Integrating Medical Informatics and Health Services Research: The Need for Dual Training at the Clinical Health Systems and Policy Levels

Reams of data pertaining directly to the core health services research mission are accumulating in large-scale organizational and clinical information systems. Health services researchers who grasp the structure of information systems and databases and the function of software applications can use existing data more effectively, assist in establishing new databases, and develop new tools to survey populations and collect data. At the same time, informaticians are needed who can structure databases that serve the needs of health service research and who can design and evaluate applications that effectively improve health care delivery. As long as health services researchers and informaticians work in separate spheres, however, opportunities to use data from health care encounters to improve care, expand knowledge, and develop more effective policies will be missed. This paper provides a brief exploration of 1) existing successful collaborations between health services researchers and informaticians and 2) needs and opportunities for additional joint work in several core research areas.In the 1970s, the health services researcher^* managed data on tapes, rented valuable and scarce CPU time on a mainframe computer, and often required the assistance of a programmer. By the early 1990s, the health services researcher had been freed, able to harness the power of desktop computers running database and statistical programs and, for nominal fees, having access to myriad publicly available secondary data sets on CDs, such as the National Health and Nutrition Examination Survey. Schools of public health and other training programs in clinical and health services research began to systematically teach the skills necessary to analyze these data.Today, reams of data pertaining directly to the core health services research mission are accumulating in large-scale organizational and clinical information systems. Health services researchers who grasp the structure of information systems and databases and the function of software applications can use existing data more effectively, assist in establishing new databases, and develop new tools to survey populations and collect data. At the same time, informaticians are needed who can structure databases that serve the needs of health service research and who can design and evaluate applications that effectively improve health care delivery. As long as health services researchers and informaticians work in separate spheres, however, opportunities to use data from health care encounters to improve care, expand knowledge, and develop more effective policies will be missed.     

医疗卫生领域知识服务与知识管理的理论和实践

本文首先回顾了信息服务向知识服务转变的背景及知识服务和知识管理的基本概念与内涵,简要介绍了英国医学知识服务2007～2010年计划和世界卫生组织的知识管理战略与策略,以期对我国医疗卫生领域知识服务与知识管理的研究和实践有所借鉴。文章对当前我国医疗卫生领域开展的部分知识服务与知识管理实践进行了重点介绍,主要包括一站式医学信息服务平台建设,开展国际卫生政策研究数据整合研究的探索、卫生政务信息整合共享及卫生政策研究领域的知识服务与知识管理模式的研究等,为建设我国医疗卫生领域的知识服务与决策支持平台奠定基础。     

Canada must keep single-tier health care, National Forum on Health maintains

As new knowledge and economic constraints affect the delivery of health care services, Canada is embarking on a reassessment of its medicare program. Even before the dialogue gets under way, however, the National Forum on Health that was appointed by the prime minister has already taken one firm stand by declaring that Canada must maintain its single-tier health care system.     

The Public Health Care Planning Problem: A Case Study using Geographic Information Systems

We address the problem of designing new networks for the delivery of public health care services in the United States. The paper is based on a case study design conducted with the Fulton County Health Department (Atlanta, GA). The research contribution this paper makes is twofold. First, it presents a planning methodology to deliver health care services through a mix of fixed health centers, satellite facilities, and mobile facilities. Second, it gives insights on how to use geographic information systems to design new health care service networks.     

“互联网+”社区赋能的现状及前景展望

为达到世界卫生组织提出的“人人享有卫生保健”和我国政府提出的“健康中国2030”战略目标，如何最大限度地发挥全科医疗在基层医疗保健中的主导作用成为亟待解决的关键问题。笔者对“互联网+”和“社区赋能”的概念、发展历史、发展现状和未来发展前景进行了深入的研究，发现“社区赋能”的理论体系强调通过社区成员的组织协作来提升其在基层医疗保健事业方面的控制力，优化医疗资源分配，改善社区医疗组织构架，从而全面提高基层医疗服务能力。“互联网+”的出现更是将“社区赋能”的理论付诸实现并赋予更为强大的功能。“互联网+”目前已在基层医疗服务、公共卫生、家庭签约、药品保障、医疗结算、医学教育和医疗管理等方面得到了广泛的应用，将“互联网+”与“社区赋能”相结合，可以最大限度地优化医疗资源配置，提高慢病管理的质量和效率，丰富基层卫生人才培养的手段，提升突发公共卫生事件应对能力。虽然“互联网+”与“社区赋能”的实际应用还存在部分群众认知和接受程度不高、信息和隐私的保密、法律和政策的缺失等诸多问题，但不可否认的是，“互联网+”与“社区赋能”的结合，是未来全科医学在基层卫生保健事业中发挥核心主导作用的有力武器。如何将“社区赋能”与“互联网+”有机融合，最大限度利用有限的基层医疗资源发挥最大的作用值得持续探索和总结。      

Operationalizing universal health coverage in Nigeria through social health insurance

Nigeria faces challenges that delay progress toward the attainment of the national government''s declared goal of universal health coverage (UHC). One such challenge is system-wide inequities resulting from lack of financial protection for the health care needs of the vast majority of Nigerians. Only a small proportion of Nigerians have prepaid health care. In this paper, we draw on existing evidence to suggest steps toward reforming health care financing in Nigeria to achieve UHC through social health insurance. This article sets out to demonstrate that a viable path to UHC through expanding social health insurance exists in Nigeria. We argue that encouraging the states which are semi-autonomous federating units to setup and manage their own insurance schemes presents a unique opportunity for rapidly scaling up prepaid coverage for Nigerians. We show that Nigeria''s federal structure which prescribes a sharing of responsibilities for health care among the three tiers of government presents serious challenges for significantly extending social insurance to uncovered groups. We recommend that rather than allowing this governance structure to impair progress toward UHC, it should be leveraged to accelerate the process by supporting the states to establish and manage their own insurance funds while encouraging integration with the National Health Insurance Scheme.     

Modeling patients' acceptance of provider-delivered e-health

ObjectiveHealth care providers are beginning to deliver a range of Internet-based services to patients; however, it is not clear which of these e-health services patients need or desire. The authors propose that patients' acceptance of provider-delivered e-health can be modeled in advance of application development by measuring the effects of several key antecedents to e-health use and applying models of acceptance developed in the information technology (IT) field.DesignThis study tested three theoretical models of IT acceptance among patients who had recently registered for access to provider-delivered e-health.MeasurementsAn online questionnaire administered items measuring perceptual constructs from the IT acceptance models (intrinsic motivation, perceived ease of use, perceived usefulness/extrinsic motivation, and behavioral intention to use e-health) and five hypothesized antecedents (satisfaction with medical care, health care knowledge, Internet dependence, information-seeking preference, and health care need). Responses were collected and stored in a central database.ResultsAll tested IT acceptance models performed well in predicting patients' behavioral intention to use e-health. Antecedent factors of satisfaction with provider, information-seeking preference, and Internet dependence uniquely predicted constructs in the models.ConclusionInformation technology acceptance models provide a means to understand which aspects of e-health are valued by patients and how this may affect future use. In addition, antecedents to the models can be used to predict e-health acceptance in advance of system development.     

邻里中心卫生单元对开展家庭医生服务的影响研究

目的　探讨邻里中心卫生单元对开展家庭医生服务的影响。方法　采用简单随机抽样法,在上海市闵行区马桥社区卫生服务中心下设的“吉祥坊”邻里中心卫生单元、旗忠社区卫生服务站、邻松社区卫生服务站分别抽取2017年1—9月的门诊就诊居民830、270、560例。采用本课题组自行设计的问卷,对居民进行面对面入户调查,调查时间为2017年10—11月,主要内容为居民的基本情况、对家庭医生签约服务的利用情况、就诊满意度。结果　共回收有效问卷1 600份,问卷有效回收率为96.39%。其中,邻里中心卫生单元就诊居民800例（邻里中心卫生单元组）,社区卫生服务站就诊居民800例（社区卫生服务站组）,两组性别、年龄等基本情况间无差异（P>0.05）。在签约及就诊方面,邻里中心卫生单元组居民的“1+1+1”签约率、社区首诊率、预约转诊率高于社区卫生服务站组（P<0.05）,两组居民“1+1+1”组合内就诊率、因病住院率、大病及时转诊率间无差异（P>0.05）;在健康管理服务利用方面,邻里中心卫生单元组居民接受健康评估、开具延伸处方、通过社区筛查发现疾病、依从性好的比例高于社区卫生服务站组（P<0.05）,两组居民开具慢性病延伸处方比例间无差异（P>0.05）;在中医药和康复服务利用方面,邻里中心卫生单元组居民接受过中医药和康复服务的比例高于社区卫生服务站组（P<0.05）。在就诊满意度方面,邻里中心卫生单元组居民对医生诊疗水平、医生服务态度、中医药和康复服务、预约转诊、开具延伸处方、自检项目的满意度评分及总体满意度评分高于社区卫生服务站组,对排队等候时间的满意度评分低于社区卫生服务站组（P<0.05）;两组居民对上门诊疗、健康体检的满意度评分间无差异（P>0.05）。结论　邻里中心卫生单元的设立可拉近家庭医生与居民的距离,有效提升居民的就诊满意度,有利于家庭医生制度的落实和分级诊疗制度的形成。     

以家庭医生为核心的社区卫生服务模式的构建与成效分析

在上海市新一轮社区综合改革背景下,马陆镇社区卫生服务中心通过竞聘重组家庭医生团队,建立家庭医生工作形式,明确家庭医生团队服务内容,开展家庭医生工作室建设,建立家庭医生团队为核心的内部管理机制等举措,构建以家庭医生为核心的社区卫生服务模式。从运行效果来看,模式构建后,常住人口及慢性病患者人群签约率、社区就诊率上升,基本医疗质量指标、基本公共卫生服务质量指标明显改善,社会评价指标、全科医生人力资源指标有所改善,科研能力有所提升。以家庭医生为核心的社区卫生服务模式的构建,对充分发挥家庭医生健康与费用“守门人”作用,建立有序就医格局,促进居民健康具有重要意义。     

Integrating mental health into primary care an integrative collaborative primary care model--the Jamaican experience

Many low-income countries face enormous constraints which limit the development of mental health services. The World Health Organization (WHO) made ten recommendations to facilitate the development of mental health services; among these is the integration of mental health into primary care. Jamaica developed an integrated collaborative system of mental health care through the adoption of a primary care model which is central to the delivery of mental health care. This model emphasized the integration of mental health into primary care and, in expanding the role of the mental health team, made it more collaborative. Mental health services were mainstreamed into primary care and several strategies facilitated this process. These included the training of staff in primary care, the availability of psychotropic medication in primary care facilities and the provision of mental health beds at the community level. Furthermore, focus was placed on human development and the involvement of consumers in the policy development and service delivery. This has resulted in a reduction in the population of the mental health hospital and expansion in the community mental health services.     

“互联网+”在安宁疗护领域的应用进展

通过介绍“互联网+”和安宁疗护的概念,分析“互联网+”在安宁疗护领域的优势,对“互联网+”在安宁疗护的症状监控与管理、心理与社会支持、患者健康教育与信息支持以及从业人员的信息支持及工作协调方面的应用进行梳理,总结面临的问题和发展前景,旨在为“互联网+安宁疗护”服务模式在中国进一步应用和发展提供参考。     

The Broward network for comprehensive care for AIDS: a public health response

Florida with 6,599 cases of AIDS as of January 30, 1989, and Broward County with 1,048 cases is experiencing a heavy impact on the health and social care systems, especially the public sector. The HRS/Broward County Public Health Unit, working with the Public Health Trust/Jackson Memorial Hospital in Miami, developed a case managed comprehensive network of services for persons with AIDS, emphasizing outpatient care, home health and support services. Working with community-based organizations and with the AIDS support group is critical to the success of such a project. One of the major goals is to decrease the burden on tax-assisted hospitals. Public health units in Florida are challenged to provide leadership in health care delivery to the underserved, and AIDS care is compatible with this concept. Unresolved issues remain regarding interactions with hospitals, regionalization and long-term funding.     

基层医疗卫生机构医防“五融合”健康管理服务模式研究

推进基层医防深度融合,做实家庭医生签约服务,是深化医药卫生体制改革的重要任务。本文以高血压、糖尿病健康管理为突破口,以家庭医生签约服务为载体,探索基层医防融合健康管理服务模式。通过基层医疗卫生机构内部的“管理融、队伍融、服务融、绩效融、信息融”,实现由全科医生团队统揽医疗和公共卫生服务,做到一次门诊既满足患者诊疗需求,同时也完成必需的基本公共卫生服务。医防“五融合”提供“防、治、管”一体的健康管理,既有利于提升服务质量,增强居民获得感,又有利于推动机构内部横向的基本医疗和基本公共卫生的融合及机构外部纵向的医疗资源整合。     

Health care and illness in Lihir, New Ireland Province, in the context of the development of the Lihir gold mine

During 2000 a review of health care and illness in Lihir, New Ireland Province, was carried out while I was employed as a Community Health Research Officer with the Lihir Management Company, the manager of a gold mine on Lihir. The review aim was to document the health care providers for the local population and the illness burden suffered by Lihirians, and then to shape services to have a more preventive emphasis. It was discovered that the health care services available were well utilized by Lihirians. Health care was provided by the church, government and the mining company, and needed better coordination of services. Lihirians faced a relatively heavy burden of illness, with malaria the most common affliction. They also suffered significantly from lymphatic filariasis and tuberculosis, and children were poorly nourished. A considerable number of recommendations have been adopted since the health review to improve the health of, and delivery of health services to Lihirians.     

上海市育龄妇女人工流产与生殖健康管理服务调查

  目的  了解分析上海市育龄妇女人工流产与生殖健康管理服务状况,探讨改善育龄妇女生殖健康管理服务的方法和途径,为进一步开展有效的育龄妇女性与生殖健康教育和提高生殖健康管理服务水平提供依据。  方法  2018年7月期间,选取在上海市3个行政区20家具有终止妊娠技术服务资质的定点医疗机构实施人工流产手术的3 013名育龄妇女作为研究对象,采用自行设计的调查问卷进行现场调查,采用SPSS 22.0统计学软件对数据进行统计分析。  结果  20~30岁女性是人工流产重点人群,已婚(81.1%)、已育(65.9%)女性占较大比例,教育水平分布均匀(22%~25%); 近一半(50.3%)女性是重复或多次流产,39.7%的女性“未采取任何避孕措施而导致本次怀孕”,43.1%的女性“没有怀孕的心理准备”; 网络(51.4%)是主要获得避孕知识的渠道,仍有17.6%的女性认为“人工流产对人体没有太多影响”,90.0%的女性本次人工流产手术后获得了生殖健康指导服务,86.7%的女性获得了生殖健康随访服务。  结论  大部分调查对象对生殖健康知识掌握不足,已婚已育女性生殖健康管理有待加强; 通过医教结合,构建社会-公共卫生服务机构-医疗机构的生殖健康管理模式,逐渐改变育龄女性对健康妊娠、安全性行为的认知; 顺应时代潮流不断创新育龄女性人工流产健康管理的内容和形式,构建专业权威的信息发布渠道,降低人工流产发生率。      

Overview of the veterans health administration (VHA) quality enhancement research initiative (QUERI)

The U.S. Veterans Health Administration (VHA)'s Quality Enhancement Research Initiative (QUERI) is an innovative integration of health services research, policy, and clinical care delivery designed to improve the quality, outcomes, and efficiency of VHA health care through the identification and implementation of evidence-based practices in routine care settings. A total of eight condition-specific QUERI centers are currently in operation, each pursuing an integrated portfolio of activities designed to identify and correct gaps in clinical quality and performance and to derive generalizable scientific knowledge regarding quality improvement processes and methods and their effectiveness. This overview article describes QUERI's mission, history, structure, and activities and provides a brief summary of key findings and impacts.     

A need for managed care in Saudi Arabia

Is the Kingdom of Saudi Arabia getting value for money invested in health? Quality care is being provided throughout health facilities in the Kingdom, however there is minimal control of utilization in all health sectors, consequently leading to abuse and over utilization, particularly in the public sector. Managed care programs have proven effective in reducing unnecessary inpatient and ancillary service utilization by reducing use of expensive procedures and unnecessary, highly specialized services, and shifting to less expensive care options. Health maintenance organizations are the best example of a managed health care model; tracking good performance and cost savings averaging between 20-40% compared to more traditional health plans. Key features of health maintenance organizations include serving a defined population voluntarily enrolled in the health plan; assumption of contractual responsibility and financial risk by plan to provide a range of services, and payment of a fixed periodic payment by the enrollee, independent of the actual use of services. The key characteristic that distinguishes health maintenance organizations from other delivery systems is prepayment for the care that is provided. Preferred Provider Organizations offer discounts for services received from a selected set of physicians and hospitals. Services received by enrollees are not fully reimbursed from this selected list of providers. Preferred Provider Organizations use health maintenance organizations administrative processes for controlling costs but do not include some of the intrinsic cost and quality controls of health maintenance organizations. Review of several studies indicate that patients enrolled in prepaid group practices (managed care organizations) were hospitalized 15-40% less often than those enrolled in fee-for-service health plans.     

社区孕前保健网底建设探索研究

背景　我国是出生缺陷高发国家，出生缺陷日益成为突出的公共卫生和社会问题。为降低出生缺陷，相关权威部门颁布并更新了《孕前与孕期保健指南》，国家实行免费孕前优生健康检查。由于宣传力度不够等原因，国家免费政策遇冷。目前社区缺少孕前健康教育专业人员。目的　总结上海市宝山区淞南镇社区卫生服务中心（简称中心）在孕前保健网底建设探索中取得的经验。方法　2018年3-12月，中心利用卫生计生系统合二为一、统一管理的有效模式，将卫生服务、计生指导与管理整合后的社区孕产期保健管理网络为基础，创建社区孕前保健管理网络，培养社区孕前保健管理队伍，广泛宣传孕前优生知识和国家免费孕前优生健康检查政策，将分级诊疗、上下联动的医疗模式运用于孕前保健。于宣传前后，对社区孕前保健管理队伍成员开展孕前优生知识知晓情况的调查；对服务对象开展不良孕产史、国家免费政策知晓情况、孕前优生知识知晓情况、孕前保健知识需求情况、孕前优生健康检查情况的调查。结果　淞南镇共240对夫妇438例接受了孕前保健健康教育服务。宣教后，孕前保健管理队伍成员免费孕前检查服务内容、服用叶酸时间、服用叶酸原因、人工流产后适宜受孕时间知晓率均高于宣教前（P<0.05）。宣教后，438例（100.0%）服务对象均知晓国家免费政策，高于宣教前的359例（82.0%）（P<0.05）。宣教后，服务对象孕前健康准备时间、孕前不宜接触的毒害物、孕前健康准备内容、开始服用叶酸时间知晓情况均高于宣教前（P<0.05）。宣教后，96对（40.0%）夫妇已作或已预约孕前优生健康检查。2017年按照原来的工作模式，免费孕前优生健康检查数未完成目标任务，目标任务83对，实际完成76对；2018年按照新的孕前保健工作模式，免费孕前优生健康检查数超额完成目标任务，目标任务75对，实际完成95对。结论　新创建的社区孕前保健管理网络具有较强的管理能力和专业优势，又具有成熟的社会宣传和政策执行能力，通过分级诊疗、上下联动的医疗模式拓展了社区孕前保健服务内涵，此模式运用前景广阔；对育龄夫妇进行一级干预，符合我国当下的形势需求，其简单易行、操作性较强、经济成本低、作用范围广，值得推广。     

A ‘fair innings' for efficiency in health services?

This paper reviews the severe visual focus problems of health economists-they have developed a one-sided fixation with equity issues, neglecting the efficiency agenda. The problems of meeting need are not just about access--they will vary with cost and supply. Economists in fact developed a more balanced agenda in the 1970s but have failed to follow it up. The paper defines the triple nationalisation of the National Health Service (NHS), and presents evidence that pluralism, using the purchaser/provider split, has become more efficient in long term care, home care and services for people with learning difficulties. Health economics has failed to explore options for using the dynamic forces of choice and competition for improving health services. The paper makes the case for a decision rule that "we should seek the process of health care service supply and development which maximises the delivery of high quality, lower cost user relevant services".