When health technologies do not reach their effectiveness potential: a health service research perspective

This paper tries to unravel the following question: why do we sometimes obtain results that are worse than expected despite having used technologies that are provenly efficacious or effective and having eliminated major groups of causes leading to poor performance? Inductive analysis and synthesis based on nine areas of health service research show that to effectively adopt some health technologies, it is not enough to simply choose an efficacious or effective change strategy. It sometimes becomes necessary to change the behavior of the health workers that will use it, and to modify certain environmental elements. Technology's effectiveness also depends on intervening simultaneously at various levels. Using a mix of evidence-based change (multifaceted) strategies is often mandatory. Improving health service calls for permanent, not sporadic, efforts; for ensuring universal access to information, and for adopting regulations to prevent poor or potentially harmful service delivery. A portion of the service improvements that have been attained have resulted from the use not of isolated change measures, but of combinations of the most effective measures as part of a single integrated intervention. To further reduce the gap between observed and expected effectiveness we should pilot behavior change strategies before adopting some health technologies, and to permanently install in our health system the multifactorial, integrated technology adoption mechanisms that we still lack. Failure to do this will mean being inefficient and pursuing short-term results at the expense of feasible and legitimate medium-term objectives.     

Transforming paradigms for provider information systems

Developments in health care information systems are being driven by the changing health care market environment as well as the availability of enhanced communication and computer technologies. These developments represent basic shifts in traditional paradigms on which provider information systems are based. The ultimate success of providers will depend on their making fundamental changes in the use of information systems to support new and evolving incentive systems, organizational structures, and market expectations.     

Health and social care costs for young adults with epilepsy in the UK

Maintaining contact with services will help improve clinical and social outcomes as children with epilepsy move into their adult lives. This study has collated evidence on the extent to which young adults with epilepsy are supported by health and social care services posttransition, and the costs of such support. UK prevalence and service use data were taken from policy and research literature, as well as national data sets and reports. Costs were attached to these data to arrive at agency and overall total costs. There are approximately 42 000 young adults (18–25 years) with epilepsy costing the UK health and social care budgets £715.3 million per annum, on average £17 000 per young adult with epilepsy. A further £61 million falls to the social security budget. Most young adults with epilepsy will rarely use these services, but those with additional health needs have high and often long‐term support needs, including supported accommodation and personal care. Current resources used by these young adults are summarised but deficits in service availability can mean long waiting times and sub‐optimal treatment. Young adults also want more support to help them take advantage of education and employment opportunities and more information about managing the impacts of epilepsy on their lives. Improving services will cost money, but has the potential to lead to better outcomes for young adults.     

MEASURING PATIENTS' EXPERIENCED QUALITY OF LIFE: THE APPLICATION OF CONTENT ANALYSIS SCALES IN HEALTH CARE

Several scales that are useful in research concerning patients' experienced (as distinct from observed) quality of life have been developed. They use content analysis and so can be applied to any recorded verbal communication from individual patients. They provide indices of psychoanalysis-based concepts of anxiety and hostility, as well as of positive feelings. Whether patients experience themselves as helpless or in control of a situation and whether patients experience themselves as having social support—phenomenology-based concepts—are also measured. Some examples of applications of these scales in health care are given together with data from 381 patients and ex-patients. Uses of the scales include obtaining information about common patterns of patient experiences, psychologically “at risk” patients, factors which precipitate surgery visits and patients' reaction to specific illnesses and treatments. They can also be employed in evaluations of rehabilitation, treatment and prevention programs.     

Towards a wireless patient: chronic illness, scarce care and technological innovation in the United Kingdom

'Modernization' is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a pound sterling 6 billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of 'innovation' and to the ways that these shifts define a move away from notions of technological advance towards management control.     

Medical technologies,nonhuman aids,human assistance,and environmental factors in the assessment of health states

Researchers have developed various health state measures to capture the value of living well. They have reached a consensus that health state measures focus on functionality and general symptoms. One can assess functionality and general symptoms with or without medical technologies (for example, medication, laser surgery, or a pacemaker), nonhuman aids (for example, glasses or a wheelchair), human assistance (for example, the help of another person), and accommodating environmental factors (for example, a barrier-free physical environment). Researchers have paid little attention to these distinctions. In this paper, I discuss why such distinctions are important and explore what implications they have for the construction and application of health state measures. I use the Health Utilities Index Mark 3 (HUI) and the health state measure in the World Health Survey (WHS) as examples of pioneer measures that explicitly acknowledge different levels of functionality and general symptoms. I conclude that the inclusion of medical technologies and nonhuman aids in the assessment of health is reasonable, but not human assistance or accommodating environmental factors. While this conclusion is in line with the HUI and WHS, I discuss a rationale for this boundary and make further suggestions regarding scoring of health states.     

Halogenated flame retardants: do the fire safety benefits justify the risks?

Since the 1970s, an increasing number of regulations have expanded the use of brominated and chlorinated flame retardants. Many of these chemicals are now recognized as global contaminants and are associated with adverse health effects in animals and humans, including endocrine and thyroid disruption, immunotoxicity, reproductive toxicity, cancer, and adverse effects on fetal and child development and neurologic function. Some flame retardants such as polybrominated diphenyl ethers (PBDEs) have been banned or voluntarily phased out by manufacturers because of their environmental persistence and toxicity, only to be replaced by other organohalogens of unknown toxicity. Despite restrictions on further production in some countries, consumer products previously treated with banned retardants are still in use and continue to release toxic chemicals into the environment, and the worldwide use of organohalogen retardants continues to increase. This paper examines major uses and known toxic effects of commonly-used organohalogen flame retardants, replacements for those that have been phased out, their combustion by-products, and their effectiveness at reducing fire hazard. Policy and other solutions to maintain fire safety while reducing toxicity are suggested. The major conclusions are: (1) Flammability regulations can cause greater adverse environmental and health impacts than fire safety benefits. (2) The current options for end-of-life disposal of products treated with organohalogens retardants are problematic. (3) Life-cycle analyses evaluating benefits and risks should consider the health and environmental effects of the chemicals, as well as their fire safety impacts. (4) Most fire deaths and most fire injuries result from inhaling carbon monoxide, irritant gases, and soot. The incorporation of organohalogens can increase the yield of these toxic by-products during combustion. (5) Fire-safe cigarettes, fire-safe candles, child-resistant lighters, sprinklers, and smoke detectors can prevent fires without the potential adverse effects of flame retardant chemicals. (6) Alternatives to organohalogen flame retardant chemicals include using less flammable materials, design changes, and safer chemicals. To date, before evaluating their health and environmental impacts, many flame retardant chemicals have been produced and used, resulting in high levels of human exposure. As a growing literature continues to find adverse impacts from such chemicals, a more systematic approach to their regulation is needed. Before implementing new flammability standards, decision-makers should evaluate the potential fire safety benefit versus the health and environmental impacts of the chemicals, materials, or technologies likely to be used to meet the standard. Reducing the use of toxic or untested flame retardant chemicals in consumer products can protect human and animal health and the global environment without compromising fire safety.     

Zoning, equity, and public health.

Zoning, the most prevalent land use planning tool in the United States, has substantial implications for equity and public health. Zoning determines where various categories of land use may go, thereby influencing the location of resulting environmental and health impacts. Industrially zoned areas permit noxious land uses and typically carry higher environmental burdens than other areas. Using New York City as a case study, the author shows that industrial zones have large residential populations within them or nearby. Noxious uses tend to be concentrated in poor and minority industrial neighborhoods because more affluent industrial areas and those with lower minority populations are rezoned for other uses, and industrial zones in poorer neighborhoods are expanded. Zoning policies, therefore, can have adverse impacts on public health and equity. The location of noxious uses and the pollution they generate have ramifications for global public health and equity; these uses have been concentrated in the world's poorer places as well as in poorer places within more affluent countries. Planners, policymakers, and public health professionals must collaborate on a worldwide basis to address these equity, health, and land use planning problems.     

The NIEHS Environmental Health Sciences Data Resource Portal: placing advanced technologies in service to vulnerable communities

BACKGROUND: Two devastating hurricanes ripped across the Gulf Coast of the United States during 2005. The effects of Hurricane Katrina were especially severe: the human and environmental health impacts on New Orleans, Louisiana, and other Gulf Coast communities will be felt for decades to come. The Federal Emergency Management Agency (FEMA) estimates that Katrina's destruction disrupted the lives of roughly 650,000 Americans. Over 1,300 people died. The projected economic costs for recovery and reconstruction are likely to exceed $125 billion. OBJECTIVES: The NIEHS (National Institute of Environmental Health Sciences) Portal aims to provide decision makers with the data, information, and the tools they need to a) monitor human and environmental health impacts of disasters; b) assess and reduce human exposures to contaminants; and c) develop science-based remediation, rebuilding, and repopulation strategies. METHODS: The NIEHS Portal combines advances in geographic information systems (GIS), data mining/integration, and visualization technologies through new forms of grid-based (distributed, web-accessible) cyberinfrastructure. RESULTS: The scale and complexity of the problems presented by Hurricane Katrina made it evident that no stakeholder alone could tackle them and that there is a need for greater collaboration. The NIEHS Portal provides a collaboration-enabling, information-laden base necessary to respond to environmental health concerns in the Gulf Coast region while advancing integrative multidisciplinary research. CONCLUSIONS: The NIEHS Portal is poised to serve as a national resource to track environmental hazards following natural and man-made disasters, focus medical and environmental response and recovery resources in areas of greatest need, and function as a test bed for technologies that will help advance environmental health sciences research into the modern scientific and computing era.     

Utilization of technology and communication technologies (TIC) in public health

The development of information and communications technologies (ICT) and Internet offers public health practitioners new tools to fulfill their missions of monitoring public health, health promotion and disease prevention, and public health protection. In recent years, new applications and practices in public health using these technologies have emerged, particularly in the area of communication among practitioners and transmission of information to the population. This article aims to give an overall view of the use of ICT in public health and to discuss the impact of these technologies on public health practices. The discussion is centred around the implications of using these new technologies: implications with regard to the new possibilities provided by these technologies, but also with regard to the difficulties involved in their use as well as issues related to unequal access and ethics. Finally, the question of the evaluation of these technologies and of their impact on public health is discussed.     

Use of health information in air pollution health research: past successes and emerging needs

In September 2006, the US Environmental Protection Agency and the US Centers for Disease Control (CDC) co-organized a symposium on "Air Pollution Exposure and Health." The main objective of this symposium was to identify opportunities for improving the use of exposure and health information in future studies of air pollution health effects. This paper deals with the health information needs of such studies. We begin with a selected review of different types of health data and how they were used in previous epidemiologic studies of health effects of ambient particulate matter (PM). We then examine the current and emerging information needs of the environmental health community, dealing with PM and other air pollutants of health concern. We conclude that the past use of routinely collected health data proved to be essential for activities to protect public health, including the identification and evaluation of health hazards by air pollution research, setting standards for criteria pollutants, surveillance of health outcomes to identify incidence trends, and the more recent CDC environmental public health tracking program. Unfortunately, access to vital statistics records that have informed such pivotal research has recently been curtailed sharply, threatening the continuation of the type of research necessary to support future standard setting and research on emerging exposure and health problems (e.g. asthma, multiple sclerosis, diabetes, and others), as well as our ability to evaluate the efficacy of regulatory and other prevention activities. A comprehensive devoted effort, perhaps new legislation, will be needed to address the standardization, centralization, and sharing of data sets, as well as to harmonize the interpretation of confidentiality and privacy protections across jurisdictions. These actions, combined with assuring researchers and public health practitioners appropriate access to data for evaluation of environmental risks, will be essential for the achievement of our environmental health protection goals.     

Graduate education in health decision support systems (HDSSs): reconfiguring the health information system (HIS) basket or putting HDSS Humpty Dumpty together again?

Building on previous discussions in graduate health information system (HIS) education, this article focuses on the design of a course in health decision support systems (HDSSs). The goal here is not simply to add to existing prospectives of HIS theories and methodologies, but to prepare these students for changing trends in HIS technologies and applications and for new challenges in HIS administration and impacts arising from these emerging, more advanced, and complex technologies. Specifically, advancing HDSS technology: (1) promises to close the gap between theory and practice, (2) creates a new perspective for the application of information technologies in health care organizations, and (3) enhances innovations in the management and implementation of health information technologies. This paper highlights the need for graduate education in HDSS domain knowledge and how such knowledge can be taught in preparing students for managing change in the future health care environment.     

Legislation on smoking in enclosed public places in Scotland: how will we evaluate the impact?

BACKGROUND: From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts. METHODS: Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas--knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities. CONCLUSION: The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.     

Personalized exposure assessment: promising approaches for human environmental health research

New technologies and methods for assessing human exposure to chemicals, dietary and lifestyle factors, infectious agents, and other stressors provide an opportunity to extend the range of human health investigations and advance our understanding of the relationship between environmental exposure and disease. An ad hoc Committee on Environmental Exposure Technology Development was convened to identify new technologies and methods for deriving personalized exposure measurements for application to environmental health studies. The committee identified a "toolbox" of methods for measuring external (environmental) and internal (biologic) exposure and assessing human behaviors that influence the likelihood of exposure to environmental agents. The methods use environmental sensors, geographic information systems, biologic sensors, toxicogenomics, and body burden (biologic) measurements. We discuss each of the methods in relation to current use in human health research; specific gaps in the development, validation, and application of the methods are highlighted. We also present a conceptual framework for moving these technologies into use and acceptance by the scientific community. The framework focuses on understanding complex human diseases using an integrated approach to exposure assessment to define particular exposure-disease relationships and the interaction of genetic and environmental factors in disease occurrence. Improved methods for exposure assessment will result in better means of monitoring and targeting intervention and prevention programs.     

The environmental and health impacts of tobacco agriculture,cigarette manufacture and consumption

The health consequences of tobacco use are well known, but less recognized are the significant environmental impacts of tobacco production and use. The environmental impacts of tobacco include tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste. The World Health Organization’s Framework Convention on Tobacco Control addresses environmental concerns in Articles 17 and 18, which primarily apply to tobacco agriculture. Article 5.3 calls for protection from policy interference by the tobacco industry regarding the environmental harms of tobacco production and use. We detail the environmental impacts of the tobacco life-cycle and suggest policy responses.     

Considering quality: engaging consumers to make better health care decisions

On May 19, 2005, Grantmakers In Health (GIH) convened nearly 50 grantmakers and leaders in the field of health care quality to discuss the challenges inherent in developing quality information, as well as how consumers use such information. This Issue Brief examines the potential of consumers to use information to select high-quality health services and to become drivers of quality improvement at the systems level. There are three broadly used mechanisms for connecting consumers to information: report cards on health plans and providers, decision support aides, and the Internet. Health foundations can play an important role in developing and disseminating quality information for consumers. They can support the development of quality indicators; assess the effectiveness of information technology, including the Internet; and fund advocacy efforts to ensure consumers have the information needed to make appropriate health care choices.     

Clinical health information technologies and the role of medicaid

Clinical health information technologies (HIT) are widely viewed as essential tools for improving the quality and efficiency of health care delivery. Medicaid agencies make substantial investments in information technology (IT), have much to gain through the widespread use of clinical HIT, and can have significant influence on the adoption of HIT by providers. Medicaid agencies, however, face legal, regulatory, and financing challenges in relation to supporting HIT adoption, use, standardization, and interoperability. This article summarizes the issues related to Medicaid's participation and support of clinical HIT, and makes recommendations for addressing policy challenges at the State and Federal level.     

Child health implications of worldwide urbanization

The upsurge of urbanization, often poorly planned and uncontrolled, has caused major impacts on human societies for at least two centuries. Urban environments and urbanized lifestyles have strong influences on health and well-being, including on infant and childhood populations in developed and underdeveloped countries, as well as among societies in developmental and environmental transition around the world. Urbanization will inevitably have significant impacts on the health of future generations. Notably, the health consequences of urbanized lifestyles are not confined to residents of cities and large towns but rather are becoming manifest in rapidly changing, previously traditional societies in rural and remote areas because globalization is altering infant feeding practices and the dietary habits and lifestyle patterns of their children. In underdeveloped countries, overcrowding and environmental pollution are huge problems that are exacerbated by undernutrition and infection, particularly respiratory and diarrheal diseases. In developed societies, other problems like injuries; poisonings; violence; drug abuse; exposure to chemical, biological, industrial, and atmospheric pollutants, including pesticides; sexually transmissible diseases; and 'lifestyle' diseases, including obesity and cardiovascular disease risk, are of great current and potential importance.     

Canadian community health centres and the Internet: exploring the challenges and solutions

Community Health Centres (CHCs) across Canada are providing essential health and social services to many communities, and this function is becoming more vital as provinces concentrate on cutting costs and developing more economic and efficient solutions to the current healthcare system. More than 300 of these community-based organizations currently serve upwards to 13% of the Canadian population, providing a wide range of services in an attempt to promote total wellness in their communities. Over one half of all CHCs are located in rural or remote areas. However, despite the apparent need for, and success of, CHCs, they are among the most underserved health provision groups in the country. Many CHCs lack critical funding and resources, particularly in the area of technology. In this Information Age, the health sector is realizing the importance of using information technologies to increase efficiency, improve services, and maintain viability. Community Health Centres, however, often do not have money for even the most basic technologies such as fax machines, let alone computers and Internet access. Community Health Centres in Canada need to be given the tools they need in order to continue providing quality health care to their communities. This article provides an overview of the current situation of CHCs in Canada vis(-)à-vis the Internet and other information technologies. Some of the practical and organizational challenges facing CHCs in this area will be discussed, as well as potential solutions that could and are being developed to overcome these barriers. It is an objective of this article to facilitate information and resource-sharing and the creation of links between CHCs across Canada. Community Health Centres may benefit from better understanding of the implications of these new technologies, discovering ways in which their peers are using the Internet, and communicating with one another in order to begin basic planning and needs assessments. As part of this overview, a brief update on the status of the HealthNet Community Access Pilot will be provided. The HealthNet Community Access Pilot is a collaborative project aimed at educating and providing CHCs across Canada with the tools to help them begin implementing Internet systems and policies within their own context. Part of this grassroots effort involves developing appropriate technical solutions, software, training materials, and support resources to help demystify and simplify the technology. Some of these tools and recommendations will be available at ITCH '96 for use by other CHCs.     

Legislative proposals for reversing the cancer epidemic and controlling run-away industrial technologies.

An interlocking legislative complex is proposed for the control of carcinogenic and other adverse impacts of established run-away petrochemical and radionuclear technologies, with particular reference to winning the losing war against cancer. These proposals are also applicable to the poorly recognized, potentially adverse public health and environmental hazards of emerging technologies, particularly genetically engineered food production. The proposals embody fundamental democratic rights--the right to know and balanced and transparent decision making--the "Precautionary Principle," reduction in the use of toxics, incentives for the development of safe industrial technologies, and criminal sanctions for suppression or manipulation of information.