A comparative analysis of hospital -based physician monitoring systems

The purpose of the multiple case-study was to determine how hospital subsystems (such as physician monitoring and credentialing; quality assurance; risk management; and peer review) were supporting the monitoring of physicians? Three large metropolitan hospitals in Texas were studied and designated as hospitals #1, #2, and #3. Realizing that hospital subsystems are a unique entity and part of a larger system, conclusions were made on the premises of a quality control system, in relation to the tools of government (particularly the Health Care Quality Improvement Act (HCQIA)), and in relation to itself as a tool of a hospital.^ Three major analytical assessments were performed. First, the subsystems were analyzed as to their "completeness"; secondly, the subsystems were analyzed for "performance"; and thirdly, the subsystems were analyzed in reference to the interaction of completeness and performance.^ The physician credentialing and monitoring and the peer review subsystems as quality control systems were most complete, efficient, and effective in hospitals #1 and #3. The HCQIA did not seem to be an influencing factor in the completeness of the subsystem in hospital #1. The quality assurance and risk management subsystem in hospital #2 was not representative of completeness and performance and the HCQIA was not an influencing factor in the completeness of the Q.A. or R.M. systems in any hospital. The efficiency (computerization) of the physician credentialing, quality assurance and peer review subsystems in hospitals #1 and #3 seemed to contribute to their effectiveness (system-wide effect).^ The results indicated that the more complete, effective, and efficient subsystems were characterized by (1) all defined activities being met, (2) the HCQIA being an influencing factor, (3) a decentralized administrative structure, (4) computerization an important element, and (5) staff was sophisticated in subsystem operations. However, other variables were identified which deserve further research as to their effect on completeness and performance of subsystems. They include (1) medical staff affiliations, (2) system funding levels, (3) the system's administrative structure, and (4) the physician staff "cultural" characteristics. Perhaps by understanding other influencing factors, health care administrators may plan subsystems that will be compatible with legislative requirements and administrative objectives. ^

Clinical decision support capabilities of commercially-available clinical information systems.

BACKGROUND: The most effective decision support systems are integrated with clinical information systems, such as inpatient and outpatient electronic health records (EHRs) and computerized provider order entry (CPOE) systems. Purpose The goal of this project was to describe and quantify the results of a study of decision support capabilities in Certification Commission for Health Information Technology (CCHIT) certified electronic health record systems. METHODS: The authors conducted a series of interviews with representatives of nine commercially available clinical information systems, evaluating their capabilities against 42 different clinical decision support features. RESULTS: Six of the nine reviewed systems offered all the applicable event-driven, action-oriented, real-time clinical decision support triggers required for initiating clinical decision support interventions. Five of the nine systems could access all the patient-specific data items identified as necessary. Six of the nine systems supported all the intervention types identified as necessary to allow clinical information systems to tailor their interventions based on the severity of the clinical situation and the user's workflow. Only one system supported all the offered choices identified as key to allowing physicians to take action directly from within the alert. Discussion The principal finding relates to system-by-system variability. The best system in our analysis had only a single missing feature (from 42 total) while the worst had eighteen.This dramatic variability in CDS capability among commercially available systems was unexpected and is a cause for concern. CONCLUSIONS: These findings have implications for four distinct constituencies: purchasers of clinical information systems, developers of clinical decision support, vendors of clinical information systems and certification bodies.

State health care reform: An analysis of strategies

The United States health care system faces significant challenges, particularly with problems of the uninsured and with the rising costs of care. These problems lead many to study and discuss strategies for reforming the health care system. Four different plans for ideal health care reform, set forth by notable scholars or organizations, are explained herein. Then, states within the United States are examined in terms of their recent efforts at health care reform. Those states proposing significant changes to their health care systems are analyzed—namely, Maine, Massachusetts, and Vermont. The strategies used in these three states are compared to the strategies laid out by the experts in order to determine which strategies are the most popular in current health care reform efforts among the states studied here. These strategies are totaled to find which organization's plan for ideal reform seems to be the most popular. The strategies of managed competition are shown to be the most popular strategies among these three state health care reforms, while the strategies of the single-payer plan discussed herein were the least popular. All three states seem to utilize strategies that build upon their previous health care system, rather than implementing strategies that completely replace the previous system. ^

Process evaluation of the Texas occupational safety & health surveillance system

Introduction: The Texas Occupational Safety & Health Surveillance System (TOSHSS) was created to collect, analyze and interpret occupational injury and illness data in order to decrease the impact of occupational injuries within the state of Texas. This process evaluation was performed midway through the 4-year grant to assess the efficiency and effectiveness of the surveillance system’s planning and implementation activities1. ^ Methods: Two evaluation guidelines published by the Centers for Disease Control and Prevention (CDC) were used as the theoretical models for this process evaluation. The Framework for Program Evaluation in Public Health was used to examine the planning and design of TOSHSS using logic models. The Framework for Evaluating Public Health Surveillance Systems was used to examine the implementation of approximately 60 surveillance activities, including uses of the data obtained from the surveillance system. ^ Results/Discussion: TOSHSS planning activities omitted the creation of a scientific advisory committee and specific activities designed to maintain contacts with stakeholders; and proposed activities should be reassessed and aligned with ongoing performance measurement criteria, including the role of collaborators in helping the surveillance system achieve each proposed activity. TOSHSS implementation activities are substantially meeting expectations and received an overall score of 61% for all activities being performed. TOSHSS is considered a surveillance system that is simple, flexible, acceptable, fairly stable, timely, moderately useful, with good data quality and a PVP of 86%. ^ Conclusions: Through the third year of TOSHSS implementation, the surveillance system is has made a considerable contribution to the collection of occupational injury and illness information within the state of Texas. Implementation of the nine recommendations provided under this process evaluation is expected to increase the overall usefulness of the surveillance system and assist TDSHS in reducing occupational fatalities, injuries, and diseases within the state of Texas. ^ 1 Disclaimer: The Texas Occupational Safety and Health Surveillance System is supported by Grant/Cooperative Agreement Number (U60 OH008473-01A1). The content of the current evaluation are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.^

The illness experiences of African Americans residing in an inner city community, Houston, Texas

This dissertation documents health and illness in the context of daily life circumstances and structural conditions faced by African American families living in Clover Heights (pseudonym), an inner city public housing project in the Third Ward, Houston, Texas. Drawing from Kleinman's (1980) model of culturally defined health care systems and using the holistic-content approach to narrative analysis (Lieblich, Tuval- Mashiach, & Zilber, 1998) the purpose of this research was to explore the ways in which social and health policy, economic mobility, the inner city environment, and cultural beliefs intertwined with African American families' health related ideas, behaviors, and practices. I recruited six families using a convenience sampling method (Schensul, Schensul, & LeCompte, 1999) and followed them for fourteen months (2010–2011). Family was defined as a household unit, or those living in the same residence, short or long-term. Single, African American women ranging in age from 29–80 years headed all families. All but one family included children or grandchildren 18 years of age and younger, or children or other relative 18 years of age and older. I also recruited six residents with who I became acquainted over the course of the project. I collected data using traditional ethnographic methods including participant-observation, archive review, field notes, mapping, free-listing, in-depth interviews, and life history interviews. ^ Doing ethnography afforded the families who participated in this project the freedom to construct their own experiences of health and illness. My role centered on listening to, learning from, and interpreting participants' narratives, exploring similarities and differences within and across families' experiences. As the research progressed, a pattern concerning diagnosis and pharmacotherapy for children's behavioral and emotional problems, particularly attention-deficit hyperactivity disorder (ADHD) and pediatric bipolar disorder (PBD), emerged from my formal interactions with participants and my informal interactions with residents. The findings presented in this dissertation document this pattern, focusing on how mothers and families interpreted, organized, and ascribed meaning to their experiences of ADHD and PBD. ^ In the first manuscript presented here, I documented three mothers' narrative constructions of a child's diagnosis with and pharmacotherapy for ADHD or PBD. Using Gergen's (1997) relational perspective I argued that mothers' knowledge and experiences of ADHD and PBD were not individually constructed, but were linguistically and discursively constituted through various social interactions and relationships, including family, spirituality and faith, community norms, and expert systems of knowledge. Mothers' narratives revealed the complexity of children's behavioral and emotional problems, the daily trials of living through these problems, how they coped with adversity and developed survival strategies, and how they interacted with various institutional authorities involved in evaluating, diagnosing, and encouraging pharmaceutical intervention for children's behavior. The findings highlight the ways in which mothers' social interactions and relationships introduced a scientific language and discourse for explaining children's behavior as mental illness, the discordances between expert systems of knowledge and mothers' understandings, and how discordances reflected mothers' ‘microsources of power’ for producing their own stories and experiences. ^ In the second manuscript presented here, I documented the ways in which structural factors, including gender, race/ethnicity, and socioeconomic status, coupled with a unique cultural and social standpoint (Collins, 1990/2009) influenced the strategies this group of African American mothers employed to understand and respond to ADHD or PBD. The most salient themes related to mother-child relationships coalesced around mothers' beliefs about the etiology of ADHD and PBD, ‘conceptualizing responsibility,’ and ‘protection-survival.’ The findings suggest that even though mothers' strategies varied, they were in pursuit of a common goal. Mothers' challenged the status quo, addressing children's behavioral and emotional problems in the ways that made the most sense to them, specifically protecting their children from further marginalization in society more so than believing these were the best options for their children.^