Quality Of Health Service Delivery Research Articles

An Assessment of the National Health Insurance Scheme in the Sekyere South District, Ghana

As part of government’s pro-poor strategy to increase access to and improve the quality of basic healthcare services, the National Health Insurance Act (National Health Insurance Authority, 2003, 2010 and 2013) was passed in 2003. The study assessed 379 heads of household, 5 heads of health facilities and the scheme managements’ perception on quality of health service delivery, implementation of the capitation programme, operation of the National Health Insurance Scheme (NHIS) and performance of scheme operators and service providers in the Sekyere South District of Ghana. Findings indicate that 73.9% of the heads of household had registered for NHIS and out of this figure 74.5% had renewed their cards. Despite a high renewal level, 30.3% are not satisfied with the services provided. With the introduction of the capitation grant, 25% of private service providers have withdrawn their services due to inadequate per capita payment on the scheme and 17.3% of the heads of household had difficulty in tracing their names at their preferred choice of health facility which have the tendency of affecting the sustainability of the NHIS. The study therefore recommends that, the National Health Insurance Authority should ensure upward adjustment of the monthly per capita payment made to service providers to reflect reality and also intensify education on the capitation policy for both service providers and the scheme beneficiaries.

The Impact of Transparency on Quality of Health Service Delivery in Bangladesh: Findings of a Field Survey of Rural and Urban Health Service Organisations

Bangladesh has gained a glorious achievement in the quantitative reduction of maternal and child mortality in the recent past. But, the quality health service delivery still needs much improvement. This is considered as a big challenge facing the Government of Bangladesh in general and the agencies providing health care services to the people. This study endeavours to explore how organisational management, electronic devices, socio-economic and political factors impact on transparency in delivering good quality health care. This study selects two health service organisations of rural and urban areas for understanding the issues surrounding transparency and quality health service provision. This study used 68 in-depth interviews and five focus group discussions for gathering the required data. The urban health service organisation provides slightly improved transparent health care delivery because of better physical communication, adequate supervision and participative civil society organisation. However, general community has limited participation to both the rural and the urban health service organisations for lack of their education, poverty and bureaucratic mis-management in the organisations. Electronic devices contribute significantly for promoting transparent health service delivery, although resource constraints have posed a big challenge. Inadequate transparency contributes to corruption and absenteeism of health professionals which has an impact on quality health care provision. Participation of local elected representatives through adequate decentralisation and strengthening information management system in health care organisations can improve transparency and quality health service delivery.

Human Papillomavirus Vaccine Knowledge and Attitudes, Preventative Health Behaviors, and Medical Mistrust Among a Racially and Ethnically Diverse Sample of College Women.

Medical mistrust is associated with disparities in a variety of health outcomes. The human papillomavirus (HPV) vaccine has the potential to decrease disparities in cervical cancer by preventing infection with the virus that causes these malignancies. No study has examined associations between medical mistrust and preventative health behaviors including the HPV vaccine among young minority women. Self-reported racial/ethnic minority students completed a web-based survey in fall of 2011. Wilcoxon and Kruskal-Wallis were used to test differences in medical mistrust scores by demographics and health behaviors. Medical mistrust varied significantly by race with Black women reporting the highest scores. Women with no regular health-care provider (HCP) or who had difficulty talking to their provider had higher mistrust. Higher medical mistrust was associated with a preference to receive HPV vaccine recommendation from a HCP of the same race or ethnicity among unvaccinated women. Black and Asian women who had not received the HPV vaccine had higher mistrust scores than vaccinated women. Perceived difficulty in talking to a HCP was associated with ever having a Pap smear. Awareness of medical mistrust and the influence on health behaviors may aid in increasing delivery of quality health services for racial and ethnic minority populations. Further research among different populations is needed to elucidate impacts of medical mistrust and provider communication on preventative health behaviors.

Out-of-pocket Costs for Medicines among Community-dwelling Older People in New Zealand

Psychotropic medicines associated with significant drug related morbidity and mortality are commonly used in RACFs. There is increasing evidence of a relationship between organisational culture and the quality of health service delivery. According to Schein, organisational culture includes visible behaviour, shared values and underlying assumptions and is influenced by organisational managers. The aim of this study was to investigate the relationship between organisational culture and psychotropic medicine use in RACFs and the role of the manager. Methods: Ethical approval was obtained for this qualitative explorative study, conducted in 8 RACFs within NSW, Australia. Purposive sampling was used to recruit on-site staff [managers (8), registered nurses (11), nursing assistants (5)] and visiting staff [doctors (8), pharmacists (7), nurse practitioners (1), clinical nurse consultants (1), specialist medical practitioners (1)] for participation in a semi-structured interview. The interview guide was based on Schein’s theory. Interviews were conducted between September 2012 and July 2013, digitally recorded and transcribed verbatim. The method of constant comparison was used to derive themes. Results: Analysis revealed features of organisational culture related to the use of psychotropic medicines in RACFs, with four major themes emerging: espoused values for resident care; inter-professional collaboration; adoption of quality improvement interventions; and staff work-load. Prioritisation of non-pharmacological management was established by RACF managers and shared by staff. Several mangers promoted inter-professional collaboration which facilitated quality use of psychotropics. Managers’ implementation of interventions to review psychotropic prescribing varied amongst RACFs. Majority of staff recognised the impact of work load on the preference for psychotropics use. Conclusions: RACF managers shape the culture of the organisation by the promotion of values and practices directed at quality use of psychotropic medicines. Strategies designed to address psychotropic prescribing in RACFs should consider organisational culture and enlist the support of managers to ensure successful implementation.

Family Planning and Health Commodities Security in Nepal

Background: Commodity security is essential for effective delivery of quality health services. Commodity security exists when people are able to choose, obtain and use products whenever they need them. With leadership of Government of Nepal’s Logistics Management Division and with technical assistance from United States Aid for International Development funded projects have been consistently working toward this goal with priority to Family Planning (FP), Reproductive Health, and Maternal Child Health commodities. Methods: A National Consensus Contraceptive Security Forecast meeting is held annually at center. The meeting is participated by Regional, District, Program Divisions, National Planning Commission, Ministry of Finance, External Donor Partners, Social Marketing agencies, and Non Governmental Organizations (NGO). The quantity needed, shipment schedule, funding requirement and funding shortfall, distribution and storage strategies for the Public, Social Marketing, and NGO sectors are presented for next five years. Results: With secured funding, increased availability of family planning commodities (stock-outs rate is less than 2%) at service delivery sites have contributed to improve national health indicators like Total Fertility Rate and Contraceptive Prevalence Rate. Key program interventions have ensured FP commodity security through effective coordination of public, private and external donor partners. Conclusion: Key lessons learned was a spirit of ‘Teamwork’ and good coordination –active involvement of other stakeholders is essential for ensuring FP commodity security. Other was an importance of ‘Advocacy’ for commodity security at district, regional and central levels of government and among stakeholders. Challenges are complexity of public procurement procedure and frequent transfer of trained staff, and distribution and transportation of health commodities from district to health facilities still poses a challenge to supply chain management. Nepal Journal of Medical Sciences | Volume 03 | Number 01 | January-June 2014 | Page 51-56 DOI: http://dx.doi.org/10.3126/njms.v3i1.10359

Application of Balanced Scorecard in the Evaluation of a Complex Health System Intervention: 12 Months Post Intervention Findings from the BHOMA Intervention: A Cluster Randomised Trial in Zambia

IntroductionIn many low income countries, the delivery of quality health services is hampered by health system-wide barriers which are often interlinked, however empirical evidence on how to assess the level and scope of these barriers is scarce. A balanced scorecard is a tool that allows for wider analysis of domains that are deemed important in achieving the overall vision of the health system. We present the quantitative results of the 12 months follow-up study applying the balanced scorecard approach in the BHOMA intervention with the aim of demonstrating the utility of the balanced scorecard in evaluating multiple building blocks in a trial setting.MethodsThe BHOMA is a cluster randomised trial that aims to strengthen the health system in three rural districts in Zambia. The intervention aims to improve clinical care quality by implementing practical tools that establish clear clinical care standards through intensive clinic implementations. This paper reports the findings of the follow-up health facility survey that was conducted after 12 months of intervention implementation. Comparisons were made between those facilities in the intervention and control sites. STATA version 12 was used for analysis.ResultsThe study found significant mean differences between intervention(I) and control (C) sites in the following domains: Training domain (Mean I:C; 87.5.vs 61.1, mean difference 23.3, p = 0.031), adult clinical observation domain (mean I:C; 73.3 vs.58.0, mean difference 10.9, p = 0.02 ) and health information domain (mean I:C; 63.6 vs.56.1, mean difference 6.8, p = 0.01. There was no gender differences in adult service satisfaction. Governance and motivation scores did not differ between control and intervention sites.ConclusionThis study demonstrates the utility of the balanced scorecard in assessing multiple elements of the health system. Using system wide approaches and triangulating data collection methods seems to be key to successful evaluation of such complex health intervention.Trial numberClinicalTrials.gov NCT01942278

Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter?

BackgroundAs health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada.MethodsCross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity.ResultsLow income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only.ConclusionsPrimary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations.

Gender-based distributional skewness of the United Republic of Tanzania's health workforce cadres: a cross-sectional health facility survey.

BackgroundWhile severe shortages, inadequate skills and a geographical imbalance of health personnel have been consistently documented over the years as long term critical challenges in the health sector of the United Republic of Tanzania, there is limited evidence on the gender-based distribution of the health workforce and its likely implications. Extant evidence shows that some people may not seek healthcare unless they have access to a provider of their gender. This paper, therefore, assesses the gender-based distribution of the United Republic of Tanzania’s health workforce cadres.MethodsThis is a secondary analysis of data collected in a cross-sectional health facility survey on health system strengthening in the United Republic of Tanzania in 2008. During the survey, 88 health facilities, selected randomly from 8 regions, yielded 815 health workers (HWs) eligible for the current analysis. While Chi-square was used for testing associations in the bivariate analysis, multivariate analysis was conducted using logistic regression to assess the relationship between gender and each of the cadres involved in the analysis.ResultsThe mean age of the HWs was 39.7, ranging from 15 to 63 years. Overall, 75% of the HWs were women. The proportion of women among maternal and child health aides or medical attendants (MCHA/MA), nurses and midwives was 86%, 86% and 91%, respectively, while their proportion among clinical officers (COs) and medical doctors (MDs) was 28% and 21%, respectively. Multivariate analysis revealed that the odds ratio (OR) and 95% confidence interval (CI) that a HW was a female (baseline category is “male”) for each cadre was: MCHA/MA, OR = 3.70, 95% CI 2.16-6.33; nurse, OR = 5.61, 95% CI 3.22-9.78; midwife, OR = 2.74, 95% CI 1.44-5.20; CO, OR = 0.08, 95% CI 0.04-0.17 and MD, OR = 0.04, 95% CI 0.02-0.09.ConclusionThe distribution of the United Republic of Tanzania’s health cadres is dramatically gender-skewed, a reflection of gender inequality in health career choices. MCHA/MA, nursing and midwifery cadres are large and female-dominant, whereas COs and MDs are fewer in absolute numbers and male-dominant. While a need for more staff is necessary for an effective delivery of quality health services, adequate representation of women in highly trained cadres is imperative to enhance responses to some gender-specific roles and needs.

Promoting patient-centred care through staff development

Providing good patient care is integral to service provision at North Middlesex University Hospital NHS Trust and evaluating patient satisfaction is one way in which the trust can ensure high quality health service delivery. This article provides an overview of actions taken by the trust following a disappointing patient satisfaction survey in 2009. This included a new staff development training initiative for the workforce, which provided an opportunity for inter-professional learning and reflection on individual professionals' attitudes, while that offered potential opportunities for change in performance. A post-training evaluation indicated levels of knowledge and understanding had increased among participating staff.

Regulations Initiatives in France for the Interoperability of Communicating Medical Devices

Telemedicine has introduced new challenges in health delivery with the introduction of advanced information communication technologies in home care medicine. To meet the high standard of quality in health service delivery, the data flow of medical data must be maintained, which implies harmonization and standardization frameworks within the field of the communicating medical devices. Those medical devices must be certified to prove their effectiveness and compliance with the requirements on health and safety of patients, before to be brought into service or used. But there is no requirement concerning the interoperability of these communicating medical devices. A group of French experts have anticipated the need in developing projects to define communication medical device in the home and by taking part in standardization projects on the interoperability of data and systems in health. They first identified the standardization rules at European and national level and confirmed that most guides and directives are well available. They based their study on three specialties, commonly using medical devices and telemedicine and covering various use cases. Then, they defined a methodology following the IHE International and Continua Alliance approach in order to define the integration profile. Eventually, they defined a generic workflow and an inventory of the integration profiles, norms and standards that can support this generic workflow.

Experiences, opportunities and challenges of implementing task shifting in underserved remote settings: the case of Kongwa district, central Tanzania

BackgroundTanzania is experiencing acute shortages of Health Workers (HWs), a situation which has forced health managers, especially in the underserved districts, to hastily cope with health workers’ shortages by adopting task shifting. This has however been due to limited options for dealing with the crisis of health personnel. There are on-going discussions in the country on whether to scale up task shifting as one of the strategies for addressing health personnel crisis. However, these discussions are not backed up by rigorous scientific evidence. The aim of this paper is two-fold. Firstly, to describe the current situation of implementing task shifting in the context of acute shortages of health workers and, secondly, to provide a descriptive account of the potential opportunities or benefits and the likely challenges which might ensue as a result of implementing task shifting.MethodsWe employed in-depth interviews with informants at the district level and supplemented the information with additional interviews with informants at the national level. Interviews focussed on the informants’ practical experiences of implementing task shifting in their respective health facilities (district level) and their opinions regarding opportunities and challenges which might be associated with implementation of task shifting practices. At the national level, the main focus was on policy issues related to management of health personnel in the context of implementation of task shifting, in addition to seeking their opinions and perceptions regarding opportunities and challenges of implementing task shifting if formally adopted.ResultsTask shifting has been in practice for many years in Tanzania and has been perceived as an inevitable coping mechanism due to limited options for addressing health personnel shortages in the country. Majority of informants had the concern that quality of services is likely to be affected if appropriate policy infrastructures are not in place before formalising tasks shifting. There was also a perception that implementation of task shifting has ensured access to services especially in underserved remote areas. Professional discontent and challenges related to the management of health personnel policies were also perceived as important issues to consider when implementing task shifting practices. Additional resources for additional training and supervisory tasks were also considered important in the implementation of task shifting in order to make it deliver much the same way as it is for conventional modalities of delivering care.ConclusionsTask shifting implementation occurs as an ad hoc coping mechanism to the existing shortages of health workers in many undeserved areas of the country, not just in the study site whose findings are reported in this paper. It is recommended that the most important thing to do now is not to determine whether task shifting is possible or effective but to define the limits of task shifting so as to reach a consensus on where it can have the strongest and most sustainable impact in the delivery of quality health services. Any action towards this end needs to be evidence-based.

Developing clinical governance in a service for people with intellectual disabilities

Purpose – Clinical governance has become internationally recognised as a whole‐system framework for the continuous improvement of quality in health service delivery. This study aims to explore the issues in implementing a comprehensive clinical governance framework in an organisation that provides services to children and adults with intellectual disabilities supported by a wide range of clinical interventions and therapies.Design/methodology/approach – This was an action research study that utilised a co‐operative inquiry approach because of its capacity to facilitate engagement in a collaborative “bottom‐up” meets “top‐down” process amalgamating theory with organisational priorities to achieve practical and planned change. Action research methodologies use a problem solving approach, focus on real‐life issues, and are open and inclusive. The study aimed to identify current practices in inter‐disciplinary team working including the measurement and monitoring of quality, and to design collaboratively an i...

International primary care and the RCGP: the College’s role in global health

In 1978 the World Health Organization (WHO) made a public declaration in Alma-Ata advocating the use of primary healthcare systems globally.1 Twenty-two years later the United Nations (UN) agreed eight Millennium Development Goals (MDGs) to be attained by 2015.2,3 Core to the delivery of them, although not explicitly mentioned, is the primary healthcare model as set out in the Alma-Ata Declaration. In 2008 the WHO Regional Office for Europe reiterated that effective primary health care was essential to the delivery of quality health services for individuals and populations by publishing the Talinn Charter.4 This too included a commitment to attain the Charter’s targets by 2015. As we approach the 2015 deadlines for both the MDGs and the Talinn Charter, governments and policy makers are increasingly interested in primary health care. At the Royal College of General Practitioners (RCGP) we observe this by a steadily growing number of international requests to support primary care development. We are entering a critical window of political activity in health funding and global health systems reform. The MDGs committed world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The goals related to the eradication of disease specifically drew international attention to communicable diseases (including HIV/AIDS, malaria, and tuberculosis) and focused resources on vertical models of health care for disease-specific diagnoses and treatment. This diverted attention away from the implementation of a horizontal model of primary health care with its less immediate yet longer-term benefits as demonstrated so clearly by Barbara Starfield.5 This imbalance in systems reform was recognised in 2012 when the UN General Assembly published a political declaration on the prevention and control of non-communicable diseases (NCDs).6 The document acknowledges the need to address the …

Global Quality Imaging: Improvement Actions

Workforce shortage, workload increase, workplace changes, and budget challenges are emerging issues around the world, which could place quality imaging at risk. It is important for imaging stakeholders to collaborate, ensure patient safety, improve the quality of care, and address these issues. There is no single panacea. A range of improvement measures, strategies, and actions are required. Examples of improvement actions supporting the 3 quality measures are described under 5 strategies: conducting research, promoting awareness, providing education and training, strengthening infrastructure, and implementing policies. The challenge is to develop long-term, cost-effective, system-based improvement actions that will bring better outcomes and underpin a sustainable future for quality imaging. In an imaging practice, these actions will result in selecting the right procedure (justification), using the right dose (optimization), and preventing errors along the patient journey. To realize this vision and implement these improvement actions, a range of expertise and adequate resources are required. Stakeholders should collaborate and work together. In today's globalized environment, collaboration is strength and provides synergy to achieve better outcomes and greater success.

Makerere University College of Health Sciences’ role in addressing challenges in health service provision at Mulago National Referral Hospital

BackgroundMulago National Referral Hospital (MNRH), Uganda’s primary tertiary and teaching hospital, and Makerere University College of Health Sciences (MakCHS) have a close collaborative relationship. MakCHS students complete clinical rotations at MNRH, and MakCHS faculty partner with Mulago staff in clinical care and research. In 2009, as part of a strategic planning process, MakCHS undertook a qualitative study to examine care and service provision at MNRH, identify challenges, gaps, and solutions, and explore how MakCHS could contribute to improving care and service delivery at MNRH.MethodsKey informant interviews (n=23) and focus group discussions (n=7) were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Interviews and focus groups were tape recorded and transcribed verbatim, and findings were analyzed through collaborative thematic analysis.ResultsChallenges to care and service delivery at MNRH included resource constraints (staff, space, equipment, and supplies), staff inadequacies (knowledge, motivation, and professionalism), overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. There were also insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialized services, risk of infections, and inappropriate medications.Suggestions for how MakCHS could contribute to addressing these challenges included strengthening referral systems and peripheral health center capacity, and establishing quality assurance mechanisms. The College could also strengthen the teaching of professionalism, communication and leadership skills to students, and monitor student training and develop courses that contribute to continuous professional development. Additionally, the College could provide in-service education for providers on professionalism, communication skills, strategies that promote evidence-based practice and managerial leadership skills.ConclusionsAlthough there are numerous barriers to delivery of quality health services at MNRH, many barriers could be addressed by strengthening the relationship between the Hospital and MakCHS. Strategic partnerships and creative use of existing resources, both human and financial, could improve the quality of care and service delivery at MNRH. Improving services and providing more skills training could better prepare MakCHS graduates for leadership roles in other health care facilities, ultimately improving health outcomes throughout Uganda.

Outside the Box: Will Information Technology Be a Viable Intervention to Improve the Quality of Cancer Care?

The use of health information technology (IT) to resolve the crisis in communication inherent within the fragmented service environment of medical care in the United States is a strategic priority for the Department of Health and Human Services. Yet the deployment of health IT alone is not sufficient to improve quality in health service delivery; what is needed is a human factors approach designed to optimize the balance between health-care users, health-care providers, policies, procedures, and technologies. An evaluation of interface issues between primary and specialist care related to cancer reveals opportunities for human factors improvement along the cancer care continuum. Applications that emphasize cognitive support for prevention recommendations and that encourage patient engagement can help create a coordinated health-care environment conducive to cancer prevention and early detection. An emphasis on reliability, transparency, and accountability can help improve the coordination of activities among multiple service providers during diagnosis and treatment. A switch in emphasis from a transaction-based approach to one emphasizing long-term support for healing relationships should help improve patient outcomes during cancer survivorship and end-of-life care. Across the entire continuum of care, an emphasis on "meaningful use" of health IT-rather than on IT as an endpoint-should help put cancer on a path toward substantive continuous quality improvement. The accompanying research questions will focus on reducing the variance between the social and technical subsystems as IT is used to improve patient outcomes across the interfaces of care.

An evaluation study on the relevance and effectiveness of training activities in Northern Uganda

In-service training is required for quality health service delivery, particularly in a human resource constrained setting. However, detailed evaluation of training effectiveness is rarely conducted because the improved theoretical knowledge demonstrated by trainees during training is commonly used as a proxy indicator of effectiveness. This study focused on a trained health workforce in Northern Uganda. The retention of specifically-trained staff 12-15 months after attending training was examined, as was the relevance and usefulness of the training as perceived by the health workers. This cross-sectional descriptive study used a structured questionnaire to interview 104 health workers (mainly paramedics) who received training in the Northern Uganda Malaria, AIDS & HIV and TB Program in the period July 2007 to February 2008. Of the 104 interviewed health workers, 71% were still deployed at the original work site at the time of the interview and 87% reported they found the training event attended to be useful. However, any form of follow up was provided to only 40% of respondents, and 25% reported having attended another similar training event on the same topic at some point in time. All programs with a substantial training component should conduct a periodic methodical evaluation of the training.

Investigating complaints to improve practice and develop policy

This paper aims to make use of patient complaints as a valuable source of information to enable improvements to the quality of health service delivery. Thematic analysis was used to analyse records of de-identified patient complaints made about medical or nursing staff or medical or nursing services between January 2006 and May 2008 in the Mount Isa Health Service District. Three main themes were identified. These themes were labelled: "communication", "wait times" and "clinical". The latter related to specific concerns about the care provided to the patient or their relative. There were 101 complaints analysed. The majority (60 per cent) of complaints related to communication. Wait times for appointments (13 per cent), and clinical (28 per cent) were included in the remainder. The findings of this research are not generalisable beyond the Health Service District within which the data were collected. However, the principle of systematically using complaints information to improve practice and develop policy can be applied within all health services. Recommendations to develop policies and improve practice that will address the matters identified in the complaints are made. Changes to complaints data records to assist future research are suggested. The need to facilitate indigenous patients' contribution to suggestions for service delivery improvement is highlighted. The paper contributes to research that makes use of patient complaints to produce higher standards of patient service delivery.

Enabling the European Patient Summary through triplespaces

One of the main items on the eHealth agenda of the European Community is the design and promotion of electronic patient summaries as an instrument to guarantee the continuity of healthcare across national boundaries and to facilitate the pervasive delivery of healthcare, thus ensuring the right to patient mobility and increasing the productivity and quality of health service delivery. From a technical point of view, this objective requires middleware technology which is able to cope with the stringent interoperability, multi-lingualism, distribution, and privacy requirements arising in eHealth settings. This paper presents triplespace computing, a coordination middleware for the Semantic Web,and demonstrates its relevance to the realization of the European Patient Summary, an infrastructure for sharing and coordinating access to patient summaries at the European level.

Integrating Electronic Health Records in the Physical Environment: A Systems Approach

Electronic health records (EHRs) are the future of the healthcare industry; however, insufficient attention is paid to where and how the hardware systems that support EHR software are integrated in the existing environment.The physical implementation of EHRs is an underlying component of the technology program that may pose barriers and/or gateways to EHR adoption in terms of patient safety and satisfaction, clinical usability of the EHR system, cultural acceptance, and organizational workflow. After confirming that environmental interventions are most effective when coupled with cultural programs, this article asserts that hardware is a necessary complement to EHR software implementation if usage is to progress strategically and ergonomically. This article then seeks to explain how, based on evidence-based design (EBD) decisions, the built environment that supports EHR software can enhance or hinder communication. The findings of this paper posit that when EHR hardware is designed ergonomically and with provider-patient communication at the forefront of point-of-care services, EHR usage in the healthcare environment can improve the quality of health services delivery.This article is the result of a literature review, case studies, academic lectures, healthcare informatics webinars, and discussions with architects, interior design professionals, and corporate EHR leaders.