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.     

Medical applications in the TANDEM-16 multiple computer system environment

This paper addresses the question of reliability and the TANDEM-16 approach to facilitate reliable computers. Specifically, the use of the TANDEM-16 within the medical environment is described. Three current applications within the Medical Computing Resources Center at The University of Texas Health Science Center at Dallas are developed, each characterized by different reliability considerations.     

Data base management,feedback control,and the Regenstrief Medical Record

Because of the differences in informational needs among medical practices, medical record systems should be fiexible. The use of data base management and use-oriented command languages helps to achieve flexibility. The Regenstrief Medical Record System is based upon a data base management system and two user-oriented command languages (the RDB Command Language and CARE). Most batch reports, file maintenance procedures, and ad hoc retrievals can be specified by the user by means of these two languages. This means that the user can specify which reports he wants and how they should look. Daily on-line activities are performed by application programs. The data base system also provides flexibility to these programs since the content and format of many of the display screens are defined by statements that are similar to the command language statements and are stored within a text file. The Regenstrief Medical Record System now carries records for 60,000 patients.     

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.     

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.     

A PC-based free text DSS for health care

A free text decision support system (DSS) has been constructed for health care professionals that allows the analysis of complex medical cases and the creation of a diagnostic list of potential diseases for clinical evaluation. The system uses a PC-based text management system specifically designed for desktop operation. The texts employed in the decision support package include The Merck Manual (published by Merck Sharpe & Dohme) and Control of Communicable Diseases in Man (published by the American Public Health Association). The background and design of the database are discussed, along with a structured analysis procedure for handling free text DSS systems. A case study is presented to show the application of this technology and conclusions are drawn in the summary that point to expanded areas of professional interaction and new frontiers yet to be explored in this rapidly progressing field.     

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.     

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.     

Opportunities for health services research in the VA with regard to care of the aged

The VA has recognized that it must respond vigorously to the problems of the aging veteran: the ways in which it responds can be significantly shaped by, and in turn will shape, health services research conducted in the VA medical care system. The VA has the resources necessary to conduct comprehensive, valuable research within its system—a large, aging patient population; the new Geriatric Research, Education and Clinical Centers; and the Gerontology fellows program. Despite some barriers to research on all modalities of care for the aging veteran, there are four promising areas in which enterprising health services research can be conducted: prognostic studies, community care, geriatric manpower, and clinical epidemiology.     

The use of graphic design in an interactive computer teaching program

The widespread diffusion of affordable computers into the scientific and educational community has provided the opportunity to design medical and scientific teaching programs illustrated either by hand or by utilizing commercially available software and manipulating existing computer generated images. The medical illustrator can provide the ideal aesthetic link between text format information and the visual representation of such knowledge in a concise presentation format. The availability of interactive multimedia programs has given the medical illustrator an environment to create and enhance Hypermedia designed specifically for the parpose of medical education. This paper will focus on the incorporation of illustration and screen design into “CT The Came,” an experimental medical teaching program currently being developed in the Johns Hopkins Body CT Imaging Laboratory. The program is designed to provide an enjoyable approach to learning Computed Tomography (CT), and is directed toward an audience of medical students, residents, and fellows.     

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.     

Medical informatics: An emerging medical discipline

The use of computer technology in medicine is no longer the domain of only a few “gadget” happy high-tech aficionados. The rapid pace of medical progress and the increasing demands on physicians' time mandate that mechanisms be developed to deliver the tools of contemporary information management directly into the hands ofall practicing physicians. It is with this intent that the Council on Long-range Planning and Development and the Council on Scientific Affairs of the American Medical Association have developed an informational report on Medical Informatics. The technology for producing information about medicine and patients is well into the information age. However, the technology for managing this information has not kept up, at least to the extent of being available in medical facilities where it is needed. Most users of medical information, physicians included, have not crossed the threshold into the electronic/computer era of information acquisition, distribution, and assimilation. The continuing development of the physician as computer user will create a more efficient work environment for the physician while at the same time improving patient care.     

AUTRES—The Johns Hopkins Hospital automated resume

The Johns Hopkins Hospital has developed AUTRES, an electronic discharge summary. This computer generated report was designed to provide improved continuity in the care of patients by offering a legible, standardized summary of the events of hospitalization. It can be sent by mail, FAX, or electronically (computer-to-computer) to the next care giver who will see the patient. It is available from any network attached terminal at the hospital and School of Medicine to support re-admission to the hospital, treatment in the emergency room, or outpatient visits. AUTRES first ran in fully supported production serving the Department of Medicine in 1988. Re-engineered to take advantage of cooperative processing, it has been implemented in Neurology, Internal Medicine, Obstetrics and Gynecology and Pediatrics, with plans for phased installation in the remaining clinical departments of The Johns Hopkins Hospital.     

A clinical database management system for improved integration of the veterans affairs hospital information system

The Department of Veterans Affairs (VA) Decentralized Hospital Computer Program (DHCP) contains data modules derived from separate ancillary services (e.g., Lab, Pharmacy and Radiology). It is currently difficult to integrate information between the modules. A prototype is being developed aimed at integrating ancillary data by storing clinical data oriented to the patient so that there is easy interaction of data from multiple services. A set of program utilities provides for user-defined functions of decision support, queries, and reports. Information can be used to monitor quality of care by providing feedback in the form of reports, and reminders. Initial testing has indicated the prototype's design and implementation are feasible (in terms of space requirements, speed, and ease of use) in outpatient and inpatient settings. The design, development, and clinical use of this prototype are described.     

Medical,cognitive and academic outcomes of very low birth weight infants at age 10–14 years in Ireland

Background

Low birth weight (LBW) is a leading cause of infant mortality and morbidity, and a specific risk for the development of neuro-developmental and academic problems.

Aim

To examine the medical, cognitive and academic outcomes of VLBW (<1,500 g) children, born in one maternity hospital in Dublin between 1995 and 1997.

Methods

The study employed a prospective/cohort design, with semi-structured, and standardised measures, along with the completion of a study-specific questionnaire. Ratings were obtained from parents and teachers.

Results

Of the 127 surviving VLBW cohort, 64 (50 %) consented to assessment at a mean age of 11.6 years (SD 1.0) along with a matched-weight and gender control sample of 51. VLBW children had an increased risk of chronic medical problems and neuro-sensory deficits, but without any increased use in services. Similarly, they had lower IQ (mean 89.7 compared to NBW 101.3, p < 0.001) and more were identified by teachers to have special education needs (33 % VLBW vs. 7 % NBW, p < 0.005). With regard to academic attainments, birth weight had a significant [t(98) = ?4.54, p < 0.001] and robust effect (η² = 0.17) on mathematical attainment scores. Those with lower SES fared least well off.

Conclusions

Although significant advances have been made in reducing infant mortality, there is a recognised increased risk of subsequent disability especially with decreasing gestational age, and when coupled with low SES. Having facilitated the survival of vulnerable infants, services must be available for the necessary on-going medical and educational support and treatment that they require throughout adolescent years.     

Intersecting Virtual Patients and Microbiology: Fostering a culture of learning

Background

The use and integration of Technology Enhanced Learning (TEL) resources in medical education has attracted considerable commentary and support. “Virtual Patients” are one such resource. Whilst evidence exists supporting the benefits of these resources, there has not been specific consideration of their implications for teaching microbiology; nor attention paid to both the internal and external factors that influence learner engagement with virtual patients. The principle aims of this study are to identify factors that explicitly and implicitly influence the student''s interaction with a microbiology virtual patient resource and how these interactions reflect upon the use of the resource.

Methods

A mixed method quantitative (online questionnaire; n=161) and qualitative (student focus groups; N=11) study was undertaken amongst third year medical students enrolled at Queen''s University Belfast in the academic year 2012 – 2013.

Results

The results supported prior evidence that virtual patients are a useful learning tool (mean score of 5.09 out of 7) that helped them to integrate microbiology principles with clinical experiences. How students used the virtual patients and the depth of the subsequent benefits was dependent upon their perception of the importance of the resource. This was influenced by a number of factors including how the resources were presented and positioned within the curriculum, whether they were formally examined or timetabled and the importance attributed by peers who had already completed the examinations.

Conclusion

Integration of virtual patients into the microbiology curriculum is widely endorsed and may even be considered superior to other methods of teaching. How students use these resources is dependent upon a positive perception of their importance. Educators should be aware of the factors that shape this perception when integrating TEL resources into curricula.     

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.     

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.