电子病历的法律效力

在系统考察国外电子病历法律研究和我国电子病历立法现状的基础上，将纸质病历的基本功能分解为11项，并根据纸质病历的特点，运用功能等同法，探讨了通过电子信息技术实现这些功能的可能性。认为，数据电文的合法性在联合国《电子商务示范法》和我国《合同法》中都已作出明确的规定，电子病历虽然与电子合同在很多方面存在差异，但本质上都具有无纸化这一共同的特点，因此，由数据电文构成的电子病历也应当能够替代纸质病历。     

实行专科医生准入制度的初步探讨

通过回顾和比较国外专科医生准入制度的发展历史，分析，总结了有关专科医生准入制度的实施要点，并就我国目前的现状和实施该制度的迫切性可行性进行剖析。认为：政府，行业学会，医疗保险机构三者之间的紧密合作与分工是建立和实施这一制度的必要前提，我国在教育，人事，保险等相关领域的配套,进构建实施这一制度所必需的要素和条件。     

Medical evaluation of work-related illness: evaluations by a treating occupational medicine specialist and by independent medical examiners compared

Treating physicians' and independent medical examiners' (IMEs') opinions were compared to identify differences of opinion and to develop a basis for understanding the differences. Twenty-three patients of an occupational health center (OHC) who had been examined by an IME were studied. OHC and IME opinions regarding diagnosis, work-relatedness, treatment recommendations, and disability assessment were categorized by degree of agreement. There was agreement on all four issues for only one patient. Opinions were most divergent with regard to disability assessment and least divergent with regard to diagnosis. Disagreement was unidirectional: the IMEs made fewer diagnoses, deemed fewer illnesses work-related, made fewer treatment recommendations, and assessed lower levels of disability than the OHC examiners. The results suggest that differences in opinion between the OHC and IMEs are due to differences in perspective, rather than skill or training.     

Waiting times in specialist medical care

Waiting times in specialist medical care are difficult to reduce owing to the fast-growing demand with supply lagging behind. These waiting times were the subject of a conference of this Journal, where experts from different backgrounds assessed the problems and discussed promising ways of coping with them at micro, meso and macro level. In the first category, a system developed in Leiden University Medical Centre was presented that provides insight into the expected waiting time per disease category, elucidates the bottlenecks in practice and supports the quality of care and the planning of patient flows. At the meso level, the discussion addressed how the differences within and between institutions and within and between regions may be reduced; this may be done, for instance, by better spread of the work load. This offers a better contribution to a structural solution than extra-regular initiatives. The conference finally discussed the importance of the current shift of important (control) tasks from the government to insurers. Those present expected that stimulation of regional initiatives of hospitals and health insurers by means of more money and latitude, allocated by the government and under its control (inspection), offers the best opportunities to shortening of the waiting lists and improvement of the quality of care.     

The anencephalic newborn: medical/legal and bioethical issues

Anencephaly, a severe congenital malformation, is frequently associated with other malformations not involving the central nervous system. Diagnosis is usually antenatal and expectation of life is very short. This article reviews noted cases reported in the past two decades, examines bioethical opinions, as well as ethical and medico-legal questions in relation to current Italian law, including medical professional responsibility and the 'slippery slope' of issues concerning the anencephalic newborn as organ donor.     

The teaching of legal medicine in British medical schools

In view of recent public anxiety concerning possible inadequacies in the field of legal medicine and ethics, a questionnaire survey was made of medical students, newly qualified housemen, medical school deans, coroners and medical defence and protection organizations. The results indicate that the teaching of legal medicine and ethics is insufficient, and a recommendation is made for an increase in such teaching.     

“医海”无崖“终极方法”非终极——阜外心血管病医院胡盛寿院长谈药物缓释支架

心血管疾病已经成为威胁人类健康的头号杀手。自上世纪初开始,人们就为治疗冠心病进行着不懈地努力,人类最初从缓解症状来解决其带来的痛苦,之后逐渐发展出手术根治和球囊支架治疗等手段。顺应当今科技发展潮流,药物缓释支架应运而生。人们一时沉浸于找到治疗冠心病"终极方法"的喜悦之中,一夜之间掀起了药物缓释支架治疗的热潮。但是,随着药物支架的大量使用,术后心脏不良事件暴露和增加引起了国内外医生和患者的广泛关注。     

Brain death: medical and legal issues

Irreversible cessation of brain function has become a widely accepted criterion of death. Case law, state statutes, and medical opinion, backed by clinical studies, all support the use of brain death criteria as a means of determining death. Current state statutes are in need of some uniformity, as 12 different statutory approaches to brain death are currently in use. Brain death should not be confused with the still unresolved issue of termination of life support to terminally ill, mentally incompetent patients, or those who are comatose yet do not meet brain death criteria.     

Emergency room triage by a medical specialist

This is an investigation of the impact of an emergency room triage by a medical specialist. The study encompassed patients who came to the medical section of the emergency room of a large university hospital during a two-week study period and a control period of the same length. The result showed that 36% of the patients could be sent home after the triage, thereby reducing the number of chemical tests and ECG examinations significantly (p less than 0.001). In addition, the patient's average treatment period was shortened by a mean of 63 min. No effect of the triage on hospital use of out-patient visits to the hospital during a one year follow-up period was noted. The triage procedure was safe for, and accepted by the patients, as was demonstrated by follow-ups involving investigation of the death register and personal interviews. The study shows that triage by a specialist is an effective method for reducing hospital service utilization and shortening patient treatment time.     

Cost-control and medical specialist payment: the Dutch alternative

The fee-for-service system is a growing problem for insurers and governments. The main reason for this is the open-ended character of this system which makes cost-control a very difficult task. The pressures on the fee-for-service system are becoming more pronounced, especially in countries such as Canada, Germany and the Netherlands which use budget restrictions on national health care expenditure (macro caps). In these countries policy makers are searching for an alternative payment system and an appropriate definition of a corresponding status for doctors. The alternative, however, does not have to lead automatically to a salaried status of doctors in the hospital organization. The Dutch experience of the change of the payment system for medical specialists illustrates the transition to a new 'negotiated order'. The introduction of the 'lump sum' and the sub-contractor relationship with the insurance companies leaves the organizational autonomy of medical specialists intact. In exchange the medical specialists cooperate with the insurers in trying to control the costs of health care. In this process of strategic change, two factors are very significant, i.e. the new leadership of the local medical specialists and the governmental 'circumvention' of the powerful associations of doctors and insurers.     

The independent relations of both residential self-selection and the environment to physical activity

Residential self-selection is supposed to bias the relation between residential environments and physical activity, but empirical analyses are still rare. This study examines the association while simultaneously considering the effect of residential self-selection criteria. One thousand two hundred and forty-five German students were asked to report their physical activity, their perceived environment, and their reasons for choosing their neighbourhood. Structural equation modelling was employed. Reasons for choosing a neighbourhood were related to actual environmental characteristics. Utilitarian reasons were related to less physical activity, hedonic reasons were related to higher physical activity. The street network was related to higher physical activity independent of residential self-selection. Our results support the weight of both individual preferences and the street network on physical activity. The residential environment has an impact on people’s amount of physical activity regardless of their reasons for choosing a neighbourhood and should therefore be considered a resource in health prevention and promotion.