Roles and responsibilities of chief medical officers in member organizations of the Association of American Medical Colleges.

PURPOSE: To explore the roles of physician leaders who hold titles such as chief medical officer (CMO), vice president for medical affairs, and vice dean for clinical affairs in Association of American Medical Colleges (AAMC) member organizations, and to identify critical success factors for these positions. METHOD: An Internet-based survey was submitted to 340 physician leaders in 281 AAMC member institutions. The survey posed questions regarding demographics, titles, reporting relationships, time commitments, scope of responsibility, accomplishments, and challenges related to recipients' positions, among other questions. RESULTS: Responses were received from 154 physicians representing 139 institutions (response rates 45% and 49%, respectively). Forty-nine percent of these positions had existed for 10 years or less. The most common administrative title was CMO (48%). Eighty-five percent of these individuals reported directly to the dean or CEO of their organization. The majority of administrative effort involved quality and safety (31%), coordination of clinical care (21%), and graduate medical education (9%). The remainder (39%) encompassed a broad portfolio of responsibilities ranging from information technology (6%) to nursing services (2%). Keys to job success included personal stature and relationships, clear definition of responsibilities, and the commitments of the senior administration to the position. CONCLUSIONS: Teaching hospitals and medical schools are creating or strengthening positions for physician leaders, most commonly called CMOs. CMOs' work involves numerous activities beyond the traditional areas of quality and safety. The effectiveness of these positions requires clear definition of the role throughout the organization and strong, evident support from senior executives in the organization.     

Using the computer to optimize human performance in health care delivery. The pathologist as medical information specialist

The demands for information retrieval, processing, and synthesis placed on all providers of health care have increased dramatically in the last several decades. Although systems have been developed to capture charge-related data in support of cost reimbursement, there has been a conspicuous lack of attention paid to information tools to directly enhance the delivery of patient care. The termination of cost reimbursement, together with an increasing recognition of the problems inherent in current manual record-keeping systems, is creating a significant new focus on medical information. This change in focus requires a shift in systems orientation away from financial and departmentally centered systems and toward patient-centered approaches. There is thus increasing recognition of the need for a physician-level medical information specialist to serve as an institution's chief information officer, assuming responsibility for the collection, manipulation, and availability of all patient care-related data. By virtue of training, typical experience, hospital presence, and a noncompetitive position with the hospital's medical staff, the pathologist is uniquely suited for this position. To effectively perform this role, a variety of new specialized data management tools are becoming available. Integrated information systems, patient care management by exception, decision support tools, and, in the future, "artificial intelligence" assists can all be expected to become staples of pathology practice, especially impacting those pathologists who choose to be responsive to the new practice milieu of medical information science.     

A search engine for virtual patient records.

Virtual patient records provide a means for integrated access to patient information that may be scattered around different healthcare settings. Within the boundaries of a health district providing all levels of care, this concept can be implemented in an Intranet environment to support longitudinal patient care activities across the participating healthcare providers. Since medical information is stored on multiple Intranet sites in various forms (e.g. codified data, transcribed documents, and images), a suite of appropriate tools is needed to enable access to such information in combined form. In most cases, however, access to medical information should be restricted to authorized users. To serve this purpose, a prototype search engine incorporating an authorization and access control functionality has been developed and presented in this paper. The system is based on the signature file access method and an experimental implementation written in JAVA is also described.     

Security of the distributed electronic patient record: a case-based approach to identifying policy issues

The growth of managed care and integrated delivery systems has created a new commodity, health information and the technology that it requires. Surveys by Deloitte and Touche indicate that over half of the hospitals in the US are in the process of implementing electronic patient record (EPR) systems. The National Research Council has established that industry spends as much as $15 billion on information technology (IT), an amount that is expanding by 20% per year. The importance of collecting, electronically storing, and using the information is undisputed. This information is needed by consumers to make informed choices; by physicians to provide appropriate quality clinical care: and by health plans to assess outcomes, control costs and monitor quality. The collection, storage and communication of a large variety of personal patient data, however, present a major dilemma. How can we provide the data required by the new forms of health care delivery and at the same time protect the personal privacy of patients? Recent debates concerning medical privacy legislation, software regulation, and telemedicine suggest that this dilemma will not be easily resolved. The problem is systemic and arises out of the routine use and flow of information throughout the health industry. Health care information is primarily transferred among authorized users. Not only is the information used for patient care and financial reimbursement, secondary users of the information include medical, nursing, and allied health education, research, social services, public health, regulation, litigation, and commercial purposes such as the development of new medical technology and marketing. The main threats to privacy and confidentiality arise from within the institutions that provide patient care as well as institutions that have access to patient data for secondary purposes.     

Comprehensive graphic-based display of clinical pathology laboratory data

In this age of ever-increasing demands for and uses of patient data, technologic advancements in the form of electronic patient records permit improved data access and prompt retrieval of higher quality patient care data, with more versatility in display, facilitating the integration of information concerning patients over time and between settings of care, which is in turn more accessible for use by practitioners and provides more efficient and effective decision support in areas of patient care. The graphic display of laboratory data is central to the evolving computerized patient record and needs to be taken into careful consideration along with clinician perception and ease of data interpretation in redesigning the graphic reporting of numeric clinical pathology laboratory data. An ideal system should generate user-friendly, graphic-based comprehensive reports highlighting abnormalities with trends for diagnosis, clinical management, and risk-factor detection.     

Statistical disclosure control architectures for patient records in biomedical information systems

Patient record data are potentially highly sensitive and their secondary use raises both ethical and data protection issues. Disclosure of patient data could cause serious difficulties for the medical profession and be potentially damaging for individual patients and clinicians. Yet at the same time patient records are a hugely valuable resource in terms of clinical research and patient treatment. A secure, remote access system for such data would therefore provide numerous benefits. In this paper we outline the statistical disclosure risks posed by patient record data in the context of establishing a grid based medical data repository. We review good practice in existing patient databases, outline a scenario model for assessing risk and suggest a new model for statistical disclosure control of patient data. The architecture and the research method we have described have general relevance for any remote data access system where maximizing both data utility and security is a priority, and has specific relevance to medical data and bioinformatics. It can straightforwardly be integrated into data access and analysis tools.     

Determining priorities for change in primary care: the value of practice-based needs assessment.

BACKGROUND: Primary care is being expected to expand the range of services it provides, and to take on many of the tasks traditionally provided in secondary care. At the same time, general practitioners (GPs) will become increasingly responsible for assessing their patients' health care needs and commissioning care from other providers. This article describes an approach taken in one general practice to meet these difficult challenges. AIM: To examine whether information on health and health care needs, when used as the basis for a priority setting exercise, can provide a useful first step in planning primary care provision within a practice. METHOD: A three-stage process of information-gathering from a number of sources, including continuous data recording of patient contacts and a postal survey of all adults registered with the practice, identification of key findings and discussion of associated issues, and priority setting of proposals for practice development using the nominal group technique. RESULTS: Continuous data recording of patient contacts with GPs and the practice nurse provided data on 4489 GP contacts with 2027 patients, 1000 district nurse contacts with 101 patients, and 361 health visitor contacts with 172 clients. More than 70% of patient records had been computerized, with 600 diagnostic READ codes identified and 11,500 separate entries made. The socioeconomic and health survey questionnaire achieved an 84% response rate. Following the priority-setting exercise, 28 proposed practice developments were identified. These were reduced to a final list of eight. CONCLUSION: A comprehensive method of practice-based needs assessment, when used as the basis for some form of priority setting, has great potential in helping to plan primary care services within a practice. The success of such initiatives will require a substantial investment of resources in primary care and fundamental changes to the way in which primary care is funded.     

Design and Implementation of Disaster Recovery and Business Continuity Solution for Radiology PACS

In the digital era of radiology, picture archiving and communication system (PACS) has a pivotal role in retrieving and storing the images. Integration of PACS with all the health care information systems e.g., health information system, radiology information system, and electronic medical record has greatly improved access to patient data at anytime and anywhere throughout the entire enterprise. In such an integrated setting, seamless operation depends critically on maintaining data integrity and continuous access for all. Any failure in hardware or software could interrupt the workflow or data and consequently, would risk serious impact to patient care. Thus, any large-scale PACS now have an indispensable requirement to include deployment of a disaster recovery plan to ensure secure sources of data. This paper presents our experience with designing and implementing a disaster recovery and business continuity plan. The selected architecture with two servers in each site (local and disaster recovery (DR) site) provides four different scenarios to continue running and maintain end user service. The implemented DR at University Hospitals Health System now permits continuous access to the PACS application and its contained images for radiologists, other clinicians, and patients alike.     

Medical support system for continuation of care based on XML web technology.

In this paper, the implementation of an Internet-based telematic service for medical support is presented, which was developed and operated in pilot form within the INTRANET HEALTH CLINIC project--a 2-year project supported by the European Commission under the Health Telematics Programme. The aim of the application is to offer high quality care to users of health services over inexpensive communication pathways, using Internet-based, interactive communication tools, like remote access to medical records and transmission of multimedia information. The XML technology was employed to achieve customised views on patient data, according to the access rights of different user profiles. Strict security and access control policy were implemented to ensure secure transmission of medical data through the Internet. The system was designed to collaborate with existing clinical patient record systems and to be adjustable to different medical applications. Current implementations include the fields of Oncology, Lupus Erythrematosis, Obstetrics and Chronic Obstructive Pulmonary disease. The results of the pilot operation with oncological patients in Greece were encouraging, so that the refining of the system and its expansion to a large number of patients is already in progress.     

Necessity of clinical decision support system created by medical staff

To support patient safety, we have established a new system that collates medical facility clinical records, examination results and orders, and implementation information comprehensively in real time, checks for consistency and validity, and sends warnings to the appropriate people at the appropriate time. Because our system actually corrects inaccurate operation information, it is different from most existing facilities for patient safety in that it reconstructs information independently from the HIS (Hospital Information System). We were permitted to send warning messages not only to the doctor who entered the orders, but also to the chief of medical staff and team members. For the warning method, we tried screen flashes and chimes, mobile phone messages, and high quality interactive voice responses. We also investigated the degree of message usefulness. Therein, by not relying on "authenticity" and "readability," but by exhaustively collecting and appropriately revising in alignment with the use of information, we have created an original system that collects accurate information. This original system was established by medical staff members. The appropriate revisions mentioned herein are items which meticulously reflect the medical professional's comments and selected operation and signify why a "Clinical Decision Support System created by medical staff" is necessary.     

Towards patient-related information needs

The quality of health care depends, among other factors, on the quality of a physician's domain knowledge. Since it is impossible to keep up with all new findings and developments, physicians usually have gaps in their domain knowledge. To handle exceptional cases, access to the full range of medical literature is required. The specific literature needed for appropriate treatment of the patient is described by a physician's information need. Physicians are often unaware of their information needs. To support them, this paper presents a first step towards automatically formulating patient-related information needs. We start investigating how we can model a physician's information needs in general. Then we propose an approach to instantiate the model into a representation of a physician's information needs using the patient data as stored in a medical record. Our experiments show that this approach is feasible. Since the number of formulated patient-related information needs is rather high, it has to be reduced. To reduce the number of formulated information needs we propose the use of additional knowledge. Four types of knowledge are discussed, viz. (a) knowledge about temporal aspects, (b) domain knowledge, (c) knowledge about a physician's specialism, and (d) a user model. Future research has to clarify which type of knowledge (or combination thereof) is most appropriate for our purpose. It is expected that the resultant set of information needs will have a manageable size and contributes to the quality of health care.     

Securing interoperability between chip card based medical information systems and health networks.

Health information systems supporting shared care are going to be distributed and interoperable. Dealing with sensitive personal medical information, such information systems have to provide appropriate security services, allowing only authorised users restricted access rights to the patients' data according to the 'need to know' principle. Especially in healthcare, 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. The DIABCARD project aims at 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(2) project, communication and application security services needed are provided like strong authentication as well as the derived services such as authorisation, access control, accountability, confidentiality, etc. The solution is based on Health Professional Cards and Trusted Third Party services. In addition to the secure handling of the patient's chip card and data in DIABCARD workstations, the secure communication between these workstations and related departmental systems has been implemented. Based on the results of this feasibility study, an enhanced security services specification for the DIABCARD example of a CCMIS is provided which will be implemented in the framework of a health network being established in the German federal state Bavaria. Beside the preferred solution of a combination of Patient Identification Card and Patient Data Card, lower level alternatives using card-verifiable certificates are explained in some details. 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.     

Technology assessment in medicine. The role of the American Medical Association

Public policy decisions about health care and decisions about an individual patient's care are only as sound as the data and information on which they are founded. The formal systematic evaluation of the safety, effectiveness, and cost-effectiveness of a medical technology provides such information and is essential to the appropriate application of technology in patient care. The American Medical Association (AMA) historically has recognized the need for the practicing medical community to develop and communicate accurate and balanced evaluative information to physicians and other health care professionals. In recent years, the association has established formal programs to accomplish this objective. This article describes the AMA's three major assessment programs, the Diagnostic and Therapeutic Technology Assessment program, the Council on Scientific Affairs, and AMA Drug Evaluations. The implications of these activities for patient care and public policy are discussed.     

Security Middleware Infrastructure for DICOM Images in Health Information Systems

In health care, it is mandatory to maintain the privacy and confidentiality of medical data. To achieve this, a fine-grained access control and an access log for accessing medical images are two important aspects that need to be considered in health care systems. Fine-grained access control provides access to medical data only to authorized persons based on priority, location, and content. A log captures each attempt to access medical data. This article describes an overall middleware infrastructure required for secure access to Digital Imaging and Communication in Medicine (DICOM) images, with an emphasis on access control and log maintenance. We introduce a hybrid access control model that combines the properties of two existing models. A trust relationship between hospitals is used to make the hybrid access control model scalable across hospitals. We also discuss events that have to be logged and where the log has to be maintained. A prototype of security middleware infrastructure is implemented.     

A security architecture for interconnecting health information systems

Several hereditary and other chronic diseases necessitate continuous and complicated health care procedures, typically offered in different, often distant, health care units. Inevitably, the medical records of patients suffering from such diseases become complex, grow in size very fast and are scattered all over the units involved in the care process, hindering communication of information between health care professionals. Web-based electronic medical records have been recently proposed as the solution to the above problem, facilitating the interconnection of the health care units in the sense that health care professionals can now access the complete medical record of the patient, even if it is distributed in several remote units. However, by allowing users to access information from virtually anywhere, the universe of ineligible people who may attempt to harm the system is dramatically expanded, thus severely complicating the design and implementation of a secure environment.This paper presents a security architecture that has been mainly designed for providing authentication and authorization services in web-based distributed systems. The architecture has been based on a role-based access scheme and on the implementation of an intelligent security agent per site (i.e. health care unit). This intelligent security agent: (a) authenticates the users, local or remote, that can access the local resources; (b) assigns, through temporary certificates, access privileges to the authenticated users in accordance to their role; and (c) communicates to other sites (through the respective security agents) information about the local users that may need to access information stored in other sites, as well as about local resources that can be accessed remotely.     

Psychotherapy in Australia: clinical psychology and its approach to depression

In Australia, clinical psychology training is dominated by cognitive and behavioral treatments (CBTs), although there is exposure to other theoretical orientations. Since 2001, over 20% of general medical practitioners (GPs) have received training in CBT, and psychiatry training increasingly incorporates CBT elements. Psychotherapy by medical practitioners is financially supported by universal health care funding with supplementation by patients and their private health insurance. Federally funded health benefits for up to 12 psychology consultations per year are provided on referral from GPs and psychiatrists, and initial takeup has been very strong. Mrs. A would be a typical patient for such a referral. However, she would not fulfill criteria for priority access from state-funded mental health services. Mrs. A would probably consult a GP and receive antidepressants, although she may also access a range of other community support programs. Access to and acceptance of psychotherapy would be greater in urban areas, and if she were of Anglo-Saxon and non-indigenous origin.     

Sharing patient care records over the World Wide Web

In order to obtain appropriate medical care, patients can be referred or transported from one hospital to another based on the capacity, capability and quality of medical care provided by hospitals. Therefore, enabling patient care records to be shared among hospitals is essential not only in delivering the quality of medical care services but also in saving medical expenses. Currently, most patient care records are paper-based and not well organized. Hence, they are usually incomplete and can hardly be accessed in time. The authors in this paper present methods to structure and represent patient care records, design mechanisms for interpreting and integrating the XML-based patient care records into the existing hospital information systems. More importantly, in our approach, each significant piece of medical record is associated with a tag based on the syntax and semantics of the XML. The XML-based medical records enable a computer to capture the meaning and structure of the document on the web. The authors have developed a unified referral information system in which patient care records can be shared among hospitals over the Internet. It can not only facilitate the referral process but also maintain the integrity of a patient's medical record from distributed hospitals. The workflow of the system basically follows the existing manual system and can easily be adapted. The working group on integration of municipal hospital information systems, Department of Health, Taipei City Government, has decided to adapt this system for referral practice among the municipal hospitals.     

Care partners reading patients’ visit notes via patient portals: Characteristics and perceptions

BackgroundCare partners are key members of patients’ health care teams, yet little is known about their experiences accessing patient information via electronic portals.ObjectiveTo better understand the characteristics and perceptions of care partners who read patients’ electronic visit notes.Patient involvementFocus groups with diverse patients from a community health center provided input into survey development.MethodsWe contacted patient portal users at 3 geographically distinct sites in the US via email in 2017 for an online survey including open ended questions which we qualitatively analyzed.ResultsRespondents chose whether to answer as care partners (N = 874) or patients (N = 28,782). Among care partner respondents, 44% were spouses, 43% children/other family members, and 14% friends/neighbors/other. Both care partners and patients reported that access to electronic notes was very important for promoting positive health behaviors, but care partners’ perceptions of importance were consistently more positive than patients’ perceptions of engagement behaviors. Open-ended comments included positive benefits such as: help with remembering the plan for care, coordinating care with other doctors, decreasing stress of care giving, improving efficiency of visits, and supporting patients from a geographical distance. They also offered suggestions for improving electronic portal and note experience for care partners such as having a separate log on for care partners; having doctors avoid judgmental language in their notes; and the ability to prompt needed medical care for patients.DiscussionCare partners value electronic access to patients’ health information even more than patients. The majority of care partners were family members, whose feedback is important for improving portal design that effectively engages these care team members.Practical valuePatient care in the time of COVID-19 increasingly requires social distancing which may place additional burden on care partners supporting vulnerable patients. Access to patient notes may promote quality of care by keeping care partners informed, and care partner’s input should be used to optimize portal design and electronic access to patient information.     

Medical information privacy and the conduct of biomedical research.

Profound changes in the health care delivery system, the increasing pervasiveness of information technology, and dramatic advancements in research in human genetics are intensifying public concerns about the privacy of medical information. The author argues that some of these concerns, such as the fear that medical data could be used to deny health insurance or employment, are "pragmatic" and can be dealt with through the political process. But other, "ideologic" concerns tend to generate strong emotions and political positions that impede rational discourse and confound attempts to seek workable compromises. He stresses that the progress of medicine has long depended on studies of collections of empirical data about individuals, and discusses the federal oversight of research involving human subjects, including provisions in place to protect their privacy and maintain the confidentiality of data while at the same time permitting necessary access to data for research. He suggests that since every individual benefits from the accumulated medical knowledge base, everyone should contribute to the ongoing expansion and renewal of that base. The author then states nine principles crafted at the Association of American Medical Colleges to guide its thinking and advocacy efforts regarding medical-information privacy issues. (For example, "the free flow of identifiable medical information within the boundaries of the health care system is essential to the optimum provision of patient care and its payment.") He acknowledges that the flows and uses of identifiable patient information within our complex health care and research systems are bewildering and hard to explain to the public, which is deeply concerned about privacy in general, and especially medical information privacy. How to address this concern and at the same time protect the completeness, accuracy, and integrity of the medical record? The author offers no specific answers beyond those embodied in the AAMC principles, but maintains that a satisfactory solution will come only from carefully crafted federal legislation that creates a comprehensive, uniform, and effective system of workable protections of the confidentiality of medical information, while protecting the access needed to puruse the nation's ambitious agenda in health research.