Dealing with the hours of work in isolation — or even as the prime mover — will not provide solutions, but will instead exacerbate problems and fault lines in the current system. We plan to continue with the service redesign. It is becoming clear that a senior consultant presence is required seven days a week and even, possibly, around the clock for acute care. This currently presents major financial challenges. Working excessive hours puts patients at unacceptable risk, is bad for the health of practitioners, and increases the risk of both accidents in the workplace and car accidents after leaving work.
Health care in general — and medicine in particular — has been slow to develop ways of working that enable safe delivery of modern medical care within a safe environment for the staff who are delivering that care. Changes to working hours have perceived, but not proven, negative effects on continuity of care and the training of junior doctors. The case studies we describe outline how it is possible to organize health care staff so that the twin aims of safety for patients and staff and a good environment for training can be realized.
While the principles might be the same, it is clear that different hospitals will take somewhat different approaches to the task of maintaining sufficient and appropriate medical cover for patients being admitted as emergency or elective patients. The extended role of nurses in both of these models is striking, in particular their role as coordinator for the hospital site and for the clinical assessment of deteriorating patients.
The availability of, and appropriate training for, these staff members is crucial to the success of the system. Initial fears that this would erode the role of the doctor have not been borne out as this system tends to allow doctors to be called appropriately to optimize the management of patient care. The coordination of all admissions and discharges by a single person who is aware of the organization of the whole hospital is key to the success of separating the elective and acute pathways for patients.
This also allows teams to concentrate on one pathway without worrying about the other. This appears to improve patient care through improved teamwork and increased efficiency in moving through the elements of the pathway facilitated by a single team. Concentrating on the way of working and minimizing the opportunity for medical errors reducing fatigue through proper rest and minimizing disruption to the circadian rhythm also appears to minimize costs and can lead to sustained financial savings. Work on competencies required for overnight care has allowed doctors with generic skills to be available for overnight emergencies for a group of specialties e.
Senior residents can be on-call from home, taking referrals from the H N team or other centres. A single team was needed to cover admissions for the emergency department. Thus fewer doctors are present in the hospital, although they work harder in short bursts. The key to the success of such a system is that all clinical professionals work together with an organized coordinated approach that includes assessment, prioritization, treatment, and, if appropriate, further referral.
The team leader, usually a senior advanced nurse practitioner, receives all calls and coordinates all activity within the hospital. This change is not easy, and it requires considerable determination and continuing input from senior staff to embed and maintain it. The difficulty lies in persuading many dedicated individuals that working differently will indeed provide better and safer care. The hospitals in the United Kingdom that have implemented this change have all shown improvement in patient safety, with some evidence of reduced costs overall.
Resources and secretariat support for this project was provided by the Royal College. Resident duty hours across borders: The full contents of the supplement are available online at http: This article was submitted and peer reviewed in Final acceptance for publication as part of this supplement was in Publication of this supplement was supported and funded by the Royal College of Physicians and Surgeons of Canada. The funding agency played no role in the design, in the collection, analysis and interpretation of data; in the writing of the manuscripts; and in the decision to submit the manuscript for publication.
The articles have been through the journal's standard peer review process for supplements. The Supplement Editors declare that they have no competing interests. National Center for Biotechnology Information , U. Published online Dec Author information Article notes Copyright and License information Disclaimer. Supplement Resident duty hours across borders: Abstract The reduction in the working hours of doctors represents a challenge to the delivery of medical care to acutely sick patients 24 hours a day.
ACCESS TO HEALTH CARE
Background Impact of working long hours and working at night The impact of physician fatigue on patient safety should be the principal focus of this discussion. Doctors in training and patient safety Evidence suggests that patients fare less well at night when they are cared for by doctors in training programs. Mitigating the effects of working at night Working patterns should reflect an approach that is safest for patients and healthiest for doctors and other staff.
The impact of daytime system inefficiencies on nighttime work Understanding the nature of clinical work done at night is key to developing organizational structures that support safe patient care. Open in a separate window. Night teams for modern care Although changes in medical technology over the past two decades have brought about significant improvements in the effectiveness of care, hospitals still require working patterns that enable the safe delivery of care while minimizing negative effects on the health of care providers. These principles include the following: Elective to emergency team handover at 4 p.
This hospital operates at two sites: Outline of problem In there were a total of on-call rotas. Key measures of improvement The vision was to reorganize care so that all patients had access to the right person with the right skills for their needs at the right time. Process of gathering information Colleagues in Human Resources collected information about all medical rotas.
The strategy was operationalized as follows: Effects of change on patients The analysis of benefits of the night teams — which had been first introduced in — took place in Effects of change on education On the night team, most junior doctors work alongside, and are supported and supervised by, SNPs who are trained to do procedural assessments.
Other changes introduced at the same time included the following: Lessons learned This major cultural change took time both to start and to embed. Message for others It is key to have a senior clinical champion who believes that this change will improve patient care. Next steps The day and night systems are now the same. Homerton University Hospital NHS Foundation Trust Context Homerton University Hospital is a bed district general hospital located in Hackney, an inner city area with a multi-ethnic, deprived population of approximately , to , people.
Outline of problem patient-centred There was a recognition in that significant and robust service redesign was the only way to guarantee good quality care and patient safety day and night while also providing adequate training opportunities, controlling costs, and meeting the EWTR i. This exercise revealed the following: Resources needed For both service redesign projects we employed a project manager for a little over 12 months. Effects of change on patient care We looked at a number of indicators to assess the impact of these changes on patient care. The following points, in particular, were observed: Effects of change on education We were able to maintain hours of direct supervision of trainees by consultants in their elective time because during that time there was no night on-call or weekend work.
Lessons learned The key to successful implementation of these changes was to involve those responsible for delivering the changes in the planning process and to manage the changes in clear phases. Message for others Effective communication is vital to implementing change of this magnitude.
Current approach We plan to continue with the service redesign. Discussion Working excessive hours puts patients at unacceptable risk, is bad for the health of practitioners, and increases the risk of both accidents in the workplace and car accidents after leaving work. Competing interests The authors declare that they have no competing interests. Declarations Resources and secretariat support for this project was provided by the Royal College.
The role of education in the delivery of health care. Hours of Work of Junior Hospital Doctors: Is there a Solution? No time to train the surgeons. The implementation and impact of Hospital at Night pilot projects: Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment SAMHSA, Substance abuse, like mental illness, exacts enormous social costs across all segments of society.
Most recipients 87 percent of specialty treatment for alcohol or drug abuse receive it in outpatient settings RWJF, , but overall, less than one-fourth of those who need treatment get it. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care. Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. Half of such funds come from dedicated funding at the federal, state, and local levels in the form of various block grants to state safety-net programs.
Medicaid and Medicare cover 21 percent of treatment, private insurance covers 14 percent, and 10 percent is paid directly by patients as out-of-pocket costs. Another 5 percent is covered through various charitable sources. Insurance policies held by many individuals constrain the use of substance abuse services by the exclusion of benefits for such services and by the use of annual and lifetime limits on benefits and other controls on service utilization.
Between and , private insurance for substance abuse services fell 0. Over the same period, out-of-pocket payments for specific types of substance abuse treatment increased Coffey et al. However, the high out-of-pocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it. Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system.
The consequences in terms of individual and population health are significant—oral health is a matter of public health concern because it affects a large proportion of the population and is linked with overall health status see Box 5—7. Oral diseases are causally related to a range of significant health problems and chronic diseases, as well as individuals' ability to succeed in school, work, and the community DHHS, b.
The effects of oral diseases are cumulative and influence aspects of life as fundamental as the foods people can eat, their ability to communicate effectively, and their social acceptability. The problems in the way the health care delivery system relates to oral health include lack of dental coverage and low coverage payments, the separation of medicine and dentistry in training and practice, and the high proportion of the population that lacks any dental insurance.
The committee focused on the problem of insurance and access to care. Oral Health as a Component of Total Health. When people think about the components of good health, they often forget about the importance of good oral health. This oversight is often reflected by health insurance coverage restrictions that exclude oral more According to the Department of Health and Human Services DHHS Office of Health Promotion and Disease Prevention, more than million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care cited by Allukian, As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care.
Individuals and families living below the poverty level experience more dental decay than higher-income groups, and their cavities are less likely to be treated GAO, More than a third of poor children ages 2 to 9 have one or more primary teeth with untreated decay, compared with Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth The pattern for adults is similar DHHS, b: Medicare excludes coverage of routine dental care, and many state Medicaid programs do not provide dental coverage for eligible children or adults.
According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period DHHS, b. Low-income Hispanic children and adults are less likely to be eligible for Medicaid than other groups, so even the limited Medicaid benefits are unlikely to be available to them.
The forecast for major oral health problems among the nation's fastest-growing population group, Hispanics, is especially alarming. The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health.
Therefore, the committee recommends that all public and privately funded insurance plans include age-appropriate preventive services as recommended by the U. Preventive Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services. Crossing the Quality Chasm IOM, b examined health system failures that compromise the quality of care provided to all Americans.
As noted, it is often the responsibility of state departments of health to monitor providers and levy sanctions when quality problems are identified. This adds to potential tensions with the public health system. Two particular quality problems have special significance in terms of assuring the health of the population: As the American population grows both older and more racially and ethnically diverse and as rates of chronic disease increase, important vulnerabilities in the health care delivery system are compromising individual and population health Murray and Lopez, ; Hetzel and Smith, Evidence shows that racial and ethnic minorities do not receive the same quality of care afforded white Americans.
These findings are consistent across a range of illnesses and health care services and remain even after adjustment for socioeconomic differences and other factors that are related to access to health care IOM, b. Furthermore, poor-quality health care is an important independent variable contributing to lower health status for minorities IOM, b. For example, racial differences in cervical cancer deaths have increased over time, despite the greater use of screening tests by minority women Mitchell and McCormack, The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured.
As discussed in Unequal Treatment IOM, b , the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual provider and patient , institution, and health system levels. The report found that aspects of the health care system—its organization, financing, and availability of services—may have adverse effects specifically for racial and ethnic minorities. For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present.
Nearly 14 million people in the United States are not proficient in English. Changes in the financing and delivery of health care services, such as the emphasis on cost controls and the almost complete conversion to managed care for the delivery of services under Medicaid, may be especially problematic for racial and ethnic minorities. The disruption of traditional community-based care and the displacement of providers who are familiar with the language, culture, and values of ethnic communities create barriers to effective care Leigh et al.
Such plans are characterized by higher per capita resource constraints and stricter limits on covered services Phillips et al. Fragmentation of health plans along socioeconomic lines engenders different clinical cultures, with different practice norms Bloche, The committee encourages the health care system and policy makers in the public and private sectors to give careful consideration to the interventions that are identified in Unequal Treatment IOM, b and aimed at eliminating racial and ethnic disparities in health care see Box 5—8.
Avoid fragmentation of health plans along socioeconomic lines. Strengthen the stability of patient—provider relationships in publicly funded more Americans now live longer. A child born today can expect to live more than 75 years, and advances in medicine have also extended the life spans of earlier generations.
As detailed in Chapter 1 , the result is that individuals over age 65 constitute an increasingly large proportion of the U. Embedded in these demographic changes is a dramatic increase in the prevalence of chronic conditions. Chronic conditions, defined as illnesses that last longer than 3 months and that are not self-limiting, affect nearly half of the U. An estimated million Americans have one or more chronic conditions, and that number is estimated to reach million by Pew Environmental Health Commission, Nearly half of those with a chronic illness have more than one such condition IOM, a.
Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age With the projected growth in the number of people over age 65 increasing from 13 percent of the population to 20 percent, the need for care for chronic conditions will also continue to grow. The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. Wagner and colleagues identified five elements required to improve outcomes for chronically ill patients:. Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up.
Systematic attention to patients' need for information and behavioral change. The health care delivery system as it exists today cannot deliver those elements. Recent surveys have found that less than half of U. Delivery of high-quality care to chronically ill patients is especially challenging in a decentralized and fragmented system, characterized by small practices AMA, Smaller practices have great difficulty in organizing the array of services and support needed to efficiently manage chronic disease.
The result is poor disease management and a high level of wasted resources. As the proportion of old and very old increases, the system-wide impact in terms of cost and increased disability may well overwhelm the human and financial resources available to care for chronically ill patients. The resources of the health care delivery system are not balanced well enough to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency such as that posed by a terrorist attack.
The relentless focus on controlling costs over the past decade has squeezed a great deal of excess capacity out of the health care system, particularly the hospital system. It has also reduced the time that physicians spend with patients and the quality of the clinical encounter. At the same time, the design of insurance plans in both the public and the private sectors does not support the integrated disease management protocols needed to treat chronic disease or the data gathering and analysis needed for both disease management and population-level health.
Underlying all of these problems is the absence of a national health information infrastructure to support research, clinical medicine, and population-level health. The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care. The committee's particular concerns are the underrepresentation of racial and ethnic minorities in all health professions and the shortage of nurses, especially registered nurses RNs practicing in hospitals.
However, the focus on these two health care professional shortage areas does not suggest the absence of problems in other fields. Acute shortages of primary care physicians exist in many geographic areas, in certain medical specialties, and in disciplines such as pharmacy and dentistry, to name two. In addition, a growing consensus suggests that major reforms are needed in the education and training of all health professionals. To deliver the type of health care envisioned in Crossing the Quality Chasm IOM, b , health care professionals must be trained to work in teams, to utilize information technology effectively, and to develop the competencies necessary to deliver care to an increasingly diverse population.
Health professions education is not currently organized to produce these results. In , 9 percent of physicians and By comparison, racial and ethnic minorities account for more than one-quarter of the nation's population. Among physicians, about 3 percent are African American, 2. The severe underrepresentation of racial and ethnic minorities in the health professions affects access to care for minority populations, the quality of care they receive, and the level of confidence that minority patients have in the health care system.
A consistent body of research indicates that African-American and Hispanic physicians are more likely to provide services in minority and underserved communities and are more likely to treat patients who are poor, Medicaid eligible, and sicker IOM, c. Some studies indicate that, on average, minority physicians treat four to five times more minority patients than do white physicians, and studies of recent minority medical school graduates indicate that they have a greater preference to serve in minority and underserved areas.
Although more research is needed to examine the impact of minority health care professionals on the level of access and quality of care, for some minority patients, having a minority physician results in better communication, greater patient satisfaction with care, and greater use of preventive services IOM, b. Although evidence has not established that increasing the numbers of minority physicians or improving cultural competence per se influences patient outcomes, existing research supports clear policies to increase the proportion of medical students drawn from minority groups.
RNs work in a variety of settings, ranging from governmental public health agency clinics to hospitals and nursing homes.
The majority, however, work in hospitals, although the proportion dropped from 68 percent in to 59 percent in Spratley et al. Hospitals are facing shortages of RNs, in addition to shortages of pharmacists, laboratory technologists, and radiological technologists. A recent national hospital survey AHA, b found that of , vacant positions, , were for RN positions. Hospital vacancy rates for RN positions averaged 11 percent across the country, ranging from about 10 percent to more than 20 percent in some states. Nationally, more than one in seven hospitals report a severe shortage of RNs, with more than 20 percent of RN positions vacant.
In general, hospitals in rural areas report the highest percentage of vacant positions. The current shortage of RNs, particularly for hospital practice, is a matter of national concern because nursing care is critical to the operation and quality of care in hospitals Aiken et al. In a study analyzing more than 5 million patient discharges from hospitals in 11 states, Needleman and colleagues consistently found that higher RN staffing levels were associated with a 3 to 12 percent reduction in indicators—including lower rates of urinary tract infections, pneumonia, shock, and upper gastrointestinal bleeding and shorter lengths of stay—that reflect better inpatient care.
The shortage of hospital-based nurses reflects several factors, including the aging of the population, declining nursing school enrollment numbers Sherer, , the aging of the nursing workforce the average age increased from Furthermore, nurses have available other professional opportunities, and women, who once formed the bulk of the nursing workforce, now have alternate career prospects. These trends do not appear to be a temporary, cyclical phenomenon. The aging of the population means an increase in the number of patients who require skilled care for chronic diseases and age-related conditions, but the growth in the pool of nursing professionals is not keeping pace with the growth in the patient population.
Although some of this increase is to be expected because of the overall aging of the U. An aging workforce may have implications for patient care if older RNs have less ability to perform certain physical tasks HRSA, The shortage of RNs poses a serious threat to the health care delivery system, and to hospitals in particular. Hospitals contribute in various ways to assuring the health of the public, particularly by providing acute care services, educating health professionals, serving as a site for research, organizing community health promotion and disease prevention activities, and acting as safety-net providers.
However, hospitals play a uniquely important role by serving as the primary source of emergency and highly specialized care such as that in intensive care units ICUs and centers for cardiac care and burn treatment. Recent changes in the structure of the hospital industry, the reimbursement of hospitals by public- and private-sector insurance programs, and nursing shortages have raised questions about the ability of hospitals to carry out these roles. During the s, the spread of managed care practices contributed to reductions in overall hospital admissions, in the length of hospital stays, and in emergency department visits.
As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed McManus, The American Hospital Association AHA, a reports that from to , the number of emergency departments in the nation decreased by 8. Over the same period, medical and surgical bed capacities were reduced by Although these reductions may have improved the efficiencies of hospitals, they have important implications for the capacity of the health care system to respond to public health emergencies.
Crowding in hospital emergency departments has been recognized as a nationwide problem for more than a decade Andrulis et al. According to the American Hospital Association a , the demand for emergency department care increased by 15 percent between and In a random survey of emergency department directors in and , 91 percent of the respondents reported overcrowding problems Derlet et al.
Hospital at night: an organizational design that provides safer care at night
The overcrowding was severe, resulting in delays in testing and treatment that compromised patient outcomes. The emergency departments of hospitals in many areas of New York City routinely operated at percent capacity Brewster et al. Patients regularly spent significant portions of their admission on gurneys in a hallway.
One consequence of this crowding is the periodic closure of emergency departments and the diversion of ambulances to other facilities. Ambulance diversions have been found to impede access to emergency services in metropolitan areas in at least 22 states U. House of Representatives, ; at least 75 million Americans are estimated to reside in areas affected by ambulance diversions.
Looking at 12 communities, Brewster and colleagues found that on average in , two hospitals in Boston closed their emergency departments each day and the Cleveland Clinic emergency departments were closed to patients arriving by ambulance for an average of nearly 12 hours a day. The increase in demand for emergency care is attributed to several factors Brewster et al. In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments. Hospitals are in better compliance with the federal Emergency Medical Treatment and Labor Act, which requires emergency departments to treat patients without regard for their ability to pay.
In addition, uninsured patients are making greater use of emergency departments for nonurgent care. The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. These include the demands placed on hospital emergency and outpatient departments by the uninsured and those without access to a primary care provider. The unique characteristic of primary care is the role it plays as a regular or usual source of care for patients and their families.
Good primary care assures continuity for the patient across levels of care, comprehensiveness of services according to the level of health or illness, and better coordination of these services over time Starfield, Defining the right level of immediate and standby capacity for emergency and inpatient care depends in part on the adequacy and effectiveness of general outpatient and primary care. For example, chronic conditions like asthma and diabetes often can be managed effectively on an outpatient basis, but if the conditions are poorly managed by patients or their health care providers, emergency or inpatient care may be necessary.
Billings and colleagues demonstrated strong links between hospital admission rates for such conditions and the socioeconomic and insurance status of the population in an area. For example, admission rates for asthma were 6. Differences in disease prevalence accounted for only a small portion of the differences in hospitalization rates among low- and high-income areas. Although Billings and colleagues did not draw conclusions about the causal pathways leading to these higher admission rates, it is likely that the contributing factors include those discussed in this chapter, such as a lack of insurance or a regular source of care and the assignment of Medicaid populations to lower-cost health plans.
A follow-up analysis found the situation to be growing worse for low-income populations, as economic pressures, including lower reimbursements rates, higher practice costs, and limitations on payment for diagnostic tests, squeeze providers who have historically delivered care to academic health centers' low-income populations Billings et al. Good primary care is associated with better birth weights Politzer et al. Geographically, areas with higher primary care physician-to-population ratios experience lower total health care costs Welch et al.
Additionally, there is evidence that primary care is associated with reduced disparities in health; areas of high income inequality that also had good primary care were less likely to report fair or poor self-rated health Starfield, The link between the availability of primary care and better health is also supported by international evidence, which shows that nations that value primary care are likely to have lower mortality rates all causes; all causes, premature; and cause specific , even when controlling for macro- and micro-level characteristics e.
Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm IOM, b makes clear that the misuse of services also characterizes disease management among insured chronically ill patients.
In the early s, managed care became a common feature of the health care delivery system in the United States.
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In theory, managed care offers the promise of a population-based approach that can emphasize regular preventive care and other services aimed at keeping a defined group as healthy as possible. These benefits are most easily achieved under a fully capitated, group practice model: This model allows a relatively stable enrolled population for whom benefits and services can be customized; knowledge of the global budget within which care is to be delivered; and a salaried workforce in which health care providers have an incentive to keep patients healthy and reduce unnecessary use of services but also have a culture in which they monitor each others' practices and quality of care.
For the patient, the model provides comprehensive care, an emphasis on prevention, and low out-of-pocket costs. Kaiser Permanente Medical Group pioneered the model more than 50 years ago on the basis of early experiences providing health care programs for employees of Kaiser industrial companies e. An important opportunity was lost when insurance companies, health plans and health providers, and the state and federal governments saw managed care primarily as a cost-containment mechanism rather than a population-based approach to delivering comprehensive and effective health care services.
Reimbursement rate reductions, restrictions on care and choice of physician, and other aspects of plan management disaffected millions of Americans from the basic concept of managed care. Furthermore, rapid turnover in enrollment, particularly in Medicaid managed care, ruined economic incentives for plans to view their enrollees as a long-term investment. This loss of trust in the idea of managed care is also the loss of a great opportunity to improve quality and restrain costs.
Loosely affiliated physician networks have no ability to identify their populations and develop programs specifically based on the epidemiology of the defined group. There is little ability to use data systems, shared protocols, or peer pressure to improve quality and reduce variations in health care practices. Managed care is undergoing rapid changes, some of which are likely to further undermine its viability.
Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services. Physicians are proving more aggressive and successful in their negotiations with plans to decrease constraints, and to date, most employers have been willing to accept the higher costs that result. Employer acceptance may change in the face of double-digit insurance premium increases.
Predicting the next configuration of insurance and plan delivery systems is dangerous in a system undergoing such rapid transition. A number of major insurance plans have announced that they will begin to offer defined-contribution options. Consumers will be expected to shop for their own care with a medical spending account coupled with catastrophic benefits for very large expenses.
This could significantly undermine the current pooling of risk and create incentives for overuse of high-technology services once a deductible for catastrophic benefits has been met. However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative. The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care. Better information technology can also support patients and family caregivers in crucial health decisions, strengthen both personal and population-based prevention efforts, and enhance participation in and coordination with public health activities.
See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure. Crossing the Quality Chasm IOM, b formulated the case that information technology is critical to the redesign of the health care system to achieve a substantial improvement in the quality of care.
A strong clinical information infrastructure is a prerequisite to reengineering processes of care; coordinating patient care across providers, plans, and settings and over time; supporting the operation of multidisciplinary teams and the application of clinical support tools; and facilitating the use of performance and outcome measures for quality improvement and accountability. From the provider perspective, better information systems and more extensive use of information technology could dramatically improve care by offering ready access to complete and accurate patient data and to a variety of information resources and tools—clinical guidelines, decision-support systems, digital prescription-writing programs, and public health data and alerts, for example—that can enhance the quality of clinical decision making.
Computer-based systems for the entry of physician orders have been found to have sizable benefits in enhancing patient safety Bates et al. Despite profound growth in clinical knowledge and medical technology, the health care delivery system has been relatively untouched by the revolution in information technology that has transformed other sectors of society and the economy.
Many health care settings lack basic computer systems to provide clinical information or support clinical decision making. Even where electronic medical record systems are being implemented, most of those systems remain proprietary products of individual institutions and health plans that are based on standards of specific vendors. The development and application of interoperable systems and secure information-sharing practices are essential to gain greater benefits from information technology.
At present, only a few institutions have had the resources to build integrated information systems that meet the needs of diverse specialties and environments. Those efforts illustrate both the costs involved in developing health information systems and some of the benefits that might be expected. So far, however, adoption of even common and less costly information technologies has been limited. Only a small fraction of physicians offer e-mail interaction 13 percent, in a poll , a simple and convenient tool for efficient communication with their patients Harris Interactive, Some of the documented reasons for the low level of physician—patient e-mail communication include concerns about lack of reimbursement for this type of service and concerns about confidentiality and liability.
These legitimate issues are slowly being addressed in policy and practice, but there is a long way to go if this form of communication is to achieve its potential for improving interactions between patients and providers. Enhanced information technology also promises to aid patients and the public in other ways.
The Internet already offers a wealth of information and access to the most current evidence to help individuals maintain their own health and manage disease. In addition, support groups and interactive programs offer additional approaches to empower consumers. Personalized systems for comprehensive home care may improve outcomes and reduce costs. Medicare's pilot project IdeaTel—Informatics for Diabetes Education and Telemedicine—offers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records www.
Making the case for quality improvement | The King's Fund
Other efforts to build a personal health record PHR created or cocreated and controlled by the individual—and instantly available to support treatment in any setting—suggest that the PHR may provide a comprehensive, accurate, and continuous record to support health and health care across the life span Jones et al. A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities.
Systems and protocols for linking health care providers and governmental public health agencies are vital for detecting emerging health threats and supporting appropriate decisions by all parties. The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible. For information technology to transform the health sector as it has banking and other forms of commerce that depend on the accurate, secure exchange of large amounts of information, action must be taken at the national level to develop the National Health Information Infrastructure NHII NRC, The committee endorses the call by the National Committee on Vital and Health Statistics NCVHS for the nation to build a twenty-first century health support system—a comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health.
Such a system can help realize the public interest related to quality improvement in health care and to disease prevention and health promotion for the population as a whole. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical. To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required.
Policies promoting the portability and continuity of personal health information are essential. Values, practices, relationships, laws, and investment and reimbursement policies must support the creation and use of data and information systems that are consistent with the vision for the NHII see Chapter 3 for an additional discussion and recommendation.
The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them. In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations. The committee discusses the extent of this separation and the particular need for better collaboration, especially in regard to assuring access to health care services, disease surveillance activities, and partnerships toward broader health promotion efforts.
Within the public health system in the United States, collaboration between the health care sector and governmental public health agencies is generally weak. This reflects the divergence and separate development of two distinct sectors following the Second World War. As disciplines and professional fields, medicine and public health evolved with minimal levels of interaction, and often without recognition of the lost opportunities to improve the health of individuals and the population.
The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy. The failure to collaborate characterizes not only the interactions between governmental public health agencies and the organizations and individuals involved in the financing and delivery of health care in the private sector but also financing within the federal government. Even the congressional authorizing committees for these activities are separate.
For example, the Substance Abuse and Mental Health Services Administration, a PHS agency, administers block grants to states to augment funding for mental health and substance abuse programs, neither of which is well supported under Medicaid. Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system.
At the same time, the Health Resources and Services Administration, the PHS agency charged with funding federally qualified safety-net clinics for the poor, and the Indian Health Service were both seeking funds to support the increasing deficits of these clinics due to the growing number of uninsured individuals and the low rates of reimbursement for Medicaid clinics. The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health.
Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the and subsequent Schedule H forms.
View data for this organization below, or select additional hospitals to create a comparison view. Display data for year: Data display type Display data below as: Other Useful Tax-exempt Hospital Information: Does the organization have a written financial assistance charity care policy? Report to credit agency? After enactment of the ACA, has the state in which this tax-exempt hospital is located expanded Medicaid? Does the state in which the tax-exempt hospital is located have a mandatory community benefit reporting statute?
Community Health Needs Assessment Activities:
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- The Future of the Public's Health in the 21st Century.?
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