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Establishment of E-Health Network for Disasters and Healthcare Improvement: Integrated Medical Information Technology System Partner concept between Academies and Medical entities Yukako Yagi University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Background: Why E-Health Network?.

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Establishment of E-Health Network for Disasters and Healthcare Improvement: Integrated Medical Information Technology System

Partner concept between Academies and Medical entities

Yukako Yagi

University of Pittsburgh Medical Center, Pittsburgh, PA, USA


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Background: Why E-Health Network? Healthcare Improvement: Integrated Medical Information Technology System

In March 1, 2001, the Institute of Medicine (IOM) stated that:

  • “The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive. Health care today harms too frequently and routinely fails to deliver its potential benefits.”

  • The difficulty in maximizing the benefits of increased clinical and business knowledge and advanced diagnostic technologies comes from the basic problem of collecting, integrating and managing health information in various formats. Further, this data is stored in multiple physical locations that are often distant and hard to access when treating individual patients, especially those with critical medical needs.

    “use of information technology is key”


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University of Pittsburgh Medical Center Healthcare Improvement: Integrated Medical Information Technology System


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Employees Healthcare Improvement: Integrated Medical Information Technology System

More than 35,000

Physicians

More than 5,000

Hospitals

20 + Overseas hospitals

Primary Service Area

29 western Pennsylvania counties

UPMC Doctors' Offices

More than 400 throughout the primary service area

Rehabilitation Centers

More than 65 hospital and outpatient facilities in the growing UPMC Rehabilitation Network

Retirement and Long-term Care

8 skilled nursing units in hospitals12 freestanding facilities offering independent living, assisted living, and skilled nursing options

UPMC has established Telemedicine Network through the system:

Facts and Figures


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Overview: Program Description Healthcare Improvement: Integrated Medical Information Technology System

  • looking increasingly towards technology-assisted solutions to optimize how they manage and deliver health care.

  • Non-Civilian Medical Facilities (NCMF) and UPMC have created a partnership to collaborate on developing technology-assisted solutions to real-world medical problems

    The partnership is defined as the Integrated Medical Information Technology System (IMITS) Program.


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Overview: Program Description Healthcare Improvement: Integrated Medical Information Technology System

  • The IMITS program pioneers the application of state-of-the-art information management (IM) and information technology (IT) solutions, including advanced business and clinical decision support tools. This initiative brought together vast clinical and information technology expertise of both institutions and aids in the recognition and treatment of many types of medical conditions. In addition, the NCMS-UPMC partnership is providing new opportunities for enhancing expertise, evaluating solutions to technical dilemmas, and deploying strategies to address key medical issues.


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IMITS Project Healthcare Improvement: Integrated Medical Information Technology System

  • Congressional Special Interest Appropriation:

    • FY02: $8.5M - Establish initial project: Integrated Medical Information Technology System

    • FY04: $10.2M - Continue current projects & expand into Pacific Rim


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Scope Healthcare Improvement: Integrated Medical Information Technology System

  • The initial focus of the IMITS Program was on telemedicine and associated advanced technologies. The overall program objective is the design of new state-of-the-art clinical and business models supporting the delivery of fully electronic multi-media enabled electronic health records. The projects described below will be organized under the umbrella of the IMITS Program.


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Scope: Healthcare Improvement: Integrated Medical Information Technology SystemMulti-specialty Tele-consultation Project

Situations:

  • There are many medical facilities in locations where specialty medical care is not readily available.

  • Patients often must travel significant distances and taking time off from work.

  • Resulting in:

  • Expense to both the patient and the enterprise

  • A delay in the diagnosis and treatment of the presenting medical condition

Solutions


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Scope: Multi-specialty Tele-consultation Project Healthcare Improvement: Integrated Medical Information Technology System

Solutions

  • Developing and refining computerized medical records, enhancing medical information retrieval and patient tracking, and creating clinical decision support rapidly increases the capability to provide high quality cost-effective medical care to non-civilian beneficiaries and civilians in even the most remote locations.

  • To design, build and test a multi-specialty teleconsultation system on a common technology platform. This system will provide widely available, flexible, clinically relevant services across multiple medical specialties on a secure, stable low cost technology platform utilizing asynchronous and synchronous communications. This will allow general clinicians and medical personnel access to remote expert advice, diagnosis and mentoring and in so doing contribute to providing a high-quality standard of care independent of location.


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Scope Healthcare Improvement: Integrated Medical Information Technology System

The Multi-specialty Tele-consultation Demonstration Project was divided into the following areas:

  • Distributed Radiology Imaging Demonstration Project – The design and implementation of a distributed radiology imaging system utilizing the Stentor platform at a medical facility in Dayton, Ohio. The system was connected to UPMC linking the radiology departments for education and service opportunities.

  • Pathology Tele-consultation System Demonstration Project – The design and implementation of a telepathology system at a facility in Mississippi. The system is connected to UPMC linking the pathology departments for education and service opportunities.

  • Behavioral Health Tele-consultation System Demonstration Project - The design and implementation of a behavioral telehealth system at a facility in Texas. The system connects to UPMC linking the behavioral health resources for education and service opportunities.

  • Pediatric Cardiology Tele-consultation System Demonstration Project


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

  • A high-level project work plan will be included in the individual scope of work documents. The main focus of the program will be on the implementation of tele-consultation applications. The tele-consultation implementation work plans have been developed based on a standard implementation methodology and are organized into seven major segments with corresponding activities as follows:


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

I. Project Set-Up

Confirm project governance and organization structure.

Confirm project roles and responsibilities.

Confirm communication structures.

Confirm methodology approach.


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

II. Analysis

Conduct application education and training.

Document functional and technical requirements.

Assess hardware, interfaces and network.

Document software requirements, conversion decisions, and data standard initiatives.

Identify training needs and sites.


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

III. Design

Complete system design.

Develop conversion specifications and interface specifications.

Identify data standards and file setups, customizations, and security requirements.


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

IV. Development

Complete system build.

Begin programming conversions, interfaces, and customizations.

Develop new policies and procedures.

Develop menus, forms, reports and screens.


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

V. Testing

Define testing scope and approach.

Identify testing team.

Develop integrated and product specific test plans/scenarios.

Conduct testing – system acceptance, unit, application, integration, stress, security and network/communications testing.


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

VI. Training

Develop training plan and materials.

Schedule and conduct user training.


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Approach/Strategy Healthcare Improvement: Integrated Medical Information Technology System

VII. Conversion/Post-Live Support

Develop go-live plan.

Identify support team for go-live.

Determine conversion downtime requirements and system freeze dates.

Prepare contingency plans.

Perform conversion.

Identify post-live issues team.

Initiate post-live support and transition.


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FY 01-02 IMITS Healthcare Improvement: Integrated Medical Information Technology System


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FY 01-02 IMITS Healthcare Improvement: Integrated Medical Information Technology System

  • Business Problem

    • Shortage of specialty physicians

      • NCMF high priority Radiology

  • Goal

    • Improve access to care and provide quality healthcare services to individuals regardless of location


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FY 01-02 Healthcare Improvement: Integrated Medical Information Technology SystemIMITS ProgramImplementation Overview

  • Extended period to move money and negotiate agreement

  • Pre-award implementation of Radiology project to meet NCMF requirements to replace legacy systems

  • Rigorous security requirements that necessitated adjustments to project timelines


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IMITS Program Healthcare Improvement: Integrated Medical Information Technology SystemDistributed Imaging

  • Dayton, OH

  • Installation of Stentor iSite COTS

  • UPMC customizations for NCMF’s workflow, global hub and spoke strategy

  • Replaces legacy PACs system

  • Establishes footprint for global NCMF image distribution infrastructure

  • Evaluation of provider acceptance and satisfaction


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FY 01-02 Healthcare Improvement: Integrated Medical Information Technology SystemIMITS ProjectsDistributed Imaging

  • Current Status

    • July 1, 2003 - Technical “go-live”

    • August 27, 2003 - Clinically live on private subnet

    • November 14, 2003 – Notified of impending final security accreditation

    • November 24, 2003 – Move from private subnet to live radiology network

    • January 20, 2004 – Clinical “go-live”

    • February 2004 – Begin UPMC customization

    • March 2004 – UPMC Radiologist wrapper installed

    • May 2004 – Clinician wrapper installed

    • June 2004 – ST&E for upgrade to iSite v3.2


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IMITS Program Healthcare Improvement: Integrated Medical Information Technology SystemTelepathology

  • Biloxi, MS

  • Installation of UPMC Static Telepathology (Mississippi, Florida, California)

  • Installation of dynamic telepathology for educational purposes (Mississippi, Florida, California)

  • R&D on whole slide imaging (Mississippi, Pittsburgh)

  • Progressive technology for imaging and storage of pathology specimens

  • Evaluation of provider acceptance and satisfaction


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IMITS Projects Healthcare Improvement: Integrated Medical Information Technology SystemTelepathology

  • Current Status

    • Feb 2003 – Version 1 Security Documents submitted for approval

    • July 2003 – Updates to Version 1 submitted

    • Sept 2003 – Version 2 Security Documents submitted for approval

    • Oct 2003 – Initial lab certification at DSI

    • Nov 2003 – Awaiting report of certification testing

    • Jan 2004 – Certification re-test

    • Feb 2004 – Awaiting IATO

    • April 2004 – IATO obtained

    • May 2004 – Awaiting CTO

    • June 2004 – CTO obtained

    • August 2004 – Final ST&E scheduled


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IMITS Projects Healthcare Improvement: Integrated Medical Information Technology SystemPediatric Tele-echocardiography

  • Current Status

    • Dec 2003 Installation equipment at all bases

    • Jan 2004 – Equipment installed

    • Mar 2004 – Awaiting ISDN re-install

    • May 2004 – Clinically live

    • Jun 2004 – Beta cases


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IMITS Program Healthcare Improvement: Integrated Medical Information Technology SystemPediatric Tele-echocardiography

  • Biloxi, MS

  • Implementation of Pediatric Tele-echo system modeled after Children’s Hospitals in Florida

  • Clinical implementation and support

  • Evaluation of parent and provider acceptance and satisfaction

  • No security requirements


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IMITS Program Healthcare Improvement: Integrated Medical Information Technology SystemEmergency Services

  • Emergency Communication Database

    • Demonstration project using international healthcare facility database in UPMC Command Center

      • NCMF identified additional required information in database

      • UPMC collecting data on health care facilities in South America

    • NCMF will evaluate via secure web access

    • Opportunity for future business relationship


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FY 01-02 Healthcare Improvement: Integrated Medical Information Technology SystemIMITS ProjectsEmergency Services

  • Expeditionary Medical Support (EMEDS)

    • NCMF forward deployed treatment facilities

    • Portable tents

      • Large IT footprint

      • Hard wired

    • Subcontract with MountainTop Technologies

      • Conduct needs assessment

      • Make recommendations for wireless solution


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IMITS Program Discontinued Projects Healthcare Improvement: Integrated Medical Information Technology System

  • Telemental Health

    • Internal NCMF issues

      • Change in leadership Wilford Hall Medical Center

      • Administrative changes in TRICARE

  • Teleradiation Oncology

    • Difficulty finding suitable site

      • IMRT requires specific equipment on linear accelerator


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FY 04 IMITS (Sept, 2004) Healthcare Improvement: Integrated Medical Information Technology System

  • $10.2M Congressional Appropriation

  • Congressional intent to expand into the Pacific Rim

    • Pacific Telehealth and Technology Hui

    • University of Hawaii

  • Expanded relationship with Wilford Hall Medical Center


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FY 04 IMITS (Sept, 2004) Healthcare Improvement: Integrated Medical Information Technology System

Extracorporeal Membrane Oxygenation (ECMO)

Platelet Gel Therapy

Telepathology

Simulation and Training

Teleaudiology

IMITS

Telemental Health

Evaluation

Distributed Imaging and Workload Balancing

Teleophthalmology

Education


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FY 04 IMITS Projects Healthcare Improvement: Integrated Medical Information Technology SystemECMO

  • Extracorporeal Membrane Oxygenation

    • Invasive procedure for maintaining oxygenation of the blood when lungs and/or heart are failing

    • Requires specialized equipment and specially trained individuals


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FY 04 IMITS Projects Healthcare Improvement: Integrated Medical Information Technology SystemECMO

  • ECMO programs generally found in urban academic medical centers.

    • 145 ECMO centers in the world

    • 112 in the US

    • Only 2 NCMF in Texas

    • No centers located in the Pacific


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FY 04 IMITS Projects Healthcare Improvement: Integrated Medical Information Technology SystemECMO

  • Interest in establishing a regional ECMO Center for the Pacific in Honolulu

    • Senator Inouye

    • Non Civilian Medical Center

    • Kapiolani Women’s and Children’s Hospital

    • Pacific Telehealth and Technology Hui

    • University of Hawaii


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FY 04 IMITS Projects Healthcare Improvement: Integrated Medical Information Technology SystemECMO

  • FY 04 ECMO project is feasibility and planning study

    • Evaluation of existing resources

    • Requirements

    • Budget

  • Deliverable will be a plan for implementation of the center with the support of FY 05 appropriations sponsored by Senator Inouye


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FY 04 IMITS Projects Distributed Imaging and Workload Balancing

  • NCMF experiencing a severe shortage of radiologist

    • 160 billets (FTE) as of July 1, 2004 only 60 filled

  • Need to maximize resources and distribute workload

    • Hub and spoke teleradiology model no longer useful

    • Symmetrical load balancing model more appropriate


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Distributed Imaging and Workload Balancing Balancing

  • UPMC implemented distributed workload model one year ago

    • Shared worklist

    • Radiologists read films from facilities other than the one they are assigned to for the day

  • Same model implemented

    • Shared worklist

    • Appropriate cases for civilian readings


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Distributed Imaging and Workload Balancing Balancing

  • Designated Non Civilian Medical Center

    • Scale up model developed for the hospital in OH

    • Attempt to keep readings within the US Gov


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Distributed Imaging and Workload Balancing Balancing

  • IMITS 04 project scope

    • Assess the current workflow at NC Medical Center

    • Recommend changes based on UPMC workflow model

    • Implement a prototype system


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Teleaudiology Balancing

  • Cochlear implants are utilized to improve hearing in severe to profound hearing loss

  • Once implanted the devices require monitoring and adjustment

  • This must now be done in person


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Teleaudiology Balancing

  • UPMC and NCMF both have cochlear implant programs

    • Only one MTF that has a cochlear implant program

    • NCMF treats patients globally

    • Interested in developing a means to remotely access and adjust implants


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Teleaudiology Balancing

  • FY 04 deliverables

    • Feasibility study

    • Vendor evaluation

    • Determine regulatory impact in civilian world

    • Plan for technology development

    • Pilot project


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Teleophthalmology Balancing

  • Joint project with Type 2 diabetes

  • NCMF requested that retinal screening images captured for the diabetes project be stored in a DICOM archive

    • Consistent with newly released ATA guidelines “Telehealth Practice Recommendations for Diabetic Retinopathy”


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Teleophthalmology Balancing

  • UPMC Radiology Informatics has done work with visible light images

    • Image archive for melanoma photographs

    • Customized viewer


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Teleophthalmology Balancing

  • FY 04 IMITS Teleophthalmology Deliverables

    • Create DICOM object with associated metadata from acquired image

    • Transport the DICOM object form point of acquisition

    • Store image in a DICOM archive irrespective of vendor


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Telemental Health Balancing

  • A major component of dealing with catastrophic events is Post Traumatic Stress Disorder

    • Victims of disasters

  • Critical incident stress management has been unsuccessful in management of PTSD

  • Cognitive Behavioral Therapy has been show to be successful


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Telemental Health Balancing

  • FY 04 Project

    • Initial data collection and assimilation for analysis

    • Partnership with simulation center in San Diego


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Telepathology Balancing

  • Three initiatives under this heading

    • Telepathology Needs Assessment Pacific Rim

    • Development of Whole Slide Imaging Capability

    • Incorporation of pathology images in enterprise image archive


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Telepathology BalancingPacific Rim Needs Assessment

  • Telepathology needs of the Pacific Rim differ from CONUS

    • Static vs. dynamic

    • Multiple time zone changes, international date line

    • Staffing at MTFs

  • FY 04 Deliverables

    • Needs assessment and feasibility study for telepathology in the Pacific Rim


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Telepathology BalancingWhole Slide Imaging

  • Technologies that allow rapid and automatic imaging of entire slides at high resolution, storage of the image and display

  • Equipment developed but technology has not been integrated into clinical practice

  • FY 04 project

    • Development and implementation of a fully integrated WSI clinical application at UPMC


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Telepathology BalancingImage Archive

  • Native telepathology images are not in DICOM format

  • File size for WSI is rather large

  • FY 04 project

    • Leverage work done to date at UPMC with visible light images for melanoma and ophthalmology to integrate pathology images into a DICOM archive


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Simulation and Training Balancing

  • Three initiatives under this heading

    • Wilford Hall Simulation Center

    • University of Hawaii Simulation Center

    • UPMC Nursing Injury Prevention Program

  • All projects will involve WISER


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Simulation and Training BalancingWilford Hall Simulation Center

  • Wilford Hall has simulation capabilities distributed in various departments throughout the MTF

  • Wants to consolidate existing capabilities and build a Simulation Center

  • FY 04 deliverable

    • Assessment of current capabilities and recommendations for an integrated simulation center


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Simulation and Training BalancingUH Simulation Center

  • University of Hawaii will be opening a new Medical School Building in 2005

  • One floor dedicated to advanced simulation and training

  • UH interested in WISER applications

  • FY 04 deliverable

    • Development of a collaborative partnership and implementation of a WISER pilot at UH


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Simulation and Training BalancingUPMC Nursing Injury Prevention

  • Work related injuries are a significant issue for nursing

  • Simulated situations can assist with assessment and prevention of injuries

  • FY 04 project

    • UPMC Nursing in collaboration with WISER will develop and implement a work related injury prevention simulation


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Platelet Gel Therapy Balancing

  • Wound healing therapy

  • Creation of platelet rich plasma that enhances wound healing and decreases healing time

  • Applicability to non-healing diabetic ulcers

  • FDA approved

  • Not reimbursed by Medicare or private insurers


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Platelet Gel Therapy Balancing

  • Additional studies needed to validate efficacy

  • FY 04 project

    • Planning and development of multi-center clinical trial comparing platelet gel therapy to standard wound care treatments

      • Literature review

      • Protocol development

      • Vendor negotiations

      • IRB approvals


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Education Balancing

  • Three initiatives under this heading

    • Nursing Leadership training

    • Nursing Magnet Program

    • Type 2 Diabetes Education in Italy


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Education BalancingNursing Leadership

  • UPMC and the NCMF have similar objectives for leadership training

  • UPMC has established the Beckwith Leadership Institute

  • FY 04 project

    • Review “Joint Leadership Core Curriculum” to determine synergies between NCMF and UPMC

    • Make recommendations for joint curriculum development


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Education BalancingType 2 Diabetes – Italy

  • Incidence of type 2 diabetes increasing in Italy

  • Need Diabetes Self Management Tools

  • Partner with the hospital in Italy and Mediterranean Institute for Transplantation and Advanced Specialized Therapies (UPMC)

  • FY 04 project

    • Initiate an on-line diabetes education program for type 2 diabetes


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Evaluation Balancing

  • Leadership from Center for Biomedical Informatics

  • Conduct rigorous and professional evaluation of the IMITS projects

    • User acceptance

    • Technology integration


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Evaluation Balancing

  • Oversight of all evaluation activity

    • Protocol development

    • Protection of humans subjects

    • IRB approvals

    • Federal and state regulations


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Conclusions Balancing

1. The civilian counterparts, particularly in developing countries are interested in implementing information technology that eliminates inefficiencies, increases utilization and improves quality of care, while also lowering administration costs. Given the limited manpower and resources facing the military non-civilian and private sectors, improved information technology and management will be the foundation for quality health care.


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Conclusions Balancing

2. University of Pittsburgh Medical Center has also some other partnership models and close cooperation with Italy, Czech Republic, Brazil and China and is looking forward to cooperate with Arab Region as well

3. One of these models of partnership between the university and medical entities can be applied in case of Arab nations region.


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Background Balancing

  • “The IOM committee believes the development and application of information systems is essential to enhance quality and improve efficiency. Information technology must play a central role in the redesign of the healthcare system if a substantial improvement in quality is to be achieved over the coming decade.”

  • These problems are even more acute when applied to a military service population for a number of reasons. First, service men and women and their families are among the most mobile members of our society. Second, due to their exposure to diseases and environmental factors in a multitude of geographic locations, they are subject to a wider variety of difficult-to-diagnose medical conditions. Complicating this is the likelihood that relevant medical data is stored in incompatible health information systems increases with the time spent deployed outside CONUS. In addition, the drawdown in military forces and the closure of medical treatment centers in the 1990s has resulted in a reduction in funding and staffing for medical care applied against a stable but aging population of beneficiaries.

  • Like its civilian counterparts, the Air Force is interested in implementing information technology that eliminates inefficiencies, increases utilization and improves quality of care, while also lowering administration costs. Given the limited manpower and resources facing the military and private sectors, improved information technology and management will be the foundation for quality health care.