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The concluding segment of this two-part article covers the tax rules for integrated delivery systems that incorporate both taxable and tax-exempt participants. The author also analyzes the different organizational forms such ventures may take.
A prototype miniaturized Total Chemical Analysis System (muTAS) has been developed and applied to on-line monitoring of glucose and lactate in the core blood of anaesthetized dogs. The system consists of a highly efficient microdialysis sampling interface sited in a small-scale extracorporeal shunt circuit ('MiniShunt'), a silicon machined microflow manifold and integrated biosensor array for glucose and lactate detection with associated computer software for analytical process control. During in-vivo testing the device allowed real-time on-screen monitoring of glucose and lactate with system response times of less than 5 min, made possible by the small dead volume of the microflow system. On-line glucose and lactate measurements were made in the basal state as well as during intravenous infusion of glucose or lactate. The prototype muTAS is currently suitable for trend monitoring but refinements are necessary before application of the system for determination of individual lactate values.
Integrating binocular motion information tunes wide-field direction-selective neurons in the fly optic lobe to respond preferentially to specific optic flow fields. This is shown by measuring the local preferred directions (LPDs) and local motion sensitivities (LMSs) at many positions within the receptive fields of three types of anatomically identifiable lobula plate tangential neurons: the three horizontal system (HS) neurons, the two centrifugal horizontal (CH) neurons, and three heterolateral connecting elements. The latter impart to two of the HS and to both CH neurons a sensitivity to motion from the contralateral visual field. Thus in two HS neurons and both CH neurons, the response field comprises part of the ipsi- and contralateral visual hemispheres. The distributions of LPDs within the binocular response fields of each neuron show marked similarities to the optic flow fields created by particular types of self-movements of the fly. Based on the characteristic distributions of local preferred directions and motion sensitivities within the response fields, the functional role of the respective neurons in the context of behaviorally relevant processing of visual wide-field motion is discussed.
The CareGroup Provider Service Network is a managed care contracting organization which provides central administrative services for over 1800 physicians and 200,000 managed care lives. Services include utilization management, disease management and credentialing for the entire network. The management model of the Provider Service Network empowers local physician groups with information and education. To meet the managed care information needs of the network, we implemented an intranet-based executive information system, PSNWeb, which retrieves data from a managed care data warehouse. The project required the integration of diverse technologies and development of a complex security/confidentiality infrastructure to deliver information to 8 major clinician groups, each with different information needs.
This article addresses the importance of public health, hospital, and clinical laboratories in the role of patient care, disease prevention, and surveillance. It also focuses on the coordination and planning that needs to take place between these institutions in order to develop a more cost-effective and responsive laboratory delivery system. The Washington Clinical Laboratory Initiative is an innovative state initiative illustrating that coordinated and integrated strategic planning of public and private sector laboratories can be accomplished within a state. It also has increased interaction, collaboration, and communication between health practitioners, health plans, hospitals, laboratories, government agencies, and academicians. This accomplishment has enabled the establishment of public policy concerning laboratory reimbursement and development of standards of laboratory practice.
At Three Rivers Youth in Pittsburgh, a freestanding adolescent partial-hospitalization program is a primary force in a multimodal integrated-treatment system for high-risk youth. Three barriers encountered in the development of the program (utilization, integration with other components, and staffing) are discussed and strategies successful in overcoming these barriers are presented. Features of the program which are believed to contribute to its success are outlined, including scheduling, clinical structures, educational services, case management, and staffing. Case illustrations from clinical practice in the program are also offered.
In early 1993 the leaders of the Sisters of Mercy in Cincinnati decided to form their four area hospitals into a new integrated regional system, The creation of this system--Mercy Regional Health System Greater Cincinnati--was made difficult by the fact that each of its four facilities had its own culture. Change, moreover, can be threatening to even the boldest. As a result of these factors, formation of the new system did not proceed as smoothly as we had planned. Things improved after we began to acquaint ourselves with the histories and cultures of the four hospitals. After that, we created a new regional leadership structure that enabled us to form administrators and employees into teams, breaking down the compartmentalization traditional in healthcare. We showed our employees that the system would open opportunities for them. We also created a new regional board of trustees to develop the system's strategic plan, manage its business infrastructure, and draw up its budget. We established a holistic health and wellness center to encourage focus on the connections between body, mind, and spirit. Through new corporate publications, newspaper advertisements, and lobby displays, we have explained our evolution both to our employees and the residents of the region. As a result, we are now in virtually all of greater Cincinnati's managed care plans.
We have developed an integrated automation system for genetic analysis and gene manipulation. The system, SX-8G Plus, is equipped with an 8-nozzle dispensing unit, a thermal cycler, a cooled reagent reservoir, four tip storage racks, four microplate platforms, buffer reservoirs, an agarose gel electrophoresis unit, a power supply, a pump for exchanging electrophoresis buffer, and a CCD camera. Automation of nucleic acid extraction and purification, the most difficult step in automating genetic analysis and gene manipulation, was realized using magnetic beads with Magtration Technology, which we have previously developed for automating the handling of paramagnetic beads. Using this system, we could perform the automated separation and purification of DNA fragments by agarose gel electrophoresis starting from sample loading. The system would enable the automation of almost all procedures in genetic analysis and gene manipulation.
This paper describes a project to develop and test a new telemedicine system using image transmission. The system was implemented at Aomori prefecture, the northernmost prefecture of Japan, to provide medical consultation to remote hospitals from a medical center located in Aomori city, capital of the prefecture. The characteristics of the system are the combination of an HDTV still image transmission system and an ordinary tele-conference system using 65 kilobit telephone line i.e., an ordinary telephone line available in almost any part of Japan. We also developed a disk storage system that stores transmitted images automatically without human intervention. The system was assessed in real clinical settings and has proved to be effective in various areas of medical consultation, including radiology, pathology, dermatology, etc. We hope that this system becomes a standard telemedicine system in the future.
STUDY OBJECTIVES: To determine whether an educational initiative could decrease rates of ventilator-associated pneumonia in a regional health-care system. SETTING: Two teaching hospitals (one adult, one pediatric) and two community hospitals in an integrated health system. DESIGN: Preintervention and postintervention observational study. PATIENTS: Patients admitted to the four participating hospitals between January 1, 1999, and June 30, 2002, who acquired ventilator-associated pneumonia. INTERVENTION: An educational program for respiratory care practitioners and ICU nurses emphasizing correct practices for the prevention of ventilator-associated pneumonia. The program included a self-study module on risk factors for, and strategies to prevent, ventilator-associated pneumonia and education-based in-services. Fact sheets and posters reinforcing the information were posted throughout the ICU and respiratory care departments. MEASUREMENTS AND RESULTS: Completion rates for the module were calculated by job title at each hospital. Rates of ventilator-associated pneumonia per 1,000 ventilator days were calculated for all hospitals combined and for each hospital separately. Overall 635 of 792 ICU nurses (80.1%) and 215 of 239 respiratory therapists (89.9%) completed the study module. There were 874 episodes of ventilator-associated pneumonia at the four hospitals during the 3.5-year study period out of 129,527 ventilator days. Ventilator-associated pneumonia rates for all four hospitals combined dropped by 46%, from 8.75/1,000 ventilator days in the year prior to the intervention to 4.74/1,000 ventilator days in the 18 months following the intervention (p < 0.001). Statistically significant decreased rates were observed at the pediatric hospital and at two of the three adult hospitals. No change in rates was seen at the community hospital with the lowest rate of study module completion among respiratory therapists (56%). CONCLUSIONS: Educational interventions can be associated with decreased rates of ventilator-associated pneumonia in the ICU setting. The involvement of respiratory therapy staff in addition to ICU nurses is important for the success of educational programs aimed at the prevention of ventilator-associated pneumonia.
INTRODUCTION: The aim of the study was to develop a method to measure the implementation of specific components of an Integrated Service Delivery system for the frail elderly. The system includes six mechanisms and tools: (1) coordination of all organizations involved in delivering health and social services, (2) a single entry point, (3) case management, (4) a single assessment tool with a case-mix classification system, (5) an individualized service plan, and (6) a computerized clinical chart. METHOD: Focus groups of researchers, clinicians, managers and policy-makers identified quantitative indicators for each component. The six components were weighted according to their relative importance in order to generate a total score. Data were collected every six months over 30 months to establish the implementation degree in the three experimental areas: Sherbrooke, Granit and Coaticook in the Province of Quebec, Canada. RESULTS: After 30 months, coordination is the most developed component in the three experimental areas. Overall, in July 2003, the Integrated Service Delivery system was implemented at the rate of 73%, 71% and 70% in Sherbrooke, Granit and Coaticook, respectively. DISCUSSION: This type of quantitative assessment provides data for managers and researchers to monitor the implementation. Moreover, when there is an outcome study, the results of the outcome study can be correlated with the degree of implementation, thus allowing for dose-response analyzes and helping to decrease the "black box" effect.
Computer models were used to simulate the feedlot segment of an integrated beef production system. Five breeds, Angus (A), Charolais (C), Hereford (H), Limousin (L), and Simmental (S), in three mating systems, pure-breeding and two- and three-breed rotational crossbreeding, were evaluated for feedlot and carcass performance. Breed data were taken from the literature. Feeder calves (steers and non-replacement heifers) entered the feedlot at 205 d of age. After a 35-d adjustment period, calves were custom-fed to four slaughter end points: 440 d, 457 d, 288-kg carcass weight, or low Choice. Cattle were fed to requirements (megacalories of ME). Input costs included feed and nonfeed expenses (purchase prices, transportation, yardage, and medicinal fees). Carcass values were $2.65 and $2.54/kg of carcass weight for steer and heifers, respectively, between 272 to 318 kg. Over- or underweight carcasses were discounted $.60/kg. At the 440-d end point, Select grade steer and heifer carcasses were discounted an additional $.22 and $17/kg, respectively. Biological efficiency was measured as megacalories of ME/kg of gain, and economic efficiencies were measured as input costs per kilogram of carcass weight, input costs per kilogram of lean weight, and input costs per carcass value. Continental breed combinations (C and S) were most efficient at age- and weight-constant end points for megacalories of ME per kilogram of gain and for input costs per carcass value and most efficient at all end points for input costs per kilogram of carcass weight and input costs per kilogram of lean weight. British breed combinations (A) were most efficient at a fat-constant end point for megacalories of ME per kilogram of gain and input costs per carcass value. Therefore, choosing breed combinations for feedlots depends on slaughter end point and measures of efficiency.
As new health systems struggle to combine in today's challenging health care market, mechanisms that facilitate and enhance integration become increasingly important. This article describes the use of clinical paths in an integrated delivery system (IDS) as a methodology to establish a single standard of high-quality care. Through education and sharing of staff development resources across the IDS, the system nurse executive at one large IDS promotes professional practice. As clinical paths are developed across the system, the best clinical practice is put to paper, providing a framework for outcome-driven care. The nurse manager assesses staff's use of clinical paths as an evaluation of their skills and competency and to identify new educational and growth opportunities.
One year ago, the radiology department at Ball Memorial Hospital, a 350-bed facility in Muncie, IN, was completely film-based. The need to support a new all-digital, 35-room emergency department (ED) hastened the facility's transition to a digital environment. Today, with the exception of mammography, the hospital's imaging services are now digital. To develop and implement the project, the hospital formed an internal implementation team. An independent consultant was also hired to evaluate the impact of these new technologies and to provide an estimated cost payback. After research, site visits, and vendor demonstrations, the hospital selected a single vendor for its picture archiving and communication system (PACS), digital radiography (DR), computed radiography (CR), and overall project management. The DR system was installed in the ED to provide digital image capture for a full range of trauma exams. The ED also initially began utilizing a Web-based PACS distribution originally implemented for after-hours teleradiology. The majority of the hospital's imaging studies are captured with 2 multi-cassette CR systems that serve 7 exam rooms in the radiology department. The hospital also installed remote operations panels to expedite entry of patient and exam information. Technologists readily embraced both CR and DR systems. The Web distribution system now transmits images to hospital-based computers and to 150 remote referring physicians. The PACS platform automatically e-mails key images and radiology reports to referring physicians. Authorized physicians can also request reports and images on an as-needed basis. The PACS vendor had previously performed multiple integrations with the radiology information system (RIS) vendor; the integration of PACS and RIS was extremely smooth. One of the critical components of a successful conversion is experienced, dedicated management. The hospital retained professional project management services to facilitate implementation and to ensure adequate training for all users.
As a result of work through the Care Data consortium in cooperation with Iowa Methodist and University of Chicago Hospitals, Methodist has implemented: an open systems integration strategy, a clinical repository, and clinician-centric access and distribution of information. The Care Data consortium gave rise to a new breed of automation that meets the needs of both ends of the clinical automation spectrum: migrating an integrated, single-vendor solution to an open systems integrated repository to users of a distributed, best-of-breed approach.
Some of the most important challenges in health-care technologies have been identified to be development of noninvasive systems and miniaturization. In developing the core technologies, progress is required in pushing the limits of miniaturization, minimizing the costs and power consumption of microsystems components, developing mobile/wireless communication infrastructures and computing technologies that are reliable. The implementation of such miniaturized systems has become feasible by the advent of system-on-chip technology, which enables us to integrate most of the components of a system on to a single chip. One of the most important tasks in such a system is to convey information reliably on a multiple-access-based environment. When considering the design of telecommunication system for such a network, the receiver is the key performance critical block. The paper describes the application environment, the choice of the communication protocol, the implementation of the transmitter and receiver circuitry, and research work carried out on studying the impact of input data characteristics and internal data path complexity on area and power performance of the receiver. We provide results using a test data recorded from a pH sensor. The results demonstrate satisfying functionality, area, and power constraints even when a degree of programmability is incorporated in the system.
PURPOSE: To evaluate ability of the University of California Los Angeles Integrated Staging System (UISS) to stratify patients with localized and metastatic renal cell carcinoma (RCC) into risk groups in an international multicenter study. PATIENTS AND METHODS: 4,202 patients from eight international academic centers were classified according to the UISS, which combines TNM stage, Fuhrman grade, and Eastern Cooperative Oncology Group performance status. Distribution of the UISS categories was assessed in the overall population and in each center. RESULTS: The UISS stratified both localized and metastatic RCC into three different risk groups (P <.001). For localized RCC, the 5-year survival rates were 92%, 67%, and 44% for low-, intermediate-, and high-risk groups, respectively. A trend toward a higher risk of death was observed in all centers for increasing UISS risk category. For metastatic RCC, the 3-year survival rates were 37%, 23%, and 12% for low-, intermediate-, and high-risk groups, respectively; in 6 of 8 centers, a trend toward a higher risk of death was observed for increasing UISS risk category. A greater variability in survival rates among centers was observed for high-risk patients. CONCLUSION: This study defines the general applicability of the UISS for predicting survival in patients with RCC. The UISS is an accurate predictor of survival for patients with localized RCC applicable to external databases. Although the UISS may be useful for patients with metastatic RCC, it may be less accurate in this subset of patients due to the heterogeneity of patients and treatments.
This chapter addresses some of those legal issues that uniquely affect the formation or operations of an integrated delivery system (IDS), a foundation, or a management services organization (MSO), but which are not discussed in any other chapters. This chapter gives special insight and guidance on issues such as licensing, credentialing and peer review, employee benefit plans, prohibitions against physician self-referrals, and the rules on disclosure of ownership and control.