Unified Health Research Articles

Animal disease and its impact on the ecological environment and public health

For centuries, people have recognized the importance and engaged in ensuring interaction between the spheres of health, animal husbandry and environmental protection. About 20 years ago, the concept of "Unified Health" appeared, suggesting a holistic and intersectoral approach to the development and implementation of programs to ensure human health, as well as programs that affect animal health and the environment. The relevance of the study of animal diseases and the impact on the ecological environment and the health of the population is beyond doubt. Moreover, the problems of epidemics in protected areas with wild animals, which also cause serious impacts not only on the environment (pastures, lands, aquatic environment), but also the population can suffer – a risk to human health. The main environmental threats to human health in relatively prosperous countries are polluted air, noise and exposure to toxic substances. Despite the fact that it is extremely difficult to prove a direct relationship between the disease and environmental pollution, such cases can be found in every country. Many of the factors that determine the development of diseases can be reduced or prevented through government regulation and information campaigns among the population. Numerous studies have also shown that the loss of biodiversity increases the risk of infectious diseases among animals, as well as the risk of their transmission to humans. While broad biodiversity reduces the transmission rate of pathogens and, consequently, the risk of diseases for humans, wild animals, livestock and plants.

Development of the Research Forum: A program for biomedicine and health research strengthening in Qatar

Background: Research strengthening and capacity development in academic health systems are important for advancing medicine, delivering best practices, improving patient outcomes, and reducing healthcare costs. The Research Forum is a biomedicine and health research strengthening program facilitated by the lead organization of the Academic Health System in Qatar. The event brought together researchers and health professionals together so they could present their research work on a particular health or research topic and network with a targeted local audience. Methods: This retrospective study evaluated the Research Forum program from August 2015 to July 2016. The Research Forum was designed as a pan-institutional multi-disciplinary program that would convene quarterly and bring health professionals and researchers together to present their work on a particular health and research topic. The primary outcome was peer-reviewed journal publications of the Research Forum events’ research presentations. The secondary outcomes were the number of attendees and speakers at the successive Research Forum events during the study period. Results: There were five Research Forum events in the first year: Neuroscience (August, 2015), Heart (October 2015), Infections (January 2016), Cancer (March 2016), and Diabetes, Obesity, and Metabolism (May 2016). A total of 722 health professionals and researchers attended the Research Forum events with 68 studies presented: 5 in Neuroscience, 10 in Heart, 12 in Infections, 18 in Cancer, and 23 in Diabetes/Metabolism. There were 13(19%) research presentations that were successfully published in peer-reviewed journals. The mean time between the study presentation and publication was 2.85 + 1.9 months (median 2; IQR 1.5, 4). None of the presenter and study characteristics variables considered for publication of presented studies was statistically significant. Conclusions: The Research Forum was a capacity building and research-strengthening program at an individual, institutional, and national level. The Research Forum was a unique program that brought together health professionals and researchers from various health institutions, universities, and organizations on a unifying health and research topic.

Regional hematology service registration system for the Russian Federation

Introduction. The hematology service registration system describes actual indicators of hematology service infrastructure and target objects of both assigned and affiliated organizations of Russian Federation regions along with its correlations. This system data base makes it possible to collect, save, and analyze information, creating a data storage library about all current existing resources and taking into account concrete, specific conditions of specialized and high-tech hematological medical assistance organizations at the local levels and formed quality and availability optimization proposals.Aim — description and justification of the need to create a unified, complex, available to all users, informational reference system with the possibility of up-to-date maintenance and accounting that allows for the keep and control of the regional characteristics and hematology service indicators of the Russian Federation.General findings. The creation of and development of the hematology service registration system began in 2018, and work on the project continues. Four main phases were selected as the key stages of the hematology service pasportisation: analyses of the current data, verification of information, creation of a user-friendly tool, system updating. Objects to monitor: medical key and related institutions, universities, affiliated organizations, laboratory service. The data working stages: data collection, manual updating, package uploading. The information sources: official websites, data high-tech medical treatment web portal, web portals of the public health authorities, Compulsory Medical Insurance Fund website, The Unified Data Health Care System, license register of the Federal Service for Healthcare Surveillance, data of the Federal State Statistics Service, official documents of Ministry of Public Health. Based on the developed checklists and forms for entering additional information for specialists of the subjects of the Russian Federation, a reference book of the Ministry of Defense (Excel file format) was created. However, in the course of further remote interaction and conducting field events in the regions of the Russian Federation during 2019–2020 new data needs for evaluating hematology services were determined. The increase of additional data inputs and its structure complication became the main reasons for further developing a new platform design concept and data conversion in database framework of the hematology service registration system (Access file format). The current objectives are as follows: authentication of the internal objects identifiers, implementation of the relational database codifier, modification of cartographic display and objects routing. The hematology service registration system contains data both for the key infrastructure nodes of Russian Federation hematology service and correlations within routing of all key system objects. Based on the positive results, the hematology service registration system is planned to be used by experts of specialized medical organizations, regional executive authorities on public health and professional communities, who will be able to accumulate all changes and indicators in dynamics within one system. The expected result is to provide the Ministry of Defense of the Russian Federation regions with methodological and informational support in specialized and high-tech medical care administration.

Actual directions of improving legislation in the field of biological and genetic technologies

One of the trends of modern state policy is the development of biological and genetic, aimed at solving socio-economic problems and problems caused by global challenges and threats associated with the consequences of the coronavirus pandemic, climate change, reduced biodiversity, and other negative manifestations. In these conditions, there is a need to revise the conceptual approaches to the legal regulation of relations in the field of the use of biological and genetic technologies, taking into account natural and social relationships. The article shows the need to apply to these relations the ecosystem approach, the concept of sustainable development, the interdisciplinary approach “Unified Health”, four “bio”, an integral part of which is to ensure safety (environmental, biological, genetic, sanitary-epidemiological, biosphere). The issues of improving the Russian legislation in the field of application of biological and genetic technologies on an intersectoral basis in connection with the environmental, sanitary and epidemiological, natural resource, agricultural and other industries are considered.The directions of harmonization of the domestic regulatory framework with international norms and treaties, including the assessment of the risks of possible harmful effects of the use of biological and genetic technologies on human health and the environment, are proposed. In Russian legislation, it is necessary to legalize the concepts of “risk assessment”, “risk factors”, as well as to determine the procedure for assessing the potentially and really harmful effects of GMOs and other results of the use of genetic and biotechnologies on human health and the environment.

Brazil\u2019s Community Health Workers Practicing Narrative Medicine: Patients\u2019 Perspectives

BackgroundNarrative medicine (NM) encourages health care providers to draw on their personal experiences to establish therapeutic alliances with patients of prevention and care services. NM medicine practiced by nurses and physicians has been well documented, yet there is little understanding of how community health workers (CHWs) apply NM concepts in their day-to-day practices from patient perspectives.ObjectiveTo document how CHWs apply specific NM concepts in Brazil’s Family Health Strategy (FHS), the key component of Brazil’s Unified Health System.DesignWe used a semi-structured interview, grounded in Charon’s (2001) framework, including four types of NM relationships: provider–patient, provider–colleague, provider–society, and provider–self. A hybrid approach of thematic analysis was used to analyze data from 27 patients.Key ResultsSample: 18 females; 13 White, 12 “Pardo” (mixed races), 12 Black. We found: (1) provider–patient relationship—CHWs offered health education through compassion, empathy, trustworthiness, patience, attentiveness, jargon-free communication, and altruism; (2) provider–colleague relationship—CHWs lacked credibility as perceived by physicians, impacting their effectiveness negatively; (3) provider–society relationship—CHWs mobilized patients civically and politically to advocate for and address emerging health care and prevention needs; (4) provider–self relationship—patients identified possible low self-esteem among CHWs and a need to engage in self-care practices to abate exhaustion from intense labor and lack of resources.ConclusionThis study adds to patient perspectives on how CHWs apply NM concepts to build and sustain four types of relationships. Findings suggest the need to improve provider–colleague relationships by ongoing training to foster cooperation among FHS team members. More generous organizational supports (wellness initiatives and supervision) may facilitate the provider–self relationship. Public education on CHWs’ roles is needed to enhance the professional and societal credibility of their roles and responsibilities. Future research should investigate how CHWs’ personality traits may influence their ability to apply NM.

Implementation of a Public Lymphoma Clinic in a Private Hospital in Brazil: Challenges and Impact of Delayed Diagnosis in Patients with Diffuse Large B Cell Lymphoma

Introduction: Since 1990, Brazil has implemented a unified public health care, but access to specialized care remains a major challenge, especially due to delays in diagnosis and access to specialized centers. In order to help cancer care access, Hospital Israelita Albert Einstein, a private hospital, has implemented a public cancer clinic in Sao Paulo, only 11km apart. In an unprecedent situation in Sao Paulo, both public and private hospitals share most of the facilities, including laboratory, pathology, radiology, radiotherapy, pharmacy and medical team. Moreover, treatment protocols are the same and most drugs are also available in the public system. With 1 year of operation of the public clinic, we aim to analyze the outcome of patients with diffuse large B-cell lymphoma (DLBCL) compared with historical data from the private hospital. Moreover, since patients are only admitted after a confirmed cancer diagnosis, we aim to look at the impact of delayed diagnosis in the outcome of the patients. Method: This is a retrospective study comparing the clinical features, treatment and outcome of patients with DLBCL treated in the public system with historical data from the private system. In order to minimize the impact of treatment protocols, only patients treated between January 2016 and February 2020 were used for historical comparison. All biopsies were reviewed by the same hemepathologist. Time to treatment initiation (TTI) time was defined by the number of days between biopsy and the first day of treatment cycle. Time from symptom onset to medical consultation (TSTC) was also calculated. Survival rates were estimated by Kaplan-Meier and differences assessed by log-rank test. Results: In one year of operation, 23 patients with DLBCL were treated in the public clinic (PC) and were compared with 41 patients from the private hospital (PH), for a total of 64 patients. Clinical features were similar between PC and PH, and for all patients, median age was 61 years (range: 27-91), 76% with PS of 0-1, 78% with advanced stage and 45% with B-symptoms. Median R-IPI was 3 for both cohorts and approximately 50% of patients in both cohorts presented with R-IPI of 3 to 5. Interestingly, a difference in the cell-of-origin (COO) was observed between both cohorts, with a higher number of germinal center B-cell lymphoma in the PC (82% vs 52%, respectively, p=0.0041). TSTC was significantly higher in the PC compared to PH (160 vs 30 respectively, p<0.001), and it was mostly impacted by the delay in obtaining the biopsy result. Moreover, TTI was higher in the PC compared with PH (7 vs 39, respectively, p<0.0001) and was most impacted by the delay in receiving biopsy slides for review. With a median follow up of 18 months, 1 year-EFS was 76% and 1 year-OS was 86%for all cohort, with no statistical difference between public and private hospitals (p=0.40 and 0.20, respectively). Conclusion: In our cohort of patients from public and private settings treated equally by the same resources, there was no difference in the outcome of patients. Despite TSTC and TTI were higher for patients from the public setting, no difference in survival was observed, and this may be partially explained by an enriched cohort of GCB DLBCL in the public system. The extremely low number of ABC DLBCL (4/23) is uncommon and suspicious for mortality of these patients before access to specialized care. Figure Disclosures Perini: Janssen, Takeda: Honoraria; AbbVie, Janssen: Speakers Bureau.

Trends in pediatric hospitalizations for ambulatory care sensitive respiratory diseases in Brazil.

To analyze the trend in hospitalization rates for ambulatory care sensitive respiratory diseases (ACSRD) of children under five years of age in Brazil. Time series study of hospitalization rates using secondary information from the Hospital Information System of the Brazil's Unified Health System. Hospitalizations of children under five years of age living in Brazilian regions. Hospitalizations were separated according to cause: nose and throat infections, asthma, bacterial pneumonias, and lung diseases. Rates were calculated for total hospitalizations for ACSRD, and by cause, age group, and region. Trends were analyzed by using means of simple linear regression and were classified into stationary (p≥.05), ascending (β positive and p<.05) or declining (β negative and p<.05) trends. All regions showed stationary trends in total hospitalization rates for ACSRDs, except in the Southeast, where trends were ascending. Asthma was the only cause that showed a declining trend. Bacterial pneumonias showed stationary trends, while lung diseases and nose and throat infections had predominantly ascending trends. Brazil's hospitalization rates for ACSRDs are high. Investigations into primary health care organization and work processes, as well as socioeconomic, cultural, and geographical factors are necessary.

Association between obesity and knee osteoarthritis in users of brazilian unified national health system

Verify possible associations between obesity and knee OA in users of Brazilian Unified National Health System (Sistema Único de Saúde - SUS) of primary care network in Catalão-GO, Brazil. This is an observational study conducted in 2014 and 2015. A total of 81 volunteers from the Basic Attention Network in the city of Catalão, with body mass index (BMI) over 30 kg/m2 in both sexes, age between 40 and 60 years, and OA on radiological examination of the knee. Obesity was classified according to BMI. The diagnosis of osteoarthritis (OA) was made clinically and by radiography according to Kellgren radiological classification. The level of physical activity was assessed using the Baecke questionnaire and the Gordon Functional Classification. The volunteers underwent an anthropometric evaluation and physical examination with inspection and palpation of the joint and subsequent radiological examination of the knee. The volunteers answered a questionnaire on the level of physical activity and functional classification. Data analysis was performed using Fisher’s exact test or chi-square test was used for comparisons of two proportions. In comparisons of continuous variables, Student’s t-test or the nonparametric Wilcoxon-Mann-Whitney test was used. The level of significance was set to 5%. Practice of regular physical exercise decreases functional impairment in obese individuals with knee OA. The weight variable demonstrated a strong association with the severity of OA and degree of functionality of patients. Obesity and OA durations and lack of patient guidance are variables that may contribute to the progression of knee OA. Although the incidence among men is lower, they are more severely affected and anthropometric evaluation and physical examination are an efficacy implementations for Brazilian users of SUS.

Особенности распределенного хранения медицинских изображений в онкологической службе в рамках создания единого цифрового контура

The development of an effective unified information space of the regional radiology diagnostics service is possible by connecting all outpatient cancer care centers and medical organizations to distributed medical image storage systems under the management of regional radiological information systems within the framework of the regional programs “Creation of the unified digital circuit in healthcare based on the unified state health information system” of the territorial subjects of the Russian Federation. The aim of the research is to study the features of using radiological information systems in the oncological profile and develop recommendations for creating distributed archives of medical images in the oncology service within the framework of the federal project. The paper considers the results of the implementation of software products “LINS LookInside”, “LINS Makhaon” in the framework of implementation of local and regional projects in cancer clinics. The data on the connected diagnostic equipment and integration with medical information systems are provided. It has been established that each medical organization with an oncological profile should have its own local PACS installed. Using the example of federal cancer centers, it is recommended to include endoscopic departments, radionuclide and ultrasound diagnostics rooms in radiological information systems, as well as to install and connect systems for automatic publication of CD/DVD discs with DICOM studies.

BikeWay: A Multi-Sensory Fuzzy-Based Quality Metric for Bike Paths and Tracks in Urban Areas

Large cities are increasingly investing in efficient mobility and sustainable transportation as an alternative to expensive and pollutant traditional vehicles. In parallel, people are also seeking cleaner and healthier options for short and last-mile distances. In order to cope with this trend, which has boosted the adoption of bikes in urban areas, a major concern of the governments has been to build bike paths and tracks that allow cyclists to move safely and through shorter distances. However, such initiatives may result in bicycles infrastructure built alongside traditional vehicular roads or on inadequate regions. Therefore, there should be a flexible way to assess the quality of bike paths and tracks, combining variables that indicate adverse conditions for the health and safety of cyclists, such as statistical risk of accidents, air and noise pollution, excessive sunlight exposure, dangerous UV radiation, among others. This article then proposes a new comprehensive quality metric that combines sensed environmental data and historical reported incidents related to bike paths and tracks, which may be employed for traditional physical signaling or to support computer-assisted solutions for cycling monitoring and alerting. Such new metric exploits fuzzy logic to model a group of variables to ultimately provide a unified safety and health quality level, referred as BikeWay. Doing so, we expect to allow dynamic and historical perceptions of how healthy and safe the bike paths and tracks are for cyclists in modern cities.

393Ischemic burden by vasodilator stress CMR predicts long-term all-cause death and the effect of revascularization in patients with known or suspected stable ischemic heart disease

Abstract Background In patients with stable ischemic heart disease (SIHD) the effect of revascularization on all-cause death (the most verifiable clinical event) is unknown. Objectives We explored the potential of the ischemic burden as derived from vasodilator stress cardiovascular magnetic resonance (CMR) to guide decision-making in this scenario. Methods In a large prospective multicenter registry, we recruited 6389 patients (mean age 65±11 years, 38% female) submitted to undergo vasodilator stress CMR for known or suspected SIHD. Baseline and CMR characteristics were prospectively recorded. The ischemic burden (at vasodilator stress first-pass perfusion imaging) and necrosis extent (at late enhancement imaging) were computed (17-segment model). The effect of CMR-related revascularization (within the following three months) on all-cause death (revised using the unified regional electronic health system registry) was explored. Results During a 5.75-year median follow-up, 717 (11.2%) all-cause deaths were documented. In multivariable analyses, more extensive ischemic burden (per 1-segment increase) independently related to all-cause death (1.05 [1.03–1.07], p&lt;0.001). In 1034 patients (517 revascularized, 517 non-revascularized) strictly 1:1 matched for the independent predictors of outcome and of undergoing CMR-related revascularization (age, diabetes mellitus, male sex, LVEF, ischemic burden and necrosis extent), CMR-related revascularization did not significantly alter all-cause death rate (13.3% vs. 13.3%, p=0.54). Nevertheless, a potent interaction existed with the ischemic burden (p&lt;0.001). CMR-related revascularization independently reduced the risk of all-cause death in 430 patients with ischemic burden &gt;5 segments (9.3% vs. 16.3%, HR 0.56 [0.32–0.98], p=0.02) but it independently increased risk in 604 patients with ischemic burden ≤5 segments (16.2% vs. 11.3%, HR 1.59 [1.03–2.45], p=0.037). Figure 1. CMR-related revascularization Conclusions In patients with known or suspected stable ischemic heart disease the ischemic burden as derived from vasodilator stress CMR can be helpful to predict the effect of revascularization on long-term all-cause death. Acknowledgement/Funding Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).

Potencialidades e fragilidades da educação a distância no contexto da atenção básica

A educação a distância como estratégia para o incremento das ações de alimentação e nutrição na atenção primária no SUS é o tema central desse artigo, com o objetivo de avaliar o processo de educação a distância para a promoção da segurança alimentar e nutricional no contexto da atenção básica. Os dados foram gerados a partir da interação dos educandos e tutores, categorizados a partir do referencial de análise de conteúdo, os resultados a luz da teoria da Problematização e apoiada pelo arcabouço teórico da Saúde Coletiva. Categorias de análise destacam-se: O processo educacional e o educando em ambiente virtual; O papel do tutor na modalidade de EAD: Ações intersetoriais e territorialização. Concluiu-se que a educação a distância é uma tecnologia que promove mudanças, quando utilizada para aproximar teoria e prática, ressignificar o trabalho e empoderar o educando para ações de transformação na atenção básica

Community-based grassroot communication strategies, process and product: The drawings that saved our hospital

A case-study analysis of an urban design communication strategy employed by our university-based design team entrusted with re-envisioning the uncertain future of a local small-town community hospital in Indiana. The design process is carefully constructed from structured public input, and community participation, whereby students, faculty, physicians, nurses, as well as ordinary citizens combine their efforts to strategically develop their ‘plan for planning’. Finding a strategy to define the scope of their future needs and the definition of important priorities to organize the project scope prior to engaging professional consultants. In this scenario, the design team is only the guide and translator, working closely with stakeholders to help them visualize and clarify the aspirations of their town. This paper will present our community-based design methods and most importantly our graphic communication techniques, specifically formulated to envision and facilitate consensus for a new unified public health system in a small Midwestern American city.

Towards new models of care: Developing a curriculum for interprofessional mental health training

Introduction Interprofessional training remains rare in mental health and psychiatry, yet this is an ideal area to benefit from this approach. Traditionally clinicians from various specialities have trained ‘in silos', with knowledge expansion the focus rather than experiential team-based learning. There is no unifying mental health curriculum to meet training needs of healthcare workforces, particularly in light of New Models of Care. A move towards reducing traditional barriers between disciplines, and more collaborative patient-focused care, must be reflected in training strategies as well as service structure. Aims To develop a comprehensive mental health curriculum relating to New Models of Care with an interprofessional focus, having recognised gaps in existing provision. Methods A literature, strategy, and policy review identified best practice in interprofessional training for mental health. A scoping exercise collected current training plans for mental health across professions, mental health trusts, primary care and others within Community Education Provider Networks. Focus groups were held with key stakeholders across professions, trusts, and institutions to further develop the curriculum structure and pilot ideas. The curriculum was drafted and reviewed with local education leads, before being finalised. Results The final interprofessional mental health curriculum presents a clearly structured, innovative approach to mental health training applicable to all professions and organisations, with an interprofessional focus to facilitate the transition to New Models of Care and improved patient experience and outcomes. Conclusion We hope this curriculum will be adopted by local education leads and departments, and will have significant, wide-reaching impact on mental health training and subsequently patient care.

Planificación según prioridades de salud. Criterios de planificación relacionados con los Planes Directores

With the aim of responding to a number of problems detected in health plan evaluations, a new direction has been proposed in Catalonia which would lead to the improved unification of the strategic and operational approaches, and leadership. The master plans that tackle those health problems with the greatest impact were created along these lines. This article presents the most salient aspects of the master plans for oncology, circulatory diseases, mental health and addictions, immigration and the field of social healthcare. Their organisational structure, mission and functions are presented, commenting on the prioritisation of activities and the principal benchmark elements of the healthcare model in the definition of planning criteria for services incorporated into the Health Map. Finally, mention is made of the evaluation procedures. The in-depth study of priority settings has resulted in significant progress towards unifying health and service planning.

Approaches to Preventing HIV/AIDS in Youth: A Hope for the Future

About 50 per cent of new HIV infections affect young people between the ages of 10 and 24. It is clear that the youth represent an important component of the current trends in the HIV/AIDS pandemic. This paper presents four key approaches that have been successful in achieving effective HIV/AIDS prevention outcomes among the youth: emphasising youth involvement in programmes; focusing on multiple levels of intervention and multiple channels of communication; integrating HIV prevention into broader reproductive health programmes; and developing national advocacy programmes and policies to prevent HIV/AIDS in young people. Examples from various countries are presented to illustrate the application of the four approaches and what their results are when applied in the context of HIV prevention programmes for youth. Consistency in regulations and policies across sectors leads to developing approaches and activities that are compatible and youth-friendly. Establishing a unified national youth health policy can be effective in supporting healthy sexuality and reproduction in youth, particularly related to HIV and STI prevention.

The Process of Health Legislation Reform in the Republic of Slovenia

AbstractSlovenia was among the first European countries to introduce laws and regulations in the social security field, including public health. The current health legislation is the culmination of a century-long development of the health care system through different periods and diverse political and economic conditions affecting the region. The present organization of the health care system reflects the pattern of partnership which already existed in the former Yugoslavia. The ultimate goal of all countries is to implement health care activities within a system ensuring active participation and partnership of citizens who are universally covered by a public health insurance scheme, health legislators and providers of health services. Slovenia has therefore not been confronted with any major difficulties in implementing health care system reforms. By amending and modifying its health legislation Slovenia will build upon its good points, improve clarity and integrate certain approaches important for the functioning of its health care system in the European Union when Slovenia becomes a full member. Changes are directed towards:strengthening inter-sectoral cooperation and health and safety at work;creating environments supporting a healthy life style and emphasizing personal responsibility for one's own health;— maintaining a unified public health insurance scheme and sufficient financing through employer and employee contributions;— introducing voluntary health insurance;— developing in a controlled way an efficient and effective private medical practice;— strengthening of management in public health institutions and increasing staff's responsibility for business success.— implementing quality improvement systems.

Psychological interventions and medical cost offset: Implications for integrative health care.

Chiles, Lambert, and Hatch (this issue) utilize meta-analysis methodology to demonstrate how psychological interventions historically have offset medical costs. Implications for future integrated health care delivery are discussed. Essentials for successful health service integration are identified, including unified substance abuse and mental health Interventions as well as managed care's systemic and financial support. Proposed provider integration involves a three-way partnership of primary care, surgical care, and behavioral care.

Transforming a Hospital through Growing, not Building, an Electronic Patient Record System

The benefits for any health care provider of successfully introducing an Electronic Patient Record System (EPRS) into their organisation can be considerable. It has the potential to enhance both clinical care and managerial processes, as well as producing more cost-effective care and care programmes across clinical disciplines and health care sectors. However, realising an EPRS's full potential can be a long and difficult process and should not be entered into lightly. Introducing an EPR System involves major personnel, organisational and technological changes. These changes must be interwoven and symbiotic and must be managed so that they grow together in stages towards a vision created and shared by all clinical professional staff, other staff, and managers in that process. The use of traditional "building" or "journey" metaphors inadequately reflects the complexity, uncertainty and, therefore, the unpredictability of the process. We propose that a more useful metaphor may be of "growing" a progressively more united, unified information system and health care organisation. We suggest this metaphor better recognises that the evolutionary process appears to be more organic than predictable and more systemic than mechanistic. An illustration is given of how these organisational clinical and technical issues might evolve and interweave in a hospital setting through a number of stages.

Two levelled design of an unified paediatric health care encounter.

The appearance of the new computer-based information technology has initiated the possibility of medical staff performing their everyday routine activities more effectively and efficiently. But to be able to use information technology as successfully as possible, unified and integrated medical encounters are urgently needed especially in the paediatrics field. The tendency to unify the medical encounter is relatively old and had already begun in the 'pre-computer era'. There were some, unpublished, attempts to unify the child's medical encounter during the last years in our country. Unfortunately they were all unsuccessful for various reasons, but it is our deep belief that the common factor for their lack of success was the inappropriateness of the methodology being used and the neglect of many system theory principles especially soft-system ones. It is the objective of this paper to briefly introduce MetaMet and its application in the design of the UNCLE (UNified Child's heaLth carE Encounter). MetaMet is an information system design approach, based on two-levelled design and its aim is to overcome at least some problems concerned with software crisis and to enable more successful design of (medical) information systems.