A detailed examination of the clinical terms and concepts required for communication by electronic messages in diabetes care.

The wider electronic exchange of clinical information between heterogeneous information systems in the delivery of diabetes care demands a common structure in the form of a message standard. A European Standard electronic diabetes message is being developed in conjunction with CEN TC251. This paper describes the methodologies that the 1998 DO IT Workshop has used to identify potential areas of difficulty in the design and implementation of the preliminary message model. To facilitate implementation and to avoid ambiguity in electronic messaging it is particularly important that there is standardisation of the definitions of the clinical terms specifically used in diabetes care across systems. Comprehensive lists of such terms to describe all areas of diabetes care do not exist and there is a lack of harmonisation of definitions in many areas. Thus, to better understand the user requirements of diabetes messaging several approaches were adopted. A review of the clinical terms and concepts contained in pre-existing datasets was undertaken with detailed study of a number of specific areas of diabetes care, analysing the conceptual structure of all the clinical terms that they comprised. Consideration of several worst case clinical scenarios for messages to communicate was also made to identify deficiencies in the message structure. This activity confirmed the importance of creating a Standard for a superset or thesaurus of diabetes specific terms, with appropriate definitions, to harmonise data communication in different IT systems to facilitate messaging. A substantial number of new terms were identified in the workshop and these will form an important first step to accomplishing a first draft superset once fully analysed. It was also apparent that certain specific areas within diabetes care, but most particularly in nursing, dietetics and podiatry, need urgent work to further develop the concepts and terms. This needs to be facilitated for an appropriate group of such professionals. To achieve such a Standard, continued co-operation with CEN/ISSS was recognised to be very important.

A comprehensive model of cooperation between caregivers related to quality of care.

BACKGROUND: The system and delivery of health care tend to suffer from fragmentation, resulting in discontinuous and costly care. Local cooperation between caregivers is essential to achieve appropriate, timely, continuous and efficient care. The article develops a general comprehensive patient-centered model of quality of care related to local cooperation between caregivers. The model can be used in quality improvement and research. THE PROPOSED MODEL: Within the framework of Donabedian's triad (structure-->process-->outcome), cooperation between caregivers is divided into two parts. Firstly, client related cooperation (multiple caregivers to one patient) is a part of the process of health care and relevant for important quality aspects: appropriateness, timeliness, continuity of care, effectiveness and efficiency. Secondly, local cooperation between caregivers, which is not restricted to one patient, is called non client related cooperation. Such non client related cooperation creates conditions for optimal patient care. Non client related cooperation has different degrees, dependent on the existence of agreements between the caregivers (such as protocols) and evaluation of these agreements. The highest degree of non client related cooperation is continuous quality improvement. To achieve a certain degree of non client related cooperation, conditions must be fulfilled in several fields (organization, information, financing and participants). APPLICATION OF THE MODEL: A "how to use the model in eight steps" is given and possible operationalizations of key concepts in the model are outlined. Finally, the use of the model is illustrated by two examples.