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1.  A Proposed Framework for Understanding the Forces behind Legislation of Universal Health Insurance—Lessons from Ten Countries 
Health Services Research  2011;46(6 Pt 2):2101-2118.
Objective
To understand the forces propelling countries to legislate universal health insurance.
Data Source/Study Design
Descriptive review and exploratory synthesis of historic data on economic, geographic, socio-demographic, and political factors.
Data Extraction Methods
We searched under “insurance, health” on MEDLINE and Google Scholar, and we reviewed relevant books and articles via a snowball approach.
Principal Findings
Ten countries with universal health insurance were studied. For the five countries that passed final universal insurance laws prior to 1958, we found that two forces of “historical context” (i.e., social solidarity and historic patterns), one “ongoing dynamic force” (political pressures), and “one uniqueness of the moment” force (legislative permissiveness) played a major role. For the five countries that passed final legislation between 1967 and 2010, the predominant factors were two “ongoing dynamic forces” (economic pressures and political pressures) and one “uniqueness of the moment” force (leadership). In general, countries in the former group made steady progress, whereas those in the latter group progressed in abrupt leaps.
Conclusions
The lessons of more recent successes—almost all of which were achieved via abrupt leaps—strongly indicate the importance of leadership in taking advantage of generalized economic and political pressures to achieve universal health insurance.
doi:10.1111/j.1475-6773.2011.01320.x
PMCID: PMC3393000  PMID: 22092227
Comparative health systems; international health; health care financing; insurance; premiums; health policy; politics; law; regulation
2.  Perceptions of Standards-based Electronic Prescribing Systems as Implemented in Outpatient Primary Care: A Physician Survey 
Objective
To compare the experiences of e-prescribing users and nonusers regarding prescription safety and workload and to assess the use of information from two e-prescribing standards (for medication history and formulary and benefit information), as they are implemented.
Design
Cross-sectional survey of physicians who either had installed or were awaiting installation of one of two commercial e-prescribing systems.
Measurements
Perceptions about medication history and formulary and benefit information among all respondents, and among e-prescribing users, experiences with system usability, job performance impact, and amount of e-prescribing.
Results
Of 395 eligible physicians, 228 (58%) completed the survey. E-prescribers (n = 139) were more likely than non-e-prescribers (n = 89) to perceive that they could identify clinically important drug–drug interactions (83 versus 67%, p = 0.004) but not that they could identify prescriptions from other providers (65 versus 60%, p = 0.49). They also perceived no significant difference in calls about drug coverage problems (76 versus 71% reported getting 10 or fewer such calls per week; p = 0.43). Most e-prescribers reported high satisfaction with their systems, but 17% had stopped using the system and another 46% said they sometimes reverted to handwriting for prescriptions that they could write electronically. The volume of e-prescribing was correlated with perceptions that it enhanced job performance, whereas quitting was associated with perceptions of poor usability.
Conclusions
E-prescribing users reported patient safety benefits but they did not perceive the enhanced benefits expected from using standardized medication history or formulary and benefit information. Additional work is needed for these standards to have the desired effects.
doi:10.1197/jamia.M2998
PMCID: PMC2705252  PMID: 19390106
3.  Quality indicators and quality assessment in child health 
Archives of disease in childhood  2009;94(6):458-463.
Quality indicators are systematically developed statements that can be used to assess the appropriateness of specific healthcare decisions, services and outcomes. In this review, we highlight the range and type of indicators that have been developed for children in the UK and US by prominent governmental agencies and private organizations. We also classify these indicators in an effort to identify areas of child health that may lack quality measurement activity. We review the current state of health information technology in both countries since these systems are vital to quality efforts. Finally, we propose several recommendations to advance the quality indicator development agenda for children. The convergence of quality measurement and indicator development, a growing scientific evidence base and integrated information systems in healthcare may lead to substantial improvements for child health in the 21st century.
doi:10.1136/adc.2008.137893
PMCID: PMC2774840  PMID: 19307196
Quality; Quality indicators; General pediatrics; Health information technology
4.  Variation in Electronic Prescribing Implementation Among Twelve Ambulatory Practices 
Background
Electronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood.
Objective
To describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings.
Design
Multi-method qualitative case study of ambulatory practices before and after e-prescribing implementation.
Participants
Sixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty.
Measurements
Field researchers used observational and interview techniques to collect data on prescription-related clinical workflow, information technology experience, and expectations.
Results
Five practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support.
Conclusions
Practice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.
doi:10.1007/s11606-007-0494-8
PMCID: PMC2359528  PMID: 18373131
electronic prescribing; medical informatics; qualitative research; health services research
5.  Functional Characteristics of Commercial Ambulatory Electronic Prescribing Systems: A Field Study 
Objective: To compare the functional capabilities being offered by commercial ambulatory electronic prescribing systems with a set of expert panel recommendations.
Design: A descriptive field study of ten commercially available ambulatory electronic prescribing systems, each of which had established a significant market presence. Data were collected from vendors by telephone interview and at sites where the systems were functioning through direct observation of the systems and through personal interviews with prescribers and technical staff.
Measurements: The capabilities of electronic prescribing systems were compared with 60 expert panel recommendations for capabilities that would improve patient safety, health outcomes, or patients' costs. Each recommended capability was judged as having been implemented fully, partially, or not at all by each system to which the recommendation applied. Vendors' claims about capabilities were compared with the capabilities found in the site visits.
Results: On average, the systems fully implemented 50% of the recommended capabilities, with individual systems ranging from 26% to 64% implementation. Only 15% of the recommended capabilities were not implemented by any system. Prescribing systems that were part of electronic health records (EHRs) tended to implement more recommendations. Vendors' claims about their systems' capabilities had a 96% sensitivity and a 72% specificity when site visit findings were considered the gold standard.
Conclusions: The commercial electronic prescribing marketplace may not be selecting for capabilities that would most benefit patients. Electronic prescribing standards should include minimal functional capabilities, and certification of adherence to standards may need to take place where systems are installed and operating.
doi:10.1197/jamia.M1759
PMCID: PMC1090467  PMID: 15684122

Results 1-5 (5)