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1.  Factors influencing the implementation of integrated management of childhood illness (IMCI) by healthcare workers at public health centers & dispensaries in Mwanza, Tanzania 
BMC Public Health  2014;14:277.
Background
Integrated Management of Childhood Illness (IMCI) was developed by the World Health Organization (WHO) and the United Nations International Children’s Fund (UNICEF) and aims at reducing childhood morbidity and mortality in resource-limited settings including Tanzania. It was introduced in 1996 and has been scaled up in all districts in the country. The purpose of this study was to identify factors influencing the implementation of IMCI in the health facilities in Mwanza, Tanzania since reports indicates that the guidelines are not full adhered to by the healthcare workers.
Methods
A cross-sectional study design was used and a sample size of 95 healthcare workers drawn from health centers and dispensaries within Mwanza city were interviewed using self-administered questionnaires. Structured interview was also used to get views from the city IMCI focal person and the 2 facilitators. Data were analyzed using SPSS and presented using figures and tables.
Results
Only 51% of healthcare workers interviewed had been trained. 69% of trained Healthcare workers expressed understanding of the IMCI approach. Most of the respondents (77%) had a positive attitude that IMCI approach was a better approach in managing common childhood illnesses especially with the reality of resource constraint in the health facilities. The main challenges identified in the implementation of IMCI are low initial training coverage among health care workers, lack of essential drugs and supplies, lack of onsite mentoring and lack of refresher courses and regular supportive supervision. Supporting the healthcare workers through training, onsite mentoring, supportive supervision and strengthening the healthcare system through increasing access to essential medicines, vaccines, strengthening supply chain management, increasing healthcare financing, improving leadership & management were the major interventions that could assist in IMCI implementation.
Conclusions
The healthcare workers can implement better IMCI through the collaboration of supervisors, IMCI focal person, Council Health Management Teams (CHMT) and other stakeholders interested in child health. However, significant barriers impede a sustainable IMCI implementation. Recommendations have been made related to supportive supervision and HealthCare system strengthening among others.
doi:10.1186/1471-2458-14-277
PMCID: PMC3987128  PMID: 24666561
Lower level health facilities; Integrated Management of Childhood Illness (IMCI); Council Health Management Team (CHMT); Factors influencing the implementation of IMCI
2.  Personal Health Management (PHM): Singapore’s national strategy to activate and empower patients and care givers through innovative personal health technologies 
Introduction
In the next two decades, Singapore will face a near-perfect demographic and chronic disease-burden “storm”. Rising public expectations of healthcare services, inflationary cost pressures and continuous resource scarcity add to the challenges the system faces. Singapore’s Ministry of Health’s (MOH) response to these impending challenges has been swift and reforms are under way that will lead to new models of care, integrated care delivery capabilities as well as increased capacity (through development of primary care and new facilities) in light of growing demands. The national Personal Health Management (PHM) strategy adds another dimension to Singapore’s national reforms, which is to leverage on one of the greatest untapped resources of healthcare: people, their families and communities.
Aims and objectives
At the core of PHM is self-management and Singapore’s continuous promotion of personal responsibility. To support self-management, there is a need to provide patients/people with access to timely, actionable health information—key ingredients of empowerment that leads to greater self-efficacy. Instead of the traditional approach of developing a “static” patient portal, Singapore is taking a unique approach of developing an “open” health technology platform capable of catering to diverse stakeholder needs, and one that allow healthcare providers, enterprises, interest groups to create and build web, mobile applications and interactive content on a common platform to support existing and new healthcare programmes and services. At the crux of the platform is personal health record which is a subset of the just launched, national electronic health record (NEHR) that provides a longitudinal view of the person’s health information generated through life-time encounters at various care settings. The development of a national demonstrator PHM project is underway, slated for launch in early Q2 2012 with participation of two regional healthcare providers aimed at providing self-management technology tools (web and mobile) for low-medium risk diabetic patients. This paper/presentation aims to outline and share Singapore’s approach to empowering patients through the national strategy, barriers and its implementation thus far and roadmap going forward.
Results
It is too early to be able to provide measureable outcomes in particular, clinical outcomes until steady-state is achieved beyond 2012. PHM is a large transformational project where the challenge goes beyond just the implementation of the technology. This is largely due to how the healthcare system is structured and financed in Singapore. The development of the national strategy has been a significant milestone; in that it has galvanised an otherwise disparate approach to self-management that will result in siloed patient information and duplication of efforts. The strategy has garnered senior leadership support from the ministry and stakeholder commitment to collaborate on the platform was a major step forward.
Conclusion
The PHM strategy is the start of an exciting journey to enable a transformation of Singapore’s healthcare system that truly puts the person in the driver’s seat of their own health. The realisation of the PHM vision will take 10 years and development will be in 3 phases starting in 2011. The successful execution of the strategy relies on close coordination and cooperation among its stakeholders. The proposed “open platform” approach recognises that there will not be a one-size-fit-all solution and that diversity will be an added strength.
PMCID: PMC3571167
self management; strategy; policy; mhealth; telehealth
3.  Self-Management Support to People with Type 2 Diabetes - A comparative study of Kaiser Permanente and the Danish Healthcare System 
Background
Self-management support is considered to be an essential part of diabetes care. However, the implementation of self-management support within healthcare settings has appeared to be challenging and there is increased interest in “real world” best practice examples to guide policy efforts. In order to explore how different approaches to diabetes care and differences in management structure influence the provision of SMS we selected two healthcare systems that have shown to be comparable in terms of budget, benefits and entitlements. We compared the extent of SMS provided and the self-management behaviors of people living with diabetes in Kaiser Permanente (KP) and the Danish Healthcare System (DHS).
Methods
Self-administered questionnaires were used to collect data from a random sample of 2,536 individuals with DM from KP and the DHS in 2006–2007 to compare the level of SMS provided in the two systems and identify disparities associated with educational attainment. The response rates were 75 % in the DHS and 56 % in KP. After adjusting for gender, age, educational level, and HbA1c level, multiple linear regression analyses determined the level of SMS provided and identified disparities associated with educational attainment.
Results
Receipt of SMS varied substantially between the two systems. More people with diabetes in KP reported receiving all types of SMS and use of SMS tools compared to the DHS (p < .0001). Less than half of all respondents reported taking diabetes medication as prescribed and following national guidelines for exercise.
Conclusions
Despite better SMS support in KP compared to the DHS, self-management remains an under-supported area of care for people receiving care for diabetes in the two health systems. Our study thereby suggests opportunity for improvements especially within the Danish healthcare system and systems adopting similar SMS support strategies.
doi:10.1186/1472-6963-12-160
PMCID: PMC3441680  PMID: 22697597
Self-management support; Type 2 diabetes mellitus; Health system; International comparison
4.  Eurocan plus report: feasibility study for coordination of national cancer research activities 
Summary
The EUROCAN+PLUS Project, called for by the European Parliament, was launched in October 2005 as a feasibility study for coordination of national cancer research activities in Europe. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people, the largest Europe–wide consultation ever conducted in the field of cancer research.
Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
It is essential to include the patients’ voice in the establishment of priority areas in cancer research at the present time. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community is evident. A top priority should be the development of translational research (in its widest form), leading to the development of effective and innovative cancer treatments and preventive strategies. Translational research ranges from bench–to–bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
The EUROCAN+PLUS Project recommends the creation of a small, permanent and independent European Cancer Initiative (ECI). This should be a model structure and was widely supported at both General Assemblies of the project. The ECI should assume responsibility for stimulating innovative cancer research and facilitating processes, becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ organizations, European institutions, Member States, industry and small and medium enterprises (SMEs), putting into practice solutions aimed at alleviating barriers to collaboration and coordination of cancer research activities in the European Union, and dealing with legal and regulatory issues. The development of an effective ECI will require time, but this entity should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co–operation between comprehensive cancer centres and basic research laboratories throughout Europe and (3) networking between funding bodies at the European level.
The European Parliament and its instruments have had a major influence in cancer control in Europe, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
Executive Summary
Cancer is one of the biggest public health crises facing Europe in the 21st century—one for which Europe is currently not prepared nor preparing itself. Cancer is a major cause of death in Europe with two million casualties and three million new cases diagnosed annually, and the situation is set to worsen as the population ages.
These facts led the European Parliament, through the Research Directorate-General of the European Commission, to call for initiatives for better coordination of cancer research efforts in the European Union. The EUROCAN+PLUS Project was launched in October 2005 as a feasibility study for coordination of national cancer research activities. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people. In this respect, the Project became the largest Europe-wide consultation ever conducted in the field of cancer research, implicating researchers, cancer centres and hospitals, administrators, healthcare professionals, funding agencies, industry, patients’ organizations and patients.
The Project first identified barriers impeding research and collaboration in research in Europe. Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain the formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
In addition, there is a shortage of leadership, a multiplicity of institutions each focusing on its own agenda, sub–optimal contact with industry, inadequate training, non–existent career paths, low personnel mobility in research especially among clinicians and inefficient funding—all conspiring against efficient collaboration in cancer care and research. European cancer research today does not have a functional translational research continuum, that is the process that exploits biomedical research innovations and converts them into prevention methods, diagnostic tools and therapies. Moreover, epidemiological research is not integrated with other types of cancer research, and the implementation of the European Directives on Clinical Trials 1 and on Personal Data Protection 2 has further slowed the innovation process in Europe. Furthermore, large inequalities in health and research exist between the EU–15 and the New Member States.
The picture is not entirely bleak, however, as the European cancer research scene presents several strengths, such as excellent basic research and clinical research and innovative etiological research that should be better exploited.
When considering recommendations, several priority dimensions had to be retained. It is essential that proposals include actions and recommendations that can benefit all Member States of the European Union and not just States with the elite centres. It is also essential to have a broader patient orientation to help provide the knowledge to establish cancer control possibilities when we exhaust what can be achieved by the implementation of current knowledge. It is vital that the actions proposed can contribute to the Lisbon Strategy to make Europe more innovative and competitive in (cancer) research.
The Project participants identified six areas for which consensus solutions should be implemented in order to obtain better coordination of cancer research activities. The required solutions are as follows. The proactive management of innovation, detection, facilitation of collaborations and maintenance of healthy competition within the European cancer research community.The establishment of an exchange portal of information for health professionals, patients and policy makers.The provision of guidance for translational and clinical research including the establishment of a translational research platform involving comprehensive cancer centres and cancer research centres.The coordination of calls and financial management of cancer research projects.The construction of a ‘one–stop shop’ as a contact interface between the industry, small and medium enterprises, scientists and other stakeholders.The support of greater involvement of healthcare professionals in translational research and multidisciplinary training.
In the course of the EUROCAN+PLUS consultative process, several key collaborative projects emerged between the various groups and institutes engaged in the consultation. There was a collaboration network established with Europe’s leading Comprehensive Cancer Centres; funding was awarded for a closer collaboration of Owners of Cancer Registries in Europe (EUROCOURSE); there was funding received from FP7 for an extensive network of leading Biological Resource Centres in Europe (BBMRI); a Working Group identified the special needs of Central, Eastern and South–eastern Europe and proposed a remedy (‘Warsaw Declaration’), and the concept of developing a one–stop shop for dealing with academia and industry including the Innovative Medicines Initiative (IMI) was discussed in detail.
Several other dimensions currently lacking were identified. There is an absolute necessity to include the patients’ voice in the establishment of priority areas in cancer research at the present time. It was a salutary lesson when it was recognized that all that is known about the quality of life of the cancer patient comes from the experience of a tiny proportion of cancer patients included in a few clinical trials. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community was evident. A top priority should be the development of translational research (in its widest form) and the development of effective and innovative cancer treatments and preventative strategies in the European Union. Translational research ranges from bench-to-bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
Having taken note of the barriers and the solutions and having examined relevant examples of existing European organizations in the field, it was agreed during the General Assembly of 19 November 2007 that the EUROCAN+PLUS Project had to recommend the creation of a small, permanent and neutral ECI. This should be a model structure and was widely supported at both General Assemblies of the project. The proposal is based on the successful model of the European Molecular Biology Organisation (EMBO), and its principal aims include providing a forum where researchers from all backgrounds and from all countries can meet with members of other specialities including patients, nurses, clinicians, funders and scientific administrators to develop priority programmes to make Europe more competitive in research and more focused on the cancer patient.
The ECI should assume responsibility for: stimulating innovative cancer research and facilitating processes;becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ and organizations;European institutions, Member States, industry and small and medium enterprises;putting into practice the aforementioned solutions aimed at alleviating barriers and coordinating cancer research activities in the EU;dealing with legal and regulatory issues.
Solutions implemented through the ECI will lead to better coordination and collaboration throughout Europe, more efficient use of resources, an increase in Europe’s attractiveness to the biomedical industry and better quality of cancer research and education of health professionals.
The Project considered that European legal instruments currently available were inadequate for addressing many aspects of the barriers identified and for the implementation of effective, lasting solutions. Therefore, the legal environment that could shelter an idea like the ECI remains to be defined but should be done so as a priority. In this context, the initiative of the European Commission for a new legal entity for research infrastructure might be a step in this direction. The development of an effective ECI will require time, but this should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass: (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co-operation between comprehensive cancer centres and basic research laboratories throughout Europe; (3) networking between funding bodies at the European level. Another topic deserving immediate attention is the creation of a European database on cancer research projects and cancer research facilities.
Despite enormous progress in cancer control in Europe during the past two decades, there was an increase of 300,000 in the number of new cases of cancer diagnosed between 2004 and 2006. The European Parliament and its instruments have had a major influence in cancer control, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
doi:10.3332/ecancer.2011.84
PMCID: PMC3234055  PMID: 22274749
5.  The Imminent Healthcare and Emergency Care Crisis in Japan 
Objectives
Japan has a universal healthcare system, and this paper describes the reality of the healthcare services provided, as well as current issues with the system.
Methods
Academic, government, and press reports on Japanese healthcare systems and healthcare guidelines were reviewed.
Results
The universal healthcare system of Japan is considered internationally to be both low-cost and effective because the Japanese population enjoys good health status with a long life expectancy, while healthcare spending in Japan is below the average given by the Organization for Economic Corporation and Development (OECD). However, in many regions of Japan the existing healthcare resources are seriously inadequate, especially with regard to the number of physicians and other health professionals. Because healthcare is traditionally viewed as “sacred” work in Japan, healthcare professionals are expected to make large personal sacrifices. Also, public attitudes toward medical malpractice have changed in recent decades, and medical professionals are facing legal issues without experienced support of the government or legal professionals. Administrative response to the lack of resources and collaboration among communities are beginning, and more efficient control and management of the healthcare system is under consideration.
Conclusion
The Japanese healthcare system needs to adopt an efficient medical control organization to ease the strain on existing healthcare professionals and to increase the number of physicians and other healthcare resources. Rather than continuing to depend on healthcare professionals being able and willing to make personal sacrifices, the government, the public and medical societies must cooperate and support changes in the healthcare system.
PMCID: PMC2672251  PMID: 19561714
6.  Deployment-related mental health support: comparative analysis of NATO and allied ISAF partners 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.23732.
Background
For years there has been a tremendous gap in our understanding of the mental health effects of deployment and the efforts by military forces at trying to minimize or mitigate these. Many military forces have recently systematized the mental support that is provided to support operational deployments. However, the rationale for doing so and the consequential allocation of resources are felt to vary considerably across North Atlantic Treaty Organisation (NATO) International Security Assistance (ISAF) partners. This review aims to compare the organization and practice of mental support by five partnering countries in the recent deployment in Afghanistan in order to identify and compare the key methods and structures for delivering mental health support, describe bottlenecks and illustrate new developments.
Method
Information was collected through document analysis and semi-structured interviews with key military mental healthcare stakeholders. The review resulted from close collaboration between key military mental healthcare professionals within the Australian Defense Forces (ADF), Canadian Armed Forces (CAF), United Kingdom Armed Forces (UK), Netherlands Armed Forces (NLD), and the United States Army (US). Key stakeholders were interviewed about the mental health support provided during a serviceperson's military career. The main items discussed were training, prevention, early identification, intervention, and aftercare in the field of mental health.
Results
All forces reported that much attention was paid to mental health during the individual's military career, including deployment. In doing so there was much overlap between the rationale and applied methods. The main method of providing support was through training and education. The educative focus was to strengthen the mental resilience of individual soldiers while providing a range of mental healthcare services. All forces had abandoned standard psychological debriefing after critical incidents. Instead, by default, mental healthcare professionals acted to support the leader and peer led “after action” reviews. All countries provided professional mental support close to the front line, aimed at early detection and early return to normal activities within the unit. All countries deployed a mental health support team that consisted of a range of mental health staff including psychiatrists, psychologists, social workers, mental health nurses, and chaplains. There was no overall consensus in the allocation of mental health disciplines in theatre. All countries (except the US) provided troops with a third location decompression (TLD) stop after deployment, which aimed to recognize what the deployed units had been through and to prepare them for transition home. The US conducted in-garrison ‘decompression’, or ‘reintegration training’ in the US, with a similiar focus to TLD. All had a reasonably comparable infrastructure in the field of mental healthcare. Shared bottlenecks across countries included perceived stigma and barriers to care around mental health problems as well as the need for improving the awareness and recognition of mental health problems among service members.
Conclusion
This analysis demonstrated that in all five partners state-of-the-art preventative mental healthcare was included in the last deployment in Afghanistan, including a positive approach towards strengthening the mental resilience, a focus on self-regulatory skills and self-empowerment, and several initiatives that were well-integrated in a military context. These initiatives were partly/completely implemented by the military/colleagues/supervisors and applicable during several phases of the deployment cycle. Important new developments in operational mental health support are recognition of the role of social leadership and enhancement of operational peer support. This requires awareness of mental problems that will contribute to reduction of the barriers to care in case of problems. Finally, comparing mental health support services across countries can contribute to optimal preparation for the challenges of military deployment.
doi:10.3402/ejpt.v5.23732
PMCID: PMC4138710  PMID: 25206953
Military; deployment; mental health; NATO; review
7.  Online prevention for patients with lifestyle related diagnoses 
Aims and objectives
To evaluate whether the introduction of large-scale personalized and technology supported telemonitoring and health coaching interventions produces benefits in terms of health related quality of life, health status and empowerment of patients with a type-2 diabetes and cardiovascular disease (CVD).
Introduction
People with lifestyle related diagnoses as type-2 diabetes and CVD are increasing. The Swedish field trial in the Renewing Health project have developed a method that combine health coaching with online-management of patients data where the patient becomes more actively involved in their own health and healthcare.
Methods
The method is applied at field trials in four Primary healthcare centres in the county of Norrbotten, Sweden. The evaluation is made through a randomized trial with 700 patients with type-2 diabetes or CVD. Fifty percent of the participants take part in the intervention group. General practitioners, diabetic nurses, physiotherapists and nutritionists co-operate to manage the patient interactions. The technical implementation is based on a national patient portal. It provides secure access for all Swedish citizens to their health information and supports also electronic interaction with healthcare professionals. During the field trial, 85% of the patients use their own computers, the others are provided with Tablet-PCs. The preventive health and diagnose measurement equipment are also provided to the patients for free during the field trial. But for large scale usage, the intention is that most of the equipment will be owned by the patients. The patients have attended group sessions were they were educated and motivated to perform lifestyle changes. They were trained on how to manage their health information and interact with the health professionals. Individualized health activity plans were developed. The patients perform health promotion activities and report parameters like number of steps, pulse and duration. They also measure and report medical parameters like blood pressure, blood glucose, PK values and 2-channel ECG. The health professionals provide reference values that make it intuitively for the patient to interpret the progress through graphical diagrams. About every 2nd month, the results are reviewed and the healthcare activity plan is revised if needed. When applicable, alarm levels are specified. Since improved lifestyle can reduce the need for medical treatment, the alarms make the healthcare professionals aware of the necessity to change prescription. The patients have on-line access to actual medication list and can select to have a notification when it is time to take medication. They can also report and follow-up performed medication.
Results
The health coaching methodology has been refined for larger scale usage. The new functionality has been integrated with the Swedish national patient portal. That makes it possible for all Swedish healthcare organizations to offer the Prescribed Healthcare method to their patients after the field trial. The field trial evaluation will be completed Q4-2013.
Conclusions
By combining health coaching services with widely available functionality for treatment instructions, preventive health- and medical diagnose measurement, visualization and medication support engage and stimulate patients to adopt a healthier lifestyle and improves compliance to medication and the activity plan.
PMCID: PMC3571191
prevention; lifestyle; telemonitoring; coaching; empowerment
8.  e-Health, m-Health and healthier social media reform: the big scale view 
Introduction
In the upcoming decade, digital platforms will be the backbone of a strategic revolution in the way medical services are provided, affecting both healthcare providers and patients. Digital-based patient-centered healthcare services allow patients to actively participate in managing their own care, in times of health as well as illness, using personally tailored interactive tools. Such empowerment is expected to increase patients’ willingness to adopt actions and lifestyles that promote health as well as improve follow-up and compliance with treatment in cases of chronic illness. Clalit Health Services (CHS) is the largest HMO in Israel and second largest world-wide. Through its 14 hospitals, 1300 primary and specialized clinics, and 650 pharmacies, CHS provides comprehensive medical care to the majority of Israel’s population (above 4 million members). CHS e-Health wing focuses on deepening patient involvement in managing health, through personalized digital interactive tools. Currently, CHS e-Health wing provides e-health services for 1.56 million unique patients monthly with 2.4 million interactions every month (August 2011). Successful implementation of e-Health solutions is not a sum of technology, innovation and health; rather it’s the expertise of tailoring knowledge and leadership capabilities in multidisciplinary areas: clinical, ethical, psychological, legal, comprehension of patient and medical team engagement etc. The Google Health case excellently demonstrates this point. On the other hand, our success with CHS is a demonstration that e-Health can be enrolled effectively and fast with huge benefits for both patients and medical teams, and with a robust business model.
CHS e-Health core components
They include:
1. The personal health record layer (what the patient can see) presents patients with their own medical history as well as the medical history of their preadult children, including diagnoses, allergies, vaccinations, laboratory results with interpretations in layman’s terms, medications with clear, straightforward explanations regarding dosing instructions, important side effects, contraindications, such as lactation etc., and other important medical information. All personal e-Health services require identification and authorization.
2. The personal knowledge layer (what the patient should know) presents patients with personally tailored recommendations for preventative medicine and health promotion. For example, diabetic patients are push notified regarding their yearly eye exam. The various health recommendations include: occult blood testing, mammography, lipid profile etc. Each recommendation contains textual, visual and interactive content components in order to promote engagement and motivate the patient to actually change his health behaviour.
3. The personal health services layer (what the patient can do) enables patients to schedule clinic visits, order chronic prescriptions, e-consult their physician via secured e-mail, set SMS medication reminders, e-consult a pharmacist regarding personal medications. Consultants’ answers are sent securely to the patients’ personal mobile device.
On December 2009 CHS launched secured, web based, synchronous medical consultation via video conference. Currently 11,780 e-visits are performed monthly (May 2011). The medical encounter includes e-prescription and referral capabilities which are biometrically signed by the physician. On December 2010 CHS launched a unique mobile health platform, which is one of the most comprehensive personal m-Health applications world-wide. An essential advantage of mobile devices is their potential to bridge the digital divide. Currently, CHS m-Health platform is used by more than 45,000 unique users, with 75,000 laboratory results views/month, 1100 m-consultations/month and 9000 physician visit scheduling/month.
4. The Bio-Sensing layer (what physiological data the patient can populate) includes diagnostic means that allow remote physical examination, bio-sensors that broadcast various physiological measurements, and smart homecare devices, such as e-Pill boxes that gives seniors, patients and their caregivers the ability to stay at home and live life to its fullest. Monitored data is automatically transmitted to the patient’s Personal Health Record and to relevant medical personnel.
The monitoring layer is embedded in the chronic disease management platform, and in the interactive health promotion and wellness platform. It includes tailoring of consumer-oriented medical devices and service provided by various professional personnel—physicians, nurses, pharmacists, dieticians and more.
5. The Social layer (what the patient can share). Social media networks triggered an essential change at the humanity ‘genome’ level, yet to be further defined in the upcoming years. Social media has huge potential in promoting health as it combines fun, simple yet extraordinary user experience, and bio-social-feedback. There are two major challenges in leveraging health care through social networks:
a. Our personal health information is the cornerstone for personalizing healthier lifestyle, disease management and preventative medicine. We naturally see our personal health data as a super-private territory. So, how do we bring the power of our private health information, currently locked within our Personal Health Record, into social media networks without offending basic privacy issues?
b. Disease management and preventive medicine are currently neither considered ‘cool’ nor ‘fun’ or ‘potentially highly viral’ activities; yet, health is a major issue of everybody’s life. It seems like we are missing a crucial element with a huge potential in health behavioural change—the Fun Theory. Social media platforms comprehends user experience tools that potentially could break current misconception, and engage people in the daily task of taking better care of themselves.
CHS e-Health innovation team characterized several break-through applications in this unexplored territory within social media networks, fusing personal health and social media platforms without offending privacy. One of the most crucial issues regarding adoption of e-health and m-health platforms is change management. Being a ‘hot’ innovative ‘gadget’ is far from sufficient for changing health behaviours at the individual and population levels.
CHS health behaviour change management methodology includes 4 core elements:
1. Engaging two completely different populations: patients, and medical teams. e-Health applications must present true added value for both medical teams and patients, engaging them through understanding and assimilating “what’s really in it for me”. Medical teams are further subdivided into physicians, nurses, pharmacists and administrative personnel—each with their own driving incentive. Resistance to change is an obstacle in many fields but it is particularly true in the conservative health industry. To successfully manage a large scale persuasive process, we treat intra-organizational human resources as “Change Agents”. Harnessing the persuasive power of ~40,000 employees requires engaging them as the primary target group. Successful recruitment has the potential of converting each patient-medical team interaction into an exposure opportunity to the new era of participatory medicine via e-health and m-health channels.
2. Implementation waves: every group of digital health products that are released at the same time are seen as one project. Each implementation wave leverages the focus of the organization and target populations to a defined time span. There are three major and three minor implementation waves a year.
3. Change-Support Arrow: a structured infrastructure for every implementation wave. The sub-stages in this strategy include:
Cross organizational mapping and identification of early adopters and stakeholders relevant to the implementation wave
Mapping positive or negative perceptions and designing specific marketing approaches for the distinct target groups
Intra and extra organizational marketing
Conducting intensive training and presentation sessions for groups of implementers
Running conflict-prevention activities, such as advanced tackling of potential union resistance
Training change-agents with resistance-management behavioural techniques, focused intervention for specific incidents and for key opinion leaders
Extensive presence in the clinics during the launch period, etc.
The entire process is monitored and managed continuously by a review team.
4. Closing Phase: each wave is analyzed and a “lessons-learned” session concludes the changes required in the modus operandi of the e-health project team.
PMCID: PMC3571141
e-Health; mobile health; personal health record; online visit; patient empowerment; knowledge prescription
9.  Navigating a Changing Continuum of Care With Heart 
Global Advances in Health and Medicine  2014;3(Suppl 1):BPA06.
Background:
The 2010 Patient Protection and Affordable Care Act (ACA) is the most significant change in healthcare since the implementation of Medicare. In the face of reductions in reimbursement, healthcare organizations are seeking creative ways to reduce the cost of care delivery. The Kaiser Permanente Northern California (KPNC) mission is to provide high-quality, affordable healthcare and to improve the health of the members and the communities it serves. In alignment with this work, KPNC values the importance of excellence in care as well as the nurturing of the mind and spirit. The continuum of care, including home health and hospice services, are at the center of the evolving environment. Uncertainties and fast-paced innovations create tension and stress for home care leaders responsible for responding to and implementing change. Meeting these challenges requires incredible creativity and resilience. The framework that best meets these diverse needs is CaritasHeart.1 CaritasHeart brings together the philosophy, theory and framework of Watson's Caring Science,2 the “heart” of Caritas, and the scientifically validated methods of HeartMath.3
Methods:
To support the cultural change inherent in CaritasHeart, education was provided to management and staff in Caring Science and HeartMath. The management teams participated in a four-part “Leading with Care” series. Managers also participated with staff in half-day sessions that introduced the philosophy, theory, and framework of the Caring Science as well as self-care practices. The 7-hour HeartMath “Revitalizing Care” program was provided to 200 managers and staff members to enhance self-care, creativity, ease, and resilience and the understanding of how to be authentically present when providing care.
Personal outcomes of participants were measured assessed using the HeartMath validated Personal and Organizational Quality Assessment-R2 (POQA) instrument. Participants completed the initial POQA self-assessment during part 1 and 2 weeks later during part II of the Revitalizing Care program. Reference values for the POQA are results from 5900 healthcare workers. Member satisfaction with care was measured using the Home Health Consumer Assessment of Healthcare Providers & Services (HH-CAHPS) percent “rate agency 9 or 10” score and the Family Evaluation of Hospice Services (FEHS) “Overall, how would you rate the care the patient received while under the care of hospice?” percent “excellent” score.
Results:
POQA results demonstrated each of the positive characteristics were above average at baseline and significantly improved in three areas: positive outlook (P < .001), gratitude (P < .01) and motivation (P < .001). Each of the six stress-related measures were below average at baseline and significantly improved (P < .001) and above average following 2 weeks of HeartMath use. HH-CAHPS “rate agency 9 or 10” scores improved 1.7 percentage points to 83.6%. FEHS scores for the period were not yet available at the time of this report.
Conclusion:
CaritasHeart was an effective leadership strategy to support the continuum and its staff within a constantly evolving healthcare environment.
doi:10.7453/gahmj.2014.BPA06
PMCID: PMC3923283
Affordable Care Act (ACA); employee self-care stress reduction; Personal and Organizational Quality Assessment; HeartMath; biofeedback
10.  Developing Next-Generation Telehealth Tools and Technologies: Patients, Systems, and Data Perspectives 
Abstract
The major goals of telemedicine today are to develop next-generation telehealth tools and technologies to enhance healthcare delivery to medically underserved populations using telecommunication technology, to increase access to medical specialty services while decreasing healthcare costs, and to provide training of healthcare providers, clinical trainees, and students in health-related fields. Key drivers for these tools and technologies are the need and interest to collaborate among telehealth stakeholders, including patients, patient communities, research funders, researchers, healthcare services providers, professional societies, industry, healthcare management/economists, and healthcare policy makers. In the development, marketing, adoption, and implementation of these tools and technologies, communication, training, cultural sensitivity, and end-user customization are critical pieces to the process. Next-generation tools and technologies are vehicles toward personalized medicine, extending the telemedicine model to include cell phones and Internet-based telecommunications tools for remote and home health management with video assessment, remote bedside monitoring, and patient-specific care tools with event logs, patient electronic profile, and physician note-writing capability. Telehealth is ultimately a system of systems in scale and complexity. To cover the full spectrum of dynamic and evolving needs of end-users, we must appreciate system complexity as telehealth moves toward increasing functionality, integration, interoperability, outreach, and quality of service. Toward that end, our group addressed three overarching questions: (1) What are the high-impact topics? (2) What are the barriers to progress? and (3) What roles can the National Institutes of Health and its various institutes and centers play in fostering the future development of telehealth?
doi:10.1089/tmj.2009.0153
PMCID: PMC2993051  PMID: 20043711
business administration/economics; telehealth tools; technology; National Institutes of Health
11.  Diabetes Management Using Modern Information and Communication Technologies and New Care Models 
Background
Diabetes, a metabolic disorder, has reached epidemic proportions in developed countries. The disease has two main forms: type 1 and type 2. Disease management entails administration of insulin in combination with careful blood glucose monitoring (type 1) or involves the adjustment of diet and exercise level, the use of oral anti-diabetic drugs, and insulin administration to control blood sugar (type 2).
Objective
State-of-the-art technologies have the potential to assist healthcare professionals, patients, and informal carers to better manage diabetes insulin therapy, help patients understand their disease, support self-management, and provide a safe environment by monitoring adverse and potentially life-threatening situations with appropriate crisis management.
Methods
New care models incorporating advanced information and communication technologies have the potential to provide service platforms able to improve health care, personalization, inclusion, and empowerment of the patient, and to support diverse user preferences and needs in different countries. The REACTION project proposes to create a service-oriented architectural platform based on numerous individual services and implementing novel care models that can be deployed in different settings to perform patient monitoring, distributed decision support, health care workflow management, and clinical feedback provision.
Results
This paper presents the work performed in the context of the REACTION project focusing on the development of a health care service platform able to support diabetes management in different healthcare regimes, through clinical applications, such as monitoring of vital signs, feedback provision to the point of care, integrative risk assessment, and event and alarm handling. While moving towards the full implementation of the platform, three major areas of research and development have been identified and consequently approached: the first one is related to the glucose sensor technology and wearability, the second is related to the platform architecture, and the third to the implementation of the end-user services. The Glucose Management System, already developed within the REACTION project, is able to monitor a range of parameters from various sources including glucose levels, nutritional intakes, administered drugs, and patient’s insulin sensitivity, offering decision support for insulin dosing to professional caregivers on a mobile tablet platform that fulfills the need of the users and supports medical workflow procedures in compliance with the Medical Device Directive requirements.
Conclusions
Good control of diabetes, as well as increased emphasis on control of lifestyle factors, may reduce the risk profile of most complications and contribute to health improvement. The REACTION project aims to respond to these challenges by providing integrated, professional, management, and therapy services to diabetic patients in different health care regimes across Europe in an interoperable communication platform.
doi:10.2196/ijmr.2193
PMCID: PMC3626139  PMID: 23612026
Medical Information Systems; Medical Expert Systems; Biomedical Engineering; Biomedical Informatics; Biomedical Computing; Telemedicine; Diabetes
12.  Women's Access and Provider Practices for the Case Management of Malaria during Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(8):e1001688.
Jenny Hill and colleagues conduct a systematic review and meta-analysis of women’s access and healthcare provider adherence to WHO case-management policy of malaria during pregnancy.
Please see later in the article for the Editors' Summary
Background
WHO recommends prompt diagnosis and quinine plus clindamycin for treatment of uncomplicated malaria in the first trimester and artemisinin-based combination therapies in subsequent trimesters. We undertook a systematic review of women's access to and healthcare provider adherence to WHO case management policy for malaria in pregnant women.
Methods and Findings
We searched the Malaria in Pregnancy Library, the Global Health Database, and the International Network for the Rational Use of Drugs Bibliography from 1 January 2006 to 3 April 2014, without language restriction. Data were appraised for quality and content. Frequencies of women's and healthcare providers' practices were explored using narrative synthesis and random effect meta-analysis. Barriers to women's access and providers' adherence to policy were explored by content analysis using NVivo. Determinants of women's access and providers' case management practices were extracted and compared across studies. We did not perform a meta-ethnography. Thirty-seven studies were included, conducted in Africa (30), Asia (4), Yemen (1), and Brazil (2). One- to three-quarters of women reported malaria episodes during pregnancy, of whom treatment was sought by >85%. Barriers to access among women included poor knowledge of drug safety, prohibitive costs, and self-treatment practices, used by 5%–40% of women. Determinants of women's treatment-seeking behaviour were education and previous experience of miscarriage and antenatal care. Healthcare provider reliance on clinical diagnosis and poor adherence to treatment policy, especially in first versus other trimesters (28%, 95% CI 14%–47%, versus 72%, 95% CI 39%–91%, p = 0.02), was consistently reported. Prescribing practices were driven by concerns over side effects and drug safety, patient preference, drug availability, and cost. Determinants of provider practices were access to training and facility type (public versus private). Findings were limited by the availability, quality, scope, and methodological inconsistencies of the included studies.
Conclusions
A systematic assessment of the extent of substandard case management practices of malaria in pregnancy is required, as well as quality improvement interventions that reach all providers administering antimalarial drugs in the community. Pregnant women need access to information on which anti-malarial drugs are safe to use at different stages of pregnancy.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Malaria, a mosquito-borne parasite, kills about 600,000 people every year. Most of these deaths occur among young children in sub-Saharan Africa, but pregnant women and their unborn babies are also vulnerable to malaria. Infection with malaria during pregnancy can cause severe maternal anemia, miscarriages, and preterm births, and kills about 10,000 women and 100,000 children each year. Since 2006, the World Health Organization (WHO) has recommended that uncomplicated malaria (an infection that causes a fever but does not involve organ damage or severe anemia) should be treated with quinine and clindamycin if it occurs during the first trimester (first three months) of pregnancy and with an artemisinin-based combination therapy (ACT) if it occurs during the second or third trimester; ACTs should be used during the first trimester only if no other treatment is immediately available because their safety during early pregnancy has not been established. Since 2010, WHO has also recommended that clinical diagnosis of malaria should be confirmed before treatment by looking for parasites in patients' blood (parasitology).
Why Was This Study Done?
Prompt diagnosis and treatment of malaria in pregnancy in regions where malaria is always present (endemic regions) is extremely important, yet little is known about women's access to the recommended interventions for malaria in pregnancy or about healthcare providers' adherence to the WHO case management guidelines. In this systematic review and meta-analysis of qualitative, quantitative, and mixed methods studies, the researchers explore the factors that affect women's access to treatment and healthcare provider practices for case management of malaria during pregnancy. A systematic review uses predefined criteria to identify all the research on a given topic. Meta-analysis is a statistical method for combining the results of several studies. A qualitative study collects non-quantitative data such as reasons for refusing an intervention, whereas a qualitative study collects numerical data such as the proportion of a population receiving an intervention.
What Did the Researchers Do and Find?
The researchers identified 37 studies (mostly conducted in Africa) that provided data on the range of healthcare providers visited, antimalarials used, and the factors influencing the choice of healthcare provider and medicines among pregnant women seeking treatment for malaria and/or the type and quality of diagnostic and case management services offered to them by healthcare providers. The researchers explored the data in these studies using narrative synthesis (which summarizes the results from several qualitative studies) and content analysis (which identifies key themes within texts). Among the studies that provided relevant data, one-quarter to three-quarters of women reported malaria episodes during pregnancy. More than 85% of the women who reported a malaria episode during pregnancy sought some form of treatment. Barriers to access to WHO-recommended treatment among women included poor knowledge about drug safety, and the use of self-treatment practices such as taking herbal remedies. Factors that affected the treatment-seeking behavior of pregnant women (“determinants”) included prior use of antenatal care, education, and previous experience of a miscarriage. Among healthcare providers, reliance on clinical diagnosis of malaria was consistently reported, as was poor adherence to the treatment policy. Specifically, 28% and 72% of healthcare providers followed the treatment guidelines for malaria during the first and second/third trimesters of pregnancy, respectively. Finally, the researchers report that concerns over side effects and drug safety, patient preference, drug availability, and cost drove the prescribing practices of the healthcare providers, and that the determinants of provider practices included the type (cadre) of heathcare worker, access to training, and whether they were based in a public or private facility.
What Do These Findings Mean?
These findings reveal important limitations in the implementation of the WHO policy on the treatment of malaria in pregnancy across many parts of Africa and in several other malaria endemic regions. Notably, they show that women do not uniformly seek care within the formal healthcare system and suggest that, when they do seek care, they may not be given the appropriate treatment because healthcare providers frequently fail to adhere to the WHO diagnostic and treatment guidelines. Although limited by the sparseness of data and by inconsistencies in study methodologies, these findings nevertheless highlight the need for further systematic assessments of the extent of substandard case management of malaria in pregnancy in malaria endemic countries, and the need to develop interventions to improve access to and delivery of quality case management of malaria among pregnant women.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001688.
Information is available from the World Health Organization on malaria (in several languages) and on malaria in pregnancy; the 2010 Guidelines for the Treatment of Malaria are available; the World Malaria Report 2013 provides details of the current global malaria situation
The US Centers for Disease Control and Prevention also provides information on malaria; a personal story about malaria in pregnancy is available
Information is available from the Roll Back Malaria Partnership on all aspects of global malaria control, including information on malaria in pregnancy
The Malaria in Pregnancy Consortium is undertaking research into the prevention and treatment of malaria in pregnancy and provides links to the consortium's publications and an online library on malaria in pregnancy
MedlinePlus provides links to additional information on malaria (in English and Spanish)
doi:10.1371/journal.pmed.1001688
PMCID: PMC4122360  PMID: 25093720
13.  A self-evaluation tool for integrated care services: the Development Model for Integrated Care applied in practice 
Purpose
The purpose of the workshop is to show the applications of the Development Model for Integrated Care (DMIC) in practice. This relatively new and validated model, can be used by integrated care practices to evaluate their integrated care, to assess their phase of development and reveal improvement areas. In the workshop the results of the use of the model in three types of integrated care settings in the Netherlands will be presented. Participants are offered practical instruments based on the validated DMIC to use in their own setting and will be introduced to the webbased tool.
Context
To integrate care from multiple providers into a coherent and streamlined client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and adequate transfers of clients. In the large range of possible activities it is often not clear what essential activities are and where to start or continue. Also, knowledge about how to further develop integrated care services is needed. The Development Model for Integrated Care (DMIC), based on PhD research of Mirella Minkman, describes nine clusters containing in total 89 elements that contribute to the integration of care. The clusters are named: ‘client-centeredness’, ‘delivery system’, ‘performance management’, ‘quality of care’, ‘result-focused learning’, ‘interprofessional teamwork’, ‘roles and tasks’, ‘commitment’, and ‘transparant entrepreneurship’ [1–3]. In 2011 a new digital webbased self-evolution tool which contains the 89 elements grouped in nine clusters was developed. The DMIC also describes four phases of development [4]. The model is empirically validated in practice by assessing the relevance and implementation of the elements and development phases in 84 integrated care services in The Netherlands: in stroke, acute myocardial infarct (AMI), and dementia services. The validation studies are recently published [5, 6]. In 2011 also other integrated care services started using the model [7]. Vilans developed a digital web-based self-evaluation tool for integrated care services based on the DMIC. A palliative care network, four diabetes services, a youth care service and a network for autism used the self-evaluation tool to evaluate the development of their integrated care service. Because of its generic character, the model and tool are believed to be also interesting internationally.
Data sources
In the workshop we will present the results of three studies in integrated diabetes, youth and palliative care. The three projects consist of multiple steps, see below. Workshop participants could also work with the DMIC following these steps.
One: Preparation of the digital self-evolution tool for integrated care services
Although they are very different, the three integrated care services all wanted to gain insight in their development and improvement opportunities. We tailored the digital self-evaluation tool for each specific integrated care services, but for all the basis was the DMIC. Personal accounts for the digital DMIC self-evalution survey were sent to multiple partners working in each integrated care service (4–16 partners).
Two: Use of the online self-evaluation tool each partner of the local integrated care setting evaluated the integrated care by filling in the web-based questionnaire. The tool consists of three parts (A-C) named: general information about the integrated care practice (A); the clusters and elements of the DMIC (B); and the four phases of development (C). The respondents rated the relevance and presence of each element in their integrated care practice. Respondents were asked to estimate in which phase of development their thought their service was.
Three: Analysing the results
Advisers from Vilans, the Centre of excellence for long-term care in the Netherlands, analysed the self-evolution results in cooperation with the integrated care coordinators. The results show the total amount of implemented integrated care elements per cluster in spider graphs and the development phase as calculated by the DMIC model. Suggestions for further development of the integrated care services were analysed and reported.
Four: Discussing the implications for further development
In a workshop with the local integrated care partners the results of the self-evaluation were presented and discussed. We noticed remarkable results and highlight elements for further development. In addition, we gave advice for further development appropriate to the development phase of the integrated care service. Furthermore, the professionals prioritized the elements and decided which elements to start working on. This resulted in a (quality improvement) plan for the further development of the integrated care service.
Five: Reporting results
In a report all the results of the survey (including consensus scores) and the workshops came together. The integrated care coordinators stated that the reports really helped them to assess their improvement strategy. Also, there was insight in the development phase of their service which gave tools for further development.
Case description
The three cases presented are a palliative network, an integrated diabetes services and an integrated care network for youth in the Netherlands. The palliative care network wanted to reflect on their current development, to build a guiding framework for further development of the network. About sixteen professionals within the network worked with the digital self-evaluation tool and the DMIC: home care organisations, welfare organizations, hospice centres, health care organisations, community organizations.
For diabetes care, a Dutch health care insurance company wished to gain insight in the development of the contracted integrated care services to stimulate further development of the services. Professionals of three diabetes integrated care services were invited to fill in the digital self-evaluation tool. Of each integrated care service professionals like a general practitioner, a diabetes nurse, a medical specialist, a dietician and a podiatrist were invited. In youth care, a local health organisation wondered whether the DMIC could be helpful to visualize the results of youth integrated care services at process- and organisational level. The goal of the project was to define indicators at a process- and organisational level for youth care services based on the DMIC. In the future, these indicators might be used to evaluate youth care integrated care services and improve the quality of youth care within the Netherlands.
Conclusions and discussion
It is important for the quality of integrated care services that the involved coordinators, managers and professionals are aware of the development process of the integrated care service and that they focus on elements which can further develop and improve their integrated care. However, we noticed that integrated care services in the Netherlands experience difficulties in developing their integrated care service. It is often not clear what essential activities are to work on and how to further develop the integrated care service. A guiding framework for the development of integrated care was missing. The DMIC model has been developed for that reason and offers a useful tool for assessment, self-evaluation or improvement of integrated care services in practice. The model has been validated for AMI, dementia and stroke services. The latest new studies in diabetes, palliative care and youth care gave further insight in the generic character of the DMIC. Based on these studies it can be assumed that the DMIC can be used for multiple types of integrated care services. The model is assumed to be interesting for an international audience. Improving integrated care is a complex topic in a large number of countries; the DMIC is also based on the international literature. Dutch integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding and improving their integrated care activities.
The web-based self-evaluation tool focuses on a process- and organisational level of integrated care. Also, the self assessed development phase can be compared to the development phase as calculated by the DMIC tool. The cases showed this is fruitful input for discussions. When using the tool, the results can also be used in quality policy reports and improvement plans. The web-based tool is being tested at this moment in practice, but in San Marino we can present the latest webversion and demonstrate with a short video how to use the tool and model. During practical exercises in the workshop the participants will experience how the application of the DMIC can work for them in practice or in research. For integrated care researchers and policy makers, the DMIC questionnaire and tool is a promising method for further research and policy plans in integrated care.
PMCID: PMC3617779
development model for integrated care; development of integrated care services; implementation and improvement of integrated care; self evaluation
14.  Integrated Personal Health Records: Transformative Tools for Consumer-Centric Care 
Background
Integrated personal health records (PHRs) offer significant potential to stimulate transformational changes in health care delivery and self-care by patients. In 2006, an invitational roundtable sponsored by Kaiser Permanente Institute, the American Medical Informatics Association, and the Agency for Healthcare Research and Quality was held to identify the transformative potential of PHRs, as well as barriers to realizing this potential and a framework for action to move them closer to the health care mainstream. This paper highlights and builds on the insights shared during the roundtable.
Discussion
While there is a spectrum of dominant PHR models, (standalone, tethered, integrated), the authors state that only the integrated model has true transformative potential to strengthen consumers' ability to manage their own health care. Integrated PHRs improve the quality, completeness, depth, and accessibility of health information provided by patients; enable facile communication between patients and providers; provide access to health knowledge for patients; ensure portability of medical records and other personal health information; and incorporate auto-population of content. Numerous factors impede widespread adoption of integrated PHRs: obstacles in the health care system/culture; issues of consumer confidence and trust; lack of technical standards for interoperability; lack of HIT infrastructure; the digital divide; uncertain value realization/ROI; and uncertain market demand. Recent efforts have led to progress on standards for integrated PHRs, and government agencies and private companies are offering different models to consumers, but substantial obstacles remain to be addressed. Immediate steps to advance integrated PHRs should include sharing existing knowledge and expanding knowledge about them, building on existing efforts, and continuing dialogue among public and private sector stakeholders.
Summary
Integrated PHRs promote active, ongoing patient collaboration in care delivery and decision making. With some exceptions, however, the integrated PHR model is still a theoretical framework for consumer-centric health care. The authors pose questions that need to be answered so that the field can move forward to realize the potential of integrated PHRs. How can integrated PHRs be moved from concept to practical application? Would a coordinating body expedite this progress? How can existing initiatives and policy levers serve as catalysts to advance integrated PHRs?
doi:10.1186/1472-6947-8-45
PMCID: PMC2596104  PMID: 18837999
15.  International partnerships in telehealth: healthcare, industry and education 
Project background
In 2010 an internationally renowned American healthcare organisation partnered with Irish industry and higher education in Waterford with the goal to expand their telehealth services. Combining the skills and expertise of Nurse Consultants, Nurse Educators, IT Specialists and Healthcare Executives, these collaborative partnerships led to the delivery of telehealth services to North America from an Irish base, and to the development of new European telehealth programmes and telehealth training in Ireland. The telehealth service includes the provision of telephone triage, health information and advice, disease management and hospital discharge programmes to clients in Ireland, the UK and the USA. Telehealth nursing is an evolving specialty that requires the development of competence in key areas of information and communication technologies, assessment, triage and critical thinking in clinical decision-making within an environment where distance separates the nurse from the client.
Aims and objectives
The aim of this paper is to report on the development, implementation and evaluation of the telehealth service with a focus on the telephone triage and advice service and the hospital discharge programmes. Objectives of this paper include describing this telehealth initiative with reference to the changing nature of global healthcare provision; discuss the educational strategy and accredited programme for training competent telehealth nurses; report the results of the evaluation of nurse performance in telephone triage and present the data relating to the impact of hospital discharge programmes on patient satisfaction and readmission rates.
Methods and results
The evaluation of the telehealth training programme was undertaken six months post initial training and service commencement. One hundred triage and health information calls were reviewed, against best practice standards and programme learning outcomes, during a four-month period. Quantitative and qualitative data that demonstrates evidence of learning transfer from training to practice and the development of nurse competence from advanced beginner to levels of proficiency will be presented. The hospital discharge programmes have undergone continuous monitoring and reporting since commencement. This has enabled the collection of evidence that supports this brief telephone intervention as a method of reducing hopsital re-admissions and increasing patient satisfcation. Quantitative results will be presented and analysed in relation to the impact on patient satisfaction and readmission rates for patients discharged from cardiovascular, renal and digestive disease services.
Conclusions
This project has demonstrated the effectiveness of partnerships in healthcare, industry and education in achieving the development, implementation and evaluation of international telehealth services. Initial education, training and ongoing support and development of nurses is essential for quality telehealth provision. Weekly call review, constructive feedback and reflection on practice are effective strategies for performance assurance and improvement. As a growing element of integrated healthcare, telehealth modules should be included in pre and post-registration nursing education curricula. Further collaboration between industry, healthcare and education are necessary in moving the telehealth agenda forward for the benefit of integrating services that impact positively on service users.
PMCID: PMC3571125
telephone triage; hospital discharge programmes; partnerships
16.  Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review 
PLoS Medicine  2012;9(6):e1001244.
A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.
Introduction
Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.
Methods and Findings
Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.
Conclusions
Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Health care can be provided through public and private providers. Public health care is usually provided by the government through national healthcare systems. Private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.
There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. Recently, as the global economic recession has put major constraints on government budgets—the major funding source for healthcare expenditures in most countries—disputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. However, critics of the private health sector believe that public healthcare provision is of most benefit to poor people and is the only way to achieve universal and equitable access to health care.
Why Was This Study Done?
Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Therefore, in order to inform policy, there is an urgent need for robust evidence to evaluate the quality and effectiveness of the health care provided through both systems. In this study, the authors reviewed all of the evidence in a systematic way to evaluate available data on public and private sector performance.
What Did the Researchers Do and Find?
The researchers used eight databases and a comprehensive key word search to identify and review appropriate published data and studies of private and public sector performance in low- and middle-income countries. They assessed selected studies against the World Health Organization's six essential themes of health systems—accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency—and conducted a narrative review of each theme.
Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. The researchers found that study findings varied considerably across countries studied (one-third of studies were conducted in Africa and a third in Southeast Asia) and by the methods used.
Financial barriers to care (such as user fees) were reported for both public and private systems. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency.
What Do These Findings Mean?
This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001244.
A previous PLoS Medicine study examined the outpatient care provided by the public and private sector in low-income countries
The WHO website provides more information on healthcare systems
The World Bank website provides information on health system financing
Oxfam provides an argument against increased private health care in poor countries
doi:10.1371/journal.pmed.1001244
PMCID: PMC3378609  PMID: 22723748
17.  How can insulin initiation delivery in a dual-sector health system be optimised? A qualitative study on healthcare professionals’ views 
BMC Public Health  2012;12:313.
Background
The prevalence of type 2 diabetes is increasing at an alarming rate in developing countries. However, glycaemia control remains suboptimal and insulin use is low. One important barrier is the lack of an efficient and effective insulin initiation delivery approach. This study aimed to document the strategies used and proposed by healthcare professionals to improve insulin initiation in the Malaysian dual-sector (public–private) health system.
Methods
In depth interviews and focus group discussions were conducted in Klang Valley and Seremban, Malaysia in 2010–11. Healthcare professionals consisting of general practitioners (n = 11), medical officers (n = 8), diabetes educators (n = 3), government policy makers (n = 4), family medicine specialists (n = 10) and endocrinologists (n = 2) were interviewed. We used a topic guide to facilitate the interviews, which were audio recorded, transcribed verbatim and analysed using a thematic approach.
Results
Three main themes emerged from the interviews. Firstly, there was a lack of collaboration between the private and public sectors in diabetes care. The general practitioners in the private sector proposed an integrated system for them to refer patients to the public health services for insulin initiation programmes. There could be shared care between the two sectors and this would reduce the disproportionately heavy workload at the public sector. Secondly, besides the support from the government health authority, the healthcare professionals wanted greater involvement of non-government organisations, media and pharmaceutical industry in facilitating insulin initiation in both the public and private sectors. The support included: training of healthcare professionals; developing and disseminating patient education materials; service provision by diabetes education teams; organising programmes for patients’ peer group sessions; increasing awareness and demystifying insulin via public campaigns; and subsidising glucose monitoring equipment. Finally, the healthcare professionals proposed the establishment of multidisciplinary teams as a strategy to increase the rate of insulin initiation. Having team members from different ethnic backgrounds would help to overcome language and cultural differences when communicating with patients.
Conclusion
The challenges faced by a dual-sector health system in delivering insulin initiation may be addressed by greater collaborations between the private and public sectors and governmental and non-government organisations, and among different healthcare professionals.
doi:10.1186/1471-2458-12-313
PMCID: PMC3533841  PMID: 22545648
Insulin initiation; Dual-sector health system; Malaysia; Diabetes; Public sector; Private sector
18.  Use of Communication Technologies to Cost-Effectively Increase the Availability of Interpretation Services in Healthcare Settings 
Telemedicine Journal and e-Health  2010;16(6):739-745.
Limited English proficiency costs healthcare providers and payers through lower patient use of preventive care, misdiagnosis, increased testing, poor patient compliance, and increased hospital and emergency room admissions. Recently published literature and unpublished data documenting the use of telephonic and video interpretation methodologies to improve healthcare communication with the persons with limited English proficiency was reviewed. Utilization of the Internet provides access to translated documents, promising practices, step-by-step guides, planning tools, and research briefs. Such tools can add value to healthcare where language is a barrier.
Abstract
Poor patient–provider communication due to limited English proficiency (LEP) costs healthcare providers and payers through lower patient use of preventive care, misdiagnosis, increased testing, poor patient compliance, and increased hospital and emergency room admissions. Scarcity of bilingual healthcare professionals and prohibitive interpretation costs hinder full implementation of language service despite federal and state laws requiring their provision. We review recent published literature and unpublished data documenting the use of telephonic and video interpretation methodologies to improve healthcare communication with LEP persons. For example, a cooperative of nine California public hospitals and their associated community clinics, psychiatric facilities, skilled nursing facilities, and public health departments have implemented shared video interpretation services with video/voice-over Internet Protocol call center technology that automatically routes requests for interpretation in 15 languages to a pool of 30 full-time interpreters and 4 trained bilingual staff. For organizations seeking to initiate or expand their language services, the Internet provides access to translated documents, promising practices, step-by-step guides, planning tools, and research briefs. Such recent technological advances make provision of language services—to respond to federal and state mandates and improve access and quality of care to LEP persons—more feasible than is widely believed. Increased government and foundation support, and collaboration among provider organizations themselves can catalyze these efforts.
doi:10.1089/tmj.2009.0186
PMCID: PMC2992399  PMID: 20626299
business administration; economics; policy; telecommunications
19.  Questioning the claims from Kaiser 
Background: The article by Feachem et al, published in the BMJ in 2002, claimed to show that, compared with the United Kingdom (UK) National Health Service (NHS), the Kaiser Permanente healthcare system in the United States (US) has similar healthcare costs per capita, and performance that is considerably better in certain respects.
Aim: To assess the accuracy of Feachem et al's comparison and conclusions.
Method: Detailed re-examination of the data and methods used and consideration of the 82 letters responding to the article.
Results: Analyses revealed four main areas in which Feachem et al's methodology was flawed. Firstly, the populations of patients served by Kaiser Permanente and by the NHS are fundamentally different. Kaiser's patients are mainly employed, significantly younger, and significantly less socially deprived and so are healthier. Feachem et al fail to adjust adequately for these factors. Secondly, Feachem et al have wrongly inflated NHS costs by omitting substantial user charges payable by Kaiser members for care, excluding the costs of marketing and administration, and deducting the surplus from Kaiser's costs while underestimating the capital charge element of the NHS budget and other costs. They also used two methods of converting currency, the currency rate and a health purchasing power parity conversion. This is double counting. Feachem et al reported that NHS costs were 10% less per head than Kaiser. Correcting for the double currency conversion gives the NHS a 40% cost advantage such that per capita costs are $1161 and $1951 for the NHS and Kaiser, respectively. Thirdly, Feachem et al use non-standardised data for NHS bed days from the Organisation for Economic Cooperation and Development, rather than official Department of Health bed availability and activity statistics for England. Leaving aside the non-comparability of the population and lack of standardisation of the data, the result is to inflate NHS acute bed use and underestimate the efficiency of performance by at least 10%. Similar criticisms apply to their selective use of performance measures. Finally, Feachem et al claim that Kaiser is a more integrated system than the NHS. The NHS provides health care to around 60 million people free at the point of delivery, long-term and psychiatric care, and continuing care after 100 days whereas Kaiser provides care to 6 million people, mainly employed and privately insured. Important functions, such as health protection, education and training of healthcare professionals, and research and development are not included or properly costed in Feachem et al's integrated model.
Conclusion: We have re-examined the statements made by Feachem et al and show that the claims are unsupported by the evidence. The NHS is not similar to Kaiser in coverage, costs or performance.
PMCID: PMC1266198  PMID: 15186560
costs and cost analysis; health care quality; health services; national health service; personal health service; quality indicators, health care
20.  Differences in the perceived role of the healthcare provider in delivering vascular health checks: a Q methodology study 
BMC Family Practice  2013;14:172.
Background
The UK Department of Health introduced the National Health Service (NHS) Health Check Programme in April 2009 in an attempt to improve primary and secondary prevention of cardiovascular disease in the UK population and to reduce health inequalities. Healthcare professionals' attitudes towards giving lifestyle advice will influence how they interact with patients during consultations. We therefore sought to identify the attitudes of primary care healthcare professionals towards the delivery of lifestyle advice in the context of the NHS Health Check Programme.
Methods
Fifty-two primary care healthcare professionals undertook a Q sort with 36 statements that represented a range of viewpoints about the importance of lifestyle change, medication, giving lifestyle advice in the primary care setting, and the individual, social and material factors that might impact on lifestyle related behaviour change. Sorts were analysed by-person using principal components analysis and varimax rotation.
Results
Five statistically independent factors (accounts) reflected distinct views on the topic. Account 1 was supportive of initiatives like the NHS Health Check, and emphasised the importance of professionals working collaboratively with patients to facilitate lifestyle change. Account 2 expressed views on the potential overuse of statin medication and placed responsibility for lifestyle change with the patient. Account 3 viewed the healthcare professional role to be one of educator, emphasising the provision of information. Account 4 perceived lifestyle change to be difficult for patients and emphasised the need for healthcare professionals to be role models. Account 5 was inconsistent about the value of lifestyle change, or the role of healthcare professionals in promoting it, a finding that may be due to ambivalence about the health check or to lack of engagement with the Q sort task. We found no strong associations between any of the factors and, gender, role, age or ethnicity.
Conclusions
Our findings suggest that healthcare professionals hold viewpoints that may influence how they interact with patients during health checks. When implementing programmes like the NHS Health Check, it would be useful to take healthcare professionals’ views into account. Attitudes and beliefs could be explored during training sessions, for example.
doi:10.1186/1471-2296-14-172
PMCID: PMC3870972  PMID: 24229342
Healthcare professional attitudes; Lifestyle advice; Primary health care; Prevention; Cardiovascular diseases; Health behaviour; Nursing; General practitioner; Q methodology
21.  Factors influencing healthcare service quality 
Background: The main purpose of this study was to identify factors that influence healthcare quality in the Iranian context.
Methods: Exploratory in-depth individual and focus group interviews were conducted with 222 healthcare stakeholders including healthcare providers, managers, policy-makers, and payers to identify factors affecting the quality of healthcare services provided in Iranian healthcare organisations.
Results: Quality in healthcare is a production of cooperation between the patient and the healthcare provider in a supportive environment. Personal factors of the provider and the patient, and factors pertaining to the healthcare organisation, healthcare system, and the broader environment affect healthcare service quality. Healthcare quality can be improved by supportive visionary leadership, proper planning, education and training, availability of resources, effective management of resources, employees and processes, and collaboration and cooperation among providers.
Conclusion: This article contributes to healthcare theory and practice by developing a conceptual framework that provides policy-makers and managers a practical understanding of factors that affect healthcare service quality.
doi:10.15171/ijhpm.2014.65
PMCID: PMC4122083  PMID: 25114946
Healthcare Organisations; Quality; Pluralistic Evaluation; Iran
22.  Changing Job Satisfaction, Absenteeism, and Healthcare Claims Costs In a Hospital Culture 
Global Advances in Health and Medicine  2014;3(Suppl 1):BPA01.
Introduction:
Fairfield Medical Center is a 222-bed community hospital located in Lancaster, Ohio. Organizational leadership chose to invest in the Transforming Stress Workshop, a 6-hour workshop with a 2-hour follow-up workshop, in order to improve the well-being of its staff and physicians.
Special thought and consideration were given to being able to sustain any benefits and/or improvements long-term. As a result, strategies were developed to integrate the program into our culture.
Methods:
Four staff members from a variety of disciplines were selected and sent to HeartMath Train-the-Trainer to gain proficiency in HeartMath methodology and tools, expanding their duties to deliver the classes. Biweekly workshops were offered from August 2007 through December 2010, educating a total of 975 employees, or 48% of the staff.
Other tactics providing a sustainable program included senior leadership support and championing, management team training, positive employee comments published internally, use of tools in committee and department meetings, incorporation into orientation and on-boarding processes, part of major initiative roll-outs, element in clinical ladder, expansion to include Transforming Team Workshops, sharing of Participant and Organizational Quality Assessment-Revised data, a lead HeartMath instructor who provides consulting to other organizations, provision of classes to local educators, and open workshops for employee family members.
Results:
Three metrics were selected to measure the success of the program: employee satisfaction, absenteeism rates, and healthcare claims cost. Statistically significant cultural and financial return on investment were demonstrated. Employees who received HeartMath training experienced a 2:1 savings on healthcare claims as compared to employees who had not received training. Employee Opinion Survey results demonstrated that employees who had HeartMath training had higher overall satisfaction scores than those who had not received training (Table and Figure) HeartMath participants demonstrated a lower overall absenteeism rate (P = 0), resulting in a $94,794 savings over a 3-year period. Cultural and financial returns on investment were demonstrated using these indicators.
Healthcare Claims Costs
Abbreviations: PMPM, per member per month; PMPY, per member per year.
HeartMath claims expense excludes five outlier claims in excess of $20 000 for conditions that could not have been avoided using HeartMath.
Non-HeartMath participants’ total claims expenses excludes six outlier cases with payments > $125 000.
Employee opinion survey: Impact of HeartMath Training, over all scores.
Conclusion:
Investing in HeartMath training and ongoing practice has proven to be a wise decision and continues to be valuable when initiating new concepts in a stressful, changing environment. Sustainability is key to long-term success and true cultural change. Continued employee training of the HeartMath tools and the continued use of the tools enriches the program planning and implementation of new initiatives at Fairfield Medical Center.
doi:10.7453/gahmj.2014.BPA01
PMCID: PMC3923278
Job satisfaction; absenteeism; healthcare claims costs; stress; HeartMath; return on investment (ROI); biofeedback
23.  Chronious: the last advances in telehealth monitoring systems 
The effectiveness of treatment depends on the patient’s ability to manage in the everyday life his/her chronic health status in accordance with the medical prescriptions outside the hospital settings. For this reason, the European Commission promotes research in tele-health applications, such as Chronious “An Open, Ubiquitous and Adaptive Chronic Disease Management Platform for COPD and Renal Insufficiency”. The aim is the improvement of healthcare service by offering an online health management solution that addresses the patient-professional interaction, personal data security, reduction of hospitalization and related costs. Chronious implements a modular hardware-software system that integrates existing healthcare legacy system, biomedical sensors, user interfaces and multi-parametric data processing with decision support system for patients and health professionals. Nowadays, very few of chronic disease management tools commercially available are accompanied with patient-professional interfaces for communication and education purposes. As added value, Chronious proposes lifestyle and mental support tools for the patients and ontological cross-lingual information retrieval system for clinicians for faster and easier queries to medical knowledge. The patient at home is equipped with a T-shirt able to record cardiac/respiratory/audio and activity signs, external devices (weight scale, glucometer, blood pressure monitoring device, spirometer, air quality sensor) and a touch-screen computer to send reminders on drugs intake and to collect information on dietary habits and mental status. All information are automatically transmitted via IP/GPRS to the Central System, that using a web-interface and ruled based algorithms allows clinicians to monitor patients status and give suggestions for acting in case of worsening trend or risk situation. As consequence, critical procedures that are quite complicated for the patient such as frequent/continuous monitoring, visits to hospitals, self-care are becoming straightforward and simpler. In addition, the information of the clinician is more direct, accurate and complete improving the prognosis for the chronic diseases and the selection of the most appropriate treatment planning. For validation purposes, Chronious is focused on chronic obstructive pulmonary disease and chronic kidney disease, being these widespread and highly expensive in terms of social and economic costs. The validation protocol considers also the most frequent related comorbidities, such as diabetes, involving the patients category which will take advantage of the highest foreseen benefits. This enables an open architecture for further applications. Project validation is divided in two progressive phases: the first one in hospital setting was aimed to verify on 50 patients if the delivered prototypes met the user requirements, the ergonomic and functional specifications. The second phase has observational features. The improved system is currently applied at home on 60 selected patients. Patients are instructed to use the system independently for an expected duration of 4 months each. In parallel, the patient is monitored with standard periodic outpatient checks. At the end, customer satisfaction and the predictive ability of the system in the evolution of the disease will be evaluated. First feedbacks are encouraging because Chronious monitoring provides friendly approaches to new technologies and reassures patients reducing the intervention time in critical situation.
PMCID: PMC3571130
chronic disease; patient-professional interfaces; lifestyle
24.  Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review 
Background
Greater use of computerized decision support (DS) systems could address continuing safety and quality problems in healthcare, but the healthcare field has struggled to implement DS technology. This study surveys DS experience across multiple non-healthcare disciplines for new insights that are generalizable to healthcare provider decisions. In particular, it sought design principles and lessons learned from the other disciplines that could inform efforts to accelerate the adoption of clinical decision support (CDS).
Methods
Our systematic review drew broadly from non-healthcare databases in the basic sciences, social sciences, humanities, engineering, business, and defense: PsychINFO, BusinessSource Premier, Social Sciences Abstracts, Web of Science, and Defense Technical Information Center. Because our interest was in DS that could apply to clinical decisions, we selected articles that (1) provided a review, overview, discussion of lessons learned, or an evaluation of design or implementation aspects of DS within a non-healthcare discipline and (2) involved an element of human judgment at the individual level, as opposed to decisions that can be fully automated or that are made at the organizational level.
Results
Clinical decisions share some similarities with decisions made by military commanders, business managers, and other leaders: they involve assessing new situations and choosing courses of action with major consequences, under time pressure, and with incomplete information. We identified seven high-level DS system design features from the non-healthcare literature that could be applied to CDS: providing broad, system-level perspectives; customizing interfaces to specific users and roles; making the DS reasoning transparent; presenting data effectively; generating multiple scenarios covering disparate outcomes (e.g., effective; effective with side effects; ineffective); allowing for contingent adaptations; and facilitating collaboration. The article provides examples of each feature. The DS literature also emphasizes the importance of organizational culture and training in implementation success. The literature contrasts “rational-analytic” vs. “naturalistic-intuitive” decision-making styles, but the best approach is often a balanced approach that combines both styles. It is also important for DS systems to enable exploration of multiple assumptions, and incorporation of new information in response to changing circumstances.
Conclusions
Complex, high-level decision-making has common features across disciplines as seemingly disparate as defense, business, and healthcare. National efforts to advance the health information technology agenda through broader CDS adoption could benefit by applying the DS principles identified in this review.
doi:10.1186/1472-6947-12-90
PMCID: PMC3524755  PMID: 22900537
25.  An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with Type 1 Diabetes in educational settings 
BMC Pediatrics  2014;14(1):228.
Background
Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university.
Method
Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3–25 years in educational settings.
Results
Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.
Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.
Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption.
Conclusion
This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2431-14-228) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2431-14-228
PMCID: PMC4263204  PMID: 25213220
Systematic review; Diabetes Type 1; Children; Adolescent; Young Person; Educational setting; School; University; College; School nurse

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