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PubMed1998

Integrated computerized patient records: the DIOGENE 2 distributed architecture paradigm with special emphasis on its middleware design.

DIOGENE 2 is a full-scale distributed/open hospital information system that by June 1995 had already achieved its migration from a former mainframe system. Thanks to that architecture there is an obvious need for a common "glue" devoted to tightening up scattered applications into a middleware-based network of interoperability. After this the design of open/distributed Electronic Patient Records (EPRs) became feasible. A brief historical sketch of DIOGENE is presented from its initial to its present phase. A working prototype of these distributed EPRs is discussed showing current achievements during its first stage of production in the clinics of the University Hospitals of Geneva. On-going expansion to other public hospitals, as well as to general practioners (GPs) in the Geneva area, are partly described.

Computer Communication Networks↗
PubMedDate not supplied

[The prevalence of digestive organ diseases and the organization of specialized care].

Analysis of 5942 case histories of inpatients and 15,482 case histories of outpatients helped reveal the morbidity structure with regard to diseases of the digestive system and assess these diseases incidence in the urban and rural population of different age and sex. The incidence of diseases of the biliferous duct was found to be 45.6, of peptic ulcer 21.4, and of pancreatitis 14.2 per 1000 population for the urban population and 7.2, 20.2, and 2.3/1000, respectively, for the rural population. The age of the urban patients is most often 40 to 49, that of the rural ones 50 to 59 years. Among surgical inpatients the share of cases with involvement of the biliferous duct was 8.8%, with gastroduodenal ulcer 14.1%, and with pancreatitis 6.4%. Diseases of the digestion organs rank fourth in the mortality structure; 92.3% of deaths are patients hospitalized in emergency.

Acute Disease↗
PubMed1990

The Stafford outbreak of Legionnaires' disease.

A large outbreak of Legionnaires' disease was associated with Stafford District General Hospital. A total of 68 confirmed cases was treated in hospital and 22 of these patients died. A further 35 patients, 14 of whom were treated at home, were suspected cases of Legionnaires' disease. All these patients had visited the hospital during April 1985. Epidemiological investigations demonstrated that there had been a high risk of acquiring the disease in the out patient department (OPD), but no risk in other parts of the hospital. The epidemic strain of Legionella pneumophila, serogroup 1, subgroup Pontiac 1a was isolated from the cooling water system of one of the air conditioning plants. This plant served several departments of the hospital including the OPD. The water in the cooling tower and a chiller unit which cooled the air entering the OPD were contaminated with legionellae. Bacteriological and engineering investigations showed how the chiller unit could have been contaminated and how an aerosol containing legionellae could have been generated in the U-trap below the chiller unit. These results, together with the epidemiological evidence, suggest that the chiller unit was most likely to have been the major source of the outbreak. Nearly one third of hospital staff had legionella antibodies. These staff were likely to have worked in areas of the hospital ventilated by the contaminated air conditioning plant, but not necessarily the OPD. There was evidence that a small proportion of these staff had a mild legionellosis and that these 'influenza-like' illnesses had been spread over a 5-month period. A possible explanation of this finding is that small amounts of aerosol from cooling tower sources could have entered the air-intake and been distributed throughout the areas of the hospital served by this ventilation system. Legionellae, subsequently found to be of the epidemic strain, had been found in the cooling tower pond in November 1984 and thus it is possible that staff were exposed to low doses of contaminated aerosol over several months. Control measures are described, but it was later apparent that the outbreak had ended before these interventions were introduced. The investigations revealed faults in the design of the ventilation system.

Adult↗
PubMed1999

The mental health care delivery system in greece: regional variation and socioeconomic correlates.

BACKGROUND: In Greece, the functional capacity of the mental health care system until 1980, was totally inadequate to meet the increasing mental health needs of the population and to provide efficient and community-based services. This situation was brought to the attention of the Commission of European Communities and a special EEC Regulation No 815/84 provided the financial technical support for an extended psychiatric reform programme. The psychiatric reform programme initiated in 1984 and ended in 1995. AIMS OF THE STUDY: This study compared the geographical distribution of neuropsychiatrists and the mental health care delivery system structural components (psychiatric beds, extramural mental health units and places in rehabilitation services), according to the regional socioeconomic development for the years 1984, 1990 and 1996. Additionally the possible effects of the operation of community-based mental health services on the psychiatric hospitalizations were examined. METHODS: Data on the geographical distribution of neuropsychiatrists in the previously mentioned years were drawn from local Medical Association from each of 54 prefectures of the country. The corresponding distribution of the mental health care delivery system components was made available from the database of the Monitoring and Evaluation of Mental Health Services Unit. Pearson product moment correlations of the regional distribution of neuropsychiatrists and the various components of the mental health care system, as population-based ratios, with the corresponding socioeconomic development in the form of the general index of development were performed. Mental hospital age standardized rates were collected from the Hospital Central Register for the periods 1984-1987 and 1990-1993. Discharge rates were elaborated according to the existence of mental health services in specific regions. RESULTS: A wide regional variation in neuropsychiatrists per 100000 population was found in all three years, with the majority of them working in the greater Athens and Thessaloniki areas. In the geographical distribution of health regions, there is an uneven significant decrease in psychiatric beds between 1984 and 1996. However in almost all regions an increase in extramural services between the two critical periods was noticed, as part of the implementation of the psychiatric reform programme. A parallel and more dramatic increase in the places of rehabilitation in 12 out of 13 regions has been observed during the implementation of the reform programme. At the level of prefectures, the changes across time, in the mean ratios of beds, extramural services and rehabilitation places were not found to be significant. A significant decrease of discharges in prefectures covered by newly established extramural services for the period 1990-1993, compared to discharge rates during the period 1984-1987, when none of these services were in operation in these prefectures, was noticed. The intercorrelation matrix between the various mean values (1990-1996) of the mental health care system components in the 54 prefectures and the local general index of development scores produced statistically significant correlation coefficients. It seems that the greater the level of local socioeconomic development the higher the degree of mental health care delivery system growth. DISCUSSION: Our results have shown uneven regional distribution of neuropsychiatrists, as well as extramural mental health units and rehabilitation places, despite the current reorganization of the whole mental health care delivery system. The positive correlation between the various structural components of the system in the 54 prefectures and the local socioeconomic conditions could be interpreted as follows. Urban areas of higher socioeconomic growth had a long history of development of inpatient services in mental hospitals. In these several community-based alternatives have been established for their transformation into modern ones. Urban areas exhibit also higher psychiatric morbidity and therefore increasing mental health needs. Additionally in several cities local University Psychiatric Departments have developed a variety of mental health and rehabilitation services. Many new services highly specialized and complementary to existing mental hospitals were established in urban areas. Rural areas are mostly uncovered by mental health care facilities. However it seems that the establishment of community-based services could have an effect on mental hospital utilization. CONCLUSION: It becomes evident that after the implementation of the psychiatric reform programme in Greece significant progress in the areas of decentralization of mental health and rehabilitation services has been observed. However there are still areas in many prefectures, mainly rural or semirural, lacking the appropriate delivery of mental health care. IMPLICATIONS FOR HEALTH CARE AND POLICY FORMULATION: Our results suggest that flexible models of services should be introduced for the benefit of population living in areas lacking the necessary socioeconomic resourses. IMPLICATIONS FOR FUTURE RESEARCH: Mental health services research in Greece should focus on quasi-experimental studies on the effectiveness of various models of mental health care in areas of different socioeconomic growth.

Journal Article↗
PubMedDate not supplied

Neuroradiology workstation reading in an inter-hospital environment: a nineteen month study.

Two workstations (WS) each with two, 2500 line display monitors were installed in the in-patient and the out-patient neuroradiology reading areas for inter-hospital workstation readings. These WSs are part of the display component of a hospital-integrated picture archiving and communication system (PACS). Direct digital neuro images from 10 CT and MR scanners located at various buildings from two medical centers are first transmitted to the PACS database and then distributed to these two WSs automatically. This paper attempts to answer two questions. First, do the WSs facilitate neuroradiology operation? Second, does it cost less for preparing WS reading than that for the traditional film reading? Two parameters, the "time required before images become available for reading after the examination" and a "workstation utilization index" were derived as a means for answering these two questions. Nineteen months of clinical data were collected and analyzed. The results demonstrate that the workstation utilization index goes up from 40% in September 1994 when the WS was first introduced to over 80% in March 1996. This upward trend substantiates the hypothesis that these WSs do facilitate the neuroradiology operation. The derived results also exhibit that it costs much less to prepare images for WS reading than for film reading. Other indirect results derived from this study including the WS utilization hours, WS functions used, and the time duration of each WS session are also presented.

Ambulatory Care↗
PubMed1991

Drug utilisation, supply and expenditure at Chitungwiza, Gweru, Mpilo, Parirenyatwa and United Bulawayo Hospitals in one year (1987-1988).

From 1987 to 1988 a total of 759,602 items were supplied to the five hospitals at a cost of Z$4,603,256.17. Over that period 373,203 (49.13pc) were supplied by the Government Medical Stores (GMS) at a cost of Z$1,341,675.32 while 386,399 (50.87pc) of the items were supplied by the Private Sector (PS) at a cost of Z$3,261,580.85. The disease pattern in hospitals' main causes of admission was used as a parameter to indicate the rationality of drug use and expenditure. The defined daily dose (DD), was used as a standard of comparison on drug usage at the five hospitals. Anti-infectives ranked highest in both use and expenditure in most hospitals while cytotoxics and vitamins respectively accounted for the highest expenditures and usage at Parirenyatwa hospital. The source of drug supplies to the hospitals was mainly the PS. Foreign currency shortages and the ineffective distribution system in the GMS seem to play an important factor in the provision and the utilisation of drugs in the public sector. In the public sector, physicians often prescribe expensive brand name products rather than the corresponding generic drugs.

Drug Costs↗
PubMed2005

A Distributed Database and a New Application for the DRG System.

The article presents a new solution for the implementation of the DRG classifying system used in Romania to finance hospitals. The new solution implies two proposals. The first one refers to the use of a fragmented and distributed database at level of each hospital, and the second refers to the management and the viewing of this database by means of an on-line application implemented in Java. The solution proposes that the distributed database should be managed by two powerful tools, meaning Oracle8 Server and Net8. Different types of users are proposed, each type with his own rights for managing and viewing the database. Excepting local users who use only their local database, there are also global users from National DRG Bureau who can see data from all local databases, at any time. This solution is more efficient, secure and modern, than the one used now.

Computer Communication Networks↗
PubMed1992

Mirror to ASHP: 1942-1992.

Highlights from the history of ASHP are presented on the occasion of the Society's 50th anniversary. Efforts to organize a formal group representing hospital pharmacists, begun in the 1920s, resulted in the formation of a subsection on hospital pharmacy of the American Pharmaceutical Association in 1936. In 1942, ASHP became a distinct organization affiliated with APhA. The body's goals were to establish minimum standards for pharmaceutical services, ensure a supply of well-qualified hospital pharmacists by providing hospital internships, facilitate information exchange, and foster cost-effective use of medicines. The development of practice standards and periodic surveys of hospital pharmaceutical services, educational efforts and accreditation programs, publications, and ASHP's role in the development of principles for hospital formulary systems are described. ASHP's endorsement of unit dose drug distribution and systems for preparation of intravenous admixtures is discussed. The evolution of pharmacists' clinical roles, their increased involvement in drug therapy decisions and the provision of drug information to patients, and the expanded responsibility implicit in the pharmaceutical care concept are traced. Today's ASHP members can build on the work of yesterday's members to provide better pharmaceutical care.

History, 20th Century↗
PubMed1977

Pharmaceutical services in nongovernmental hospitals on the West Coast.

A survey of nongovernment, nonprofit and for-profit hospitals in Washington, Oregon and California was conducted to determine the incidence of selected hospital pharmacy services (1) directly related to drug distribution and (2) not directly related to drug distribution. Questionnaires were mailed to all qualifying hospitals in the three states; the return rate was 75.4%. Unit dose drug distribution was used in combination with other delivery systems by 58.3% of the respondents; 26.5% used unit dose exclusively. Over half of the respondents provided i.v. admixture programs, outpatient and inpatient discharge prescriptions, and inpatient medication profiles. Additionally, 77.9% provided pharmacy consultation to physicians. Nonprofit hospitals had significantly higher pharmacy staffing levels (both pharmacists and supportive personnel) than for-profit hospitals in the categories, "open seven days per week," "open nine to 16 hours per day," "open 17 to 24 hours per day, "101 to 200 beds" and "201 or more beds." Hospitals that provided the following services had significantly higher pharmacy staffing levels than those that did not provide the serices: unit dose drug distribution, i.v. admixture services, inpatient discharge prescriptions, inpatient medication profiles, drug therapy monitoring, and cardiopulmonary resuscitation team participation (difference of supportive staff only).

Hospitals, Proprietary↗
PubMed2005

Medication errors in an internal medicine department. Evaluation of a computerized prescription system.

OBJECTIVE: Evaluation of a computerized physician order entry in an Internal Medicine Department, with a unit-dose distribution system. SETTING: Pharmacy Department, Internal Medicine Department. S. Francisco Xavier Hospital, Lisbon, Portugal. METHOD: This study was carried out in December 2001 and January 2002. After two years experience of the CPOE system, medication errors were evaluated prospectively, in an internal medical department of a 360-bed academic hospital. Data were collected once a week. Pharmacists reviewed all medical prescriptions as part of their routine work. Medication errors detected were recorded on a data collection form with a design based on the types of errors as defined by the American Society of Hospital Pharmacists (ASHP). Completed forms were reviewed and medication errors were classed according to ASHP guidelines. RESULTS: A total of 2268 orders were monitored (162 patients). In these orders, 73 medication errors (22.4% of the patients) were detected and documented (59 prescribing errors and 14 monitoring errors). The most common prescribing errors were deficiencies related to the right class but wrong drug (28.3%): omeprazole vs. ranitidine/sucralfate in stress ulcer prophylaxis; incorrect dose (30%) and unclear orders (13.3%). Errors related to incorrect frequency of administration (5%); maintenance of IV route (5%); duplicated drug therapy (11.7%); drug interactions (1.7%) and length of therapy (3.3%) were also detected. The 14 monitoring errors detected were failures to review a prescribed regimen for appropriateness and detection of problems. CONCLUSIONS: Computerized prescription order entry has demonstrated effectiveness in eliminating medication errors related to transcribing and patient identification. Nevertheless, medication errors related to prescription and monitoring still occur. The use of clinical decision support systems and pharmacist involvement is vital to achieve maximum medication safety and reduce medication error rates.

Drug Prescriptions↗
PubMed1998

Determinants of prescribing costs for ulcer-healing drugs and upper gastrointestinal endoscopy in general practice.

BACKGROUND: Prescriptions for ulcer-healing drugs (UHDs) and endoscopy costs represent major expenditures for dyspepsia in primary care. Healthcare expenditure for dyspepsia could be better understood if the factors contributing to the expenditure for dyspepsia could be identified. AIMS: To determine whether prescribing costs of UHDs and use of endoscopy in general practice were related to the characteristics of the practices or to the characteristics of the population it served DESIGN: Twenty-seven GP practices in south London were studied prospectively over 6 months. Prescribing costs for UHDs were obtained from PACT and data for endoscopies from hospital PAS systems. Demographic data on practice size, age and sex distribution were obtained from the district FHSA. The Jarman index, Townsend score and proportion of ethnic minorities in the practice population were determined from the Population Census Survey. RESULTS: Total expenditure on UHDs by the 27 practices was Pound Sterling 1 million per annum and endoscopy rate was 1.1% per annum. Expenditure on UHDs was negatively correlated with practice size (P = 0.006) and use of open access endoscopy (P < 0.005) and positively correlated with number of patients aged over 45 years (P = 0.007). Endoscopy use was positively correlated with proportion of ethnic minorities (P = 0.008) and negatively with male:female ratio (P = 0.049). CONCLUSIONS: Resource utilization on dyspepsia in general practice is determined by both practice and population characteristics.

Anti-Ulcer Agents↗
PubMedDate not supplied

The reemergence of the hospital-based laboratory.

The Reference Laboratory Alliance (RLA) in Pittsburgh is an example of multiple hospital laboratories integrated for the purpose of delivering competitive outpatient laboratory services in a managed-care environment. Developed in 1994, the RLA model includes a "virtual" core laboratory (comprising four tertiary care centers of excellence) and a distributed network of more than 30 community hospitals. Linked through information systems, logistics, and an extensive committee structure, the RLA is capable of delivering a "seamless" service to the region's managed-care organizations. In its first full year of operation, the RLA is expected to shift between $12 and $15 million worth of laboratory activity back into the community's hospitals. Through its pathology component, the RLA is now actively engaged in redefining the role of the clinical laboratory in the managed-care environment.

Community Networks↗
PubMed2004

[Microbiological isolates associated with nosocomial infections in intensive care units: data of 274 intensive care units participating in the German Nosocomial Infections Surveillance System (KISS)].

OBJECTIVE: To describe the frequency and distribution of microbiological isolates in association with nosocomial infections (NI) in intensive care units (ICUs) in Germany. METHODS: The hospital infection surveillance system (KISS = Krankenhaus-Infektions-Surveillance-System) started in Germany in January 1997 as a nationwide surveillance project for the voluntary registration of nosocomial infections. For ICUs reporting focuses on device-associated primary bloodstream infections, urinary tract infections, as well as on pneumonia and bronchitis. The data collected for each patient who acquires a nosocomial infection include the site of infection and patient demographics. Up to 4 pathogens can be recorded for each infection. RESULTS: From 1997 until 2002 274 ICUs were participating. The data of 590 695 patients with 18 073 device associated infections (ventilator-associated pneumonia and bronchitis, central line-associated bloodstream infection (BSI) and urinary catheter-associated urinary tract infection (UTI)) were analyzed. In the group of device-associated NI S. aureus was most frequently isolated (16.5/100NI) followed by Ps. aeruginosa (14.2/100NI), E. coli (13.9/100NI), enterococci (13.4/100NI) and C. albicans (11.2/100NI). Of all S. aureus isolates 20.0 % were MRSA. There was an increase of the MRSA rate from 8 % in 1997 to 26.9 % in 2002. The most frequent pathogen in BSI was coagulase-negative staphylococcus (31.0/100NI). In ventilator-associated pneumonia and bronchitis S. aureus was the most frequent pathogen (24.2 and 24.9/100NI). In more than half of all catheter-associated UTI E. coli (25.7/100NI) and enterococci (25.4/100NI) were found. After stratification for the type of ICU differences in the distribution of pathogens could be shown. CONCLUSIONS: The KISS data give an overview of the most important pathogens associated with nosocomial infections on ICUs in Germany.

Cross Infection↗
PubMed1989

A computer-assisted management information system for nutrition services.

A computer-assisted management information system was created to facilitate effective management of clinical nutrition services and labor resources in a 330-bed teaching and research hospital. Standards were developed for the quality and quantity of nutrition care, time required to provide nutrition care, and utilization of dietitians' time. Computer software was developed to report the volume of services provided, the need for services, and the utilization of labor hours. Data were evaluated to determine whether services were consistent with standards and to calculate a recommended number of clinical dietitian full-time equivalents for the hospital. Furthermore, the management information system was instrumental in developing a fee-for-service structure, for evenly distributing work loads among dietitians, and for monitoring adherence to standards of care.

Dietetics↗
PubMed2003

Identification and verification of critical performance dimensions. Phase 1 of the systematic process redesign of drug distribution.

BACKGROUND: Worldwide patient safety has become a major social policy problem for healthcare organisations. As in other organisations, the patients in our hospital also suffer from an inadequate distribution process, as becomes clear from incident reports involving medication errors. Medisch Spectrum Twente is a top primary-care, clinical, teaching hospital. The hospital pharmacy takes care of 1070 internal beds and 1120 beds in an affiliated psychiatric hospital and nursing homes. OBJECTIVE: In the beginning of 1999, our pharmacy group started a large interdisciplinary research project to develop a safe, effective and efficient drug distribution system by using systematic process redesign. The process redesign includes both organisational and technological components. This article describes the identification and verification of critical performance dimensions for the design of drug distribution processes in hospitals (phase 1 of the systematic process redesign of drug distribution). METHODS: Based on reported errors and related causes, we suggested six generic performance domains. To assess the role of the performance dimensions, we used three approaches: flowcharts, interviews with stakeholders and review of the existing performance using time studies and medication error studies. CONCLUSIONS: We were able to set targets for costs, quality of information, responsiveness, employee satisfaction, and degree of innovation. We still have to establish what drug distribution system, in respect of quality and cost-effectiveness, represents the best and most cost-effective way of preventing medication errors. We intend to develop an evaluation model, using the critical performance dimensions as a starting point. This model can be used as a simulation template to compare different drug distribution concepts in order to define the differences in quality and cost-effectiveness.

Attitude of Health Personnel↗
PubMed1987

The distributional implications of using relative prices in DRG payment systems.

Decisions by state Medicaid programs and other third-party payers to use DRGs as the basis of hospital payment require the resolution of numerous technical design issues, including determining relative price schedules, that are likely to have important distributional implications for payers and hospitals. At issue is the development of price schedules that reflect average resource use in the populations using DRG reimbursement. An examination of differences between the Medicare relative prices and other relative prices based on different populations in New York State revealed that significant cross-subsidies among payers and hospitals would occur if Medicare relative prices were used as the basis of payment for patients outside the Medicare program. Such unintended cross-subsidies would compromise a major goal of DRG payment: to reduce "inequitable" charge and cost differentials among third-party payers.

Blue Cross Blue Shield Insurance Plans↗