Making the health care system 'safe' for persons with HIV infection or AIDS.

If health care reform is implemented in states and nationally, the safety of this process needs to be examined for persons with human immunodeficiency virus (HIV) infection or the acquired immunodeficiency syndrome (AIDS). Reform should assure ongoing prevention and transmission control of HIV and continuous coverage of medical costs for persons ill with HIV or AIDS. These persons currently benefit from various state and federal categoric programs designed to assure access to preventive and personal care services. Washington State has passed health care reform legislation that envisions integrating these programs to provide a system of population-based and personal health care. This legislation was analyzed using existing epidemiologic and entitlement information about persons with HIV infection or AIDS in the state to assess its effect. The relationship between public health and personal care services will be a central concern for those with HIV infection or AIDS, and complete coverage of this group may be achieved relatively late in the process of implementing health care reform. Health personnel planning under health care reform will affect the delivery of HIV- and AIDS-related services. Including treatment of AIDS in the basic benefit package merits particular attention. These issues parallel those being faced by the nation as a whole as it seeks to ensure epidemic disease control and compassionate care for long-term disabling illness if health care reform is implemented.     

From Hippocrates to facsimile: Protecting patient confidentiality is more difficult and more important than ever before

Although patient confidentiality has been a fundamental ethical principle since the Hippocratic Oath, it is under increasing threat. The main area of confidentiality is patient records. Physicians must be able to store and dispose of medical records securely. Patients should be asked whether some information should be kept out of the record or withheld if information is released. Patient identity should be kept secret during peer review of medical records. Provincial legislation outlines circumstances in which confidential information must be divulged. Because of the "team approach" to care, hospital records may be seen by many health care and administrative personnel. All hospital workers must respect confidentiality, especially when giving out information about patients by telephone or to the media. Research based on medical-record review also creates challenges for confidentiality. Electronic technology and communications are potential major sources of breaches of confidentiality. Computer records must be carefully protected from casual browsing or from unauthorized access. Fax machines and cordless and cellular telephones can allow unauthorized people to see or overhear confidential information. Confidentiality is also a concern in clinical settings, including physicians'' offices and hospitals. Conversations among hospital personnel in elevators or public cafeterias can result in breaches of confidentiality. Patient confidentiality is a right that must be safeguarded by all health care personnel.     

Mental health law: civil liberties and the principle of reciprocity.

At a conference organised by the Law Society, Mental Health Act Commission, and Institute of Psychiatry possible reform of mental health legislation in England and Wales was discussed. It was concluded that radical legal reform was required, and that the law should be designed specifically for provision of care in both hospital and the community. Reform should be based on principle rather than pragmatism, particularly the principle of reciprocity--patients'' civil liberties may not be removed for the purposes of treatment if resources for that treatment are inadequate. Protection of society from nuisance or even violence is insufficient reason for detention. Legal provision for compulsion of patients, whether in hospital or the community, must be matched by specific rights to treatment.     

Ageism in cardiology

This article supports the argument that ageism exists in health care, particularly on the equity of access to cardiological services. Rates of use of potentially life saving and life promoting interventions and investigations decline as the patient gets older. Higher rates of cardiological interventions occur among younger people, despite the high incidence of the condition among older individuals. Any ageism in clinical medicine and policy is simply a reflection of the presence of ageist attitudes in wider society, where the youth receives a higher priority over age. Ageism in medicine needs to be addressed to preserve or recapture this trust within an aging population. A wide ranging approach is necessary if equity in the provision of health care services is to be ensured which includes improvement of clinical guidelines and more specific monitoring of health care. Educational efforts to raise awareness that age stereotyping and ageist attitudes are unethical should be initiated. Research initiatives, which cover large numbers of older people, should be developed and older people should be empowered to influence choices and standards of treatments. Finally, legislation may be required to eradicate ageism in society.     

Should living wills be legalized?

Living wills allow patients to state their wish to die and not be kept alive through the use of medications, artificial means or "heroic" measures. They have been made legal documents in 38 states in the United States. Living wills permit advance expression of a patient''s wishes, promote effective communication and demonstrate respect for the patient as a person. Problems with legal recognition of such wills include the need for agreement on fundamental terms, possible restriction of patients'' rights, limitation of options in decision-making and possible negative effects on the physician-patient relationship. Before legislation is enacted, public and professional attitudes toward the care of terminally ill patients should be assessed. All health care professionals should receive better education in this area, and palliative care services should be made more widely available. Only if these measures fail should living wills be made legal documents in Canada.     

部分国家和地区分级诊疗特点及启示

通过剖析部分国家和地区分级诊疗的特点,即分级诊疗是医疗卫生服务体系健全的自然结果,分级诊疗的实质在于服务整合,合理的支付制度是分级诊疗的重要促进因素;提出以强基层、建机制的原则发展分级诊疗,将医疗机构分工合作、服务功能整合作为分级诊疗的重要路径,增强医保对医疗服务体系的影响力以促进分级诊疗等建议。     

军队医院医疗风险管理的措施及意义

随着我国法治社会的发展及医疗体制的改革,医疗风险成为军队医院管理面临的难题和挑战。目前,我国现有的医疗法规不够完善,医务人员与患者的医疗风险防范意识不足,社会舆论导向性偏移等问题制约着我国医疗系统的发展。作为医疗卫生系事业的重要力量,军队医院要加强医疗风险管理,制定风险评估方法,完善风险管理体系以及加强风险教育,进一步提高医疗服务质量,从而有利维护军队医院在群众心中的信誉和形象。     

Developing primary health care.

Primary health care is best provided by a primary health care team of general practitioners, community nurses, and other staff working together from good premises and looking after the population registered with the practice. It encourages personal and continuing care of patients and good communication among the members of the team. Efforts should be made to foster this model of primary care where possible and also to evaluate its effectiveness. Community services that are not provided by primary care teams should be organised on a defined geographical basis, and the boundaries of these services should coincide as much as possible. Such arrangements would facilitate effective community care and health promotion and can be organised to work well with primary care teams. The patient''s right to freedom of choice of a doctor, however, should be retained, as it adds flexibility to the rigidity of fixed geographically based services.     

Need for primary health care: an objective indicator.

The allocation of resources for primary health care should be based on the community''s needs and not only on the workload of general practitioners. I therefore present an objective indicator that may be used to assess the need for primary health care.     

Animal welfare official inspections: farmers and inspectors shared concerns

Official inspections to check the compliance of farms with European legislation to protect farm animals are often perceived negatively by farmers. In addition, the inspections have a limited effect on improving farm compliance. We looked at the perceptions of both farmers and their inspectors about animal welfare and the inspections in a case study of dairy production in France. The identification of gaps and commonalities between both parties should help us to propose improvements in the inspection method by which inspections could more likely encourage compliance with animal welfare legislation. To achieve this aim, we conducted semi-structured interviews with 22 dairy farmers and their 19 inspectors. Both farmers and inspectors described animal welfare in terms of the state of the animal and of the living conditions and care provided to them. The majority of farmers found that the official checklist used by the inspectors is inappropriate to assess the welfare of their animals; inspectors themselves reported that they often use their own criteria and indicators (often based on the observation of animals) in addition to the official checklist. Both groups disagreed with some requirements of the legislation. These findings suggest that the content and background of the legislation to protect animals should be made clearer to both farmers and inspectors and that these two groups of actors should be involved in the definition of key points to be checked on farms, with special attention to animal-based indicators. All this could improve farmers' engagement with the results of the inspections and, hopefully, could lead to better compliance with legislation and improvements in animal welfare on farms.     

Continuing Medical Education in Midpassage

Mandatory continuing education for physicians and other health professionals raises numerous problems. Issues that were considered academic when continuing education was voluntary now take on major practical and political significance. There is the risk that future legislation will mandate activities and methodologies which have not been proven. Research and development in continuing education must be accelerated so that decisions can be based on proper data. Centers of research and development should be established to encourage research and provide a sound foundation for the future of continuing education.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

Arbitration Agreements and Your Malpractice Coverage

With new legislation and favorable case law developments, many providers of health care services are turning to binding arbitration agreements as a partial solution to the medical malpractice crisis. Existing data indicate tremendous advantages can be gained from the use of such agreements, if they are carefully drawn to comply with new law, tailored to the particular situation in which they will be used and coupled with appropriate procedures to secure the intended benefits.Arbitration is not a substitute for insurance, but if a provider has taken the calculated risk of forgoing insurance he should not be without a carefully drawn binding arbitration agreement.     

US regulatory hurdles: towards international harmonization.

What regulatory requirements must be met before a new medical device can be marketed in the USA? In this article, David Thomas reviews the regulations, examines the impact of recent legislation and looks at the emerging trend towards international harmonization of the regulation of health care products.     

The route to a national health policy lies through the states.

National health program legislation has been becalmed in the Congress for almost 80 years. Despite periodic cries of "crisis," legislation never emerges from committee. Periodically, campaigns have been mounted without success. Tactical efforts to circumvent direct action by legislating bits and pieces of related programs, Medicare and Medicaid, health maintenance organization support, and pre-budgeting, have complicated operation of the medical care system and stimulated intractable cost inflation. For the first 150 years of American history, responsibility for public health and welfare legislation rested with the states. Most public health policies originated in a state or a few states and then later became national legislation. The state efforts were, in effect, natural experiments. After the Depression and the flood of funding from the federal government in subsequent years, the states faded as innovators. It is proposed that funding a few state models to restimulate state initiative in this regard will provide a more effective route to a national health program.     

Effective communication between hospital staff and patients in compliance with personal data protection regulations

Secure communication between patients and health care facilities is especially important In 2016, the European Union (EU) introduced a new regulation — the General Data Protection Regulation (GDPR), applicable in all EU member states — aimed at improving protection of personal data. The GDPR provides broad guidelines on data protection, but generally lacks specific details. Consequently, although member states must comply with the GDPR, there is some flexibility to develop new regulations to suit national characteristics and practices, especially in key economic sectors, such as health care. The aim of the present article is to discuss the benefits and limitations of legal provisions governing the patient identification (both in-person and remotely). This analysis is based on Polish laws that were recently passed to comply with the GDPR. In some cases, these data protection regulations may be unnecessarily strict, making routine care more difficult than intended by the GDPR. National legislation in Poland imposes strict data protection measures, such as prohibiting the public display of patient names or calling out the patient’s name in public. However, after health care personnel around the country criticised many of these measures, the law will be modified to address those concerns. For example, the patient’s name can be displayed on a wrist band and on containers with the patient’s medicines. Nonetheless, numerous questions still need to be resolved to adapt the general data protection rules to ensure the effective operation of the hospital to avoid problems related to accurate patient identification.     

Community-based mental health care in Africa: mental health workers’ views

The World Health Organization (WHO) has for long proposed the development of community-based mental health services worldwide. However, the progress toward community mental health care in most African countries is still hampered by a lack of resources, with specialist psychiatric care essentially based in large, centrally located mental hospitals. It is again time to reconsider the direction of mental health care in Africa. Based on a small inquiry to a number of experienced mental health professionals in sub-Saharan Africa, we discuss what a community concept of mental health care might mean in Africa. There is a general agreement that mental health services should be integrated in primary health care. A critical issue for success of this model is perceived to be provision of appropriate supervision and continuing education for primary care workers. The importance of collaboration between modern medicine and traditional healers is stressed and the paper ends in a plea for WHO to take the initiative and develop mental health services according to the special needs and the socio-cultural conditions prevailing in sub-Saharan Africa.     

Psychiatric and nonpsychiatric facilities in the care of psychogeriatric patients.

The care of elderly patients who are mentally impaired requires reorganization in the delivery of mental health services to these patients. In this paper recommendations are made for the improvement of such services. These include the development of comprehensive psychogeriatric assessment services, which should be based mainly in general hospitals, the rationalization of the roles of facilities that provide nonpsychiatric long-term care, the development of specialized facilities for demented elderly patients, and a focus on education in psychogeriatrics for both undergraduate and postgraduate students in medicine and in other health care professions.     

静磁场保健寝具磁参数的评价

基于对生物磁学效应的研究,磁疗成为替代医学和补充医学的一种有效的治疗方法,本文通过对现有静磁场（恒定磁场）保健寝具磁标准和磁剂量的评述,首次提出磁保健寝具三围空间磁场的概念,指出采用磁感应强度在空间的强度分布作为磁保健剂量标准。论述了三围空间磁场具体磁参数的评价,包括所用磁源的表面磁感应强度,寝具织物表面磁场的穿透力、梯度、有效磁通量和空间能量等磁场分布的描述性指标。指出了静磁场保健寝具磁参数的合理的评价参量：为确保织物表面磁感应强度在目前认知的400～1100Gs有效安全剂量内,依据使用时的织物厚度,磁保健寝具选用的磁体表磁应在1000-3000Gs左右．且磁场的梯度不宜过大,磁场的平均穿透力在25-30cm左右,以确保空间磁场能量的有效作用于人体深处。