A computerized surveillance system for asthma.

PURPOSE: Asthma is a chronic inflammatory airways disease characterized by acute exacerbations interspaced by symptom-free periods. Its management imposes a substantial burden on healthcare services, as well as personal suffering and significant financial tolls. The aim of this paper is to demonstrate links between routinely used computerized databases and to establish an automatic mechanism for monitoring asthma patients. DESIGN/METHODOLOGY/APPROACH: The study population was all adult subscribers to a major health maintenance organization (HMO) in Southern Israel (230,000 adults, age 20-65 years). Relevant data for this retrospective analysis (2000 to 2004) were extracted from several computerized databases routinely used in the service: pharmacy; administrative; and each person's personal computerized medical file in the primary care clinic. FINDINGS: Based on data from 72 regional primary care clinics, during the study period, 11,054 adults were treated simultaneously by beta2 agonists and steroids--assumed to be asthmatics. In contrast, asthma diagnosis was recorded in only 4,061 personal files. The intersection between two databases yielded 2,569 persons recorded in both. These findings attest to the feasibility of developing computerized automatic surveillance systems for monitoring asthma patients with certain algorithms to assure service quality. RESEARCH LIMITATIONS/IMPLICATIONS: Data extracted from the various databases were unequal quality, a factor that imposed data management difficulties. PRACTICAL IMPLICATIONS: Similar surveillance systems can be developed relatively easily by using comparable algorithms for monitoring different chronic diseases or introducing management indices to secure quality of services. ORIGINALITY/VALUE: The paper focuses on developing an automatic asthma monitoring model, using information from routinely used computerized HMO DBs.

Screening for diabetic retinopathy with a mobile non-mydriatic digital fundus camera in southern Israel.

BACKGROUND: Diabetic retinopathy is a leading cause of adult blindness and accounts for about 10% of cases of legal blindness in Israel. Only about half of the patients with diabetes in Israel have regular eye examinations. OBJECTIVES: To evaluate, for the first time in southern Israel, a new service for diabetic retinopathy screening that uses a mobile non-mydriatic mobile fundus camera in primary care patients. METHODS: Diabetic members of the largest health fund in southern Israel and over 18 years old were invited for non-mydriatic fundus examination between January and October 2009. Screening was performed by a trained photographer using the Topcon TRC NW-6S non-mydriatic camera in nine primary care centers. RESULTS: A total of 4318 diabetic patients were screened, of whom 53% were classified as normal. The incidence of diabetic retinopathy was 15.8% (1.2% had proliferative retinopathy and 2.4% had suspected macular edema and were referred for laser treatment). Other possible sight-threatening conditions were detected in 9.3%. Fundus pictures were inadequate for assessment in 16% of cases. CONCLUSIONS: Diabetic retinopathy screening with a mobile non-mydriatic fundus camera improved the quality of care for diabetic patients in southern Israel. This screening method identified patients requiring prompt referral to the ophthalmologist for further complete eye examination. Extending this screening program to other areas in the country should be considered.

Defining and measuring physicians' responses to clinical reminders.

Decision-support systems, and specifically rule-based clinical reminders, are becoming common in medical practice. Despite their potential to improve clinical outcomes, physicians do not always use information from these systems. Concepts from the cognitive engineering literature on users' responses to warning systems may help to define physicians' responses to reminders. Based on this literature, we suggest an exhaustive set of possible responses to clinical reminders, consisting of four responses named "Compliance", "Reliance", "Spillover" and "Reactance". We suggest statistical measures to estimate these responses and empirically demonstrate them on data from a large-scale clinical reminder system for secondary prevention of cardiovascular diseases. There was evidence for Compliance, probably since the physicians found the reminders informative, but not for Reliance, in line with the notion that Compliance and Reliance are two distinct types of trust in information from decision-support systems. Our research supports the notion that CDSS can promote closing the treatment gap and improve physicians' adherence to guidelines.

A co-payment for consultant services: primary care physicians' referral actualization.

Prospective evaluation of the effect of a new copayment for specialists consultations on actualization of referrals (2,432 patient), was examined. Actualization of the appointment, reasons for not actualizing, and sociodemographic characteristics were recorded. Actualization was 85.1% in community consultation clinics and 91.7% in hospital outpatient clinics. The main reasons for non actualization were: inability to reach the clinic (53.4%), the problem had resolved (15%), and co-payment (2%). In addition, 19.1% stated that they did not actualize a past consultant visit due to co-payment. Referring physicians noted that co-payment had some effect on their decision, especially with the elderly or lower income patients. A relatively small compulsory co-payment was not found to have a long term effect on utilization of specialists' services.

Intervention program to reduce waiting time of a dermatological visit: managed overbooking and service centralization as effective management tools.

BACKGROUND: Long waiting times are an impediment of dermatological patient care world-wide, resulting in significant disruption of clinical care and frustration among carers and patients. OBJECTIVE: To reduce waiting times for dermatological appointments. METHODS: A focus group including dermatologists and management personnel reviewed the scheduling process, mapped potential problems and proposed a comprehensive intervention program. The two major approaches taken in the intervention program were revision of the scheduling process by managed overbooking of patient appointments and centralization of the dermatological service into a centralized dermatological clinic. RESULTS: Following the intervention program, the average waiting time for dermatological appointments decreased from 29.3 to 6.8 days. The number of scheduled appointments per 6 months rose from 17,007 to 20,433. Non-attendance proportion (no-show) decreased from 33% to 28%. Dermatologist work-hours were without significant change. CONCLUSIONS: Waiting lists for dermatological consultations were substantially shortened by managed overbooking of patient appointments and centralization of the service.

Introducing co-payment for consultant specialist services.

BACKGROUND: Full medical coverage may often result in overuse. Cost-sharing and the introduction of a co-payment have been shown to cause a reduction in the use of medical services. OBJECTIVES: To assess the effects of the recently introduced co-payment for consultant specialist services on patient utilization of these services in southern Israel. METHODS: Computerized utilization data on specialist services for 6 months before and 6 months after initiation of co-payment were retrieved from the database of Israel's largest health management organization. RESULTS: A decrease of 4.5% was found in the total number of visits to Soroka Medical Center outpatient clinics and 6.8% to community-based consultants. An increase of 20.1% was noted in the number of non-actualized visits to the outpatient clinics. A decrease of 6.2% in new visits to hospital outpatient clinics and 6.5% to community clinics was found. A logistic regression model showed that the residents of development towns and people aged 75+ and 12-34 were more likely not to keep a prescheduled appointment. CONCLUSION: After introduction of a modest co-payment, a decrease in the total number of visits to specialists with an increase in "no-shows" was observed. The logistic regression model suggests that people of lower socioeconomic status are more likely not to keep a prescheduled appointment.

Introduction of computerized medical records. A survey of primary physicians.

UNLABELLED: The purpose of the study was to survey primary physicians about the possible impact of computerized medical records on clinical practice. METHODS AND DESIGN: 236 primary care physicians from the Negev health district in Israel, attending a course prior to installation of computerized record keeping, were given two open-ended questions together with a twenty-four statement attitude questionnaire using a five point Likert scale. RESULTS: The beliefs of physicians highlighted the potential that computerized charts can help with office work, prevent loss of information, and facilitate communication between medical staff. On the other hand, the survey indicated that physicians felt its application was not universal and were uncomfortable with the fact that its use is mandatory. There were major concerns relating to how the medical record was displayed, anticipated increase in workload, and presumed extra time needed for data entry. CONCLUSIONS: Most of the physicians surveyed were positive regarding the help that computerized medical records could provide. They were, nevertheless, concerned with the burden of change and adaptation of new technology and software design to clinical practice and its affect on communication.