The Informatics Institute: why do we need it?

Why should physician executives care about medical informatics? For that matter, what is medical informatics anyway? Broadly defined, medical informatics is the study of the collection, storage, retrieval, and analysis of data and information in health care to support clinical and administrative decision making. Informatics is important because, in the past 10 years, powerful computer, software, and information technologies have been developed to enable health care organizations to automate some of the work of decision making, for improved quality of care and cost control, and for successful managed care contracting. This new emphasis on informatics in health care was the impetus for the founding by ACPE earlier this year of The Informatics Institute, which will be involved in educational and research activities in the growing area of medical informatics. In this new column in Physician Executive, Dr. Marshall Ruffin, President and CEO of the Institute, will discuss the role of medical informatics in health care delivery and financing and its relation to physician executives.     

Transfer of ownership: antidote to closure

In the 1990s, many hospitals will continue to be confronted with financial, regulatory, and medical staff issues that threaten their survival. Inadequate reimbursement, HCFA certification problems, and aging medical staffs are just a few examples of the many difficult issues health care institutions face today and that have contributed to the phenomenal number of failing hospitals. Failing hospitals must consider all their options, such as turnaround process, modification of service mix, change to a specialty hospital, transfer to a new owner, or closure. Selection of the most appropriate option hinges on the hospital's goals and mission, its need in the community, and its owner's and sponsor's desire or ability to continue in the health care business. This article will discuss the transfer of ownership option.     

Informed decision making: the new paradigm

Health care cannot survive in its present form. It is becoming unaffordable for a large share of the country's population. Its quality and effectiveness inexplicably vary between communities and across time. With all these problems, the process of health care can be understood. All that are needed are good, basic data; its access, management, and analysis; and then presentation of facts and observations. Together, these functions describe the translation of data into information--the field of medical informatics. Information about such management concerns as clinical efficiency (which largely is related to appropriateness and cost-effectiveness) and about the realities of day-to-day medical practice can be used to improve the value of health care. Informed decision making is based solely on confidence that, given the right information and understanding, we can all make the right decisions. The right decisions mean better patient acceptance and satisfaction, a sense of value enhancement by payers, and support of the Hippocratic tradition.     

Stakeholder Actions and Their Impact on the Organizational Cultures of Two Tobacco Companies

We link the behaviors of executives and lawyers in two tobacco companies, in defending their tobacco products to the actions of stakeholders (e.g., the U.S. Government and Congress, medical researchers, consumers, public‐health organizations, tobacco‐control advocates, and insiders who have spoken out). Included in our analysis, which is based on publicly available documents spanning over a period of almost six decades, are critical incidents in which moral disengagement tactics were applied in the decision‐making process. We infer that the disengagement tactics applied by tobacco decision makers are indicative of what Schein and other organizational scientists describe as organizational culture. We equate the critical incidents to the espoused beliefs and values and underlying assumptions which comprise organizational culture and explain that the cultures of these two tobacco companies are not consistent with the stakeholder theory of management. We conclude that the critical incidents we analyze were immoral and the representatives were indeed accountable for these behaviors. From an organizational change perspective, we discuss how analyzing these critical incidents can serve to assess the extent to which an organizational culture is ethical. Furthermore, these critical incidents can be fed back to organizational decision makers and can then be used to initiate organizational changes.     

A study of expediting practices in manufacturing firms

Abstract

This paper presents the results of an empirical investigation of one of the most common yet least optimized production management practices—expediting. The intention of this study was to generate quantitative insight into issues that underlie expediting decision making, such as the relative frequency of various causes of expediting, commonly used expediting strategies and tactics, and the interaction of expediting and the production scheduling environment in use. The study centered around a survey sent to 1768 manufacturing staff personnel, with 182 usable questionnaires returned. It is hoped that the data and conclusions presented in this paper will be of use to production management researchers who are interested in expediting as a managerial decision.     

Where does informatics fit in health care organizations?

Why is medical informatics important to health care leaders? As an emerging science, informatics focuses on applying computing and communication technology to decision making for clinicians and managers. It enhances the understanding of how information and communication systems can impact the work health care managers must accomplish. As the cost of technology for digital information management continues to decline, organizations and individuals will look for ways to offset the human costs of managing and conveying information. The way of the paper medical record is being replaced by the less expensive and more efficient digital information systems. Leaders of health care organizations need to look for every opportunity to deploy networks and computers to reduce the labor costs of data collection, storage, retrieval, and analysis.     

Physician and nonphysician managers as decision makers: are the differences justified or just an illusion?

If the cost of health care is to be curtailed, it is necessary to understand physician behavior and decision making. Not only is physician decision making critical from a clinical perspective, but, as the number of physician executives increases, they must be able to integrate their clinical expertise and management skills into the business context. This article explores differences in decision making methods between physician and nonphysician managers.     

Intelligence gathering for decision making

Empirical studies of decision making seldom consider the intelligence gathering activities required for decision making. In an attempt to fill this void, this study set out to identify and assess some of the key steps in gathering intelligence, considering the difficulty of the decision and available resources. The study found performance gapping and premising to be crucial activities and explored how each is carried out. A variety of premising and gapping tactics were uncovered, with some having better success than others. These tactics were found to influence the search approach selected to uncover alternatives and the success of the resulting decision. The best results were noted when search efforts are guided by needs documented with a quantitative performance gap; and when formal search or negotiation is used to identify alternatives. These findings hold for decisions that have high and low difficulty and for those with high and low resource support. The implications of these findings for decision makers and decision making are discussed.     

Re-forming the traditional organization medical staff

The traditional, two-bylaws-model organized medical staff was created in another age (1919) to serve a simple health care system, controlled by physicians, in which the only players were patients, doctors, nurses, and small hospitals. This medical staff model does not meet the needs of the U.S. health care system of the 1990s. The purpose of this article is to provide the physician executive with a resource to use when he or she is called on to help determine what, if any, changes are needed in his or her organization to make the role of physician leaders more effective. Finding the right answer to this question is part of discovering ways to reduce health care costs without reducing the funds available to pay for direct delivery of health care services. Maintaining traditional, bureaucratic, legalistic organized medical staff activities is a very expensive game that we can no longer afford to play.     

MedDigital trends and tactics to lead into the future

Physician executives need to harness appropriate digital technology by understanding key trends and implementing best tactics. Being and doing MedDigital means taking back control and improving care--and, at the same time, improving efficiencies and the bottom line. This article presents seven e-trends that are shaping health care: (1) Consumers and patients are pushing doctors to go digital; (2) from Web health information to MedDigital decision support; (3) beyond managed care to custom health; (4) wireless is the way of the new world; (5) Passive web portals yield to digital destinations; (6) e-commerce means lower transaction cost; and (7) develop e-health care ROI methodologies and track results. The authors provide myriad examples of new technology that will revolutionize health care and provide both physicians and consumers with valuable interactive tools to enhance health, treatment, and decision-making.     

Dispensing death,desiring death: an exploration of medical roles and patient motivation during the period of legalized euthanasia in Australia

A qualitative case study was conducted to explore the clinical decision making processes that underpinned the practice of euthanasia under the Rights of the Terminally Ill (ROTI) Act. The key informant for this research was Philip Nitschke, the general practitioner responsible for the legal cases of euthanasia. His information was supported by extensive document analysis based on the public texts created by patients in the form of letters and documentaries. Further collaborating sources were those texts generated by the media, rights groups, politicians, the coroner's cort, and the literature on euthanasia and assisted suicide. A key study finding was that the ROTI legislation did not adequately provide for the specific medical situation in the Northern Territory, Australia. The medical roles, as proscribed by the legislation, carried many inherent assumptions about the health care context and the availability of appropriately qualified medical staff committed to providing euthanasia. These assumptions translated into difficulties in establishing clinical practices for the provision of euthanasia. A further finding concerned the motivations of those who requested euthanasia. This article addresses the medical roles and the motivations of those seeking euthanasia.     

Managing health care quality.

Using the cited principles of professional staff credentialing and quality assurance, a department chairman, medical director, or other health care executive will be in an excellent position to assess quality of care against established standards and manage problems in the routine provision of medically appropriate care. He or she will also be able to assure the hospital's board that the hospital and its medical staff are well positioned to meet future challenges to provide effective quality, utilization, and risk management.     

Patient Hochschulmedizin

Patient university medicine. Changes of the legal framework of university hospitals in the context of the German health reform The situation of university of medicine can be compared to that of ?a servant of two masters“. Issues of performance and financing as well as legal regulations and administrative procedure have their roots in both the academic and the health system. While medical training is unthinkable without hospital practice, the ?supra-maximalist care“ produced by university hospitals is absolutely essential in the interest of public health. Out of the complexity of teaching, research and medical care grow valuable additional results but also above average costs which could reduce the competitiveness of university hospitals, once the change of financing to DRGs as a consequence of health reform is generally applied. The problem is made worse by outdated academic decision structures, by unsuitable buildings and by the lack of public funds for their structural maintenance and modernization. With this situation in mind the Federal States of Germany in the mid nineties began to search for alternative sources of investment and for a more efficient legal framework. The article explores the question which proposed solutions were subjects of discussion and why the concept of a public law institution became the favourite in the end.     

A model for long range planning in higher education

In essence this paper proposes a model for a systematic, continuous instructional planning process to develop strategies and tactics for those institutions of higher education desiring perpetuation, growth, and flexibility to meet changing needs in a changing environment and organization.The model accounts for a viable structural linkage of the many organizational components, and the several kinds of information and decision making processes which are important to the successful functioning and growth of already complex organizations.The model also, even though somewhat implicity, includes procedures which are self-orienting to the personnel involved and thus which facilitate the maintenance of a realistic, flexible, theoretically based approach to planning processes important to the well being and the growth and development of the personnel involved.     

Physician perspectives on the structure and function of group practice HMOs

This article explores physicians' perspectives regarding how their HMOs function and their satisfaction with and loyalty to HMOs. Three HMOs were studied: a mature (28-year-old) staff model, a 16-year-old staff model, and a 13-year-old group model with both HMO and fee-for-service patients. While these HMOs were found to vary somewhat in terms of emphasis on patient care versus costs, methods used to control costs and degrees of centralization of decision making, they all received high overall satisfaction and loyalty scores. The staff model HMO with a more decentralized decision making structure received the highest satisfaction/loyalty score from its physicians. The degree to which physicians perceive the HMO to be effective and supportive and the use of educational programs and peer review to influence resource use were also found to be significantly related to physician satisfaction and loyalty.     

Reporting quality of health care to the board

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care--i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding more information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organizationwide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process, they will not be addressed in this article.     

Health care applications of complexity science. Life at the edge of chaos

The authors explore complexity science, a relatively new field of inquiry, which holds for both clinicians and health care leaders the real possibility of stimulating fresh insights and approaches to health and medical care-both its provision and its organization. Two case studies are presented to illustrate how complexity theory can provide health care leaders with a new perspective on how to address the myriad challenges they confront daily: (1) a patient with dissociative identity disorder; and (2) a physician task group charged to advise on hospital medical staff reorganization and governance. These case studies help clinicians and leaders of health care organizations understand how complexity: (1) may be relevant, even helpful, as they consider difficult challenges in both patient and organizational management; and (2) might emerge as a synthesizing force as they face the extraordinarily complicated task of jointly creating integrated health care systems. A resource section is provided for those who may wish to further pursue the topic.     

Elevating the role of medical informational officer

Consider the reasons why a chief medical informatics officer should be part of the senior management team of a health care organization.     

Demand rising for medicine's rarest birds

The prognosis from most quarters is that the U.S. health care delivery system is moving inexorably toward managed care. The final form that managed care takes under whatever health reform measure finally takes shape in Washington is still in doubt, but it is clear that care will be managed in the future. It also seems increasingly clear that the system evolving will require more primary care providers, and that they will occupy some very key decision-making roles in the clinical firmament. In this article, staff writer Donna Vavala brings together the thoughts and predictions of several health care leaders on this critical topic in medical management.     

Unexplained clinical variance: are health plans (partly) responsible?

More research is needed to determine if health plan decision making is contributing to clinical variance in health care. But an informal survey shows it is.