Benchmarking Electronic Medical Records Initiatives in the US: a Conceptual Model

This article provides a conceptual model for benchmarking the use of clinical information systems within healthcare organizations. Additionally, it addresses the benefits of clinical information systems which include the reduction of errors, improvement in clinical decision-making and real time access to patient information. The literature suggests that clinical information systems provide financial benefits due to cost-savings from improved efficiency and reduction of errors. As a result, healthcare organizations should adopt such clinical information systems to improve quality of care and stay competitive in the marketplace. Our research clearly documents the increased adoption of electronic medical records in U.S. hospitals from 2005 to 2007. This is important because the electronic medical record provides an opportunity for integration of patient information and improvements in efficiency and quality of care across a wide range of patient populations. This was supported by recent federal initiatives such as the establishment of the Office of the National Coordinator of Health Information Technology (ONCHIT) to create an interoperable health information infrastructure. Potential barriers to the implementation of health information technology include cost, a lack of financial incentives for providers, and a need for interoperable systems. As a result, future government involvement and leadership may serve to accelerate widespread adoption of interoperable clinical information systems.     

Redesigning the Medical Office for Improved Efficiency: An Object-Oriented Event-Driven Messaging System

Medical practitioners are under ever increasing pressure to maximize patient care, while minimizing costs. One productivity area that has not previously undergone thorough investigation is the efficient utilization of time for intra-office communication. Medical office personnel typically need to communicate patient information and resource requests, as well as personal messages. An intra-office communication system is designed that reduces time-waste typically incurred in medical office environments. Redesigning medical offices with intra-office communication systems provides time savings of several man hours per day. The subsequent increase in time efficiency enables higher quality of patient care and larger patient loads to be managed by existing medical staff.     

Evaluation of an infrared/radiofrequency equipment-tracking system in a tertiary care hospital

Optimal management of assets in large hospitals is important to both cost control and patient care. A prospective controlled evaluation was conducted to determine whether an asset-tracking system using combined radiofrequency and infrared signals could increase equipment utilization, increase appropriate charge capture, and decrease personnel time spent looking for equipment. Two wards at Duke University Medical Center were randomly assigned as intervention and control. Beds, sequential compression devices (SCDs), and infusion pumps were monitored during a 6-week intervention period, preceded and followed by 6-week control periods. The system's accuracy for detecting equipment, relative to a trained surveyor, was greater than 80%. Accuracy for locating equipment to a specific room was 60–80%. With the system available, we observed increased utilization of infusion pumps but not of beds or SCDs. Nursing staff and system users had positive impressions of the system and its potential. Tracking systems can successfully locate hospital equipment and may improve utilization.     

A large-scale professionally oriented medical information system — Five years later

Success is the word used most often to describe El Camino Hospital's computerized medical information system. Operational since 1972, the system has gained total support from virtually all hospital personnel. Physicians, nurses, and administrative people use the system routinely as part of their day-to-day activities. HEW-sponsored studies have heralded the system for its impact on improving patient care and containing costs. The following paper is an overview of the system from installation to the present. It tells of the vast information available to hospital professionals through simple lightpen selections on a CRT screen, how it handles most manual activities, how it reduces errors, and how it replaces the nurses' Kardex files. Automated systems technology is vital to the future of health care, and it is a valuable tool for enhancing the quality of patient care and improving the use of labor resources. This paper further gives an important insight into other benefits offered to all hospitals by the advent of systems such as the one at El Camino.     

Improving the quality of ambulatory health care with enhanced medical information systems: Using the computer to diagnose faulty clinical processes

The lack of consistency in the performance of the processes which implement clinical decisions is an important problem in ambulatory care. Since delayed or neglected actions in patient care may have serious consequences, we studied the use of industrial quality management techniques to determine where three clinical processes could be improved. These quantitative and graphical tools were useful in showing that in some processes, the failure rate could be as high as 33%. However, lack of readily available process data prevented a full analysis of the extent of the failures, so specific suggestions for improvement could not be made. Medical informatics and management specialists have an important role in designing enhanced medical information systems with which to examine and improve patient care processes. This new generation of MIS's should include order entry systems with flags for selected transactions, audit trails for all automated processes, functional integration of the separate departmental information systems, and enhanced communications features.     

Personal Health Records: Definitions,Benefits, and Strategies for Overcoming Barriers to Adoption

Recently there has been a remarkable upsurge in activity surrounding the adoption of personal health record (PHR) systems for patients and consumers. The biomedical literature does not yet adequately describe the potential capabilities and utility of PHR systems. In addition, the lack of a proven business case for widespread deployment hinders PHR adoption. In a 2005 working symposium, the American Medical Informatics Association's College of Medical Informatics discussed the issues surrounding personal health record systems and developed recommendations for PHR-promoting activities. Personal health record systems are more than just static repositories for patient data; they combine data, knowledge, and software tools, which help patients to become active participants in their own care. When PHRs are integrated with electronic health record systems, they provide greater benefits than would stand-alone systems for consumers. This paper summarizes the College Symposium discussions on PHR systems and provides definitions, system characteristics, technical architectures, benefits, barriers to adoption, and strategies for increasing adoption.     

Foregoing prehospital care: should ambulance staff always resuscitate?

Approximately 400,000 people die outside US hospitals or chronic care facilities each year. While there has been some recent movement towards initiating procedures for prehospital Do Not Resuscitate (DNR) orders, the most common situation in the US is that emergency medical systems (EMS) personnel are not authorized to pronounce patients dead, but are required to attempt resuscitation with all of the modalities at their disposal in virtually all patients. It is unfair and probably unrealistic for EMS personnel to have to make a determination of the validity of a non-standard prehospital DNR order (for example, a living will or a durable power of attorney for health care). Existing prehospital DNR protocols range from being very restrictive in the scope of patients allowed to participate and in their implementation, to those that are more liberal. Potential benefits of prehospital DNR orders include freeing up vital personnel and material for use by those who would more fully benefit, and alleviating the enormous emotional strain on patients, families, EMS personnel, and hospital medical staffs involved in unwanted resuscitations that only prolong the dying process. Given this, prehospital DNR orders present several legal and moral problems. These include proper patient identification, the nature of the document itself, precautions incorporated into a DNR system to prevent misuse, potential liability for EMS and hospital personnel, and potential errors in implementation. Functioning prehospital DNR systems need to include: 1) specific legislation detailing the circumstances in which such a document could be used, the wording of such a document, and protection from liability for those implementing the document's directives; 2) having the currently valid document immediately available to the EMS personnel or base station doctors; and 3) acceptable means of identifying the patient. Relatively few US jurisdictions as yet have a prehospital DNR order system, although it is an idea whose time is overdue. Society's imperative to use available technology has pushed us into a situation where a technique to save those with a potential to continue a meaningful and wanted existence is being used indiscriminately to prolong the agony of death.     

Physician Clinical Communication Systems—An Australian Perspective

Information systems are increasingly being adopted by both community- and hospital-based providers of health care services. A gap is in linkages between carers both within a hospital and between hospitals and community providers. A range of technologies is available to improve communication of patient clinical data and other information. This paper discusses the benefits and challenges of electronic communications and reports on a successful case of physician use of a hospital communication system (information systems, technology, physicians, health care).     

Computerized Physician Order Entry: Helpful or Harmful?

Computerized physician order entry (CPOE) is touted as a major improvement in patient safety, primarily as a result of the Institute of Medicine''s 1999 report on medical errors and the subsequent formation of the “Leapfrog Group” of companies to preferentially direct their employees'' health care to those institutions that install such systems (as part of directives that “Leapfrog” feels will improve patient care). Although the literature suggests that such systems have the potential to improve patient outcomes through decrease of adverse drug events, actual improvements in medical outcomes have not been documented. Installation of such systems could actually increase the number of adverse drug events and result in higher overall medical costs, particularly in the first few years of their adoption.In the last five years, hospitals, including our own, have begun to use computerized systems that require physicians and other health care providers to electronically enter patient care orders.¹ Before this time, only a handful of hospitals used such systems. These computer programs contain algorithms that alert health care providers to potentially harmful therapeutic decisions before orders are processed. The installation of these systems is costly (millions of dollars) and requires major behavioral changes, not only by physicians, but also by the entire health care organization.² In January 2003, Cedars-Sinai Health System in Los Angeles removed its recently installed computerized physician order entry (CPOE) system from use after almost unanimous protest from the medical staff. Why are hospitals and other health care organizations pursuing this avenue at this time? Does the literature support the premise that these systems are beneficial for patient care? Do such systems decrease total health care costs? The answers to these questions are still evolving. In this forum, we address these questions and describe some of the pertinent medical literature on this subject.     

A Mobile Agent Approach for Secure Integrated Medical Information Systems

Different patient-related information in medical organizations is the primary reference for medical personnel diagnosing, treating, and caring patients. With the rapid development of information technology, paper-based medical records have gradually been changed to electronic forms. However, different medical organizations present individual system specifications and data-saving formats so that the medical information of the same patient cannot be exchanged, shared, and securely accessed. In order not to largely change the present medical information systems as well as not to increase abundant costs, Virtual Integrated Medical-information Systems (VIMS) is proposed to assist various hospitals in information exchange. Furthermore, with Mobile Agent, the dispersed medical information can be securely integrated. It presents confidentiality, non-repudiation, source authentication, and integrity in network transmission. Virtual Integrated Medical-information Systems (VIMS) is a virtual electronic integration system combined with Mobile Agent technology. With the features of independence, adaptability, mobility, objectives, and autonomy, Mobile Agent is applied to overcome the problems from heterogeneous systems. With the features, the over-dispersed medical records can be integrated. Moreover, Mobile Agent can ensure the instantaneity and usability of medical records from which doctors can make the most appropriate evaluation and diagnoses. It will avoid the waste of medical resources, such as repetition medication, as well as become the reference of further consultation or health check. Not only can it improve the medical care quality, but it can be provided for medical research.     

Three Decades of Research on Computer Applications in Health Care: Medical Informatics Support at the Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality and its predecessor organizations—collectively referred to here as AHRQ—have a productive history of funding research and development in the field of medical informatics, with grant investments since 1968 totaling $107 million. Many computerized interventions that are commonplace today, such as drug interaction alerts, had their genesis in early AHRQ initiatives.This review provides a historical perspective on AHRQ investment in medical informatics research. It shows that grants provided by AHRQ resulted in achievements that include advancing automation in the clinical laboratory and radiology, assisting in technology development (computer languages, software, and hardware), evaluating the effectiveness of computer-based medical information systems, facilitating the evolution of computer-aided decision making, promoting computer-initiated quality assurance programs, backing the formation and application of comprehensive data banks, enhancing the management of specific conditions such as HIV infection, and supporting health data coding and standards initiatives.Other federal agencies and private organizations have also supported research in medical informatics, some earlier and to a greater degree than AHRQ. The results and relative roles of these related efforts are beyond the scope of this review.Three decades ago, when the federal government''s National Center for Health Services Research and Development began to support research on computer applications in health care, few imagined the impact that information systems and sciences would have on medical care today. For most, the idea of a national clearinghouse of guidelines, available through a computer that sits on a home office desktop, seemed like science fiction. For a few researchers and those supporting their work, however, visions of what could become possible in the management of health care information called for development of computerized systems and the evaluation of their effects on quality, cost, and access to care.The Agency for Healthcare Research and Quality (AHRQ, from 1999) and its predecessor agencies—the National Center for Health Services Research and Development (beginning in 1968) and the Agency for Health Care Policy and Research (from 1989 to 1999)—have a rich history of funding research, development, and evaluation in medical informatics. Although the grant investments since 1968 total only $107 million ($246 million in 2000 dollars), they supported initiatives that have established a research framework for many of the computer applications now being used today.The focus of AHRQ''s early research funding in medical informatics was on acquiring patient care data and communicating patient care management information. The goal was not only to improve the quality of care, but also to achieve reductions in costs and medical personnel resource use by processing data more efficiently. Research aimed at improving communication of information was targeted at what we would call today “getting the right information to the right place at the right time.” The promise of this research was its ability to provide findings that would guide reorganization of care delivery, take advantage of the more rapid communication of necessary information, and reduce manpower needs.¹ Over time, AHRQ''s funding has emphasized the application of health services research methods to evaluations of information technology used in community health settings. This article highlights key accomplishments emerging from AHRQ''s funding that have improved the quality of patient care in studied sites and have the potential to improve health care in all settings.Other federal agencies (such as the National Library of Medicine, the Veterans Health Administration, and the Department of Defense) and private organizations (such as The John A. Hartford Foundation, The Robert Wood Johnson Foundation, and the American Hospital Association) have supported developments in medical informatics, with some having greater research expenditures and earlier histories than AHRQ. Nevertheless, it is the Agency''s contributions to medical informatics that are the focus of this study. The purpose of this article is to provide a historical perspective for understanding the benefits of past research funded by AHRQ that supports health care applications of information technology today and that foreshadows AHRQ''s medical informatics initiatives for the future.     

Short-stay units and observation medicine: a systematic review

OBJECTIVES: To conduct a systematic review of how short-stay observation units (SOUs) affect the efficiency of healthcare delivery and the quality of services provided. DATA SOURCES: MEDLINE, CINAHL, Best Evidence and The Cochrane Library were searched for the period 1 January 1960 to 31 July 2000. STUDY SELECTION: Studies were eligible if published in English and rated at National Health and Medical Research Council evidence levels I, II-1, II-2, or II-3; 12 comparative studies published between 1985 and 1998 met these criteria. DATA EXTRACTION: Data pertaining to clinical outcomes, length of stay, re-presentation rates, emergency department efficiency and costs of care were extracted and evaluated independently. DATA SYNTHESIS: As there was considerable heterogeneity in the patient populations and outcomes, results were summarised rather than subjected to meta-analysis. CONCLUSION: SOUs have the potential to increase patient satisfaction, reduce length of stay, improve the efficiency of emergency departments and improve cost effectiveness. However, SOUs have commonly been implemented alongside new clinical protocols, and it is not possible to distinguish the relative benefits of each. As demand increases, providing effective and cost-efficient care will become increasingly important. SOUs may help organisations that are attempting to streamline patient care while maintaining their quality of service delivery.     

Physicians in health care management: 6. Physician *bytes* computer.

Revolutionary advancements in information technology are improving access to medical information, operational efficiency and clinical effectiveness. Health care facilities and agencies are planning to acquire information systems that will affect clinical and administrative functions. Federal and provincial agencies are beginning to define and collect diverse health care data and integrate them in a national database. As the demand for and access to information grows physicians will be key providers and users. They will have increasing access to critical patient data through clinical information systems; however, their practice patterns, clinical outcomes and resource utilization will also be subject to increasing scrutiny. To ensure appropriate use of technology and information systems, careful planning, selection, implementation and management will be needed. Physicians will require training to use the information and systems effectively. They must also recognize the increasing importance of such systems in delivering and managing health care; they must play a pivotal role in resolving management, information and systems issues and in promoting sound information and management strategies; and they must encourage research and education in medical informatics.     

Information and Communications Technologies Health Projects in Panama: A Systematic Review and their Relation with Public Policies

This paper presents a review about Information and Communications Technologies (ICTs) health projects in Panama. The main contribution is to provide a vision of the situation in Panama, allowing an understanding of the dynamics of health policies and how they have affected the implementation of ICT’s Projects to improve the health of Panamanians. We analyze the projects found with ICT’s in health of Panama, which allow us to see a perspective of projects information is obtained from 2000 to 2016, however it is important to highlight that there may be other projects that we do not know because we did not find enough information or evidence of the same. That is why this review has interviews with key personnel, who have guided us with the search for information. 56% of technology projects are concentrated in the capital city and only 16% in the province of Chiriquí. 64% of these projects are focused on the development of information systems, mainly focused on electronic patient registration. And 60% refers to projects related to primary health care. The MINSA and CSS both with a 20% participation in ICT project, in addition we can notice the dispersion of projects for hospitals, where each one is developing programs per their needs or priorities. The national information about ICT projects of Health, it has been notorious the state of dispersion and segmented of public health information. We consider that it is a natural consequence of Policy in Panamanian Health System. This situation limits the information retrieval and knowledge of ICT in Health of Panama. To stakeholders, this information is directed so that health policies are designed towards a more effective and integral management, administering the ICT’s as tools for the well-being of most the Panamanian population, including indigenous group.     

患者主索引服务在医院信息互联互通中的实现与应用

建立医院患者主索引服务系统,以解决因医院各信息系统内患者信息不一致所导致的医疗数据难以协同共享的问题。为提高医疗质量,强化信息化建设,实现院内外系统互联互通,解决冗余、多态、无主次、无关联、不匹配、紊乱等信息孤岛现象,引入了建立患者主索引技术。本文以漯河中心医院为例,提供一种建立患者主索引的实施方案,详细阐述了该方案在医院信息中应用的技术手段、实现过程和应用效果。该方案保证患者信息的统一性与一致性,实现患者就诊信息在院内各个医疗信息系统中的互联互通,能够帮助医院提高服务质量、节省成本、增加经济效益。     

Can health care teams improve primary care practice?

In health care settings, individuals from different disciplines come together to care for patients. Although these groups of health care personnel are generally called teams, they need to earn true team status by demonstrating teamwork. Developing health care teams requires attention to 2 central questions: who is on the team and how do team members work together? This article chiefly focuses on the second question. Cohesive health care teams have 5 key characteristics: clear goals with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication. Two organizations are described that demonstrate these components: a private primary care practice in Bangor, Me, and Kaiser Permanente's Georgia region primary care sites. Research on patient care teams suggests that teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. In addition, medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes. A number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. Taking small steps toward team development may improve the work environment in primary care practices.     

The Business Value of Health Care Information Technology

The American health care system is one of the world''s largest and most complex industries. The Health Care Financing Administration reports that 1997 expenditures for health care exceeded one trillion dollars, or 13.5 percent of the gross domestic product. Despite these expenditures, over 16 percent of the U.S. population remains uninsured, and a large percentage of patients express dissatisfaction with the health care system. Managed care, effective in its ability to attenuate the rate of cost increase, is associated with a concomitant degree of administrative overhead that is often perceived by providers and patients alike as a major source of cost and inconvenience. Both providers and patients sense a great degree of inconvenience and an excessive amount of paperwork associated with both the process of seeking medical care and the subsequent process of paying for medical services.Traditionally, health practitioners have sought a return to traditional fee-for-service payment to mitigate the inconvenience associated with managed care. More populist proposals include universal health insurance or mandatory enrollment in health maintenance organizations. Advocates of managed care argue that the business methods required for effective trials of this approach are only beginning to be realized. By all accounts, information technology is a necessary part of these initiatives, but there is universal consensus that our current systems are inadequate to the task. (Oxford Health System''s difficulties in 1998, for example, have been attributed in part to inadequate deployment of information technology.) To this author, the model for the current generation of health care information systems is strikingly similar to that for the information systems employed by the Internal Revenue Service. In each case, the system allows for low-cost changes to administrative code brought about by legislation, but in both cases the “ripple effects” of additional complexity and administrative burden far exceed the cost of immediate change. To paraphrase a quotation attributed to Major Richard Dailey, made about his police force during the 1998 Chicago Democratic Convention, our information systems “are not here to create disorder; they are here to preserve disorder.”This case explores one alternative source for models in health care delivery. Through an examination of a typical patient experience, we explore Porter''s notion of the value chain and “just-in-time” logistics common to successful organizations like Wal-Mart and Amazon.com (see Suggested Readings). We close with a brief discussion of how these logistics and inventory systems apply to health care. Clearly, logistics are important in patient care, accounts receivable are a cause of severe working capital problems in health care, and the logistics of caring for patients are becoming more complex. But the concepts we discuss have an even greater importance: Effective management of these issues through information technology may restore our most precious commodity—time.     

Advances in antiplatelet therapy for acute coronary syndromes

Admissions to emergency care centres with acute coronary syndromes remain one of the principal burdens on healthcare systems in the Western world. Early pharmacological treatment in these patients is crucial, lessening the impact on both morbidity and mortality, with the cornerstone of management being antiplatelet agents. While aspirin and clopidogrel have been the drugs of choice for nearly a decade, an array of newer, more potent antiplatelet agents are now available or in late stage development. Data are rapidly gathering suggesting these agents have superior anti-ischaemic properties, improving patient outcomes, but that for some agents increased vigilance and appropriate patient selection may be necessary to guard against bleeding complications. In this review, the authors aim to deliver an overview of the changing field of antiplatelet therapy and provide information about the relative risks and benefits of these newer agents, many of which will be entering widespread clinical use imminently.     

Patient-Care Questions that Physicians Are Unable to Answer

ObjectiveTo describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers.DesignIn a previous study, investigators observed primary care physicians in their offices and recorded questions that arose during patient care. Questions that were pursued by the physician, but remained unanswered, were grouped into generic types. In the present study, investigators attempted to answer these questions and developed recommendations aimed at improving the success rate of finding answers.MeasurementsFrequency of unanswered question types and recommendations to increase the chance of finding answers.ResultsIn an earlier study, 48 physicians asked 1062 questions during 192 half-day office observations. Physicians could not find answers to 237 (41%) of the 585 questions they pursued. The present study grouped the unanswered questions into 19 generic types. Three types accounted for 128 (54%) of the unanswered questions: (1) “Undiagnosed finding” questions asked about the management of abnormal clinical findings, such as symptoms, signs, and test results (What is the approach to finding X?); (2) “Conditional” questions contained qualifying conditions that were appended to otherwise simple questions (What is the management of X, given Y? where “given Y” is the qualifying condition that makes the question difficult.); and (3) “Compound” questions asked about the association between two highly specific elements (Can X cause Y?). The study identified strategies to improve clinical information retrieval, listed below.ConclusionTo improve the chance of finding answers, physicians should change their search strategies by rephrasing their questions and searching more clinically oriented resources. Authors of clinical information resources should anticipate questions that may arise in practice, and clinical information systems should provide clearer and more explicit answers.     

Guidelines for young child feeding in the Caribbean--Part I. Caribbean Food and Nutrition Institute

The guidelines for young child feeding have been developed and prepared as a supportive-tool primarily for health personnel involved in the care of infants and children in Caribbean countries. The recommendations address some practical aspects of nutrition before, during and after pregnancy. These are: The benefits of breastfeeding and strategies for its promotion, protection and support; review of infant feeding options for mothers with HIV and other infections; nutrition of the newborn; feeding of low birth weight infants and those with special requirements; replacement feeding for infants who are not breastfed; complementary feeding with emphasis on the continuation of breastfeeding for two years and beyond; guidelines on vitamin and mineral supplementation; management of feeding-related problems in early childhood; policy issues and nutrition education in relation to the promotion of adequate nutrition in early childhood.