Ethical and quality pitfalls in electronic health records

Developing a Digital Solution for Remote Assessment in Multiple Sclerosis: From Concept to Software as a Medical Device

There is increasing interest in the development and deployment of digital solutions to improve patient care and facilitate monitoring in medical practice, e.g., by remote observation of disease symptoms in the patients’ home environment. Digital health solutions today range from non-regulated wellness applications and research-grade exploratory instruments to regulated software as a medical device (SaMD). This paper discusses the considerations and complexities in developing innovative, effective, and validated SaMD for multiple sclerosis (MS). The development of SaMD requires a formalised approach (design control), inclusive of technical verification and analytical validation to ensure reliability. SaMD must be clinically evaluated, characterised for benefit and risk, and must conform to regulatory requirements associated with device classification. Cybersecurity and data privacy are also critical. Careful consideration of patient and provider needs throughout the design and testing process help developers overcome challenges of adoption in medical practice. Here, we explore the development pathway for SaMD in MS, leveraging experiences from the development of Floodlight™ MS, a continually evolving bundled solution of SaMD for remote functional assessment of MS. The development process will be charted while reflecting on common challenges in the digital space, with a view to providing insights for future developers.

Code status at time of rapid response activation - Impact on escalation of care?

Background

A code status documents the decision to receive or forgo cardiopulmonary resuscitation in the event of cardiac arrest. For patients who undergo a rapid response team activation (RRT) for possible escalation to an intensive care unit (ICU), the presence or absence of a code status represents a critical inflection point for guiding care decisions and resource utilization. This study characterizes the prevalence of code status at the time of RRT and how code status at RRT affects rates of intensive treatments in the ICU.

Methods

We conducted a single-center retrospective cohort study of 895 rapid response activations occurring over six months. The study included all rapid response team activations for non-obstetric adult inpatients documented in the patient chart. All data was obtained through retrospective chart review. STROBE reporting guidelines were followed.

Results

At the time of RRT activation, 56% of patients had a documented code status. Code status prevalence was much higher among medical rather than surgical services (74% vs. 13%). For patients escalated to the ICU, having a DNR code status at RRT was not associated with decreased odds of receiving cardioactive medications or advanced respiratory support. Before RRT activation, palliative care utilization was low (9%) but more than doubled after RRT (24% before discharge).

Conclusions

Barely half of the patients had an active code status at the time of RRT activation. Similar rates of invasive ICU treatments among full code and DNR patients suggest that documented code statuses do not reflect in-depth goals of care discussions, nor does it guide medical teams caring for the patient at times of decompensation.

The anatomy of electronic patient record ethics: a framework to guide design, development, implementation, and use

BACKGROUND

This manuscript presents a framework to guide the identification and assessment of ethical opportunities and challenges associated with electronic patient records (EPR). The framework is intended to support designers, software engineers, health service managers, and end-users to realise a responsible, robust and reliable EPR-enabled healthcare system that delivers safe, quality assured, value conscious care.

METHODS

Development of the EPR applied ethics framework was preceded by a scoping review which mapped the literature related to the ethics of EPR technology. The underlying assumption behind the framework presented in this manuscript is that ethical values can inform all stages of the EPR-lifecycle from design, through development, implementation, and practical application.

RESULTS

The framework is divided into two parts: context and core functions. The first part 'context' entails clarifying: the purpose(s) within which the EPR exists or will exist; the interested parties and their relationships; and the regulatory, codes of professional conduct and organisational policy frame of reference. Understanding the context is required before addressing the second part of the framework which focuses on EPR 'core functions' of data collection, data access, and digitally-enabled healthcare.

CONCLUSIONS

The primary objective of the EPR Applied Ethics Framework is to help identify and create value and benefits rather than to merely prevent risks. It should therefore be used to steer an EPR project to success rather than be seen as a set of inhibitory rules. The framework is adaptable to a wide range of EPR categories and can cater for new and evolving EPR-enabled healthcare priorities. It is therefore an iterative tool that should be revisited as new EPR-related state-of-affairs, capabilities or activities emerge.

Examination and diagnosis of electronic patient records and their associated ethics: a scoping literature review

Background

Electronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain.

Methods

To identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology.

Results

The medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters ‘privacy’, ‘autonomy’, ‘risk/benefit’, ‘human relationships’, and ‘responsibility’. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved.

Conclusions

While there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns.

[Ethics and medicine]

The article deals with the problem of ethical constituent both in medical and teaching practice. As to the medical practice, its ethical component is treated as an obligatory one, no matter what physician specialty is. That is why, the importance of ethical aspects in medicine increases greatly now. Neurology is one of the quickly developing disciplines, new data being obtained on etiology, pathogenesis, diagnostics and treatment of diseases previously considered incurable. Clinical tests of new drugs demand patients Informed Consent, this being one of the important ethical aspects of medical practice. The importance of the problem is illustrated by the examples of ethically unacceptable experiments on human beings in the United States after the Second World War and The Nuremberg Tribunal. Ethical issues that arise in the teaching process are considered. Ethical problems arising from the use of electronic technique of medical information storage are also analyzed. As to the teaching practice in higher medical institutions, its main ethical constituent concerns moral aspects of medical students training.

The stroke navigator: meaningful use of the electronic health record to efficiently report inpatient stroke care quality

To facilitate high-quality inpatient care for stroke patients, we built a system within our electronic health record (EHR) to identify stroke patients while they are in the hospital; capture necessary data in the EHR to minimize the burden of manual abstraction for stroke performance measures, decreasing daily time requirement from 2 hours to 15 minutes; generate reports using an automated process; and electronically transmit data to third parties. Provider champions and support from the EHR development team ensured that we balanced the needs of the hospital with those of frontline providers. This work summarizes the development and implementation of our stroke quality system.

Assessment of Doctors' Knowledge and Attitudes Towards Confidentiality in Hospital Care

The physician's duty of confidentiality is based on the observance of the patient's privacy and intimacy and on the importance of respecting both of these rights, thus creating a relationship of confidence and collaboration between doctor and patient. The main objective of this work consists of analyzing the aspects that are related to the confidentiality of patients' data with respect to the training, conduct and opinions of doctors from different Clinical Management Units of a third-level hospital via a questionnaire. The present study aimed to define the problem and determine whether the opinions of these professionals correspond to those observed in a previous work conducted at the same center. Of the 200 questionnaires that were collected, 62.5% were from consultants and the rest were from residents (37.5%) with an average of 14.4 ± 12.5 years in professional practice. The respondents noted habitual situations in which confidentiality was breached in the reference hospital (74%). The section on their attitudes and behaviors towards situations related to confidentiality showed a slightly lower average score than that of their medical knowledge; significant differences in these scores were observed between the consultants and residents as well as between the extreme age groups (≤ 30 vs. ≥ 51 years) and years of professional practice, thus more inadequate attitudes were consistently noted in younger doctors who had fewer years of experience. Finally, the respondents answered that the training of doctors in the aspects of healthcare law and ethics was the most important measure that the hospital could adopt regarding confidentiality practices.

A prospective investigation of direct and indirect home care activities in three rural Norwegian municipalities

BACKGROUND

Home care providers struggle to manage their day-to-day work, which is increasing in volume and complexity. In general, they are expected to achieve more with the same planning methods, resources, and capacity. To meet emerging needs and use the available resources more effectively and efficiently, evidence and strategies are needed to inform planning methods for home care services. However, limited data are available to inform this change. This paper investigated the amount of time used to carry out direct activities and six indirect activities across three rural Norwegian municipalities (M1, M2 and M3).

METHODS

Home care staff recorded data over 8 weeks in 2016; the majority of the staff used a smartphone application and some staff used a manual form to report the durations of the activities.

RESULTS

The median time spent on direct activities was 11-13 min, and this work constituted less than 50% of the total work in the three municipalities. The median driving time was 5-7 min, which accounted for 43-54% of the total indirect work. Administration, particularly reporting and documentation, displayed greater differences across the municipalities, together accounting for 38-50% of the total indirect time. M2 and M3 used substantially more time for documentation, including 20 min in M2 and M3, in contrast to only 1 min in M1. Similarly, the median reporting times were 30 min (M2) and 28 min (M3), compared with only 17 min in M1.

CONCLUSIONS

Home care staff spent less time on direct activities than on indirect activities, of which several activities have the potential for change. These results may help managers utilize resources effectively and plan appropriately, and they may also serve as a basis for future research to identify areas with improvement opportunities and, in turn, make more time available for direct patient care.

The pros and cons of digital health communication tools in neurosurgery: a systematic review of literature

Effective communication is critical in healthcare facilitation. Our aim is to illustrate the impact of digital communication tools in the field of neurosurgery based on the cumulative recently published reports to show an evidence-based review of both benefits and limitations. We performed a systematic review of records published from January 2003 to March 2018. A specific set of keywords such as "digital" and "communication" were used on PubMed database to conduct a thorough online search. 13 articles, out of 52, were comprehensively studied after complying with our inclusion and exclusion criteria. Many of the reviewed studies reported several applications of digital health communication tools in neurosurgery including 46% (6/13) in the Emergency Room and 23% (3/13) in the Operating Room. 38.5% (5/13) were applied in teaching hospitals. Reviewed studies were divided into two groups according to their applications (interventional (3/13) and non-interventional (10/13)). In the Emergency Room, digital health tools facilitated timely diagnosis and management, while in the operating room it permitted revolutionary robotic surgery. It showed potential for "no-risk learning" at academic institutions. While the fruitful impacts were convincing of the digital communication tools' ability to enhance healthcare in neurosurgery, proper adherence to regulations against data loss and theft, two potential complications of digital tool misuse, must be maintained. Additionally, both time efficiency and the necessity of waiting for better implementation of communication tools proved to be obstacles to consistent digital tool integration.

Digital Care in Epilepsy: A Conceptual Framework for Technological Therapies

Epilepsy is associated with a significant increase in morbidity and mortality. The likelihood is significantly greater for those patients with specific risk factors. Identifying those at greatest risk of injury and providing expert management from the earliest opportunity is made more challenging by the circumstances in which many such patients present. Despite increasing recognition of the importance of earlier identification of those at risk, there is little or no improvement in outcomes over more than 30 years. Despite ever increasing sophistication of drug development and delivery, there has been no meaningful improvement in 1-year seizure freedom rates over this time. However, in the last few years, there has been an increase in patient-triggered interventions based on automated monitoring of indicators and risk factors facilitated by technological advances. The opportunities such approaches provide will only be realized if accompanied by current working practice changes. Replacing traditional follow-up appointments at arbitrary intervals with dynamic interventions, remotely and at the point and place of need provides a better chance of a substantial reduction in seizures for people with epilepsy. Properly implemented, electronic platforms can offer new opportunities to provide expert advice and management from first presentation thus improving outcomes. This perspective paper provides and proposes an informed critical opinion built on current evidence base of an outline techno-therapeutic approach to harnesses these technologies. This conceptual framework is generic, rather than tied to a specific product or solution, and the same generalized approach could be beneficially applied to other long-term conditions.

The effect of electronic health records on patient safety: A qualitative exploratory study

BACKGROUND

Electronic health records (EHRs) are increasingly used in healthcare settings and it is believed that they have brought benefits to patients and healthcare services alike. Few previous studies, however, have explored the impact of these records on patient safety.

AIM

The overall purpose of this study was to explore the effect of EHRs on patient safety, as perceived by nurses.

METHODS

This qualitative exploratory study was conducted using semi-structured interviews with staff nurses working in hospitals that employed the same EHR system in Jordan. Seventeen nurses were interviewed working in various units and wards of ten hospitals which had used EHRs between 1 and 5 years. Field notes were taken during interviews and analyzed thematically.

RESULTS

Two major themes emerged from the data. One regarded the enhancements that EHRs have made to patient safety; and the other surrounded concerns raised by the use of these systems. Under each main theme there were four subthemes. EHRs directly or indirectly improved patient safety by minimizing medication errors, improving documentation of data, enhancing the completeness of data, and improving the sustainability of data. The interviewees expressed concern that the following may jeopardize patient safety: data entry errors, technical problems, minimal clinical alerts, and poor use of system communication channels.

CONCLUSION

A range of opinions were reported by the interviewees, from being fully supportive of EHRs to being reluctant to agree with the idea that they can improve patient safety. However, the concerns raised by the interviewees might be associated with poor system design or improper human use of the system. Thus, it is necessary to design systems with specifications that support patient safety and, moreover, involving nurses in this process might facilitate this outcome.

Satisfaction with Paper-Based Dental Records and Perception of Electronic Dental Records among Dental Professionals in Myanmar

Objectives

To overcome challenges in the implementation of electronic dental record systems in a low-resource setting, it is crucial to know the level of users’ satisfaction with the existing system of paper-based dental records and their perceptions of electronic dental records.

Methods

A cross-sectional paper-based questionnaire survey was conducted among Myanmar dental professionals who worked in one of two teaching hospitals or in private dental clinics. Descriptive data were analyzed and regression analysis was carried out to identify factors influencing perceptions of electronic dental records.

Results

Most dental professionals (>60%) were satisfied with just three out of six aspects of paper-based dental records (familiarity, flexibility, and portability). In addition, generalized positive perceptions were found among decision makers towards electronic dental records, and 86% of dentists indicated that they were willing to use them. Financial concerns were identified as the most important barrier to the implementation of electronic dental records among dentists who were not willing to use the proposed system.

Conclusions

The first step towards implementing electronic dental records in Myanmar should be improvement of the content and structure of paper-based dental records, especially in private dental clinics. Utilization of appropriate open-source electronic dental record software in private dental clinics is recommended to address perceived issues around financial barriers. For the long term, we recommend providing further education and training in health informatics to healthcare professionals to facilitate the efficient use of electronic dental record software in Myanmar in the future.

Patient-centered communication in the era of electronic health records: What does the evidence say?

OBJECTIVE

Patient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known.

METHOD

A comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis.

RESULTS

Results indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management.

CONCLUSION

More rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care.

PRACTICE IMPLICATIONS

Training alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians' and patients' abilities to effectively communicate.

Natural Language Processing-Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A Comparative Usability Study

Background

The process of documentation in electronic health records (EHRs) is known to be time consuming, inefficient, and cumbersome. The use of dictation coupled with manual transcription has become an increasingly common practice. In recent years, natural language processing (NLP)–enabled data capture has become a viable alternative for data entry. It enables the clinician to maintain control of the process and potentially reduce the documentation burden. The question remains how this NLP-enabled workflow will impact EHR usability and whether it can meet the structured data and other EHR requirements while enhancing the user’s experience.

Objective

The objective of this study is evaluate the comparative effectiveness of an NLP-enabled data capture method using dictation and data extraction from transcribed documents (NLP Entry) in terms of documentation time, documentation quality, and usability versus standard EHR keyboard-and-mouse data entry.

Methods

This formative study investigated the results of using 4 combinations of NLP Entry and Standard Entry methods (“protocols”) of EHR data capture. We compared a novel dictation-based protocol using MediSapien NLP (NLP-NLP) for structured data capture against a standard structured data capture protocol (Standard-Standard) as well as 2 novel hybrid protocols (NLP-Standard and Standard-NLP). The 31 participants included neurologists, cardiologists, and nephrologists. Participants generated 4 consultation or admission notes using 4 documentation protocols. We recorded the time on task, documentation quality (using the Physician Documentation Quality Instrument, PDQI-9), and usability of the documentation processes.

Results

A total of 118 notes were documented across the 3 subject areas. The NLP-NLP protocol required a median of 5.2 minutes per cardiology note, 7.3 minutes per nephrology note, and 8.5 minutes per neurology note compared with 16.9, 20.7, and 21.2 minutes, respectively, using the Standard-Standard protocol and 13.8, 21.3, and 18.7 minutes using the Standard-NLP protocol (1 of 2 hybrid methods). Using 8 out of 9 characteristics measured by the PDQI-9 instrument, the NLP-NLP protocol received a median quality score sum of 24.5; the Standard-Standard protocol received a median sum of 29; and the Standard-NLP protocol received a median sum of 29.5. The mean total score of the usability measure was 36.7 when the participants used the NLP-NLP protocol compared with 30.3 when they used the Standard-Standard protocol.

Conclusions

In this study, the feasibility of an approach to EHR data capture involving the application of NLP to transcribed dictation was demonstrated. This novel dictation-based approach has the potential to reduce the time required for documentation and improve usability while maintaining documentation quality. Future research will evaluate the NLP-based EHR data capture approach in a clinical setting. It is reasonable to assert that EHRs will increasingly use NLP-enabled data entry tools such as MediSapien NLP because they hold promise for enhancing the documentation process and end-user experience.

The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System

BACKGROUND

The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied.

OBJECTIVE

We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices.

METHODS

This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note.

RESULTS

Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42].

CONCLUSION

Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation.

Use of a Bundle Checklist Combined With Physician Confirmation Reduces Risk of Nosocomial Complications and Death in Trauma Patients Compared to Documented Checklist Use Alone

BACKGROUND

Bundle checklists are increasingly utilized in patient care, but data are inconsistent regarding their efficacy in reducing nosocomial complication rates. We examined whether checklist usage was associated with nosocomial complications; when documented, elements were verified by provider bedside rounds.

METHODS

We performed a retrospective cohort study of trauma patients admitted to our hospital during a three-phase implementation of a quality improvement project. For this analysis, patients were categorized under predocumentation (PD), documentation only (DO), or documentation with provider review (PR) cohort based on temporal designations. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between documentation cohorts and nosocomial complications.

RESULTS

No difference was observed in mean hospital stay, intensive care unit (ICU) days, or ventilator days. The DO cohort showed no significant differences in the risk of complications. Among ICU patients, when compared with the PD cohort, the PR cohort demonstrated a decreased risk of all complications OR 0.72 (95% CI 0.55-0.93), pulmonary embolus OR 0.29 (95% CI 0.11-0.73), pneumonia OR 0.66 (95% CI 0.50-0.88), and death OR 0.50 (95% CI 0.31-0.79).

CONCLUSIONS

Bedside confirmation of bundle checklists during physician extender rounds reduces the risk of pulmonary embolus, pneumonia, and death when compared to chart documentation alone. This study underscores the importance of the team approach to the bundle checklist and it's ability to reduce morbidity and mortality.

Improving diagnostic accuracy using EHR in emergency departments: A simulation-based study

It is widely believed that Electronic Health Records (EHR) improve medical decision-making by enabling medical staff to access medical information stored in the system. It remains unclear, however, whether EHR indeed fulfills this claim under the severe time constraints of Emergency Departments (EDs). We assessed whether accessing EHR in an ED actually improves decision-making by clinicians. A simulated ED environment was created at the Israel Center for Medical Simulation (MSR). Four different actors were trained to simulate four specific complaints and behavior and 'consulted' 26 volunteer ED physicians. Each physician treated half of the cases (randomly) with access to EHR, and their medical decisions were compared to those where the physicians had no access to EHR. Comparison of diagnostic accuracy with and without access showed that accessing the EHR led to an increase in the quality of the clinical decisions. Physicians accessing EHR were more highly informed and thus made more accurate decisions. The percentage of correct diagnoses was higher and these physicians were more confident in their diagnoses and made their decisions faster.

Special requirements for electronic medical records in neurology

Electronic medical records (EMRs) are being rapidly adapted in the United States with goals of improving patient care, increasing efficiency, and reducing costs. Neurologists must become knowledgeable about the utility and effectiveness of the important parts of these systems specifically needed for care of neurology patients. The field of neurology encompasses complex disorders whose diagnosis and management heavily relies on detailed medical documentation of history and physical examination, and often on specialty-specific ancillary tests and extensive neuroimaging. Small discrepancies in documentation or absence of an in-hand ancillary test result can drastically change the current workup or treatment decision of a complex patient with neurologic disease. We describe current models and opportunities for improvements to EMRs that provide utility and efficiency in the care of neurology patients.

Advanced technology and confidentiality in hand surgery

Advanced technology has the potential to improve the quality of care for our patients, but it also poses new challenges, especially in maintaining patient confidentiality. The Health Insurance Portability and Accountability Act and the newly enacted Health Information Technology for Economic and Clinical Health Act provide certain guidelines governing patients' medical record confidentiality. This article discusses the other new challenges facing hand surgeons, such as the use of social media, telemedicine, e-mails, and the Internet.

Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments

Recently, the healthcare sector has shown a growing interest in information technologies. Two popular health IT (HIT) products are the electronic health record (EHR) and health information exchange (HIE) networks. The introduction of these tools is believed to improve care, but has also raised some important questions and legal and privacy issues. The implementation of these systems has not gone smoothly, and still faces some considerable barriers. This article reviews EHR and HIE to address these obstacles, and analyzes the current state of development and adoption in various countries around the world. Moreover, legal and ethical concerns that may be encountered by EHR users and purchasers are reviewed. Finally, links and interrelations between EHR and HIE and several quality of care issues in today's healthcare domain are examined with a focus on EHR and HIE in the emergency department (ED), whose unique characteristics makes it an environment in which the implementation of such technology may be a major contributor to health, but also faces substantial challenges. The paper ends with a discussion of specific policy implications and recommendations based on an examination of the current limitations of these systems.

Public policy and healthcare systems

Public policy in healthcare affects physician and patient choices. In many ways it may limit choices. These choices present conflicts that are discussed here. Some issues depend on the laws enacted to enable either a single-payer system or that mixed with a private-payer system. In each case, the systems attain some cost controls through means such as gatekeepers, long wait lists, authorization processes, national fee schedules, complex coding schemes, or placing physicians on salary. National health systems are compared here. No one system has proven completely satisfactory, and each has its advantages. There are many factors that contribute to the escalating costs of care that lead to many healthcare public policies to constrain costs. Initiatives to incentivize preventive actions are a more positive step, but ones that are difficult to define in detail.

Tissue banking, bioinformatics, and electronic medical records: the front-end requirements for personalized medicine

Personalized medicine promises patient-tailored treatments that enhance patient care and decrease overall treatment costs by focusing on genetics and "-omics" data obtained from patient biospecimens and records to guide therapy choices that generate good clinical outcomes. The approach relies on diagnostic and prognostic use of novel biomarkers discovered through combinations of tissue banking, bioinformatics, and electronic medical records (EMRs). The analytical power of bioinformatic platforms combined with patient clinical data from EMRs can reveal potential biomarkers and clinical phenotypes that allow researchers to develop experimental strategies using selected patient biospecimens stored in tissue banks. For cancer, high-quality biospecimens collected at diagnosis, first relapse, and various treatment stages provide crucial resources for study designs. To enlarge biospecimen collections, patient education regarding the value of specimen donation is vital. One approach for increasing consent is to offer publically available illustrations and game-like engagements demonstrating how wider sample availability facilitates development of novel therapies. The critical value of tissue bank samples, bioinformatics, and EMR in the early stages of the biomarker discovery process for personalized medicine is often overlooked. The data obtained also require cross-disciplinary collaborations to translate experimental results into clinical practice and diagnostic and prognostic use in personalized medicine.