Goal Of Health Care Research Articles

OP101 Do We Need To Extend Health Technology Assessment To Health Enhancement Assessment?

INTRODUCTION:Several health technologies used for therapy can also be used for health enhancement. Drugs stimulating cognitive abilities are but one example. Health Technology Assessment (HTA) has not been developed for assessing enhancements. This raises the question of how HTA should address the blurred distinction between therapy and enhancement. Should we (i) carve out a distinction between therapy and enhancement and limit HTA to therapy, (ii) use HTA for both therapy and enhancement (with some modifications), or (iii) should we develop a separate health enhancement assessment (HEA)?METHODS:A literature search of the medical, philosophical, and bioethical literature was conducted for debates, arguments, and suggested solutions to the issue of therapy versus enhancement.RESULTS:The same improvement in health may be therapeutic in one patient, but an enhancement in another. Moreover, both therapy and enhancement share the same goal: increased health and wellbeing. A wide range of arguments try to establish a difference between therapy and enhancement. They refer to naturalness, rehabilitation, normality, species-typical functioning/potential, disease, sustainability, and responsibility. On closer scrutiny few of these arguments do the job in bolstering the therapy-enhancement distinction. We already use a wide range of means to extend human abilities. Moreover, the therapy-enhancement distinction raises a wide range of ethical issues that are relevant for the assessment of a number of emerging health technologies.CONCLUSIONS:Existing HTA methodology can address a wide range of non-therapeutic health enhancements. However, a series of broader issues related to the goal of health care and responsibility for altering human evolution may not be addressed within traditional HTA frameworks. Specific HEAs may therefore be helpful.

Analyzing Challenges Associated with the Implementation of Community Based Health Insurance (CBHI) in Rwanda

With the aim of achieving the fourth, fifth and sixth Millennium Development goals, since 2000 Rwanda has been striving to put much effort in reinforcing the Community Based Health Insurance scheme (CBHI). The scheme is known to be covering the largest percentage of the poorer population. Its implementation had recorded success from year to year, whereby the trend went from 1% of coverage in 2000 to 91% in 2010. However, the quick recovery of Rwanda and the success in achieving global goal of healthcare for all, there are undocumented facets of health system management that need to be documented (health care standards and poor services offered to people under CBHI policy and the mismanagement of CBHI funds). Through various documentations (local newspapers, researches), this study has addressed the roots of the above healthcare ethical issues and strategies to mitigate the extent of the problem. Firstly, Rwandan education system should train more nurses and doctors in order to increase the number of workforce in Rwandan health system. Secondly, put in place incentive mechanism to retain the existing health professionals and attract the new ones working in rural areas. Thirdly, offering more ethics related training programs to nurses and other health facilities’ staff who deal with patients. Finally, Rwandan government with other key stakeholders should rethink CBHI structure by formalizing relationship between CBHI sections at local level and the national board in charge (RSSB) as a well-structured institution in order to avoid a bizarre and recurring mismanagement of CBHI funds.

Innovation Acquisition: A Strategy for Global Scalability of the Health Promotion Agenda

Reverse innovation has been promoted as a solution to public health challenges in developing countries, but reframing the concept as "innovation acquisition" can help avoid echoes of colonialism while refocusing the innovative process on achieving specific healthcare goals.

The electronic Patient Reported Outcome (ePRO) Tool: Testing usability and feasibility of a mobile app for patients with complex chronic disease and disability in primary care settings

Introduction: People experiencing complex chronic disease and disability (CCDD) face some of the greatest challenges of any patient population. These individuals struggle to manage their many health conditions, which may be exacerbated by psychological and social challenges. Primary care providers working in integrated interdisciplinary teams also find it difficult to manage these patients’ multiple discordant conditions and symptoms, and their often complex social challenges. The electronic Patient Reported Outcome (ePRO) tool is designed to overcome some of these challenges through supporting goal-oriented primary care delivery. Using the tool patients and providers collaboratively develop health care goals on a portal which is linked to a mobile device to help patients track goal progress. Multiple providers on the patients care team can view patient goals and work together to care for patients. Theory/Methods: This study tested the usability and feasibility of adopting the ePRO tool into a single inter-disciplinary primary care practice in Toronto, Canada. We used the Fit between Individuals, Task and Technology (FITT) framework to guide our feasibility and usability assessment to explore whether the ePRO tool is, 1) feasible for adoption in inter-disciplinary primary care practices and, 2) usable from both the patient and provider perspective. This usability and feasibility pilot is part of a broader user-centred design strategy that is guiding development of the ePRO tool. We conducted a 4-week pilot study in which patients and providers used the ePRO tool to collaboratively set health related goals that patients then monitored using a mobile device. Providers and patients were separately trained to use the tool. Patients and providers set up goals on the system during an initial visit, and had at least one follow-up visit at the end of the 4-week pilot to discuss goal progression. Focus groups and interviews were conducted with patients and providers to capture usability and feasibility measures. Data from the ePRO system was extracted to provide information regarding how the tool was used. Results: A total of 6 providers and 11 patients participated in the study. Three patients dropped out within the first two weeks due to health issues, and in one case, due to increased anxiety caused by using the ePRO tool. The tool was used heavily by patients, with 8 individuals completing 210 monitoring protocols, which included over 1300 total questions. Providers and patients accessed the portal an average of 10 and 1.5 times respectively over the course of the pilot. Patients and providers found the system easy to use. Some patients reported that using the tool helped in their ability to self-manage, catalyzed a sense of responsibility over their care, and improved patient-centred care delivery. Some providers saw the tool as helping to focus conversations on goal-setting. However, the tool did not fit well with provider workflows and current processes, in particular the monitoring questions were not adequately tailored to individual patient needs, and monitoring became tedious and time consuming for patients. Discussion: Heavy tool use may be attributable to the ease of use of the tool, the noted impact on patient self-management and patient-centred care delivery, as well as the potential for the tool to improve patients’ sense of responsibility over their care. Providers were equally positive about the potential of the tool to improve efficiency and patient-centredness at the point of care, particularly if suggested changes were to be implemented. However, our assessment indicates that overall usability and feasibility of the ePRO tool was low. Concerns regarding the impact on patient-provider relationships, the repetitive nature of questions, and an inability of the system to connect with other monitoring activities that they were already completing (e.g. physical activity monitoring using other apps/devices), were among the more notable issues identified by patients. For providers they experienced difficulty integrating the ePRO tool into their daily workflow, what was exacerbated by the lack of inter-operability between the ePRO tool and the providers’ electronic medical record, which are common challenges in eHealth tool adoption. Conclusion: While our study suggests relatively low usability and feasibility of the ePRO tool, we are encouraged by the early impact on patient outcomes as well as the generally positive response from patients and providers regarding the importance, and potential of the tool to improve care delivery for patients with CCDD in integrated multi-disciplinary primary care settings. As is consistent with our user-centred design development approach, we have modified the tool based on user feedback to improve usability and feasibility and are now testing the re-developed tool through an exploratory trial.

Linking macro-level goals to micro-level routines: EHR-enabled transformation of primary care services

Information and communication technologies are known to be instrumental in the enhancement of healthcare management capabilities in developing countries. Turkey - a developing country - has undergone a major healthcare transformation marked by the redesign of primary care delivery and the implementation of a nation-wide Electronic Health Records (EHR) system. In this research, presenting Turkey's case, we investigate the consequences of EHR implementation in developing countries. We argue that to better understand the consequences, we need to link macro-level healthcare goals with micro-level system usage behaviors that actualize the macro-level goals or alternatively result in unintended negative health outcomes. We posit that this linkage is achieved through the meso-level structures, namely the EHR and the organizational context, in which it is embedded. Hence, we examine the EHR's role in this relationship. Our findings indicate that EHR usage both enables and constrains the achievement of clinicians' professional goals in the context of primary care delivery. Moreover, goal alignment between the government agency as the designer of the system and the clinicians influence the outcomes of the EHR-enabled transformation. When the healthcare goals are aligned, the system enables the clinicians to achieve their professional goals and their system usage behaviors converge, contributing to improvements in health outcomes. Contrarily, when the goals are misaligned, the system constrains goal achievement and the clinicians show divergent usage behaviors, including goal abandonment. In turn, goal abandonment may lead to negative consequences and even adversely affect the achievement of population-level healthcare goals in the long run.

Recovering disrupted social capital: insights from Lao DPR rural villagers' perceptions of local leadership.

BackgroundSocial capital is often believed to be one of the key prerequisites for successful implementation of community-based health programs. In less-developed countries, local leaders are positioned as major players in broad community health strategies and interventions, and their capacities and roles are expected to increase in prominence in future community-health-care promotions. In this study, we examined how local leaders’ capacities could be related to social capital in rural villages in Lao PDR, and thus to villagers’ willingness to participate in community-based health efforts.MethodsWe adopted a qualitative approach, conducting semi-structured interviews for both individuals and focus groups. In 2012, 103 people from six villages in the Khoun and Phoukoud districts participated in the interviews. For the individual interviews, we interviewed 22 mothers who had given birth in the past 5 years. For the focus groups, we interviewed 30 women (six groups), 30 men (six groups), and 21 senior villagers (five groups).ResultsFirst, we noted large variations in the levels of community social capital across villages: four out of six study villages showed a high level of social capital, while two villages suffered greatly from a low level of social capital. In search of the reasons for the disrupted social capital in the latter two villages, interviews revealed that failed leadership, especially in regard to local resource allocations—lack of transparency and corrupt practices—were commonly cited reasons for disrupted social capital. The data also showed that the villagers’ mistrust of these failed local leaders critically reduced their willingness to participate in community-based health efforts, and especially in those that involved resource mobilization and risk-sharing for healthcare. Finally, we found that good communication skills and participatory decision-making styles were attributes that rural villagers in Lao PDR expected of their local leaders.ConclusionThis study suggests that failed local leadership is detrimental to community participation, resource mobilization, and building communities’ social capital. To achieve intended health care goals through community-based interventions, there is a need to first support local leadership at all levels through capacity-building and improved communication within communities.

Patient and Family Experience in the Healthcare Value Equation

As outlined in the 2001 Institute of Medicine landmark paper “Crossing the Quality Chasm,” the overarching goal of healthcare is to provide safe, efficient, effective, equitable, timely, and patient-centered care (Crossing the Quality Chasm: A New Health System for the 21st Century, 2001). In addition to these six aims, the cost of care must also be considered and VALUE, our ability to achieve these aims at an affordable cost, is at the forefront of discussions across the nation. VALUE is often defined in terms of the equation: VALUE = QUALITY/COST. This definition prompts important questions about the meaning of quality and cost in healthcare. Traditionally, VALUE in medicine highlights quantitative metrics of quality such as access to services, patient safety measures, preventable conditions, peri-operative complications, re-admissions, resource utilization, and mortality. Metrics such as these are OUTCOMES that define the QUALITY of the care provided. When QUALITY is assessed, patient and family experience measures are often viewed as secondary to clinical outcome measures and relegated to a minor role or excluded all together from the value equation. We assert that in the current medical landscape, the role of patient and family experience should be considered paramount in delivering the best quality, outcomes, and safety at the lowest cost and, therefore, providing the greatest VALUE for the consumer. As such, any discussion of VALUE should include patient and family experience in the equation: $$ \mathrm{VALUE} = \mathrm{QUALITY} \left(\mathrm{Experience} + \mathrm{Clinical} \mathrm{Outcomes} + \mathrm{Safety}\right)/\mathrm{COST} $$

International Scientific Cooperation as a Tool for e-Health Promotion

Objectives: Nowadays trends in high-tech implementation is connected with introduction of value-oriented preventive medicine. This approach is seen as a tool to modernize the lifestyle with affordable funding. Method: The concept of full cycle integrated project “Development of Distant Medical Care” is discussed to be implemented in Russia within upcoming 10 years. Findings: For Russian Federation the idea of a so called full cycle integrated project was proposed. The project aims at value-based medical care organized with the help of biosensors implementation, and consists of 3 stages: the usage of foreign sensors and devices (till 2016); the formation of the Russian branch of the telemedicine sector (2016-2020); the incorporation of e-Health into the existing medical industry in the Russian Federation (after 2020). The main idea of e-Health development is neither a device, nor patients themselves, but rather the medical service as a whole. Main challenges associated with this issue are concerned. It is shown that international collaboration and acceptance of successful practices is proved to be absolutely necessary to fulfill the goal of the value-based healthcare. Telemedicine is seen as a part of arising e-Infrastructure – the organization and formation of innovative infrastructure based on digitalization. Improvements: Horizon 2020 program is shown to be a probable tool to accomplish the discussed purpose. Adoption of the existing successful approaches could contribute a lot for socio-economic development.

Make the healthy choice the easy choice: using behavioral economics to advance a culture of health.

Despite great advances in the science and technology of health care, a large gap separates theoretically achievable advances in health from what individuals and populations actually achieve. Human behavior sits on the final common pathway to so many of our health and health care goals, including the prevention and management of illness and the fostering of wellness. Behavioral economics is a relatively new field offering approaches to supplement many of the conventional approaches to improving health behaviors that rely on education or standard economic theory. While those conventional approaches presume that an educated public will naturally make decisions that optimize personal welfare, approaches derived from behavioral economics harness existing and predictable patterns of behavior that often lead people to make choices against their best interests. By keeping these predictable patterns of behavior in mind when designing health insurance, health care programs or the health-related aspects of everyday life, behavioral economists aim to meet people half-way: no longer asking them to reshape their behavior to something more health promoting, but helping the behavioral patterns they already follow lead them to better health.

From Metabonomics to Pharmacometabonomics: The Role of Metabolic Profiling in Personalized Medicine.

Variable patient responses to drugs are a key issue for medicine and for drug discovery and development. Personalized medicine, that is the selection of medicines for subgroups of patients so as to maximize drug efficacy and minimize toxicity, is a key goal of twenty-first century healthcare. Currently, most personalized medicine paradigms rely on clinical judgment based on the patient's history, and on the analysis of the patients' genome to predict drug effects i.e., pharmacogenomics. However, variability in patient responses to drugs is dependent upon many environmental factors to which human genomics is essentially blind. A new paradigm for predicting drug responses based on individual pre-dose metabolite profiles has emerged in the past decade: pharmacometabonomics, which is defined as “the prediction of the outcome (for example, efficacy or toxicity) of a drug or xenobiotic intervention in an individual based on a mathematical model of pre-intervention metabolite signatures.” The new pharmacometabonomics paradigm is complementary to pharmacogenomics but has the advantage of being sensitive to environmental as well as genomic factors. This review will chart the discovery and development of pharmacometabonomics, and provide examples of its current utility and possible future developments.

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana

BackgroundIn 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana’s health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC.MethodsUsing qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers.A stakeholders’ workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC.ResultsThe key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC.ConclusionThis study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.

The Nurse as the Patient's Advocate: A Contrarian View.

An important role for all health care professionals is to be an advocate for their patients, and there is no question that many patients need advocacy to reach their health care goals. The role of advocate takes many forms, but one is to speak up when one is concerned for the safety or well-being of a patient. A nurse is often the member of a health care team most likely to notice changes that might signal problems or poor responses to treatment. The duty of the nurse is to speak up in a timely and urgent manner when the nurse believes-or fears-that the patient's safety may be at risk. Yet the role of nurses as advocates for their patients has assumed near-mythic status. Rather than seeing advocate as one among many equally important and interrelated professional roles, the nurse, when asked, "Who are you?" is likely to give the heartfelt and passionate answer, "The patient's advocate!" This essay examines and critically analyzes the advocacy role adopted by the nursing profession and outlines the challenges it has created to nursing's contributions to collaborative practice, ethics, and policy in health care.

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana.

BackgroundIn 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana’s health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC.MethodsUsing qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers.A stakeholders’ workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from participants for the achievement of the goals of UHC and PHC.ResultsThe key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS, inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC.ConclusionThis study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC.

Prospects of a vaccine for the prevention of congenital cytomegalovirus disease.

Congenital human cytomegalovirus (HCMV) infection is one leading cause of childhood disabilities. Prevention of congenital HCMV disease by vaccination has consequently been identified as a priority public healthcare goal. Several vaccine candidates have been introduced in the past that aimed at the prevention of primary HCMV infection in pregnancy. None of these has provided complete protection, and no licensed vaccine is thus far available. An additional level of complexity has been reached by recent studies indicating that the burden of HCMV transmission and disease following non-primary infections in pregnancy may be higher than previously anticipated. Substantial progress in our understanding of the immunobiology of HCMV infection in pregnancy has fostered studies to test revised or novel vaccine strategies. Preventing HCMV transmission has been identified a surrogate endpoint, rendering the conduction of vaccine studies feasible with reasonable effort. Identification of the glycoprotein complex gH/gL/UL128-131 as a mediator of HCMV host cell tropism and evaluation of that complex as a major target of the neutralizing antibody response made manufacturers consider vaccine candidates that include these proteins. Detailed structural analyses of the neutralizing determinants on HCMV glycoprotein B (gB) have revived interest in using this protein in its pre-fusion conformation for vaccine purposes. Studies in pregnant women and in animal models have provided evidence that addressing the T lymphocyte response by vaccination may be crucial to prevent HCMV transmission to the offspring. CD4 T lymphocytes may be of particular importance in this respect. A simultaneous targeting of both the humoral and cellular immune response against HCMV by vaccination thus appears warranted in order to prevent congenital HCMV infection. There is, however, still need for further research to be able to define an immunological correlate of protection against HCMV transmission during pregnancy. This brief review will highlight recent developments in our understanding of the natural history and immunobiology of HCMV infection in pregnancy and their possible impact on the strategies for the development of an HCMV vaccine.

Preface - Access to Knowledge Revisited.

To review and update the Preface to the 1998 Yearbook of Medical Informatics, which had as its Special Topic "Health Informatics and the Internet". Assessment of the accuracy of predictions made in 1998 and consideration of key developments in informatics since that time. Predictions made in 1998 were generally accurate regarding reduced dependence on keyboards, expansion of multimedia, medical data privacy policy development, impact of molecular biology on knowledge and treatment of neoplasms, and use of imaging and informatics to advance understanding of brain structure and function. Key developments since 1998 include the huge increase in publicly available electronic information; acknowledgement by leaders in government and science of the importance of biomedical informatics to societal goals for health, health care, and scientific discovery; the influence of the public in promoting clinical research transparency and free access to government-funded research results; the long-awaited arrival of electronic health records; and the "Cloud" as a 21st century reformulation of contracting out the computer center. There are many challenging and important problems that deserve the attention of the informatics community. Informatics researchers will be best served by embracing a very broad definition of medical informatics and by promoting public understanding of the field.

What Causes Care Coordination Problems? A Case for Microanalysis.

Introduction:Care coordination (CC) is an important fulcrum for pursuing a range of health care goals. Current research and policy analyses have focused on aggregated data rather than on understanding what happens within individual cases. At the case level, CC emerges as a complex network of communications among providers over time, crossing and recrossing many organizational boundaries. Micro-level analysis is needed to understand where and how CC fails, as well as to identify best practices and root causes of problems.Coordination Process Diagramming:Coordination Process Diagramming (CPD) is a new framework for representing and analyzing CC arcs at the micro level, separating an arc into its participants and roles, communication structure, organizational structures, and transitions of care, all on a common time line.Conclusion:Comparative CPD analysis across a sample of CC arcs identifies common CC problems and potential root causes, showing the potential value of the framework. The analyses also suggest intervention strategies that could be applied to attack the root causes of CC problems, including organizational changes, education and training, and additional health information technology development.

Healthcare model with use of information and communication technology for patients with chronic disease.

The healthcare system is positioned in the patient's environment and works with other determinants of the treatment. Patient care requires a whole system compatible to the needs of organizational and technical solutions. The purpose of this study is to present a new model of patient-oriented care, in which the use of information and communication technology (ICT) can improve the effectiveness of healthcare for patients with chronic diseases. The study material is the process of healthcare for chronically ill patients. Knowledge of the circumstances surrounding ecosystem and of the patients' needs, taking into account the fundamental healthcare goals allows us to build a new models of care, starting with the economic assumptions. The method used is modeling the construction of efficient healthcare system with the patient-centered model using ICT tools. We present a new systemic concept of building patient's environment in which he is the central figure of the healthcare organization - so called patient centered system. The use of ICT in the model of chronic patient's healthcare can improve the effectiveness of this kind of care. The concept is a vision to making wide platform of information management in chronic disease in a real environment ecosystem of patient using ICT tools. On the basis of a systematic approach to the model of chronic disease, and the knowledge of the patient itself, a model of the ecosystem impacts and interactions through information feedback and the provision of services can be constructed. ICT assisted techniques will increase the effectiveness of patient care, in which nowadays information exchange plays a key role.

Positive effects of medical staffing on readmission within 30 days after discharge: a retrospective analysis of obstetrics and gynecology data.

Improving quality of care is a major healthcare goal; however, the relationship between limited resources and appropriate healthcare distribution has always been problematic. Planning for resource shortages is important for improving healthcare quality. The aim of our study was to evaluate the effects of manpower planning on improvements in quality of care by estimating the effects of medical staffing on readmission within 30 days after discharge. We conducted an observational study using 2011-14 National Health Claim data from 692 hospitals and 633 461 admissions. The database included information on uterine (including adnexa) procedures (195 270 cases) and cesarean deliveries (438 191 cases). The outcome variable was readmission within 30 days after discharge. A generalized estimating equation model was used to evaluate associations between readmission and medical staffing. The number of doctors and the proportion of registered nurses (RNs) were significantly associated with a lower risk of readmission within 30 days (proportion of RNs, Relative Risk (RR): 0.97, P values: 0.0025; number of doctors, RR: 0.96, P values: <0.0001). The number of nurses (RNs + licensed practical nurses) was not associated with readmission within 30 days (RR: 1.01, P values: <0.0001). Our results suggested that higher numbers of doctors and higher proportions of RNs were positively correlated with a lower risk of readmission within 30 days. Human resource planning to solve manpower shortages should carefully consider the qualitative aspects of clinical care and include long-term planning.

Realizing the Value of EHR Systems Critical Success Factors

Now that a majority of hospitals and primary care physicians have made the transition to electronic health record (EHR) systems, realizing value from this investment has become a major issue. The issue raises two key questions: Why do so many EHR implementations continue to fall short of achieving intended healthcare outcome goals? What differentiates those that succeed from those that fall short? This article builds on prior research using a systems framework to analyze the EHR implementation process. It focuses on ten common themes (CSFs) that appear to differentiate institutions which achieve positive healthcare outcomes from those that do not. Results are highly relevant for healthcare institutions now seeking to focus on realizing the value of their EHR systems.

Health care plan: a treatment as a piece of a puzzle. Considerations with respect to judgement of the Central Disciplinary Board for Health Care

When faced with the question whether a particular treatment is indicated, dentists have to ask themselves to what extent it fits within a health care goal. If it does not, then the indication is usually rejected because it is in conflict with professional standards. Dentists who nevertheless consider such an indication have to bear the responsibility to make clear to the patient not only the general risks of a certain treatment but also the additional risks associated with the hazardous indication.