The computerized patient record and confidentiality. The nabobs of negativism are wrong

The handwritten medical record has been the method of choice for documenting health care data since the last millennium. Given this successful tenure, it would be natural to greet any new information system that purports to be an advancement with skepticism. Moreover, physicians as a group are hardly progressive. Yet health care is taking a giant leap and is finally accepting computerization. The advantages and drawbacks of computerized information systems have long been thoroughly tested in such diverse industries as the military, banking, and the airlines. It is difficult to imagine any of these industries in their modern form without an advanced information system.     

Utilization management in Alberta's new funding environment

Although physicians have the greatest influence on the resource utilization of hospital patients, Canadian hospitals have not been too successful in bringing physicians into the resource planning and decision-making processes. This is because most hospitals have been unable to provide the information needed by physicians to participate in resource management in a meaningful way. With the introduction of a new system in the Canadian Province of Alberta that fundamentally changes the way hospitals are funded, it has become even more important to involve medical staffs in the utilization management process. This article describes the new funding system and highlights some of the ways in which Wetaskiwin Health Care Centre has leveraged information technology to support the utilization management process in this new environment.     

Physician Utilization of Computers:

This study demonstrates how social network analysis can be used to identify the underlying communication and influence structure that affects the diffusion of the use of a computer-based medical information system among physicians. Interviews, hospital records, and computer system tapes were used to collect data on referrals, consultations, and practice characteristics from 24 physicians who comprise a private group practice. Multidimensional scaling was used to spatially represent the referral and consultation network among the physicans. Also, several indices that measure structural characteristics of the network and practice characteristics of physicians were derived. Four groups of physicians were identified who have similar computer utilization patterns and who perform similar roles within the network. The results indicate that the use of network analytic techniques to study complex physician networks may provide new insights into the diffusion process.     

Health care futures. What lies ahead? Where are we going? Panel discussion

Who would have guessed that managed care would dominate the health care industry in the final two decades of the millennium? That physicians would be joining labor unions? Or that they would be going back to school to become Fellows of the American College of Physician Executives? To find out what may be in store for health care in America five to 10 years hence, The Physician Executive asked nine health care experts to participate in a two-part panel discussion. Here's what they see ahead in managed care, information technology, and biotechnology. Part 2 will appear in the July/August Issue of The Physician Executive.     

The National Practitioner Data Bank: the first 18 months

In response to a need for information on the quality of professional practice and a perceived threat to the preservation of the peer review process, as well as to concern about the cost to society of incompetent physicians, Congress passed the Health Care Quality Improvement Act of 1986. The Act established a legal basis for protecting peer review and quality assurance activities. It also established a national reporting system, the National Practitioner Data Bank (NPDB), which is intended to ensure that appropriate information is available to be used in the peer review process.     

A new industrial order for physicians: a talk with Jeff C. Goldsmith, PhD. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Jeff C. Goldsmith, PhD, President of Health Futures, Inc. on October 12, 1999 to discuss how the Internet will affect health care delivery in the millennium. One of the most profound changes that he sees is how the relationship between physicians and patients will be altered. Empowered consumers are where the real revolution is happening--a trend sometimes overlooked by physicians. Goldsmith says, "The key thing physicians have missed is that the patient is in charge of the process.... The Internet has enabled patients to aggregate their collective experience across disease entities." But there is too much information. "It is almost universally acknowledged by patients and physicians that there is a terrible quality problem. Getting from information to knowledge is a huge commercial opportunity for somebody." He doesn't think that people have put enough emphasis on the collective learning part of this new technology.     

Physician acceptance of new medical information systems: the field of dreams

Physicians often fail to embrace a complex information system, may not see its relevance to their practices, and are characteristically reluctant to invest the time and energy to be trained in its use. Why is widespread physician buy-in so difficult to achieve? From physicians overwhelmed with change to failing to begin with an adequate physician base of support, this article explores some of the reasons that physicians demonstrate little buy-in to this process and offers suggestions to help create a more successful implementation. Ways to build acceptance include acknowledging the importance of physicians as customers and training them early and often.     

The spreadsheet and physician productivity.

Friction between medical education faculty members and other physicians at St. Vincent Medical Center, Toledo, Ohio, led to a program to assess both the costs and the contribution of the teaching faculty to the overall goals of the institution. Because the existing information system proved to be unequal to the task, a specially designed spreadsheet system was developed to be used for medical education physicians. The computer-based system that was developed permits a detailed analysis of the productivity of these physicians. More important, it allowed the medical education function to provide solid justification of its efforts on behalf of the medical center.     

The impact of health care reform on group practice

Just two years ago, it would have been very difficult to imagine that reform of the health care system would today be a national domestic priority and that Congress would be considering one of the most significant and far-reaching pieces of legislation in the past 50 years. The issue is still in doubt, but it seems clear that, in this session of Congress or the next, legislation of far-reaching consequences will likely be passed. In fact, change on a widespread scale has already begun. During 1993, every state legislature except those of Nevada and Wyoming considered measures that would alter the way medical care is financed and delivered. Of the states that acted, both last year and in recent legislative sessions, eight have passed laws with the ultimate objective of ensuring access to medical care for all citizens. Government, at both the state and federal level, is clearly taking on the health care issue. The impact of reform on physicians, and thus on group practices, will be substantial. This article outlines the current course of health care reform and addresses its specific implications for the management of group practices.     

Impact of managed care on physician organizational behavior.

This article examines how physicians act, react, and organize when managed care forces them to consolidate into larger groups and business corporations. Physicians have experimented with ownership by hospitals or business corporations to gain capital, management skills, and information systems. Now they're moving toward physician-owned groups with "outsourcing" of administrative and information system functions. The mood, movement, and momentum of physicians, in short, is toward integrated physician organizations bound together by information that amplifies on their core competencies and capacities to deliver care.     

Perceived Risks from Radiation and Nuclear Testing Near Semipalatinsk, Kazakhstan: A Comparison Between Physicians, Scientists, and the Public

Determining the difference in perception of risk between experts, or more educated professionals, and laypeople is important so that a potential hazard can be effectively communicated to the public. Many surveys have been conducted to better understand the difference between expert and public opinions, and often laypeople exhibit higher perceptions of risk to hazards in comparison to experts. This is especially true when health risk is due to radiation, nuclear power, and nuclear waste. This article focuses on one section of a risk perception survey given to two groups of individuals with a more specialized education (scientists and physicians) and laypeople (villagers) in the Semipalatinsk region of Kazakhstan. All of these groups live near the former Soviet nuclear test site. Originally, it was expected that the scientists and physicians would have similar perceptions of radiation risk, while the public perceptions would be higher, but this was not always the case. For example, when perceptions of risk pertain to the health impacts of nuclear testing or the dose-response nature of radiation exposure, the physicians tend to agree with the laypeople, not the scientists. The villagers are always the most risk-averse group, followed by the physicians and then the scientists. These differences are likely due to different frames of reference for each of the populations.     

Provider satisfaction: an analysis based on expectation

Provider organizations will need to be in closer touch with their medical staffs in order to successfully anticipate and react to the many changes that lie ahead in the financing and delivery of health care services. This will mean understanding both physicians feelings and expectations. If you were asked today how satisfied your physicians are with your HMO, what would be your reply? How would you know? This staff-model HMO conducted a formal survey of its physicians to determine their expectations of the organization and their level of satisfaction with their work and environment. Such a tool is recommended for others interested in maintaining good relations with their physicians.     

Medical decision-making around the time of death of cognitively impaired nursing home residents: a pilot study

The purpose of this article is to describe the end-of-life process in the nursing home for three groups of cognitively-impaired nursing home residents: those who died with a medical decision-making process prior to death; those who died without such a decision-making process; and those who had a status-change event and a medical decision-making process, and did not die prior to data collection. Residents had experienced a medical status-change event within the 24 hours prior to data collection, and were unable to make their own decisions due to cognitive impairment. Data on the decision-making process during the event, including the type of event, the considerations used in making the decisions, and who was involved in making these decisions were collected from the residents' charts and through interviews with their physicians or nurse practitioners. When there was no decision-making process immediately prior to death, a decision-making process was usually reported to have occurred previously, with most decisions calling either for comfort care or limitation of care. When comparing those events leading to death with other status-change events, those who died were more likely to have suffered from troubled breathing than those who remained alive. Hospitalization was used only among those who survived, whereas diagnostic tests and comfort care were used more often with those who died. Those who died had more treatments considered and chosen than did those who remained alive. For half of those who died, physicians felt that they would have preferred less treatment for themselves if they were in the place of the decedents. The results represent preliminary data concerning decision-making processes surrounding death of the cognitively-impaired in the nursing home. Additional research is needed to elucidate the trends uncovered in this study.     

信息不对称对闭环供应链MTO和MTS模式的影响研究

在MTO(按订单生产)和MTS(按库存生产)两种模式下,比对了信息不对称和信息共享下产品定价、废旧品回收率和零售商利润的区别,研究结果显示:(1) 产品定价、废旧品回收率和零售商利润不受生产模式改变的影响;(2) 在某些条件下,信息共享下产品的批发价、零售价、和废旧品回收率均高于信息不对称时的相应值,进行信息共享会增加闭环供应链的总体利润,但零售商有可能通过信息共享丧失信息优势,从而使得其利润受损。因此为了促使零售商参与信息共享,信息共享参与方应投资建立安全的通信系统,以保证共享信息不被泄露。另外本文通过引入纳什讨价还价模型建立了一个公平的利润划拨机制,该机制使得最后的利润划分只取决于各参与方的议价能力,与各参与方对通信系统投资大小无关。     

The limits of medical quality assurance systems

Quality Assurance (QA) via the process of review systems is a retrospective look at what was. It is a picture of the past. Any such system is bound to have limitations, because the past cannot be changed. In QA, the ultimate aim should be to educate physicians as to where they made mistakes so that they can learn how to prevent them in the future. The distribution of what mistakes can be avoided, so that all physicians can learn from others' mistakes, takes the whole team closer to the aim of real QA--preventing mistakes. The first part of this article looks at QA in general terms; the second part looks at inherent biases that should be removed so that the team reaches the goal of bona fide quality.     

Quality versus variance: a plea for a different focus and terminology

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)     

New governance for a new era: issues and challenges for integrating systems

In this second part of a two-part column, Dr. Ruffin provides greater detail on seven key factors that he believes will govern the operations of integrated systems. Successful systems, he says, will be those that attract and retain physicians, have disciplined governance, integrate care through sharing of information among system elements, conserve capital, ensure strategic growth, control costs, and are proficient at processing information. It is important to understand, he says, that, in the movement from a fee-for-service payment mechanism, in which the various elements of the health care field bill for their services independently and according to rules designed for their benefit, to an integrated system, in which such independence can only lead to chaos, very substantial changes will be required in the governance of our health care institutions and organizations.     

A rational approach to career change

Recently, the number of physicians who have been interested in alternative careers has vastly increased. Many physicians express dissatisfaction with clinical practice, but they are uncertain about which nonclinical options are appropriate for them. Pursuing a different career after many years of studying and practicing medicine can seem like an overwhelming task. In this article, the author briefly outlines a decision-making process that can be used in analyzing career options and suggests some careers that have provided challenging opportunities for physicians.     

Super doc and real health reform

A large array of social, economic, and professional issues will have to be confronted and resolved before primary care physicians can take their logical place as leaders in the health care delivery system. Linkages will have to be forged between primary care physicians and specialists and between primary care physicians and nonphysician providers of primary care. Key to successful resolution of the current dilemma is ensuring that primary care physicians are compensated at a fair level for their skills. It is the disparity in physician incomes that lies at the heart of the problem, according to the author.     

The health care system has an eating disorder

The health care system crisis has been proclaimed and analyzed so much by economists, policy analysts, politicians, business executives, and journalists that the key statistics and phrases are becoming as familiar as the lyrics of a popular song-14 percent of the GNP goes to health care, 37 million Americans lack health insurance, too many specialists and not enough primary care physicians, etc. What I have not found is a comprehensive assessment of how the health care system got so sick. The different social science specialists focus on their respective symptoms or organs, but do not propose therapies to treat the entire organism. Ilya Prigogine's Theory of Dissipative Structures (now old hat since he won the Nobel Prize in 1977) demonstrated that self-organizing systems, be they health care systems or individual patients, respond in similar ways to the demands of illness and growth. Therefore, a clinical correlation for the health care system may have more than poetic appeal. I would like to offer the following clinical analogy for what ails our health care system.