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The ways in which technology benefits healthcare
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Patient Education Materials for Health IT and EHRs

Patient Education Materials for Health IT and EHRs | healthcare technology | Scoop.it
Want to tell patients about your transition to EHRs? Here are free health IT patient education materials available at your fingertips.

 

Health IT Resources for Organizations


Many organizations have recognized the benefits of health IT and are looking for ways to be involved and support the modernization of our health care system. These patient education materials are available to assist organizations in spreading the word about the value of health IT and electronic health records (EHRs) to consumers. Together, we are working in partnership with you to empower individuals to be partners in their health through health IT.

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Could EMRs Make Patient Satisfaction Scores More Meaningful?

A lot has already been written about whether or not EMRs lead – directly or indirectly – to higher patient satisfaction scores, but I’ve yet to find anything on those scores being included in the patient’s record itself. The idea occurred to me this past weekend, as I was on the phone with a survey firm asking patient satisfaction questions on behalf of Kaiser Permanente.

 

The visit in question was routine and had gone well, so my ratings were high, and the call was quick. Would the doctor who had been involved ever see my direct responses? Do doctors see these scores in aggregate, or can they look them up by individual patient? Would they feel themselves more accountable if they could see how a patient rated their last encounter while looking at that person’ EMR?

 

I supposed it could go either way. A healthy, highly satisfied patient’s record would display high scores and vice versa. That person’s doctor could look at these scores before the next encounter to see what could be improved upon, what to keep doing, or what to start doing with other patients of a similar condition. I wonder if the ability to view a particular patient’s satisfaction scores wouldn’t somehow make the doctor feel even more accountable for their patient’s health – if they’d have more “skin in the game,” so to speak.

 

Perhaps it could have a negative effect. Low satisfaction scores could lead to an emotionally charged appointment if a doctor doesn’t fully understand why the scores were given.

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Infographic:Mobile Technology in Healthcare

The following infographic from healthcare solutions firm Healthx highlights the change that smartphones and tablets have had on the health industry. Results show that there will be 44 million m-health app downloads by the end of 2012, which will rise to 142 million by 2016.

 

Key highlights of the infographic include:

 

Top Mobile Operating Systems


Top SmartPhone Platforms


mHealth Revenue Predictions


Mobile Stats & Growth


Mobile Engagement in Healthcare

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Processed EHR text can be used to develop CDS tools

Free text in electronic health records, with the help of natural language processing (NLP) technology, can be used to create accurate clinical decision support (CDS) tools, according to a study published this week in the Journal of the American Medical Informatics Association.

 

Researchers from the Mayo Clinic set out to develop a CDS system for cervical cancer screening geared specifically toward identifying patients with abnormal Papanicolaou (Pap) reports. According to the study's authors, providers often don't follow proper protocol for cervical cancer screenings; they believed that the use of CDS would help providers in their screening efforts.

 

Pap reports, however, are compiled in non-computer-friendly free text in patient records; free text, according to the authors, has been "largely underutilized" in CDS efforts, due to accuracy concerns. To that end, the authors opted to create various NLP tools for text extraction, with an ultimate goal in mind of creating a CDS system using a free-text rulebase--which would pull information from EHRs--and a guidelines rulebase--which would pull from national cervical cancer screening guidelines.

 

Overall, screening recommendations from the CDS system for 74 patients were examined, with appropriate recommendations made for all but one of the patients. That led the authors to conclude that NLP was a reliable method for retrieving EHR information for such uses

 

"In the near future," the authors added, "our approach would be replicated for other free text-based decision problems such as colon cancer screening, sleep disorder management and asthma management."

 

This is not the first study to tout the use of NLP on free text. A study published last summer in the Journal of the American Medical Association found that use of NLP on free text in EHRs identified post-operative complications with better accuracy than claims data.

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Establishing an evidence base for e-health: the proof is in the pudding

Seven years have passed since the World Health Assembly adopted resolution WHA58.28 urging the World Health Organization and its Member States1 to endorse e-health as a way to strengthen health systems.

 

In defining e-health as “the cost-effective and secure use of information and communication technologies in support of health and health-related fields”, the resolution offered a definition that was comprehensive and generic, yet specific enough for researchers wishing to evaluate the impact of e-health to know what to evaluate.

 

Specifically, the resolution urged Member States to “mobilize multisectoral collaboration for determining evidence-based e-health standards and norms, to evaluate e-health activities, and to share the knowledge of cost-effective models, thus ensuring quality, safety and ethical standards and respect for the principles of confidentiality of information, privacy, equity and equality”.

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Stanford develops smartphone plug-in to detect oral cancer

Stanford University researchers have created a new smartphone plug-in that they say can quickly--and cheaply--identify potentially cancerous mouth lesions, among other conditions, university officials say.

 

The device is about the size of a pack of gum and clips over the smartphone's camera, according to researchers. It shines fluorescent light into the patient's mouth to highlight lesions and other potential problems.


Still in prototype-stage, the device takes a "high-resolution, panoramic image of a person's complete mouth cavity. Illuminated by the device's blue fluorescent light, malignant cancer lesions are easily detected as dark spots," university officials said in a statement.


The smartphone then transmits the images to a provider, clinic or other facility to be analyzed for a full diagnosis.


Manu Prakash, an assistant bioengineering professor at Stanford and the device's creator, sees the device as having its main use in the developing world, where tobacco use is high, dentists are scarce, and dental checkups few and far between.

 

 

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Doctors Believe Using Health Apps Will Cut Down on Visits

Doctors Believe Using Health Apps Will Cut Down on Visits | healthcare technology | Scoop.it

Many doctors believe that using apps that keep track of your health will help cut down on doctor visits, a new infographic suggests.

 

According to data revealed by Float Mobile Learning, 40% of doctors believe that using mobile health technologies such as apps that monitor fitness and eating habits can reduce the number of office visits needed by patients.

 

About 88% of doctors are in full support of patients monitoring their health at home, especially when it comes to watching weight, blood sugar and vital signs, and many believe consumers should take advantage of the apps currently on the market to help along the process.

 

“With the forthcoming changes to the U.S. healthcare system, there will be an increased focus on wellness programs and preventative medicine,” Chad Udell, managing director of Float Mobile Learning, told Mashable.

 

“Mobile health offers a tremendous opportunity for people to become more involved in their own health and wellness.”

 

It’s no secret that the mobile health industry is growing. There are more than 10,000 medical and healthcare apps available for download in the Apple App Store, making it the third-fastest growing app category among iPhone and Android users.

 

Doctors are also getting in on the trend, as 80% said they use smartphones and medical apps. Physicians are also 250% more likely to own a tablet than other consumers.

 

Udell noted that doctors continue to buy tablet devices in droves largely because they offer an easy way to stay in touch with their co-workers and patients. The infographic also noted that 56% of doctors said they turn to mobile devices to make faster decisions, and 40% said it reduces time spent on administration work.

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Patients want to use social media tools to manage health care

Patients want to use social media tools to manage health care | healthcare technology | Scoop.it

Two reports say more people seek services and health information delivered through social media, and that physicians are in most demand to share them.

 

Some patients have moved beyond wanting social media content they can “follow” or “like.” They want social media to be something that helps them coordinate care and navigate the health care system, and they think physicians are the best people to deliver it.

 

A survey of 1,060 U.S. adults by the PwC Health Research Institute found that a third of respondents are gravitating toward social media as a place for discussions of health care.

 

Patients’ attraction to these online communities is prompting many health care organizations to reshape their social media strategy from one focused on marketing to one that is part of an overall business strategy to engage patients, interact with them and even provide services in an attempt to help bring down the costs of providing care. And physicians are playing a major role in this revised strategy.

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Is Facebook Poised to Revolutionize Health Care?

Is Facebook Poised to Revolutionize Health Care? | healthcare technology | Scoop.it

Facebook is declining comment, but almost all observers are expecting them to introduce a tool that will “save lives.” That could be an expanded version of its Lifeline program, which allows people to alert the company when they think a friend is expressing suicidal intentions, a broader rollout of anti-cyberbullying initiatives or perhaps something altogether different.

 

Take, for example, a tool that helps friends alert Facebook when they are worried that a friend may be showing signs of suicidal intentions. Brian S. McGowan, a health care educator and education technologist who writes for The Atlantic, sees such a technology as being a way to end the isolated feelings patients suffer from. In March, McGowan wrote a general blog post on the concept of isolation in health care, but finding ways around it could be particularly useful in fighting depression.

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Report Finds Improvement in Warnings From CPOE Systems

Report Finds Improvement in Warnings From CPOE Systems | healthcare technology | Scoop.it
The ability of computerized provider order entry systems to detect potential medication errors has improved considerably over the past few years, according to a report from the patient safety organization Leapfrog Group, Modern Healthcare reports.


For the report, the Leapfrog Group conducted a simulated test of CPOE systems at 253 hospitals that voluntarily responded to the Leapfrog Hospital Survey during the last three months of 2011.


Report Findings


The report found that in 2011, CPOE systems did not generate an appropriate warning for more than one-third of routine medication orders and slightly more than 1% of potentially fatal medication orders.
The figures are an improvement over Leapfrog Group's previous simulated test of CPOE systems, conducted at 214 hospitals between June 2008 and January 2010.

 

The previous test found that CPOE systems did not generate an appropriate warning for about 50% of routine medication orders and about one-third of potentially fatal drug orders.
The report notes that nearly all of the hospitals included in the first test improved their CPOE performance in the latest simulation (Robeznieks, Modern Healthcare, 4/27).

 

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How IT Creates Lasting Health Benefits

Tom Priselac: The Cedars-Sinai Health System's mission spans patient care, medical education, clinical research, community services for the uninsured, and improving health status. There's no way for us to deliver high-quality care in a cost-effective way without using IT as a strategic differentiator. In 2007, we embarked on an electronic medical records (EMR) initiative called CS-Link.


Darren Dworkin: As CIO, I looked at the processes that EMR would affect and how improvements across all divisions of this $2.5 billion organization would enable business growth and enhance the patient experience. The tagline for the project, now in its second-to-last phase, was "One Patient, One Record," stressing collaboration. We spent time convincing stakeholders to view EMR as an opportunity to redesign how they work and improve business processes. One of the most visible outcomes of CS-Link for patients and caregivers will be a portal that bridges the silos in the healthcare network. This portal will eventually be available to all our patients. (For more on Cedars-Sinai, see "Can Watson, IBM's Supercomputer, Cure Cancer?")

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4 tips for leveraging big data

1. Understand what kind of data you have, and where it's stored.

 

One of the biggest challenges for hospitals, Richmond said, is recognizing what data is available and retrieving it from where it's stored. "Hospitals are largely unaware of how data can be deployed to help them improve the value of what they're delivering and the care they're giving, and how it can help them grow," he said.

 

"What we find almost universally is hospitals discover all the nooks and crannies in their institutions where they have valuable data assets."

 

These assets could be in the form of labor data bases containing employee information, patient level transactions or other encounter data, or even time-stamped data telling how patients are moving through the OR or ED. "It's about identifying where these assets are and [combining] them," Richmond said. "That's why we call it 'connecting the dots,' to give them views not just within these data streams, but also across them in a combinatorial way."

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Why reference models matter in healthcare IT?

There is one fundamental thing in this business you have to get right, if you want to succeed: requirements.

 

Recently, I heard a question targeted at my colleagues at Ocean, something in the lines of “what do you think is your greatest accomplishment ?”

 

Ocean’s software stack has a lot of impressive components, the template designer with its TDO support, the back end repository, Tom’s Eiffel work that is called the Archetype workbench, and clinical knowledge manager are all polished pieces of software with a lot of work behind them (and don’t forget the archetype designer)

 

However, my pick would not be one of these if I were to choose greatest thing out there. I’d choose the RM, the reference model of openEHR. Why? Well, it is because I have a past that has lots and lots of software development. The vendor that is trying to deliver a product to the clinician stands between the clinician an the technical infrastructure, code and hardware.

 

If you work with all the common approaches and tools of recent times, that is, if you’re doing Object Oriented development with a mainstream language such as C# or Java, it is highly likely that you’ll go through the well known lifecycle of an application. Even if you use agile methods and good practices such as test driven development, there is one fundamental thing in this business you have to get right, if you want to succeed: requirements.

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6 reasons to manage and archive your social media

Social media's use in healthcare is without a doubt growing. But as organizations learn how to leverage these tools, a recent whitepaper by Osterman Research makes clear organizations also need have plans in place to both manage and archive their social media use.

 

The report describes six reasons organizations should consider managing and archiving their social media.

 

1. Its use is growing, along with the use of enterprise social media. Recently published statistics show an ever-growing use of sites such as Facebook, LinkedIn, Twitter, Tumblr, and more. In fact, Pinterest, the newest platform, had nearly five million unique US visitors in November 2011, according to the report, and roughly 20 million users in March 2012. In addition, 19 percent of organizations surveyed are using an enterprise-grade social media platform, although, this is significantly less than the number of those using consumer-focused tools. "Despite the comparatively low use of enterprise-grade social media platforms at present [there will be] significant growth is the market for these tools," read the report. This is due to decision makers recognizing the value of social media for collaboration, knowledge sharing, skills discovery, and more, as well as decision makers recognizing the significant level of threats they face from the unregulated use of non-enterprise tools in a workplace context.

 

2. Recent trends have more discovering its business benefits. When managed properly, the report shows social media can create a sense of community and affirmation for employees, business partners and others within the organization. "It can provide a means of information sharing and gathering that is simply not possible with other corporate tools," the study read. "Moreover, if organizations can create the appropriate environment within their organization, viewing it as an integral component of their larger corporate culture, they can speed decision-making and improve the quality of corporate decisions." With the proper use of social media, organizations can also leverage their employees to serve as "an amplification channel" for message the company is looking to promote on a wide scale, according to the report.

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6 things health care marketers need to know about Pinterest

6 things health care marketers need to know about Pinterest | healthcare technology | Scoop.it

Pinterest is revolutionizing the way users categorize and visually represent information. It is taking the social media world by storm, and marketers are scrambling to not only understand but successfully engage in this site!

 

Here are few stats about Pinterest that will leave you—as health care marketers—eager to learn more.

 

Pinterest hit 10 million unique monthly views faster than any site in U.S. history.


On average, each time a person visits the site she spends 58.8 minutes "pinning." Facebook has an average visit time of 12.1 minutes.


Nearly one-third of all Pinterest users have an annual household income of $100 thousand or more.

 

Almost 70 percent are female. (Keep in mind, females control 90 percent of all household health care decisions.)


The largest demographic on the site are ages 25 to 34.


50 percent of Pinterest users have children.

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OK I’m on Twitter…Now What? A Primer for Physicians (aka Twitter 101 for Docs)

OK I’m on Twitter…Now What? A Primer for Physicians (aka Twitter 101 for Docs) | healthcare technology | Scoop.it
So you’ve decided to take the plunge (or at least, dip your toes) into the Twitterverse. Congratulations! Welcome to a vibrant interactive community. You’ll find plenty of different personalities here and lots of opinions. But if you are like I was back in January 2011, you currently have no idea how to actually use Twitter, let alone how a physician might want to use it.

 

There are plenty of places to find information about how to start a Twitter account, (for example here), so I am going to take a leap of faith and say that if you are reading this, you have already set one up. If not, check out some online resources regarding starting your account and come back to this blog so you can figure out what you might want to do after the basic infrastructure is lay down (or, if you are just relatively adventurous, just head to Twitter and start your account without listening to any of the “pundits”).

 

This post is not meant to give you the ins-and-outs about Twitter. I think they do a pretty good job explaining the basics on their help center. There, you’ll find the “how’s” of Twitter, like how to post a tweet or how to follow others.

 

Instead, this post contains some of my basic recommendations about how you might first want to get involved in Twitter a professional manner. As I have said before, getting involved means starting small. I think you will quickly see why many people have stayed involved.

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Emerging technologies in Patient Monitoring Systems

Future of patient monitoring is clearly based on IT integration, data access and capture from across hospitals and remote access from any point within the hospital or across globe. Protocol based standardised charting solutions saving on time and effort of care giver, recording the information flawlessly for future access and meaningful interpretation for clinical as well as costs evaluations.

 

Today’s technologies talk about information access at bedside bringing together Vital signs, Information from HIS/CIS, Laboratory results, Radiology images, etc at Acute Point of Care to accelerates clinical decision-making, improve care delivery and facilitate consultation between clinicians at the bedside including industry’s best technologies.

 

Patient monitors should be standardised, scalable and mobile across all care units. This enables flexibility in staff utilisation, reduces training time. Scalability of patient monitors accommodate all acuity levels and patient types within and across departments, upgrades and expands with ease, supports the sharing of assets, helps build a tailored solution as the demands grow – smoothly and without redundancy.

 

Standardisation, scalability and mobility also saves time preparing patients for transport and for their return, monitoring same parameters in transit as at the bedside, optimises staff and equipment utilization. This increases patient safety and productivity.

 

Patient monitors should have device Integration to consolidate monitoring and therapy information for a better view of patient’s care state at a single point, providing a more complete view of decision-relevant patient data, supporting rapid treatment and generates more comprehensive chart-ready documents, automatically.

 

They should be IT enabled and open a pathway between patient monitoring and hospital IT systems which delivers highest performance, builds on existing, non-proprietary hospital infrastructure, offers literally infinite connectivity through open architectural design, connects effortlessly across multiple sites and finally allows system growth through a partnership between hospital IT department and Medical equipment supplier’s professional Services.

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Interview: How Physicians Can Create A Personal Brand With Twitter

Interview: How Physicians Can Create A Personal Brand With Twitter | healthcare technology | Scoop.it

Firstly, patients don’t want to talk to a faceless, nameless entity; they want to sense the person behind it — the personal. They want to like and get to know you, not just interact with your business. Remember that emotions are everything — they always have been and they always will be. Without them we cease to be human and we cease to invest in the human race. Your brand voice and your social voice are one and the same. Don’t make the mistake of trying to separate them.

 

Secondly, I’d want them to take away the knowledge that social media has dissolved the walls that existed between the consumer and the brand, and has provided the opportunity for one-on-one connection in a way never before possible. The best physicians are embracing this and using social media as a way to expand their knowledge base to their patients, empowering them and strengthening their own personal brands in the process.

 

And lastly, it’s so important to acknowledge the fact that today’s patients, consumers and clients have the ability to communicate online all day, every day, sharing, tweeting and blogging about how they feel. Sentiment is oozing out of every post they make, and we should not fear it, but instead, embrace it as the new lifeblood of branding. The ability to listen and understand how our patients feel (whether good or bad), what is important to them and what their expectations are, provides huge opportunities for forming the emotional allegiances needed for enduring personal brand loyalty.

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Health Insurers and Social Media

Health Insurers and Social Media | healthcare technology | Scoop.it

Insurance companies now need to market themselves to individuals, not just employers: a brave new world for some. Changes in pay models are on the horizon, as the concept of outcome-based health management grows. And the industry (particularly commercial payers) is battling a negative industry image, all against the backdrop of an increased demand for customer service.

 

It is clear that the landscape for health insurance payers is dramatically changing. Layered onto this is the explosion of social media, creating an opportunity for payers to not only market themselves using innovative tools, but to engage with their customers in highly accessible and customized ways.

 

Whether it’s Facebook, LinkedIn, or YouTube, social media is a big part of people’s lives. And they’re increasingly turning to these communities for health care information. A recent PwC consumer survey showed that more people now turn to the Internet (48 percent) to make decisions about their health care than turn to doctors (43 percent). A similar survey by Accenture found that more than three-quarters of consumers went online to seek information about insurers.

 

While many payers have invested significantly in portal and Web technologies over the last decade, few have mastered the social media channel as a way to engage with customers. Engagement is the single most important differentiator between these new forums and its predecessors. Payers that are succeeding have found ways to interact meaningfully, and are using social media platforms to enhance their brands, educate broad audiences, and significantly raise the bar for customer service.

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Social media, mHealth strategies should include seniors

The mHealth community, despite its obvious love of at-home monitoring for those with chronic conditions, is missing a major opportunity to create apps for seniors, according to Eric Dishman, who complained about the problem at length to Forbes magazine in a recent interview.

 

"No one is building apps for seniors," Dishman said. "Look at the number of seniors and disposable income. We don't like to think about getting old." He added that such trends could very soon translate into a generation of older Americans hungry for mobile apps, software, devices to keep them from feeling old.

 

Social networking making inroads with seniors: Once considered too complicated for seniors, social networks are evolving quickly into micro-networks, or bounded communities that seniors are learning to navigate, according to Dishman. Combining it with easy-to-use tablet technology, he said, is appealing more and more to senior consumers.


"Your mom can wake up with a simple-to-use touch tablet, look at the screen to check the weather; the device asks how she's doing, reminds her to take medication," Dishman said. "A caregiver or nurse is alerted to needs, since they're on the social network."

 

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Why social media may not be worth it for doctors

Social media in healthcare is all the rage these days. You can’t visit even one physician-oriented website without someone breathlessly advising you to be on Twitter, Facebook, LinkedIn, YouTube and now Pinterest. Yet the only reason these talking heads can give you is, “because they are really popular and everyone is doing it.”

 

Social media consulting is a bubble economy at the moment.

 

Don’t listen to them.

 

If you are the typical doctor in the typical medical practice, there is no business case for social media.

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Mobile health apps prompt questions about privacy

Mobile health apps prompt questions about privacy | healthcare technology | Scoop.it
The FDA is working on guidance for developers about how to ensure patient safety.

 

As smartphone users have grown more comfortable forking over information about their bank accounts and physical whereabouts to mobile applications, a growing group of app developers are betting health-related data will be next.

 

Consider Bethesda-based M3 Information. The company has created an app that asks patients a series of nearly 30 questions designed to assess whether they exhibit symptoms of depression, anxiety, bipolar disorder or post-traumatic stress disorder.

 

But the app, known as WhatsMyM3, stops short of a definitive diagnosis. Instead, it issues a score that suggests the patient may be at an elevated risk and recommends they discuss the results with a primary care physician.

 

In some ways, the app is indicative of the broader mobile health market. Applications are being built to assist physicians at a patient’s bedside or help remotely monitor chronic conditions, but remain somewhat limited by concerns about their ability to ensure patient safety and privacy.

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symtym: EHR Adoption a Power Law?

symtym: EHR Adoption a Power Law? | healthcare technology | Scoop.it

The graphs from the article (infra) would seem to suggest that EHR adoption (either basic or full) is a linear (proportionate) process, where the scaling factor is “α”:

 

But, as with most endeavors—wonder if it is more than a proportionality? The article further suggests that physician payments may suffice—more money (more “α”) and more adoption in a linear manner. If adoption has a power law (non–linear) relationship with time; then what are the factors that affect “κ”? Utility? Ubiquity? Both carry significant inertia (beyond a critical adoption level) that is most likely non–linear.

 

Abstract. [M]ore than half of all office–based physicians were using electronic health record systems, but only about one–third of those physicians had systems with basic features such as the abilities to record information on patient demographics, view laboratory and imaging results, maintain problem lists, compile clinical notes, or manage computerized prescription ordering.…[A]doption of electronic health record systems across geographic regions converged from 2002 through 2011, adoption continued to lag for non–primary care specialists, physicians age fifty–five and older, and physicians in small (1–2 providers) and physician-owned practices.…

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The financial impact of health information exchange on emergency department care

The national experience with HIE is growing, both in terms of the number of sites exploring this technology16 17 and the business models that rely on it. Unfortunately, because of the economic immaturity of HIE, most HIE benefits are estimates.18–20 Reports of measurable financial benefit are few in number.21 22

 

Presenting convincing evidence is a challenge because of the relatively small but growing number of HIE efforts, the differences in HIE, the ways in which HIE is enabled and used, and the methodology challenge of measuring value in ‘real world’ settings. Although HIE among institutions usually takes place through a single intermediary HIO, as more organizations share data with one another on a point-to-point basis, measuring the marginal contribution of each external data source and thus the overall value of HIE will become even more problematical.23

 

As part of our 6-year effort providing access to clinical and administrative data through a single HIO supporting HIE for every consenting patient treated in any of the region's major hospitals and in some ambulatory care clinics, we conducted a 2-year study examining overall use, user perspectives, and a range of other factors.24–26 We report here the direct financial impact study results by determining how HIE data access by emergency department (ED) physicians affected hospital admissions and diagnostic testing.

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Pharma and e-health: The emergence of activist patients

Pharma and e-health: The emergence of activist patients | healthcare technology | Scoop.it

While pharma knows patients have migrated online, the industry’s understanding of where those patients spend their time and how they leverage the e-health platform remains murky. What percentage of all Internet users are e-patients? Are those e-patients more likely to use Facebook or Wikipedia, apps or websites like askthedoctor.com, mobile or laptops?

 

This understanding is critical if pharma companies want to manage social media and the online space. At eyeforpharma’s Pharma Forecasting Excellence conference in Berlin, Milos Graonic, a senior vice president at Nielsen, discussed the emergence of what he calls “activist patients” and crunched the numbers on their burgeoning e-health movement.

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