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This vision must energize a wide range of leadership cheap hyzaar 12.5 mg visa blood pressure goals, endure over the course of years order discount hyzaar line blood pressure chart images, and be of sufﬁcient clarity to guide a range of decisions buy cheap hyzaar 50mg arteria coronaria dextra. Asset development falls squarely on the shoulders of the organization’s administrative and medical staff leadership and its board purchase hyzaar 12.5mg online blood pressure chart by time of day. The ﬁrst asset is leadership that is smart, honest, seasoned, and committed and that values the healthy exchange of ideas. They viii Foreword ask hard questions and are pragmatic; they are superb practitioners of the art of the possible. The second asset is the ability to effect change, at times dramatic change, in work processes, culture, and organizational competen- cies. This ability requires developing and communicating a vision, political skill in mobilizing stakeholders, stamina, and the willing- ness to learn. It also means the organizations take steps to mitigate the many factors that often impede their ability to effect change, such as fuzzy goals, poor management of implementations, and failure to put someone in charge. The third asset is prowess in a small number of critical areas of information systems implementation. Superb support is the factor that causes an application to “stick,” to become an integral part of the fabric of practice. Support includes training, responsive enhancements, ongoing communication and discussion of status and problems, and evolution of work and clinical policies and pro- cedures. Workﬂow must be thoroughly understood; at times the workﬂow must be reengineered, and at times the application must be reengineered. Solid and effective relationships must be established between information systems professionals and users. This relationship is one of realism about the systems and the changes they will bring and one in which there are shared goals and a mutual interest in learning from each other. Clin- ical information systems must have a technical foundation that is reliable, high performance, secure, supportable, and adaptable. Few things cripple a clinical information system as quickly as a slow or unreliable infrastructure. Limited ability to enhance applications or augment them with new technologies can result in a poor ﬁt be- tween an application and the clinical workﬂow and in a failure of the application to adapt as organizations and patient care evolve. Poorly Foreword ix designed applications may not weaken as rapidly as an infrastructure that crashes routinely, but they do weaken. Information technology is an extraordinarily potent contribu- tor to our collective efforts to improve the delivery of healthcare. All segments of the healthcare industry must work together and contribute for this vision to occur. He has the remarkable ability to clearly and insightfully write about exceptionally complex topics. He describes emerging information technologies and challenges to our ability to deliver superb healthcare. Jeff highlights the convergence of these technologies and these challenges and sets the stage for a new era of healthcare. This book will serve its readers well as they lead their organiza- tions into this new era. What I learned both encouraged and excited me, and you will ﬁnd the reasons for that excitement in the pages that follow. The Internet “bubble” created a tremendous stir in equity mar- kets, the media, and society in general before bursting ignomin- iously in 2000 and taking more than a trillion dollars of investors’ capital with it. In healthcare, an immense economic sector that moves very slowly, the Internet was like an unidentiﬁed ﬂying ob- ject that ﬂew in one window and out the other without even denting the walls, leaving observers wondering what all the fuss was about. As I surveyed the technology, however, I became convinced that several innovations would have a more powerful impact on reshap- ing healthcare institutions and the processes of medicine themselves than the Internet. Moreover, these innovations—computer-assisted molecular and cellular diagnosis, computerized clinical decision support and artiﬁcial intelligence, telemedicine (enabling diagnosis of and intervention in illness from a distance), wireless and mobile computing applications, as well as affordable connectivity through the broadband Internet—were converging in a single complex new tool, the so-called “electronic medical record. As it develops in the next decade, it will not be a historic record of what was done to patients (enabling providers to bill for their services) so much as a navigational tool for physicians and the care team to help them guide patients and their families to a healthier place. To forecast where these technologies are headed and how they will affect the major ac- tors in health system—hospitals, physicians, consumers, and health plans—seemed like a worthy subject for a book. It then explores how emerging information technologies will affect hospitals, physicians, consumers, and health plans and how their relationships will change as they take up and use these new tools. All these actors crave a more satisfying role in the healthcare xii Preface process and yet will not, in some unqualiﬁed way, embrace impor- tant changes that they do not understand or do not believe will help them. The book also examines the growing absence of ﬁt between our healthcare payment framework and other policies and the emerg- ing capacity to organize healthcare digitally. It discusses what poli- cymakers need to do to speed the transformation in the healthcare system and the leadership challenge involved in bringing about that transformation. The technologies discussed herein are real, and their potential for helping create a more respon- sive, safer, and more effective health system is enormous. Disciplining technology and those who create it to meet our needs is the ultimate task of leadership. To achieve the transformation in healthcare that society de- serves will require enlightened leadership—in the health professions and healthcare management and from government policymakers. It will also require a willingness on the part of healthcare practi- tioners and managers to understand and master the technologies themselves—to adapt them, play with them, and collaborate with those who create them—to make them easier to adopt and use. This book seeks to inspire a new generation of health- care professionals and managers to understand, master, and deploy these powerful new tools. Jeff Goldsmith May 2003 Preface xiii Acknowledgm ents Many people assisted in making this book possible. Neal Patterson, chairman and founder of Cerner Corporation, a pioneer- ing healthcare informatics ﬁrm, opened the door by inviting me to serve on Cerner’s board of directors. Gartner executives and analysts Jim Adams, Dave Garets (now of HealthLink), Janice Young, Thomas Handler, Wes Rishel, and Ken Kleinberg all contributed knowledge and ideas for this book. Christine Malcolm, formerly of Computer Sci- ences Corporation, now of Rush-Presybterian–St. On the hospital side, John Glaser, chief information ofﬁcer at Partners HealthCare in Boston; David Blumenthal, director at the Institute for Health Policy and Physician at The Massachusetts Gen- eral Hospital/Partners HealthCare System; and Michael Koetting, vice president of planning at the University of Chicago Hospitals, were kind enough to read the manuscript and offer valuable advice on how to make it clearer, sharper, and more relevant. By happy coincidence, the University of Virginia is a hotbed of medical informatics activity and thought. Several Charlottesville colleagues helped early in the process to shape the book’s premise and focus on physicians. Robin Felder, professor of pathology and director of the University of Virginia’s Medical Automation Re- search Center, helped me understand the rapid advances in remote sensing technology and their future role in preventive health. On the scientiﬁc front, a fellow Cerner board member, William Neaves, president of the Stowers Institute; Paul Berg, professor emeritus of Stanford University; and George Poste, former chief scientiﬁc ofﬁcer of Smith Kline Beecham, helped shed light on ad- vances in genetic diagnosis. Steven Burrill of Burrill and Company, a biotechnology investment bank, has produced superb analyses of the role of information technology in advancing genetic diagnosis and therapy.
Domenighetti G purchase hyzaar 12.5mg with visa pulse pressure fitness, Moccia A order 50mg hyzaar otc hypertension vasoconstriction, Gayer R: Observational case-control with the acute respiratory distress syndrome 50 mg hyzaar with mastercard blood pressure medication nerve damage. Chest 1997 purchase 50mg hyzaar mastercard hypertension questionnaires; 111:1008–1017 patients in intensive care (Awakening and Breathing Controlled 264. Crit Care Med 1998; 26:1977–1985 observer variability in measurement of pulmonary artery occlusion 266. Am J Respir Crit Care Med 1999; 160:415–420 positioning in hypoxemic acute respiratory failure: A randomized 287. N Engl J Med 1983; 308:263–267 Prone positioning in patients with moderate and severe acute respi- 288. Osman D, Ridel C, Ray P, et al: Cardiac flling pressures are not ratory distress syndrome: A randomized controlled trial. 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Chronic diseases and their major risk factors place huge economic demands on our nation buy generic hyzaar line useless eaters hypertension zip. For example discount hyzaar 12.5 mg otc heart attack billy, from 1987 through 2001 discount hyzaar generic blood pressure quotes, increases in obesity prevalence alone accounted for 12% of the growth in health spending purchase hyzaar cheap online arrhythmia icd 10 code. In 30 years, the number of Ameri- Estimated Annual Direct Medical Expenditures* cans aged 65 years or older is expected to double,44 generating a 25% increase in Cardiovascular disease and stroke** $313. Smoking $96 billion in 2004***23 Diabetes $116 billion in 200749 Complementing this trend is the expected Arthritis $80. Without concerted strategic intervention, chronic diseases and their risk factors can be expect- ed to cause more harm—and be more costly to society. We cannot effectively address escalat- ing health care costs without addressing the problem of chronic diseases. Chronic disease prevention, to be most effective, must oc- cur in multiple sectors and across individuals’ entire life spans. Prevention encompasses health promotion activities that encourage healthy living and limit the initial onset of chronic diseases. Prevention also embraces early detection efforts, such as screening at-risk populations, as well as strategies for appropriate management of existing diseases and related complications. The health benefts of quitting smoking are numerous, and many are experienced rapidly. Within 2 weeks to 3 months after quitting, heart attack risk begins to drop and lung function begins to improve. Fifteen years after quitting, an ex-smoker’s risk for heart disease is about the same as that of a lifelong nonsmoker. Lifestyle changes in diet and exercise, including a 5%–7% maintained weight loss and at least 150 minutes per week in physical activity, can prevent or delay the onset of type 2 dia- betes for Americans at high risk for the disease. Their efforts resulted in a sustained weight loss of about 10 to 15 pounds, reducing their risk of getting diabetes by 58%. An adult with healthy blood pressure and healthy blood cholesterol levels has a greatly reduced risk for cardiovascular disease. A 12- to 13-point reduction in systolic blood pressure can reduce cardiovascular disease deaths by 25%,54 and a 10% decrease in total cholesterol levels reduces the risk for coronary heart disease by 30%. A study of the Toward No Tobacco program, which was designed to prevent cigarette use among middle and high school students, found that for every dollar invested in school tobacco prevention pro- grams, almost $20 in future medical care costs would be saved. In one study of communities with at least 20,000 residents, every $1 invested in community water fuoridation yielded about $38 in savings from fewer cavities treated. For women aged 40 years or older, mammograms every 12–33 months signifcantly reduce mortality from breast cancer. Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50% to 60%. Researchers and practitioners at national, state, and local levels have designed, tested, and implemented effective programs and policies for chronic disease prevention and control, many at very little cost. For example, Trust for America’s Health estimates that an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years. Whether healthy or ill, a person spends far more time outside the physician’s offce than inside it. Of special concern are the 46 million uninsured Americans under the age of 65 who have limited coverage for health care services. It is es- sential to have a coordinated, strategic prevention approach that promotes healthy behaviors, expands early detection and diagnosis of disease, supports people of every age, and eliminates health disparities. With community-based public health efforts that embrace prevention as a pri- ority, we can become a healthier nation. The function of protecting and developing health must rank even above that of restoring it when it is impaired. To realize this vision, the nation must harness the collective capacity and energy of communities, health care professionals, voluntary and professional organizations, the private sector, govern- mental agencies, and academic institutions to take tangible action in the following key areas: well-being, policy promotion, health equity, research translation, and workforce development. Strategies are needed to facilitate and support individual responsibility and behavior change at schools and workplaces and in faith-, community-, and medical-based settings, such as: • School-based strategies that foster environments and instruction that promote healthy eating, daily physical activity, sun protection, and the avoidance of tobacco, alcohol, and illicit drugs. Policy promotion Policy and environmental changes can affect large segments of the population simultaneously. Adopting healthy behaviors is much easier if we establish supportive community norms and adopt a philosophy that embraces health in all policies and settings. We must promote proven social, environmental, policy, and systems approaches that support healthy living for individuals, families, and communities, such as: • Urban design and land-use strategies that lead to increased physical activity, as well as changes to transportation and travel policy and infrastructure that reduce dependence on motorized transport and increase physical activity. Health equity Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances. To ensure health equity, we must: • Increase health promotion efforts targeting social determinants of health, such as increased access to affordable healthy food options in underserved communities through the development of community gardens, as well as taxing and zoning policies that encourage the development of full-service grocery stores in neighborhoods where they are lacking. Examples include early childhood education, work-study programs that improve graduation rates and access to secure employment with livable wages, and employer- sponsored health promotion programs for blue-collar and low-wage workers. Research translation Promising research fndings are relevant only when they reach the people they are designed to serve. Key scientifc advances must be applied and evaluated, refected in state and local health policies, and widely adopted as community practices across the country. We must: • Support community-based prevention research to identify the causes of health inequities and the best ways to provide resources needed for health and access to high-quality preventive care and clinical services. Workforce development A skilled, diverse, and dynamic public health workforce and network of partners is crucial to promote health and prevent chronic disease at the national, state, and local levels. We must work toward the day when: • Every state has a strong, adequately funded chronic disease prevention program. Prevalence of disabilities and associated health conditions among adults—United States, 1999. Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke—United States, 2003. Prevalence of doctor-diagnosed arthritis and arthritis-at- tributable activity limitation—United States, 2003–2005. Racial/ethnic differences in the prevalence and impact of doctor-diagnosed arthritis—United States, 2002. The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions—United States, 2003. The Surgeon General’s call to action to prevent and decrease overweight and obesity.
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