Category Archives: Health Care

Academia, Health Care, Public Health, Society

Leadership & Character

Juxtaposing Two Renowned Leaders of Health

When considering leadership in health care, I think first of how that leadership has affected health care in particular. Being a leader in health care does not guarantee great impact; however, an effective leader can have great impact over a large scope. This is how I framed my search to find two leaders in health care to highlight in this paper.

The first leader of health care that I will discuss is Clara Barton. According to Chambers (2002), Barton, independent to a fault, has been described as having a persuasive power about her. A fairly timid girl, Barton had self-image problems growing up that were at times debilitating; however, it seemed that as long as her interest was in helping others Barton performed selflessly, with heroism and bravado usually reserved for men during the time. Barton, a school teacher, found herself in the middle of the Civil War caring and tending to the soldiers on the battlefield. Dubbed the angel of the battlefield, Barton would not cease in caring for the soldiers even under enemy fire.

Barton, according to Chambers (2002) was not a very effective manager, but she could convince anyone to do anything that she needed to get done, it was said. Barton presents with a leadership style that is transformational (Robbins & Judge, 2010). She sees a need and immediately works to fill the void, inspiring others to do the same. Barton was ultimately responsible for founding the American Red Cross, a neutral organization that today responds to over 67, 000 disasters per year providing medical supplies, food, and housing in order to promote health equity even during wartime. Barton was a socialized charismatic leader, and her accomplishments are truly inspirational (Robbins & Judge, 2010).

The second leader of health care, more so in death than in life, that I chose to discuss is Johns Hopkins. Most people are familiar with Johns Hopkins Hospital and Johns Hopkins University, but it might be surprising to know that these namesakes were only made possible by the posthumous gift of $7-million from Hopkins’s estate (Herringshaw, 1901; “Johns Hopkins,” 1891). Hopkins started life from an affluent family, but a choice to free the family’s slaves forced Hopkins out of his formal education to help on the family tobacco farm. Since leaving the family farm, it seemed, by all accounts, that Hopkins had an innate ability for business (“Johns Hopkins,” 1891). Hopkins became very successful in business early in his lifetime, and he always tried to return his good fortune to the community. This innate ability for business, along with his unwavering business ethics, would seem to make Hopkins a likable and well-respected leader, possibly invoking a sense that he was born with these traits (Borgatta, Bales, & Couch, 1954; Cawthon, 1996; Robbins & Judge, 2010). It was in the spirit of community leader that Hopkins fulfilled his final philanthropy by funding an orphanage, a university, colleges, and a hospital that to this day is world-renowned. Johns Hopkins was an authentic leader (Robbins & Judge, 2010).

Whether a leader is naturally born with certain traits or learns behaviors from their environment, what matters most is that they be prepared to lead when the time comes. Without the onus of personal responsibility, no true leaders can exist.

References

Borgatta, E. F., Bales, R. F., & Couch, A. S. (1954). Some findings relevent to the great man theory of leadership. American Sociological Review, 19(6), 755-759. doi:10.2307/2087923

Cawthon, D. L. (1996). Leadership: the great man theory revisited. Business Horizons, 39(3), 1-4. doi:10.1016/S0007-6813(96)90001-4

Chambers, L. (2002). Fearless under fire. Biography, 6(4), 64-67, 96-97.

Herringshaw, T. W. (Ed.). (1901). Johns Hopkins. Herringshaw’s encyclopedia of American biography of the nineteenth century. Retrieved from http://books.google.com/

Johns Hopkins. (1891). The national cyclopaedia of American biography (Vol. 5). Retrieved from http://books.google.com/

Robbins, S. P. & Judge, T. A. (2010). Leadership. Essentials of Organizational Behavior (pp. 159-180). Upper Saddle River, NJ: Pearson Prentice Hall.

Academia, Health Care, Public Health, Society

Determinants of Health – Mental Illness

When attempting to solve many of the issues relevant to public health, it is essential to understand the factors that contribute to disparities across various ethnic, racial, cultural and socioeconomic boundaries (Satcher & Higginbotham, 2008). In northeastern Connecticut, however, health disparities are primarily related to the socioeconomic strata, as much of the population is Caucasian and there are identifiable health disparities within this group (U.S. Census Bureau, 2002, 2008; U.S. Department of Health and Human Services, 2009). The disparity that I will focus on in this paper is mental illness.

According to Adler and Rehkopf (2008), unjust social disparity leads to greater health disparity, but what is unjust about social disparity? Adler and Rehkopf continue to describe efforts of researchers to evaluate how socioeconomic status, both, in conjunction with and independent of race or ethnicity, contribute to health disparities. There exists a significant difference in the manner in which different cultures approach mental health needs (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008). Whites, who are more prone to suffering mental health issues, according to McGuire and Miranda (2008), preferring to seek professional care while Blacks are more likely to opt for self-directed care. Though Wang, Burglund, and Kessler (2001) tell of mental health treatment disparities between Whites and Blacks, in their study, 14 times more Whites responded than Blacks which may suggest that Whites are more apt to discuss mental health issues and Blacks might not unless they are motivated by extrinsic factors, such as poor care or the impression thereof. As long as Blacks are not prevented or discouraged from seeking care, there is no injustice in choosing self-care; however, it may not be the most effective option. Cultural awareness on the part of health care providers who may have an opportunity to provide health education to Blacks may alone increase the utilization of mental health services among the Black demographic.

More importantly, mental illness often exists in the presence of poverty and the lack of education. Much of the literature, such as Schwartz and Meyer (2010), seems to make the implication that low socioeconomic status is a causative risk-factor for mental illness, yet the literature also makes the distinction that one of the lowest groups on the socioeconomic ladder, Blacks, have a lower incidence, overall, of mental illness. This may be true in some instances; however, it is more likely that mental illness may be the proximal cause for an afflicted person’s socioeconomic status, especially if the illness manifested early enough to interfere with the person’s education.

More research needs to be undertaken to identify effective programs that aim to mitigate bias of mental health conditions within the community. As mental health disorders lose their stigma, more people who suffer from mental health issues will be able to seek care comfortably and unafraid, leading to increased treatment rates and increased synthesis within the community. This synthesis alone would alleviate much of the socioeconomic burden. Additionally, we need to shift our focus and strive to fix health issues locally, not nationally or globally. The world is comprised of a network of communities of individuals. Impacting the individual is the first step to affecting positive social change. Focusing on individual health will ultimately impact community, national, and global health.

The U.S. Health care system is overtaxed in caring for people with mental illness. According to Insel (2008), we need to refocus our efforts on providing care for mental illness to reduce the enormous indirect costs estimated at $193.2-billion per year. A viable solution in addressing mental illness as a health disparity, I feel, lies in understanding the manner that mental illness causes lower socioeconomic status which, in turn, causes risk of disparate care. Programs designed to aim for situational mitigation instead of mental health recovery will be less costly, more effective and, overall, more ideal. There will still be an obvious and great need for treatment and recovery programs, but with mitigation, I posit that they will be more effective, also.

References

Adler, N. E. & Rehkopf, D. H. (2008). U.S. disparities in health: descriptions, causes, and mechanisms. Annual Review of Public Health, 29(1), 235-252. doi:10.1146/annurev.publhealth.29.020907.090852

Hatzenbuehler, M. L., Keyes, K. M., Narrow, W. E., Grant, B. F., & Hasin, D. S. (2008). Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population. Journal of Clinical Psychology, 69(7), 1112-1121. doi:10.4088/JCP.v69n0711

Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165, 663-665. doi:10.1176/appi.ajp.2008.08030366

McGuire, T. G. & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs, 27(2), 393-403. doi:10.1377/hlthaff.27.2.393

Newport, F. & Mendes, E. (2009, July 22). About one in six U.S. adults are without health insurance: Highest uninsured rates among Hispanics, the young, and those with low incomes. Gallup-Heathways Well-Being Index. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx

Satcher, D. & Higginbotham, E. J. (2008). The public health approach to eliminating health disparities. American Journal of Public Health, 98(3), 400–403. doi:10.2105/AJPH.2007.123919

Schwartz, S. & Meyer, I. H. (2010). Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses. Social Science and Medicine, 70, 1111-1118. doi:10.1016/j.socscimed.2009.11.032

U.S. Census Bureau. (2002). Census 2000. Retrieved from http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250616

U.S. Census Bureau. (2008). Population estimates: Annual estimates of the resident population by age, sex, race, and Hispanic origin for counties in Connecticut: April 1, 2000 to July 1, 2008 [Data]. Retrieved from http://www.census.gov/popest/counties/asrh/files/cc-est2008-alldata-09.csv

U.S. Department of Health and Human Services. (2009). Community health status indicators report. Retrieved from http://communityhealth.hhs.gov/

Academia, Culture, Emergency Medical Services, Health Care

Motivation: A Career that I Enjoy

I am lucky to work in a career that I absolutely enjoy. As a paramedic in the emergency medical services (EMS), I am called upon to help those in my community in the worst of circumstances to help them when they feel helpless. There are drawbacks, however. Many people rely on EMS for problems that even they do not view as emergent, and others just plainly abuse the system. Still, I enjoy being the one called upon to help. My primary motivations are my sense of community, my ability to reduce suffering, and my ability to raise the standard of care within the system. Maslow (1943) includes some of the earliest accepted work on motivational theory, and more contemporary work is based on the acceptance, rejection or modification of his theories, so I will focus on Maslow to begin. My needs, according to Maslow, are not as important to motivation. Need fulfillment will not motivate me to perform; however, a lack of fulfillment may prevent me from performing. This is especially true for Maslow’s lower-order needs. Maslow discusses how emergency situations can “obscure the ‘higher’ motivations [and create] a lopsided view of human capacities and human nature” (p. 375), and while my career is focused on responding to emergencies, this may hold true for me. While Maslow’s theory is not wholly accepted motivational schema (Robbins & Judge, 2010), EMS managers, and other public safety managers, would do well to understand this exception to motivational theory.

Many EMS managers, it seems, subscribe to McGregor’s (1957/2000) theory X without understanding the ramifications or the competing theory Y. There is a deep-seated belief that the workforce is lazy and will do anything possible to undermine the operation. This results in micromanagement tactics that seem to promote an unwillingness to promote the goals of the employer. McGregor highlights this and cautions that it a result of poor management technique, not a cause that is easily rectified by the chosen technique.

Other theories, such as goal-setting, equity theory, and expectancy theory, as described in Robbins and Judge (2010), are all lacking in one particular constant: there is no constant in human behavior. There are a number of ways that a single motivational factor might influence a particular person on any particular day. For any theory to always be true in every situation, it would cease to be a theory and become a law. This being said, as managers, we need to measure the importance of certain tasks and focus our efforts on communicating this importance to the workforce. It is the manner of this communication that will tend to fail or succeed, based on both the needs of the manager and the needs of the employee at the moment the message is passed.

References

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

McGregor, D. (2000). The Human Side of Enterprise (Reprinted from Adventure in thought and action: Proceedings of the fifth anniversary convocation of the School of Industrial Management, Massachusetts Institute of Technology, Cambridge, 1957, April 9. Cambridge, MA: MIT School of Industrial Management). Reflections, 2(1), 6-14. doi:10.1162/152417300569962

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Academia, Health Care, Public Health, Society

Community Health: How Healthy is My Community?

I currently reside in Windham County, Connecticut. Windham County is primarily rural with one community, Willimantic, comprising most of the urban demographic. Windham County is functionally divided in half (north to south) in regards to health and hospital services. Primarily, Windham Community Memorial Hospital serves the west and Day Kimball Hospital serves the east. Accordingly, the eastern and western portions of the county may not be representative of each other, yet both are represented as a singular group when considering county-based statistics. This is a shortcoming of county-based statistics. In this instance, Willimantic, in the western portion of Windham County, may negatively affect the statistics of towns like Killingly, Pomfret, and Putnam, in the eastern portion of the county, due primarily to an increase in impoverished populations residing in Willimantic (U.S. Census Bureau, 2002). Additionally, data is lacking for a number of measures, according to the Community Health Status Indicators Project Working Group (2009), but continuing efforts will be made to increase reporting over time.

According to the U.S. Census Bureau (2008) and the U.S. Department of Health and Human Services (2009), the population of Windham County is 117,345 and is predominantly white (94.3%) with the remaining (5.7%) divided among, in order of predominance, Hispanics, Blacks, Asians and Pacific Islanders, and American Indians. The particularly vulnerable populations identified are adults age 25 and older who do not hold a high school diploma, are unemployed, are severely disabled and unable to work, suffer major depression, or have recently used illicit drugs. The uninsured rate in Windham County is well below the 16% national average at 9.5% (Newport & Mendes, 2009; U.S. Department of Health and Human Services, 2009).

Windham County fares equal or better in most measures, at least within the margin of error; therefore, I feel that Windham County, though not exceptionally healthy, is better than most and striving to meet the national standards (U.S. Department of Health and Human Services, 2009). For example, though the incidence of cancer and subsequent death resulting remains higher than peer counties, Windham County falls well within the expected range of death measures and exceeds peer counties in homicide, stroke, suicide, and unintentional injuries. Windham County also falls below the national standardized target for both stroke and coronary heart disease deaths. Infant mortality and birth measures seem representative of peer counties. Windham County also meets or exceeds environmental standards in all cases except for two reports of E. coli infections. There were also reports of five cases of Haemophilus influenzae B, two cases of Hepatitis A, and three cases of Hepatitis B — the only unexpected cases of infectious diseases reported. Pertussis incidence was limited to 25% of expected cases.

Windham County is not exceptional, but living here gives me the sense that the focus is on preventative care rather than acute care, which might explain how the health goals are being achieved overall. The report from the U.S. Department of Health and Human Services (2009) is in agreement.

References

Community Health Status Indicators Project Working Group. (2009). Data sources, definitions, and notes for CHSI2009. Retrieved from http://communityhealth.hhs.gov/

Newport, F. & Mendes, E. (2009, July 22). About one in six U.S. adults are without health insurance: Highest uninsured rates among Hispanics, the young, and those with low incomes. Gallup-Heathways Well-Being Index. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx

U.S. Census Bureau. (2002). Census 2000. Retrieved from http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250616

U.S. Census Bureau. (2008). Population estimates: Annual estimates of the resident population by age, sex, race, and Hispanic origin for counties in Connecticut: April 1, 2000 to July 1, 2008 [Data]. Retrieved from http://www.census.gov/popest/counties/asrh/files/cc-est2008-alldata-09.csv

U.S. Department of Health and Human Services. (2009). Community health status indicators report. Retrieved from http://communityhealth.hhs.gov/

Emergency Medical Services, Health Care, Public Health

Long-term care versus acute care

This discussion, again, allows me to ponder some musings of my colleagues and consider them in scholarly reflection. As a paramedic, I frequently respond to skilled nursing facilities (SNFs) to care for patients with minimal medical complaints or exacerbations of chronic conditions. The comments are always the same: What is the point of having nurses here if they cannot care for their patients? As I have never had an acceptable answer to this quandary, I will use this opportunity to explore the usefulness of SNFs based on measured outcomes. I will also compare the abilities of acute care facilities (ACFs) with those of SNFs to weigh the appropriateness of relying on ACFs to care for SNF patients.

The leading number of long-term care facilities are elderly SNFs, and as such, the elderly are the major demographic cared for in SNFs, yet there is a shortage, even within SNFs, of health care providers skilled in geriatric care (Cohen, 2002; Gaugler, Duval, Anderson, & Kane, 2007; Shi & Singh, 2011b). As Gaugler, Duval, Anderson, and Kane (2007) describe, the mere admission of an elderly patient into an SNF is associated with poor outcomes, “questionable quality of care, early mortality for many residents, and psychological or emotional upheaval for caregiving families” (p. 14). As long-term care also includes varying degrees of home care, family care, and limited residential care (e.g. assisted living centers), an international effort has been underway to help determine ways of identifying and limiting SNF admissions in order to limit potential negative outcomes and maintain patients’ self-efficacy and quality of life (Kennedy et al., 2007).

SNFs and ACFs are similar in that they both house patients, have nursing staff, are demographed by the number of beds housed, and, typically, have some sort of medical team responsible for the patients’ overall care. ACFs are numerous in type and offering. General hospitals, specialty hospitals, free-standing emergency clinics, and tertiary care centers are just some of the ACFs available to treat illness and injury (Shi & Singh, 2011a). ACFs tend to focus treatment on acute manifestations of illness and injury, while SNFs (and other long-term care facilities) focus on continuing care for chronic maladies (Shi & Singh, 2011a, 2011b; Singh, 2011). While ACFs rely on outcome measures to improve the care that is offered, such as that in stroke, it appears that SNFs and other long-term care facilities operate on a more traditional sense without regard to their effect on patient outcomes (Ahmed & Ekundayo, 2009; Díez-Tejedor & Fuentes, 2001; Kennedy et al., 2007; Martin & Ancoli-Isreal, 2008).

As I contemplate my original question in light of the available literature, I find that the elderly should only be institutionalized as a last resort (e.g. lay-led self-care, home health care, independant or assited living), training in geriatric care needs to be improved within SNFs, and outcome measures need to be further developed and assessed to fully understand the impact of long-term care on the elderly population (Ahmed & Ekundayo, 2009; Cohen, 2002, Gaugler et al., 2007; Kennedy et al., 2007, Martin & Ancoli-Israel, 2008). Until these three issues are rectified, SNFs will need to rely on ACFs to safely, effectively, and efficiently care for their patients.

References

Ahmed, A. & Ekundayo, O. J. (2009). Cardiovascular disease care in the nursing home: The need for better evidence for outcomes of care and better quality for processes of care. Journal of the American Medical Director’s Association, 10(1), 1-3. doi:10.1016/j.jamda.2008.08.019

Cohen, J. J., Gabriel, B. A., & Terrell, C. (2002). The case for diversity in the health care workforce. Health Affairs, 21(5), 90-102. doi:10.1377/hlthaff.21.5.90

Díez-Tejedor, E. & Fuentes, B. (2001). Acute care in stroke: Do stroke units make the difference? Cerebrovascular Diseases, 11(Suppl. 1), 31-39. doi:10.1159/000049123

Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, R. L. (2007). Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatrics, 7(1), 13-26. doi:10.1186/1471-2318-7-13

Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., Richardson, G., … Rogers, A. (2007). The effectiveness and cost effectiveness of a national lay‐led self care support programme for patients with long‐term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and Community Health, 61(3), 254–261. doi:10.1136/jech.2006.053538.

Martin, J. L. & Ancoli-Israel, S. (2008). Sleep disturbances in long-term care. Clinical Geriatric Medicine, 24(1), 39–vi. doi:10.1016/j.cger.2007.08.001.

Shi, L. & Singh, D. A. (2011a). Inpatient facilities and services. Current issues in healthcare policy and practice (pp. 1-44). Sudbury, MA: Jones & Bartlett.

Shi, L. & Singh, D. A. (2011b). The future of health services delivery. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Singh, D. A. (2011). Overview of long-term care. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Academia, Clinical, Emergency Medical Services, Health Care, Public Health, Technology

Scrutinizing the Literature of EMR

 As I scrutinize Dimitropoulos and Rizk (2009) for possible inclusion in a literature review for my research, I find it both promising and troubling. The article appears to be pertinent to my research question of how various laws and practices might adversely affect shared access of electronic health records; however, it is important to understand if this article is a documentation of primary research or a review of existing research, and as I describe below, this is unclear. This lack of clarity obscures other facets of the article that important to a researcher. These are also described below.

Initially, the work of Dimitropoulos and Rizk appears to be pertinent to my research based on the title and the publication in which it appears. Health Affairs is a respected journal within the realm of public health research, practice, and instruction, and it is ranked seventh of all health policy and service journals by Journal Ranking (http://www.journal-ranking.com). Publication within Health Affairs does not degrade the reputation of the authors and serves only to promote their work to their peers. As my research is within the realm of public health, Health Affairs is an obvious avenue to pursue for relevant work, and as this article by Dimitropoulos and Rizk appears to reflect a specific focus on the relationship between privacy laws and the ability, or lack thereof, to share health information, it appears to have relevance.

According to the abstract, Dimitropoulos and Rizk (2009) examine how variations is state (and, territorial) privacy laws might inhibit sharing health information via an central exchange, or repository. Though it would seem plausible for Dimitropoulos and Rizk to conduct their own research, the abstract seems to imply that they are merely reporting on the findings of a committee charged with examining such irregularities in privacy laws amongst the states and territories, presumably, of Canada. After reading the report, though, I find a disconnect between the abstract and the article. In the abstract, it appears more as if the authors are detached reporters, but within the body of the article, it seems as though they appear to take ownership of the primary research. This is confusing as it was plainly stated that the research was conducted by a large consortium of state officials: “the project initially engaged organizations in thirty-four … and later … forty-two jurisdictions. This collaborative work is commonly referred to as the Health Information Security and Privacy Collaboration (HISPC)” (p. 429).

This report is confusing to read as the perspective shifts frequently between first- and third-person. Additionally, the authors describe opinions formed and emotions felt during the primary research (opinions and emotions that only the primary researchers could know), yet it is unclear if these were transmitted through other writing or if the authors formed and felt these themselves. It is unclear whether the authors, Dimitropoulos and Rizk (2009), were participating researchers or merely reporters.

Both authors are noted to work for RTI International’s Survey Research Division, yet this corporation is not credited with any of the original research (Dimitropoulos & Rizk, 2009). I would have to conduct further research into the authors, their employer, and the project, itself, in order to make a final determination of the credibility of this article. This research would, hopefully, give the authors’ words better context, also. Complicating this is the absence of clearly delineated references, although a few appear within the Notes section that appear to be worth investigating.

Dimitropoulos and Rizk (2009) describe an effort to create a cohesive environment that will enhance the ability to share health information throughout a number of jurisdictions. As such, there is no scientific inquiry and it follows that adherence to the scientific method would be inappropriate. Again, however, it is unclear if this research is original or not.

In closing, it appears that Dimitropoulos and Rizk (2009) are credible in their writing; however, as each article must be able to stand on its own, and the article is lacking in form and perspective, I question the origination, application, and utility of this article, at least as it pertains to my original research question. Privacy in computing has been a major concern in the past two decades (Johnson, 2004). I feel that I could find more pertinent literature by expanding my search beyond this article.

References

Dimitropoulos, L. & Rizk, S. (2009).A state-based approach to privacy and security for interoperable health information exchange.Health Affairs, 28(2), 428-434. doi:10.1377/hlthaff.28.2.428

Johnson, D. G. (2004). Computer ethics. In L. Floridi (Ed.), The Blackwell guide to the philosophy of computing and information (pp. 65-75). Malden, MA: Blackwell.

Academia, Health Care, Technology

Using Intelligence in ePCR Database Design

The intelligence of a database design begins with the intelligent approach in which the developer focuses on the particular need the database is to fulfill. It is especially important to constrain, or specialize, a database used in health care, else the database can quickly grow beyond the bounds of efficiency. Efficiency can be found directly from table design, and it can be further achieved with business rules and logic. Designing a database for storing patients’ medical records also has some risk of increasing the likelihood of medical errors and statistical incongruities if done improperly; therefore, a qualified database administrator should be consulted (Campbell, 2004; McGlynn, Damberg, Kerr, & Brook, 1998). However, a preliminary needs assessment can be accomplished by asking a few simple questions: Who? What? Where? Why?

Who needs to use the database? For whom is the data useful? By identifying the scope, or domain, of each database user, the developer can gain a sense of which data points are important (McGlynn et al., 1998; Thede, 2002). For instance, in health care, a purely diagnostic database should efficiently offer comparative differential diagnoses to aid a physician in caring for patients; however, a database of this type will not offer much to the administrative arm of the practice. By understanding the relationship between physician diagnosis and billing, relational techniques can serve to ensure greater accuracy in billing procedures.

What data needs to be stored and retrieved? By listing the specific data to be stored, the developer has an opportunity to optimize the storage methods by creating an efficient and normal relational table foundation (Kent, 1983; Sen, 2009). A patient care reporting database, for instance, must be able to store patient identifying information, or demographics. Depending on the specific needs of the practice, demographic data can usually be stored in a single table. Other relational tables could be used to store references between the patient demographic record and pertinent medical information, thereby minimizing duplication (Thede, 2002).

From where does the data need to be accessed? Does this database require authentication for use on a local area network or a complex security policy for wide area network access (Campbell, 2004; McGlynn et al., 1998)? More importantly, however, is portability of the data. If the data is going to be replicated in a large composite database, the data needs to meet the specifications of the repository. This is often achieved by the publication of a template, or a clear set of directives on how data is to be formatted before transmitting data to the repository. An example of this is the Medicare electronic records requirements set forth in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. By accounting for common templates in the design phase, the developer can avoid having to parse data prior to transmitting the data over the network.

Why are we storing the data? Today, it is very common to store data if merely for purposes of recording an interaction, such as a patient contact. However, it is important to understand how the data will be used in the future. Will the data need to be immediately accessible, such as in emergency or critical care areas, or could the data be compiled and batch processed during times of off-peak network load, such as in billing or logistics. Could paper reporting fulfill the immediate need better? If so, should the data on the paper report be entered in a database later? Regarding transcription, it is important to be knowledgeable about the available technology for creating scanned images, portable electronic documents, and the use of optical character recognition in order to properly prepare for the storage of each.

By answering the who, what, where, and why of the database needs assessment, we ultimately answer the question of how to design and implement the database. As an example, in order to design an ambulance run form, we must take into consideration demographics, the history of present illness (or, the reason for the ambulance request), past and pertinent medical history, including, but not limited to: medications, past medical problems and surgeries, and allergies to medications and environment. It is also important to store the assessment, care, and outcome, as well as the disposition of the incident and the destination facility. Additionally, medical standards, such as diagnostic codes, medications, protocols, and algorithms, could be stored in reference tables for preventing redundancy within the data model (Kent, 1983; McGlynn et al., 1988; Sen, 2009, Thede, 2002). Ambulances are mobile; therefore, network access is an important consideration when designing an electronic ambulance patient care reporting database. For this type of database schema, I would recommend using a small, efficient database locally with a mechanism in place to replicate the data to the larger repository when the network is accessible.

Another challenge in creating a database is learning how not to store information. Information is made of of data, but only data should be stored (Collins, 2009). Programming logic can be used to synthesize data into information and, further, into knowledge. Many database designers mistakenly store information, or even knowledge, quickly inflating the size of the database and decreasing its efficiency and normalcy (Kent, 1983; Sen, 2009).

In conclusion, developing an electronic patient care reporting database for a physician practice has some inherent risk if done poorly; however, a knowledgeable member of the office team can highlight the project requirements by performing the needs analysis.

References

Campbell, R. J. (2004). Database design: What HIM professionals need to know. Perspectives in Health Information Management, 1(6), 1-15. Retrieved from http://www.ncbi.nlm.nih.gov/

Collins, K. (2009). Managing information technology. Exploring Business (pp. 122-130). Retrieved from http://www.web-books.com/

Health Insurance Portability and Accountability Act (HIPAA) of 1996, P.L.104-191. (1996).

Kent, W. (1983). A simple guide to five normal forms in relational database theory. Communications of the ACM, 26(2), 120-125. Retrieved from http://www.bkent.net/Doc/ simple5.htm

McGlynn, E. A., Damberg, C. L., Kerr, E. A., & Brook, R. H. (1998). Health information systems: design issues and analytical applications. Retrieved from http://www.rand.org/pubs/monograph_reports/2007/MR967.pdf

Sen, A. (2009, May 7). Facts and fallacies about first normal form. Retrieved from http://www.simple-talk.com/sql/learn-sql-server/facts-and-fallacies-about-first-normal-form/

Thede, L. Q. (2002). Understanding databases. In S. P. Englebardt & R. Nelson, Health care informatics: an interdisciplinary approach (pp. 55-80). St. Louis, MO: Mosby.

Academia, Health Care, Technology

Information Theory in Health Informatics

Contemporary information theory has its roots in the development of telephony. During the middle of last century, an engineer at Bell Telephone Laboratories, Dr. Claude E. Shannon, innovated information theory by extending the mathematical observations of Boltzmann, Szilard, von Neumann, and Wiener in the area of physics, quantum mechanics, and particle physics (Weaver, 1949). Dr. Shannon, however, applied the theory to communication technology, introducing entropy to the theory (Nelson, 2002; Weaver, 1949).

Weaver, who worked at the Sloan-Kettering Institute for Cancer Research, adopted Shannon’s technical message transmission observations and adapted them with his understanding of the semantics of a messages meaning (as cited in Nelson, 2002). Shannon and Weaver’s Information and Communication Model details both the components of a message and the requirements of delivery. An example, as it would relate to health care informatics, would be when a nurse charts a patient’s medical history by encoding it via a desktop client application and the same data is viewable by the same nurse at other computer terminals, other nurses, and the treating physician. The data is also stored along the communication pathway for future retrieval and delivery when the patient presented again. Though this example satisfies Shannon, if the intended recipient were blind, the information shown on a computer screen would be meaningless, according to Weaver, and would indicate a limitation to overcome.

Evaluating hospital information systems developed, in part, from the Shannon and Weaver model, Bruce I. Blum (1986) conducted analysis of object (data, information, and knowledge) processing in both hospital and ambulatory care settings. He concluded that system designs should reflect the artificial delineation between these three types of objects and that these systems will benefit practitioners and patients by improving the overall health care process. Blum (1986) called for the “integration of existing systems with medical knowledge and knowledge-based paradigms” (p. 797) in order to have a positive impact on health care delivery in the coming decades.

Information theory is concerned with the adaptability of a message through a particular channel for optimum transmission. In health informatics, as Blum (1986) points out, information theory can be a benefit by improving “[1)] structure — the capacity of the facilities and the capacity and qualification of the personnel and organization, [2)] process — the changes in the volume, cost and appropriateness of activities, [and 3)] outcome — the change in health care status attributed to the object being evaluated” (p. 794). The major challenges, however, would be initial implementation and acceptance (Blum, 1986).

References

Blum, B. I. (1986). Clinical information systems. The Western Journal of Medicine, 145(6), 791-797. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1307152/pdf/ westjmed00160-0055.pdf

Nelson, R. (2002). Major theories supporting health care informatics. In S. P. Englebardt & R. Nelson (Eds.), Health care informatics: An interdisciplinary approach (pp. 3-27). St. Louis, MO: Mosby.

Weaver, W. (1949, September). Recent contributions to the mathematical theory of communication. Retrieved from http://academic.evergreen.edu/a/arunc/compmusic/ weaver/weaver.pdf

Academia, Health Care, Technology

Implementing an EMR system

Electronic records streamline the flow of many of the components of patient care. EMRs and ePCRs are very useful in lowering costs, simplifying business processes, and increasing patient safety, as well as overall efficiency, if implemented correctly (Smith, 2003).

Currently, I work as a critical care paramedic providing patient care in acute settings, whether prehospital of interfacility. Within this capacity, I also teach classes to other health care providers, including first responders, emergency medical technicians, paramedics, nurses, physicians, and allied health personnel. I am familiar with the concepts of electronic patient care reporting (ePCR) and the importance and utility of electronic medical records (EMR); however, the only means of electronic reporting available in my capacity as a paramedic is poorly developed ePCR software coupled with intermittent network connectivity, so I still choose to utilize paper reporting. My part-time job with a local municipal ambulance provider relies on a widely available third-party ePCR system that seems to work well. I do utilize this ePCR system when working for this provider.

I have also gained experience with information technology and object-oriented programming concepts while developing platform-independent, client-server distributive applications designed for the internet and intranets. I also have experience with Windows and Unix/Linux platforms.

References

Smith, P. D. (2003). Implementing an EMR system: One clinic’s experience. Family Practice Management, 10(5), 37-42. Retrieved from http://www.aafp.org/fpm/2003/0500/p37.html

Academia, Clinical, Culture, Emergency Medical Services, Health Care, Politics, Public Health, Society

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.

References

Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from http://www.cga.ct.gov/2003/olrdata/ph/rpt/2003-R-0515.htm

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from http://www.nationalreview.com