HOSPITAL MAMAGEMENT

Introduction Chapter I. Management of medical and health services A. Nature of the Work B. Working Conditions C. Employment D. Education, Training & Qualifications E. Task Chapter II. Hospital Management System Chapter III. Essential Elements of Hospital Administration A. Signatures and Certificates B. Ethical and legal aspects C. Special Consumer Protections D. Product liability in medical care delivery E. Essential Elements for Postabortion Case F. Origins of postabortion care G. Experience with the original model H. Essential elements of Pac model I. Challenges in Implementation J. Future Directions Chapter IV.Functional Hospital Organisation A. The process oriented company B. Hospital Process Orientation (HPO): Development of a Measurement Tool Chapter V. Medical Records & Hospital A. Hospital Medical Record B. Electronic Medical Records

Chapter VI. Hospital Inventory Management A. Secrets to smart inventory control B.Supply chain ownership

Chapter VI. Epidemiology and Environmental Health A. Environmental Epidemiology: Challenges and Opportunities B. Division of Environmental Health Epidemiology C. Description of duties:

HOSPITAL MAMAGEMENT

Introduction
Hospital Management is a new theory in management faculty. Earlier a senior doctor used to perform the role of a hospital manager. However, nowadays everything demands a specialist. Almost all the things related to hospital have changed. Many categories concerning medical sciences and hospital have altered totally. There are various types of hospitals today, including ordinary hospitals, specialty hospitals and super specialty hospitals. The categories are regarding to the types of facilities they offer to the people. Eligible professionals are needed for the smooth operating of a hospital. Various courses and training programs have been developed to find out eligible hospital managers. A hospital manager is in a way responsible for administrative dealings of the hospital. He accepts the charge of various aspects of hospital management and health administration reverencing to the patients and healthcare. Eligibility Required For Hospital Management Bachelor of Hospital Administration is a three-year degree course for the undergraduate students. The students should have finished their 10+2 with Biology with total 50% marks, for BHA degree. Masters in Hospital Administration is a two-year duration postgraduate course. This course is available for both medical and non-medical background candidates. Graduates in any stream can apply for this program. Personal skills required for Hospital Management A number of potentials are required for a candidate for this field. The candidate must have rapid judgment capability related to up-to-date management doctrines and techniques. Friendly attitude, ability to handle public and pressure, ability of handling deadlines, brilliant communication skills and leadership skills are required to an efficient hospital manager. Job opportunities in the Hospital Management There are plenty of job opportunities in the field of Hospital Management. Assistant Hospital Administrator is the best option for the fresh degree holders. They can start their career as managers of non-health departments like finance. Anyone having this degree can find job in large corporate and public zonal hospitals, international and domestic healthcare institutes and health insurance companies, nursing homes.

CHAPTER I

MANAGEMENT OF MEDICAL AND HEALTH SERVICES

Overview

Earnings of medical and health services managers are high, but long work hours are common. A master's degree is the standard credential for most positions, although a bachelor's degree is adequate for some entry-level positions in smaller facilities. Employment will grow fastest in residential care facilities and practitioners' offices and clinics.

A. Nature of the Work Healthcare is a business and, like every other business, it needs good management to keep it running smoothly. The term "medical and health services manager" encompasses all individuals who plan, direct, coordinate, and supervise the delivery of healthcare. Medical and health services managers include specialists and generalists. Specialists are in charge of specific clinical departments or services, while generalists manage or help to manage an entire facility or system. The structure and financing of healthcare is changing rapidly. Future medical and health services managers must be prepared to deal with evolving integrated healthcare delivery systems, technological innovations, an increasingly complex regulatory environment, restructuring of work, and an increased focus on preventive care. They will be called upon to improve efficiency in healthcare facilities and the quality of the healthcare provided. Increasingly, medical and health services managers will work in organizations in which they must optimize efficiency of a variety of interrelated services, for example, those ranging from inpatient care to outpatient follow-up care. Large facilities usually have several assistant administrators to aid the top administrator and to handle daily decisions. They may direct activities in clinical areas such as nursing, surgery, therapy, medical records, or health information. In smaller facilities, top administrators handle more of the details of daily operations. For example, many nursing home administrators manage personnel, finance, facility operations, and admissions, and have a larger role in resident care. Clinical managers have more specific responsibilities than generalists, and have training or experience in a specific clinical area. For example, directors of physical therapy are experienced physical therapists, and most health information and medical record administrators have a bachelor's

degree in health information or medical record administration. These managers establish and implement policies, objectives, and procedures for their departments; evaluate personnel and work; develop reports and budgets; and coordinate activities with other managers. In group practices, managers work closely with physicians. Whereas an office manager may handle business affairs in small medical groups, leaving policy decisions to the physicians themselves, larger groups usually employ a full-time administrator to advise on business strategies and coordinate day-to-day business. A small group of 10 or 15 physicians might employ one administrator to oversee personnel matters, billing and collection, budgeting, planning, equipment outlays, and patient flow. A large practice of 40 or 50 physicians may have a chief administrator and several assistants, each responsible for different areas. Medical and health services managers in managed care settings perform functions similar to those in large group practices, except their staffs may be larger. In addition, they may do more work in the areas of community outreach and preventive care than managers of a group practice. Some medical and health services managers oversee the activities of a number of facilities in health systems. Such systems may contain both inpatient and outpatient facilities and offer a wide range of patient services. Work environment. Some managers work in comfortable, private offices; others share space with other staff. Most medical and health services managers work long hours. Nursing care facilities and hospitals operate around the clock; administrators and managers be called at all hours to deal with problems. They also travel to attend meetings or inspect satellite facilities. B. Working Conditions Most medical and health services managers work long hours. Facilities such as nursing homes and hospitals operate around the clock, and administrators and managers may be called at all hours to deal with problems. They also may travel to attend meetings or inspect satellite facilities. Some managers work in comfortable, private offices; others share space with other managers or staff. They may spend considerable time walking, to consult with coworkers. C. Employment

Medical and health services managers held about 250,000 jobs in 2000. Almost 2 out of 5 jobs were in hospitals. About 1 in 5 were in nursing and personal care facilities or offices and clinics of physicians. The remainder worked mostly in home health agencies, ambulatory facilities run by state and local governments, offices of dentists and other health practitioners, medical and dental laboratories, residential care facilities, and other social service agencies. D. Education, Training & Qualifications Medical and health services managers must be familiar with management principles and practices. A master's degree in health services administration, long-term care administration, health sciences, public health, public administration, or business administration is the standard credential for most generalist positions in this field. However, a bachelor's degree is adequate for some entry-level positions in smaller facilities and at the departmental level within healthcare organizations. Physicians' offices and some other facilities may substitute on-the-job experience for formal education. For clinical department heads, a degree in the appropriate field and work experience may be sufficient for entry. However, a master's degree in health services administration or a related field may be required to advance. For example, nursing service administrators usually are chosen from among supervisory registered nurses with administrative abilities and a graduate degree in nursing or health services administration. Bachelors, masters, and doctoral degree programs in health administration are offered by colleges, universities, and schools of public health, medicine, allied health, public administration, and business administration. In 2001, 67 schools had accredited programs leading to the master's degree in health services administration, according to the Accrediting Commission on Education for Health Services Administration. Some graduate programs seek students with undergraduate degrees in business or health administration; however, many graduate programs prefer students with a liberal arts or health profession background. Candidates with previous work experience in healthcare also may have an advantage. Competition for entry to these programs is keen, and applicants need above-average grades to gain admission. Graduate programs usually last between 2 and 3 years. They may include up to 1 year of supervised administrative experience, and course work in areas such as hospital organization and management, marketing, accounting and budgeting, human resources

administration, strategic planning, health economics, and health information systems. Some programs allow students to specialize in one type of facility - hospitals, nursing homes, mental health facilities, or medical groups. Other programs encourage a generalist approach to health administration education. New graduates with master's degrees in health services administration may start as department managers or as staff employees. The level of the starting position varies with the experience of the applicant and size of the organization. Hospitals and other health facilities offer postgraduate residencies and fellowships, which usually are staff positions. Graduates from master's degree programs also take jobs in large group medical practices, clinics, mental health facilities, multifacility nursing home corporations, and consulting firms. Graduates with bachelor's degrees in health administration usually begin as administrative assistants or assistant department heads in larger hospitals. They also may begin as department heads or assistant administrators in small hospitals or nursing homes. All States and the District of Columbia require nursing home administrators to have a bachelor's degree, pass a licensing examination, complete a State-approved training program, and pursue continuing education. A license is not required in other areas of medical and health services management. Medical and health services managers often are responsible for millions of dollars of facilities and equipment and hundreds of employees. To make effective decisions, they need to be open to different opinions and good at analyzing contradictory information. They must understand finance and information systems, and be able to interpret data. Motivating others to implement their decisions requires strong leadership abilities. Tact, diplomacy, flexibility, and communication skills are essential because medical and health services managers spend most of their time interacting with others. Medical and health services managers advance by moving into more responsible and higher paying positions, such as assistant or associate administrator, or by moving to larger facilities.

E. Task The medical and health service management performs many important tasks which include:

Planning the strategies implemented in the hospitals and supervising the daily mechanism To coordinate with doctors and make plans for the betterment of the medical institution. To monitor and manage the financial aspects of buying medications and equipments for the Managing of employees in the health organization. The medical and health service management also makes sure that the patients and people

under which the medical staff of the hospital operates.

hospital.

that are taking consultancy or treatment from their health care organizations are provided with all the necessary facilities and health assistance that would be beneficial to the patients. The medical and health service management also manages the financial aspects of running the medical organization as they take into account all the medicals bills and treatment charges and maintain the accounts. The medical and health service management has the major responsibility of managing all the affairs of the business. Any lack of proficiency from the medical and health service management would result in building bad reputation for the hospital or medical organization is affiliated with. The health service management should make sure that the patients are treated by expertise doctors and professional and all the health services being provided to the patients is the most advanced and reliable. The medical and health service management have a team of expert employees who are well versed in managing the managerial aspects of the medical institutions. The hospitals and medical firms are reluctant to hire any managerial staff and employees if they do not have experience in the field of the medical and health service managers. Most hospitals require the managerial staff to take special training and specialization courses before they are added to the department. The medical and health service management also develop new policies and rules under which the employees of the hospital have to operate. The medical and health service management supervise employees and work on strategies to save financial assists of the organizations and to run the health care industry more prominently. The medical and health service management organize meetings and perform research oriented assignments on behalf of the organizations. They also provide the doctors with all the latest and up to date medical instruments so they can treat the patients professionally. The management is also responsible for employee training and placement in the organization.

CHAPTER II HOSPITAL MANAGEMENT SYSTEM

Overview
Medinous a flagship product of Nous is an integrated health information system, which addresses the critical requirements of hospitals. MediNous system provides the benefits of streamlining of operations, enhanced administration and control, improved response, cost control and improved profitability. Medinous can be easily customized to the requirements of any hospital. Nous Enterprise Solutions Pvt Ltd has developed an integrated Hospital Management System (HMS), which addresses all the major functional areas of modern multi-specialty hospitals. MediNous HMS enables better patient care, patient safety, and efficiency and reduced costs. It provides easy access to critical information there by enabling the management to take better decisions on time. The package has been developed on the latest relational database system technology ORACLE. MediNous system provides the benefits of streamlining of operations, enhanced administration and control, improved response, cost control and improved profitability. MediNous can be easily customized to the requirements of any hospital. Other Features of MediNous Hospital Management System:

Medinous HMS is a fully integrated online system. MediNous HMS supports multi currency system, which is converted to the base currency for accounting purposes. MediNous HMS Supports Multi Location implementation wherein the hospital has Outpatient, Inpatient and other services in many physical locations. Doctors can get the investigation reports online at their terminal (or any terminal) without waiting for the physical report reaching them. Doctors can see the previous investigation results for a patient for better diagnosis.

Doctors can view their daily appointment schedules for any day from any terminal. MediNous HMS is highly secure and flexible. It allows the administrator to configure different information access privileges for different individuals depending on their role in the Hospital. Electronic signature of doctor is attached to the prescription. Inventory valuation is done in FIFO with earliest expiry date in Pharmacy.

MediNous Hospital Management System provides the following reports and more at the click of button daily cash collections, patient turnover, billing and medical records related reports etc. Enabling management to take better decisions

Hospital Management System - Help desk The Help Desk Module automates the day-to-day functions of the Front office management of a hospital. This module helps in assisting patient with accurate information and supports in handling patient related enquiries efficiently. This module having excellent features and advanced search facilities improves the quality of services rendered to the user. It provides for queries relating to the following: i. Patient related enquiries Bed Allotment Admission Details Demographic Details Payment Details and Discharge Details.

ii. Doctor related enquiries Availability Details OP Clinic Details Appointment Schedules Operation Schedules and Charge Details

Hospital Management System Registration

The Registration module is an integrated patient management system, which captures complete and relevant patient information. The system automates the patient administration functions to have better and efficient patient care process

Patient Registration Details Inpatient and Outpatient Registration Medical Alerts Details Appointment Scheduling (Patient / Doctor wise) Doctor's Schedule Summary Doctors Daily Schedule List Patient Visit History Medical Record Movements Appointments for Radiology tests and Operation Theatre Patient Visit Slip Sponsorship Details

It provides for enquiries about the patient, the patient's location, admission, and appointment scheduling and discharge details. Furthermore, this system even takes care of package deals for a patient for a fixed cost. Medical Record keeps an abstract of clinical data about patients. It allows easy retrieval of medical records on patients.

Hospital Management System - Electronic Medical Record The EMR Module is a fully integrated knowledge repository that caters to Medical and clinical records of patients in the hospital. The system supports medical professionals of various departments of the hospital with relevant information like medical examinations, diagnoses, treatment histories, test results and so on. The module provides access to critical and complete patient data that leads to high quality cost effective and efficient patient care. The EMR has the following features

Patient Search with Various Search Strings Patient Demographic Viewing Previous Visit Details Medical History of the Patient Billing Details of Patient

In addition the user can view investigation requests, prescriptions, reports and other clinical details. The system provides separate access rights for each part of the EMR. The patient medical file can be securely retrieved from this module and sent across LAN and WAN and also can be E-mailed.

Hospital Management System Billing The Patient Billing module handles all types of billing for long-term care. This module facilitates cashier and billing operations for different categories of patients like Outpatient, Inpatient and Referral. It provides automatic posting of charges related to different services like bed charges, lab tests conducted, medicines issued, consultant's fee, food, beverage and telephone charges etc. This module provides for credit partly billing and can be seamlessly integrated with the Financial Accounting Module. The billing module is extensively flexible by which each of your billing plans can be configured to automatically accept or deny. The system is tuned to capture room and bed charges along with ancillary charges based on the sponsorship category. The Billing Screens is used for Inpatient and Outpatient Billing and Invoicing. Further more the charges for various services rendered can be recorded through service module and this can be used for billing purpose,

Payment Modes / Details Sponsorship Conditions Details Patient Billing Details Package Installment Approval from Sponsor Company Sponsorship Details Package Registration Sponsor Verification Retroactive Processing User-defined Billing cycles Automatic Room and Board charges Recurring Ancillary charge capability Auto-generated Codes and Billing Criteria Provision for Pre-billing Extensive third-party Billing

The system supports multiple reports utilizing various print options with user-defined parameters. Hospital Management System - Financial Accounting The Financial Accounting Module deals with Cash/Bank, Receipt/Payments, Journal Voucher and General Ledger etc. Books like Cashbook, Bankbook and Ledger book can be generated. This module generates reports like Trail Balance, Balance Sheet and Profit and Loss statement. The Financial Accounting Screens describe about the Account Payable, Account Receivable and General Ledger. Also describe the activities related to IP, OP, Bank related activities and provision to clearing the Supplier Invoice and keep track of the Account Receivable and Revenue related activities. The services that are covered by the sponsor companies, Insurance Agencies, Family Accounts, Individual Accounts, sponsorship details of the patient, Health Card Insurance are recorded in the system.

Hospital Management System - Fixed Assets The Fixed Assets Module deals with all the activities that are related to the Fixed Assets Part of Financial Accounting. This describes activities that are related to:

Identifying an item as a Fixed Asset Allocating depreciation Managing its movement Maintenance Revaluation and Disposal etc.,

Hospital Management System Payroll The Payroll & Personnel module deals with Pay (and deduction) calculation, printing of salary slip, salary certificates, and PF statements, Gratuity Statement and provides a monthly analysis.

It deals with the maintenance of employee bio-data, Attendance / Overtime details. It also reports on absenteeism, leave encasements etc. The Personnel & Payroll department is responsible Employee Related Activities like appointing the staff, maintaining the employee database, Fixing allowances and deductions, Leave entitlements, Leave sanctions, Loan, Termination Process, Maintenance of Hospital documents, Insurance details, Tenancy Contracts and Vehicle Registration.

Hospital Management System - Outpatient Management The Outpatient module serves as an entry point to schedule an appointment with the Hospital Resident Doctor or Consultant Doctor for Medical Consultations and diagnosis. This module supports doctors to take better and timely consultation decisions by providing instant access to comprehensive patient information. Patient visits are divided into New, Follow-up and Review. This module also handles requests and results of laboratory tests and other examinations. External Doctors visit to in patients can be defined as "Call on". Some patients may avail only the hospital facilities like Lab, Radiology, Nuclear Medicine, and Physiotherapy and so on.

Medical Alerts Details Consultation Duty Roster Diagnosis Details Triage Parameters Patients Appointments Daily / Weekly Schedule Summary Appointment Scheduling / Rescheduling Facility Outpatient Medical Observation Details Investigation / Treatment History Clinical Service Details Group / Package Registration Facility Common Billing Clinical Services Doctors Diagnosis Statistics

Further more, Confidentiality of Doctors Observation, Previous History of Patients Visit, Online Prescription, Online Request for Investigations and so on, are the special features in Doctors Observation screen. This system calculates the cost for the services rendered to the patient and reflects in the billing module appropriately resulting in smooth billing process. Hospital Management System - Inpatient Management The inpatient module is designed to take care of all the activities and functions pertaining to Inpatient Management. This module automates the day-to-day administrative actives and provides instant access to other modules, which leads to a better patient care. It provides comprehensive data pertaining to Admission of Patients & Ward Management: Availability of beds, Estimation, Agreement preparation, Collection of advance, planned admission, Emergency admission and so on. The Inpatient module also deals with Ward Management: Shifting from one ward to the other, Bed availability, Surgery, Administration of drugs, nursing notes, charge slip and so on.

Admission Cost Estimation Admission Approval Admission Request Doctor Transfer Details Nursing Notes IP Medical Observation Pending Drug Request Surgery Scheduling Details Discharge Notification Summary Expected Date and Time of Discharge

The module tracks every visit made by the patient and caters to follow-up visits of patients, along with multiple appointments. Hospital Management System Pharmacy

Enquiry Quotation Purchase order Online approval, Pharmacy drug configuration Pharmacy stores configuration

Drug issue to patients and billing Unit dosage facility Supplier information Maintenance of drug inventory Automatic reorder level setting Purchase Requisitions Purchase Order Online request for stock from various sub-stores Online stock transfer Maintenance of stock at different sub-stores Return of items nearing expiry Destruction of expired items Physical stock verification and adjustment Goods receipt Stock Transfer (inter store stock transfer) Stock Adjustment Stock in Hand reports

In addition the online prescription facility assists and facilitates the physicians to track the patient's prescription details and as well reflects the medication billing details in the Billing module. Hospital Management System - General Store & Inventory

General Stores and Inventory module deals with Purchase of Items, Issue of Items, Maintenance of Stock, Automatic Reorder level Setting, Online request for stock from various sub-stores, Online stock transfer, maintenance of stock at different sub-stores, Physical stock verification and adjustment, Return of items to supplier etc

Stock management Multi UOM and Multi currency system Stock control Stock Purchase through Enquiry generation Sub stores issues and receipt of stocks External hospital stock issues and receipt Option to include and track gift or donation of stock Stock requisitions from sub-stores and corresponding management Quotations and Purchase Requisitions Purchase order generation and processing- LPO, Emergency Purchase order, Principal and Blanket PO Advance payment requisitions to Finance Goods Receipt Note and Purchase returns Automatic stock updates on receipt of goods Stock returns and destruction tracking Invoice verification Supplier management and supplier payment bucket facility available Supplier invoice management

Hospital Management System Laboratory The Laboratory module automates the investigation request and the process involved in delivering the results to the concerned department/doctor of the hospital. Laboratory module starts with receiving the online request from doctors and also allows laboratory personnel to generate requests. The Laboratory module supports to perform various tests under the following disciplines: Biochemistry, Cytology, Hematology, Microbiology, Serology, Neurology and Radiology. Tests are grouped under various sections and sample type (specimen). Based on the request the user can input the sample and generate the sample number. Results can be entered based on the sample type either to one test or multiple tests. If the test result requires approval, the supervisor has to approve the result and it is made available to concerned doctors.

Sample Result Entry Test Report Entry Specimen Association Details Antibiotic Details Result Range for Test Investigation Request Bulk Sample Request Sample Details Samples Received from External Laboratory Samples Dispatch to External Reference Laboratory Investigation and Treatment History

Test report can be made confidential. Tests can be performed only after the billing is done. This rule is exempted when the case is declared as Urgent. In addition, this module facilitates investigations for referral patients. Hospital Management System Radiology

Radiology module caters to services such as X-ray, Scanning, Ultra sound etc. Scheduling of Radiology resources is possible. The system stores all the result details of various tests and makes a Report based on the Test Results. These Tests are carried out both for Inpatient and Outpatient. The system stores all the details (like patient number, Test Report like X-Ray, Scanning details) and for each scan the system generates a unique number for the image. Investigations can be done only after the billing is done. This rule is exempted when the case is declared as Urgent.

Hospital Management System - Nuclear Medicine The main function of this module is to conduct the various Tests and make a report based on the Test Results and a unique number is generated for each image. The tests are carried out for Inpatient and Outpatient. Appointments have to be fixed by the Patient before the test. The concerned consultant analyses the result and makes a report based on the findings. Hospital Management System Physiotherapy This module facilitates tracking the services given to patients depending on the consultant's recommendations. Physiotherapy sessions are carried out both for Inpatient and Outpatient. Appointment has to be fixed by the patient for these sessions.

All the Appointments to the Physiotherapy will be through the consultant. There will be no direct appointment. Hospital Management System Dental Dental module caters to the services rendered by the dentists. Treatment and follow-up treatments are tracked using this module. Progress readings can be recorded through this module.

Hospital Management System Service The service module deals with all the services available in the hospital and the charges for these services are stored through this module. There are various services that are available in the hospital can be seen in
i.

Service Master: This master gives the details about package details, Group detail Room Type Master: This gives the details about Room Type (Ex: Private, Semi-private, Deluxe, ICU, Suite etc) and their charges. Consultation Charge Master: This gives the details about Doctor and the charges (like new visit, Follow-up, Review and Call-on). Revenue Type Master: This gives the predetermine charges for various service given by hospital (Like Ambulance, Anesthetists Fee, Baby Cot etc).

ii. iii. iv.

Hospital Management System - User Manager The User Manager module basically deals with security through controlling the access to the information available in the application. Any user associated with a user group can access only those

screens for which the user group has rights. It also deals with the System Related Activity like User Monitor, Creating User Group Master, User Master and view the User Group Lookup of employee database, Maintenance of company documents, User defined error message, Generating Daily Statistical Summary

CHAPTER III ESSENTIAL ELEMENTS OF HOSPITAL ADMINISTRATION

The healthcare industry is highly regulated by a complex statutory and regulatory framework at every level. Electronic commerce in such a highly regulated industry presents some challenges to say the least. States have approached e-commerce in a myriad of ways, leaving consumers and businesses confused as to whose law applies. Electronic records and signatures are essential elements of many electronic transactions, particularly in healthcare. Electronic signatures that can't be forget. It is a computed digest of the text that is encrypted and sent with the text message. A digital signature created by use of encryption keys can provide this high level of security because it ties an originator's identity to an electronically transmitted message by means of an algorithm. The digital signature is not a computer's "picture" of a handwritten signature, but a condensed mathematical representation of the message itself that can be created only by the originator using a private encypted key. Thus, a digital signature provides authentication of data and user. A. Signatures and Certificates: A digital signature ensures that the document originated with the person signing it and that it was not tampered with after the signature was applied. However, the sender could still be an impersonator and not the person he or she claims to be. To verify that the message was indeed sent by the person claiming to send it requires a digital certificate (digital ID) which is issued by a certification authority The sender uses a one-way hash function to compute a small digest of her text message. Using her private key, she encrypts the digest, turning it into a digital signature. The signature and the message are then encrypted using the recipient's public key and transmitted. The recipient uses his

private key to decrypt the text and derive the still-encrypted signature. Using his public key, he decrypts the signature back into the sender's digest and then recomputed a new digest from the text message. If the digests match, the message is authenticated. Digital signatures are a fundamental component of business in cyberspace. And numerous laws, state and now federal, have codified digital signatures into law. These laws are a mistake. Digital signatures are not signatures, and they can't fulfill their promise. Understanding why requires understanding how they work.

i. Health cares information and its use E-SIGN provides guidance on how records may be stored and retained electronically. If a document is required to retain by law, an electronic version of the document will be acceptable. The electronic document accurately reflects the information in the record and is accessible to all relevant people in a form that may be accurately reproduced at a later date, whether by printing, electronically transmitting or other means. No specific type of technology is mandated by E-SIGN. The law is technology neutral; allowing individual parties to choose the technology that best suits their needs. The term "electronic" is defined broadly in E-SIGN and means related to technology having electrical, digital, magnetic, wireless, optical, electromagnetic or other similar capabilities. Under E-SIGN, the term "transaction" means an action or set of actions relating to the conduct of business, consumer or commercial affairs between two or more persons. The term "electronic record" means a contract or other record created, generated, sent, communicated, received or stored by electronic means. Health care records (HCR) include both informations relating to the physical or mental health of patients, and information regarding the provision of health care by health care practitioners or health care facilities. Relatives, social workers and other third parties may supplement personal health information provided by the patient. The provision of health care is recorded in the professional notes, observations and opinions of health care practitioners and administrative staff. These data are entered into the health care record not only by the health care practitioners caring for the patient (including physicians, dentists, nurses and professions allied to medicine) but also by professionals providing support services, non-clinical staff acting on the professionals behalf and even by patients themselves. This diversity of origin and use of health care data present problems of security in the conventional and electronic health care records. ii.Issues in security of electronic health care records EHCR are health care records that are stored, processed or transmitted using computer technology. The EHCR enables information to be used simultaneously by many individuals who may

be remote from each other and from the patient, but this can be achieved only by use of the appropriate computer equipment. Thus the user who has no access to the necessary hardware or lacks the skills to operate it may be denied the information. In contrast, it is possible for those with the skills to examine and alter computer records without leaving any indication of their actions. Computerized records can be stamped with the identity of the users who create or modify them, although the mechanisms, by which most computers currently confirm the user's true identity, such as through password control, leave much to be desired and impersonation is not difficult. To compound the problem, identical copies of EHCR can be made at will, often without trace, readily transmitted over networks that now encircle the globe and linked with other data about the same individual to compile detailed profiles of their life style, health and financial status. B.Ethical and legal aspects The consequences of using an insecure information system in health care are far reaching. Patients may be embarrassed by, or socially ostracised following, disclosure of sensitive information about mental health, sexually transmitted diseases, adolescent care, drug addiction and genetic fingerprints. Their clinical care may be compromised by inaccurate or missing data as a result of unauthorised modification, from system malfunction or due to errors in program design. There is the potential for serious harm or death should such errors remain unrecognised. The EHCR must therefore be designed, implemented and run in such a way that the potential to harm the patient is minimised. Information security is a complex and highly technical subject with which even computer professionals are rarely fully conversant. Very few health care professionals have sufficient understanding of the principles of information security to confidently assume responsibility for security of information. If properly designed, access to EHCR can be controlled more comprehensively than is possible with the conventional HCR. The introduction of the EHCR thus offers the opportunity to comply more closely with the ethical requirement to respect the individual's right to privacy while not impeding the freedom of access to information needed by the clinicians involved in delivery of health care. In either case, we would suggest that the overall responsibility for security of health care data in a health care facility rest with the most senior clinician (e.g. the medical director or Dean) or delegated authority. There is no justification for access to health care records to be controlled by the administrative staff who own or operate the computer system holding EHCR, even though they may have the responsibility to ensure that the mechanisms controlling access are applied effectively.

Regular audits of these security measures should be conducted but physical controls such as encryption may be necessary where regular monitoring is not considered feasible.

C.Special Consumer Protections The term "consumer" means an individual who obtains, through a transaction, products or services, which are used, primarily for personal, family or household purposes. E-SIGN imposes special requirements on anyone obligated to provide written disclosures to consumers. Those special requirements are imposed to ensure that consumers can make fully informed decisions about electronic transactions and to provide some protection for consumers. Essentially, E-SIGN provides that the consumer must have affirmatively consented to receive the required information electronically. Under E-SIGN, threshold questions in healthcare are whether a proposed arrangement is a transaction for purposes of E-SIGN, whether the transaction is affecting or in interstate commerce, whether a consumer is involved and what exceptions, if any, apply. If it is assumed that E-SIGN applies to electronic healthcare transactions (and in most cases that may be a reasonable assumption), there still are many unanswered questions about how electronic commerce in healthcare should be conducted. D. Product Liability in Medical Care Delivery A person who alleges an injury caused by a defective product may elect to base his legal cause of action on any of the three principles of products liability theories: negligence, warranty, or strict liability. These may be the criteria in criminal, civil, or consumer case proceeding for product liability in the court of law. However, the proceeding on a negligence theory in a products liability case requires an injured party to show that a specific defendant failed to exercise proper care in designing, testing, manufacturing, or marketing the allegedly defective medical product and that, as a reasonably foreseeable and proximate result of such negligence, the patient suffered the injury. The miraculous extension of life by high technology medical care, organ transplantation, mechanical substitutes, newer antibiotics, anesthetic agent and prosthetic products show the increase in powers of medical care delivery. Developing concurrently with the remarkable

achievements of modern medical science and technology has been a similarly profound legal revolution in the body of law commonly known as products liability. Product liability describes the physical agent, which caused the injury in a situation in which a person is under a legal duty to the injured person. The injury or death of the patient may result unexpectedly by faulty, defective or negligently designed medical or surgical instruments or inadequate operating instructions. The manufacturer becomes responsible for injury or death in such case. The patient must prove that the defendant manufacturer departed from standards of due care, with respect to negligent design, manufacture, assembly, packaging, failure to test and inspect for defects or failure to warn or give adequate instructions. If the instrument functioned satisfactorily in previous operations or for several previous years in the hospitals possession, it is a proof that it was not defective at the time of supplying. If subsequently the instrument develops a defect through ordinary and gradual wear and tear, or if the physician or the hospital misuses the manufacturers, medical products, the negligence liability would be imposed on the hospital or physician owner for the failure to inspect, test and repair such defects. The manufacturer becomes responsible if the patients can prove that the subsequent development of this defect was due to negligent design, structurally inferior component material, or improper assembly. An adequate warning cautions the user to follow directions and may also notify the risk of disregarding directions1. This article reviews the theories available to an individual who alleges an injury cased by a defective product and sets forth the elements necessary to establish a cause of action on any of the principal products liability theories and the potential liability of the manufacturer of drug, blood products, medical equipments and various other product used in medical care delivery when some thing goes wrong due to the use of these product and comment future of product liability. i. Theories of products liability

Whatever the danger and state of medical knowledge, and however rare the susceptibility of the user, when the drug company positively and specifically represents its product to be free and safe from all dangers, and when the treating physician relies upon that representation, the drug company is liable when the representation proves to be false and harm results. The legal doctrine of negligence may be defined in terms of the duty of the person of ordinary sense grounds for products liability case requires an injured party to show that a specific defendant failed to exercise proper care in designing, testing, manufacturing, or marketing the allegedly defective product and that, as a reasonably foreseeable and proximate result of such negligence, the patient suffered injury.

Historically, a purchaser of goods has also been able to claim a breach of warranty against the immediate seller on the grounds that the goods were not as they were contracted to be. If a buyer could show that a seller made representations either expressly or impliedly about the quality of the goods that turned out to be inaccurate, the buyer would be allowed to recover appropriate damage without establishing any negligence by the seller. In early common law, the rule of cavent emptor, or buyer beware, prevailed. Changing social and economic considerations resulted in warranties, but only in situations where there had been an actual sale contract. Given the contractual underpinnings of this cause of action, courts were reluctant to expand recovery for breach of warranty against anyone with whom the patient had not directly contracted. The term privity was given to the requirement that the parties have had actual dealings among themselves. As the common law developed, however, certain aspects of tort law were grafted onto warranty law. As a result of this commingling of tort and contract law with breach of warranty actions, the privity requirement gradually eroded. Today, most countries including India allow a suit for breach of warranty against a seller by the ultimate consumer-under consumer protection act. An injured party proceeding on a warranty theory of liability need not prove negligence. Instead, it must be shown that the manufacturer or seller breached an expressed or implied promise that the product was both free from defects and fit for the ordinary purposes in which such products are customarily used. Many countries have evolved basis for liability on the part of the manufacturer of a defective product. This is known as strict liability in tort. The theory behind strict liability is that is better social policy for manufacturers, rather than injured consumers, to bear the economic burdens, through products liability insurance or otherwise, for any injuries caused by defective products. Under the strict liability theory, an injured party need not prove negligence or any breach of warranty, but rather must establish only that the product causing the injury was defective when it left the control of the manufacturer or the seller. Generally, there are four fundamental types of product defects. The first may be considered the manufacturing defect. An improperly manufactured product is one that has been incorrectly manufactured or assembled and is thereby different from similar products manufactured. The second category of defective products is the defectively designed product. Such a products is identical to similar products manufactured by the defendant, all of which bear a common design flaw that renders the product unreasonably dangerous. The third category is a product that is defective because it has been inadequately tested. The fourth category is a product that is considered defective because the manufacturer has failed to

provide the user with proper warnings or instructions regarding the products use. This type of claimed defect occurs frequently in cases involving pharmaceutical and medical products. Under the strict liability theory, potential liability attaches not only to the products manufacturer, but also to its retailer and to any other person in the distribution chain who is in the business of selling such a product. Development in products liability theories, from negligence through strict liability, has made it easier for an injured party to establish a viable theory of recovery. Each new theory has expanded the law rather than merely replaced its predecessor. This broadening of recovery theories, however, has added new complexities to the products liability field. Depending on the facts of the case and upon the theories advanced, each products liability cause of action will have separate elements, varying burdens of proof, and different potential defenses. The central theme, however-which runs throughout all products liability causes of action in the existence or nonexistence of a product defect at the time the product left the defendants control. This theme is essential to products liability and distinguishes it as a separate and unique field of law3. ii. The manufacturers liability A manufacturers liability for its products may be established under the three theories discussed above negligence, warranty, and strict liability. For an injured party patient to establish a successful cause of action in negligence it must be proved that the defendant manufacturer departed from reasonable standards of due care with respect to the design, testing, manufacture, assembly, inspection, packaging, or advertising of the product or failed to warn or give adequate instructions with respect to its use. The manufacturer owes this duty of due care to the ultimate user and not just to the immediate purchaser. A manufacturers liability on the theory of breach of warranty is often more closely linked with the contract of sale between the parties involved, specifically the manufacturer and the injured buyer. Privity of contract has been the principal hurdle in breach of warranty actions. Even if privity can be established, traditional warranty theory also requires the patients reliance, to his detriment, on an express or implied assertion by the defendant about the nature of the defective product. Without all of these elements, which are often difficult to establish, a warranty action will fail. Strict liability is a more attractive theory for a patient because it eliminates the key requirement of a negligence cause of action the need for the patient to show that the defendant failed to exercise proper care in the manufacturing or marketing of the product. It also avoids the need for any contractual obligations between the manufacturer and the injured party as requirement for recovery. Under the strict liability theory, a patient needs only to establish that the product

in question was so defective as to be unreasonably dangerous and that, as a result, injury was suffered. In developing drug theories, the courts have expressly recognized and taken into account the fact that some products are unavoidably unsafe given current scientific knowledge. While there are very few decided cases, it would seem that this previously developed liability jurisprudence is directly applicable to artificial medical aid and given the embryonic nature of scientific understanding and experience in this field. To support the analogy of artificial organ liability concepts in terms of established drug liability theories, greater detail of a manufacturers duty deserves review. The manufacturer has the duty to warn of complications, side effects, and any potential hazards associated with its products. This duty requires a manufacturer to warn of known hazards as well as those hazards that it has a reasonable basis to suspect might occur. The courts have expressly recognized that prescription drugs are unavoidably unsafe products that can be dispensed only under a physicians authorization. With extraordinary medical devices, there is no question that the manufacturer has the duty to furnish full and complete warnings to any physician considering implanting such a device. The question, which logically and necessarily follows, is whether the manufacturers duty to warn also extends to the patient-consumer. Although in the prescription drug context a manufacturers duty to warn generally extends only to the medical community, it is unclear at present whether, with respect to extraordinary medical devices, the manufacturers duty to warn should also extend to the patient-consumer. iii.Liability of the physician A patients suit against a physician for an injury resulting from the physicians treatment is predicated on professional negligence or malpractice. Malpractice may be defined as bad or unskillful practice on the part of a physician or a surgeon resulting in injury to a patient. : the failure of a physician to exercise the required degree of care, skill, and diligence, or the treatment by a surgeon or a physician in a manner contrary to accepted rules and with injuries resulting to the patient, are all base upon which malpractice claims may be founded. To present a cause of action for malpractice successfully against a professional practitioner, the patient must establish four essential elements. First, a cause of action must show that the physician in question owed the patient-patient a particular duty or obligation. This legal duty derives from the physician patient relationship, which requires the physician to act in accordance with specific standards of care established by the profession for the

protection of the patient against unreasonable risks. Second, the patient patient must establish that the physician failed to act in accordance with these standards. An act or omission violating the standard of care owed to the patient is required. Third, the patient-patient must establish that a causal and reasonably foreseeable connection exists between the acts or omissions of the physician and the resulting injury. Fourth, the patient patience must prove that the physicians or omissions caused some actual loss or damage. The failure to establish any one of these four elements may defeat a malpractice claim. Claims for breach of warranty provide an alternative approach for actions by patients against medical practitioners resulting from injuries suffered from medical instruments, drugs, or devices used in treatment. The determinative issue in this instance is whether a sale existed upon which a warranty action could be based7. A sale of goods, independent of the medical services provided, is generally the touchstone for warranty recovery. Strict liability, has become a frequent theory upon which attempts to establish a physicians liability are often premised by a patient injured through the use of any medical instrument or device. However, courts have been hesitant to apply strict liability against physician. Courts analyzing the physician-patient relationship have noted that the primary purpose of this relationship is the performance or rendition of professional medical service, distinguishing this from the sale of medical products. Accordingly, most courts in various country have rejected the application of the strict liability theory to the medical treatment provided by physicians. Respond superior is a common law doctrine that imputes responsibility for an employees acts, carried out during the course of his employment, to the employer as the one who derives advantage from the act and, therefore, must answer for any resultant injury. The two requirements for application of this doctrine are specific. The person charged with liability must be an employer, or someone in direct control of the party who allegedly caused the injury. Further, the person charged with causing the injury must have been acting with the scope of his employment at the time the injury resulted. These two requirements have restricted application of this doctrine in the health care context. A doctor is a professional and traditionally was not classified as a hospital employee. Rather, the doctor was viewed as an independent contractor retained at the expense and will of the patient, not the hospital. Although development in this area has been slow, some jurisdictions have changed the legal status accorded hospitals. Hospitals have an integral role in the patients overall treatment, and patients assume that if an error is committed, the hospital will take responsibility. This is based

on the apparent authority of the hospital to supervise the treatment given, and has become another basis for attributing liability to hospitals. The law is accepted in a majority of jurisdictions. That hospitals potential liability is to encompass most, if not all, of the hospitals physicians, specialist, and staff. Another basis adopted by some jurisdictions for hospital liability for negligent treatment is termed corporate negligence. Under this doctrine, established by the USA Supreme Court in the leading case of Darling v. Charleton Community Memorial Hospital, a hospital has a duty to provide adequate medical care to its patients. This duty charged the hospital with responsibility for all treatment, which takes place within its boundaries; extending liability beyond activities traditionally considered under their direct control and governed by principles of respondents superior and, thus, includes liability for acts or omissions of persons, such as physicians, who are not hospital employees. These broad principles of negligence liability on the part of the hospital would seem to be equally applicable in the specialized area of organ transplantation, although it must be recognized that proof of negligence in this evolving scientific area may often be difficult. E. Essential Elements for Postabortion Case Complications from spontaneous abortions and unsafely induced abortions pose a serious global threat to women's health and lives. An estimated 46 million induced abortions are performed annually; about 20 million are unsafe, and 95% of these take place in the developing world. Unsafe abortion accounts for an estimated 13% of pregnancy- related deathsrepresenting approximately 67,000 womenevery year. In many other cases, unsafe abortion causes such long-term consequences as chronic pain, pelvic inflammatory disease, tubal occlusion and secondary infertility. Hospital records from developing countries suggest that 38-68% of women treated for complications of abortion are younger than 20; while these data suggest that abortion complications take a high toll on adolescents, they represent only young women who make it to a hospital for treatment. The World Health Organization (WHO) estimates that 10-50% of women who have an unsafe abortion need medical care; some women who experience spontaneous abortion also need treatment. The tragedy of unsafe abortionwhich WHO defines as "any procedure for terminating an unwanted pregnancy [carried out] either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both"is that it is the most easily prevented cause of maternal death. Unmet need for acceptable contraceptive services results in large numbers of unwanted or unintended pregnancies. With one in four women living in countries where abortion is forbidden or

allowed only to save a woman's life, safe and legal abortion services are out of reach for many women with an unwanted pregnancy. Some barriers to addressing unsafe abortion and related maternal morbidity have been reduced or eliminated over the last several decadesfor example; some laws restricting access to contraception have been lifted or liberalized. Other barriers, however, remain; these include limited resources, restrictions on midlevel providers' performance of uterine evacuation and political sensitivities about abortion-related issues. Although modern contraceptives have become increasingly accessible, use remains low in many countries. An estimated 120-165 million women, including 12-15 million unmarried women, want to prevent or space their pregnancies but are not using a method; many resort to unsafe abortion. Even if all contraceptive users were to use methods perfectly all the time, nearly six million unintended pregnancies would occur annually. While most health systems provide treatment for abortion complications as part of emergency obstetric care, the infrastructure to make these services widely available usually is lacking in developing countries. Policies that prohibit midlevel providers from offering treatment for abortion complications result in reduced services. Global initiatives with the potential to address unsafe abortion as a preventable cause of maternal mortalityspecifically, the Safe Motherhood Initiative, launched in 1987have been hindered by the perception that unsafe abortion is not a "core" safe motherhood issue (because it is the result of an unwanted pregnancy and is not related to childbirth), and by social and political sensitivities regarding abortion. In this comment, we chronicle the development and expansion of a post abortion care model designed to promote interventions that address abortion-related public health concerns even when abortion laws and policies are restrictive. We review years of program experience with the original model, which led to the development of an expanded and updated model, Essential Elements of Postabortion Care (PAC). Implementing the model challenges global public health leaders, donors, technical assistance agencies and ministries of health to work with communities to ensure that all women who want to prevent or space pregnancies can obtain contraceptive services; that all women have access to services to manage complications from abortion, whether induced or spontaneous; and that all women receiving treatment also receive counseling and the reproductive and other health services they need at the treatment visit, as well as follow-up care and contraceptive resupply. F. Origins of Postabortion Care Since the 1950s, many developed and some developing countries have liberalized their abortion laws, although this trend is not much evident in Africa or Latin America. Arguments for legal

reform usually center on public health concerns such as reducing maternal mortality and improving reproductive health, as well as on the recognition of reproductive rights as an essential element of human rights. The political situation and commitment of advocacy groups in each country largely determine the success of liberalization efforts. However, the Helms Amendment has prohibited the direct use of U.S. foreign aid for most abortion-related activities since 1973. At the 1984 International Conference on Population in Mexico City, the U.S. government further restricted population funding: Under the "Mexico City policy," foreign nongovernmental organizations that used their own funds to perform abortion (in cases other than those in which the pregnancy threatened the woman's life or resulted from rape or incest), to provide counseling and referral for abortion, or to lobby to make abortion legal or more available could no longer receive family planning support from the U.S. Agency for International Development (USAID). That policy was lifted in 1993, under the Clinton administration, but was reinstated in 2001 under the Bush administration. As clarified by a presidential memorandum in 2001, the policy does not prohibit support for "treatment of injuries or illnesses caused by legal or illegal abortions, for example, post-abortion care. However, with widespread restrictive abortion policies, a new language and a new strategy were needed to enable agencies to implement programs and conduct operations research on abortion-related treatment and related reproductive health services. The term "postabortion care" was first articulated as a critical element of women's health initiatives in Ipas's 1991 strategic planning document, which encouraged "the integration of postabortion care and family planning services in health care systems" as a means of breaking the cycle of repeat unwanted pregnancy and improving the overall health status of women in the developing world. In 1991, Ipas listed postabortion family planning and other reproductive health care as essential elements of a framework for providing quality abortion care, based on Bruce's quality of care framework; in 1998, Ipas and PRIME published a framework for quality of postabortion care. In 1993, AVSC International (now EngenderHealth), Ipas, the International Planned Parenthood Federation (IPPF), the JHPIEGO Corp. and Pathfinder International formed the Postabortion Care Consortium to educate the reproductive health community about the consequences of unsafe abortion and promote postabortion care as an effective public health strategy. In 1994, Ipas published the original postabortion care model, which comprised three elements: emergency treatment services for complications of spontaneous or unsafely induced abortion; postabortion family planning counseling and services; and links between emergency abortion treatment services and comprehensive reproductive health care.

The original model presented postabortion treatment as an essential emergency obstetric service. Health systems often relied on resource-intensive uterine evacuation methods, such as sharp curettage (also known as dilation and curettage, or D&C), that prevented them from offering services at every health care level. To reduce barriers to treatment for women, services needed to be highquality, locally accessible and sustainable by the health care system. Vacuum aspiration has a typical effectiveness rate of more than 98% and, compared with sharp curettage, is associated with lower rates of the four most common uterine evacuation complications. In 1991, a WHO technical working group identified vacuum aspiration as an essential element of care at the first referral level (i.e., at sites to which primary-level providers refer women needing treatment for abortion complications).Electric vacuum and manual vacuum aspiration have equivalent effectiveness rates. Manual vacuum aspiration, an accessible and low-cost method, enables midlevel providers and other health professionals in primary-level facilities that do not have operating theaters, general anesthesia or electricity to offer uterine evacuation on-site. Offering uterine evacuation at primary-level facilities also creates an opportunity for providers (often the same ones who perform uterine evacuation) to offer reproductive and other health services at the treatment visit. Second, the model emphasized the need for postabortion family planning services. A working group at a pivotal 1993 conference in Bellagio, Italy, recommended that "a range of contraceptive methods, accurate information, sensitive counseling and referral for ongoing care should be made available and accessible to all women who have undergone abortion." The group further recommended that "at a minimum, women should leave abortion-care facilities understanding their immediate return to fertility, that there are ways to prevent future unwanted pregnancies and where to obtain contraceptive methods, if they so desire." Research has since demonstrated the benefits of contraceptive services in preventing abortion. The third element of the model linked emergency abortion treatment and comprehensive reproductive health services. In many developing countries, a woman's first or only contact with the formal health care system may be when she visits a facility for postabortion care. That visit creates an opportunity for providers to assess her health needs and to offer appropriate reproductive health or other services . Through the 1990s, international conferences and organizations increasingly began to press population, safe motherhood and women's health initiatives to support women's right to postabortion care. The 1994 International Conference on Population and Development (ICPD) Programme of Action urged all governments and organizations to "strengthen their commitment to women's health" and "deal with the health impact of unsafe abortion as a major public health concern" The Fourth

World Conference on Women, held in 1995 in Beijing, recognized that "unsafe abortions threaten the lives of a large number of women, representing a grave public health problem as it is primarily the poorest and youngest who take the highest risk," and referred to the ICPD Programme of Action for solutions. IPPF and the International Federation of Gynecology and Obstetrics defined women's rights related to sexual and reproductive health in 1995 and 1997, respectively. In 1996, the International Confederation of Midwives passed a resolution promoting the participation of midwives in the provision of Postabortion care services. The 1999 ICPD +5 Conference Programme of Action strengthened the call to "recognize and deal with the health impact of unsafe abortion as a major public-health concern by reducing the number of unwanted pregnancies through the provision of family planning counseling, information and services and by ensuring that health services are able to manage the complications of unsafe abortion." Significantly, even though the Bush administration reinstated the Mexico City policy, the policy explicitly permits the continuation of postabortion care programs Nonetheless; integrating postabortion care into global and national programs has been a slow process. G. Experience with the Original Model As postabortion care gained global support, governments and agencies began to implement programs; a USAID evaluation in 2001 confirmed that more than 40 countries had postabortion activities. During the middle and late 1990s, programs following the original model focused mainly on introducing manual vacuum aspiration at tertiary-level facilities and strengthening linkages between treatment and family planning services. Results from a study in Kenya showed that the most effective approach to integration in a hospital setting was for staff to provide family planning on the gynecologic ward. A 1997 Population Reports provided recommendations for postabortion care service improvements and expansion beyond hospital facilities. Although an increasing number of tertiary facilities were offering services, only a small proportion of women who experienced complications from unsafe or incomplete abortion were finding their way to hospitals for treatment and postabortion family planning services. Operations research from several countries contributed significantly to increased momentum for decentralized postabortion services. To expand access, some ministries of health authorized midwives and other providers at primary-level facilities to offer postabortion care services, including treatment with manual vacuum aspiration. In many cases, this occurred once services at tertiary and other hospital facilities were functional and could accept referrals for abortion complications that could not be managed by primary-level providers. In the late 1990s, with funding from USAID and assistance from cooperating

agencies, the governments of Ghana, Kenya and Uganda demonstrated that midwives in primarylevel facilities could provide high-quality postabortion care services using manual vacuum aspiration and that primary-level services increased postabortion family planning counseling and method provision.

Essential Elements of Postabortion Care Community and service provider partnerships Prevent unwanted pregnancies and unsafe abortion Mobilize resources to help women receive appropriate and timely care for complications of abortion Ensure that health services reflect and meet community expectations and needs Counseling Identify and respond to women's emotional and physical health needs and other concerns Treatment Treat incomplete and unsafe abortion and potentially life-threatening complications Family planning and contraceptive services Help women practice birth spacing or prevent an unwanted pregnancy Reproductive and other health services Preferably provide on-site, or via referrals to other accessible facilities in provider's network

The momentum created by project results, together with revised country-level reproductive health service policies and standards supporting postabortion care by mid- and primary-level providers, led to the expanded availability of services. Results from a study with private-sector nursemidwives in Kenya, as well as anecdotal evidence from a pilot project in Uganda, illustrated that

additional health services should be offered or were being offered to women following the provision of treatment and contraceptive services. During this time, several other agencies and countries independently added to their postabortion care model a reproductive health counseling element to support women in resolving issues related to abortion and a community element to promote education for community members, reduce the need for abortion and improve reproductive health. These well-documented efforts prompted further expansion of service delivery into primary health care facilities and communities, and increased support for prevention-oriented postabortion care activities. Results from the USAID global evaluation of postabortion care reinforced this momentum. Inspired by the trend toward more comprehensive postabortion care services, in June 2000, PAC Consortium participants formed a task force to initiate an update and expansion of the original postabortion care model. H. Essential Elements of Pac Model The Essential Elements of PAC model, endorsed by the PAC Consortium in May 2002, reflects, from a provider and a consumer perspective, an enhanced vision of high-quality, sustainable services. The model's five elements (see box) shift the focus from facility-based medical treatment to a public health approach that responds to women's broader sexual and reproductive health needs. i. Community and Service Provider Partnerships This element of the model recognizes community members' vital role in treatment, prevention and advocacy efforts. Community health education and mobilization have been identified as key strategies to combat unsafe abortion, increase access to and quality of postabortion care programs, and improve women's reproductive health and lives. To achieve universal local access to sustainable, high-quality postabortion care and related health services, community leaders and advocacy groups, lay health workers, traditional healers and formally trained service providers must work in partnership. Components of this partnership include the following: Education to increase contraceptive use and thereby help women prevent unwanted pregnancy, space births and reduce unsafe abortion; Participation by community members in decisions about availability, accessibility and cost of services; Education about obstetric emergencies and appropriate care-seeking behaviors; Mobilization of community resources, including transportation, to ensure that women experiencing obstetric emergencies receive timely care;

 access to services for special populations of women, including adolescents, women with HIV or AIDS, women who have experienced violence or genital cutting, women who have sex with women, refugees, commercial sex workers, and women with cognitive or physical disabilities; Advocacy for holistic, human rights-based reproductive health policies and services that meet community expectations, priorities and needs; and planning for sustainability. ii. Counseling Effective counseling enhances a woman's understanding of the psychosocial circumstances surrounding her reproductive past and future, and increases her confidence in her ability to participate in her health care. Client- centered counseling ensures that women, rather than their providers, make voluntary choices about their treatment, contraceptive methods and other options. Postabortion care counseling covers more than fertility and contraceptionalthough it must emphasize these elements and consists of more than information provision and sensitive communication. This counseling provides an opportunity to help women explore their feelings about their abortion, assess their coping abilities, manage anxiety and make informed decisions. Counseling is a vital element of care, moving postabortion services from being purely curative to being preventive. It helps providers determine when women need special care because of extreme emotional distress or circumstances such as young age, inexperience with the health care system or fear of discrimination. Some expected benefits of counseling are that client-provider interactions will be more respectful, treatment will be less painful and more effective, women's understanding and use of other health services will increase, their satisfaction with the health care encounter will rise and health outcomes will improve. The aims of counseling are to solicit and affirm women's feelings and provide emotional support throughout the postabortion care visit; ensure that women receive accurate and appropriate information about their medical conditions, test results, treatment and pain management options, and follow-up care; ensure that women understand how to prevent complications after the procedure and that they know when and where to seek care for complications if they arise; help women clarify their thoughts and decisions about pregnancy, abortion, treatment, resumption of ovulation and future reproductive health; and enable providers, by listening to and asking questions of women, to better understand and respond to factors that can affect a woman's health care needs, such as experiences with

sexually transmitted infections (including HIV), violence-induced trauma or the effects of female genital cutting.

iii.Treatment The first element of the original model and the focus of many postabortion care activities, treatment remains a critical part of care, because woman who has had an incomplete spontaneous or unsafely induced abortion will, in many cases, need uterine evacuation and other medical intervention. The revised model includes language recognizing that postabortion care does not always involve complications and that complications are not always life-threatening but may be in the absence of swift and appropriate medical attention. It further recognizes that safe, effective treatment involves the use of vacuum aspiration wherever possible and includes standard infection prevention precautions, informed consent, appropriate pain management, sensitive physical and verbal patient contact, and follow-up care. iv. Family Planning and Contraceptive Services The revised postabortion care model recognizes that some women receiving postabortion treatment need family planning services to help them space births, while others need contraceptive services because they have no plans to conceive. Therefore the model emphasizes the importance of overcoming barriers to offering family planning and contraceptive services during the same visit and at the same location as postabortion treatment. When a facility does not provide these services at the time of abortion-related treatment, the opportunity to provide them may be lost. Women may not make another visit, to that facility or another, for such services. In addition, if the facility is not the one that a woman would go to for resupply of her method, or if it does not have her method of choice, providers need to link her to a referral site. Ideally, the woman would leave the treatment facility with an interim method to use until she obtains her preferred method at a referral site. For this to happen, facilities' contraceptive service infrastructure must be adequate, and providers must be knowledgeable about which methods are appropriate for women following treatment. Making a wide range of births pacing practices and contraceptive methodsincluding, where authorized, emergency contraceptionavailable to all women of reproductive age is an effective strategy for preventing unwanted pregnancies and unsafe abortion, and for helping women achieve their reproductive desires. Facilities must ensure that treatment is not contingent upon women's acceptance of a contraceptive method.

v. Reproductive and Other Health Services An important relationship in the new model is between effective counseling and increased use of the reproductive and other health services women want. The model encourages the provision of all appropriate health services at the time women receive postabortion care, preferably at the same facility. When a facility is unable to provide needed services, it should have functional mechanisms in place for making referrals (either within the facility or to another one), receiving feedback from referral sites or providers, and performing follow-up; such mechanisms should include consistent and accurate record-keeping. The following additional services might be offered: Education about the prevention of sexually transmitted infections, including HIV, as well as screening, diagnosis and treatment; Services addressing gender-based violence, including screening, counseling and referral; Infertility diagnosis, counseling and treatment; Nutrition screening and education, and treatment of nutritional deficiencies; Hygiene education; and Screening, counseling and treatment for reproductive-related cancers. I. CHALLENGES IN IMPLEMENTATION Implementers of the Essential Elements of PAC model face some of the same obstacles that hampered both the original model and new ones. Service delivery challenges include establishing sustainable procurement and resupply mechanisms for uterine evacuation instruments, contraceptives, and essential drugs and supplies; improving contraceptive method provision, infection prevention and pain management practices; and ensuring that services are high-quality, accessible and sustainable. Another challenge is meeting the growing expectation that community partnerships and counseling can increase access to and use of reproductive health services, improve the quality of clinical interventions and even prevent health problems from occurring. Social, religious, policy and legal restrictions on abortion and contraception continue to pose challenges to programs offering postabortion care. Advocacy will be needed to increase awareness and implementation of postabortion care in Safe Motherhood, essential emergency obstetric care and other global health initiatives. Continued advances in women's rights are necessary as opinion leaders, partners and family members persist in limiting women's contraceptive, pregnancy and childbirth choices. One of the greatest challenges will be finding creative ways to meet the increasing need for high-quality contraceptive, postabortion care and other reproductive health services in a context of stable or declining resources. As countries and organizations embrace the Essential Elements of PAC model, they will need strategies such as introducing elements of the model in

prioritized order over time or altering service provider guidelines and networks to maximize the use of already overburdened and limited resources. J. .FUTURE DIRECTIONS The PAC Consortium will reach out to global partner organizations to share best practices for expanding postabortion care activities to include the five essential elements. As programs based on the Essential Elements of PAC model are designed, implemented and evaluated, and our understanding of high-quality, sustainable services is further informed, further revisions to the model are likely. In communities implementing the model, we can expect to see increased use of reproductive health and postabortion care services; earlier emergency care-seeking behavior; increased contraceptive use; fewer unwanted pregnancies; fewer unsafe and repeat abortions; and, most likely, fewer maternal deaths. Anticipated results at health care facilities include increased quality and use of contraceptive, postabortion care and other reproductive health services that respond to community needs and priorities; enhanced provider performance in meeting women's postabortion care and other health needs; and improved referral systems and follow-up mechanisms for contraceptive, postabortion care and other health services. As health care evolves from a strictly medical to a broader public health focus, to reflect both consumer and provider perspectives and to encompass curative and preventive services, leaders and consumers should demand that women's sexual and reproductive health care be made still more comprehensive and accessible. Leaders and consumers must also continue to strengthen advocacy networks to promote women's broader health needs and concerns, and call on health systems to offer a complete range of high-quality preventive, diagnostic and treatment services linked to social and legal support systems. Implementing such a vision of comprehensive, integrated services will reduce the need for treatment of abortion complications and enable women to exercise their full sexual and reproductive rights.

CHAPTER IV FUNCTIONAL HOSPITAL ORGANISATION

During the last decade, there has been a transition from viewing the company as a number of functional departments to a business structure focusing more on the business processes being performed (McCormack, Johnson, 2001) There are many reasons why this transition has taken place, but the most important is that a process-oriented company should be more focused on the needs of the customer and should be able to deliver better value in terms of end-to-end services. In the hospital world, process orientation has been introduced through new organisation models such as the patient-focused hospital (Lathrop et al., 1991) and the development and implementation of new co-ordination mechanisms such as clinical pathways (Zander, 1992). A change in the organizational structure or an implementation of clinical pathways does not automatically lead to more process orientation culture. Therefore, it is important for management to know to what extent the different changes compel an organisation towards process-orientation. This paper looks at how process orientation can be measured using data from one large European University hospital. After a restructuring in divisions and the implementation of the care programs and clinical pathways, hospital management came to the conclusion that they had no tools to evaluate if these changes were resulting in a process orientation on the work-floor. In agreement with hospital management, an existing tool of business process orientation measurement was adopted and adapted to the specific context of healthcare. This paper reports on how the measurement tool was changed and validated in order to come up with a useful instrument (the Hospital Process Orientation tool) to measure the process orientation of the employees in the hospital. The Hospital Process

Orientation (HPO) tool can be useful to measure the effects of changes which are assumed to lead to more process-orientation or even patient focus. In this way the pay-off of these investments can be made more tangible. The HPO tool offers hospitals a way to evaluate how they are evolving towards more process orientation. In the first part of the paper some more insights are given on what the meaning is of process orientation, more specifically pertaining to hospitals. In the second part of the paper, the process measurement tool, its adaptation, and validation for hospitals are described. Finally, some managerial conclusions are put forward.

A.

The process oriented company

i. Process orientation The traditional way to structure an organization is through the formation of departments and vertically functional units consisting of individuals with a similar area of expertise. Up to a few years ago, this way of organizing was highly dominant: people can specialize themselves within their field of expertise, the centralization of functions reduces costs, everyone knows which tasks they are supposed to perform and the structure of the organization can easily be drawn and presented. However, the functional organization no longer fits into these current characteristics of the rapidly evolving and technologically deploying business world. During the last decade, there has been a transition from viewing the company as a number of departments to focusing on the business processes being performed. The abundant literature on Business Process Management highlights this transition (Armistead, Rowland, 1998). The focus on business processes implies a strong emphasis on how work is done within an organization, in contrast to a focus on what is done. A process is defined as a specific ordering of work activities across time and place with a beginning, an end, and clearly identified inputs and outputs: a structure for action (Davenport, 1993). Processes are generally independent of formal organizational structures, crossing functions or departments and involving people with different expertise and roles. However, formal organizational structures can strongly influence the effectiveness of processes. Consequently, the main difficulty to overcome organizational malfunctions and to break cultural barriers will be to identify an organizational structure that allows the company to focus on processes and not functions. One possibility to achieve this, is by evolving towards a more process based, horizontally oriented organization. A more conservative approach would be to set up a matrix organization, in which

functional and process responsibilities interact with each other. A large survey in European companies confirms that more than 50% of the companies change their structure in the early stage of the implementation of business process management and that up to 70% do this in a well progressed stage (Armistead, Pritchard, 1999). Very often, business process management implementations result in a flatter organization, where people are given more responsibility, get increased decision making capabilities, act more autonomous and are more flexible whenever needed. A flat organization allows managers to be close to customers and have a first hand awareness of the reality of the business (Hammer, Champy, 1993). A flatter organization requires role modifications and a careful consideration of how knowledge is created and transferred across the organization. There are several other reasons to spend more attention on business processes (Andersen, Fagerhaug, 2002): Focusing on processes ensures better focus on the customer; Value creation with regard to the end product takes place in horizontal processes; Defining process boundaries contributes to better communication and well-understood process requirements across the functional areas; Managing entire processes, operating throughout different departments, reduces the risk of sub optimization; Appointing process owners avoids fragmentation of responsibilities; Managing processes provides a better foundation for controlling time and resources. In a process oriented organization, processes are mapped so that task responsibilities are described with a focus on processes. This form of responsibilities exceeds the functional borders and encourages all members of the different departments to collaborate and achieve common goals. It also implies the use of process oriented performance indicators, obliging the members of an organization to work together as one group. The process perspective provides an especially useful framework for addressing a common organizational problem: fragmentation or the lack of functional integration.

ii. Process orientation in a hospital From a historical point of view, hospitals are considered as a collection of professional functions, brought together to care and later cure for the patients. In this way it is not surprising that historically these hospitals were organised along functional departments. The further evolution of the hospital structure has been characterised by increasing specialisation(within the functions) and centralisation(to capture economies of scales). The consequences by multiple ancillary and support

departments. Such a hospital organisation involves "multiple agents who have partial information, disparate (local) goals and limited communication capabilities" (Kumar et al., 1993). According to Galbraith (1973), there are two possible strategies to better co-ordinate the activities in such a complex organisation: (a) reducing the need for information processing or (b) increasing the capacity to process more information. The first strategy of reducing the need for information processing has been strongly emphasised in the so-called patient-focused hospital idea which has been promoted by several American consultants. The basic idea of patient-focused hospital is that there is something wrong with the operating structure of the hospital and that the health service delivery needs to be restructured in such a way that it is centred on the patient and his needs. This involves creating more or less autonomous departments which are treating resource homogeneous patient groups, and redeploying resources to such departments and cross-training of personnel (Lathrop, 1993). The development of more integrated information systems is a second approach to promote integration in a complex organisation. Kumar and colleagues (1993) find that the greatest benefits of integrated scheduling of ancillary services are realised when the personnel of the ancillary services do not consider their intermediate production (e.g. laboratory test) as their final output, but when the patient is placed central. In other words, accepting integration assumes a patient-focused hospital where the smooth throughput of patients is more important than the high utilisation of facilities. These ideas are further developed in the current patient flow literature. Both strategies place the patient and his needs as the starting point of attention for structuring the hospital organization. The development of clinical pathways or care maps in the nineties introduced a new way of working in the hospital world. Clinical pathways (originally called critical pathways) were originated from the project management methods developed during the 1950s for the manufacturing industry. They can be seen as schedules of medical and nursing procedures, including diagnostic tests, medications, and consultations designed to perform an efficient, coordinated program of treatment. These clinical pathways were the start of the awareness that the treatment of a patient must be considered (as a time-based) sequence of activities which are performed in a team of different professional disciplines (input) to create a certain outcome (output) (Coffey et al., 2005). The development and implementation of clinical pathways are considered as a major step in the process orientation of a hospital (Vera et al., 2007). These clinical pathways can be used in a traditional functional organisation whereby clinical pathways can be considered as projects or programs which are superimposed on the functional hospital structure.

Based on the previous discussion, it can be concluded that process orientation in hospitals can be achieved in two ways: By implementing coordination mechanisms (such as clinical pathways), horizontal processes are put on top of the existing vertical structure, without changing the functional organization. A second manner to achieve process oriented thinking is to consider the needs of the patient as the basis of the creation of a new organizational structure. This means that the service line, which contains multiple services and disciplines, will have to be optimally organized and integrated with reference to the real needs of the patient. In the extreme case, every patient can by regarded as a project for which specific resources are temporarily united. An aggregation of similar projects is called a program or a product line or service-line In a process-based organization design, these service-lines are organised in a separate division which are profit centers and where pay for performance is the rule (Vera et al., 2007). In other words, a process orientation can as well be present in a functional structure as in a service-line structure. A change in the organizational structure does not automatically imply an increase in process orientation. Furthermore being process-oriented is more than being patient-focused. Many of the more back-office departments (such as informatics, laboratory)in a hospital do not work directly for a patient, but deliver services to other departments. The processes in these departments must not necessarily be patient-focused, but they have to be sure to deliver the right type of service at the right time and cost to their (internal) customers. In other words patient-focused and processorientation are not necessarily interchangeable labels for the same construct. In this perspective it is important for management to know to what extent the different changes (such as the implementation of clinical pathways or the adoption of a service-line structure) really lead towards processorientation. iii. Process orientation in a large European University Hospital The study of process orientation in a hospital was carried out in one of the larger university hospitals in Europe. The patient oriented reflection and the organizational change began in the early nineties. Since 1997, a reorganization initiated by a large consultancy firm has triggered a process of restructuring into divisions and decentralisation of responsibilities. This led to eleven divisions, each of them managed by three people: a clinical director, an administrative director and the head of the nursing staff. Although the divisions were composed of medical units and nursing wards which had many interactions around patient groups, the restructuring into divisions is not a guarantee for a more

patient-focused process. To enhance this patient and care focus, the hospital started the development of care programs as a new organizational dimension. The purpose is to define homogeneous groups of patients in order to improve the management of the care process and the allocation of resources (input) with respect to that specific patient group, aimed at achieving an explicit outcome (output). The philosophy of care programs is certainly one of process orientation, but it became clear that he implementation of these kinds of programs is not easy in an organisation which traditionally thinks in terms of functions. One of the major challenges was to bring together different professional disciplines (including physicians) to collaborate along these care programs. This inter- and multidisciplinary thinking was fostered by the development of clinical pathways in the hospital. 112 clinical pathways are already being used or are in development. Although the aim of the restructuring was that the care programs and the clinical pathways were supposed to support a process orientation, hospital management came to the conclusion that this was not always the case. They assumed that a major factor could be the problem that hospital employees were not used to thinking in terms of processes and lacked training to develop these skills. Moreover they had the opinion that there was no comprehensive approach to assess the process orientation of their people on the work-floor.

B. Hospital Process Orientation (HPO): Development of a Measurement Tool

i. Business Process Orientation (BPO) As companies are increasingly focusing on restructuring their operational thinking from a functional vertical organization towards a more process oriented horizontal organization, McCormack and Johnson (2001) developed a measurement tool which enables them to measure and quantify an organizations Business Process Orientation (BPO). In 2001, McCormack and Johnson defined BPO as an organization that, in all its thinking, emphasizes process as opposed to hierarchies with special emphasis on outcomes and customer satisfaction. (McCormack, Johnson, 2001). By using the measurement tool, an organization can get an insight into the following issues: What is BPO? How do I know when I have it? What is the impact of BPO on my organization? Can BPO make a competitive difference?

The measurement tool consists of 35 questions measuring seven dimensions. The seven dimensions can be further subdivided into two parts: the BPO-Components and the BPO-Impacts. The BPO-components include three dimensions: Process View (PV - 4 items): This dimension indicates that process orientation is defined as thorough documentation and understanding from top to bottom and beginning to end of a process (McCormack, Johnson, 2001). Process Jobs (PJ - 3 items): This dimension indicates to what extend the jobs and responsibilities in the organization are process oriented, encouraging people from different departments to collaborate in order to achieve common goals (McCormack, Johnson, 2001). Process Management and Measurement (PM 4 items): This dimension verifies the presence of measures that include aspects of the process such as output quality, cycle time process cost and variability (McCormack, Johnson, 2001). This dimension specifies to what extend the performance of organizational processes is measured and analyzed. The aggregation of the three BPO-Components indicates an organizations BPO score. In other words these components measure the process orientation. The BPO-Impacts include the remaining four dimensions. They determine whether the BPO score results in improved organizational performance and long-term health. They deal with such issues as Interdepartmental Dynamics and Organizational Performance. To evaluate the importance of a certain BPO score, an organization can position itself by means of the BPO maturity model (McCormack, Johnson, 2001). This model describes the different stages through which an organization must go in order to reach the goal of being fully process oriented. The BPO maturity model enables companies to benchmark themselves with competitors or other organizations, based on their relative position in the model. Moreover, the maturity model can be further detailed by including the individual scores of each BPO component and their related BPO Impacts. The detailed BPO maturity model provides information on the different domains in which supplementary efforts must be made. However, the BPO measurement tool was mainly tested in the industrial world. The services sector, and more specifically the healthcare sector, is not well represented in the benchmarking database. This implies that it is not sure whether the BPO model is completely valid for healthcare institutions.

In agreement with hospital management, the BPO tool was selected as the basic tool for measuring recess orientation. Since the initial BPO questionnaire was originally designed to measure process orientation in industrial companies at a managerial level, the questionnaire had to be adapted to correspond to a healthcare environment and allow all levels of the hospital to correctly interpret the items.

ii. Adjustments to the initial BPO items In general, the following adjustments were made, based on interviews and discussions with hospital management: To measure the personal perception of a respondent with regard to the items that are stated, the items were rephrased using the I-form where possible. This was done to avoid that respondents would answer the questions based on a perception of what their units opinion would be about the items. As the structure of some initial items seemed incomprehensible or too complex to be directly used in the adapted BPO questionnaire, the connotation and phrasal construction was simplified. The terminology and expressions applied in the questionnaire were adjusted to the commonly used vocabulary within the hospital. Process terms were based on the introductory principles to BPM, and the definitions and purposes of care programs and critical pathways. To make the questionnaire accessible to all operational levels of the hospital, the choice of the words used to express the items was critically appraised to come to clear, simple and unified statements. iii. Construction of additional items To broaden the scope of the BPO measurement tool and get more insight into the specific consequences related to the implementation of care programs and clinical pathways, the three BPO dimensions were enlarged with additional items. A brief description of the purpose of the additional items is given below. Process View (PV): This dimension was enlarged with three items measuring the knowledge about the (care) processes to which a respondent contributes, and to assess whether patients with similar needs and process characteristics are perceived as one homogenous group.

 Process Jobs (PJ): For this dimension, four additional items were formulated. The items intend to give a better insight into the respondents opinion about organizational aspects related to empowerment, job enrichment, decentralization of decision making and the alignment of supporting process jobs (such as administration, pharmacy, cleaning, etc.). Process Management and Measurement (PM): Two additional items complete the third BPO component. The supplementary items assess whether the respondents are aware of the objectives of the (care) processes to which they contribute and whether the outcome of performance indicators is used to improve these (care) processes. A major goal of bringing in new items in the BPO survey was to cover in a more adequate way the patient-orientation and/or patient-focus as management was convinced that process-orientation and patient focus were intimately linked. The new tool is called hospital process orientation (HPO) tool. The rewording and extension of the survey introduce the necessity to further validate the survey.

CHAPTER V MEDICAL RECORDS & HOSPITAL

A.

Hospital Medical Record

Medical records are the life history of the sick, the unfortunate, and the desperate. The night shift basically had just three jobs. Our primary job was to pull records when the ER called for them. And Fridays and Saturday nights that could be just about all you did. The second job was to refile records that had been returned to the records room. This was usually handled by the day shift, so a lot of nights there weren't any to be filed or very few, or there was a note telling us not to do it that night for some reason. The third job was to pull records for shipment to a microfiche company that would photograph them onto microfiche and return the 'fiche' to us, and destroy the masters. We had a list of names and color codes to be pulled, and would pull them and put them aside and straighten them out, and put them in boxes. Straightening meant attaching all the EKG strips to the metal tabs, putting all the xrays in the front pocket of the folder, and similar stuff. I always worried that the records were inaccessible for a while, but I was assured that if I had to, I could call the microfiche company. (These weren't for deceased people; those records were pulled during the day and put in a different box, if I recall correctly.)

Records were sometimes ordered "stat" which means immediately which meant they wanted it ahead of anything else, even other records unless they had also been called for "stat". Sometimes the messenger would arrive breathless; sometimes it would be a nurse (that was always nice!) I was never asked to take a record up myself. Records were color-coded so that if you knew how to spell the person's name, you could find it by color. So when you got a call for a record, you always made sure you had the spelling of the first few letters of the last name and the first name. Naturally, some records were out of place. Some were way out of place. And some were so big and pulled so frequently, that they were kept to the side of the shelf they belonged in.

i. Nature of the Work

Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy. Technicians assemble patients health information, making sure that patients initial medical charts are complete, that all forms are completed and properly identified and authenticated, and that all necessary information is in the computer. They regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information. Technicians regularly use computer programs to tabulate and analyze data to improve patient care, better control cost, provide documentation for use in legal actions, or use in research studies. Medical records and health information technicians duties vary with the size of the facility where they work. In large to medium-size facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptions while a medical records and health information administrator manages the department. (See the statement on medical and health services managers elsewhere in the Handbook.) In small facilities, a credentialed medical records and health information technician may have the opportunity to manage the department. Some medical records and health information technicians specialize in coding patients medical information for insurance purposes. Technicians who specialize in coding are called health information coders, medical record coders, coder/abstractors, or coding specialists. These

technicians assign a code to each diagnosis and procedure, relying on their knowledge of disease processes. Technicians then use classification systems software to assign the patient to one of several hundred diagnosis-related groups, or DRGs. The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system. In addition to the DRG system, coders use other coding systems, such as those required for ambulatory settings, physician offices, or long-term care. Medical records and health information technicians also may specialize in cancer registry. Cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. Registrars review patient records and pathology reports, and assign codes for the diagnosis and treatment of different cancers and selected benign tumors. Registrars conduct annual followups on all patients in the registry to track their treatment, survival, and recovery. Physicians and public health organizations then use this information to calculate survivor rates and success rates of various types of treatment, locate geographic areas with high incidences of certain cancers, and identify potential participants for clinical drug trials. Public health officials also use cancer registry data to target areas for the allocation of resources to provide intervention and screening. ii. Work environment. Medical records and health information technicians work in pleasant and comfortable offices. This is one of the few health-related occupations in which there is little or no direct contact with patients. Because accuracy is essential in their jobs, technicians must pay close attention to detail. Technicians who work at computer monitors for prolonged periods must guard against eyestrain and muscle pain. Medical records and health information technicians usually work a 40-hour week. Some overtime may be required. In hospitalswhere health information departments often are open 24 hours a day, 7 days a weektechnicians may work day, evening, and night shifts. Training, Other Qualifications, and Advancement Medical records and health information technicians entering the field usually have an associate degree from a community or junior college. Many employers favor technicians who have become Registered Health Information Technicians (RHIT). Advancement opportunities for medical record and health information technicians are typically achieved by specialization or promotion to a management position.

iii. Education and training. Medical records and health information technicians generally obtain an associate degree from a community or junior college. Typically, community and junior colleges offer flexible course scheduling or online distance learning courses. (See the Sources of Education, Training, and Financial Aid section of the Handbook for more information regarding community and junior colleges.) In addition to general education, coursework includes medical terminology, anatomy and physiology, legal aspects of health information, health data standards, coding and abstraction of data, statistics, database management, quality improvement methods, and computer science. Applicants can improve their chances of admission into a program by taking biology, math, chemistry, health, and computer science courses in high school. iv. Certification and advancement Most employers prefer to hire Registered Health Information Technicians (RHIT), who must pass a written examination offered by the American Health Information Management Association (AHIMA). To take the examination, a person must graduate from a 2-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Technicians trained in non-CAHIIM-accredited programs or trained on the job are not eligible to take the examination. In 2007, there were about 245 CAHIIM accredited programs in Health Informantics and Information Management Education. Some employers prefer candidates with experience in a health care setting. Experience is valuable in demonstrating certain skills or desirable qualities. It is beneficial for health information technicians to possess good communication skills, as they often serve as a liaison between health care facilities, insurance companies, and other establishments. Accuracy is also essential to technicians because they must pay close attention to detail. A candidate who exhibits proficiency with computers will become more valuable as health care facilities continue to adopt electronic medical records. v. Certification and advancement. Experienced medical records and health information technicians usually advance in one of two waysby specializing or by moving into a management position. Many senior technicians specialize in coding, in cancer registry, or in privacy and security. Most coding and registry skills are learned on the job. A number of schools offer certificate programs in coding or include coding as part of the associate degree program for health information technicians, although there are no formal degree

programs in coding. For cancer registry, there are a few formal 2-year certificate programs approved by the National Cancer Registrars Association (NCRA). Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry. Certification in coding is available from several organizations. Coding certification within specific medical specialty areas is available from the Board of Medical Specialty Coding and the Professional Association of Healthcare Coding Specialist (PAHCS). The American Academy of Professional Coders (AAPC) offers three distinct certification programs in coding. The AHIMA also offers certification for Certified Healthcare Privacy and Security because of growing concerns for the security of electronic medical records. Certification in cancer registry is available from the NCRA. Continuing education units are typically required to renew credentials. In large medical records and health information departments, experienced technicians may advance to section supervisor, overseeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians with RHIT credentials may become director or assistant director of a medical records and health information department in a small facility. However, in larger institutions, the director usually is an administrator with a bachelors degree in medical records and health information administration. Hospitals sometimes advance promising health information clerks to jobs as medical records and health information technicians, although this practice may be less common in the future. Advancement usually requires 2 to 4 years of job experience and completion of a hospitals in-house training program. vi. Employment Medical records and health information technicians held about 170,000 jobs in 2006. About 2 out of 5 jobs were in hospitals. The rest were mostly in offices of physicians, nursing care facilities, outpatient care centers, and home health care services. Insurance firms that deal in health matters employ a small number of health information technicians to tabulate and analyze health information. Public health departments also employ technicians to supervise data collection from health care institutions and to assist in research. vi. Job Outlook Employment is expected to grow faster than average. Job prospects should be very good; technicians with a strong background in medical coding will be in particularly high demand.

viii. Employment change Employment of medical records and health information technicians is expected to increase by 18 percent through 2016faster than the average for all occupationsbecause of rapid growth in the number of medical tests, treatments, and procedures that will be increasingly scrutinized by health insurance companies, regulators, courts, and consumers. Also, technicians will be needed to enter patient information into computer databases to comply with Federal legislation mandating the use of electronic medical records. New jobs are expected in offices of physicians as a result of increasing demand for detailed records, especially in large group practices. New jobs also are expected in home health care services, outpatient care centers, and nursing and residential care facilities. Although employment growth in hospitals will not keep pace with growth in other health care industries, many new jobs will, nevertheless, be created. Cancer registrars should experience job growth. As the population continues to age, the incidence of cancer may increase. ix. Job prospects. Job prospects should be very good. In addition to job growth, openings will result from the need to replace technicians who retire or leave the occupation permanently. Technicians with a strong background in medical coding will be in particularly high demand. Changing government regulations and the growth of managed care have increased the amount of paperwork involved in filing insurance claims. Additionally, health care facilities are having some difficulty attracting qualified workers, primarily because employers prefer trained and experienced technicians prepared to work in an increasingly electronic environment with the integration of electronic health records. Job opportunities may be especially good for coders employed through temporary help agencies or by professional services firms. Earnings Median annual earnings of medical records and health information technicians were $28,030 in May 2006. The middle 50 percent earned between $22,420 and $35,990. The lowest 10 percent earned less than $19,060, and the highest 10 percent earned more than $45,260. Median annual earnings in the industries employing the largest numbers of medical records and health information technicians in May 2006 were:

General medical and surgical hospitals Nursing care facilities Outpatient care centers Offices of physicians

$29,400 28,410 26,680 24,170

B. Electronic Medical Records Electronic Medical Records (EMRs), or computer-based medical records of patients, have already gained importance in the western world with governments taking up initiatives to implement them across the nations. Comparatively, in Asia, esp. in countries like India and China, there is a long way to go before the benefits of EMRs can be realised. 1. High costs of implementing EMRs have been a major worry for hospitals in the west of late. As a leading developer of archiving software for healthcare, what are IBM's views on this? The return for hospitals to invest in an electronic medical record solution far outweighs the initial cost of implementing the systems. IBM is very confident that we have the healthcare industry experience and technology expertise to assist hospitals in ensuring that their electronic medical record investment reaps the benefits they are seeking. (Note: In June 2005 - IBM acquired the 'Healthlink' company, which had a dedicated healthcare practice focused on clinical and business process optimization, delivered via IT Strategy and Implementation Services. The Healthlink professional have extensive industry and vendor knowledge with large-scale, multi-entity implementation experience - consistently ranked as No 1 for Healthcare consulting firms and has 100% client reference ability. 60% of Healthlink consultants have more than 16 years of relevant healthcare business, clinical and IT operational experience.) 2. What is a good strategy a hospital can employ when implementing EMRs? The first step a hospital needs to take before embarking on any electronic medical record system implementation is to engage all internal stakeholders (e.g. the physicians, nurses etc) early in the project.

Secondly, there needs to be an enforcement of key guidelines and standards so that the new EMR system is compatible with the other hospital systems. The last thing the hospital wants to happen is for another 'silo system' to emerge. The advice to hospitals is do not add EMR as another non-compatible system, you need to consider very early on how is it going to co-exist with your existing hospital systems. Thirdly, hospitals need to use the right implementation expertise in combination with the right change management expertise in order to implement a successful electronic medical record system. They should not attempt to do it themselves, with only their in-house expertise or just relying on the ISV to implement, as this will result in a less than perfect outcome.

CHAPTER VI

HOSPITAL INVENTORY MANAGEMENT

Each year, the average health system invests millions of dollars in pharmaceuticals. While hospital pharmacists are expert at evaluating the efficacy of drugs, many haven't looked closely enough at their inventory management processes. In fact, the typical health system pharmacy does not use calculated methods for determining product orders. As a result, hospital pharmacies average a relatively low 10.2 inventory turns per year, lose contract compliance opportunities, and continue costly process inefficiencies. A disciplined inventory management program applies "buying science" to pharmacy procurement and can make a huge difference in inventory investment, labor conservation and patient safety. While many hospitals today use robotics to fill prescriptions and sophisticated systems to track and monitor patient care, most still use manual processes to determine what, how often and how much to order. The vast majority of hospital pharmacies still rely on a "want book," using pen and paper to take notes throughout the day on items to be ordered. They double the work by visually inspecting the on-hand inventory of items in the pharmacy, and cap off this process by manually entering their daily order into technology systems provided from their pharmaceutical distributor. Many pharmacy buyers were trained as pharmacy technicians and in lieu of formal purchasing instruction, rely on their own intuition. A typical hospital pharmacy has more than 2,000 products in its inventory. Relying on visual inspection, memory or experience to decide how much to order leads to costly overstock and stressful buying emergencies. Compounding this problem is the fact that most hospital pharmacies do not have a process for accurately reconciling what is received against what their pharmaceutical distributor bills. The serious consequences of traditional pharmacy purchasing include:

lack of inventory control missed contract compliance excess inventory levels frequent stock-outs and costly emergency deliveries workflow interruptions and expensive rework increased health system labor requirements

Taking control of inventory is much easier than it was a few years ago. The right inventory process redesign includes three components: technology; buyer experience; and change management. At the core of the program is a discipline that relies on velocity rankings, a term used to illustrate the speed at which a product moves off the shelf. Wholesale channels use inventory classifications of A, B,C, and D items as product velocity metrics. An "A" item can typically represent 10% of the stocked SKUs (stock keeping units) but 60% of sales, while a "D" item can represent 25% of stocked SKUs and only 10% of sales. Each velocity group has its own inventory turn goals. These rankings help focus more of a pharmacy buyer's time on "A" items and less time on slower moving "B" and "C" items. Ideally, the order process incorporates computer calculated reorder points and reorder quantities for each item, built in to the ordering process, eliminating the need for the want book. The pharmacy can rely on suggested, automatically generated order quantities, contract compliance checks, and other time and cost saving decision-support features. A process like this ensures adequate on-hand inventory while preventing costly overstock. Thorough manual reconciliation of daily distributor deliveries is burdensome and impractical for most hospitals. With the millions of dollars worth of inventory on their pharmacy shelves, however, hospitals need reassurance that what they receive and what they paid for are the same. Hospitals should take advantage of their distributors' receiving technologies that automate the check-in process and instantly compare what is delivered to what is invoiced. Hospital pharmacies will realize significant measurable benefits from redesigning their inventory management processes, such as: Increased inventory turns-The higher the number of inventory turns, the less capital is invested at any given time. Hospital pharmacies should strive for an inventory turn rate of at least 14 turns, and ideally over 16.

Improved contract compliance-Contract items represent a significant area for pharmacy savings for pharmacy-the more compliant with buying group contracts, the higher the savings. Without a disciplined inventory management process, a pharmacy runs the risk of stock-outs that lead to non-contract purchases. Outmoded pharmacy buying methods contributed to an average 40% of hospital pharmacy drug spend invested in non-contract items.

Southwest Washington Medical Center (SWMC), a 442-bed hospital outside of Vancouver, Wash., adopted McKesson's Asset Management program last year, and its pharmacy department experienced savings of 2.5 hours a day in purchasing staff time. In one year, the department increased its inventory turns and realized a cost savings of $170,000. Pharmacy staff say the program has allowed them to identify areas in need of improvement, and to find other opportunities for savings. Hospital pharmacies can expect new challenges over the next decade, including adopting electronic medication administration record technology, implementing automated prescriber order entry, and coping with continuing clinical labor shortage. Modernized inventory management can help them address these challenges, by optimizing the purchasing and inventory management processes to free up pharmacist time, reduce costs, and increase capital availability for future needs. The result is a more efficient system that can produce significant savings for the hospital while providing pharmacy with more time to focus on patient care activities.

Secrets to smart inventory control

No matter how you slice and dice it inventory control represents the guts of effective materials management. All the charisma, communication skills and confidence won't cut it if you can't get the fundamentals right so that doctors, nurses and administrators have what they need when they need it. Smart inventory control is as simple as the acronym IOU--identify your needs and opportunities, optimize your data and information management tools and understand the nuances of the supply and demand chains. "Inventory control is about product availability and balancing the costs of ownership with the costs of procuring, which includes purchasing, receiving and paying," said Dave Kaczmarek, vice president, The McFaul & Lyons Group LLC, Horsham, PA.

Hospitals need to actively manage what is bought, when it is bought, how much, as well as for what price, including discounts and rebates," noted Chris Holt, vice president, UPS Supply Chain Solutions--Consulting Services, which concentrates its coverage in the vendor community and does not work directly with hospitals. Although it sounds pretty basic on paper it can be just as elusive in practice.

Supply chain ownership

One way to effectively maintain control over your facility's inventory is to make sure you own your internal supply and demand chain process and not cede that control to a GPO or supplier. "The supply chain is a series of steps," Kaczmarek said. "The hospital can only control those steps it performs. Likewise the suppliers and GPOs cannot actually control the hospital portion. Each participant can--and usually tries to--influence the actions of the others. Hospitals must resist undo influence by any partner that might result in a negative outcome." Conversely, for a hospital to use a GPO effectively and control its supply chain it must maintain complete control over inventory levels, product substitutions, identification of fast moving inventory and obsolescence/innovation, according to Perry Kjargaard, program director of Information Control's DynaMed Materials Management System, Gaithersburg, MD. In essence, you can't have one without the other, which is why sharing ownership can be reasonable. "Hospitals are in the business of saving lives, not managing inventory," Kjargaard said. "Outsourcing this function--when it is under control--can provide huge benefits. Vendors can be compensated through cost savings and both parties can develop a very productive and trusting relationship. It should be noted however, that this may not be the answer when inventory issues are serious. The vendor should only assume responsibility for this function when the hospital is realizing efficiency. Contracts can be executed with vendors where operational goals are achieved before the function is outsourced." But the extent to which suppliers and GPOs control a facility's supply chain may be somewhat overstated. "While suppliers and group purchasing organizations (GPOs) want to 'control' the supply chain, it is important for hospitals to understand that they don't," Holt said. "While the suppliers and GPOs

can push, prod and establish incentives for hospitals to make certain decisions, only hospitals can make the final decision about their supply chain." Obtaining data can impede that progress, according to Holt. "Hospitals fail to understand that they usually don't have quick and easy access to data needed to make informed decisions," Holt said. "They usually need to go to the owner of the data which often is their supplier or their GPO. Once the hospital goes this route, the hospital's ability to 'control' the supply chain becomes extremely difficult." Holt argued that true control, stemming from relevant data mined from the system and presented in a useful format, "belongs to the group that understands what is bought, when it is bought, how much and for what price." Certainly, suppliers that offer just-in-time, stockless, modified stockless and vendor-managed inventory programs (where the vendor makes deliveries directly to the end user's storage location) can be a tempting alternative to those who drop teeming pallets off at the loading dock. "The first question that needs to be understood is--why does the hospital need to control its own inventory management operation?" Holt asked. JIT deliveries can result in decreased inventory, purchase orders and invoicing, allowing the facility "to have 'control' of the inventory process while ceding many of the activities that are not core to the mission of the hospital." Such strategies can make a lot of sense, Kaczmarek concurred. "They can also be a disaster," he countered. So many questions must be answered. "An organization needs to ask and find answers to so many questions.Is the relationship strategic or business? What is the true cost and what benefits can be reasonably expected? Are goals truly aligned? The biggest disaster comes when a valid cost analysis is not completed. "Any of these options mean that the organization will pay the vendor more," he continued. "They must be assured that internal costs will actually be decreased more than the additional vendor fee. This means that FTE reductions must actually take place. The other disaster comes when the organization does not manage the relationship. You can cede the function, but you cannot cede the responsibility or accountability."

i.

Capability vs. performance Healthcare facilities can improve their inventory control efforts by either focusing on their

capabilities or their performance. Certainly, by concentrating on the former you can more easily accomplish the latter. Kjargaard calls for hospitals to simply understand their inventory and how the process really works via item standardization and data cleansing services. "When this function is successfully completed, the client will know what they have and where it is," Kjargaard noted. "They will know what is redundant and what their true usage is. This inventory is then matched up to the requirements. At this point, an organization should be able to determine how effective their inventory management efforts have been and where the weaknesses are." Because each situation is different, there's no silver bullet solution, Holt said. But hospitals can locate "opportunities for implementing 'quick hit' savings by understanding the process of how and when products are purchased, as well as the product purchase history for both expense and nonphysician preference items, and use that available consumption (demand) data to recalculate the required level of inventory that is needed by the customer." Kaczmarek asserts that materials management directors should look beyond what's merely within their purview. "Remember that inventory is 'anything that is bought and held prior to use,'" he said. "If you limit any discussion on inventory control to that inventory under the direct control of materials management, you are missing a significant portion of the dollars. "You improve your capability, by having better trained staff, better understanding of the strengths and weaknesses of your current system, and good collaborative relationships between the materials department and the other departments that hold (and sometimes even manage) inventory," he continued. Specifically target and seek the cooperation of those departments that hold the most inventory, especially unofficial inventory, he advised. Unofficial inventory, which is ordered by and expensed to administrative and clinical departments directly, can make or break a budget so it's important for the materials manager to reach out to those areas, he added.

ii.

Process first, software second Software products from companies like Information Control and Minneapolis-based Lawson

Software can serve as useful tools to track purchasing, consumption, replenishment, substitutions, replacements and a host of other departmental key performance indicators. These products help hospitals automate many of the manual steps in what Dan Sougstad, Lawson's director of healthcare market development, calls the "order-to-pay and replenish-to-use business cycles." In fact, Lawson's vision is to eliminate all human intervention starting once the time, an item is consumed by the patient, to an automated requisition (once inventory falls below re order point), to an automated PO, to an automated invoice, to an automated match and pay, according to Sougstad. "This allows time for hospitals to focus on the high-value-added activities of demand management (e.g., value analysis, contract purchasing, contract pricing) and supplier management (e.g., service level negotiation, strategic sourcing)," he said. "Supplies are a significant expense for hospitals--and efficiently getting the right supplies to the right place at the right time is a critical part of the healthcare value chain." While it may seem intuitive, however, many, if not most, fundamental inventory control hurdles can best be solved with brains and not bits and bytes. Believe it or not, when faced with an inventory challenge some facilities throw their professional ingenuity' out the window and their operational muscle squarely behind a software vendor, online electronic commerce exchange or consultant to magically save the day. "Software is never a solution to poor processes," Kaczmarek said. "Software can be invaluable in optimizing your inventory and simplifying the processes. But you cannot optimize an inventory that is not accurate. And maintaining inventory accuracy generally is a function of good performance--i.e., the basics. This means maintaining accurate data, completing transactions in a timely manner and being accurate in the physical processes such as counting, recording, etc." Sometimes all it takes is a simple telephone call or e-mail to a colleague, peer or even a vendor. "Many issues that hospitals face are not unique to just one institution," Sougstad said. "Customers do reach out to peers and information management providers to understand the problem and results of previous efforts to address the issue. At the end of the day, the hospital, with a good understanding of the problem and symptoms, will have a clear picture of their path forward."

An organization has to clean up its act first and master the basics before it should implement any automated assistance. "The first thing that needs to happen is to determine where the problem is," Kjargaard said. "Is it the software? The policies and procedures, the manual intervention, etc.?" Not surprisingly, Kjargaard favors relying on an outside source. "Making this determination will most likely be done more efficiently with the use of an independent source. These specialists have the advantage of having exposure to inventory practices of many different organizations. They can bring this experience into any type of review Hence, automation before preparation is a recipe for disaster. "Once the basics and the direction the process needs to be headed are determined, that is when a hospital should consider using technology to improve the efficiency of the process," Holt noted. "If the process is automated too soon, automating a broken process will allow for wrong decisions to be made quicker resulting in a less efficient operation." iii. Maximize your computing power Solving that pesky inventory control challenge may not require a major software or systems upgrade either. That's because many facilities don't even use all of the capabilities of their current packages. In fact, they may not even know everything that their systems can do for them. "From my experience most current software provides adequate programs and access to the information that allows users to manage inventories well," Kaczmarek observed. "More often that not, users do not take full advantage of the programs and/or information. Admittedly, some systems make it difficult to get the information in a format that is conducive to good analysis." Kjargaard agrees to an extent. While Information Control encourages customers to use what they already have purchased and implemented, it's not always so absolute because expansion may be needed. "Many organizations only use part of the software that is installed," Kjargaard said. "Good inventory management is realized by having complete functionality and access to critical information. An essential ingredient of a successful supply chain operation is a robust and fully functional material management application. Without access to all critical information, it is virtually impossible for management to make an educated decision." Simply stated, a facility can't--and shouldn't--separate the process from the tools. "The key is to have the software both support and direct the right process," Sougstad said. "For instance, if the process is fragmented before software is deployed, the process will be fragmented after software is deployed. To be effective, software needs to be deployed to support a good process. At the same

time, software can present actionable information to the right person at the right time, to enable appropriate action to be taken." Holt argues that any decision depends on myriad factors, including how effective the current process for inventory management is, what software is currently in place and its capabilities, how knowledgeable the staff is in using the software and how much of the software capabilities are being used. The same holds true for choosing which inventory control techniques and tools to apply, be they exchange carts or PAR levels, bar code scanners or radiofrequency identification tags, Internetenabled materials management information systems or enterprise resource planning systems, automated supply cabinets or open systems. "Each option has its place in the lexicon of inventory control tools," Kaczmarek noted. "It is often more a matter of maximizing or optimizing the use of the tools rather than which combination of tools one uses. The optimal inventory control operation will make the most efficient use of its resources to produce the best possible outcome."

iv.

Smart Inventory Control

Pros each share their top five trade secrets The McFaul & Lyons Group's Kaczmarek: 1. Concentrate on the inventories where you can gain the largest benefit. These are typically the supply intensive clinical departments like surgery and cath lab. 2. Establish a dialog with department managers who have large inventories to educate them about the need for/benefits of managing those inventories and gain their cooperation in improving. 3. Try to establish acceptable substitutes for as many routine items as possible. When there are substitutes known the safety stock can be reduced substantially. 4. Use your computer system to its maximum capabilities.

5. For perpetual inventories, work at keeping the inventory accurate rather than finding ways to compensate for the inaccuracy. A good cycle count program can be a great start

CHAPTER VI

EPIDEMIOLOGY AND ENVIRONMENTAL HEALTH

Epidemiological studies have long provided a basis for health policy for such environmental exposures as microbiological contaminants in drinking water, arthropod vectors, and occupational exposures. In these cases, disease states are the health effects of relevance. New applications of epidemiology to environmental health policy necessitate the inclusion of such exposures or reactions as drug reactions, noise, housing, accidents, air pollution, pesticides, chemical water pollutants, and radiation. In dealing with these, non-disease effects have been shown to be important, new or specially developed statistical or survey methods are often required, and improved environmental measurements are assuming greater prominence. Interactions of multiple pollutants and multiple sources of exposure, including cigarette smoking, are common. For illustration, epidemiological studies which have influenced the air quality criteria of the U.S. are cited. Through air quality standards, these are influencing air pollution control policy. The American Public Health Association has recently modified its Basic Principles of Healthful Housing to reflect the data on health effects (including annoyance) due to noise. Epidemiological analyses of the effects of pollutants from fossil-fueled and nuclear-fueled power plants are currently influencing power plant sitting, control, and development policies Environmental Epidemiology: Challenges and Opportunities Epidemiology is struggling increasingly with problems with correlated exposures and small relative risks. As a consequence, some scholars have strongly emphasized molecular epidemiology, whereas others have argued for the importance of the population context and the reintegration of epidemiology into public health. Environmental epidemiology has several unique features that make these debates especially pertinent to it. The very large numbers of environmental exposures require prioritization, and the relative risks are usually very low. Furthermore, many environmental exposures can be addressed only by comparing populations rather than individuals, and the disruption of both local and global ecosystems requires us to develop new methods of study design. The population context is also very important to consider in risk management decisions because of the involuntary

nature of most environmental exposures and the diversity of possible outcomes, both health- and no health-related. Studies at the individual or molecular level tend to focus the research hypotheses and subsequent interventions at that level, even when research and interventions at other levels may be more appropriate. Thus, only by starting from the population and ecosystem levels can we ensure that these are given appropriate consideration. Although better research is needed at all levels, it is crucially important to choose the most appropriate level, or levels, of research for a particular problem. Only by conducting research at all these levels and by developing further methods to combine evidence from these different levels can we hope to address the challenges facing environmental epidemiology today. Modern "risk factor" epidemiology may be facing its limits Epidemiology often appears to be struggling with ever-larger problems with correlated exposures and small relative risks This crisis has produced, for some, a stronger emphasis on molecular epidemiology Other authors have argued that the best solution is for epidemiology to focus again on population and to reintegrate itself into public health . This "ecoepidemiology" approach involves conducting research at all possible levels of analysis, but the population level is fundamental in that it defines the key public health problems to be addressed and the population context in which these problems occur. These issues have been debated extensively in the general epidemiology literature, but there has been less consideration of how these debates relate specifically to the current practice of environmental epidemiology. In fact, environmental epidemiology has several unique features that make this debate especially pertinent to it. These include the very large number of exposures, which occur in low concentrations in complex mixtures and often do not differ greatly among individuals within one area. Therefore, the relative risks are usually very low. Furthermore, the most important long-term environmental health problems are probably the indirect and long-term effects on local and global ecosystems, which are only beginning to receive attention from environmental epidemiologists. In fact, most previous discussions have not considered the ecosystem level, which is unique to environmental epidemiology. Besides the scientific issues, consideration of the population and ecosystem context is important in risk management decisions). Prevention of involuntary population exposures such as outdoor air pollution or environmental tobacco smoke involve scientific, practical, and ethical issues quite different from those involved in the prevention of "lifestyle" factors such as active tobacco smoking or diet.

Perhaps the most pertinent characteristic of environmental epidemiology is that, by definition, it focuses on the environment in which individuals live rather than on their personal characteristics or lifestyles. During the past centuries, environmental health and environmental epidemiology have achieved remarkable health gains by focusing on reducing the population's exposure to contaminants in air, water, and soil. However, in the last decades, this focus has been changing to match developments in epidemiology and molecular biology. With increasing emphasis on individual exposures and susceptibility and on mechanisms, environmental epidemiologists are in danger of losing their population perspective of disease causation and prevention. Environmental health problems can be approached on four different levels: the molecular, the individual, the population, or the ecosystem level. In this paper we first list briefly the main challenges to environmental epidemiology today and then discuss the advantages and disadvantages of these different "levels of approach" in addressing the challenges of environmental epidemiology. We conclude that the main environmental health problems need to be defined at the population and ecosystem levels, instead of allowing the available research methodology to define the problems that are considered most appropriate for study. Research and development of new research methods is needed at all levels, from the molecular to the ecosystem, but it is crucially important to choose the most appropriate level, or levels, of research for a particular environmental problem. Developing further our research methods and combining evidence from these various levels of research are the keys to addressing the current challenges to environmental health, and also provide significant opportunities for the development of the field. B. Division of Environmental Health Epidemiology

The Division of Environmental Health Epidemiology directs a multi-disciplinary environmental health program involved in the investigation of diseases, conditions, or deaths that result from interactions between people and their environment. The Division provides statewide leadership through science and service that promotes health and quality of life by preventing or controlling adverse health effects relating to the environment. Description of Duties: The targeted population includes all residents of Pennsylvania. The Division supports and administers indicated environmental and occupational assessments, consultations, investigations, studies, surveillance, and public health interventions. The Division also provides technical environmental public health advice, support, and education to other agencies and the public in this area. In its daily activities, the Division interfaces with communities, state and federal agencies, and other groups involved with environmental protection and environmental and occupational health services. The Division is comprised of five programs: General Environmental

Health, Health Assessment, Environmental Public Health Tracking, Occupational Health, and Toxicology. 1. The General Environmental Health Program provides epidemiological,

medical, and environmental health support to others in the resolution of environmental health problems and emergencies that require public health attention. This support can take the form of environmental health consultations, assessments, studies, investigations, surveillance, and evaluations as well as public health recommendations. 2. The Health Assessment Program conducts health assessments, consultations,

and education targeted at hazardous waste sites located throughout the state. The program continues to be funded through a Cooperative Agreement with the federal Agency for Toxic Substances and Disease Registry (ATSDR) that began in 1989. 3. The Environmental Public Health Tracking (Surveillance) Program

investigates the linkages between environmental exposures and health effects. It deals specifically with chronic diseases and other non-infectious health effects that may be related to exposure to chemicals, physical agents, biomechanical stressors, or biological toxins in the environment. It is also involved with planning, capacity building, and developing or enhancing health effect, exposure, and/or hazard surveillance systems that can be integrated into a statewide and national environmental health public health tracking network. The program continues to be funded through a Cooperative Agreement with the federal Centers for Disease Control and Prevention (CDC) that began in 2002. A critical part of this program is biomonitoring. Biomonitoring is the assessment of exposure to toxic substances in humans by the laboratory measurement of these substances (or their metabolites) in specimens, such as blood and urine. 4. The Occupational Health Program investigates occupational health problems

throughout the state and makes public health recommendations to correct these problems, provides occupational health outreach and education to targeted groups in need of this service, provides occupational health consultations in response to outside requests, and administers the Departments adult blood lead surveillance program. 5. The Toxicology Program reviews and evaluates environmental data and

provides information on the effects of chemicals on human health and

recommendations to protect the public health, in response to requests from Commonwealth agencies and the public for technical assistance or health consultation. This may include developing health risk guidelines for use by environmental agencies, supporting agencies involved in the development of Commonwealth fish advisories, and providing health advice to other state agencies or the public on environmental health issues.