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This paper examines a new approach to managed healthcare where a network of care providers exchanges patient information through the internet. Integrating networks of clinical specialists and general care providers promises to achieve qualitative and economic improvements in the German healthcare system. In practice, problems related to patient management and data exchange between the managing clinic and assorted caregivers arise. The implementation and use of a cross-spectrum computerized solution for the management of patients and their care is the key for a successful managed healthcare system. This paper documents the managed healthcare of chronic headache patients and the development of an IT-solution capable of providing distributed patient care and case management.

The electronic medical record (EMR) has been used in Department of Veterans Affairs health care facilities since the mid 1980s. Health care reform is a top priority in the United States, and the adoption of a standardized EMR is a major component and cost-saving tool. From scheduling patients for surgical procedures to provider documentation and production of vital reports for the local facility and the National Veterans Health Administration office, the EMR is successful with less clinical overhead. Use of the EMR reduces redundant tests, medical errors, and improves hand-off communications.

To understand what is new in health information technology (IT), we updated a systematic review of health IT with studies published during 2004-2007. From 4,683 titles, 179 met inclusion criteria. We identified a proliferation of patient-focused applications although little formal evaluation in this area; more descriptions of commercial electronic health records (EHRs) and health IT systems designed to run independently from EHRs; and proportionately fewer relevant studies from the health IT leaders. Accelerating the adoption of health IT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding IT implementation.

The data regarding the number of deaths from road accidents per year in Italy is presently available only after extensive time, in the range of years. This situation originates from problems related to data collection as well as to the subsequent management of the information. The two sources which allow the quantification of this mortality are: statistic of "Road Accidents documented by the Police Force", consisting in accidents reported by the Police and involving deceased or injured victims; general mortality statistics The first source presents problems related to quality and completeness; the second, problems related to dimensions: reports of mortality due to traffic accidents (presently about 6000 reports per year) end up, as they should, in the flow of general mortality (more than 560,000 reports per year), which necessarily lengthens response time. This excessive time interval between notification of deaths from traffic accidents and their actual availability in terms of statistics has, as of today, a negative impact not only on the prompt knowledge of the phenomenon, but also on the necessary appraisal in light of reaching the objectives proposed by the European Union by 2010 (reduction of 50% health consequences of traffic accidents). This article aims to show that it would be easy to set up a Rapid Monitoring System for deaths due to traffic accidents by creating an appropriate sub-flow of the general mortality statistics. Based on reported appraisals, we aim to show that it seems highly practicable (and convenient) to extend this system to all accidental and violent mortality, inclusive of drug-related mortality (presently underestimated). The authors feel that the System herein described could, in a matter of months, provide, at very low costs, useful and reliable information regarding health and social issues. It is worthwhile pointing out that what hereby proposed does not interfere in any way with the flow of general mortality currently in use and may also be used for parallel collection of data which is currently not being recorded.

Background: Adoption of EHRs by U.S. ambulatory practices has been slow despite the perceived benefits of their use. Most evaluations of EHR implementations in the literature apply to large practice settings. While there are similarities relating to EHR implementation in large and small practice settings, the authors argue that scale is an important differentiator. Focusing on small ambulatory practices, this paper outlines the benefits and barriers to EHR use in this setting, and provides a "field guide" for these practices to facilitate successful EHR implementation., Discussion: The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, pre-implementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process., Summary: The EHR implementation experience depends on a variety of factors including the technology, training, leadership, the change management process, and the individual character of each ambulatory practice environment. Sound processes must support both technical and personnel-related organizational components. Additional research is needed to further refine recommendations for the small physician practice and the nuances of specific medical specialties.

Maimonides Medical Center (MMC), a 705-bed tertiary hospital located in Brooklyn, New York, is a not-for-profit, voluntary hospital and the third largest independent teaching hospital in the United States. Its strategic plan includes research and academic initiatives, specifically, physician and nursing leadership development and a nursing scholarship program. In 1996 executive management allocated resources for the development of an information technology environment to improve the quality of care, increase patient satisfaction, reduce costs, and position the hospital for future growth initiatives, all accomplished through the use of an Electronic Health Record (EHR). The result was the Maimonides Access Clinical System (MACS) that has transformed the delivery of health care throughout MMC and serves as a model for other US hospitals. In addition, since 2007, MMC has also participated in the Brooklyn Health Information Exchange (BHIX) a New York State HEAL grant initiative implementing a Regional Health Information Organization (RHIO), an exchange of clinical information between Brooklyn hospitals, nursing homes, and home health agencies that aids in the transition of care for its shared patients.

The Emergency Care Summary (ECS) in Scotland provides essential clinical and demographic information about patients needing unscheduled or emergency care. Information about patients' medications, adverse drug reactions and allergies is transferred twice every day from GP systems to the ECS. Access is then available to authorised health-care professionals at the national help line, at out-of-hours services and in accident and emergency departments. An economic analysis of the ECS implementation showed that annual benefits exceeded annual costs after about seven years. Approximately 77% of the benefits were non-financial and 23% from redeployed finance. No cash savings were planned and none were realised. As ECS utilisation increased from 2006, the net benefits became positive. This relationship between utilisation and net benefits is a common feature of successful e-health investment.

Many practices today are considering the purchase of an electronic medical record (EMR) system. "When should we get one? Are we ready for this type of technology in our practice? How will the physicians feel about it? How about the staff? How will it change our work flow? And most of all, who is going to pay for it?" are common questions that arise. In fact, funding the EMR is the number one reason most practices delay the decision to move forward with this type of technology in the office.

Government, through its unique roles as regulator, purchaser, provider, and facilitator, has an opportunity and an obligation to play a major role in accelerating the implementation of electronic health record systems and electronic health information exchange. Providers, who are expected to deliver appropriate care at designated locations at an appropriate cost, are dependent on health information technology for efficient effective health care. As state and federal governments move forward with health care purchasing reforms, they must take the opportunity to leverage policy and structure and to align incentives that enhance the potential for provider engagement in electronic health record adoption.

An electronic medical records (EMR) system is a key information technology that will help lead to management information systems that go a long way in attacking health care inflation. This article explains some the ways EMR can be used to drive these efficiencies, especially given the recent shift in workforce demographics. These efficiencies include increasing prescription drug compliance, reducing gaps in care, and providing safe redirection from the emergency room to other more appropriate care settings. The authors assert that even though the larger role of information technology is not so easily heard amid the ongoing private/public debate about U.S. health care reform, it nonetheless is essential to controlling health care costs and establishing new frontiers of efficiency and innovation.

Background: The lack of physicians with specialty stroke training represents a significant challenge to the future of stroke. This deficit limits both quality stroke care and clinical research initiatives., Methods: The use of telemedicine for stroke ('telestroke') has been an attempt to overcome this shortage and extend stroke expertise to locations which lack coverage. However, the initial telestroke systems required a point-to-point connection for transmission and only provided videoconferencing which limited their generalizability and usefulness. 'Telestroke 2.0' is the authors' vision of an integrative web-based telestroke system combining high-quality audiovideo transmission, the ability of consults and teleradiology to be carried out from any desktop or laptop computer with web-access, decision and technical support, creation of billable physician documentation and electronic medical record connectivity., Results: These features will facilitate the development of statewide and regional telestroke call networks with an opportunity for physician supply companies to fill in coverage gaps. In addition, telestroke 2.0 may improve acute stroke research by increasing trial efficiency via the addition of non-academic recruitment sites, enhancing trial validity by centralizing neurologic examinations via recorded encounters, and generalizing clinical trial results to community hospital settings., Conclusions: Greater diffusion and long-term sustainability of telestroke systems will be dependent upon improvements in patient and hospital reimbursement for acute stroke and telestroke care., (Copyright 2009 S. Karger AG, Basel.)

Effectively determining the future return-on-investment of regional healthcare delivery and electronic healthcare record systems requires consideration of many alternative designs for their performance, cost and ability to meet stakeholder expectations. Successfully testing, validating and communicating the expected consequences of alternative business practices, processes, protocols and policies requires an objective analytical approach. Agent-based modeling and simulation (ABMS), a technique for determining the system-level results of complex, interacting, and often conflicting individual-level decisions, provides such an approach. ABMS of healthcare delivery can provide actionable guidance for decision makers by enabling healthcare experts to define the individual, agent-level rules of operation; allowing them to see how the agent rules play out over time in a detailed real-world context; providing them with the tools to assess the consequences of alternative plans; and giving them a clear method for communicating results to the broader stakeholder community.

Without administrative terminologies there is no revenue to manage. The use of healthcare IT to capture the codes for administrative and financial support functions will impact the revenue cycle and the management of it. This is presumed to occur because clinical data coded at the point of care becomes the source for claims data. Thus, as electronic health record system applications utilizing terminologies are implemented, healthcare providers need to systematically consider the effect on the coding function and management of the revenue cycle. A key factor is the sequence of events changes, i.e., instead of a health information management professional selecting billing codes at the conclusion of an encounter based on the review of the record, clinical data generates the claims data via mapping. Efficiencies and management challenges result.

Many care providers are implementing EHR to improve safety, quality and efficiency of patient care. In addition to the benefits reported in previous studies, EHRs provide a foundation that facilitates quality improvement in healthcare. While quality improvement methods are increasingly being applied in healthcare, these methods depend on having reliable data on key structure, process and outcome measures. One challenge quality improvement projects face is finding timely, cost-effective ways to measure and monitor care processes. This article presents a framework for measurement in healthcare and describes how EHRs provide the infrastructure necessary to measure care processes. In addition, a case study contrasts measurement challenges faced by one hospital system prior to EHR implementatiol with simplified measurement processes enabled through EHR. Utilizing EHR as a measurement tool to enable ongoing quality improvement efforts enables care providers to increase the value they receive from investing in EHR.

The Military Health System (MHS) deployed its electronic health record (EHR), AHLTA to Military Treatment Facilities (MTFs) around the world. This paper focuses on the approach and barriers to using structured text in AHLTA to document care encounters and illustrates the direct correlation between the use of structured text and achievement of expected benefits. AHLTA uses commercially available products, a health data dictionary and standardized medical terminology, enabling the capture of structured computable data. With structured text stored in the AHLTA Clinical Data Repository (CDR), the MHS has seen a return on its EHR investment with improvements in the accuracy and completeness of coding and the documentation of care provided. Determining the aspects of documentation where structured text is most beneficial, as well as the degree of structured text needed has been a significant challenge. This paper describes how the economic value framework aligns the enterprise strategic objectives with the EHR investment features, performance metrics and expected benefits. The framework analyses focus on return on investment calculations, baseline assessment and post-implementation benefits validation. Cost avoidance, revenue enhancements and operational improvements, such as evidence-based medicine and medical surveillance can be directly attributed to use structured text.

The Massachusetts General Hospital Physicians Organization (MGPO) has implemented physician incentives to drive timely entry of notes into the outpatient electronic health record. Data from the Partners Quality Data Warehouse (QDW) were used to refine and produce a note completion metric and to create reports. This initiative has led to a decrease in the average time to complete a note from 197 to 90 hours, in less than a year.

Personal health records (PHRs) are a rapidly growing area of health information technology despite a lack of significant value-based assessment.Here we present an assessment of the potential value of PHR systems, looking at both costs and benefits.We examine provider-tethered, payer-tethered, and third-party PHRs, as well as idealized interoperable PHRs. An analytical model was developed that considered eight PHR application and infrastructure functions. Our analysis projects the initial and annual costs and annual benefits of PHRs to the entire US over the next 10 years.This PHR analysis shows that all forms of PHRs have initial net negative value. However, at the end of 10 years, steady state annual net value ranging from$13 billion to -$29 billion. Interoperable PHRs provide the most value, followed by third-party PHRs and payer-tethered PHRs also showing positive net value. Provider-tethered PHRs constantly demonstrating negative net value.

Personal health records (PHRs) are a rapidly expanding area in medical informatics due to the belief that they may improve healthcare delivery and control costs of care. To truly understand the full potential value of a technology, a cost analysis is critical.However, little evidence exists on the value potential of PHRs, and a cost model for PHRs does not currently exist in the literature.This paper presents a sample cost model for PHR systems, which include PHR infrastructure and applications. We used this model to examine the costs of provider-tethered, payer-tethered, third-party, and interoperable PHRs. Our model projects that on a per-person basis, third-party PHRs will be the most expensive followed by inter operable PHRs, and then provider-tethered PHRs and payer-tethered PHRs are the least expensive. Data interfaces are a major cost driver, thus these findings underscore the need for standards development and use in the implementation ofPHR systems.

Outsourcing release-of-information requests helps hospitals alleviate administrative and compliance burdens and expense. Recently, state lawmakers have begun to draft legislation reducing the maximum fee that may be charged for copies of electronically stored records. The reduced fees may not cover expenses. If such legislation makes it difficult for outsourcing companies to make a profit from this service, hospitals ultimately could bear the expense and risk.

Background: Database systems have been developed to store data from large medical trials and survey studies. However, a reliable data storage system does not guarantee data entering reliability.We aimed to evaluate if double-blind control of the data manager might have any effect on data-reliability. Our secondary aim was to assess the influence of the inserting position in the insertion-sheet on data-entry accuracy and the effectiveness of electronic controls in identifying data-entering mistakes., Methods: A cross-sectional survey and single data-manager data entry.Data from PACMeR_02 survey, which had been conducted within a framework of the SESy-Europe project (PACMeR_01.4), were used as substrate for this study. We analyzed the electronic storage of 6,446 medical charts. We structured data insertion in four sequential phases. After each phase, the data stored in the database were tested in order to detect unreliable entries through both computerized and manual random control. Control was provided in a double blind fashion., Results: Double-blind control of the data manager didn't improve data entry reliability. Entries near the end of the insertion sheet were correlated with a larger number of mistakes. Data entry monitoring by electronic-control was statistically more effective than hand-searching of randomly selected medical records., Conclusion: Double-blind control of the data manager should be considered an avoidable cost. Electronic-control for monitoring of data-entry reliability is suggested.

Every project decision affects your costs. It comes down to which costs are associated with each element of the project.

Purpose: The present study reports the current status of computerizing medical records in Japan. In 2001, the Ministry of Health, Labour and Welfare formulated the Grand Design for the Development of Information Systems in the Healthcare and Medical Fields. The Grand Design stated a numerical target for "spreading the use of electronic medical records (EMR) in at least 60% of Japan's hospitals with 400 or more beds by 2006." The objective of this study was to examine the extent to which EMR and order entry systems (OES) have been adopted as of February 2007 and to evaluate the Japanese government's policy regarding the computerization of medical records., Methods: We conducted a postal survey targeting medical institutions throughout Japan. In February 2007, we mailed self-administered questionnaires to all 1574 hospitals with 300 or more beds, and to a random selection of 1000 hospitals with less than 300 beds in addition to 4000 clinics. Responses were received from 812 (51.6%), 504 (50.5%), and 1769 (44.8%), respectively. We asked questions concerning: (i) the extent to which EMR and OES had been introduced; (ii) the reasons why certain institutions had not introduced EMR and (iii) the subjective evaluation of the efficacy and cost-effectiveness of EMR., Results: The percentage of institutions that had introduced EMR as of February 2007 was 10.0% for hospitals and 10.1% for clinics. Even the percentage for hospitals with 400 or more beds was just 31.2%, illustrating that the government's target had not been reached. The most common reason given for not introducing EMR was: "The cost is high" which was observed in 82.0% of hospitals. It was considered that the introduction of EMR could improve 'inter-hospital networks', and 'time efficiency for physicians' by around 45% and 25% of hospitals, respectively., Conclusion: Healthcare information computerization in Japan is behind schedule because the introductory costs are high. For the computerization of healthcare information to be further promoted, prices of EMR systems should be lowered to a level which individual hospitals can afford. Furthermore, the communication between EMR systems should be further standardized to secure functional and semantic interoperability in Japan.