Context Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care. Objective To determine hospital, community, and market factors associated with ED closures. Design Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs). Setting All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009. Main Outcome Measure Closure of an ED during the study period. Results From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36 335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7). Conclusion From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.

https://jamanetwork.com/journals/jama/articlepdf/1161864/joc15048_1978_1985.pdf

Factors Associated With Closures of Emergency Departments in the United States

Extending the understanding of computerized physician order entry: Implications for professional collaboration, workflow and quality of care

INTRODUCTION The process of geocoding forms a basic fundamental component of spatial analysis in a wide variety of research disciplines and application domains (e.g., health [Vine et al. 1998, Boulos 2004, Rushton et al. 2006]; crime analysis [Olligschlaeger 1998, Ratcliffe 2001]; political science [Haspel and Knotts 2005]; computer science [Hutchinson and Veenendall 2005b, Bakshi et al. 2004]). This act of turning descriptive locational data such as a postal address or a named place into an absolute geographic reference has become a critical piece of the scientific workflow. However, the geocoding of today is a far cry from the geocoding of the past. Geocoding data that used to cost $4.50 per 1,000 records as recently as the mid-1980s (Krieger 1992) quickly moved to $1.00 per record in 2003 (McElroy et al. 2003), and can now be done for free with online services (e.g., Yahoo! Inc. [2006], Locative Technologies [2006]), with far greater spatial accuracy and match rates. As the availability and accuracy of reference datasets have increased over the past several decades (Dueker 1974, Werner 1974, Griffin et al. 1990, Higgs and Martin 1995, Martin and Higgs 1996, Johnson 1998a, Martin 1999, Boscoe et al. 2004), geocoding has undergone marked transitions to accommodate and exploit changes in both data format and user expectations. These transitions can clearly be seen in the input, output, and internal processing of the geocoding process. The input data suitable for geocoding have expanded from simple postal addresses (O'Reagan and Saalfeld 1987) to include textual descriptions of relative locations (Levine and Kim 1998, Davis et al. 2003, Hutchinson and Veenendall 2005b). The output capabilities of the geocoding process have moved from simple nominal geographic codes (Tobler 1972, Dueker 1974, Werner 1974, O'Reagan and Saalfeld 1987) to full-fledged three-dimensional (3-D) geospatial entities (Beal 2003, Lee 2004). Likewise, the internal processing mechanisms that produce the geographic output have moved from simple feature assignment (O'Reagan and Saalfeld 1987) to complex interpolation algorithms using a variety of heterogeneous data sources (Bakshi et al. 2004, Hutchinson and Veenendall 2005a, b). While significantly improving the usability, reliability, and accuracy of the geocoding process, these developments have brought with them a host of issues that a potential user must recognize and be prepared to contend with. Specific issues include the assumptions made during the interpolation process (Dearwent et al. 2001, Karimi et al. 2004), the underlying accuracy of the reference dataset (Gatrell 1989, Block 1995, Drummond 1995, Martin and Higgs 1996, Chung et al. 2004), the uncertainty in the matching algorithm (O'Reagan and Saalfeld 1987, Jaro 1984), and the choice of areal unit geocoded to (Krieger 1992, Geronimus et al. 1995, Geronimus and Bound 1998, Krieger et al. 2002a, 2003). These topics have received considerable research in recent times, and a great deal of literature is available. This article will survey the field of geocoding through a cross-disciplinary study of the geocoding literature focusing foremost on the technical aspects of the process. The changing concept of geocoding will be described, and the fundamental components of the geocoder will be outlined. Potential sources of error in the geocoding process will be explored, and particularly difficult geocoding scenarios requiring further research will be highlighted. The primary contributions of this article will be to inform the reader of the state of the art in geocoding through a discussion of its evolution over time and to warn of potentially sticky situations that can arise in the geocoding process if one is not aware of how one's decisions and assumptions can affect the geocoded results. This work should be seen as distinct from the recent work published by Rushton et al. (2006), which also offers a review of the geocoding process, but is focused on its application to health research, in particular cancer studies. …

From Text to Geographic Coordinates: The Current State of Geocoding

Rationale:Moving patients from low-performing hospitals to highperforming hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival. Objective:To characterize the existing critical care network in terms of the pattern of transfers. Methods:In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations. Measurements:We measured the characteristics of the interhospital transfer network and the extent to which intensive care unit patients are referred to each hospital in that network—-a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical, and radiologic capabilities. Results:There were 47,820 transfers of critically ill patients among 3308 hospitals. 4.5% of all critical care stays of any length involved an interhospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital positions were associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals’ centrality. Conclusions:Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.

/pdf/the-structure-of-critical-care-transfer-networks-vfr83212iv.pdf

The structure of critical care transfer networks

Standards have played an important role in the evolution of information and communication technology (ICT). ICTs are defined here as technologies dedicated to information processing, involving the use of digital computers and software to convert, store, protect, process, transmit, and retrieve information (Wikipedia 2005). These technologies, in general, establish the technological infrastructure upon which information system and applications are built.

https://misq.org/misq/downloads/download/editorial/17/

Standard making: a critical research frontier for information systems research

In this article, we describe the need for telemedicine standards and classify various standards of telemedicine. The emerging issues in telecommunications standards, the application of these standards in the health care industry, and future development directions of telemedicine standards are described. Especially, the telemedicine code standardization of drugs and health care providers, multimedia-conferencing-based ISO telemedicine standards, information security management, wireless technology advances for telemedicine using sensor networks, and future standardization issues and considerations are introduced and discussed in detail.

Telemedicine in the USA: standardization through information management and technical applications

Geographic information systems (GIS) are increasingly being used in public health and medicine. Advances in computer technology, the encouragement of its use by the federal government, and the wide availability of academic and commercial courses on GIS are responsible for its growth. Some view GIS as only a tool for spatial research and policy analysis, while others believe it is part of a larger emerging new science including geography, cartography, geodesy, and remote sensing. The specific advantages and problems of GIS are discussed. The greatest potential of GIS is its ability to clearly show the results of complex analyses through maps. Problems in using GIS include its costs, the need to adequately train staff, the use of appropriate spatial units, and the risk it poses to violating patient confidentiality. Lastly, the fourteen articles in this special issue devoted to GIS are introduced and briefly discussed.

Introduction: Geographic Information Systems in Public Health and Medicine

This study examined the extent to which health studies, mostly in public health and epidemiology, used geographical information systems (GIS). We identified a wide range of tools they used—ranging from geocoding through simple buffer/overlay functions to spatial query functions. However, studies tend to rely on tools outside of GIS for spatial statistical analyses. This may reflect a lack of spatial statistical tools that are suitable for health researchers whose data are rather geographically aggregated count data than continuous data. Implementation within GIS of spatial analytical tools suitable for aggregated data over a region will increase the use of GIS beyond simple GIS operations in health studies.

Health and GIS: Toward Spatial Statistical Analyses

Hospitals and other health-care providers today are being pressed more than ever to use technologies for reducing medical errors. Particularly, medication errors are likely to increase fast as Americans age. This paper intends to provide a starting point for understanding information technologies and database systems supporting such technologies as Computerized Physician Order Entry (CPOE), Automated Dispensing System (ADS), and Bar Coding System designed to reduce medication errors in hospitals. Although vendors provide the necessary communication software and applications, actions involving governments, technology vendors, pharmaceutical companies, and clinical researchers are needed to put to actual use the applications with a massive potential to significantly reduce medication-related errors.

Toward Efficient Medication Error Reduction: Error-Reducing Information Management Systems

We examined the level of hospice knowledge of caregivers of minority elderly hospice patients and determined how it influences the hospice enrollment decision and the decision on the use of hospice services after enrollment. Based on qualitative analysis of medical records and interviews with caregivers of minority elderly hospice patients who received personal care from paid caregivers (eg, other than family caregivers), we found that hospice knowledge increased access to hospice among minority patients who otherwise would not opt for hospice or enroll too late for comprehensive hospice care services. Furthermore, the highest level of knowledge-acquired through caregivers' health care occupations-appears to influence hospice care after hospice enrollment. Caregivers with that level of knowledge made requests for changes in site of care and/or additional services that may enhance the quality of hospice care that their loved ones receive.

/pdf/does-caregiver-knowledge-matter-for-hospice-enrollment-and-25jz9r1oa2.pdf

Kyusuk Chung

Papers

Telemedicine in the USA: standardization through information management and technical applications

Introduction: Geographic Information Systems in Public Health and Medicine

Health and GIS: Toward Spatial Statistical Analyses

Toward Efficient Medication Error Reduction: Error-Reducing Information Management Systems

Does caregiver knowledge matter for hospice enrollment and beyond? Pilot study of minority hospice patients.