Secondary Healthcare Providers Research Articles

Better, Sooner, More Convenient? The reality of pursuing greater integration between primary and secondary healthcare providers in New Zealand.

Objectives:This article focuses on the results of evaluations of two business plans developed in response to a policy initiative which aimed to achieve greater integration between primary and secondary health providers in New Zealand. We employ the Consolidated Framework for Implementation Research to inform our analysis. The Better, Sooner, More Convenient policy programme involved the development of business plans and, within each business plan, a range of areas of focus and associated work-streams.Methods:The evaluations employed a mixed method multi-level case study design, involving qualitative face-to-face interviews with front-line staff, clinicians and management in two districts, one in the North Island and the other in the South Island, and an analysis of routine data tracked ambulatory sensitive hospitalisations and emergency department presentations. Two postal surveys were conducted, one focussing on the patient care experiences of integration and care co-ordination and the second focussing on the perspectives of health professionals in primary and secondary settings in both districts.Results:Both evaluations revealed non-significant changes in ambulatory sensitive hospitalisations and emergency department presentation rates and slow uneven progress with areas of focus and their associated work-streams. Our evaluations revealed a range of implementation issues, the barriers and facilitators to greater integration of healthcare services and the implications for those who were responsible for putting policy into practice.Conclusion:The business plans were shown to be overly ambitious and compromised by the size and scope of the business plans; dysfunctional governance arrangements and associated accountability issues; organisational inability to implement change quickly with appropriate and timely funding support; an absence of organisational structural change allowing parity with the policy objectives; barriers that were encountered because of inadequate attention to organisational culture; competing additional areas of focus within the same timeframe; and consequent overloading of front-line staff which led to workload stress, fatigue and disillusionment. Where success was achieved, this largely hinged on the enthusiasm of a small pool of front-line workers and their initial buy-into the idea of integrated care.

Human trafficking and health: a cross-sectional survey of NHS professionals’ contact with victims of human trafficking

Objectives(1) To estimate the proportion of National Health Service (NHS) professionals who have come into contact with trafficked people and (2) to measure NHS professionals’ knowledge and confidence to respond...

Identifying Quality Indicators Used by Patients to Choose Secondary Health Care Providers: A Mixed Methods Approach.

BackgroundPatients in health systems across the world can now choose between different health care providers. Patients are increasingly using websites and apps to compare the quality of health care services available in order to make a choice of provider. In keeping with many patient-facing platforms, most services currently providing comparative information on different providers do not take account of end-user requirements or the available evidence base.ObjectiveTo investigate what factors were considered most important when choosing nonemergency secondary health care providers in the United Kingdom with the purpose of translating these insights into a ratings platform delivered through a consumer mHealth app.MethodsA mixed methods approach was used to identify key indicators incorporating a literature review to identify and categorize existing quality indicators, a questionnaire survey to formulate a ranked list of performance indicators, and focus groups to explore rationales behind the rankings. Findings from qualitative and quantitative methodologies were mapped onto each other under the four categories identified by the literature review.ResultsQuality indicators were divided into four categories. Hospital access was the least important category. The mean differences between the other three categories hospital statistics, hospital staff, and hospital facilities, were not statistically significant. Staff competence was the most important indicator in the hospital staff category; cleanliness and up-to-date facilities were equally important in hospital facilities; ease of travel to the hospital was found to be most important in hospital access. All quality indicators within the hospital statistics category were equally important. Focus groups elaborated that users find it difficult to judge staff competence despite its importance.ConclusionsA mixed methods approach is presented, which supported a patient-centered development and evaluation of a hospital ratings mobile app. Where possible, mHealth developers should use systematic research methods in order to more closely meet the needs of the end user and add credibility to their platform.

Heart failure in 2015: let's get organised!

Heart failure represents a serious challenge to the healthcare system because of its high prevalence, morbidity and mortality. The pending increase in prevalence due to the ageing population and the relatively poor prognosis of heart failure highlight the necessity to further optimise the organisation of heart failure care [1, 2]. Strategies to enhance the coordination between primary, secondary and tertiary healthcare workers may improve clinical outcome and reduce heart failure associated costs. In the Dutch Alphen-Leiderdorp-Leiden region, collaboration between general practitioners and cardiologists was recently initiated aiming to develop a regional all-phase integrated heart failure care program. A survey among general practitioners in Alphen and heart failure patients of the Alrijne Hospital revealed that patients preferred to receive care from the heart failure clinic, but they wanted their general practitioner to be more involved. General practitioners would appreciate to expand their involvement in heart failure care. Subsequently, a working group was created consisting of cardiologists, heart failure nurses and primary healthcare workers that developed four protocols aiming to streamline patient flow from primary to speciality care and vice-versa. All protocols are in line with the most recent European Society of Cardiology heart failure guideline [3]. The first protocol stipulates the diagnostic measures to be taken by the general practitioner and cardiologist when heart failure is suspected. If the diagnosis is established, the cardiologist identifies the underlying cardiac problem, which is crucial for therapeutic reasons, as the precise pathology determines the specific treatment. The available diagnostic and therapeutic modalities are outlined in the second protocol, which was developed in collaboration with the Leiden University Medical Centre (LUMC). The third protocol describes the seamless transition to long-term management of stable patients. The general practitioner is the main caregiver in stable patients. However, several circumstances necessitate persistent (co)-treatment by a cardiologist in a secondary hospital or in a tertiary referral hospital. The fourth protocol describes the organisation of care for end-stage heart failure patients. The general practitioner mainly delivers palliative care and hospital admissions are prevented. Specific attention is paid to temporary deactivation of implantable cardioverter-defibrillator therapy. The protocols are merged in one flowchart (Fig. 1) to emphasise the all-phase integrated clinical framework for diagnostic and therapeutic decision making in heart failure patients. Fig. 1 Flowchart for all phase integrated diagnostic and therapeutic decision making in heart failure. ACE angiotensin-converting enzyme, (NT-pro) BNP (N-terminal pro) brain natriuretic peptide, BP blood pressure, CMR cardiac magnetic resonance, CRT cardiac ... Co-operation between primary, secondary and tertiary healthcare providers may optimise heart failure care. By working together, tailored care in adherence with the guidelines can be provided as close to home as possible. The current framework complies with the recent recommendations of the World Heart Failure Alliance since it provides a system that delivers timely access to diagnostic services and treatment of heart failure, as well as a seamless transition to long-term care [2]. The concept that a standardised regional program can improve care has already been established in acute infarction patients [4] and resulted in the Dutch national project ‘Connect acute infarction’. Potentially, the presented framework may be used as a start-up for a new national project ‘Connect heart failure’, which may offer a prospective solution to the increasing demand for heart failure care.

The Role of General Practitioners in Cancer Care: A Mixed Method Design.

The aims of this study were to identify the current role of general practitioners (GP) and the unmet needs of cancer patients in primary care. First, we conducted individual interviews with 10 cancer patients. Next, we developed a questionnaire, which was distributed among cancer patients across Estonia. Altogether, 113 questionnaires were returned. We observed that while the patients were satisfied with their GP's work, they mostly preferred to discuss cancer-related problems with oncologists. The role of GPs in regard to other diseases was perceived as very important, also patients found it relevant to consult all investigations with their primary health care physician. The main problems experienced by the patients were a lack of proper accessible information about their disease and its inadequate presentation by doctors, as well as problems with coordination between primary and secondary health care providers. In conclusion, we can say that even treatment of cancer is centralised to oncology clinics, patients also contact their GPs during cancer care. Therefore, GPs should be aware of patients' general health and comorbid medical problems. Better communication between primary and secondary health care doctors as well as more integration of GPs in cancer care is needed.

Thirty day all-cause mortality in patients with Escherichia coli bacteraemia in England

Escherichia coli is the commonest cause of bacteraemia in England, with an incidence of 50.7 cases per 100 000 population in 2011. We undertook a large national study to estimate and identify risk factors for 30-day all-cause mortality in E. coli bacteraemia patients. Records for patients with E. coli bacteraemia reported to the English national mandatory surveillance system between 1 July 2011 and 30 June 2012 were linked to death registrations to determine 30-day all-cause mortality. A multivariable regression model was used to identify factors associated with 30-day all-cause mortality. There were 5220 deaths in 28 616 E. coli bacteraemia patients, a mortality rate of 18.2% (95% CI 17.8–18.7%). Three-quarters of deaths occurred within 14 days of specimen collection. Factors independently associated with increased mortality were: age < 1 year or > 44 years; an underlying respiratory or unknown infection focus; ciprofloxacin non-susceptibility; hospital-onset infection or not being admitted; and bacteraemia occurring in the winter. Female gender and a urogenital focus were associated with a reduction in mortality. This is the first national study of mortality among E. coli bacteraemia patients in England. Interventions to reduce mortality need to be multifaceted and include both primary and secondary healthcare providers. Greater awareness of the risk factors for and symptoms of E. coli bacteraemia may prompt earlier diagnosis and treatment. Changes in antimicrobial resistance patterns need to be monitored for their potential impact on infection and mortality.

Optimizing polypharmacy among elderly hospital patients with chronic diseases--study protocol of the cluster randomized controlled POLITE-RCT trial.

BackgroundTreatment of patients with multimorbidity is challenging. A rational reduction of long-term drugs can lead to decreased mortality, less acute hospital treatment, and a reduction of costs. Simplification of drug treatment schemes is also related to higher levels of patient satisfaction and adherence. The POLITE-RCT trial will test the effectiveness of an intervention aiming at reducing the number of prescribed long-term drugs among multimorbid and chronically ill patients. The intervention focuses on the interface between primary and secondary health care and includes a pharmacist-based, patient-centered medication review prior to the patient’s discharge from hospital.MethodsThe POLITE-RCT trial is a cluster randomized controlled trial. Two major secondary health care providers of Mecklenburg-Western Pomerania, Germany, take part in the study. Clusters are wards of both medical centers. All wards where patients with chronic diseases and multimorbidity are regularly treated will be included. Patients aged 65+ years who take five or more prescribed long-term drugs and who are likely to spend at least 5 days in the participating hospitals will be recruited and included consecutively. Cluster-randomization takes place after a six-month baseline data collection period. Patients of the control group receive care as usual. The independent two main primary outcomes are (1) health-related quality of life (EQ-5D) and (2) the difference in the number of prescribed long-term pharmaceutical agents between intervention and control group. The secondary outcomes are appropriateness of prescribed medication (PRISCUS list, Beers Criteria, MAI), patient satisfaction (TSQM), patient empowerment (PEF-FB-9), patient autonomy (IADL), falls, re-hospitalization, and death. The points of measurement are at admission to (T0) and discharge from hospital (T1) as well as 6 and 12 months after discharge from the hospital (T2 and T3). In 42 wards, 1,626 patients will be recruited.DiscussionIn case of positive evaluation, the proposed study will provide evidence for a sustainable reduction of polypharmacy by enhancing patient-centeredness and patient autonomy.Trial registrationCurrent Controlled Trials ISRCTN42003273

Effectiveness and cost-effectiveness of a guideline-based stepped care model for patients with depression: study protocol of a cluster-randomized controlled trial in routine care.

BackgroundDepression is a widespread and serious disease often accompanied by a high degree of suffering and burden of disease. The lack of integration between different care providers impedes guideline-based treatment. This constitutes substantial challenges for the health care system and also causes considerable direct and indirect costs. To face these challenges, the aim of this project is the implementation and evaluation of a guideline-based stepped care model for depressed patients with six treatment options of varying intensity and setting, including low-intensity treatments using innovative technologies.Methods/designThe study is a randomized controlled intervention trial of a consecutive sample of depressive patients from primary care assessed with a prospective survey at four time-standardized measurement points within one year. A cluster randomization at the level of participating primary care units divides the general practitioners into two groups. In the intervention group patients (n = 660) are treated within the stepped care approach in a multiprofessional network consisting of general practitioners, psychotherapists, psychiatrists and inpatient care facilities, whereas patients in the control condition (n = 200) receive routine care. The main research question concerns the effectiveness of the stepped-care model from baseline to t3 (12 months). Primary outcome is the change in depressive symptoms measured by the PHQ-9; secondary outcomes include response, remission and relapse, functional quality of life (SF-12 and EQ-5D-3 L), other clinical and psychosocial variables, direct and indirect costs, and the incremental cost-effectiveness ratio. Furthermore feasibility and acceptance of the overall model as well as of the separate treatment components are assessed.DiscussionThis stepped care model integrates all primary and secondary health care providers involved in the treatment of depression; it elaborates innovative and evidence-based treatment elements, follows a stratified approach and is implemented in routine care as opposed to standardized conditions. In case of positive results, its sustainable implementation as a collaborative care model may significantly improve the health care situation of depressive patients as well as the interaction and care delivery of different care providers on various levels.Trial registrationThis study is registered with ClinicalTrials.gov, number NCT01731717 (date of registration: 24 June 2013).

The use of publicly available quality information when choosing a hospital or health‐care provider: the role of the GP

Patients barely use publicly available quality information for making a decision concerning secondary health care, but instead rely on information coming from their general practitioner (GP). An intermediate role of GPs has been suggested concerning the use of publicly available quality information. The aim of the study is to quantify and explore GPs' use of publicly available quality information when referring patients or suggesting secondary health-care provider to them. In this cross-sectional study, an invitation to an electronic questionnaire was sent to 858 GPs in the south of the Netherlands. GPs were asked about their use of and perception towards publicly available quality information through closed-ended and open-ended questions. Differences among subgroups were tested for significance using Pearson's chi-square tests. The majority of respondents (89.5%) never or rarely use publicly available quality information. They perceive them as invalid and unreliable. Distance to the hospital, prior experiences and personal contacts with specialists guide them when advising and referring. Almost 90% of respondents never or rarely suggest quality information as support for decision making to their patients. No significant differences between subgroups were observed. This study is among the firsts exploring and quantifying GPs' use of publicly available quality information. The results suggest that publicly available quality information appears in its current format and application not useful for GPs. GPs have to be aware of their influential role in patients' decision making and possibly have to take more responsibility in guiding them through the jungle of quality information.

Anti-Anisakis IgE Seroprevalence in the Healthy Croatian Coastal Population and Associated Risk Factors

BackgroundThe main objective of the study was to determine the degree of sensitization to Anisakis spp. antigens in healthy coastal population of Dalmatia given the high thermally unprocessed fish intake rate present in this area, suggested as a significant risk factor for anisakiasis. We performed a monocenter, cross-sectional pilot study stratified by geographic area of residence, conducted at the County secondary healthcare provider Medicine-biochemical Laboratory in Split (Croatia), from November 2010 till December 2011, on 500 unpaid volunteer subjects undergoing routine blood analysis and belonging to the south coast of the Adriatic Sea.Methodology/Principal FindingsWe studied the IgE seroprevalence to Anisakis spp. Ani s l and Ani s 7 allergens by indirect ELISA in healthy subjects, which were selected at random in the region of Dalmatia (Southern Croatia), among islands, coastal urban and inland rural populations. In order to detect possible cross-reactivity to other human helminthes, serum samples were tested also for the presence of IgG antibodies to Ascaris lumbricoides and Toxocara canis. The overall and coastal Anisakis seroprevalences for the sampled population were 2% and 2.5%, respectively. The logistic univariate regression analysis confirmed that regarding anti-Anisakis IgE seroprevalence, raw fish intake, daily fish intake, homemade origin of fish dish and occupational contact (professional, artisanal or hobby contact with fishery or fish industry) were risk factors associated to Anisakis spp. sensitization, but neither of the variables was exclusive for a particular seropositive population. Also, a significant difference was observed between seropositive and seronegative subjects that had stated allergy or symptoms associated with allergy (atopic dermatitis, asthma or rhinitis) in their previous history.Conclusions/SignificanceBeing the first in Croatia, our study underlines the necessity of incorporating Anisakis spp. allergens in routine hypersensitivity testing of coastal population.

Development and evaluation of a de-identification procedure for a case register sourced from mental health electronic records

BackgroundElectronic health records (EHRs) provide enormous potential for health research but also present data governance challenges. Ensuring de-identification is a pre-requisite for use of EHR data without prior consent. The South London and Maudsley NHS Trust (SLaM), one of the largest secondary mental healthcare providers in Europe, has developed, from its EHRs, a de-identified psychiatric case register, the Clinical Record Interactive Search (CRIS), for secondary research.MethodsWe describe development, implementation and evaluation of a bespoke de-identification algorithm used to create the register. It is designed to create dictionaries using patient identifiers (PIs) entered into dedicated source fields and then identify, match and mask them (with ZZZZZ) when they appear in medical texts. We deemed this approach would be effective, given high coverage of PI in the dedicated fields and the effectiveness of the masking combined with elements of a security model. We conducted two separate performance tests i) to test performance of the algorithm in masking individual true PIs entered in dedicated fields and then found in text (using 500 patient notes) and ii) to compare the performance of the CRIS pattern matching algorithm with a machine learning algorithm, called the MITRE Identification Scrubber Toolkit – MIST (using 70 patient notes – 50 notes to train, 20 notes to test on). We also report any incidences of potential breaches, defined by occurrences of 3 or more true or apparent PIs in the same patient’s notes (and in an additional set of longitudinal notes for 50 patients); and we consider the possibility of inferring information despite de-identification.ResultsTrue PIs were masked with 98.8% precision and 97.6% recall. As anticipated, potential PIs did appear, owing to misspellings entered within the EHRs. We found one potential breach. In a separate performance test, with a different set of notes, CRIS yielded 100% precision and 88.5% recall, while MIST yielded a 95.1% and 78.1%, respectively. We discuss how we overcome the realistic possibility – albeit of low probability – of potential breaches through implementation of the security model.ConclusionCRIS is a de-identified psychiatric database sourced from EHRs, which protects patient anonymity and maximises data available for research. CRIS demonstrates the advantage of combining an effective de-identification algorithm with a carefully designed security model. The paper advances much needed discussion of EHR de-identification – particularly in relation to criteria to assess de-identification, and considering the contexts of de-identified research databases when assessing the risk of breaches of confidential patient information.

Lesbian Health Care: Women's Experiences and the Role for Social Work

ABSTRACT Lesbian patients and their families may be exposed to discriminatory practices in the health care system. This qualitative study of 57 Midwestern lesbian parents used open- and closed-ended questions to examine the experiences the respondents had with their primary and secondary health care providers. Four themes emerged from the data: systemic barriers to health care, coming out to providers, seeking lesbian, gay, bisexual, and transgender-friendly health care providers, and concern about mistreatment and prejudice within the health care system. Implications for service delivery, health care education, and directions in policy and research are explored.

Long-term health care utilisation and costs after spinal fusion in elderly patients

Spinal fusion surgery rates in the elderly are increasing. Cost effectiveness analyses with relatively short-length follow-up have been performed. But the long-term effects in terms of health care use are largely unknown. The aim of the present study was to describe the long-term consequences of spinal fusion surgery in elderly patients on health care use and costs using a health care system perspective. 194 patients undergoing spinal fusion between 2001 and 2005 (70 men, 124 women) with a mean age of 70years (range 59-88) at surgery were included. Average length of follow-up was 6.2years (range 0.3-9.0years). Data on resource utilisation and costs were obtained from national registers providing complete coverage of all reimbursed contacts with primary- and secondary health care providers. Data were available from 3years prior fusion surgery until the end of 2009. Use of hospital-based health care increased in the year prior to and the first year following surgery. Hereafter it normalised to the level of the background population and was mainly composed of diseases unrelated to the spine. In contrast, the use of primary health care appeared to increase immediately after surgery and continued to increase to a level that significantly exceeded that of the background population. It could be demonstrated that the increase was mainly due to an increasing number of general practitioner consultations. Spinal fusion surgery in older patients does not generate excess hospital-based health care use in the longer term as compared with the background population, but primary care use increases.

Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London

ObjectiveDespite improving healthcare, the gap in mortality between people with serious mental illness (SMI) and general population persists, especially for younger age groups. The electronic database from a large and comprehensive secondary mental healthcare provider in London was utilized to assess the impact of SMI diagnoses on life expectancy at birth.MethodPeople who were diagnosed with SMI (schizophrenia, schizoaffective disorder, bipolar disorder), substance use disorder, and depressive episode/disorder before the end of 2009 and under active review by the South London and Maudsley NHS Foundation Trust (SLAM) in southeast London during 2007–09 comprised the sample, retrieved by the SLAM Case Register Interactive Search (CRIS) system. We estimated life expectancy at birth for people with SMI and each diagnosis, from national mortality returns between 2007–09, using a life table method.ResultsA total of 31,719 eligible people, aged 15 years or older, with SMI were analyzed. Among them, 1,370 died during 2007–09. Compared to national figures, all disorders were associated with substantially lower life expectancy: 8.0 to 14.6 life years lost for men and 9.8 to 17.5 life years lost for women. Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost).ConclusionThe impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity. Strategies to identify and prevent causes of premature death are urgently required.

Ethnic Disparity in Access to Stem Cell Transplantation for Multiple Myeloma.

Abstract 1781Poster Board I-807Previous studies have shown that ethnic differences exist in the treatment of a number of malignant diseases, with non-white ethnic minorities frequently receiving suboptimal care. High-dose chemotherapy and autologous stem cell transplantation (ASCT) became the standard of care for most patients with multiple myeloma (MM) under the age of 65 and some older patients in the early 1990s. In this study, we investigated whether patients from ethnic minorities have had appropriate access to ASCT for the treatment of MM in a large, multiethnic, equal access healthcare provision area in the UK. Hammersmith Hospital (HH) is a tertiary referral centre for SCT for the Northwest London catchment area with a population of 1.732.020 in 2001 according to the last UK Census (65.5% Whites, 19.9% Asians, 8.8% Blacks, and 5.8% others). All patients diagnosed with haematological malignancies within the catchment area who are considered eligible for SCT are referred to HH from primary or secondary healthcare providers. A Cancer Research UK/National Cancer Intelligence Network report 2002-2006 has shown ethnicity-specific MM incidence rate ratios of 1.89-2.86 (upper and lower 95%CI) for Blacks and 0.82-1.02 for Asians relative to Whites (1.0) in the UK. Considering the 2001 ethnic distribution in the catchment area, this means that the ratio of MM patients expected to undergo ASCT at HH would be 0.25-0.38 for Blacks and 0.22-0.31 for Asians relative to Whites. Between 1994 and 2008, 311 MM patients received a planned single ASCT at HH as standard post-induction therapy. Of those, 235 were White, 47 were Black, and 29 were Asian. There were no differences between the ethnic groups in terms of age, time from diagnosis to ASCT, or remission status at the time of the transplant. IgA myeloma was significantly (p=0.007) more frequent in Whites (24%) than in Asians (10%) and Blacks (6%). Thus, the ethnic ratio of MM patients who actually received ASCT at HH was 0.2 for Blacks and 0.12 for Asians relative to Whites, indicating an under-representation of ethnic minorities. We next analysed the ethnicity-specific treatment ratios observed over three 5-year periods (94-98, 99-03, and 04-08) and found that the ratio of Blacks undergoing ASCT had been gradually increasing, and was reaching the lower end of the expected rate in the most recent 5-year period (0.13, 0.18, and 0.25). Asians had been dramatically under-represented in the first 5-year period and were still slightly outside the expected ratio in the last (0.03, 0.12, and 0.19). When we analysed the outcome of treatment, there was no significant difference between the ethnic groups in terms of overall survival from diagnosis or from the time of ASCT. Although these data have been gathered in one healthcare provision area only, they indicate that MM patients from ethnic minorities may not have had appropriate access to ASCT in the UK particularly in the early years of this treatment becoming a standard of care. Further studies are needed to determine whether ethnic minorities are generally at risk not to receive new standards of care for haematological diseases and whether patient- or healthcare provider-based factors are responsible for ethnic disparities. DisclosuresNo relevant conflicts of interest to declare.

Building an inter-organizational communication network and challenges for preserving interoperability

Background The ideal scenario for information technology to bridge information gaps between primary and secondary healthcare and to improve the quality of healthcare in the medication process is to build an interoperable communication network. This type of undertaking requires diverse information systems to be integrated, and central to this are the preservation of data integrity and the integration of different pieces of patient data. Objectives and methodology In this study, we focused on sources of challenges to the integration process and to the building of an interoperable communication network. Interviews, document analysis, and observations were conducted to evaluate the integration process in a project that involved medication data communication between primary healthcare providers (i.e., general practitioners and community pharmacists) and secondary healthcare providers (i.e., hospital pharmacists and specialist physicians). Results The project encountered numerous integration problems, many of which persisted even after extensive technical intervention. An analysis of the problems revealed that they were mostly rooted either in problematic integration of work processes or in the way the system was used. Despite the project's ideal technical condition, the integration could be accomplished only by applying human interfaces. Conclusion The main challenge to building interoperable communication network does not lie in technical integration. The real problem occurs when the technical linkage is implemented without the work processes being aligned and integrated.

Payment by results or payment by activity?

In 2005, the Government introduced a new method of funding for secondary healthcare providers in England, known as ‘payment by results’, although a more appropriate term would be ‘payment by activity’.

Concepts underlying continuity of care - the system of concepts described in ENV 13940a

In 1998, the Technical Committee 'Health Informatics' (TC 251) of CEN (European Committee for Standardisation) set up a specific project team to address aspects of sharing patient-related information needed in the process of care, in order to support continuity of care, giving way to a European pre-standard, numbered ENV 13940. The authors were both members of that project team. The system of concepts and the terms defined in this European pre-standard are designed to support the management of healthcare-related information over time, and the delivery of relevant health care by different agents, encompassing primary care professionals and teams, healthcare funding organisations, managers, patients, secondary and tertiary healthcare providers, and community care teams. Beyond the terms used in the standard, which have no actual value outside the framework of the document itself, the goal is to establish a common conceptual framework for continuity of care across national, cultural and professional barriers. It is neither to define how the processes should be performed in a particular healthcare framework, nor to have any regulatory impact on the actual delivery of care. The European pre-standard does not address other aspects of health care, such as security, the specific management of professional acts and their life cycle, terminology and classification, nor the financing mechanism for healthcare delivery.