Legal review: informed consent--a shift from paternalism to self-determination?

This shift from a paternalistic standard for determining how much information should be disclosed to a person to a standard that values the self-determination of a person is consistent with the philosophical change in decision-making in a variety of areas of health care. Haber begins his article with a discussion of the psychiatry profession's proposed change in terminology from "patient" to "client." He argues that such a change would be more than semantic: It would serve the moral purpose of increasing such a person's autonomy. The right of patients to see their own medical records was formally recognized as part of the Patient's Bill of Rights in 1972 and has since been recognized by courts and incorporated into many state statutes. Likewise, the refusal of medical treatment has become a right more commonly recognized by the law throughout the 1970s and 1980s. For example, "living wills" are now a common vehicle for patients to express their views regarding the right to refuse treatment. Courts have recognized this right in cases of Jehovah's Witnesses refusing transfusions, the right to have life-sustaining procedures discontinued, and the restrictive involuntary commitment statutes that arose in the 1970s. Both the risks and benefits of medical treatments have increased with the forward march of technology. Patients have the right to choose to participate with their physicians in their own health care decision making; the trend toward the reasonable patient standard in medical malpractice suits that relied on negligent failure to obtain informed consent reflects a recognition of that right.     

An introduction to technology for patient-centered, collaborative care

"Patient-centered, collaborative care" is healthcare jargon. But underlying the jargon is the principle that a patient who receives such care strongly agrees that "I receive exactly the healthcare I want and need exactly when and how I want and need it." Currently only about 1 in 4 Americans who have adequate financial resources can make this claim. Think of a pyramid. At the apex is the highest level of "patient-centered, collaborative care." At the base are measures about "what's the matter" (from the clinical perspective) and "what matters" (from the patient perspective). As patients and clinicians act collaboratively on these measures, they climb closer to the apex of the pyramid. Given the realities of healthcare in the Unites States, should busy professionals take time to think about ways to climb pyramids? In this "Introduction" we describe why the answer to this rhetorical question ought to be "yes." In the articles that comprise this issue, readers will learn how technology that supports patient-centered, collaborative care can help bridge the gap between desirable goals and limited time. All the authors understand technology (such as hardware and software), and the way humans use the technology (called techne) will not overcome the many obstacles to the attainment of patient-centered, collaborative care. Nevertheless, we are hopeful that the examples described in these articles suggest ways that significant progress toward patient-centered, collaborative care can be made. The articles are practical. The results are persuasive. It is worth the climb!     

Sustaining the edge: factors influencing strategy selection in academic health centers

Competition within the acute care sector as well as increased penetration by managed care organizations has influenced the structure and role of academic health centers during the past decade. The market factors confronting academic health centers are not dissimilar from conditions that confront other organizations competing in mature industries characterized by declining profitability and intense rivalry for market share. When confronted with intense competition or adverse external events, organizations in other industries have responded to potential threats by forming alliances, developing joint ventures, or merging with another firm to maintain their competitive advantage. Although mergers and acquisitions dominated the strategic landscape in the healthcare industry during the past decade, recent evidence suggests that other types of strategic ventures may offer similar economic and contracting benefits to member organizations. Academic health centers have traditionally been involved in network relationships with multiple partners via their shared technology, collaborative research, and joint educational endeavors. These quasi-organizational relationships appear to have provided a framework for strategic decisions and allowed executives of academic health centers to select strategies that were competitive yet closely aligned with their organizational mission. The analysis of factors that influenced strategy selection by executives of academic health centers suggests a deliberate and methodical approach to achieving market share objectives, expanding managed care contracts, and developing physician networks.     

America's Health Care Revolution

Califano describes the American health care system in terms of a revolution "which promises to be bruising and bloody." The combination of advanced technology, demographic change and for-profit forces within the health care industry has created, he says, a situation in which miracles abound and guiding the system, which has become too costly and mercenary is "a delicate and treacherous business."     

The pricing of U.S. hospital services: chaos behind a veil of secrecy

Although Americans and foreigners alike tend to think of the U.S. health care system as being a "market-driven" system, the prices actually paid for health care goods and services in that system have remained remarkably opaque. This paper describes how U.S. hospitals now price their services to the various third-party payers and self-paying patients, and how that system would have to be changed to accommodate the increasingly popular concept of "consumer-directed health care."     

New communications tools expand educational options

Administrators must make well-informed decisions regarding new communications technology to disseminate information to diverse constituencies in the facility and its service area. For example, communicating and using information about rapidly changing regulations is important in today's competitive environment. Administrators are faced with choosing from among such electronic media as satellite programming, telephone systems, cable television, and microwave radio to meet their institutions' needs. Teleconferences and closed-circuit educational programming also offer cost-efficient choices. Consultants can assist the management team in developing an appropriate system, whether sharing in an existing program or private network or installing an independent satellite-receiving dish, or "downlink." The team, including medical personnel, must choose the hardware that the institution can use most effectively in accomplishing its objectives. Studying other facilities' systems, such as St. Joseph Hospital, Providence, RI, with its independent receiving dish, shows the practical applications of the often confusing technology. Administrators should not be put off by "'technology frenzy." About 600 U.S. institutions have receiving stations or access to them; most will have them in the future. Even smaller facilities can become leaders with this cost-effective technology. Administrations must lead in accepting the challenge to improve health care communications.     

Privatization in a publicly funded health care system: the U.S. experience

The United States has four decades of experience with the combination of public funding and private health care management and delivery, closely analogous to reforms recently enacted or proposed in many other nations. Extensive research, herein reviewed, shows that for-profit health institutions provide inferior care at inflated prices. The U.S. experience also demonstrates that market mechanisms nurture unscrupulous medical businesses and undermine medical institutions unable or unwilling to tailor care to profitability. The commercialization of care in the United States has driven up costs by diverting money to profits and by fueling a vast increase in management and financial bureaucracy, which now consumes 31 percent of total health spending. The Veterans Health Administration system--a network of government hospitals and clinics--has emerged as the leader in quality improvement and information technology, indicating the potential for public sector excellence and innovation. The poor performance of U.S. health care is directly attributable to reliance on market mechanisms and for-profit firms, and should warn other nations from this path.     

Managed care: the next generation

Managed care today affects most Americans. Of the 160 million Americans receiving employee coverage, 120 million are in a managed care setting. HMO development to date has been driven by the desire to reduce health benefit costs for employers. Employees, the real consumers, perceive a clash between "good care and good profits." Health plans have generated profits by reducing utilization and keeping a portion of the savings. In the future, market conditions will force plans to develop new ways of maintaining profitability. Also, plans will survive by focusing on factors that matter most to consumers-such as overall care quality and access. Care systems that combine the benefits of open-access systems with the benefits of point-of-service products represent the next generation of consumer-driven healthcare.     

The future of nursing: combining humanistic and technological values

Technology is increasing. "The most stable characteristic of the present health care system, is change, characterized by expansion and experimentation . . ." To date, nursing has taken a reactive role, adapting out of necessity rather than taking an active part in initiating or promoting specific change. Consequently the health care system has had and continues to have a greater impact on nursing than nursing on the health care system. Two hypothetical frameworks, humanistic and technological, are presented with which to approach the problem of increasing technology. The values and implications of each are examined within the context of the nursing profession.     

Staff expectations on implementing new electronic applications in a changing organization

This study was undertaken to describe staff expectations prior to implementation of new electronic applications in a changing organization. Changes are a part of human existence; changes based on implementation of technology and information and communication technology are taking place in the health care sector globally. The Swedish public health care and social care sector is taking a similar path. A qualitative approach with group interviews of 23 staff divided in 5 groups was performed. Latent content analysis was used to analyze the transcribed interviews. The theme, taking standpoint today in relation to the past, emerged from 3 areas of discussion: "distance holding," "ruled by the organization," and "health care development in the future." New restraints on staff affect the caregiving process. Managers should consider whether a particular change is revolutionary or evolutionary and act in the change process according to the possible psychological impact of the change.     

The telecardiology revolution: improving the management of cardiac disease in primary care

Telecardiology allows for the remote specialist interpretation of electrocardiographic recordings via telephone transmission. It has the potential to change the way cardiac care is being delivered in the primary care setting. This review discusses the current status of cardiac care in the community, and highlights how telecardiology can help support general practitioners in the diagnosis and management of acute and chronic cardiac disease, as well as provide the potential for screening opportunities in particular patients at risk. Also reviewed is the success of recent trials of a telecardiology service in the north west of England. Thanks to developments in technology and ever decreasing costs, telecardiology has the potential to save time, money and lives. Telecardiology, it would seem, is set to revolutionize cardiac care in the community, making savings and bridging the gap between primary and secondary care.     

Providers' payment and delivery system reforms hold both threats and opportunities for the drug and device industries

For decades, medical device and specialty drug makers have produced a steady stream of breakthroughs and incremental improvements, from cancer therapies to orthopedic joint replacements, drug-eluting stents, and cardiac pacemakers. The advances were financed by a fragmented health care system that paid for whichever clinical technologies were favored by physicians without strong concern for cost. But now hospitals, health systems, insurers, and policy makers are embracing payment reforms that seek to control costs and foster uniformity in the adoption of new drugs and devices. This article explores payment reforms that will have an impact on the medical technology industry and describes opportunities for the industry to flourish in this new, more financially constrained landscape.     

Publisher's note

Attainment of the goal "health for all by the year 2000" seems unlikely in India, where the public health care system is in a state of deterioration and government spending on health care has steadily decreased. Continued neglect of the health care system will have dire effects for the future of the country, especially given the HIV trend. Despite its lethality, HIV/AIDS is now regarded as no more urgent than treatable diseases such as malaria, tuberculosis, and water-borne diseases. As this publisher's note states, "Even if we scream our throats hoarse, nothing much is going to happen unless and until a proper system of governance is established and mass action programs are taken up earnestly." Improvement of the health status of the Indian people depends not only on medical care, but also on community involvement in program planning and implementation, government coordination, and involvement by private and voluntary agencies.     

U.S. medical students' attitudes about patients' access to care

OBJECTIVE: Accessing adequate medical services remains a major struggle for many Americans, but U.S. medical students' beliefs regarding access to care have not been thoroughly examined. METHODS: All medical students in the Class of 2003 at 16 U.S. schools were eligible to complete three questionnaires during their medical training: during freshman orientation, orientation to wards, and their senior year (n=2316, response rate=80.3%). Students responded to three questions about health care provision. RESULTS: Overall, 35% of students strongly agreed that "physicians have a responsibility to take care of patients regardless of their ability to pay;" only 5% disagreed. Only 8% disagreed that "access to basic health care is a fundamental human right." We found the same significant associations with opinions on access as we did with "responsibility to treat," although the associations tended to be stronger for access. Only 10% of students agreed that "Managed care, as it is now delivered, is a good way to deliver health care to the U.S. population." CONCLUSION: Most U.S. medical students support universal access to medical care, though variations in this support, its decline with additional years of medical education, and concerns about managed care are noteworthy, and have policy implications for America's health and health care workforce.     

Cardiac picture archiving and communication systems and telecardiology - technologies awaiting adoption

Diagnostic and therapeutic procedures associated with cardiology are heavily supported by diagnostic imaging technology. The management of such images, including radiographs, echocardiography examinations and cardiac angiography studies, requires a suitable means of handling the data. A number of manufacturers are now offering picture archiving and communication systems (PACS) and telecardiology options. These could greatly improve the efficiency of data management for cardiac examinations, including linkage to radiology and hospital information systems and electronic patient records. A barrier to the implementation of cardiac PACS has been the relatively high capital cost. There have also been technical difficulties in implementing a suitable interface. Historical problems have included 'turf wars' between different specialist groups and a reluctance to shift from well established practice patterns. Early cooperative work between radiologists and cardiologists in the development of coronary arteriography has been replaced by contention between cardiologists, radiologists and vascular surgeons, often driven by economic considerations rather than the needs of the patient. At this stage, cardiac PACS and telecardiology have great potential for improving the coordinated care of cardiac patients in Australia.     

Cardiac picture archiving and communication systems and telecardiology--technologies awaiting adoption

Diagnostic and therapeutic procedures associated with cardiology are heavily supported by diagnostic imaging technology. The management of such images, including radiographs, echocardiography examinations and cardiac angiography studies, requires a suitable means of handling the data. A number of manufacturers are now offering picture archiving and communication systems (PACS) and telecardiology options. These could greatly improve the efficiency of data management for cardiac examinations, including linkage to radiology and hospital information systems and electronic patient records. A barrier to the implementation of cardiac PACS has been the relatively high capital cost. There have also been technical difficulties in implementing a suitable interface. Historical problems have included 'turf wars' between different specialist groups and a reluctance to shift from well established practice patterns. Early cooperative work between radiologists and cardiologists in the development of coronary arteriography has been replaced by contention between cardiologists, radiologists and vascular surgeons, often driven by economic considerations rather than the needs of the patient. At this stage, cardiac PACS and telecardiology have great potential for improving the coordinated care of cardiac patients in Australia.     

The significance of long-term care in health reform

The American Association of Homes and Services for the Aging, long-term care institutions, and housing providers applaud the proposed state entitlement program in the President's plan, because it is consistent with the belief that individuals should have autonomy and should be able to live as independently as possible for as long as possible. The author presents a convincing argument that elderly and disabled people prefer home and community-based care delivered at home or in home-like settings (aging in place) over the far more expensive nursing facility care, which is now perceived as care of the "last resort."     

The ethics of recruiting foreign nurses

Because they face a growing nursing shortage, many U.S. health care institutions have turned to recruiting foreign nurses. For foreign nurses, the practice is often an opportunity to make a better life for themselves and their families. And it helps solve a serious problem for the U.S. organizations involved. But the recruitment of foreign nurses raises a number of ethical questions. The first article here examines the practice as seen from three viewpoints, the global, that of the particular recruiting health care organization, and that of the recruited foreign nurse. The author concludes that the practice can be both a "blessing" and a "curse." The second article discusses the practice as seen from a Third World nation from which the United States, along with other Western countries, is recruiting nurses. The author, who formerly supported the practice, now opposes it.     

Lessons from the eight countries

While the eight countries presented in this issue differ considerably from each other, they have important similarities. All have faced the problem of increasing health care expenditures, and all are coming to recognize problems with health care technology such as inappropriate use and poor quality of care. Health reforms appear to be accelerating in the countries examined. In addition, all countries now have stated policy goals of assessing the benefits of health care technologies and most have established formal programs for health care technology assessment. Technology assessments impact varies, but it is becoming an important factor in technology acquisition. These trends point to a future for technology assessment and perhaps to better management of health care technology. International cooperation is important if this goal is to be realized.     

Why ethics should be part of health technology assessment

From the heydays of HTA in the 1970s, it has been argued that ethics should be a part of HTA. Despite more than 30 years with repeated intentions, only few HTA reports include ethical analysis, and there is little agreement on methods for integrating ethics. This poses the question of why it is so important to integrate ethics in HTA? The article analyzes ten arguments for making ethics part of HTA. The validity of the arguments depend on what we mean by "integrating," "ethics," and "HTA." Some of the counterarguments explain why it has taken so long to integrate ethics in HTA and why there are so many ethical approaches. Nevertheless, some of the arguments for making ethics part of HTA appear to be compelling. Health care is a moral endeavor, and the vast potential of technology poses complex moral challenges. A thorough assessment of technology would include reflection on these moral aspects. Ethics provides such a moral reflection. Health technology is a way to improve the life of human individuals. This involves questions of what "the good life" is, and hence ethical issues. Trying to ignore such questions may inflict with the moral foundation of health care: to help people. Additionally, HTA is an evaluation, and as such also a reflection on values. Hence, there is a profound affinity between HTA and ethics. Accordingly, ethics cannot be "integrated" in HTA as ethics is already a constitutive part of HTA. However, ethics can be acknowledged and emphasized.