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PubMed1995

ICU for the '90s: the "intensive customer unit".

Health care in the '90s is more complex and costly than ever before, and the healthcare consumer is knowledgeable and discriminating. Critical care nurses, who have always been responsive to technological change, must now be more responsive to consumer needs. This requires a change in mindset and a commitment to satisfying the "healthcare consumer". This article identifies nursing's customers, defines customer service and details a five-step plan for building an intensive customer unit. A successful customer service program in the intensive care unit leads to economic stability for both unit and institution, to humanistic integrity and to professional advancement for nurses.

Critical Care↗

PubMed1994

Physician resource planning: quest for answers.

The average annual rate of physician growth in Canada, just over 4% prior to 1989, has fallen to about 2% since 1990, approximating the average annual growth rate of the Canadian population. The growth rate is not uniform for all specialties, with surgical specialties experiencing the smallest increases. Sub-specialist growth in the past 5 y has occurred preferentially in disciplines identified as areas of need and those identified as emerging specialties. Assessment of average workloads of physicians derived from full-time equivalent measurements, reported by the National Physician Data Base, indicates increasing workloads in the specialist group, which is most marked in the surgical specialties. Among a number of factors influencing workload measures, which might explain differences noted among specialty groups, are age, gender, lifestyle choices, technology changes, physician growth rates, and saturation of the market place balancing physician availability with "demand" for services. All such factors, along with the impact of current health care reform initiatives, must be considered when forecasting and managing physician resources.

Canada↗

PubMed1994

[Plasma fractionation. Progress, problems and perspectives].

In the last few years, plasma fractionation has been subjected to major technological changes which have contributed to improve the viral safety and overall purity of plasma derivatives. New viral inactivation treatments, primarily solvent-detergent and pasteurization, have been introduced in the manufacturing processes of plasma derivatives to ensure the inactivation of major plasma-borne viruses, including HIV and hepatitis B and C viruses. Concurrently, new highly purified products obtained by chromatographic methods (mainly ion exchange and/or immunopurification) have been developed in the last five years and have replaced former preparations, providing a significantly higher safety level in terms of purity and viral risks. For an example, the new generation of Factor VIII and Factor IX concentrates (to treat hemophilia A and hemophilia B, respectively), which have been introduced in the last five years, are purified over 10,000- to 20,000-fold from plasma, as compared to only 50- to 100-fold for the former products. Similarly, new, standardized, clotting factor or protease inhibitor concentrates have been made available, thus permitting to carry out selective hemotherapy of specific diseases. Examples include the development of von Willebrand factor, factor XI, protein C, or alpha 1-antitrypsin concentrates for the substitutive therapy of congenital or acquired deficiencies. In addition, the concept of good manufacturing practices has been implemented, whereas carefully controlled, validated processes are contributing to the consistency in the quality of those products. Current major problems in plasma fractionation relate to the potential occurrence of new pathogenic agents that could resist present viral inactivation treatments and to the potential effect of given purification technologies on the development of immunogenic properties of proteins. Current trends indicate that significant progress in viral safety of plasma derivatives (for example through the introduction of new concept such as viral filtration) are to be expected very soon. Further research in this very important field is mandatory as plasma should remain the starting material of important therapeutic products in the coming years.

Cell Fractionation↗

PubMed1993

Technology assessment and cost management.

Endoscopic, less-invasive surgery has reshaped health care. The skill of correctly assessing purchases and leases is critical to a surgical service's success. Video technology changes rapidly, and systems become obsolete in months, not years. Each update presents new learning curves, thus additional educational costs. Choosing reusable instrumentation may include hidden costs not fully appreciated, whereas disposables may create waste management and environmental problems. Assessing and managing the costs related to less-invasive surgery require in-depth analyses of an institution's specific needs and of available and future technology.

Costs and Cost Analysis↗

PubMed1993

[Automation in hematologic cytology].

Automation in hematological cytology can identify blood cells in suspension by new parameters: electrical field variations, light intensity modifications absorbtion or diffraction by one or two lasers, fluorescence intensity, cytochemical reactions or specific lysis. The new technology change the strategy of hematological laboratories. Automation realizes perfectly the white blood cell differential and modifies hematological language with respect to anemia and white blood cells diseases.

Automation↗

PubMed1993

Communication in the physician-patient relationship.

Political, legal, ethical, social, economic, and technological changes in the twentieth century have produced a profound effect on the health care and health status of Americans and the way in which physicians and patients communicate. In the latter half of this century, the responsibility for individual health care has shifted from a physician-oriented, paternalistic approach to a patient-centered one. Patients now assume two identities: health consumers and active participants in the medical decision-making process. This phenomenon has created an environment where consumer demand for information has shifted from a single focus on symptoms, diagnosis, and treatment of diseases to an increasing preoccupation with cost, quality, and access to health care. This shift emphasizes the critical role played by medical librarians in the dissemination of needed information, and it challenges librarians to take a leadership role in opening newer channels of communication between physicians and patients. The 1992 Janet Doe Lecture analyzes the evolutionary change in the physician-patient relationship and its modes of communication, projects future roles for medical librarians, and provides an extensive list of references for further reading.

Communication↗

PubMed1996

[Aging, family relations and life course].

Integration of sociological research findings into the study of late life individual development is attempted. The human lifecourse is presenting itself as de-standardized and individualized. Phases of renewed learning and selfmanaged changes become requirements for fulfilment in late life. The labor market and technological change contribute to the fragmentation of the life course. More attention has to be payed to train for a learning of re-learning, and for the capacities of the self to respond creatively to changes in the biography. One important element in increased endeavour in this context is the attempt to face intergenerational differences and to learn to grow with conflict even in old age.

Adaptation, Psychological↗

PubMed1996

Converging technologies and their impact on the clinical laboratory.

Rapid technological change is transforming the world in which we live. Because laboratory services are defined by available products and tools of technology, this "technological revolution" is having a significant and profound effect on how clinical laboratories are organized, staffed, equipped, and operated. In this review, I discuss individually and collectively the advances and developments being made in the general areas of measurement, digital, communication, and transportation technology and demonstrate how the convergence of the products evolving from these technologies is affecting the clinical laboratory.

Clinical Laboratory Techniques↗

PubMedDate not supplied

'Health-for-All' in the twenty-first century: a global perspective.

Changes in the broad determinants of health since the Alma Ata Conference in 1978 necessitate a renewed examination of the underlying principles and focus of the Primary Health Care (PHC) strategy. The PHC approach has been adopted by most countries and has led to improved access to certain basic health services. However, the health gains in other areas are less encouraging. Some elements of the PHC approach, for example, the effective implementation of equity-oriented health policies and the need to improve management principles within health services, have yet to be fully implemented. Moreover, to address the underlying determinants of health status, the World Health Organization's (WHO) renewed global health policy will have to include certain issues that were not considered at Alma Ata. For example, the health impacts of global recession and globalization and the need for human-centered sustainable development strategies were not considered at Alma Ata. A renewed global health policy will also have to consider demographic, epidemiological, environmental and technological changes that have emerged since 1978. It is important that WHO's renewed policy be based on sound evidence, a commitment to ethical principles and broad use of partnerships for health at global, national and local levels. One implication of this new context of health development for the renewed health policy will be that 'thinking globally and acting locally' will have to complemented by stronger global action to protect local and national health.

Cross-Cultural Comparison↗

PubMed1998

Research implications of improvements in access to the ONS Longitudinal Study.

In this article we outline significant changes in the way the ONS Longitudinal Study data are stored, accessed and analysed. The data were held previously on mainframe computers. Recent technological changes have made it possible to introduce PC-based systems without compromising confidentiality. The advantages of this new computing environment are illustrated with recent findings on geographic inequalities in health.

Adolescent↗

PubMed1998

Assessing outcomes of an academic computing initiative.

Academic computing initiatives rank high on the list of priorities of many dental schools. However, outcomes of academic computing initiatives have not been presented. The objectives of this program evaluation were to: 1) document a strategic initiative for academic computing over a five-year period; 2) assess outcomes; and 3) demonstrate how outcomes assessment changed strategic goals for the future. In 1992, Temple University School of Dentistry developed an academic computing plan. The plan proposed to develop the computer literacy of faculty, teach students the computer skills they need to be successful in their careers, and introduce computer-aided instruction as a new teaching tool. Before a new five-year plan was developed in 1997, the original plan's outcomes were summarily assessed. Assessment instruments included faculty and student surveys, budgets, inventory records, and utilization statistics. The school has reached two of three goals of the 1992 plan. Eighty percent of all full-time faculty have computers, are computer literate, and use computers for a variety of purposes. The school has implemented a comprehensive predoctoral dental informatics curriculum. However, the implementation of computer-aided instruction has not met expectations. Goals of the 1998-2003 plan include establishing an online learning infrastructure, improving student access, implementing computer-based oral health records, and further improving the computer literacy of faculty and students. Planning and supporting academic computing initiatives is a substantial challenge. Factors such as institutional culture, capital investment, ongoing support, and technological change influence plans and their success. While process and structure can be assessed relatively easily, measures for changed educational outcomes are still lacking.

Budgets↗

PubMed1998

Health and medical informatics education: perspectives for the next decade.

It is argued that the progress of information processing and information technology changes our societies. Examples are given that there is a significant economic relevance of information technology for medicine and healthcare and for the quality of healthcare as well. In order to adequately pursue the goal of 'Transforming healthcare through innovative use of information technology for the 21st century' (the topic of the 6th International Conference on Health and Medical Informatics Education and of this special issue of the International Journal of Medical Informatics), health professionals are needed who are well-educated in health informatics or medical informatics, respectively. Raising the scope and the quality of education in the field of health and medical informatics would help to raise the quality and efficiency of healthcare. In this context the International Medical Informatics Association (IMIA) and its working group 1 (WG1) on Health and Medical Informatics Education can make a contribution by disseminating information and by elaborating recommendations on courses and programs in health and medical informatics. For this purpose IMIA WG1 has established a WWW site (http://www.imia.org/wg1) with information on health and medical informatics programs and courses. All teachers and institutions are encouraged to submit information about courses and programs offered and to set pointers to their own WWW sites. In addition, a mailing list was installed to facilitate communication between all persons involved in health and medical informatics education. For subscription, a message has to be sent to 'listserv@relay.urz.uni-heidelberg.de'. The body of the message should read 'SUBSCRIBE IMIA-WG1'.

Databases as Topic↗

PubMed1998

[The cost of sickness in the Netherlands in 1994; the main determinants were advanced age and disabling conditions].

OBJECTIVE: To estimate the costs of health care in 1994, the development of the costs assigned to specific diseases, and the future costs. DESIGN: Descriptive. SETTING: Erasmus University, Department of Public Health, Rotterdam, the Netherlands. METHOD: For each health care sector, costs were allocated to 62 diagnostic groups, age and sex making maximal use of national registries and other sources with data on health care use in the Netherlands. RESULTS: More than 80% of the 60 billion Dutch guilders that were spent on health care in 1994 could be assigned to specific diseases. Most costs were made for non-fatal diseases like mental deficiency, dementia and musculoskeletal disease. Except for cardiovascular disease, the share of major causes of death in the total costs was not significant. Average costs per inhabitant were low during youth and adulthood but increased exponentially with age from age 50 onwards. Between 1988 en 1994, health care costs experienced an annual growth rate of 5.2%, caused by price and wage increases (one half), ageing (a quarter) and other effects on health care costs such as epidemiological and technological change (a quarter). CONCLUSION: The main determinants of health care use in the Netherlands were old age and disabling conditions. Due to ageing and other influences, real health care costs in the years to come will increase by an average annual rate of 2.4%.

Adolescent↗

PubMed1998

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.

Computer Systems↗

PubMed1998

Innovation and survival: a case study in planning medical library services.

In the information age, information utilities like libraries are as sensitive to the stresses of change as any other organization. This article is a case study of a small, specialized medical library as it attempted to understand, and cope with, the complex simultaneous challenges of serious budgetary constraints, technological change, and shifting user demands in the mid 1990s. To support planning decisions in a period of declining use statistics, the Medical Library at Women's College Hospital, Toronto, carried out a user survey that posed choices about priorities among services. Conclusions drawn from the survey and its related planning process may help similar organizations design an appropriate service blend for future users.

Efficiency↗

PubMed1998

Can Europe afford not to implement evidence-based medicine in heart failure?

Technological change in cardiovascular medicine is extremely rapid and is likely to continue to accelerate. Society, of course, demands that new products and services are clinically effective in combating disease, reducing disability and extending life. Society also requires them to be cost-effective. Within this framework there is a vital need to produce authoritative information to assist in making very important healthcare decisions. A strategy for assessing both the effectiveness and the economics of cardiovascular disease management programmes has four discrete, mutually reinforcing tasks: (1) identifying the technologies that need to be assessed, (2) collecting data on the selected technologies, (3) synthesizing the data collected, and (4) disseminating the information collected. There is no single strategy to prevent a global financial crisis in heart failure care. However, a set of recommendations have been proposed as a means to overcome major obstacles. These recommendations have been elaborated mainly from a practical point of view and, while they are not meant to be exhaustive, they may represent an agenda for action. Future research, and especially experience relating to the economics and outcomes of heart failure care developments, will be of utmost interest and may act as a basis for further healthcare decisions.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed1999

The role of enteroscopy in clinical practice.

Enteroscopy does not yet carry the conviction that physicians are used to with gastroscopy and colonoscopy. The examination is never complete. The distance of small bowel examined in any individual examination is unknown. Although some therapeutic maneuvers are possible, the further the endoscope is into the small bowel the more difficult it becomes to pass and control the instruments. There is more room for improvement in enteroscopy than in almost any other area of gastrointestinal endoscopy. Nonetheless, there have been real gains for patients with difficult gastrointestinal bleeding and small bowel pathology with advances in diagnostic and therapeutic ability with enteroscopes achieved by a combination of relatively minor technologic changes and some clinical enthusiasm.

Biopsy↗

PubMed1998

Thirteen years of manipulating the mouse genome: a personal history.

In 1974, Dr. Ralph Brinster published a paper describing the consequences of injecting embryonal carcinoma cells, the predecessors of embryonic stem cells, into mouse blastocysts. Despite their early promise, embryonal carcinoma cells would not efficiently populate the germ line of mice. A decade later Elizabeth Robertson and I described the efficient generation of germline chimaeras from cultured embryonic stem cells and shortly afterwards the genetic manipulation of the mouse germline using ES cells. Our demonstration of the potency of Embryonic Stem cells gave birth to a new era in manipulative mouse genetics, one in which endogenous genes can now be mutated at will using gene targeting of retroviral mutagenesis. This review focuses on the development and testing of concepts and techniques during the thirteen years after we knew germline modification of endogenous genes in the mouse would be possible. This period is one in which more and more sophisticated tools for manipulating the mouse germline were developed and implemented. In this review I have taken the rare opportunity to reveal some of my thought processes, frustrations, successes and failures as we moved through this exciting period of rapid technological change. As I look forward to the next thirteen years, I feel that this will be an equally exciting period for manipulative genetics as we struggle to formulate concepts and design experiments that enable us to understand gene function in an era when the sequence of all genes will be known.

Animals↗