address the challenge at its core: convenient and reliable, two-way communication and interaction with referring physicians. In an integrated RIS/PACS solution, patient tracking in the RIS and PACS study status are logged and available to users. The time of the patient's registration at the imaging center, the exam start and completion time, the patient's departure time from the imaging center, and results status are all tracked and logged. An integrated RIS/PACS solution provides additional support to the radiologist, a critical factor that can improve the turnaround time of results to referring physicians. The RIS/PACS enhances the interpretation by providing the patient's history, which gives the radiologist additional insight and decreases the likelihood of missing a diagnostic element. In a tightly integrated RIS/PACS solution, results information is more complete. Physicians can view reports with associated images selected by the radiologist. They will also have full order information and complete imaging history including prior reports and images. Referring physicians can access and view images and exam notes at the same time that the radiologist is interpreting the exam. Without the benefit of an integrated RIS/PACS system, the referring physician would have to wait for the signed transcription to be released. In a seamlessly integrated solution, film-tracking modules within the RIS are fused with digital imaging workflow in the PACS. Users can see at a glance if a historical exam is available on film and benefit when a complete study history--both film-based and digital--is presented with the current case. It is up to the imaging center to market the benefits of reduced errors, reduced turnaround times, and a higher level of service to referring physician community, and encourage them to take advantage of the convenience it provides. The savvy imaging center will also regard the integrated RIS/PACS as a valuable marketing tool for use in attracting radiologists.

Appointments and Schedules↗
PubMed2003

Closing service system gaps for homeless clients with a dual diagnosis: integrated teams and interagency cooperation.

BACKGROUND: There is great concern about fragmentation of mental health service delivery, especially for dually diagnosed homeless people, and apprehension that such fragmentation adversely affects service access and outcomes. AIMS OF THE STUDY: This study first seeks to articulate two alternative approaches to the integration of psychiatric and substance abuse services, one involving an integrated team model and the other a collaborative relationship between agencies. It then applies this conceptualization to a sample of dually diagnosed homeless people who participated in the ACCESS demonstration. METHODS: Longitudinal outcome data were obtained through interviews at baseline, 3 months, and 12 months with homeless clients with a dual diagnosis (N = 1074) who received ACT-like case management services through the ACCESS demonstration. A survey of ACCESS case managers was conducted to obtain information on: (i) the proportion of clients who received substance abuse services directly from ACCESS case management teams, and the proportion who received services from other agencies; and (ii) the perceived quality of the relationship (i.e. communication, cooperation and trust) between providers--both within the same teams and between agencies. Hierarchical linear modeling was then used to examine the relationship of these two factors to service use and outcome with mixed-model regression analysis. RESULTS: Significant (p<.05) and positive relationships were observed in 4 of the 20 analyses of the association of service use and measures of communication, cooperation, and trust (either intrateam or inter-agency) while none were significant and negative. At 12 months, receipt of a higher proportion of services from agencies other than the ACCESS team was associated with fewer days homeless, and greater reduction of psychiatric symptoms, contradicting the hypothesis that integrated team care is more effective than interagency collaborations. DISCUSSION AND LIMITATIONS: This study broadens the conceptual framework for addressing service system fragmentation by considering both single team integration and interagency coordination, and by considering both program structure and the quality of relationships between providers. Data from a multi-site outcome study demonstrated suggestive associations between perceptions of communication, cooperation and measures of clinical service use. However, the proportion of clients treated entirely within a single team was associated with poorer housing and psychiatric outcomes. These empirical results must be regarded as illustrative rather than conclusive because of the use of a non-experimental study design, imperfections in the available measures, and the incomplete sampling of case managers. IMPLICATIONS FOR HEALTH POLICY: This study suggests that fragmentation of services for dually diagnosed clients may be reduced by improving the interactions within and between agencies providing these services. While primary emphasis has been placed on developing integrated teams, interagency approaches should not be prematurely excluded. IMPLICATIONS FOR FUTURE RESEARCH: Research on approaches to reducing system fragmentation have focused on either global efforts to integrate numerous agencies in a community or highly focused efforts to develop specialized teams. Future research should also focus on the possibility of fostering constructive relationships between selected pairs or subsets of agencies. Research in this area will also benefit from the further development measures of team integration and of both intra-team and inter-agency communication, collaboration, and trust.

Case Management↗
PubMed2004

The influence of hospital integration on hospital financial performance.

A clinical and functional integration strategy has a positive influence on increasing hospital revenue, and a solely functional integration strategy has a negative influence on increasing hospital expenses. Functional integration and clinical/functional integration strategies have a positive influence on hospital profit and the overall operations of the hospital. The mechanism of influence differs, however, based on the strategy used. Clinical/functional strategy has an impact on increasing hospital revenue, while functional integration strategy has an impact on reducing hospital expenses. Overall, the study shows that a functional integration strategy is more profitable than a clinical/functional integration strategy.

Delivery of Health Care, Integrated↗
PubMed2005

Semantic integration in healthcare networks.

A seamless support of information flow for increasingly distributed healthcare processes requires to integrate heterogeneous IT systems into a comprehensive distributed information system. Different standards contribute to ease this integration. In a research project focussing on the development of a reference architecture for inter-institutional health information systems, we identified and categorised concurring integration standards by distinguishing between technical and semantic integration on the one hand, and data and functional integration on the other hand. In addition, standards for semantic integration are roughly categorised according to their scope. By placing standards into a corresponding matrix a "semantic gap" is revealed, which cannot be covered by standards as it contains volatile medical concepts. As a conclusion, it is recommended to conceptually consider the necessity of system evolution in systems architectures and also in future integration standards.

Computer Communication Networks↗
PubMed2006

Case report: Taiwan's experience in adopting IHE technical framework to integrate systems.

Though more and more hospitals adopt PACS in Taiwan, they all meet the same problem of system integration. The Integrating the Healthcare Enterprise (IHE) association proposes an integrated technical framework and process profiles to solve problems of heterogeneous system integration in medical environment for information sharing. Therefore, this paper reports the experience of a case hospital that successfully applied IHE framework to integrate its HIS, RIS and PACS in Taiwan. This paper indicates that using the IHE can help evaluate the integration ability of PACS vendors, enhance staff's ability, shorten the PACS implementation time, reduce the cost, and reserve system's expansibility. The case hospital was able to successfully implement it's PACS because of executive's full support, using the standard, and providing complete training to reduce user's resistance. This paper not only shares the experiences of IHE adoption of a case hospital but also summarizes key factors to implement PACS successfully. Again, this paper confirms that standard is helpful to integrate heterogeneous system.

Diffusion of Innovation↗
PubMed1994

The influence of DNA and nucleosome structure on integration events directed by HIV integrase.

DNA copies of the human immunodeficiency virus (HIV) genome integrate nonrandomly into the chromosomal DNA of the host cell. In this report, we investigate the molecular basis of this selectivity using the virus-encoded HIV integrase to direct integration of a synthetic HIV long terminal repeat substrate into either DNA molecules of known structure or previously defined nucleosomal complexes. We find that the structure of the target greatly influences the site of integration, and, moreover, DNA curvature, flexibility, and rigidity in solution all influence the frequency of integration. Importantly, for DNA with all of these properties, the distortion of the double helix directed by association with the histone proteins promotes the integration reaction and alters the distribution of sites that are selected for integration. We suggest that both intrinsic DNA structure and the folding of DNA into chromosomal structures will exert a major influence on target site selection for integration of the viral genome.

Base Sequence↗
PubMed1994

Clinical importance of extraordinary integration patterns of human T-cell lymphotropic virus type I proviral DNA in adult T-cell leukemia/lymphoma.

The proviral DNA of human T-cell lymphotrophic virus type I (HTLV-I) is known to be integrated monoclonally in the malignant cells of adult T-cell leukemia/lymphoma (ATL), which is a peripheral T-cell malignancy caused by this virus. We studied the relationship between the integration patterns of HTLV-I and clinical characteristics in 89 patients with ATL. The proviral DNA of HTLV-I was examined by the standard Southern blot analysis using the endonucleases EcoRI and Pst I. One clear band of greater than 9 kb was detected in most of the patients (83 case) when cellular DNA was digested with EcoRI. On the other hand, extraordinary integration patterns of HTLV-I proviral DNA were detected in 6 patients; 3 of them showed two bands, while the other 3 showed one band smaller than 9 kb. When cellular DNA was digested with PstI, the band patterns of these patients were quite different from those of typical patients. The patients with the extraordinary integration patterns had clinical characteristics dissimilar to those of the other 83 patients with the ordinary integration pattern. The patients with two bands by EcoRI digestion always had severe hypoxemia with extremely high levels of serum lactate dehydrogenase at first presentation and showed peculiar organ infiltrations, such as retina and muscle, which were less frequent in the other ordinary 83 patients. They all died within 8 months after the onset. In contrast, the patients with one smaller band by EcoRI digestion always had small and mature T lymphocytes with bilobulated nuclei without lymphadenopathy and showed a favorable clinical course, which was uncommon in the ordinary cases. They were alive 20 to 38 months after diagnosis. Rearranged bands of the T-cell receptor gene were detected in all patients with unusual integration. These findings indicate that the integration patterns of HTLV-I proviral DNA have a clinical implication and may be one of the explanations for heterogeneity in the behavior of this disease.

DNA, Viral↗
PubMed1993

High frequency expression of integrated proviruses derived from enhancer trap retroviruses.

Since retroviruses integrate preferentially into transcriptionally active loci, the provirus may come under the control of regulatory elements of the gene into which it integrated and thus become a functional tag for that gene. In order to determine the frequency of retroviral integration near active endogenous enhancer elements, a retroviral enhancer trap vector was constructed. Lacking the long terminal repeat enhancer, expression of the neomycin resistance (neo) gene, used as a reporter, is dependent upon endogenous enhancer elements able to activate the long terminal repeat promoter. Infection of murine fibroblast cells indicated that a high proportion of the proviral copies expressed the neo gene. Infection of hematopoietic lines confirmed this high frequency of expression of integrated proviruses. Overall, between 43 and 74% of proviruses integrated into several different cell lines expressed the neo gene. These data suggest that retroviral integration is not only dependent upon transcriptional activity of the genomic target sites, but, more specifically, retroviruses preferentially integrate near active enhancer elements which are often associated with developmentally regulated genes.

3T3 Cells↗
PubMed1998

An integrated model for inner-city health-care delivery: the Deaconess Center.

Under the auspices of the Buffalo General Hospital and the faculty of medicine of the State University of New York at Buffalo, a comprehensive delivery system for primary care has been established in a local inner-city neighborhood. At the Deaconess Family Medicine Center, located within an inner-city location of Buffalo, New York, several divisions have been integrated to provide comprehensive patient-oriented primary care. These divisions include a primary care clinic, an urgent care clinic, a substance abuse clinic, and a community pediatrics clinic. Professional services are provided by attending physicians and residents. The horizontal integration of these four divisions is in turn vertically integrated with the tertiary care teaching hospital inpatient and obstetrical services, providing a continuum of patient care. The horizontal integration serves as an entry point for patients to enter the hospital's health-care system, while the vertical integration capability serves to capture any specialized referrals or inpatient needs. This article discusses the structure of the center, with special reference to service integration, service delivery, and patient capture; medical education; and the place of integrated units in the strategic plan of a tertiary care hospital.

Delivery of Health Care, Integrated↗
PubMed2000

Nuclear integrations of mitochondrial DNA in primates: inference of associated mutational events.

To infer the possible mutational events taking place along the interorganellar transfer of genetic material from mitochondria to the nucleus, four integrations of mitochondrial DNA (mtDNA) in the human genome were characterized together with their flanking nuclear sequences. By determining their presence/absence status in different primate species, these integrations were inferred to have occurred on the lineages leading to catarrhines (Old World monkeys and hominoids), to hominoids and to humans, respectively. In case of a polymorphic state, with respect to its presence in a certain species, each preintegration sequence was either cloned in the same species or in a primate taxon that branched off before the transfer of the mtDNA to the nucleus took place. For the four mtDNA integrations presented here, random mobilization of the mtDNA and differing mechanisms for generating free ends in the nuclear target sequences can be inferred. Additionally, no common sequence features at the preintegration sites could be observed for these integrations. Moreover, the comparisons of the sites before and after integration suggest different ways of integration. Thus, mtDNA integrations represent unique molecular recombinations in the evolutionary history and can, according to their presence/absence status in different species, help to determine the branching order in phylogenetic trees.

Animals↗
PubMed2005

Hierarchical nature of morphological integration and modularity in the human posterior face.

Morphological integration and modularity are important points of intersection between evolution and the development of organismal form. Identification and quantification of integration are also of increasing paleoanthropological interest. In this study, the "posterior face," i.e., the mandibular ramus and its integration with the associated midline and lateral basicranium, is analyzed in lateral radiographs of 144 adult humans from three different geographic regions. The null hypothesis of homogenously pervasive morphological integration among "posterior-face" components is tested with Procrustes geometric morphometrics, partial least squares, and singular warps analysis. The results reveal statistically significant differences in integration. Only loose integrative relationships are found between midline and lateral components of the basicranium, which may indicate the presence of at least two different basicranial modules. This modularity can be interpreted in terms of spatiotemporal dissociation in the development of those basicranial structures, and gives support to hypotheses of independent phylogenetic modifications at the lateral and midline basicranium in humans. In addition, morphological integration was statistically significantly stronger between the middle cranial fossa and the mandibular ramus than between the ramus and the midline cranial base. This finding confirms previous hypotheses of a "petroso-mandibular unit," which could be a developmental consequence of well-known phylogenetic modifications in coronal topology of the posterior face and base in hominoid evolution, related to middle cranial fossa expansion. This unit could be involved in later evolutionary tendencies in the hominid craniofacial system.

Adult↗