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PubMed2006

Technology solutions for better outcomes: integrated information management in key to productivity increases in medicine.

The challenges to healthcare systems around the world are primarily impacted by two topics: demographic factors and progress in medicine. An ageing population inherently needs more medical services which add financial burdens, in particular, to public healthcare. Since the level of medical education is growing at the same time, we are observing an increased demand for sophisticated (in general expensive) medicine. Drastic changes in financing seem unavoidable. Multiple diagnoses, repeated examinations, trial-and-error, overcapacities and other signs of missing economical considerations are reinforced by reimbursement systems. In a world where, in principle, all information is available everywhere, more than a patient's history should be accessible. Other industries have knowledge management systems in place that make state-of-the-art expertise available everywhere. Intelligent patient databases could consist of learning cycles that (i) enable the individual to benefit from structured knowledge, in addition to personal experience of the physician, and (ii) use the knowledge generated from the individual to extend the database. The novel area of molecular medicine fits perfectly well into these scenarios. Only attached to an IT backbone can the flood of information be managed in a beneficial way. Efficiency improvements in healthcare address the needs of all parties in the system: patients, providers, and payers. The opportunities, however, can only materialize if everyone is prepared to change. IT will set the standards for the biggest challenge in healthcare: The paradigm shift in medicine.

Diffusion of Innovation↗

PubMed2004

Nursing curriculum and continuing education: future directions.

Redefinition of roles and functions in the healthcare systems of the future requires embracing to the value of continuing education. Within this framework healthcare professional education and continuing education, there are several core competencies described by Institute of Medicine (IOM) [A.C. Greiner, E. Knebel (Eds.), Health Professionals Education: Bridge to Quality, IOM, available at, May 2003] that form the foundation for practice for nurses and other healthcare professionals. An overarching sentence in the document says "All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics" (p. 45). These IOM core competencies are: (1) Common value for respecting patients' differences, values, preferences and expressed needs. (2) Ability to cooperate, collaborate, communicate and integrate care using interdisciplinary teams. (3) Knowledge of and willingness to employ evidence-based practice principles. (4) Capability to apply quality and safety improvement approaches in care. (5) Understand, value and use informatics to all areas of health care, to reduce errors, manage knowledge and information, and make decisions and communicate. In enveloping these core competencies in basic and continuing education, it is necessary to build an evidence base for education itself, demand that faculty are prepared for the future. A crucial need is for healthcare professional students (including nursing students) learn interdisciplinary collaboration in the education of patients. A global strategy, using these competencies for preparing faculty is necessary; and some models already exist that can be further developed to meet future needs that are informatics driven in our increasingly technological future care systems.

Curriculum↗

PubMed1997

From hospital information system components to the medical record and clinical guidelines & protocols.

This paper introduces an ongoing project towards the development of a new generation HIS, aiming at the integration of clinical and administrative information within a common framework. Its design incorporates explicit knowledge about domain objects and professional activities to be processed by the system together with related knowledge management services and act management services. The paper presents the conceptual model of the proposed HIS architecture, that supports a rich and fully integrated patient data model, enabling the implementation of a dynamic electronic patient record tightly coupled with computerised guideline knowledge bases.

Clinical Protocols↗

PubMed2000

Health policy and case management.

The purpose of this article is to analyze the performance of and support for case management using a policy framework in order to increase case managers' awareness of policy making and facilitate successful planning for future policy initiatives. Feldstein's (1996) theory of opposing legislative outcomes indicates that legislation can be viewed on a continuum, ranging from legislation that meets the needs of the public to legislation considered to be in the self-interest of the participants and legislators. The current health care system requires that case managers working for publicly funded health care organizations balance the need for stewardship of U.S. tax dollars and the health care needs of consumers. It is apparent from the literature that case managers are successfully achieving this balance. However, certain conditions should exist that allow for case manager decision-making that promotes effective and efficient utilization of health care resources. Case managers must work within the context of the health care policy environment. Realizing that it is more likely that the conflicts between stewardship and the provision of health care services will continue, case managers' knowledge and influence regarding policy making becomes imperative in order to ensure that these conflicting goals do not become mutually exclusive.

Case Management↗

PubMed1999

A medical resident inpatient hospice rotation: experiences with dying and subsequent changes in attitudes and knowledge.

PURPOSE: To evaluate intern experience in end-of-life care and self-assessed changes in attitude and knowledge, following a mandatory rotation on an inpatient hospice and in a nursing home. SUBJECTS AND METHODS: Twenty-seven interns enrolled in an internal medicine residency program completed a questionnaire examining experiences with dying patients, prior training in end-of-life care, and self-ratings of pertinent attitudes and knowledge. The questionnaire used a retrospective before and after design. Comparisons were evaluated using dependent two-tailed r-tests. RESULTS: Prior training was largely limited to undergraduate didactic courses. Few interns had received formal training in symptom management. Most felt poorly prepared to care for terminally ill patients. Eighty-two percent of interns had previously cared for a dying patient only in acute care. Fifty-nine percent had never cared for a dying patient without intravenous fluids. Prior modeling of end-of-life care communication by attending physicians was uncommon. On a 5-point scale (strongly disagree-strongly agree) mean responses increased from 2.1 before-rotation to 3.0 after-rotation (p < 0.001) for the statement, "I feel as comfortable with a dying patient as I do with any other patient." Pain management knowledge increased from 2.0 before-rotation to 3.8 after-rotation (p < 0.001). Seventy-seven percent strongly agreed with the statement, "some training in care of terminally ill patients should be mandatory for all internists." CONCLUSIONS: Prior experiences did not adequately prepare interns to deliver competent care. Significant improvements in attitude and knowledge were noted following the intervention. More hands-on clinical experiences in end-of-life care for residents are needed. Occasional didactic sessions will be inadequate.

Journal Article↗

PubMed2003

Evolving from bioinformatics in-the-small to bioinformatics in-the-large.

We argue the significance of a fundamental shift in bioinformatics, from in-the-small to in-the-large. Adopting a large-scale perspective is a way to manage the problems endemic to the world of the small-constellations of incompatible tools for which the effort required to assemble an integrated system exceeds the perceived benefit of the integration. Where bioinformatics in-the-small is about data and tools, bioinformatics in-the-large is about metadata and dependencies. Dependencies represent the complexities of large-scale integration, including the requirements and assumptions governing the composition of tools. The popular make utility is a very effective system for defining and maintaining simple dependencies, and it offers a number of insights about the essence of bioinformatics in-the-large. Keeping an in-the-large perspective has been very useful to us in large bioinformatics projects. We give two fairly different examples, and extract lessons from them showing how it has helped. These examples both suggest the benefit of explicitly defining and managing knowledge flows and knowledge maps (which represent metadata regarding types, flows, and dependencies), and also suggest approaches for developing bioinformatics database systems. Generally, we argue that large-scale engineering principles can be successfully adapted from disciplines such as software engineering and data management, and that having an in-the-large perspective will be a key advantage in the next phase of bioinformatics development.

Computational Biology↗

PubMed2001

Review of a personal experience in the management of carcinomatosis and sarcomatosis.

BACKGROUND: Peritoneal surface malignancy can result from seeding of gastrointestinal cancer or abdomino-pelvic sarcoma; it can also occur as a primary disease, such as peritoneal mesothelioma. In the past, this clinical situation was treated only with palliative intent. METHODS: An aggressive approach to peritoneal surface malignancy involves peritonectomy procedures, perioperative intraperitoneal chemotherapy and knowledgeable patient selection. The clinical assessments necessary for valid clinical judgements include the cancer histopathology (invasive vs expansive progression), the preoperative abdominal and pelvic CT, the peritoneal cancer index and the completeness of cytoreduction score. Proper patient selection is mandatory for optimizing the results of treatment. RESULTS: In a series of phase II studies, appendiceal tumors with peritoneal seeding became the paradigm for success with an 85% long-term survival in selected patients. Carcinomatosis from colon cancer had an overall 5-year survival of 50% with selected patients. Also, sarcomatosis patients overall had a 40% 5-year survival in selected patients. Peritoneal mesothelioma showed a 36% 5-year survival. In all malignancies, early aggressive treatment of minimal peritoneal surface dissemination showed the greatest benefit. CONCLUSIONS: Oncologists must accept responsibility for knowledgeable management of peritoneal surface dissemination of cancer because a curative approach has been demonstrated in large phase II studies and all historical controls show 0% long-term survival. Adjuvant phase III studies with perioperative intraperitoneal chemotherapy in diseases where peritoneal surface spread occurs are indicated.

Antineoplastic Agents↗

PubMed1999

Management of peritoneal-surface malignancy: the surgeon's role.

BACKGROUND: Peritoneal surface malignancy can result from seeding of gastrointestinal cancer or abdominopelvic sarcoma; it can also occur as a primary disease, for example, peritoneal mesothelioma. In the past, this clinical situation was treated only with palliative intent. METHODS: An aggressive approach to peritoneal surface malignancy involves peritonectomy procedures, perioperative intraperitoneal chemotherapy and knowledgeable patient selection. The clinical assessments necessary for valid clinical judgements include the cancer histopathology (invasive vs expansive progression), the preoperative abdominal and pelvic computed tomogram, the peritoneal cancer index and the completeness of cytoreduction score. Proper patient selection is mandatory for optimizing the results of treatment. RESULTS: In a series of phase-II studies, appendiceal tumors with peritoneal seeding was the paradigm for success with a 75% long-term survival in properly selected patients. Carcinomatosis from colon cancer had an overall 5-year survival of 20% but with selected patients this reached 50%. Also, sarcomatosis patients overall had only a 10% 5-year survival but selected patients had a 75% survival. In all malignancies, early aggressive treatment of minimal peritoneal surface dissemination showed the greatest benefit. CONCLUSIONS: The surgeon must accept responsibility for knowledgeable management of peritoneal surface dissemination of cancer. A curative approach has been demonstrated in large phase-II studies. Adjuvant studies with perioperative intraperitoneal chemotherapy in diseases where peritoneal surface spread occurs are indicated.

Clinical Trials, Phase II as Topic↗

PubMed2000

Creating knowledge structures in the pharmaceutical industry: the increasing significance of virtual organisation.

This paper explores the specific trend and challenges facing the pharmaceutical industry regarding the exploitation of Internet e-commerce technology and virtual organisation to develop and maintain competitive advantage. There are two important facets of the current trend. One is the rapid development of a complex network of alliances between the established pharmaceutical companies and the specialised biotechnology company start-ups. The other is the rapid growth of internet e-commerce companies dedicated to developing specialised technological platforms for acquiring and selling genetic and biochemical knowledge. The underlying challenge is how big pharmaceutical companies can emulate some of the innovation processes of smaller biotechnology company start-ups, and how they can appropriate and applied new technological knowledge on the development of new drugs. Pharmaceutical companies in order to retain competitive advantage need to continuously monitor all aspects of knowledge management with regard to the R&D and manufacturing process (as well as customer management and marketing). Technological change and organisational restructuring should be aimed at boosting the capacity of large firms to innovate rapidly.

Drug Industry↗

PubMed2006

An e-learning portal for nurses in Singapore General Hospital.

Singapore General Hospital (SGH) pioneered e-learning systems in Singapore as a knowledge management initiative for nurses. This paradigm shift in nursing education is a proactive step taken to address the increasing sophistication of healthcare systems, expanding demand and perennial shortage of nursing talent. E-learning has been a success at SGH, through providing systematic sharing of knowledge and capture of experience, through both formal and informal online channels. It also made training more effective and less costly. Formal methods of knowledge sharing comprise online learning through interactive training modules and slides presentation with narration, while informal learning comprises of peer group discussion and journal review. Both elements have been essential in making e-learning a success and in creating a lifelong learning culture in SGH.

Education, Distance↗

PubMed2004

Community asthma education program for parents of urban asthmatic children.

OBJECTIVES: To demonstrate the effectiveness of community asthma education provided by peers in the urban community. METHOD: A convenience sample of 267 self-referred, primarily African-American parents or primary caregivers of asthmatic children aged 18 months to 16 years completed a five-session education program. Program efficacy was evaluated at baseline, immediately postinstruction, and at three-, six-, and 12 months retention. Outcomes included three questionnaires measuring asthma self-management knowledge, control and quality of life. RESULTS: Immediately following program completion, participants demonstrated improvements in asthma knowledge (13% increased proportion correct, p < 0.01), ability to control their child's asthma 16% increased score, p < 0.01), and asthma quality of life (7% increased score, p < 0.01). Retention of knowledge with steady improvement of control and quality of life was observed up to one year postinstruction, as compared with immediate postprogram scores (p = 0.09 and 0.05, respectively). CONCLUSIONS: A community-based asthma educational program for caregivers should be an important component of childhood asthma management. The complexities of asthma management are best taught in educational programs that are easily accessible, provide a comfortable environment for participants, and are taught by peers.

Adolescent↗

PubMed2005

What else can I do but take drugs? The future of research in nonpharmacological treatment in early inflammatory arthritis.

Nonpharmacological treatments, including physiotherapy and occupational therapy, have assumed a complementary role to drug therapy in managing inflammatory arthritis. Clinicians and researchers are facing 3 major challenges concerning the use of these treatments. First, strong evidence is only present in a few nonpharmacological interventions, such as exercise, patient education, and low level laser in the treatment of rheumatoid arthritis. The evidence on the majority of interventions is, however, weak or inconclusive. Second, knowledge is lacking on the elements associated with models of nonpharmacological care. The multidisciplinary team approach has been viewed as the standard for arthritis treatment; however, the team structure and the communication style among team members vary around the world. The influence of these elements on treatment success remains unclear. Finally, disparities in knowledge management and translation in nonpharmacological research have hindered the clinical use of these treatments and the growth of research in the field. To address the challenges, the author is recommending 4 research priorities for nonpharmacological treatments: 1. Evaluation of less well-studied interventions; 2. Understanding the relationships among rehabilitation-related variables and disability; 3. Development and evaluation of innovative care models; and 4. Design and evaluation of knowledge transfer innovations.

Arthritis, Rheumatoid↗

PubMed2001

Knowledge, attitudes and management strategies in Scandinavia concerning hormone replacement therapy: a comparison between gynecologists in Denmark, Norway and Sweden.

OBJECTIVES: To describe and compare attitudes, knowledge and management strategies concerning the prescription of hormone replacement therapy (HRT) between gynecologists from three Scandinavian countries. DESIGN AND METHODS: In a cross-sectional study gynecologists in Denmark (n=386), Norway (n=475) and Sweden (n=1323) were invited by letter to complete and return an enclosed questionnaire. Then 1653 of the 2184 (76%) contacted gynecologists completed and returned the questionnaire. RESULTS: of the 1653 Scandinavian gynecologists, 42% offered HRT to all women provided there was no contraindication, while 58% recommended HRT to selected women after considering the advantages and disadvantages of HRT. In Norway and Sweden, the proportion of gynecologists routinely prescribing HRT for women without contraindications increased with age and in the oldest age group of gynecologists (>55 years) 49 and 56%, respectively, recommended HRT to all women. The gynecologists were unanimous in their choice of the type of HRT for perimenopausal women as 94% preferred cyclical or sequential combined (estrogen/progestogen) treatment or estrogen monotherapy (orally or transdermally) for hysterectomized women (95%). For postmenopausal women, 75% of the gynecologists offered continuous combined HRT while cyclical combined therapy was chosen by 15% of the gynecologists. No significant differences were found between physicians in the three countries regarding indications and contraindications to HRT. CONCLUSIONS: Scandinavian gynecologists are generally well informed concerning HRT and liberally recommend HRT for women without contraindications.

Adult↗

PubMed2004

Registration and regulation of health informatics professionals in the UK National Health Service.

Whilst good health informatics can contribute directly to the delivery of effective patient care, bad informatics can kill. The UK is establishing a regulatory body to register health informatics specialists who can demonstrate that they meet agreed standards of professional practice: the UK Council for Health Informatics Professions (UKCHIP). UKCHIP will also manage the introduction of a Code of Conduct (based on the IMIA Code) and processes for continuous professional development, appeals, and removal from the Register. The challenge has been to design a process that provides a suitable structure for all informatics staff, including records, coding, audit, library and knowledge management, ICT, systems, information management and clinical management specialists. The contention is that this inclusive model of regulation has international applicability.

Codes of Ethics↗

PubMed2005

Fever management: paediatric nurses' knowledge, attitudes and influencing factors.

AIMS: This paper describes Australian paediatric nurses' knowledge of and attitudes toward fever and its management and the predictors of their intentions to administer paracetamol to a febrile child. BACKGROUND: Despite evidence-based support for the beneficial effects of fever over the past three decades, health professionals' negative attitudes toward fever and their reliance on antipyretics to reduce it have persisted and continue to be reported in the literature. METHODS: A self-report questionnaire was used. An instrument was developed, piloted by test-retest and revised prior to data collection. Fifty-one paediatric nurses working in medical wards of a metropolitan paediatric hospital in Australia participated. RESULTS: Nurses' mean knowledge score about the physiology of fever, general fever management and antipyretics was 62%, which was not as high as expected. Participants reported positive attitudes toward the benefits of fever, the necessity for its reduction in children with pre-existing cardiac or respiratory conditions and towards regular antipyretic administration masking the infective process. Negative attitudes included disbelief that temperature is often unrelated to illness severity. Conflicting attitudes toward febrile convulsions were highlighted by beliefs that antipyretic therapy prevents these and that antipyretics do not prevent initial febrile convulsions. Predictors of intentions to administer paracetamol were beliefs about the effectiveness of paracetamol and nurses' beliefs about the expectations of others in relation to paracetamol administration. Nurses reported strong intentions to administer paracetamol to the next febrile child they cared for. Limitations of the study include the use of a nurse manager for recruitment and collecting the data at only one site. CONCLUSIONS: Fever management is an integral aspect of paediatric nursing. For its consistent rational management, nurses must have appropriate knowledge and positive attitudes. This highlights the need for continuing education in fever management.

Acetaminophen↗

PubMed2005

Quality, value, accountability and information as transforming strategies for patient-centred care: a commentary from an international perspective.

The reviewed paper describes how one of the largest integrated healthcare systems in the US has successfully transformed itself to provide 21st-century healthcare. Even though there are other examples of successful transformation of public health services, it is difficult for large, bureaucratic systems to change, and a substantial number of ministries of health or social security health systems in the developing world are run under the assumption that change is very difficult if not impossible to achieve. The VA has significant differences and more financial resources compared to most of the developing world public health institutions; but still, change is often not only about money, but also about strategic direction, commitment and leadership. On the basis of the main strategies used by the VA in its transformation process, the author makes some comments and suggestions for improving developing world healthcare organizations through lessons learned from the VA management strategies. Demand-driven or patient-centred systems are key for success and for the buy-in and involvement of the population and users of healthcare services, but this is easier said than done, especially in developing healthcare systems with immature information systems, access mechanisms and knowledge management. There is a belief in general that large bureaucratic organizations have a hard time adapting and transforming in response to the rapid change of society, technology and most importantly the needs and expectations of their users. The article describes how the largest integrated healthcare organization in the United States, the Veterans Health Administration, has undertaken changes that have turned it into a modern, well-managed organization that outperforms its competitors and has significantly increased its efficiency and users' satisfaction.

Delivery of Health Care, Integrated↗

PubMed2005

The electronic health record--the time is now.

Health care is changing because of the need to effectively manage both acute and chronic illness in the delivery of quality patient-centered care. This will force a change from the physician-centric model to one that uses a care team approach in both the hospital and ambulatory settings. The electronic health record promotes communication among team members, knowledge management, and the need to more rapidly translate evidence-based guidelines and performance criteria to the bedside and office. Electronic health records with embedded clinical decision support systems hold great promise. Multiple parties are pushing this agenda forward, which will lead to more comprehensive, efficient quality care. Use of the quality improvement tool as described shows how effective these methods are in managing coronary artery disease. Physicians and all members of the care team need to embrace this evolution.

Chronic Disease↗

PubMed2004

Management of childhood asthma: physicians' perspective in Turkey.

Many attempts have been made to decrease asthma-related mortality and morbidity, including preparation and distribution of guidelines. However, several studies from different regions of the world have reported low asthma control among children as well as adults. A questionnaire-based study was performed involving a number of Turkish physicians taking care of pediatric asthmatics, and aimed to document asthma-related knowledge. Of 219 physicians, 126 (57%) completed the questionnaire. The majority were pediatricians (92%), with an average of 253 +/- 14.1 outpatients per week, and an asthmatic ratio of 15.8%. According to the self-reported knowledge, management of acute asthma received the highest (3.42 +/- 0.05) and chronic asthma the lowest scores (3.18 +/- 0.06). The study group further credited inhaled and oral steroids similarly for the treatment of exacerbations and reported infrequent usage of spirometry and oxygen saturation than physical finding to estimate attack severity. Although with regard to most subjects, physicians' opinions appeared to be in agreement with the guidelines, there were certain differences implying need for future educational training. Chronic management, reported as the least understood part of the guidelines, suggests requirement of new models for estimating chronic disease severity.

Adrenal Cortex Hormones↗