Medicina de sistemas: una nueva visión de la práctica clínica / Systems Medicine: A New Approach to Clinical Practice

La gran mayoría de las enfermedades respiratorias son consideradas patologías complejas puesto que su susceptibilidad o desenlace están influidos por la interacción entre factores dependientes del huésped (genéticos, comorbilidad, edad, etc.) y del ambiente (exposición a microorganismos y alérgenos, tratamiento administrado, etc.).El enfoque reduccionista ha sido muy importante para la comprensión de los diversos componentes de un sistema. La biología o medicina de sistemas es una aproximación complementaria cuyo objetivo es el análisis de las interacciones entre los componentes dentro de un nivel de organización (genoma, transcriptoma, proteoma) y posteriormente entre los distintos niveles. Las actuales aplicaciones de la medicina de sistemas incluyen la interpretación de la patogénesis y fisiopatología de las enfermedades, el descubrimiento de biomarcadores, el diseño de nuevas estrategias terapéuticas y la elaboración de modelos computacionales para los distintos procesos biológicos. En la presente revisión se exponen las principales nociones sobre la teoría que subyace a la medicina de sistemas así como sus aplicaciones en algunos procesos biológicos del ser humano

Most respiratory diseases are considered complex diseases as their susceptibility and outcomes are determined by the interaction between host-dependent factors (genetic factors, comorbidities, etc.) and environmental factors (exposure to microorganisms or allergens, treatments received, etc.).The reductionist approach in the study of diseases has been of fundamental importance for the understanding of the different components of a system. Systems biology or systems medicine is a complementary approach aimed at analyzing the interactions between the different components within one organizational level (genome, transcriptome, proteome), and then between the different levels. Systems medicine is currently used for the interpretation and understanding of the pathogenesis and pathophysiology of different diseases, biomarker discovery, design of innovative therapeutic targets, and the drawing up of computational models for different biological processes. In this review we discuss the most relevant concepts of the theory underlying systems medicine, as well as its applications in the various biological processes in humans

[Standardized management of acupuncture-moxibustion clinic in Singapore General Hospital].

The standardized management of acupuncture-moxibustion in Singapore General Hospital is introduced. With gradual improvement of outpatient infrastructure, re-training of medical staff, strict disinfection of manipulation, periodical inspection of medical instruments, unified management of writing, saving and processing in medical records and public education of TCM knowledge, a standardized management system in accordance with modernized hospital is gradually established. As a result, efficiency and quality of clinical treatment is continuously increasing. From April of 1998 to December of 2012, a total of 74 654 times of treatment were performed, and treatment amount per day is gradually increased. The unusual condition of acupuncture is avoided. Periodical strict inspection of joint committee authenticated by domestic and overseas medical health organization is repeatedly passed and accepted. Additionally, three clinical researches funded by Singapore Health-care Company are still in progress in acupuncture-moxibustion department.

The electronic health record as a healthcare management strategy and implications for obstetrics and gynecologic practice.

PURPOSE OF REVIEW: To review the current trends, utilities, impacts and strategy for electronic health records (EHRs) as related to obstetrics and gynecology. RECENT FINDINGS: Adoption and utilization of EHRs are increasing rapidly but variably, given pressures of financial incentives, policy and technological advancement. Adoption is outpacing published evidence, but there is a growing body of descriptive literature regarding incentives, benefits, risks and costs of adoption and utilization. Further, there is a rising body of evidence that EHRs can bring benefits to processes and outcomes, and that their implementation can be considered as a healthcare management strategy. Obstetrics and gynecology practices have specific needs, which must be addressed in the adoption of such technology. Specialty specific literature is sparse but should be considered as part of any strategy aimed at achieving quality improvement and practice behavior change. SUMMARY: Obstetrics and gynecologic practice presents unique challenges to the effective adoption and use of EHR technologies, but there is promise as the technologies, integration and usability are rapidly improving. This technology will have an increasing impact on the practice of obstetrics and gynecology in the coming years.

How to set up a successful tumor ablation practice.

Tumor ablation services have increased in prevalence across the country and can now be found in modern health care systems of all sizes. These services have become an integral part of the coordinated multidisciplinary approach to patient care that must take place at any oncologic center of excellence. However, building a reputable tumor ablation practice at an institutional level can be a very difficult task as there are many financial, political, and material considerations that must be addressed during the early phases of operation to ensure its success. This article discusses each of these considerations in turn and provides insight into ways to overcome the inherent challenges faced when bringing all of the necessary elements together to create a thriving tumor ablation practice at an institutional level.

Understanding and surviving the transition to value-based oncology.

This paper and the three presentations it supports are drawn from the theme of the 2012 Cancer Center Business Summit (CCBS): "Transitioning to Value-Based Oncology: Strategies to Survive and Thrive." The CCBS is a forum on oncology business innovation, and the principal question the organizers address each year is "What are the creative, innovative, and best business models and practices that are being conceived or piloted today that may provide a responsible and sustainable platform for the delivery of cancer care tomorrow?" At this moment in health care-when so much is in flux and new business models and solutions abound-the oncology sector has a solemn responsibility: to forge the business models and relationships that will help to define a new cancer care value proposition and a sustainable health care system of tomorrow for the benefit of the patients it serves to get it "right."

Chiropractors as safety net providers: first report of findings and methods from a US survey of chiropractors.

OBJECTIVE: This study evaluates the actual or potential contribution of the chiropractic profession in meeting US healthcare workforce needs. METHODS: The authors performed a descriptive cross-sectional mail survey of US chiropractors in 2002 to 2003. RESULTS: The amount of charity care provided by chiropractors closely approximates that of medical physicians; on a weekly basis, approximately 2 weekly hours of chiropractic care are provided for free, and 4 weekly hours are provided at a reduced fee. CONCLUSION: Chiropractors serve a vital, though often overlooked, role in the US health care safety net.

Bridging the quality chasm: integrating professional and organizational approaches to quality.

Current Western health care practices face the challenge to improve their quality on multiple dimensions simultaneously. This requires new ways to think about how to deliver health care services. A careful and 'flexible' standardization of care into 'care programs', we argue, is central. Yet such standardization is powerless without the application of four additional design principles: a thorough restructuring and delegation of tasks, the application of integrated planning, the use of indicators about the functioning of the care programs, and implementing process-supporting information technology. Vice versa, these additional principles can only function properly when integrated with care programs. We will only be able to improve the safety, effectiveness, patient-centeredness, and timeliness of health care, while reducing costs and improving equity, by integrating professional and organizational approaches to quality. This paper describes a series of interrelated design principles that together depict how future health care delivery could be organized.

[Quality system in cardiology: practical example to develop an organizational model for management certification without bureaucracy]. / Il sistema qualità in cardiologia: un esempio pratico per sviluppare un modello organizzativo certificabile senza burocrazia.

It is a difficult task to define practical guidelines and a pragmatic achievement for the new document of the Italian Ministry of Health for structures of the national health system obtaining a quality system according to the ISO 9000 standard. The present article illustrates the different steps to accomplish the quality management in our cardiology department, recently internationally certified, and it gives several practical examples of the path followed in the different sections of the department to obtain the best management of all the Operative Units, identifying customer requests and measuring customer satisfaction.

Practice-based learning for improvement: the pursuit of clinical excellence.

Physicians often seem to be paralyzed waiting for a health plan, a health maintenance organization, or an integrated health care system to bring about change or improvement in health care. But small changes in individual practices (microsystems) can have a profound impact on outcomes in an organization (microsystem). With simple graphical measurement tools, physicians can teach patients to measure and empower themselves to learn to improve both their health and their health care. At the same time, physicians can learn a great deal from their patient population data. When these measurement tools and a well-known and widely accepted method for clinical practice improvement called rapid cycle testing were used in a population of patients with diabetes, the average fasting blood sugar changed from 187 to 110 and the average hemoglobin A1c from 10.5 to 7.2. This article shows that measurement using specification charts and control charts in patient care can have a profound impact on patients, physicians, and organizations. Understanding these principles and using time-sequence measurement with graphical data feedback, physicians can engage in practice-based learning and can participate in improvement in the microsystems over which they have control.

Using a computer-based clinical management system to improve effectiveness of a homeopathic service in a fundholding general practice.

UNLABELLED: Problems which the development attempts to address. This study's overall objectives were to determine whether: * The aims of collaboration between General Practitioner (GPs) and a homeopath can be made explicit and service delivery optimised by using computer-based data collection in a multi-disciplinary primary care team that includes a homeopathic practitioner. * Outcomes of the homeopathic service can be evaluated in a practical way, which allows quality assurance through rapid audit cycles. METHOD: The primary care team (PCT) explored the problems of developing a rational and quality assured complementary therapy service in a series of meetings in an NHS practice where complementary therapists are members of the PCT. This led to the defining of data-collection structures and processes needed. The researchers designed and supervised their implementation and evaluation through a series of action research cycles. A database was designed which allowed the clinicians to track interventions and outcomes using the Measure Your Own Medical Outcome Profile (MYMOP). Critical incidents were brought to fortnightly clinical meetings and methods were continually adapted as problems arose and new options emerged at six-weekly audit meetings. RESULTS: GPs tended to refer patients who do not fit easily into biomedical disease categories. Patients referred tend to self-rate themselves as experiencing notably poor wellbeing. MYMOP has to be used skillfully with homeopathic patients, especially where psychological distress is identified as one of their main complaints. CONCLUSIONS: It is possible to introduce rigour and reflectiveness when providing a homeopathic service in general practice by assessing the needs of patient and practitioners, agreeing intake guidelines, developing referral processes, implementing audit cycles. Clear lines of communication can be established and a patient-centred outcome measure can be introduced into the treatment cycle.

The use of the ASTRO-PU and the ASTRO(97)-PU in the setting of prescribing budgets in English general practice.

OBJECTIVES: To examine the variation in prescribing costs explained by the Age, Sex and Temporary Resident Originated Prescribing Unit (ASTRO-PU) and its replacement, the ASTRO (97)-PU, in order to determine the appropriateness of their use in the setting of prescribing budgets in English general practice. METHODS: Linear regression analysis was used to analyse routinely collected patient and prescribing data from one English health authority (Lincolnshire Health) for the fiscal year 1995. RESULTS: The goodness-of-fit of the regression models constructed varied according to whether practices had dispensing status (i.e. rural practices that have permission to dispense drugs to their own patients as a means of compensating for the lack of pharmacies in such areas), with the ASTRO-PU and ASTROP(97)-PU explaining a higher proportion of the variation in prescribing costs amongst practices with such status. CONCLUSIONS: This paper draws two main conclusions. First, the weights embodied in the ASTRO-PU and the ASTRO(97)-PU may have been biased by the number of dispensing practices sampled during their construction. Second, the denominators may be more applicable to dispensing practices, implying that primary care groups may need to follow the principle of 'local flexibility' during the budget-setting process.

All terrain vehicle.

MSOs (management service organizations) offer health systems and physicians a flexible, resilient vehicle for integration. But they work much better when providers tailor them carefully to their markets and give them a clear mission.

Practice acquisition: a due diligence checklist. HFMA Principles and Practices Board.

As healthcare executives act to form integrated healthcare systems that encompass entities such as physician-hospital organizations and medical group practices, they often discover that practical guidance on acquiring physician practices is scarce. To address the need for authoritative guidance on practice acquisition, HFMA's Principles and Practices Board has developed a detailed analysis of physician practices acquisition issues, Issues Analysis 95-1: Acquisition of Physician Practices. This analysis includes a detailed due diligence checklist developed to assist both healthcare financial managers involved in acquiring physician practices and physician owners interested in selling their practices.

Czechoslovakia's changing health care system.

Before World War II, Czechoslovakia was among the most developed European countries with an excellent health care system. After the Communist coup d'etat in 1948, the country was forced to adapt its existing health care system to the Soviet model. It was planned and managed by the government, financed by general tax money, operated in a highly centralized, bureaucratic fashion, and provided service at no direct charge at the time of service. In recent years, the health care system had been deteriorating as the health of the people had also been declining. Life expectancy, infant mortality rates, and diseases of the circulatory system are higher than in Western European countries. In 1989, political changes occurred in Czechoslovakia that made health care reform possible. Now health services are being decentralized, and the ownership of hospitals is expected to be transferred to communities, municipalities, churches, charitable groups, or private entities. Almost all health leaders, including hospital directors and hospital department heads, have been replaced. Physicians will be paid according to the type and amount of work performed. Perhaps the most important reform is the establishment of an independent General Health Care Insurance Office financed directly by compulsory contributions from workers, employers, and government that will be able to negotiate with hospitals and physicians to determine payment for services.