Experts speak: advice from key informants to small, rural hospitals on implementing the electronic health record system.

The US government has allocated $30 billion dollars to implement Electronic Health Records (EHRs) in hospitals and provider practices through a policy called Meaningful Use. Small, rural hospitals, particularly those designated as Critical Access Hospitals (CAHs), comprising nearly a quarter of US hospitals, had not implemented EHRs before. Little is known on implementation in this setting. We interviewed a spectrum of 31 experts in the domain. The interviews were then analyzed qualitatively to ascertain the expert recommendations. Nineteen themes emerged. The pool of experts included staff from CAHs that had recently implemented EHRs. We were able to compare their answers with those of other experts and make recommendations for stakeholders. CAH peer experts focused less on issues such as physician buy-in, communication, and the EHR team. None of them indicated concern or focus on clinical decision support systems, leadership, or governance. They were especially concerned with system selection, technology, preparatory work and a need to know more about workflow and optimization. These differences were explained by the size and nature of these small hospitals.

Evaluation of aging in place model with home care services and registered nurse care coordination in senior housing.

A state-sponsored evaluation of aging in place (AIP) as an alternative to assisted living and nursing home has been underway in Missouri. Cost, physical, and mental health assessment data reveal the cost-effectiveness and positive health measures of AIP. Findings of the first four years of the AIP evaluation of two long-term care settings in Missouri with registered nurse care coordination are compared with national data for traditional long-term care. The combined care and housing cost for any resident who received care services beyond base services of AIP and who qualified for nursing home care has never approached or exceeded the cost of nursing home care at either location. Both mental health and physical health measures indicate the health restoration and independence effectiveness of the AIP model for long-term care.

From a blame culture to a just culture in health care.

BACKGROUND: A prevailing blame culture in health care has been suggested as a major source of an unacceptably high number of medical errors. A just culture has emerged as an imperative for improving the quality and safety of patient care. However, health care organizations are finding it hard to move from a culture of blame to a just culture. PURPOSE: We argue that moving from a blame culture to a just culture requires a comprehensive understanding of organizational attributes or antecedents that cause blame or just cultures. Health care organizations need to build organizational capacity in the form of human resource (HR) management capabilities to achieve a just culture. METHODOLOGY: This is a conceptual article. Health care management literature was reviewed with twin objectives: (a) to ascertain if a consistent pattern existed in organizational attributes that lead to either blame or just cultures and (2) to find out ways to reform a blame culture. CONCLUSIONS: On the basis of the review of related literature, we conclude that (a) a blame culture is more likely to occur in health care organizations that rely predominantly on hierarchical, compliance-based functional management systems; (b) a just or learning culture is more likely to occur in health organizations that elicit greater employee involvement in decision making; and (c) human resource management capabilities play an important role in moving from a blame culture to a just culture. PRACTICE IMPLICATIONS: Organizational culture or human resource management practices play a critical role in the health care delivery process. Health care organizations need to develop a culture that harnesses the ideas and ingenuity of health care professional by employing a commitment-based management philosophy rather than strangling them by overregulating their behaviors using a control-based philosophy. They cannot simply wish away the deeply entrenched culture of blame nor can they outsource their way out of it. Health care organizations need to build internal human resource management capabilities to bring about the necessary changes in their culture and management systems and to become learning organizations.

The application of remote monitoring to improve health outcomes to a rural area.

The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients.

Economic modeling comparing trauma and general surgery reimbursement.

BACKGROUND: The viability of trauma care as a surgical subspecialty is continually challenged by economic pressures related to reimbursement and opportunity costs. METHODS: The literature was examined for articles focused on economic implications of a trauma focused surgical practice. Economic forecasting techniques were applied using a recalculating spreadsheet to examine charge and revenue generation comparing the effects of numerous variables affecting a trauma or general surgical service. RESULTS: Elective general surgery practices derive the majority of revenues from procedural services, whereas trauma practices derive the majority of revenues from evaluation and management. Only centers with high admission volume can expect trauma surgeons to cover salary and expenses, predictably in association with high opportunity costs. CONCLUSION: The differences in time, effort, and patient volume required for a trauma surgeon to generate revenues comparable to an elective practice are dramatic. The current system creates disincentives for surgeons to participate in trauma care.

Assessment of patients' acceptance of and satisfaction with teledermatology.

Teledermatology refers to the use of information and communication technologies (such as videoconferencing or transmission of digital images) to enable the practice of diagnostic dermatology between participants separated by geographic distance. The objective of this study was to critically review the quality of evidence about patient satisfaction with teledermatology applications. Sample size, reporting of validity and reliability, used instrument and its underlying constructs were determined for all studies where information was available. Fourteen studies were identified, five refer to store-and-forward applications, the remaining ones describe video-based systems. The systematic review demonstrated that methodological deficiencies in the published research impact the generalizability of findings. The two types of teledermatology (video-based and store-and-forward) require different satisfaction instruments as they are based on different contexts of care delivery, with video-mediated communication being key in the former and patients' absence from the diagnostic process in the latter mode of care delivery.

Nursing home costs and quality of care outcomes.

The relationship between cost and quality of care in nursing homes was examined using quality indicator measures of resident outcomes. While each individual quality measure makes only small contributions to costs, when considered across the facility, quality could have a substantial financial impact on the operations of the home.