Data warehousing: toward knowledge management

With rapid changes taking place in the practice and delivery of health care, decision support systems have assumed an increasingly important role. More and more health care institutions are deploying data warehouse applications as decision support tools for strategic decision making. By making the right information available at the right time to the right decision makers in the right manner, data warehouses empower employees to become knowledge workers with the ability to make the right decisions and solve problems, creating strategic leverage for the organization. Health care management must plan and implement data warehousing strategy using a best practice approach. Through the power of data warehousing, health care management can negotiate bettermanaged care contracts based on the ability to provide accurate data on case mix and resource utilization. Management can also save millions of dollars through the implementation of clinical pathways in better resource utilization and changing physician behavior to best practices based on evidence-based medicine.     

Community-based integrated care: myth or must?

ISSUE: In spite of the many efforts that have been made to rationalize and improve the functioning and the quality of health care delivery in industrialized countries, too limited a degree of success has been achieved so far. This paper argues that this limited success originates from a lack of coherence among the various strategies and instruments developed to rationalize and improve the delivery of health care. ADDRESSING THE ISSUE: This fact can be shown by reducing the complexity of today's health care into three levels of decision making: the primary process of patient care, the organizational context, and the financing and policy context of health care systems. Distinct rationales exist on each of these three levels of decision making as actors have their own perspectives, cultures, disciplines, and traditions concerning the delivery of health care. These differences can often result in ambiguity of goals, conflicting interests between decision makers, bureaucracy, poor information transfer, and limited use of the available scientific knowledge on all three levels. In such a context, rationalization and quality-improvement efforts are frustrated and will have limited effectiveness. Therefore, the various rationalization strategies and instruments on all three levels of decision making should be embedded in our health care systems in a synergistic way. DEMONSTRATING THE PROPOSED SOLUTION: Community-based integrated care is a promising approach to addressing this issue successfully. How this concept might function as a unifying concept for quality improvement will be illustrated by relevant developments in the Academic Medical Center, University of Amsterdam in The Netherlands.     

Opinion polling and decision making: a critical appraisal of quality of life assessment

The relationship between quality of life (QOL) assessments and decision making, in relation to the delivery of health services, is subjected to critical appraisal. Three levels of decision making in the health care system are taken into account in the analysis. Criticisms of opinion polling provide the basis for the appraisal. Examples of criticisms considered are: Might the use of QOL information be manipulative? Could the interviews or questionnaires used to obtain QOL data influence personal opinions? Are the methods used sometimes defective and/or superficial? Will QOL information always be used in decision making in ways that are ascertainable and justifiable? It is concluded that the time has come for the main focus of critical appraisal in QOL research to shift, from an emphasis on evaluation of the quality of methods used for assessments of QOL, toward an emphasis on the practical usefulness of QOL data.     

Exploring information systems outsourcing in U.S. hospital-based health care delivery systems

The purpose of this study is to explore the factors associated with outsourcing of information systems (IS) in hospital-based health care delivery systems, and to determine if there is a difference in IS outsourcing activity based on the strategic value of the outsourced functions. IS sourcing behavior is conceptualized as a case of vertical integration. A synthesis of strategic management theory (SMT) and transaction cost economics (TCE) serves as the theoretical framework. The sample consists of 1,365 hospital-based health care delivery systems that own 3,452 hospitals operating in 2004. The findings indicate that neither TCE nor SMT predicted outsourcing better than the other did. The findings also suggest that health care delivery system managers may not be considering significant factors when making sourcing decisions, including the relative strategic value of the functions they are outsourcing. It is consistent with previous literature to suggest that the high cost of IS may be the main factor driving the outsourcing decision.     

Clinical performance improvement: measuring costs and benefits

Market shifts in health care reimbursement have made the improvement of clinical performance a key strategic goal for health care delivery systems, including hospitals, physician groups, and integrated delivery systems. This process requires a clinical management infrastructure, advanced clinical information technology, engaged physicians, and alterations to the strategic plan for the delivery system. Because the change to a clinical efficiency orientation takes several years for organizations to achieve, adoption of this approach must begin before markets become fully mature for managed care and most practicing physicians are aware of the change. This article outlines how to evaluate the costs and benefits of improving clinical performance and how to determine when an organization should begin making this change. It advises delivery systems executives to raise the priority of clinical performance improvement and to measure both the near-term and long-term impact of this approach on revenue, cost, quality, and market share.     

Patientenbeteiligung bei medizinischen Entscheidungen in der Integrierten Versorgung Gesundes Kinzigtal: Ergebnisse einer kontrollierten Kohortenstudie

An integrated health care project called “Gesundes Kinzigtal” was conducted in a rural area in Germany. As part of the project, physicians were trained and other measures were taken to enhance patient involvement in medical decision making. As part of the external evaluation, various effects regarding patient involvement in medical decision making, patient involvement and information preference, decision confidence, patient satisfaction with ambulatory care and patient quality of life were examined. The data were gathered by means of a questionnaire on an annual basis between 2007 and 2009. Effects were compared between patients who were participating in the integrated care project and two control groups. Analyses are based on the data of 1,205 patients. Over time all outcomes decreased slightly, except for information preference and physical quality of life. No statistically significant intervention effects on patient involvement in medical decision making or any other outcome variable could be found. The intensity of the training was presumably too low to establish an enduring change in the physician–patient interaction.     

Creating a culture for health care quality and safety

Approximately 67% of hospital quality indicators require some type of laboratory testing to monitor compliance. Unfortunately, in many hospitals, laboratory data information systems remain an untapped resource in eliminating medical errors and improving patient safety. Using case scenarios, this article demonstrates potential consequences for patient safety and quality of care when information sharing between medical technologists and nurses is not a part of a hospital's culture. The outcome for this patient could have been avoided if a more inclusive health care quality and safety culture existed. Creating a culture for health care quality and safety requires consensus building by clinical and administrative leaders. Consensus building occurs by managing relationships among and between a team of independent, autonomous physicians, nurses, allied health professionals, and health care administrators. These relationships are built on mutual respect and effective communication. Creating a quality culture is a challenging but necessary prerequisite for eliminating medical errors and ensuring patient safety. Physician leaders promoting and advancing cultural change in clinical care from one of exclusive decision making authority to a culture that is based on shared decision making are a necessary first step. Shared decision making requires mutual respect, trust, confidentiality, responsiveness, empathy, effective listening, and communication among all clinical team members. Physician and administrative leaders with a focus on patient safety and a willingness to change will ensure a culture of health care quality and safety.     

Parental bargaining, health inputs and child mortality in India

The primary objective of this paper is to examine the relationship between the status of women in the household, the use of health care (demand for prenatal care and hospital delivery) and child mortality in India. Parents care about the health of their children but cannot directly affect child health by their actions. Instead they can, through their actions, control the use of health inputs. I jointly estimate the decision to use prenatal care, the decision to deliver the baby in hospital and child mortality. The estimation methodology allows us to account for unobserved heterogeneity and self-selection in the use of health inputs. The estimation results show that: (1) a woman's education has a stronger effect on health care usage relative to that of her husband; (2) a woman's control over household resources (ability to keep money aside) has a significant effect on health care usage; (3) both prenatal care and hospital delivery significantly reduces the hazard of child mortality; and (4) not accounting for unobserved heterogeneity and self-selection in the use of health inputs results in under-estimation of the effect of health inputs on child mortality.     

Development and implementation of an information management and information technology strategy for improving healthcare services: a case study

PeaceHealth is a multistate, not-for-profit integrated delivery network that owns and operates five acute care hospitals, one critical access hospital, and twenty-five outpatient clinics. PeaceHealth employs approximately two hundred physicians and seventy allied health professionals; it has relationships with one thousand affiliated physicians. In 1990, PeaceHealth developed a set of strategic priorities for delivering seamless care across the continuum, and creating partnerships between caregivers and patient-consumers. A major component of these strategies was development and implementation of the technology, knowledge, organizational, and community infrastructures that would support delivering and using high-quality, timely information when and where it is needed for effective clinical, operational, and financial decision making. Executing this strategy has resulted in implementation of standard enterprisewide information systems, including a computer-based patient record system in inpatient and outpatient settings, tactical and strategic decision support systems, a well-developed intranet and access to the Internet, and a knowledgeable workforce that have enabled PeaceHealth to support and improve its services and business by bringing interactive information directly to patients, caregivers, managers, directors, and executives. This case study discusses the drivers behind the development of this strategy, specific components of the information management and information technology infrastructure, examples of the impact they have had on patients, caregivers, and the organization, and lessons learned.     

Strategic information systems: can you support your decisions?

Information technology will continue to have a profound effect on decision analysis. Clinicians and technologists must continue to work together to achieve systems that enhance patient quality and managerial decision making. Users will continue to grow more sophisticated in using information systems for patient care and organizational analyses. Strategic information systems will not solve all problems that health care professionals may face. However, better decisions will result from improved availability of information. The acceptance, support, and imagination of power users will enhance and drive information system development and design. Strategic information systems will provide opportunities for data analysis enabling health care professionals to better support decisions.     

Activity-based cost management in health care--another fad?

By providing improved information for strategic planning purposes activity-based cost management (ABM) systems can help hospitals and other health care providers improve the quality and efficiency of the care they provide control costs and manage their resources better. The NHS is starting to evaluate the ABM approach. Describes a research project in one specialist hospital in Sheffield UK which found that conventional approaches to costing can be inaccurate by as much as 100 per cent; conventional approaches will consistently undercost complex, specialist, infrequent episodes of care and overcost straightforward frequent episodes; and the resulting information from ABM about costs and processes significantly improves the decision-making capabilities of managers particularly in relation to ?what if? situations.     

Which health information systems for the evaluation of health actions?

The evaluation of health actions requires large amounts of information allowing an assessment of relevance, coherence, efficacy, efficiency and impact of these interventions. Information systems should support evaluation processes by helping to obtain pertinent indicators, tracers and standard operating procedures. To reach this objective, specific functions need to be implemented, including traceability, documentation, investigation and scientific awareness. But this supposes that health information systems respect quality criteria that this article defines. The following criteria are considered: simplicity, validity, acceptability, informative value, representativeness, continuity, reactivity, fluidity, flexibility of the system, and also confidentiality of information. The historical developments of medical informatics have induced the creation of independent information systems, answering to specific objectives. This lack of integration is an obstacle to the evaluation of health actions because of the difficulty to view transversally and longitudinally the sequence of actions for a same patient. Thus integrated health information systems, organised around patient care episodes, are necessary to support evaluation and to contribute effectively to decision making in public health, because the evaluation of health actions implies the availability of information about the individuals who are the targets of these actions.     

充分发挥统计信息的管理效应

统计信息可以反映医院经营活动中不同环节、不同方面的情况.对各种统计信息进行整合,对统计资料实行＂档案化＂管理,可为医院领导和机关职能部门了解决策的执行情况、医疗资源的利用情况、评价医疗质量、巩固和拓展医疗市场以及＂优质、高效、低耗＂管理目标的实现情况等提供依据,充分发挥统计工作的作用.     

The use of computer-based simulation in a Master of Health Administration curriculum.

In this paper, the use of a simulation tool to support the appreciation of data and information by health administration students with varied backgrounds and educational training is discussed. Specifically, the authors developed educational and training material that can be used in a variety of courses to improve information management and decision making. Improved information management is being recognized as a critical component of the movement to achieve consistent quality in patient care, institutional performance, and policy planning. This is now especially important as new information systems are making data and good quality evidence increasingly more available. Ultimately, it is hoped that this process will lead to findings that will assist evidence-based decision making within all health providers.     

Clinical decision making and health care policy: what is the link?

The relationship between clinical decision making and health care policy is here considered in different ways. First, it is suggested at the most simple level that a key link between the two is that both are concerned with health. Second, the need for accepting the presence of uncertainty at both levels is highlighted: uncertainty related to inputs and outputs; to assessing weights for various outcomes; to attitudes to risk; etc. Third, the paper emphasises the desirability of looking beyond only the output 'health' at the two levels of decision making. Not that the relationship between clinical and health service decision making is taken to be constant across all health care systems in all countries. The paper suggests rather that just how clinical decision making is affected by the health care environment in which it finds itself needs more investigation than it has received to date. The authors indicate that the recent growth in the formal analysis of medical decision making is to be welcomed but stress the need to extend such analysis to consider the impact on clinical decision making of health care policy making.     

Use of emergency transport by patients with cardiopathies: a focus group study.

BACKGROUND: The importance of emergency systems accessible by telephone for the early attention of patients with ischemic cardiopathy is well known. In Andalusia, this service is provided by calling 061. However, studies show an insufficient use of the existing emergency system in this type of patient. OBJECTIVE: To identify explanations related to the decision regarding the method of transport to health-care systems, by private means of transport or 061 services, for people with ischemic cardiopathy from the onset of symptoms until their arrival at the Emergency Department. METHODS: Eleven focal groups were held with subjects diagnosed with ischemic cardiopathy. The discussions were related to the method of transport (using 061 or their own means of transport to a major hospital or to a nearby health facility for onward transfer), depending on the existence of previous experience and distance to the hospital. RESULTS: The method of transport is related to the degree of ignorance about what is happening, perceptions regarding the fastest way to reach the hospital, people available around the patient when the event takes place, vehicle availability and possible stressful situations. CONCLUSIONS: This study provides information about the reasons for using or not using the emergency transport systems for these patients and understanding how decisions were made. The study's importance lies in the possibility of improving individuals' access to health care systems through education-based actions and a strategic information and training plan that targets patients, families and health professionals.     

An Application of the Hospital-in-the-Home Unlearning Context

Many researchers who have investigated health care organizations have indicated that health care professionals are replete with outdated knowledge, and some researchers go even further to argue that without the presence of a context that facilitates unlearning (forgetting) practitioners may lose the ability to recognize relevant changes with respect to knowledge pertaining to all aspects of the health care sector and they may decide to rely on potentially out-of-date knowledge and inappropriate ways of interpreting data with attendant loss of decision quality and attendant risks. This article presents an analysis and develops a model of the factors that influence unlearning which is focused on the health care industry and is comprised of three constituent components: (1) a framework characterizing the lens through which individuals view situations; (2) a framework for characterizing how individual habits change; and (3) a framework for characterizing the manner in which emergent understandings are consolidated into existing knowledge and knowledge structures. The model was developed and analyzed using qualitative data from the Hospital-in-the-Home Unit of a Spanish Regional Hospital. From a practical perspective the article provides for the identification of factors that influence the nature and effectiveness of the unlearning context in Hospital-in-the-Home-Units in regional hospitals. This not only valuably adds to the knowledge of the way these units function but also may enable actions to be taken to improve the learning processes associated with such units, resulting in an improvement in the quality of knowledge used in day-to-day decision making. It is to be assumed that, as a result of improving the quality of knowledge used in decision making, the quality of decisions will be improved.     

An application of the Hospital-in-the-Home unlearning context

Many researchers who have investigated health care organizations have indicated that health care professionals are replete with outdated knowledge, and some researchers go even further to argue that without the presence of a context that facilitates unlearning (forgetting) practitioners may lose the ability to recognize relevant changes with respect to knowledge pertaining to all aspects of the health care sector and they may decide to rely on potentially out-of-date knowledge and inappropriate ways of interpreting data with attendant loss of decision quality and attendant risks. This article presents an analysis and develops a model of the factors that influence unlearning which is focused on the health care industry and is comprised of three constituent components: (1) a framework characterizing the lens through which individuals view situations; (2) a framework for characterizing how individual habits change; and (3) a framework for characterizing the manner in which emergent understandings are consolidated into existing knowledge and knowledge structures. The model was developed and analyzed using qualitative data from the Hospital-in-the-Home Unit of a Spanish Regional Hospital. From a practical perspective the article provides for the identification of factors that influence the nature and effectiveness of the unlearning context in Hospital-in-the-Home-Units in regional hospitals. This not only valuably adds to the knowledge of the way these units function but also may enable actions to be taken to improve the learning processes associated with such units, resulting in an improvement in the quality of knowledge used in day-to-day decision making. It is to be assumed that, as a result of improving the quality of knowledge used in decision making, the quality of decisions will be improved.     

Making the grade: a status report on hospital report cards

Hospital report cards that document patients' medical outcomes are attracting increasing attention for their role in guiding health care decisions by employers, consumers and providers. Significant questions remain, however, regarding the validity and utility of this information. This Issue Brief is based on a seminar held by the Center for Studying Health System Change at which two expert panels discussed whether report cards make the grade. The first panel approached this subject through a Socratic dialogue that focused on the release of a hypothetical community hospital report card. The second panel weighed in on two research presentations related to report cards. The panelists agreed that efforts to collect and report clinical outcomes data are flawed. Even so, release of the data can help improve clinical quality and foster an environment in which health care quality information ultimately has an impact on health care decision making.     

The need for cost-effectiveness studies in telemedicine

Telemedicine has the potential substantially to improve the delivery of health care. However, cost-effectiveness studies are needed to help define the appropriate scope and application of telemedicine in different settings. Reports on the evaluation of telemedicine are dominated by technical and feasibility studies. Such studies may be very helpful for initial decision making. However, any cost information at this level tends to be very preliminary and often concerned with making a case to proceed further. Decision makers will wish for further information as the telemedicine application is introduced, to consider its effectiveness - its performance under routine conditions. Without information on the costs and effectiveness of telemedicine services, decision makers run the risk of supporting telemedicine systems that are not responsive to health-care needs or which do not provide cost-effective services. The most immediate needs seem to be improvements in the conduct and reporting of studies, and additional information on the performance of telemedicine in routine practice. Investigators need to provide transparent accounts of their studies, describing in detail the approaches taken, sources of data and assumptions made, and indicating the reliability of their results. Decisions may have to be made on the basis of limited studies, but sufficient detail must be made available to decision makers.