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The big news of '94 was not the rise and fall of government-led health reform, it was hospital system integration, mergers and acquisitions. Here is the how, who and why of both the non-profit and investor-owned sectors and some educated guesses at what is yet to come.
OBJECTIVES: The Styrian Hospital Organization with 21 hospitals including the Graz University Hospital, and the Heidelberg University Hospital implemented a new HIS based on SAP/R3, ISH, ISH* MED with the objective to have an integrated system to support patient administration and management, patient care, clinical documentation, research etc. METHODS: Heidelberg University Hospital chose a step by step method for the introduction of the system, beginning with patient administration (ISH) and proceeding with clinical functions (ISH* MED). In Styria, the full functionality was implemented--as part of the selection process--in one peripheral hospital and in the Ear, Nose and Throat (ENT) Department of the Graz University Hospital, including special documents to support the processes in the highly specialized ENTunits. RESULTS AND CONCLUSIONS: The standard modules are performant, stable and basically well accepted. Particularly in Graz, it has been shown that the requirements of highly specialized departments for work flow management, documentation and integration of subsystems and data from different sources can be fulfilled by special documents and programs--although at the expense of additional workload particularly in the initial phases of such a project.
A proposal is presented here to use modified mobile genetic elements for making chromosomal insertions in vivo, into any desired chromosomal site. The idea lies in replacing the sequences which direct specificity of integration of those elements with other DNA sequences, homologous to the desired target chromosomal site. The idea is analysed on the basis of a lambda phage integration system. A design for a universal system for making chromosomal insertions into any site of choice is proposed.
A variety of health care industry changes affect hospital/system materiel management directors as never before. Among them: the switch to patient care in alternative sites, system integration, new health care partnerships, and evolving technology and benchmarking needs. The key drivers for management include total product cost, compliance, standardization, utilization, and long-term partnering.
Groupe RICHE is bringing to the market of health IT the Open Systems approach allowing a new generation of health information systems to arise with benefit for patients, health care professionals, hospital managers, agencies and citizens. Groupe RICHE is a forum for exchanging information, expertise around open systems in health care. It is open to any organisation interested by open systems in health care and wanting to participate and influence the work done by its user, marketing and technical committees. The Technical Committee is in charge of the maintenance of the architecture and impact the results of industrial experiences on new releases. Any Groupe RICHE member is entitled to participate to this process. This unique approach in Europe allows health care professionals to benefit from applications supporting their business processes, including providing a cooperative working environment, a shared electronic record, in an integrated system where the information is entered only once, customised according to the user needs and available to the administrative applications. This allows Hospital managers to satisfy their health care professionals, to smoothly migrate from their existing environment (protecting their investment), to choose products in a competitive environment, being able to mix and match system components and services from different suppliers, being free to change suppliers without having to replace their existing system (minimising risk), in line with national and regional strategies. For suppliers, this means being able to commercialise products well fitted to their field of competence in a large market, reducing investments and increasing returns. The RICHE approach also allows agencies to define a strategy, allowing to create a supporting infrastructure, organising the market leaving enough freedom to health care organisations and suppliers. Such an approach is based on the definition of an open standard architecture. The RICHE esprit project defined in 1993 the three layered architecture, with four main components and their services of which the main principles have recently been adopted by the CEN TC251 as a european pre-standard. From this architecture specifications various implementations have been completed including the IMS DHE, the GESI DHE and the REFERENCE Kernel. However putting into practice this approach on a large scale is not so easy. Interesting lessons have been learned in the last years in different countries.
We have described a reconstituted avian sarcoma virus (ASV) concerted DNA integration system with specially designed mini-donor DNA containing a supF transcription unit, a supercoiled plasmid acceptor, purified bacterially expressed ASV integrase (IN), and human high-mobility-group protein I(Y). Integration in this system is dependent upon the mini-donor DNA having IN recognition sequences at both ends and upon both ends of the same donor integrating into the acceptor DNA. The integrated DNA product exhibits all of the features associated with integration of viral DNA in vivo (P. Hindmarsh et al., J. Virol., 73:2994-3003, 1999). Individual integrants are isolated from bacteria containing drug-resistant markers with amber mutations. This system was used to evaluate the importance of sequences in the terminal U5 and U3 long terminal repeats at positions 5 and/or 6, adjacent to the conserved CA dinucleotide. Base-pair substitutions introduced at these positions in U5 result in significant reductions in recovered integrants from bacteria, due to increases in one-ended insertion events. Among the recovered integrants from reactions with mutated U5 but not U3 IN recognition sequences were products that contain large deletions in the acceptor DNA. Base-pair substitutions at positions 5 and 6 in U3 mostly reduce the efficiency of integration of the modified donor. Together, these results indicate that sequences directly 5' to the conserved CA dinucleotide are very important for the process of concerted DNA integration. Furthermore, IN interacts with U3 and U5 termini differently, and aberrant end-processing events leading to nonconcerted DNA integration are more common in U5 than in U3.
Many Canadian provincial governments are exploring methods to increase the integration of health services in an effort to improve the care provided, while maintaining or reducing the costs. Integrated health delivery systems are being implemented in the United States, Britain and other European countries. Such systems aim to provide a full continuum of care to a defined target population under a financing system of capitation. This article explores the issues associated with the governance accountabilities of an IDS. A review of potential governance models is completed, and the factors that influence the choice of a governance model for an integrated delivery system are presented. In 1987. Ewell identified governing boards as the weakest link in the integrated health care systems of the United States. It is suggested that early attention to governance in the development of IDS models in Canada may improve the effectiveness of these systems.
Respiratory motion is difficult to compensate for with conventional radiotherapy systems. An accurate tracking method for following the motion of the tumor is of considerable clinical relevance. We investigate methods to compensate for respiratory motion using robotic radiosurgery. In this system the therapeutic beam is moved by a robotic arm, and follows the moving target through a combination of infrared tracking and synchronized x-ray imaging. Infrared emitters are used to record the motion of the patient's skin surface. The position of internal gold fiducials is computed repeatedly during treatment, via x-ray image processing. We correlate the motion between external and internal markers. From this correlation model we infer the placement of the internal target during time intervals where no x-ray images are taken. Fifteen patients with lung tumors have recently been treated with a fully integrated system implementing this new method. The clinical trials confirm our hypothesis that internal motion and external motion are indeed correlated. In a preliminar study we have extended our work to tracking without implanted fiducials, based on algorithms for computing deformation motions and digitally reconstructed radiographs.
Magnetic force increases as the distance (d) of the force- generating elements (F approximately 1/d(2)) decreases, whereas elastic force decreases as the distance decreases (F approximately kd). These opposing characteristics suggest that combining both force systems will establish an integrated system with a long-range working ability. The objective of this study was to determine the vertical closure force (F(X)) and the transverse axis moment (M(Y)) of an integrated force system, ie, attracting magnets with elastics (vertical or Classes II and III). F(X) and M(Y) were examined on the orthodontic measurement and simulation system. It was found that the integrated force system had a positive closure force (+F(X)) that never declined to 0 and a long working range. Three regions characterized the force-deflection curve of F(X): the magnetic region (0-3 mm, for magnets with 3/16-in medium elastics), in which the decline in magnetic force was larger than the increase in elastic force (6.3-2.5 N); the constant region (3-7 mm), in which the decline in magnetic force equaled the increase in elastic force (2.5-2.9 N); and the elastic region (7-10 mm), in which there was only an increase in elastic force (2.9-3.5 N). The transverse axis moment (+M(Y)), which tends to close the bite, developed especially in magnets with a single vertical elastic. Clinically, inactivation of vertical elastics by closing the mouth can be overruled by the integrated force system because it exerts adequate force level at both short and long distances.
This paper describes the development and implementation of the first phase of a comprehensive clinical information system in the Kaiser Permanente Northwest Region. This system integrates information from disparate departmental systems into a single clinical database. By using periodic batch downloads of patient data from departmental systems into the clinical database, rather than requiring real-time updates, we have been able to implement this system with relative ease and speed. It contains patient demographics, lab, outpatient pharmacy, radiology, pathology, dictated consults, admission histories and physicals, discharge summaries, and other dictated reports for over 380,000 Health Plan Members. The system is fast, intuitive, reliable, and user-friendly. In March 1994, there were approximately 1,600 active users. These individuals accounted for approximately 410,000 transactions in the month, with an average daily transaction volume of 11,450. Quantifiable cost-savings, in terms of decreased chart pulls and decreased phone calls for information, have offset the cost of development and implementation to some extent. Less quantifiable improvements in the quality of care and the associated cost-savings may eclipse the quantifiable benefits. This system lays the foundation for our clinical information system efforts.
A computer network system has been developed in the Orthodontic Clinic, Osaka University Dental Hospital, to improve treatment efficiency and patient service. The system consists of a 32-bit host computer, its peripheral units, and personal computers connected to the host computer by data-transmission circuits, making up a local area network (LAN). It is possible in this system to integrate various types of data, such as the patient's basic information, treatment records, image data, and diagnostic analysis results to construct a relational database. It has been shown that the computer system developed in the orthodontic clinic has various clinical advantages.
A multianalyte flow electrochemical cell (MAFEC) for bioanalysis is constructed, characterised and used for simultaneous carbohydrate analysis incorporating mediated amperometric enzyme electrodes. Although multidetection schemes can be addressed with microfabricated systems, it is demonstrated that a "meso" analytical device of low cost can give answers to traditional simultaneous multianalysis problems, being robust, and easy to construct and operate. The cell operates as a radial flow thin-layer device and can achieve mass transport controlled response for fast electrochemical reactions. When appropriate enzymatic electrodes are used the response becomes kinetically limited, but still shows a better than 5% R.S.D. for response to different sugars analysed. All the enzymatic sensors are mediated with different osmium compounds appropriate for each enzyme's mechanism (NAD or PQQ dehydrogenases) in some cases combining multienzyme sensors. All sensors were optimised so that different sugars do not produce interferences to other sensors. Matrix interferences were kept low by operating all sensors at or below 150 mV versus Ag/AgCl. The integrated system was used for the simultaneous detection of fructose, sucrose, glucose, galactose, and lactose, fully characterising the system for these analytes (sensitivity, dynamic range). Cross referenced calibration curves were used for signal treatment and interpretation and it was possible to analyse real juice and milk samples with results agreeing with the standard enzymatic methods for the same analyses with a sampling frequency of more than 100 h(-1).
Regional health systems attempting to achieve the vertical integration of health services ultimately must achieve clinical integration. The thesis of this article is that vertical integration in health care involves the coordination of inputs (equipment, supplies, human resources, information, and technology) and intermediate outputs (preventive, diagnostic, acute, chronic, and rehabilitative services) to attain the end goal of optimal personal health. Given this perspective on vertical integration, the coordination of specialty services and primary care within a system structure--that is, the clinical integration of patient care--is central to the realization of vertically integrated regional health systems. Institution-level and environmental factors that facilitate and challenge the attainment of clinical integration are elucidated, and a set of clinical integrating mechanisms are outlined with presentation of real-world examples of those mechanisms. The analysis concludes by summarizing the next steps in realizing the vision of clinically integrated, regional systems of health care.
An immunosorbent assay system was integrated into a glass microchip. The scale merits of liquid microspace for molecular behavior contributed remarkably to reduced assay time, and troublesome operations required for conventional immunosorbent assays could be replaced by simple operations. Moreover, a micro-immunoassay system suitable for simultaneous assay of multiple samples was constructed on a microchip. The chip had branching multichannels and four reaction and detection regions; thus the constructed system could process four samples at a time with only one pump unit. A higher throughput assay was realized with the branching structure chip.
The integration and evolution of existing systems represents one of the most urgent problems facing those responsible for healthcare information systems so that the needs of the whole organisation are addressed. The management of the healthcare record represents one of the major requirements in the overall process, however it is also necessary to ensure that the healthcare record and other healthcare information is integrated within the context of an overall healthcare information system. The CEN ENV 12967-1 'Healthcare Information Systems Architecture' standard defines a holistic architectural approach where the various, organisational, clinical, administrative and managerial requirements co-exist and cooperate, relying on a common heritage of information and services. This paper reviews the middleware-based approach adopted by CEN ENV 12967-1 and the specialisation necessary for the healthcare record based on CEN ENV 12265 'Electronic Healthcare Record Architecture'.
Two types of central nervous system integrators are critical for oculomotor performance. The first integrates velocity commands to create position signals that hold fixation of the eye. The second stores relative velocity of the head and visual surround to stabilize gaze both during and after the occurrence of continuous self and world motion. We have used recordings from single neurons to establish that the "position" and "velocity" integrators for horizontal eye movement occupy adjacent, but nonoverlapping, locations in the goldfish medulla. Lidocaine inactivation of each integrator results in the eye movement deficits expected if horizontal eye position and velocity signals are processed separately. These observations also indicate that each brainstem compartment generates and stores these signals. Consequently, each integrator exhibits functional autonomy. Therefore, we propose that the intrinsic electrophysiological properties of the constituent neurons in each brainstem subnucleus may be sufficient for producing integrator rhythmicity.
An integrated system for acquisition and processing of intracranial and extracranial Doppler signals and automatic embolic signal detection has been developed. The hardware basis of the system is a purpose-built acquisition/processing board that includes a multigate Doppler unit controlled through a computer. The signal-processing engine of the system contains a fast Fourier transform (FFT)-based, spectral-analysis unit and an embolic signal-detection unit using expert system reasoning theory. The system is designed so that up to four receive gates from a single transducer can be used to provide useful reasoning information to the embolic signal-detection unit. Alternatively, two transducers can be used simultaneously, either for bilateral transcranial Doppler (TCD) investigations or for simultaneous intra- and extracranial investigation of different arteries. The structure of the software will allow the future implementation of embolus detection algorithms that use the information from all four channels when a single transducer is used, or of independent embolus detection in two sets of two channels when two transducers are used. The user-friendly system has been tested in-vitro, and it has demonstrated a 93.6% sensitivity for micro-embolic signal (MES) identification. Preliminary in-vivo results also are encouraging.
Integrating systemic chemotherapy into the treatment of patients with invasive bladder cancer, where the majority of deaths are from systemic relapse, is crucial if survival is to be improved. However, the global recommendation of a single treatment approach for all patients is becoming outdated as several groups have found that appropriately selected patients enjoy comparable survival whether treated by transurethral resection alone or by partial or radical cystectomy. Thus, refining case selection becomes a critical area of investigation. Patients with a high risk of systemic relapse should be considered for systemic therapy early in the course of the disease, ideally as part of a clinical trial. The availability of growth factors has reduced the toxicities of the regimens currently in use. Improvements in assessing biologic potential are required, so that treatment recommendations will allow patients the maximal chance of cure and maintenance of organ function, while minimizing toxicities in patients for whom systemic approaches are unwarranted. Of interest are recent reports that G-CSF may enhance tumor sensitivity to methotrexate in vitro and increase the sensitivity of implanted urothelial tumors to chemotherapy in nude mice. Such findings suggest an expanded role for these agents. Unfortunately, simple escalation of all components of a combination regimen does not appear to be a viable strategy, as it is unlikely to significantly increase CR proportions without prohibitive toxicities. However, as more is understood about drug resistance, and in particular its development in vivo, better sequencing of the available of options should be possible. The availability of effective salvage therapies suggests that this is an appropriate therapeutic approach. In addition, a number of strategies aimed at reversing the mdr phenotype are under study. These include calcium channel blockers such as verapamil, cyclosporin, and tamoxifen. Alternatively, some groups are investigating transfecting the mdr gene into bone marrow cells to reduce the sensitivity of these cells to cytotoxic agents. These novel designs can be tested both in patients with metastatic disease and in patients with locally advanced (T3b, T4, and N+) disease, who have a high risk of metastatic failure and low CR proportions to available regimens.