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Integrating research, surveillance, and practice in environmental public health tracking.

The Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services is working with selected state and local health departments, academic centers, and others to develop an environmental public health tracking initiative to improve geographic and temporal surveillance of environmental hazards, exposures, and related health outcomes. The objective is to support policy strategies and interventions for disease prevention by communities and environmental health agencies at the federal, state, and local levels. The first 3 years of the initiative focused on supporting states and cities in developing capacity, information technology infrastructure, and pilot projects to demonstrate electronic linkage of environmental hazard or exposure data and disease data. The next phase requires implementation across states. This transition could provide opportunities to further integrate research, surveillance, and practice through attention to four areas. The first is to develop a shared and transparent knowledge base that draws on environmental health research and substantiates decisions about what to track and the interpretation of results. The second is to identify and address information needs of policy and stakeholder audiences in environmental health. The third is to adopt mechanisms for coordination, decision making, and governance that can incorporate and support the major entities involved. The fourth is to promote disease prevention by systematically identifying and addressing population-level environmental determinants of health and disease.

Disease↗

Consortium Research on Indicators of System Performance (CRISP).

Since the CRISP project is in its early stages, reports of performance indicator data are not yet available. It will be late in 1994 before we have sufficient experience with our measures to encourage their use for both internal quality improvement and external evaluation. Some of our participating systems are quite far along in the development of individual indicators and have some experience with their fluctuations over time, but we are just beginning the process of studying cross-system comparisons. Use of measures in comparing the performance of integrated delivery systems is still an unproved technology, no matter how successful the measures may have been in other contexts. We believe that our approach to measuring system performance fits very well with the current direction of health care reform. We hope that the project will allow integrated systems of care to take a lead role in defining and testing measures of performance.

Data Collection↗

Orem's model used for health promotion: directions from research.

Orem's theories of self-care and self-care deficit contain several propositions important to health promotion. This article presents results of tests of these relationships, which indicated partial support for the model. In an aggregate sample of 369 adolescents, self-care and self-care agency were significant predictors of health. This relationship held when health was defined as a general positive state of integrity and soundness, but not when it was considered as merely the absence of disease.

Adolescent↗

Policy, organisation and practice of specialist old age psychiatry in England.

OBJECTIVE: To describe and compare service arrangements in old age psychiatry across England according to three broad domains: (i) levels of professional autonomy; (ii) degree of community orientation (delivery of and links with community services) and (iii) degree of integration between health and social care provision. DESIGN: Cross sectional survey of consultants in old age psychiatry in England. Potential respondents were sourced from the Royal College of Psychiatrists and Regional Advisers in Old Age Psychiatry. MEASURES: A self-administered postal questionnaire was piloted and refined. The questionnaire domains listed above reflect core policy issues for older people's services, covering the domains above. RESULTS: There is marked variation in the deployment and use of professional staff in old age psychiatry, ranging from open access to multidisciplinary assessment to services only accessible by clinician referral. Patterns of linkage with primary care are likewise variable with only half of services providing the types of support recommended by the Audit Commission (2000). Community orientation was evident to a considerable extent in support to care homes and assessment practices. Links between health and social care appeared strongest in terms of liaison and training. There was less evidence of more formal integration through shared management of staff or for links with intensive home support for those with dementia. CONCLUSIONS: The data provide a unique picture and benchmark of the configuration of old age psychiatry, a core element of mental health care in old age, after some 25 years of development in the UK. There appears to be substantial variation on all three domains of comparison.

Aged↗

Essential steps and practical applications for database studies.

As the information that is collected from health care encounters becomes more available, managed care pharmacy will have greater insights on the impact of pharmaceutical policy on patient outcomes. Database studies provide valuable information that depicts actual health care consumption and provides a tool to help manage the health care benefit. As compared with clinical trials, one of the strengths of database studies is that they are nonintrusive to patients and providers. However, the integrity of the data and any subsequent analysis are dependent on accurate and consistent coding practices at the time of data entry into the system. This article describes the 6 main steps required to complete a database study.

Benchmarking↗

Where's the data? Hierarchical storage management systems.

Management of the vast volume of documents and data that must be maintained in an EPRS requires well designed architecture that can manage the complexities involved in allowing secure, long-term storage of the information combined with speed of access necessary to please users. This calls for a tightly integrated platform of hardware and software components that are optimized to work in the health information environment.

Abstracting and Indexing↗

Linking primary care performance to outcomes of care.

BACKGROUND: Substantial research links many of the defining characteristics of primary care to important outcomes; yet little is known about the relative importance of each characteristic, and several characteristics have not been examined. These analyses evaluate the relationship between seven defining elements of primary care (accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust) and three outcomes (adherence to physician's advice, patient satisfaction, and improved health status). METHODS: Data were derived from a cross-sectional observational study of adults employed by the Commonwealth of Massachusetts (N = 7204). All patients completed a validated questionnaire, the Primary Care Assessment Survey. Regression methods were used to examine the association between each primary care characteristic (11 summary scales measuring 7 elements of care) and each outcome. RESULTS: Physicians' comprehensive ("whole person") knowledge of patients and patients' trust in their physician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their physician. With other factors equal, adherence rates were 2.6 times higher among patients with whole-person knowledge scores in the 95th percentile compared with the 5th percentile (44.0% adherence vs 16.8% adherence, P < .001). The likelihood of complete satisfaction was 87.5% for those with 95th percentile trust scores compared with 0.4% for patients with 5th percentile trust scores (P < .001). The leading correlates of self-reported health improvements were integration of care, thoroughness of physical examinations, communication, comprehensive knowledge of patients, and trust (P < .001). CONCLUSIONS: Patients' trust in their physician and physicians' knowledge of patients are leading correlates of three important outcomes of care. The results are noteworthy in the context of pervasive changes in our nation's health care system that are widely viewed as threatening to the quality of physician-patient relationships.

Adult↗

Secure interoperability of patient data cards in health networks.

In the healthcare area, chip card based information systems occur in the shape of patient data cards providing informational self determination and mobility of the users as well as quality, integrity, accountability, and availability of the data stored on the card, thus improving the shared care of patients. Dealing with sensitive personal medical information, shared care information systems have to provide appropriate security services, only authorized users allowing restricted rights to the patients' data according to the "need to know" principle. The DIABCARD project aims the implementation and evaluation of a chip card based medical information system (CCMIS) for facilitating communication and co-operation between health professionals in different organisations or departments caring the same patient with Diabetes as an example. In co-operation with the EC-funded TrustHealth project, the communication and application security services needed are provided as strong authentication and the derived services like authorization, access control, accountability, confidentiality etc. The solution is based on Health Professional Cards and Trusted Third Party services. Besides the secure handling of the patient's chip cart in DIABCARD workstations, also the secure communication between these workstations and related departmental systems has been implemented. Finally, a few legal issues, future trends like the XML standard set and their implications for the solution presented as well as for distributed health information systems in general are shortly discussed.

Computer Communication Networks↗

Integrating epidemiology and epizootiology information in ecotoxicology studies. III. Ecosystem health.

Epidemiology is the study of disease incidence rates in humans and epizootiology is the nonhuman animal equivalent. There have been few attempts to integrate epidemiological and epizootiological data from human and nonhuman animal populations coexisting in the same environment. The authors propose that epizootiology research be conducted on chemical pollutants using the framework of the natural environment as a laboratory. These kinds of studies are termed "epizootiologic ecotoxicology." It is suggested that guilds, defined as a group of human individuals or a group of nonhuman species that use their environment in a similar way, be used as experimental probes to assess the effects of chemicals on ecosystems and humans. Improved data would increase the likelihood that effects in exposed populations will attain statistical significance so that high-risk populations can be detected while the number of affected individuals is low. Epizootiologic ecotoxicology information, the product of this research, must be treated as an important component of a unified health evaluation system.

Animals↗

Integrated multimedia timeline of medical images and data for thoracic oncology patients.

A prototype multimedia medical database has been developed to provide image and textual data for thoracic oncology patients undergoing treatment of advanced malignancies. The database integrates image data from the hospital picture archiving and communication system with textual reports from the radiology information system, alphanumeric data contained in the hospital information system, and other electronic medical data. The database presents information in a timeline format and also contains visualization programs that permit the user to view and annotate radiographic measurements in tabular or graphic form. The database provides an efficient and intuitive display of the changing status of oncology patients. The ability to integrate, manage, and access relevant multimedia information may substantially enhance communication among distributed multidisciplinary health care providers and may ensure greater consistency and completeness of patient-related data.

Databases, Factual↗

[Psychological problems and cognitive impairments in the GUCH Community].

The increase of the GUCH Community requires a new definition of cardiac surgical success, which has to be considered either in terms of survival or quality of life and quality of health. Clinical and psychological problems are present in this population secondary to native cardiac disease, surgical correction, and social environment. Cognitive impairment after cardiac surgery is not rare, but an exhaustive evaluation of the psychological and neurodevelopmental outcome of patients operated on for total correction of congenital heart disease is complex and its clinical significance can be obtained by the integration of cardiological data, psychological status, and sociodemographic variables.

Age Factors↗

Interest and limitation of a global ethnopharmacological survey.

Since 1983 an ethnopharmacological research called the TRAMIL Programme (Applied Research on the Traditional Popular Medicine in the Caribbean Basin) has been underway in several countries of the West Indies and Central America. The programme, which started in Haiti and in the Dominican Republic, has now extended to Colombia, Costa Rica, Dominica, Guatemala, Honduras and Venezuela. The most important goal of the programme is to evaluate the traditional use of medicinal herbs in order to help unprivileged populations from this geographical area. The study is approached from the point of view of solutions to everyday health problems, rather than as a simple catalogue of plant or traditional remedy usage. An appropriate methodology is employed, including inventory and botanical determination, bibliographical research, study of the unknown species through analytical, toxicological and/or pharmacological methods and transmission of controlled information which ensures the value of natural medication to the public. The TRAMIL Programme leads to protection of cultural heritage and integration of effective and secure traditional remedies in primary health care.

Central America↗

Informed-consent issues with adolescent health behavior research.

OBJECTIVE: To identify the informed-consent issues when conducting adolescent health behavior research. METHODS: A literature review was conducted across diverse academic fields about the informed-consent issues that were relevant to adolescent health behavior research. RESULTS: Issues included defining consent, assent and permission, minimal risk, risk assessment; legal issues; adolescent capacity to participate in research, and parental permission. CONCLUSIONS: Integrity in research means doing the right thing. Obtaining adolescent informed consent must be obtained every time data are collected. There seem to be occasions in which waiver of parental permission in some adolescent health behavior research is warranted.

Adolescent↗

Improving the process through which health plans and providers exchange performance-related mammography data.

The ability of health plans to bring about quality improvement is limited by the fact that physician networks are highly differentiated, with physician groups participating in many plans and plans contracting with many physician groups. The primary purpose of our study was to investigate the problems in the current system of quality monitoring by managed-care organizations (MCOs) at a large integrated health care delivery system (Montefiore Medical Center) and to develop ways of addressing these problems through collaboration among MCOs. The project began by mapping the current system for collecting, reporting, and using performance data to improve performance, using breast cancer screening as an example. We found that neither health plans nor providers were satisfied with the current system. From the perspective of the health plans, the current quality monitoring was costly and, more important, was not yielding appreciable increases in screening rates. From the providers' perspective, multiple health plan requests for chart pulls and other data collection activities cost them substantial amounts of time and money and generated multiple mailings of educational materials and reports, but rarely supplied meaningful information about their performance. From the perspective of the hospital, the current procedure of reporting from MCO to provider or center bypassed the institution's own quality monitoring and management structure and thus limited the institution's ability to assist in quality improvement. This study clearly showed the importance of collaboration among plans at a given provider site. Specifically, it pointed to the need for provider-oriented reporting of data, rather than plan-oriented reporting, to give physicians numbers that they believe. It also showed the need to engage the institution's own quality-management system to assist in bringing about improvements.

Cooperative Behavior↗

Integration of concurrent trauma registry and performance improvement programs.

Health information management systems have had a tremendous impact on the delivery of healthcare. The implementation of an integrated, concurrent trauma registry and performance improvement system has had a remarkable impact on the University of Pennsylvania's trauma program. Having both the registry and performance improvement programs concurrent and integrated has allowed better utilization of staff and has produced more accurate, relevant and timely data.

Hospital Information Systems↗

Nurses' opportunistic interventions with patients in relation to smoking.

AIM: This paper reports a study exploring nurses' provision of opportunistic health education on smoking for hospital patients. BACKGROUND: Smoking cessation guidelines recommend assessment of patients' smoking habits and provision of smoking cessation advice when possible, and highlight the importance of the role of nurses in health promotion and health education. In the past, nurses have been criticized for lack of knowledge, skills and confidence in relation to health education and the perception that it is additional to, rather than integrated with, nursing care. METHODS: A qualitative case study design was selected to explore the health education practice of 12 nurses working in acute wards in three general hospitals in Scotland. Data were collected in 2000 through non-participant observation, semi-structured interviews and the use of a radio-microphone to record nurse-patient interactions. The data analysis was guided by four key elements of health education practice: 'the teachable moment', 'readiness to learn', 'the provision of health information' and 'oral communication'. FINDINGS: Smoking was part of the nurses' agenda, as most recognized opportunities to introduce health education on smoking during nursing care, suggesting a tentative move towards the integration of health education with nursing care. Evidence from patients' interactions indicated ample opportunity for nurses to provide smoking-related health information. However, the content of nurses' interactions on smoking was variable, with some limited by poor communication skills and inadequate knowledge of smoking and smoking cessation. The context of the interactions was also important in understanding some of the restrictions on conversational progress. CONCLUSIONS: Nurses require the knowledge and skills to perform a health education role, and the inclusion of smoking cessation guidelines in nursing curricula would contribute to this. Where patients are in hospitals for short periods of time, opportunistic health education on smoking needs to be introduced as the basis for more specialist intervention.

Attitude of Health Personnel↗