The organization of health services research in the Veterans Administration

The VA health services research, development, and education efforts are organized in four main programs: (1) the Intramural Research Program, (2) the VA-University Health Services Research Affiliation Program, (3) the Health Services Research Training Program, and (4) the Contract Research Program. This report first describes the administrative location and structure of the Health Services Research and Development Service within the VA Department of Medicine and Surgery. Then the goals, organizational structure, and major activities of each program are presented.     

Government regulations and other influences on the medical use of computers

This paper presents points brought out in a panel discussion held at the 12th Hawaiian International Conference on System Sciences, January 1979. The session was attended by approximately two dozen interested parties from various segments of the academic, government, and health care communities. The broad categories covered include the specific problems of government regulations and their impact on specific clinical information systems installed at The University of Texas Health Science Center at Dallas, opportunities in a regulated environment, problems in a regulated environment, vendor-related issues in the marketing and manufacture of computer-based information systems, rational approaches to government control, and specific issues related to medical computer science.     

National health care surveys and health care management

The bulk of medical care in the United States is provided in hospitals, physicians' offices, and nursing homes. The National Center for Health Statistics conducts three health record surveys that collect information on patient and provider characteristics and the services provided in these three settings. This paper describes each of these three surveys in terms of background (scope and data set), design, collection, processing procedures, and data dissemination. In addition, specific examples of how the survey data have been or can be used for management purposes in terms of monitoring, evaluating, and planning the utilization of health care in the United States are given.     

Automation: The competitive edge for HMOs and other Alternative Delivery Systems

Until recently, many, if not most, Health Maintenance Organizations (HMO) were not automated. Moreover, HMOs that were automated tended to be automated only on a limited basis. Recently, however, the highly competitive marketplace within which HMOs and other Alternative Delivery Systems (ADS) exist has required that they operate at a maximum effectiveness and efficiency. Given the complex nature of ADSs, the volume of transactions in ADSs, the large number of members served by ADSs, and the numerous providers who are paid at different rates and on different bases by ADSs, it is impossible for an ADS to operate effectively or efficiently, let alone show optimal performance, without a sophisticated, comprehensive automated system. Reliable automated systems designed specifically to address ADS functions such as enrollment and premium billing, finance and accounting, medical information and patient management, and marketing have recently become available at a reasonable cost.     

Planning and decision making for ambulatory surgery

There has been rapid growth in the number of ambulatory surgical centers in the United States over the past few years. Yet little research has been done to assist community health planners and surgeons in decision making and planning for ambulatory surgery. In this paper, an analytical framework is developed to assist surgeons in deciding whether to perform a procedure on an ambulatory or an inpatient basis. The Hospital Discharge Survey data collected by the National Center for Health Statistics are also analyzed to investigate their applicability in this analytical framework as well as to aid planners in developing community-wide ambulatory surgery projections. In spite of the limitations on the available data, the models developed here suggest possible future avenues for planning ambulatory surgeries.     

The use of X-terminals as clinical workstations

The Medical Computer Facility at the Fox Chase Cancer Center has installed X-terminals in patient examination rooms and at nursing stations for clinical data acess by physicians and nurses. The X-terminals are connected to UNIX operating system RISC processors via Ethernet. The RISC processors communicate with databases on a minicomputer cluster. Simultaneous presentation of textual (e.g., pathology and radiology reports) and graphical (e.g., clinical laboratory results) clinical data is provided under X-Windows. CT and MRI images can also be displayed in windows. Our experiences implementing X-terminal clinical workstations in a production environment will be discussed.     

A prototype generalized network technology for hospitals

A demonstration implementation of a distributed data-processing hospital information system using an intelligent local area communications network (LACN) technology is described. This system is operational at the UCSF Medical Center and integrates four heterogeneous, stand-alone minicomputers. The applications systems are PID/Registration, Outpatient Pharmacy, Clinical Laboratory, and Radiology/Medical Records. Functional autonomy of these systems has been maintained, and no operating system changes have been required. The LACN uses a fiber-optic communications medium and provides extensive communications protocol support within the network, based on the ISO/OSI Model. The archtecture is reconfigurable and expandable. This paper decribes system architectural issues, the applications environment, and the local area network.     

Biochemical reactions in cation transport

This review was written during the tenure of grants from the U.S. National Institutes of Health and the Conquer Cancer Campaign.     

MDA-Image: An environment of networked desktop computers for teleradiology/pathology

MDA-Image, a project of The University of Texas M. D. Anderson Cancer Center, is an environment of networked desktop computers for teleradiology/pathology. Radiographic film is digitized with a film scanner and histopathologic slides are digitized using a red, green, and blue (RGB) video camera connected to a microscope. Digitized images are stored on a data server connected to the institution's computer communication network (Ethernet) and can be displayed from authorized desktop computers connected to Ethernet. Images are digitized for cases presented at the Bone Tumor Management Conference, a multidisciplinary conference in which treatment options are discussed among clinicians, surgeons, radiologists, pathologists, radio-therapists, and medical oncologists. These radiographic and histologic images are shown on a large screen computer monitor during the conference. They are available for later review for follow-up or representation.     

A chartless record—Is it adequate?

The computerized medical record supported by The Medical Record (TMR) has been the only record of physician-patient encounters on the nephrology service of the Durham Veterans Administration Medical Center since April 1981. Physicians using the system evaluated the adequacy of the computerized record as a replacement for the paper chart. The computerized record was able to capture and display all pertinent data. Manual or computerized narratives provided a useful supplement to the core computerized record only in those rare instances that a physician needed to point out which of the data in the record were important to his decision making.     

Legal constraints and alternatives in the Veterans Administration

The Veterans Administration is a federal system that has functioned, so far, independently of state and local laws and rules. The system has proven flexible, however, as it has adjusted to meet needs perceived within its organization where legal justification has been found. The impact of the overall health care system in the United States is beginning to be felt within the Veterans Administration as the possibility of national health insurance implementation may greatly affect the number and kinds of patients seen in the hospitals. The response of the Veterans Administration system will have to be within its legal framework and an understanding of the relationship between the actual operation of the system and the law will be necessary. More and better understanding of the practical impact of external programs such as comprehensive health planning, manpower training and licensing laws will be necessary for the Veterans Administration to successfully adjust within the United States' health care framework.     

User comments

An automated medical record system (AMRS) at the Harvard Community Health Plan supports medical records membership and the management needs of the 146,000-member health maintenance organization. The ARMS is fully integrated into the operation of HCHP's health centers and into the clinical practice of the medical staff. User interviews conducted as part of a systems planning effort revealed a high level of satisfaction with the system. The acceptance of and enthusiasm for the AMRS was coupled with a variety of ideas for improvement and enhancements to the system. Most of these suggestions were not uniquely related to the automated technology supporting the system but rather addressed medical records issues familiar to conventional paper systems. While this distinction is subtle, it further confirms the viability of an automated system and suggests directions for future growth.     

Risk in a “Fee for Service” Health Care System

This paper describes an approach for assessing the financial risk inherent in a bid for the development and operation of a Management Information System (MIS) that includes processing of claims associated with a “Fee for Service” Health Care System. The discussion establishes the motivation for a risk assessment, defines the context of the problem, and proposes a risk-analysis procedure. Results attainable with the proposed approach are compared with those of a conventional analysis. The advantages of the proposed approach are addressed in terms of the added effort required.     

The Health Maintenance Facility

The Health Maintenance Facility (HMF) is the code name for a space-based medical clinic. The HMF is an integral part of the U.S. sponsored space station program due to be launched in the late 1990s. Contained in this module will be equipment, facilities, and supplies that can be used to support space station crew health. The range of medical care will depend upon the skill of the crew, the tools available, and the support systems that can be used from earth. The design of this system and its heavy dependence upon computer resources provide an excellent model for looking forward into the earth based medical clinics of the future.     

Health services research in alcoholism

Alcoholism has become an important health care problem for the United States and the VA medical care system. The percentage of inpatients in Veterans Administration hospitals with a diagnosis of alcoholism rose from 13.0% in 1970 to a high of 15.6% in 1977. Health services research work in alcoholism has generally fallen into four major areas: community diagnosis; utilization of services by alcoholics; the effectiveness, efficiency, and quality of services; and the organization of information systems and their applicability to alcoholism. Obstacles to research include a poor understanding of the prevalence of the disease among the veteran's population, but the system offers many more opportunities than obstacles. A new information system. SATAR (Substance Abuse Treatment Automated Records), offers a chance for large-scale investigation of the problem of alcoholism among VA patients when combined with other information systems and allows for special comparisons through its large, integrated network of hospitals and clinics.     

An ultrasonic head position interface for wheelchair control

To give quadriplegics independent mobility, a “smart” microprocessor-based electric wheelchair has been developed by the Palo Alto Veterans Administration Medical Center and Stanford University. Ultrasound distance-ranging technology is employed to track the user's head position in two-dimensional space. These data are then used to determine the chair's direction and speed. A working prototype vehicle using this type of motion control has been successfully demonstrated. Obstacle detection, wall-following, and cruise control modes are other implemented features of the current design.     

Assessment of variables contributing to Cyclosporine distribution in blood

Factors which can account for the poor correlation between whole blood and plasma Cyclosporine (CsA) levels in patients on CsA prophylaxis are evaluated. The study took account of the influence of plasma separation procedures, and the sample haematocrit on CsA distribution in the blood of renal transplant patients (n=35). CsA was measured using both specific and non-specific CsA radioimmunoassays. Significant negative correlations occurred between CsA distribution and the haematocrit, independently of the plasma separation procedure or the specificity of the assay. All results were lower when using the specific assay but a significantly higher percentage of CsA was measured in the plasma by specific assay compared to nonspecific assay when plasma was separated at both 22°C (t-test, p<0.02) and at 37°C, p<0.01). This may relate to the selective binding of CsA and its analogues by blood cells. This study is a prelude to the development of more consistent plasma separation procedures in the monitoring of this drug.     

Reactive Airways Dysfunction Syndrome (RADS) due to chlorine gas exposure

Reactive Airways Dysfunction Syndrome (RADS) has been described following exposure to various irritant gases⁽¹⁾. We describe a case of RADS occurring following exposure to chlorine gas and which has persisted at 6 years follow-up.     

Validation of the self regulation questionnaire as a measure of health in quality of life research

Objectives

Several epidemiological studies address psychosomatic ''self regulation'' as a measure of quality of life aspects. However, although widely used in studies with a focus on complementary cancer treatment, and recognized to be associated with better survival of cancer patients, it is unclear what the ''self regulation'' questionnaire exactly measures.

Design and setting

In a sample of 444 individuals (27% healthy, 33% cancer, 40% other internal diseases), we performed reliability and exploratory factor analyses, and correlated the 16-item instrument with external measures such as the Hospital Anxiety and Depression Scale, the Herdecke Quality of Life questionnaire, and autonomic regulation questionnaire.

Results

The 16-item pool had a very good internal consistency (Cronbach''s alpha = 0.948) and satisfying/good (r_rt = 0.796) test-retest reliability after 3 months. Exploratory factor analysis indicated 2 sub-constructs: (1) Ability to change behaviour in order to reach goals, and (2) Achieve satisfaction and well-being. Both sub-scales correlated well with quality of life aspects, particularly with Initiative Power/Interest, Social Interactions, Mental Balance, and negatively with anxiety and depression.

Conclusions

The Self Regulation Questionnaire (SRQ) was found to be a valid and reliable tool which measures unique psychosomatic abilities. Self regulation deals with competence and autonomy and can be regarded as a problem solving capacity in terms of an active adaptation to stressful situations to restore wellbeing. The tool is an interesting option to be used particularly in complementary medicine research with a focus on behavioural modification.     

Evolution of a computerized support system for health care capacity planning

This paper describes the evolution of a computerized support system for health care capacity planning within the Veterans Administration (VA) health care system. The VA's early attempts at computerization are described, along with the subsequent refinements made necessary by the deficiencies in those early attempts. The evolution of both the planning logic and the software configurations is set forth, along with some plans for future development.