Insulating patients from the cost of health care: changes in the financing and regulation of health care in the past 50 years

The evolution of the current financing of health care in the United States has been outlined. Although the decisions leading to the current system have been well intentioned, the result is a costly system in which many patients are left without health insurance coverage. Two methods of reconnecting patients to the cost of care are presented (tiered co-pays and MSAs), which may be acceptable to patients. We can only hope that, over time, these types of cost-sharing methods, combined with the evolution of other patient-centric, "evidence-based" models of care (such as identification and intensive case management of high-risk cases) may lead to a more efficient and affordable system of health care in the United States.     

Who are the Informaticians? What We Know and Should Know

The beginning of the 21st century has seen a surge in interest and enthusiasm for health care information technology based on its ability to demonstrate improvements in the quality, safety, and cost-efficiency of health care. One question, however, for which we have fewer answers is “who will be the individuals that develop, implement, and evaluate these systems?” In particular, while most attention has been paid to the exemplar leaders in health information technology, less has been focused on the issue of the workforce necessary to sustain the systems to achieve their vision. The discipline of medical informatics must pay sufficient attention to the professional workforce that will deploy systems outside the informatics research setting so their benefits may more widely accrue.     

Health insurance values and implementation in The Netherlands and the Federal Republic of Germany. An alternative path to universal coverage

The health care systems in the Netherlands and the Federal Republic of Germany are based on a set of values that involve mutual obligations between private parties. These obligations are realized through systems incorporating private practice physicians, community and church- and municipality-affiliated hospitals, and nonprofit and for-profit insurers. The underlying values and implementation approaches in these systems provide an alternative to the adoption of a Canadian-style health insurance system. A discussion that focuses on "obligations" rather than "rights" may be a more useful approach for the design of reforms of the American health system in the 1990s. Such a discussion would focus on the mutual responsibility of all parties to create and maintain a universal private health care system.     

Evaluation and Certification of Computerized Provider Order Entry Systems

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance.     

An interim report of an intervention strategy for diabetes care in Jamaica

The high prevalence (17.9%) of diabetes mellitus and its attendant costs have been recognized for some time. The diabetic public has hitherto been too oriented to seeking health care at the secondary and tertiary health care centres; a much too costly approach. As a part of a wellness promotion thrust as well as an awareness and intervention strategy, a number of health care agencies have collaborated in a training programme of lay diabetes facilitators. This was intended to allow a domino effect of "each one teach one" within the community. This intervention programme was undertaken over an 18-month period. No significant changes were achieved in glycaemia levels. The impact on hospital admissions and community awareness is yet to be assessed. Laboratory results indicated good correlation between glycosuria and hyperglycaemia. This could influence the thrust in maintaining glycosuria assessment alongside blood glucose monitoring. This approach would have a cost benefit for government clinics islandwide. Whilst it may be difficult to identify any one parameter that may be responsible for change, it will be possible to assume that this intervention strategy, the only innovation in the health care delivery modalities, may have contributed.     

Smart Health Monitoring Systems: An Overview of Design and Modeling

Health monitoring systems have rapidly evolved during the past two decades and have the potential to change the way health care is currently delivered. Although smart health monitoring systems automate patient monitoring tasks and, thereby improve the patient workflow management, their efficiency in clinical settings is still debatable. This paper presents a review of smart health monitoring systems and an overview of their design and modeling. Furthermore, a critical analysis of the efficiency, clinical acceptability, strategies and recommendations on improving current health monitoring systems will be presented. The main aim is to review current state of the art monitoring systems and to perform extensive and an in-depth analysis of the findings in the area of smart health monitoring systems. In order to achieve this, over fifty different monitoring systems have been selected, categorized, classified and compared. Finally, major advances in the system design level have been discussed, current issues facing health care providers, as well as the potential challenges to health monitoring field will be identified and compared to other similar systems.     

The Business Value of Health Care Information Technology

The American health care system is one of the world''s largest and most complex industries. The Health Care Financing Administration reports that 1997 expenditures for health care exceeded one trillion dollars, or 13.5 percent of the gross domestic product. Despite these expenditures, over 16 percent of the U.S. population remains uninsured, and a large percentage of patients express dissatisfaction with the health care system. Managed care, effective in its ability to attenuate the rate of cost increase, is associated with a concomitant degree of administrative overhead that is often perceived by providers and patients alike as a major source of cost and inconvenience. Both providers and patients sense a great degree of inconvenience and an excessive amount of paperwork associated with both the process of seeking medical care and the subsequent process of paying for medical services.Traditionally, health practitioners have sought a return to traditional fee-for-service payment to mitigate the inconvenience associated with managed care. More populist proposals include universal health insurance or mandatory enrollment in health maintenance organizations. Advocates of managed care argue that the business methods required for effective trials of this approach are only beginning to be realized. By all accounts, information technology is a necessary part of these initiatives, but there is universal consensus that our current systems are inadequate to the task. (Oxford Health System''s difficulties in 1998, for example, have been attributed in part to inadequate deployment of information technology.) To this author, the model for the current generation of health care information systems is strikingly similar to that for the information systems employed by the Internal Revenue Service. In each case, the system allows for low-cost changes to administrative code brought about by legislation, but in both cases the “ripple effects” of additional complexity and administrative burden far exceed the cost of immediate change. To paraphrase a quotation attributed to Major Richard Dailey, made about his police force during the 1998 Chicago Democratic Convention, our information systems “are not here to create disorder; they are here to preserve disorder.”This case explores one alternative source for models in health care delivery. Through an examination of a typical patient experience, we explore Porter''s notion of the value chain and “just-in-time” logistics common to successful organizations like Wal-Mart and Amazon.com (see Suggested Readings). We close with a brief discussion of how these logistics and inventory systems apply to health care. Clearly, logistics are important in patient care, accounts receivable are a cause of severe working capital problems in health care, and the logistics of caring for patients are becoming more complex. But the concepts we discuss have an even greater importance: Effective management of these issues through information technology may restore our most precious commodity—time.     

Maximizing the benefits of health care information systems

Information systems can improve cost control, increase the timeliness and accuracy of patient care and administration information, increase service capacity, reduce personnel costs and inventory levels, and improve the quality of patient care. However, experience shows that most of these benefits will not occur automatically following system implementation. Operational problems may exist that diminish information timeliness, accessibility, and accuracy; policies and procedures may not have been sufficiently tailored to reflect the realities and intents of the systems; and personnel tasks may not have been adequately restructured. In order to realize the full potential of information systems, health care organizations must plan for and implement strategies that are designed to maximize such benefits. This paper describes a method for developing benefits maximization strategies. The processes used to define strategies and their outcomes are presented.     

The Informatics Opportunities at the Intersection of Patient Safety and Clinical Informatics

Health care providers have a basic responsibility to protect patients from accidental harm. At the institutional level, creating safe health care organizations necessitates a systematic approach. Effective use of informatics to enhance safety requires the establishment and use of standards for concept definitions and for data exchange, development of acceptable models for knowledge representation, incentives for adoption of electronic health records, support for adverse event detection and reporting, and greater investment in research at the intersection of informatics and patient safety. Leading organizations have demonstrated that health care informatics approaches can improve safety. Nevertheless, significant obstacles today limit optimal application of health informatics to safety within most provider environments. The authors offer a series of recommendations for addressing these challenges.This position paper focuses on next steps in using health informatics to improve patient safety. The paper does not attempt to provide a comprehensive review of patient safety-related technical accomplishments, because recent Institute of Medicine (IOM) reports have done so. This paper focuses instead on current pressing issues and opportunities for addressing them in the short-term future. The intended audience includes provider organizations responsible for the safe delivery of health care; policy makers responsible for funding and regulatory decisions that influence health care safety, and the health informatics developers community (including vendors) who build the computer systems that support patient care.     

Computerized Physician Order Entry: Helpful or Harmful?

Computerized physician order entry (CPOE) is touted as a major improvement in patient safety, primarily as a result of the Institute of Medicine''s 1999 report on medical errors and the subsequent formation of the “Leapfrog Group” of companies to preferentially direct their employees'' health care to those institutions that install such systems (as part of directives that “Leapfrog” feels will improve patient care). Although the literature suggests that such systems have the potential to improve patient outcomes through decrease of adverse drug events, actual improvements in medical outcomes have not been documented. Installation of such systems could actually increase the number of adverse drug events and result in higher overall medical costs, particularly in the first few years of their adoption.In the last five years, hospitals, including our own, have begun to use computerized systems that require physicians and other health care providers to electronically enter patient care orders.¹ Before this time, only a handful of hospitals used such systems. These computer programs contain algorithms that alert health care providers to potentially harmful therapeutic decisions before orders are processed. The installation of these systems is costly (millions of dollars) and requires major behavioral changes, not only by physicians, but also by the entire health care organization.² In January 2003, Cedars-Sinai Health System in Los Angeles removed its recently installed computerized physician order entry (CPOE) system from use after almost unanimous protest from the medical staff. Why are hospitals and other health care organizations pursuing this avenue at this time? Does the literature support the premise that these systems are beneficial for patient care? Do such systems decrease total health care costs? The answers to these questions are still evolving. In this forum, we address these questions and describe some of the pertinent medical literature on this subject.     

Self-management in adolescents with chronic illness. What does it mean and how can it be achieved?

The concept of self-management is based on the notion that it will improve wellbeing and strengthen self-determination and participation in health care, while reducing health care utilisation and health costs. Increasing self-management is a desirable goal for the 15%-20% of children and adolescents who have a significant ongoing health care need related to a chronic health condition. Promoting self-management in young people with chronic illness can be difficult for parents and health care practitioners. Doctors can help parents recognise the potentially competing aspects of the parenting role--protecting young people's health while supporting their growing independence and autonomy. Optimal care may or may not be achievable, depending on a young person's level of development. As children mature through adolescence, they increasingly want their own voice to be heard, as well as the right to privacy and confidentiality in health care consultations. As well as listening to parents and supporting their roles, doctors should see young people alone for part of the consultation, taking a psychosocial history and carefully maintaining confidentiality.     

Language barriers to informed consent and confidentiality: the impact on women's health

Obtaining informed consent and maintaining confidentiality are critical to the way we practice medicine and remain a crucial part of our medicolegal responsibility to the patient and to society. Nevertheless, little attention has been paid to these topics in populations who may have limited English proficiency. Despite research suggesting that language barriers have direct effects on health and health care delivery, many health care settings do not provide professionally trained interpreters to patients who need them. This is clearly a challenge that will only grow as our nation becomes more diverse. Perhaps nowhere is this issue more significant than in women's health, given the very personal and sensitive nature of the medical exams and interventions. As health care providers, we must conduct and facilitate research on how language barriers compromise quality of care, and we must advocate for systems and policy change.     

Analysis of the EHR Systems in Spanish Primary Public Health System: The Lack of Interoperability

This paper presents the impact of the Electronic Health Records (EHRs) systems jointly in the Spanish Primary Public Health System. Different EHRs that exist in each of the Spanish regions are discussed. Moreover, other purpose of this analysis is to identify the current state of knowledge about health information systems adoption in primary care in Spain. For the analysis and study of EHRs systems in Spain we have relied on the use of different sources, mostly items related to the study of EHRs systems in different areas. We will analyze some technical aspects of these and some of their major implications, both positive and negative. Moreover, we have resorted to make direct contact with the organizations that have implemented the EHRs systems. The result of this study leads to a main idea, the need for interoperability between different systems. We will delve into how we have reached this conclusion and that is the key to EHRs systems homogenization of Spanish territory. EHR systems used in different regions of Spain offer the access to medical information as well as provide a clinical analysis of each patient more quickly. The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap.     

The impact of holistic medicine, medical groups, and health concepts.

Holistic medicine (Greek, holos, meaning entire or whole) focuses on the whole person--mind-body-spirit, well-being, and wellness. It is a new health care movement or medical approach that is gaining momentum. The basic concepts are simple and clear, avoiding a piecemeal approach to health with treatment of one disease. Two or three physicians may form holistic medical groups, sometimes inviting nonphysician health care professionals to join. Some of these nonphysicians are not licensed, and standards need to be devised. Governmental agencies are impressed by low-cost resuits, especially with chronically ill patients. There are also groups that have spiritual health care modalities and ministrations. Nevertheless, there are commercialistic tendencies and faddism in some centers, and the literature has been criticized as being for laymen by laymen; however, the movement deserves a sympathetic hearing.     

High need patients receiving targeted entitlements: what responsibilities do they have in primary health care?

Patient responsibilities in primary health care are controversial and, by comparison, the responsibilities of high need patients are less clear. This paper aims to suggest why high need patients receiving targeted entitlements in primary health care are free to have prima facie special responsibilities; why, given this freedom, these patients morally have special responsibilities; what these responsibilities are, and how publicly funded health systems ought to be able to respond when these remain unmet. It is suggested that the special responsibilities and their place in public policy acquire moral significance as a means to discharge a moral debt, share special knowledge, and produce desirable consequences in regard to personal and collective interests. Special responsibilities magnify ordinary patient responsibilities and require patients not to hesitate regarding attendance for primary health care. Persistent patient disregard of special responsibilities may necessitate limiting the scope of these responsibilities, removing system barriers, or respecifying special rights.     

欧洲卫生服务供给模式的改革

基于WHO欧洲委员会“增加财富与增进健康的卫生系统——塔林宪章”的卫生改革框架．卫生服务的供给模式已经成为欧洲卫生改革的重点。本文从卫生服务供给的角度介绍了欧洲国家近年来所实施的改革政策与措施。通过强调转变卫生服务模式,提高卫生系统的反应性,改善卫生服务的质量,加强公共卫生、疾病预防和健康促进,以及加强卫生人力资源建设等关键措施来完善卫生服务供给模式,为我国深化卫生改革提供了可以借鉴和学习的经验。     

Perspective: Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group

Transgender patients have particular needs with respect to demographic information and health records; specifically, transgender patients may have a chosen name and gender identity that differs from their current legally designated name and sex. Additionally, sex-specific health information, for example, a man with a cervix or a woman with a prostate, requires special attention in electronic health record (EHR) systems. The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender variant persons. In September 2011, the WPATH Executive Committee convened an Electronic Medical Records Working Group comprised of both expert clinicians and medical information technology specialists, to make recommendations for developers, vendors, and users of EHR systems with respect to transgender patients. These recommendations and supporting rationale are presented here.     

The empirical object of medical informatics

Medical informatics is the science of information processing and the creation of information processing systems in medicine and health care delivery. Its methodological approach is based on the area specific applicability of a multidisciplinary theory of engineering and managing computerized information systems related to its empirical object. This paper gives a systemic view of the health care system, representing the empirical object of medical informatics.     

Primary care and health. A cross-national comparison

Ten Western industrialized nations were compared on the basis of three characteristics: the extent of their primary health service, their levels of 12 health indicators (eg, infant mortality, life expectancy, and age-adjusted death rates), and the satisfaction of their populations in relation to overall costs of the systems. Information was derived primarily from published sources. Indices were developed to characterize the extent of primary care in each country and the standing of each country relative to the others on the health indicators. There was general concordance for primary care, the health indicators, and the satisfaction-expense ratio in nine of the 10 countries. Ratings for the United States were low on all three measures. West Germany also had low ratings. In contrast, Canada, Sweden, and the Netherlands had generally high ratings for all three measures. The lack of concordance in the ratings in the United Kingdom may be a result of relatively low expenditures for other social services and public education in that country. The findings may add to the debate and deliberations concerning modifications in organization and financing of care that are currently being considered in the United States.