National Health Care Systems
    Globalization and Virtual Infrastructures
American Medical Informatics Association Spring...
OBJECTIVES:

To present a framework for study of virtual
infrastructures in national health care
systems.

To suggest issu...
INTRODUCTION

The Commonwealth Fund Report:

Mirror, Mirror on the Wall: An International
 Update on the Comparative Perfo...
Health Care Systems
 A health care system is a dynamic set of
 interconnected individuals, institutions,
 organizations, a...
Virtual Infrastructures
 Overlapping distribution networks, systems brokerage
 functions, and the adoption of a software p...
Economic analysis of national health care systems
  shows that the important positive correlation
  between gross national...
According to evolutionary economic theory, the
   transformation of organizational systems must
   be examined within thei...
Global health care services markets and networks
exert powerful influences on the institutional
ecologies of national heal...
Ideology: integrated theories and values that
constitute a coherent socio-political system
expressed in patterns of stakeh...
Research Program
National Health Care Systems
 Infomed – Cuban national health care network and portal,
 Ministry of Healt...
COMPARATIVE COUNTRY CONTEXT


Country                    Cuba          Uganda        UK            India         USA
Popul...
Qualitative Case Analysis
 Qualitative case analysis is a research methodology particularly
 appropriate to the study of t...
Health Care Markets: Four Models

        Control   Clans          Hierarchies

     Market
     Dynamics
                ...
Norms and Standards : Behavioral Control- CLANS                       Institutional Infrastructures : HIERARCHIES



S    ...
D FREE MARKETS                                                          BUSINESS CONTRACTS
E  *OPEN INTERNET NETWORK STRUC...
Health Care System Transformation

  Pressures for collaboration, data-sharing and access to
  distributed resources incre...
The Cuban National Health Care System
Evolution of the CNHCS
 Development of a science base and infrastructure (1959-1973):
 early transformation of the health ...
The Virtual Medical Library
Electronic access to diverse publications through the Cuban Virtual
Medical Library (1992):
- ...
The Virtual University
 Inaugurated by the Ministry of Public Health in 1999, the Virtual
 University offers:
 - An intern...
An Example:
The Pediatric Surgery National Network
Red Nacional de Cirugía Pediátrica (RENACIP)

    Selection of the lead...
Network Development
 Identification of regional experts.
 Creation of a discussion list for cases treated by designated
 e...
Characteristics of the CNHCS
 A systems perspective integrating health care service delivery,
 research, information resou...
Ethical Considerations

Privatization of information and science.

Protection of intellectual property.

Individual privac...
Transferability and System Development:
Critical Issues
        System scale.
        Ideology
           Intellectual pro...
FUTURE RESEARCH


 Evidence-based design of sustainable social systems.

 Development of quantitative and qualitative
 met...
References




1.    Séror A. A Case Analysis of Infomed: The Cuban National Health Care Telecommunications Network
      ...
National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures
National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures
National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures
National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures
National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures
Upcoming SlideShare
Loading in …5
×

National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures

2,113 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
2,113
On SlideShare
0
From Embeds
0
Number of Embeds
42
Actions
Shares
0
Downloads
66
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures

  1. 1. National Health Care Systems Globalization and Virtual Infrastructures American Medical Informatics Association Spring Congress Orlando, Florida May 22-24, 2007 Ann C. Séror, MBA, PhD eResearch Collaboratory URL: http://www.eresearchcollaboratory.com Email: annseror@eresearchcollaboratory.com
  2. 2. OBJECTIVES: To present a framework for study of virtual infrastructures in national health care systems. To suggest issues for future research and intervention.
  3. 3. INTRODUCTION The Commonwealth Fund Report: Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care (May, 2007) See www.commonwealthfund.org Ranking of UK, Germany, New Zealand, Australia, Canada and the US on quality, access, efficiency, equity and healthy lives
  4. 4. Health Care Systems A health care system is a dynamic set of interconnected individuals, institutions, organizations, and projects offering products and services in health care markets: Information Research Education Public health Patient care - preventative and curative
  5. 5. Virtual Infrastructures Overlapping distribution networks, systems brokerage functions, and the adoption of a software perspective emphasizing the devices and channels through which information is processed and distributed. Accessibility through Internet websites and gateways designed to facilitate integrated use of the resources. “VIRTUAL” describes any web-based service, organization or institution arising from the technical infrastructure defined above.
  6. 6. Economic analysis of national health care systems shows that the important positive correlation between gross national product and indicators of health care quality such as life expectancy is mediated by variables related to equitable distribution of wealth as well as rates of public expenditure in the healthcare sector. Source: Sen A. Economics and Health. The Lancet 1999;354:20
  7. 7. According to evolutionary economic theory, the transformation of organizational systems must be examined within their social and institutional contexts. This transformation emerges through the “co-evolution of physical and social technologies” where social technologies include institutions and their network configurations. Sources: E. J. Castilla, quot;Organizing Health Care: A Comparative Analysis of National Institutions and Inequality Over Time,quot; International Sociology, vol. 19, pp. 403-435, 2004; and R. R. Nelson and B. Sampat, quot;Making Sense of Institutions as a Factor Shaping Economic Performance,quot; Journal of Economic Behavior & Organization, vol. 44, pp. 31-54, 2001.
  8. 8. Global health care services markets and networks exert powerful influences on the institutional ecologies of national health care systems. These pressures pose the convergence hypothesis. Compatibility between organizations and the characteristics of their environments. Response to external requirements for legitimacy rather than functional efficiency or effectiveness in local service delivery. Source: P. DiMaggio and W. Powell, 1983, quot;The Iron Cage revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields,quot; American Sociological Review, vol. 48, 147-160.
  9. 9. Ideology: integrated theories and values that constitute a coherent socio-political system expressed in patterns of stakeholders’ participation in financing, administration, and regulation of health care.
  10. 10. Research Program National Health Care Systems Infomed – Cuban national health care network and portal, Ministry of Health See Séror AC A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and Portal Journal of Medical Internet Research, 2006;8(1):e1 <URL: http://www.jmir.org/2006/1/e1/> Ministry of Health and Family Welfare - India Ministry of Health Online – Uganda Kaiser Permanente – USA British National Health Service – NHS – UK See Séror AC Internet Infrastructures and Health Care Systems: a Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser Permanente J Med Internet Res 2002;4(3):e21 <URL: http://www.jmir.org/2002/3/e21/>
  11. 11. COMPARATIVE COUNTRY CONTEXT Country Cuba Uganda UK India USA Population (millions) 11.3 28.8 59.7 1,103.4 298.2 Total Health 229 135 2,560 91 6,096 Expenditure per capita (Int. $-2004 External Resources (% 0.2 28.5 0.0 1.6 0.0 of total health exp.) Private exp. (% of total 13.2 (2003) 69.6 (2003) 14.3 (2003) 75.2 (2003) 55.4 (2003) health exp.) Out-of-pocket exp.- 75.2 (2003) 52.8 (2003) 76.7 (2003) 97.0 (2003) 24.3 (2003) percentage of private exp. Life expectancy (m/f – 75/80 48/51 76/81 61/63 75/80 WHO 2004) Child Mortality (m/f per 8/7 144/132 6/5 81/89 8/7 1000 population-WHO 2004) Physicians per 1000 5.91 0.08 2.30 0.60 2.56 population (WHO 2004) Literacy 97.2/96.9 79.5/60.4 99/99 59.5/48.3 99/99 (CIA World Factbook 2003)
  12. 12. Qualitative Case Analysis Qualitative case analysis is a research methodology particularly appropriate to the study of the health care sector. Ragin CC. The distinctiveness of case-oriented research. Health Services Research, 1999, 34(5 Pt 2):1137-1151. Technological innovation and economic globalization drive rapid changes rendering nomological model identification elusive. Idiographic case research methods offer tools for descriptive analysis and assessment of complex health care management systems within their social, economic, and cultural contexts. Sources: Séror AC. Internet infrastructures and health care systems: a qualitative comparative analysis on networks and markets in the British National Health Service and Kaiser Permanente. Journal of Medical Internet Research, 2002, 4(3); Yin RK. Enhancing the quality of case studies in health services research. Health Services Research, 1999 ,34(5 Pt 2):1209-1224. Multiple sources of data include: Published research. Internet sites of the health care institutions. Network configurations. Interviews.
  13. 13. Health Care Markets: Four Models Control Clans Hierarchies Market Dynamics Professional National Supply Covenents Constitutions Push Free Markets Business Demand Contracts Pull
  14. 14. Norms and Standards : Behavioral Control- CLANS Institutional Infrastructures : HIERARCHIES S PROFESSIONAL COVENANTS NATIONAL CONSTITUTIONS U * PROPRIETARY NETWORK STRUCTURE (WAN/LAN). *PROPRIETARY NETWORK STRUCTURE (WAN/LAN). P *Distributive multi-agent system architecture. *Federation architectures. P *Subject gateways. *Institutional gateways. L *Associative clinical process integration. (medical specialties) *Federative structural integration. Y- P *Access controlled by healthcare professionals. *Access controlled by institutional and telecommunications U network structures. S *Decentralized professional authority. *Centralized national and regional hierarchies. *Professional criteria for presentation of Web content and other *Institutional standards for presentation of Web content and other H electronic healthcare information. electronic healthcare information. *Professional certification of healthcare workers, services and *Institutional certification by network affiliation. institutions. ____________________________________________ _____________________________________________ PROFESSIONAL VALUES CITIZENSHIP VALUES Example: American Medical Association -http://www.ama- Example : British National Health Service -http://www.nhs.uk/ assn.org/ PRINCIPLE : System performance effectiveness: Universal PRINCIPLE: Professional norms, Hippocratic oath. service and citizen equality. Social contract.
  15. 15. D FREE MARKETS BUSINESS CONTRACTS E *OPEN INTERNET NETWORK STRUCTURE. *PROPRIETARY NETWORK STRUCTURES. M *Search engines. *Corporate gateways. A *Dynamic associative integration. *Federative business process integration. (business transactions) N *Access controlled by individual consumer choices and *Access controlled by collective choices and network structures. D availability of products and services in the market. - *Decentralized and deprofessionalized authority with individual *Managerial authority with enterprise hierarchies governing P consumer participation. institutions. U *Certification of products and services by independent evaluators. *Certification of products and services by institutional L evaluators, consumer organizations, and accreditation agencies. L *Criteria for individual consumer evaluation of web content and *Criteria for collective consumer evaluation of web content and other electronic information developed with consumer other electronic information by accreditation agencies. participation. _______________________________________________ ___________________________________________ CONSUMER VALUES MANAGERIAL VALUES PRINCIPLE: Responsible self-regulation. Emergent norms. PRINCIPLE: Consumer contract efficiency.(cost/benefit)
  16. 16. Health Care System Transformation Pressures for collaboration, data-sharing and access to distributed resources increase the focus on interconnection of services both within and across institutions. Technological trends and commercial pressures foster service decomposition and distribution through networks rather than host-centric systems. Three generations of medical informatics system evolution: System creation at the enterprise or institutional level beginning in the 1960’s. Integration of enterprise architectures in the 1980’s Horizontal linkage and coordination across contemporary system boundaries. Effective contemporary systems encompass components of all three generations.
  17. 17. The Cuban National Health Care System
  18. 18. Evolution of the CNHCS Development of a science base and infrastructure (1959-1973): early transformation of the health care system and creation of integrated polyclinics (1963) to serve the Cuban population. Elaboration of a centralized management model (1974-1989): integration of information from various sources through institutional information architectures. Introduction of community medicine (1974) and subsequently (1984) the family doctor-and- nurse model. Horizontal coordination and globalization through virtual infrastructures (1990-present): emphasis on national infrastructure for institutional linkage through Infomed and integration in international telecommunications infrastructures.
  19. 19. The Virtual Medical Library Electronic access to diverse publications through the Cuban Virtual Medical Library (1992): - The U.S. National Library of Medicine. - Medline. - The Cuban National Library of Medicine. - The collection of specialized Cuban medical journals. Foreign authors contribute articles translated into Spanish, thus creating a controlled electronic information market in medicine and health sciences. The Cuban VML integrates resources from the developed and developing world with a view to present the most advanced scientific research, accounts of medical experience in developing countries, and documentation of natural and traditional approaches to medicine.
  20. 20. The Virtual University Inaugurated by the Ministry of Public Health in 1999, the Virtual University offers: - An international center for postgraduate education in medicine and related disciplines. - Linkage between the health care publication infrastructure and Cuban university resources. - Linkage to international content such as the supercourse, Epidemiology, the Internet, and Global Health. - A Virtual Clinic for expert consultation among associated physicians and healthcare professionals. - A forum for discussion of cases presenting particular pedagogical value. The interactive design of the Virtual University promotes a market for reciprocal sharing of expertise and learning.
  21. 21. An Example: The Pediatric Surgery National Network Red Nacional de Cirugía Pediátrica (RENACIP) Selection of the lead network institution: the Pediatric Teaching Hospital quot;Octavio de la Concepción de la Pedrajaquot; of Holguín by the Cuban Ministry of Public Health in 2001: To develop the specialty of pediatric surgery throughout the country. To make available high quality research results for the practice of this specialty. To link the resources of all the concerned health care institutions across the country. Source: Trinchet Soler RM, Pedrianes Vigo M., Origen, estado actual y perspectivas de la Red Nacional de Cirugía Pediátrica. Acimed 2004; 12(3). Available at: http://bvs.sld.cu/revistas/aci/vol12_3_04/aci11304.htm
  22. 22. Network Development Identification of regional experts. Creation of a discussion list for cases treated by designated experts or through collective consultation and analysis. Best practice protocols. - Evidence-based development. - Face-to-face discussion for approval. Provincial university and enterprise alliances with the Cuban Empresa de Servicios Informáticos A virtual library specialized in pediatric surgery. Linkage to international discussion lists focused on this and related specialties.
  23. 23. Characteristics of the CNHCS A systems perspective integrating health care service delivery, research, information resources and education. Horizontal coordination and integration through INFOMED and telecommunications infrastructures with vertical control through MINSAP and government hierarchy. Government and health care administration serving social control, universal citizen access and humanitarian service. Dual health care service market structure with emphasis on open information markets in education, research and practice supporting trade on international services markets.
  24. 24. Ethical Considerations Privatization of information and science. Protection of intellectual property. Individual privacy and the common good.
  25. 25. Transferability and System Development: Critical Issues System scale. Ideology Intellectual property and innovation Individual privacy and confidentiality Government and health care administration Public and private sectors Modern and traditional medicine Cultural, ethnic and linguistic diversity Educational attainment – literacy Research community and innovation External Control Role of human resources Ethics
  26. 26. FUTURE RESEARCH Evidence-based design of sustainable social systems. Development of quantitative and qualitative methodologies for system description and evaluation. Cross-national research programs.
  27. 27. References 1. Séror A. A Case Analysis of Infomed: The Cuban National Health Care Telecommunications Network and Portal. Journal of Medical Internet Research 2006;8(1):e1. Available at: http://www.jmir.org/2006/1/e1/ 2. Séror A. Internet Infrastructures and Health Care Systems: A Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser Permanente. Journal of Medical Internet Research 2002;4(2). Available at: http://www.jmir.org/2002/3/e21/index.htm 3. Dallago B. The Organizational Effect of the Economic System. Journal of Economic Issues 2002;36(4):953-979. 4. Séror A. The Internet, Global Healthcare Management Systems and Sustainable Development: Future Scenarios. The Electronic Journal on Information Systems in Developing Countries 2001;5. Available at: http://new.ejisdc.org/ojs/index.php 5. Ashby WR. Design for a Brain: The Origin of Adaptive Behavior. New York: Wiley; 1960. 6. Ostrom E. Designing Complexity to Govern Complexity. In: Hanna S, Munasinghe M, editors. Property Rights and the Environment: Social and Ecological Issues: The Beijer International Institute of Ecological Economics; 1995. p. 33-45. 7. Reich M. Reshaping the State from above, from within, from Below: Implications for Public Health. Social Science & Medicine 2002;54(11):1669-1675. 8. Mechanic D. The Comparative Study of Health Care Delivery Systems. Annual Review of Sociology 1975;1:43-65. 9. Mechanic D, Rochefort D. Comparative Medical Systems. Annual Review of Sociology 1996;22:239-270. 10. DiMaggio P, Powell W. The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields. American Sociological Review 1983;48(2):147-160. 11. Baum J, Oliver C. Toward an Institutional Ecology of Organizational Founding. Academy of Management Journal 1996;39(5):1378-1428. 12. Yin R. Case Study Research: Design and Methods. London: Sage; 2002. 13. Yin R. Enhancing the Quality of Case Studies in Health Services Research. Health Services Research 1999;34(5):1209-1224.

×