Aims and Objectives
To identify and prioritise diseases which can be managed by an integrated care model. To develop an adequate methodology therefore. To develop a list of indicators for the design of integrated care models. To research and analyse international experience and evidence.
Identification and prioritisation of the diseases through means of a literature review, a questionnaire for health professionals and a workshop with scientific and professional experts. Cooperation between the Medical University Vienna and the Competence Centre Integrated Care of the Viennese Sickness Fund.
A report with a priority list of diseases relevant for the Austrian health care system for which integrated care models should be developed over the next years. A role model for other health care systems wanting to develop a national priority list and strategy for integrated care models.
Integrated Care is an adequate model to face the challenges of today's health care systems and can be utilised to restructure health care provision on a national level.
disease management programmes; priority setting; Austria
Since 2001, UCLA has operated IMPACT: Improving Access, Counseling and Treatment for Californians with prostate cancer. Funded by the California Department of Public Health, with a cumulative budget of over $80 million, the program provides comprehensive care for low-income, uninsured Californian men with biopsy-proven prostate cancer. Health services research conducted with program enrollees, through the UCLA Men’s Health Study, yields an opportunity to perform qualitative and quantitative assessments of patient-reported outcomes in these men, all members of historically underserved, primarily minority populations. This review summarizes data from several studies in which validated instruments were administered longitudinally in 727 participants, prospectively measuring health-related quality of life (HRQOL), self-efficacy in interactions with physician interactions, social and emotional health, symptom distress, satisfaction with care, and other patient-reported outcomes.
The UK government's latest primary care mental health initiative, Improving Access to Psychological Therapies (IAPT), seeks to achieve its aims partly through the extensive use of low-intensity workers (LIWs). As clinical supervisors to teams of primary care mental health workers (PCMHWs) already offering brief, evidence-based interventions in primary care mental health services, we draw on the growing body of literature and our own experience to discuss dilemmas associated with the roles of such workers. These concern clinical governance, training, supervision and integration into existing services. We discuss how IAPT service characteristics may provide solutions to some of these dilemmas. We argue that it is unlikely they will be completely resolved and that IAPT services, in addressing future challenges, could benefit from lessons learned from the PCMHW role.
IAPT; low-intensity workers; primary care mental health
The concept of knowledge management has been prevalent in the business sector for decades. Only recently has knowledge management been receiving attention by the health care sector, in part due to the ever growing amount of information that health care practitioners must handle. It has become essential to develop a way to manage the information coming in to and going out of a health care organization. The purpose of this paper was to summarize previous studies from the business literature that explored specific knowledge management tools, with the aim of extracting lessons that could be applied in the health domain.
We searched seven databases using keywords such as "knowledge management", "organizational knowledge", and "business performance". We included articles published between 2000-2009; we excluded non-English articles.
83 articles were reviewed and data were extracted to: (1) uncover reasons for initiating knowledge management strategies, (2) identify potential knowledge management strategies/solutions, and (3) describe facilitators and barriers to knowledge management.
KM strategies include such things as training sessions, communication technologies, process mapping and communities of practice. Common facilitators and barriers to implementing these strategies are discussed in the business literature, but rigorous studies about the effectiveness of such initiatives are lacking. The health care sector is at a pinnacle place, with incredible opportunities to design, implement (and evaluate) knowledge management systems. While more research needs to be done on how best to do this in healthcare, the lessons learned from the business sector can provide a foundation on which to build.
To describe key success factors, derived from literature review and international case studies that enable effective integration between clinicians, teams and organizations.
Effective integration is dependent on consideration of diverse factors operating at macro, meso and micro levels of health care.
Literature review and four international case studies.
A maximum variation sample of four ICOs was selected from organizations and services nominated by international experts as ‘high performing’; ensuring a range of national policy contexts, organizational arrangements, and integrative approaches. Case studies in the USA, Holland and Scotland, drew on data from 10 to 15 semi-structured interviews with managers and clinicians and on document review. Interviews explored understanding of and objectives for ‘integration’, external influences and impact of internal characteristics (e.g. leadership, governance, IT) in facilitating/hindering integration. Clinical interviewees also described hypothetical patient journeys. Analysis focused on potential barriers and facilitators to integration.
Findings suggest integration requires four tiers of ‘success factors’: 1) a supportive ‘operating environment’ with appropriate policy, regulation, law, and payment systems; 2) organisational culture, infrastructure and processes (which may cross organizational boundaries) to support integration and enable; 3) effective inter-professional teams operating within or between organizations with linked infrastructure; shared assessments; common standards; care co-ordination and shared care plans and 4) activated patients to participate in care planning.
Those wishing to develop effective ICOs will need to ensure that each of these four tiers is addressed simultaneously across all levels (i.e. macro, meso and micro) of health care.
integrated care; success factors; international case studies; literature review
COPD exerts a substantial burden on health and health care systems globally and will continue to do so for the foreseeable future. Treatment however can be costly and health care providers are interested in both whether treatments can offer improvements in disease burden and whether they represent value for money. Economic evaluations seek to resolve this issue by producing results that can be used to inform and assist the decision maker in allocating scarce health care resources. In this paper we introduce economic evaluation and then use these themes to review and critically appraise the existing COPD economic evaluations, in order to assess quality in light of today’s standards. The use of existing economic evaluations in informing the decision maker is then discussed. Ten out of the fifteen studies were clinical trial or observational study based, and the remaining five on a decision analytic model. Study design, interventions, outcome measures and the use of uncertainty varied considerably; consequentially the results are difficult to compare in any consistent manner. Efforts for future studies to harmonize study design and methodology, particularly towards adopting a modeling framework, using current treatment as comparator and adopting a common effectiveness measure, such as the QALY, should be made in order to produce results that are comparable and useful to a decision maker.
COPD; burden of disease; economic evaluation; cost effectiveness; pharmacoeconomic
Improving the quality and effectiveness of clinical practice is becoming a key task within all health services. Primary medical care, as organised in the UK is composed of clinicians who work in independent partnerships (general practices) that collaborate with other health care professionals. Although many practices have successfully introduced innovations, there are no organisational development structures in place that support the evolution of primary medical care towards integrated care processes. Providing incentives for attendance at passive educational events and promoting 'teamwork' without first identifying organisational priorities are interventions that have proved to be ineffective at changing clinical processes. A practice and professional development plan feasibility study was evaluated in Wales and provided the experiential basis for a summary of the lessons learnt on how best to guide organisational development systems for primary medical care.
Practice and professional development plans are hybrids produced by the combination of ideas from management (the applied behavioural science of organisational development) and education (self-directed adult learning theories) and, in conceptual terms, address the lack of effectiveness of passive educational strategies by making interventions relevant to identified system wide needs. In the intervention, each practice participated in a series of multidisciplinary workshops (minimum 4) where the process outcome was the production of a practice development plan and a set of personal portfolios, and the final outcome was a realised organisational change.
It was apparent during the project that organisational admission to a process of developmental planning needed to be a stepwise process, where initial interest can lead to a fuller understanding, which subsequently develops into motivation and ownership, sufficient to complete the exercise. The advantages of introducing expert external facilitation were clear: evaluations of internal group processes were possible, strategic issues could be raised and explored and financial probity ensured. These areas are much more difficult to examine when only internal stakeholders are engaged in a planning process.
It is not possible to introduce practice and professional development plans (organisational development and organisational learning projects) in a publicly funded health care system without first addressing existing educational and management structures. Existing systems are based on educational credits for attendance and emerging accountability frameworks (criteria checklists) for clinical governance. Moving to systems that are less summative and more formative, and based on the philosophies of continual quality improvement, require changes to be made in the relevant support systems in order achieve policy proposals.
Emergency room utilization in Canada is considerably higher than in other industrialized countries. Despite significant investments, recurrent emergency room crises persist. Focusing particularly on the situation in Quebec, this paper examines the evolution of Canada's and Quebec's healthcare systems over the past 40 years and identifies the key developments that resulted in today's problems and the challenges that must be addressed. In this historical overview, we argue that emergency room problems arise from past decisions that gave hospitals a predominant role in the healthcare system and partly modified their original mission, as well as from counterproductive funding modalities. Other decisions have also weakened primary care services, which are strongly focused on acute health problems and are poorly coordinated with the rest of the system. Symptomatic remedies have only eased the pressure on emergency rooms, but the real solution is more complex and must address the historical residues that are paralyzing our healthcare system.
During the twentieth-century, dramatic changes in the manner and location of care for the dying resulted in the conception and birth of the modern American hospice movement. Idealistic nurses, clergy, and others concerned about the plight of terminally ill cancer patients launched hospice as a necessary health care reform. As new hospice programs opened across the country, the idealism of the early leaders gave way to more pragmatic issues such as program viability. As hospice was studied and integrated into the health care system, it came to be redefined by the politics of health policy and the health care industry. As a result, there is a disarticulation between the needs of seriously ill persons and their families and the health care that is available to them. Important lessons can be learned from the history of the Medicare hospice benefit to help guide current palliative care policy initiatives. While formalized reimbursement for hospice enhanced organizational sustainability, many critical issues remain.
policy; hospice; Medicare; nursing; outcomes
A review of mass media response to the smoking issue over the past 25 years reveals that sustained involvement of the broadcast and print media has served significantly to heighten public awareness and reduce smoking rates in the total U.S. population. Public service advertising has been an integral part of the smoking control movement from its outset, but today's intensely competitive media environment has forced health promoters to look beyond public service announcements in the development of total communication programs. Media advocacy--using the media to sharpen public awareness and mold public policy to serve the public interest, a technique derived from political campaigns--is emerging as a powerful tool in the smoking control movement. Its emphasis is on changing the entire social context of tobacco use in America, rather than the smoking behavior of people. Because media advocates' success pivots on their access to the media, they must be able both to create news and to react quickly to breaking news and unexpected events. The opportunistic, risk-taking nature of media advocacy requires that most efforts be waged at the State and local levels. An increasing number of State health departments and other organizations are using paid advertising to improve the frequency and reach of nonsmoking messages. Research verifies that paid media campaigns increase the target audience's exposure to smoking control messages, but planning and making efficient media purchases require sophistication and, of course, the necessary funds. Irrefutable medical evidence linking smoking to disease and addiction, combined with the powerful social force of the nonsmokers' rights movement, offer hope that a smoke-free society is an achievable goal.(ABSTRACT TRUNCATED AT 250 WORDS)
Primary health care, as practised in many developing countries, is a set of guidelines for designing health strategies that are both appropriate to the health needs of the population and to cultural and socio-economic contexts. Four aspects of primary health care experience in developing countries may be relevant to Canadian health care: the integration of health and development, participation of the community in problem identification and program planning, the role of the community-based worker, and the use of health information. Canadian physicians may draw on this experience to address present challenges in our health system: providing health services to marginal groups, viewing health in a broader perspective, the escalating costs of health services, and increasing community involvement in planning health services.
community medicine; family medicine; international health; primary health care
In 2004, Mozambique, supported by large increases in international disease-specific funding, initiated a national rapid scale-up of antiretroviral treatment (ART) and HIV care through a vertical "Day Hospital" approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public-sector PHC services.
In 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district-level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow-up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non-HIV aspects of primary health care.
The integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss-to-follow-up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems.
Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains.
Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded.
Emergent themes coalesced into 3 overarching themes addressing practice-related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner.
Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.
access to care; allied health; health disparities; qualitative research; rural health care providers
The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS.
Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included.
Nine distinct challenges were identified: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician.
Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success.
Challenges; Computerized Order Entry; Prescribing; Medication Errors
The U.S. Agency for Healthcare Research and Quality's (AHRQ) Integrated Delivery Systems Research Network (IDSRN) program was established to foster public-private collaboration between health services researchers and health care delivery systems. Its broad goal was to link researchers and delivery systems to encourage implementation of research into practice. We evaluated the program to address two primary questions: 1) How successful was IDSRN in generating research findings that could be applied in practice? and 2) What factors facilitate or impede such success?
We conducted in-person and telephone interviews with AHRQ staff and nine IDSRN partner organizations and their collaborators, reviewed program documents, analyzed projects funded through the program, and developed case studies of four IDSRN projects judged promising in supporting research implementation.
Participants reported that the IDSRN structure was valuable in creating closer ties between researchers and participating health systems. Of the 50 completed projects studied, 30 had an operational effect or use. Some kinds of projects were more successful than others in influencing operations. If certain conditions were met, a variety of partnership models successfully supported implementation. An internal champion was necessary for partnerships involving researchers based outside the delivery system. Case studies identified several factors important to success: responsiveness of project work to delivery system needs, ongoing funding to support multiple project phases, and development of applied products or tools that helped users see their operational relevance. Factors limiting success included limited project funding, competing demands on potential research users, and failure to reach the appropriate audience.
Forging stronger partnerships between researchers and delivery systems has the potential to make research more relevant to users, but these benefits require clear goals and appropriate targeting of resources. Trade-offs are inevitable. The health services research community can best consider such trade-offs and set priorities if there is more dialogue to identify areas and approaches where such partnerships may have the most promise. Though it has unique features, the IDSRN experience is relevant to research implementation in diverse settings.
Mexico is undergoing profound health reform, extending health insurance to previously uninsured populations and changing the way health care services are delivered. Legislation enacted in 2003 and implemented in 2004 mandated funding and infrastructure that will allow 52% of Mexico's population to access medical care at no cost by 2010. This ambitious social reform has not been without challenges, particularly financial sustainability. Health promotion, because of its potential to prevent or delay chronic diseases and injuries and their associated costs, is a key component of health care reform (1).
In 2006, the Ministry of Health's General Directorate of Health Promotion developed the Health Promotion Operational Model. Based on Ottawa Charter functions, the model integrates health promotion activities within the overall health care system. The main goal of this model is to build strong human capital and to improve organizational capacity for health promotion starting at the local level by training health care personnel to implement health promotion activities. Organizational development workshops started in 2006, and implementation plans in all 32 Mexican states were in place by end of 2008 (2).
New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).
Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:
1. Loss of autonomy
2. Inadequate management funding and support
3. Inconsistency and variations in contracting processes
4. Lack of publicity and advice around enrolment issues
5. Workforce and workload issues
6. Financial risks
On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.
The key lessons concern:
• the need for a national primary health care strategy
• active engagement of general practitioners and their professional organisations
• recognition of implementation costs
• the need for infrastructural support, including information technology and quality systems
• robust management and governance arrangements
• issues related to critical mass and population/distance trade offs in service delivery models
Data quality has a direct impact on reliability and validity, however, the procedures are usually briefly summarized in the methods section of reports. Sustaining data quality and integrity over time can pose serious challenges and prompted the development of a Data Quality Program based on Donabedian’s quality framework. Although many are familiar with the structure, process, and outcome components in health care quality, application to a research project may be unfamiliar. This article summarizes the data quality program for a cohort study of nursing home elders with delirium by providing an “insider’s view” of the procedures and protocols followed over several years.
quality improvement; data quality; reliability; validity; cohort studies; methodology; nursing homes; delirium
Over the past 15 years, repeated national meetings have developed recommendations for a Canadian antimicrobial resistance strategy. Despite this, in 2011 there is no comprehensive, integrated national program with appropriate governance and funding to address antimicrobial resistance.
The Public Health Agency of Canada supports a reference laboratory for diagnosis and characterization of selected resistant strains, targeted surveillance programs which monitor resistance trends for selected animal and human organisms, development of national infection control guidelines including for antimicrobial resistant organisms, and a few local pilot projects to address community acquired MRSA. Sporadic programs of variable intensity and quality are supported by some provinces, health regions and individual facilities but these are not comprehensive, standardized or integrated. Individual researchers and research groups, however, have published substantial information describing the prevalence and impact of resistance in Canada.
Current review of activities by the Public Health Agency of Canada and initiatives by the National Coordinating Centre for Infectious Diseases may move the country forward in developing an effective national approach to address antimicrobial resistance.
antimicrobial resistance; Canada; antimicrobial stewardship
The specialty of tropical medicine originated from the needs of the colonial era and is removed from many of the health care requirements of tropical countries today. Tropical medicine concentrates on parasitic diseases of warm climates, although other infections and diseases related to poverty rather than climate dominate medicine in developing countries challenged by population pressure, civil strife, and migration. In the new century, tropical medicine would best be absorbed into the specialty of infectious diseases, which should incorporate parasitic diseases, travel medicine, and sexually transmitted diseases. Pressing questions for health care and research in developing countries concern the provision of appropriate services for problems such as HIV/AIDS, tuberculosis, sexually transmitted diseases, and injuries. The question of how to provide appropriate clinical care in resource poor settings for the major causes of morbidity and premature mortality has been neglected by donors, academic institutions, and traditional tropical medicine.
A candidate gene approach to identifying novel causes of disease is concept-limiting and in the new era of high throughput sequencing there is now no need to restrict the experiment to a few interesting genes. We have recently completed a large-scale exon re-sequencing project using Sanger sequencing technology to analyse approximately 1 Mb of coding sequence of the X chromosome in probands from >200 families with various forms of intellectual disability. We review the lessons learnt from this experience. Comparing large data sets will certainly reveal pathogenic mutations in genes that were not possible to identify previously. However, the task of distinguishing pathogenic mutations from rare sequence variants is not easy and is the most substantial challenge to the next decade. High-throughput technology has the attraction of being cheap, fast and comprehensive but for projects that require detailed coverage of a genomic region at an exhaustive level they may require a combination of large-scale with a small-scale follow-up of difficult regions to sequence. The number of rare truncating variants present in coding regions of the X chromosome that are not pathogenic was 1%. The importance of the quality of the starting material both clinically and molecularly and the number of sequence variants both rare and common that any one individual has across their coding sequence is discussed.
Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases.
We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia.
Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system.
The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.
Health policy and systems research (HPSR), which aims to produce reliable and rigorous evidence to inform the many critical decisions that must be made about health systems, is a new concept in Nigeria. In this study, policy makers and other stakeholders in the health sector identified the challenges and the potential intervention strategies to HPSR evidence use in policy making in Nigeria. The major challenges identified included capacity constraints at individual and organizational levels, communication gaps and poor networking between policy makers and researchers, and the non-involvement of healthcare recipients in identifying and planning care delivery needs. The main solutions suggested included promotion of strategies to encourage partnership between researchers and policy makers, improvement of staff incentives and facilities for research activities, improved budgetary provision for research, and sustainable institutional capacity development. These strategies have been shown to improve evidence-based policy making in developed countries and are likely to produce better outcomes in the developing world.
Published literature on integrated care usefully brings together wide-ranging definitions and concepts (e.g., breadth, function) but pays little attention to the historical record (e.g., political priorities, policy agendas, and social pressures). Historical analysis highlights how these factors have shaped the integrated care agenda over time.
To draw out lessons for future policy by considering UK policy developments around ‘integration’ since 1948.
Literature-based review, combining historical evidence (1910 onwards) from UK published and grey literature. Analysis of integration of health and social care, and the integration of primary and secondary care.
Results and conclusions
Historical analysis reveals that policymakers have often shared a desire to improve the quality and efficiency of services by coordinating policies, processes, organisations, services and actors. Key ‘drivers’ of integration have been changing professional and public perceptions of the remit of the health services, which organisations have a part to play in safeguarding the public’s health, and how we conceptualise the boundaries of healthcare. However, history also teaches us how easily reforms currently envisaged as furthering the cause of integration can, in the long run, further cement existing gaps in service provision.
integration; integrated care; horizontal integration; vertical integration; historical analysis; UK NHS
The basic premise of this effort is that health care can be made more effective and affordable by applying modern computer technology to improve collaboration among diverse and distributed health care providers.
Information sharing, communication, and coordination are basic elements of any collaborative endeavor. In the health care domain, collaboration is characterized by cooperative activities by health care providers to deliver total and real-time care for their patients. Communication between providers and managed access to distributed patient records should enable health care providers to make informed decisions about their patients in a timely manner. With an effective medical information infrastructure in place, a patient will be able to visit any health care provider with access to the network, and the provider will be able to use relevant information from even the last episode of care in the patient record. Such a patient-centered perspective is in keeping with the real mission of health care providers.
Today, an easy-to-use, integrated health care network is not in place in any community, even though current technology makes such a network possible. Large health care systems have deployed partial and disparate systems that address different elements of collaboration. But these islands of automation have not been integrated to facilitate cooperation among health care providers in large communities or nationally.
CERC and its team members at Valley Health Systems, Inc., St. Marys Hospital and Cabell Huntington Hospital form a consortium committed to improving collaboration among the diverse and distributed providers in the health care arena. As the first contract recipient of the multi-agency High Performance Computing and Communications (HPCC) Initiative, this team of computer system developers, practicing rural physicians, community care groups, health care researchers, and tertiary care providers are using research prototypes and commercial off-the-shelf technologies to develop an open collaboration environment for the health care domain. This environment is called ARTEMIS — Advanced Research TEstbed for Medical InformaticS.