Integrating ecosystem markets to co-ordinate landscape-scale public benefits from nature.

Ecosystem markets are proliferating around the world in response to increasing demand for climate change mitigation and provision of other public goods. However, this may lead to perverse outcomes, for example where public funding crowds out private investment or different schemes create trade-offs between the ecosystem services they each target. The integration of ecosystem markets could address some of these issues but to date there have been few attempts to do this, and there is limited understanding of either the opportunities or barriers to such integration. This paper reports on a comparative analysis of eleven ecosystem markets in operation or close to market in Europe, based on qualitative analysis of 25 interviews, scheme documentation and two focus groups. Our results indicate three distinct types of markets operating from the regional to national scale, with different modes of operation, funding and outcomes: regional ecosystem markets, national carbon markets and green finance. The typology provides new insights into the operation of ecosystem markets in practice, which may challenge traditionally held notions of Payment for Ecosystem Services. Regional ecosystem markets, in particular, represent a departure from traditional models, by using a risk-based funding model and aggregating both supply and demand to overcome issues of free-riding, ecosystem service trade-offs and land manager engagement. Central to all types of market were trusted intermediaries, brokers and platforms to aggregate supply and demand, build trust and lower transaction costs. The paper outlines six options for blending public and private funding for the provision of ecosystem services and proposes a framework for integrating national carbon markets and green finance with regional ecosystem markets. Such integration may significantly increase funding for regenerative agriculture and conservation across multiple habitats and services, whilst addressing issues of additionality and ecosystem service trade-offs between multiple schemes.

The view of a general practitioner on immediate access for patients to their laboratory test results.

This position paper presents the role of laboratory test results in traditional general practice and provides a recommendation for responsible sharing of results with patients for improved safety, efficiency and outcomes. This paper looks at the relationship between the laboratory, the general practitioner consultation, the patient, safety and general practice capacity. We suggest changes in the traditional practice of communicating laboratory test results whereby normal or abnormal results are made available to patients as soon as they become available. We also endorse the opinion that using online tools such as email or text messages could enhance the provision of rapid access to laboratory test results for patients.

Primary Care Patient Records in the United Kingdom: Past, Present, and Future Research Priorities.

This paper briefly outlines the history of the medical record and the factors contributing to the adoption of computerized records in primary care in the United Kingdom. It discusses how both paper-based and electronic health records have traditionally been used in the past and goes on to examine how enabling patients to access their own primary care record online is changing the form and function of the patient record. In addition, it looks at the evidence for the benefits of Web-based access and discusses some of the challenges faced in this transition. Finally, some suggestions are made regarding the future of the patient record and research questions that need to be addressed to help deepen our understanding of how they can be used more beneficially by both patients and clinicians.

Accessing personal medical records online: a means to what ends?

BACKGROUND: Initiatives in the UK to enable patients to access their electronic health records (EHRs) are gathering momentum. All citizens of the European Union should have access to their records by 2015, a target that the UK has endorsed. OBJECTIVES: To identify the ways in which patients used their access to their EHRs, what they sought to achieve, and the extent to which EHR access was related to the concept of making savings. METHODS: An audit of patients' online access to medical records was conducted in July-August 2011 using a survey questionnaire. Two hundred and twenty six patients who were registered with two general practices in the National Health Service (NHS) located in the UK and who had accessed their personal EHRs at least twice in the preceding 12 months i.e. from July 2010 to July 2011, completed the questionnaire. Data analysis A thematic analysis of the comments that patients gave in response to the open ended questions on the questionnaire. RESULTS: Overall, evaluations of record access were positive. Four main themes relating to the ways in which patients accessed their records were identified: making savings, checking past activity, preparation for future action, and setting new expectations. CONCLUSIONS: Quite apart from any benefits of savings in healthcare resources, this study has provided qualitative evidence of the active ways in which patients may make use of access to their EHRs, many of which are in line with proportionate health management strategies. Access to personal EHRs may contribute to the development of new expectations among patients.

The impact of patient record access on appointments and telephone calls in two English general practices: a population-based study.

Background Government policy expects all patients who wish to have online record access (RA) by 2015. We currently have no knowledge of the impact of patient record access on practice workload. Setting Two urban general practices in Manchester. Question What is the impact of patient RA on telephone calls and appointments in UK general practice? Method We asked patients in two urban general practices who used RA whether it had increased or decreased their use of the practice over the previous year. Using practice data, we calculated the change in appointments, telephone calls and staff cost. We also estimated the reduction in environmental costs and patient time. Results An average of 187 clinical appointments (of which 87 were with doctors and 45 with nurses) and 290 telephone calls were saved. If 30% of patients used RA at least twice a year, these figures suggest that a 10 000-patient practice would save 4747 appointments and 8020 telephone calls per year. Assuming a consultation rate of 5.3% annually, that equates to a release of about 11% of appointments per year, with significant resource savings for patients and the environment. Discussion This is the first such study in the UK. It shows similar results to a study in the USA. We discuss the study limitations, including the issue of patient recall, nature of the practices studied and nature of early adopter patients. Strengths include combining national data, practice data and local reflection. We are confident that the savings observed are the result of RA rather than other factors. We suggest that RA can be part of continuous practice improvement, given its benefits and the support it offers for patient confidence, self-care and shared decision-making.

Patient record access--the time has come.

There are now a number of systems across the world that enables patients to view their electronic health records. These include kiosks that have fingerprint authentication and also net-based access. The paper outlines the approach taken by the UK NHS explains the legal underpinning of access. Starting form the premise that record access is here to stay the paper outlines the research on benefits and risks of record access, concluding that, with simple precautions, record access is safe and affords many benefits to both patients and clinicians. It goes on to consider possible impacts of record access on the way records might be written as a co-produced document and emphasizes that national standards for record sharing need to be written.

Sharing electronic health records: the patient view.

The introduction of a national electronic health record system to the National Health Service (NHS) has raised concerns about issues of data accuracy, security and confidentiality. The primary aim of this project was to identify the extent to which primary care patients will allow their local electronic record data to be shared on a national database. The secondary aim was to identify the extent of inaccuracies in the existing primary care records, which will be used to populate the new national Spine. Fifty consecutive attenders to one general practitioner were given a paper printout of their full primary care electronic health record. Participants were asked to highlight information which they would not want to be shared on the national electronic database of records, and information which they considered to be incorrect. There was a 62% response rate (31/50). Five of the 31 patients (16%) identified information that they would not want to be shared on the national record system. The items they identified related almost entirely to matters of pregnancy, contraception, sexual health and mental health. Ten respondents (32%) identified incorrect information in their records (some of these turned out to be correct on further investigation). The findings in relation to data sharing fit with the commonly held assumption that matters related to sensitive or embarrassing issues, which may affect how the patient will be treated by other individuals or institutions, are most likely to be censored by patients. Previous work on this has tended to ask hypothetical questions concerning data sharing rather than examine a real situation. A larger study of representative samples of patients in both primary and secondary care settings is needed to further investigate issues of data sharing and consent.