加拿大医疗保健本制面面观之一加拿大医疗体制的特点

加拿大向来以社会安定、福利优越而闻名，其中在众多的福利中，可能最让加拿大人引以为豪的是它的全民医疗保健体制。美国前总统克林顿上台伊始，就曾组织智囊机构对加拿大的医疗体制进行深入的研究，试图对美国现行私人医疗保险体制进行改革，并建立一个类似加拿大的全民医疗保障体系。虽然方案提了一个又一个，最终由于美加两国税收体制的根本不同而无法实行其全民免费医疗的设想。     

基于人群健康的国家卫生筹资系统建模研究

通过对目前国内外卫生筹资状况的分析，依据复杂系统相关理论，界定国家卫生筹资系统概念边界。通过定性分析，建立起该系统的概念模型与逻辑模型，并探索该系统在实际运用中存在的问题，提出政策建议，为国家卫生筹资政策的制定提供理论依据。     

The sustainability of the Spanish National Health System

The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.     

Health promotion in Canada - a case study

This case study describes and explains the development of health promotion in Canada, with particular emphasis on the social and political context. It explores how health promotion thinking emerged, was interpreted and implemented. It illustrates the balance between policy and practice, as well as outlining the role of health promotion infrastructures. The review has been developed at a time of considerable change to the landscape of health promotion in Canada. For some, this raises concerns about capacity for future leadership and continuing contribution to health reform. For others, the brief but rich legacy of experience reviewed here suggests new opportunities for further strong health promotion action in Canada-albeit in the context of new constructs and partnerships. It is hoped that this case study will contribute to a critical and timely dialogue on how health promotion values, principles and strategies can continue to inform action. This is vital as we commit to global Health for All for the 21st century in the face of challenge and change.     

The researchers of the National Institutes of Health. Their vicissitudes in the National System of Health

Medical researchers that work at the National Institutes of Health have a preponderant role in the scientific production of Mexico. This article focuses their behavior during the last 12 years, within the National System of Investigators (SNI). According to the citation and publication indices, the medical researchers are of greater productivity and quality. The number of investigators of the Institutes that have obtained their entrance to the SNI has grown in 129.8%, during the period of study and has been constant in each one of the Institutes of Health, with the exception of the INPer, that besides to have smaller number of researchers within the SNI, shows a tendency to low. The investigators level 1 have stayed between 10 to 12 per year in most of the Institutes, with exception of Nutrition, Cardiology and Public Health that have managed to maintain effective to more than 20 investigators of this level during the last 5 years; in the case of Nutrition over 30. These three Institutes also have maintained the greater number of investigators level 2 and 3; it emphasizes Nutrition that is counted with the average of publications by researcher in the institutes is of 4.9 +/- 3 papers. The researchers of Nutrition, Pediatría, the INPer and Neurology contribute with more than 4 publications by each year. Nevertheless, when we only included the publications of groups III-V, only the researchers of Nutrition publish annually 6 to 7 high quality research paper. All the professionals of the Institutes that have an appointment of Investigator in Medical Sciences do not belong to the SNI. In the case of the Institute of Medical Sciences and Nutrition, of 131 workers with this appointment (Julio 2003), only 47 (35.9%) belong to the NSI. When analyzing the participation of the professionals that do not belong to the SNI in the mentioned published papers from 1999 to 2002 it was found that of 484 publications of group III, in 108 (22%) nonmembers of the SNI and without appointment of investigator participated in these publications; of 85 of group IV, in 16 (19%) and of 52 of group V, in 12 (23%). Of the analysis of this information, strategies directed to particular groups can be undertaken, to mainly increase the scientific productivity in the National Institutes of Health and, to improve their quality and its scientific impact.     

Physicians for a National Health Program

A new organization called Physician's for a National Health Program (PNHP) is mobilizing physician support for a universal, comprehensive public system of health care for the United States. Recent changes in power relations within medicine (the so-called proletarianization of physicians) are prodding many physicians to abandon their traditional reactionary role in health policy. PNHP is working with elderly, labor, community, and health care activist groups to put a national health program (NHP) back on the U.S. health policy agenda. In this article, five key features of an NHP needed to simultaneously assure access, control costs, and minimize bureaucracy are noted.     

A Web-based Electronic Health Record System for National Surveillance

Objective

This showcase aims to demonstrate the viability of Practice Fusion’s web-based electronic health record system for national surveillance. Practice Fusion also wishes to provide aggregate data to public health departments for surveillance for free. This showcase also hopes to engage those potential partners around uses of the company’s research database.

Introduction

Practice Fusion is a web-based electronic health record system with over 150,000 medical professional users treating over 50 million patients. The company focuses on small, ambulatory practices and is predominately comprised of practices in the field of primary care. The user base makes it an ideal system for public health surveillance. The Research Division has undertaken pilot projects to demonstrate the viability of using the data for surveillance for acute diseases, like influenza-like illness, chronic diseases, like diabetes, and risk factors, like hypertension.

Methods

Surveillance systems based on electronic health records have clear advantages over case based reporting, but the majority of those systems are limited to the small geographical area affiliated with the hospital or health plan associated with the project. Practice Fusion has coverage in all 50 states and runs on a single, multi-tenant database making comparisons across those states and the localities within them immediately feasible. The company wishes to engage the organizations represented at ISDS in order to advance public health surveillance using the research database. It is very difficult to obtain electronic health record data currently, but with the appropriate data use agreement Practice Fusion believes that it is a moral imperative to use its aggregate data for surveillance. The Research Division has developed methods for the surveillance of influenza-like illness with its system and comparisons to the CDC have proven its viability.

Conclusions

By comparing trends and levels of influenza-like illness generated from Practice Fusion’s research database to Google Flu Trends and the gold standard estimates produced by the CDC, web-based electronic health record systems have proved to be a viable foundation for syndromic surveillance. The implementation of the system also shows that case definitions for surveillance need not be overly simplistic if they do not require cases to be submitted from physicians, but rather can be programmed to be identified through automated algorithms.