Re: physician prescribing tool development
-BEGIN PGP SIGNED MESSAGE- Hash: SHA1 Calle Hedberg wrote: | | | That's VERY interesting - I have heard about this before, but I have not | seen any of the actual studies/papers showing 20-30% loss of efficiency. | (It's largely in line with my personal observations, and it largely | explain why EHRs in resource poor settings usually are utter failures - | you just don't have the 20-30% extra time if you are seeing 60-70 | patients per day to begin with). | | Can you provide any direct references (or even better URLs) to such | studies? | I don't have any URL's or references either. I want to comment that it's just not resource poor settings where this efficiency hit leads to failure, it's also true here in the US. That's because the pressure to reduce the average visit time per patient with the physician is an extremely powerful economic force in workflow re-design. I was the introducer at the TEPR 98 session on cost justification. There was only one presentation that addressed the issue of time spent per patient, that was by Dr. Wenner. He made an assertion then about the increased time/cost of EHR's and I challenged where the evidence was. Much to my suprise, the clinical head of a large healthcare software vendor, standing in the back of the room (we were SRO), came to Dr. Wenner's defense, saying that it was the case. Dr. Wenner sells a bit of software called Instant Medical History, used in primary care settings that have patients do a pre-interview on computer, the synopised results of which are available during the physician/patient encounter. This is yet another area where evidence seems lacking and marketing seems predominant. -BEGIN PGP SIGNATURE- Version: GnuPG v1.2.4 (GNU/Linux) Comment: Using GnuPG with Thunderbird - http://enigmail.mozdev.org iD8DBQFBYWwCY+HG7UEwVGERAmG5AJ9tpyxjvPauN063Q1fe5P0zsEYp9gCdFaXG 5MFWXf+m4dZllhcfhQZL5M0= =GHE/ -END PGP SIGNATURE-
Re: physician prescribing tool development
On Fri, 2004-10-01 at 16:40, Daniel L. Johnson wrote: Dear All, First of all, this is not an announcement; this is merely conversation, because Gunther Schadow does not want to make any announcements until there is something to announce. ... I'm replying in a batch here... __ On Fri, 2004-10-01 at 16:54, Joseph Dal Molin wrote: Dan...what will be context...primary care/clinics or acute care?? I'm not aware of a difference; Martha and I are primary care clinicians who, I think, include both acute and chronic care visits. It is not, as far as I know, initially aimed at the emergency department or the doc-in-a-box urgent care setting. __ On Fri, 2004-10-01 at 17:10, Calle Hedberg wrote: you mention that Studies have shown approximately a 20-30% loss of physician efficiency during visits with the use of EHR software Can you provide any direct references (or even better, URLs) to such studies? I am guilty of perpetuating what I've heard at meetings, and haven't scrutinized the literature personally. This was my recollection from sessions on EHR in March at the AHQA (American Health Quality Association) meeting. One presentation in particular, by an urgent care physician/medical manager, Dr. Jane Brock, was a eloquent survey of the personal and institutional frustrations of EHR use that resulted in 2 proposals of marriage from (male) physicians in the audience. __ On Fri, 2004-10-01 at 18:13, Andrew Ho wrote: On Fri, 1 Oct 2004, Daniel L. Johnson wrote: 1: to test the utility of the new FDA-mandated computerized package insert (Dr. Schadow was an FDA consultant in its design). Do you know how these package inserts from FDA's electronic labeling (http://www.fda.gov/bbs/topics/NEWS/2003/NEW00991.html) requirement will be published? I do not. Gunther told me last month, if I recall correctly, that these have not been finalized. _ On Sat, 2004-10-02 at 00:06, Tracy Bost wrote: As part of the design process, what tier, framework, technology,etc will be used? I have been remaining willfully ignorant of the technical plans. You have driven me back to the grant proposal, which says, The prescribing tool will be built entirely based on standards and open source components and programmed in Java for maximum portability structured according to the HL7 [RIM]... [its] implementation of the HL7 RIM and HL7 data types in Java under the... Java SIG... will be the basis of the data architecture for this... project. The Java SIG objects will be persisted in an...[RDBMS] using the Hibernate object relational broker system The...mapping will be ... generated from the HL7 RIM meta-data The common [rdbs] will be PostgrSQL. The system will be client-server based and initially...web-browser based For the server engine...a Servlet capable Java-based web-server suchas Jakarta Tomcat...[using] SML...XSLT... [staying] away from complex application server architectures in order to focus...on a reusable infrastructure...that is not loced into a certain architectural system model like J2EE, CORBA, etc. _ Hope this helps satisfy curiosity. Dan Johnson
RE: physician prescribing tool development
Calle Hedberg wrote: Can you provide any direct references (or even better URLs) to such studies? October 04, 2004 Wayne Wilson wrote: I don't have any URL's or references either. Excerpt of possible reports: Copyright © 2004, American Medical Informatics Association J Am Med Inform Assoc. 2004 March; 11 (2): 100-103 DOI: 10.1197/jamia.M1411 Computerized Physician Order Entry: Helpful or Harmful? Robert G. Berger, MD and J.P. Kichak, BA http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=353014 CPOE systems will prove to be more costly to institutions than just the purchase and maintenance of the hardware and software involved in such a purchase or development. The increased time required by physicians to enter data into CPOE products will result in increased personnel costs for direct patient care. The Leapfrog Group used the results of the first Harvard study as its entire basis for its theoretical calculations of decrease in health care costs as a result of institution of CPOE systems. However, these calculations can show an opposite trend when taking into account the follow-up Harvard study and adding the increased time required by housestaff (the primary users of the system) to enter their daily orders. Although the absolute numbers are small, the installation of CPOE created a 200% increase in actual serious ADEs during the first two years of implementation (from the second Harvard publication discussed previously, which showed an absolute increase from five ADEs to 15 ADEs in the first two years of use of CPOE). Therefore, if the Harvard studies are reflective of the effects of CPOE in general, national health care costs as a result of ADEs will increase transiently to $6 billion per year (using the Leapfrog numbers) during the first two years of CPOE implementation. Because housestaff work hours have recently been limited to 80 hours per week, the additional time required for them to enter data in CPOE will almost certainly result in additional health care personnel costs to hospitals in the form of physician extenders to provide direct patient care. This additional time required to enter computer-based orders has been estimated at 5% of their total workweek hours.20,21 If a large hospital employs 500 housestaff, an additional 25 full-time equivalent physicians or physician extenders would be required for direct patient care, assuming that before the institution of CPOE, a resident's 80-hour week was entirely spent doing direct patient care. This would add approximately $1.6-2 million to individual hospital budgets in addition to the costs of purchase and maintenance of a CPOE system itself. Computerized POE: Changing Roles for the Clinical Pharmacist http://www.aphanet.org/PInfo/JAPhA_Sept-Oct_99_Article.htm Along with the change to POE came a change in the role of pharmacists at our institution. POE automates many aspects of the medication order so pharmacists no longer have to spend so much time checking drug doses, drug allergies, and drug-drug interactions. Thus pharmacists have been freed to spend more time on clinical activities including drug utilization review (DUR) and drug therapy management to improve patient care. Copyright © 2001, American Medical Informatics Association J Am Med Inform Assoc. 2001 July; 8 (4): 361-371 Controlled Trial of Direct Physician Order Entry Effects on Physicians' Time Utilization in Ambulatory Primary Care Internal Medicine Practices J. Marc Overhage, MD, PhD, Susan Perkins, PhD, William M. Tierney, MD, and Clement J. McDonald, MD http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=130081 Objective: Direct physician order entry (POE) offers many potential benefits, but evidence suggests that POE requires substantially more time than traditional paper-based ordering methods. The Medical Gopher is a well-accepted system for direct POE that has been in use for more than 15 years. The authors hypothesized that physicians using the Gopher would not spend any more time writing orders than physicians using paper-based methods. Quotations of other reports: (1) Jha AK, Kuperman GJ, Teich JM, Leape L, Shea B, Rittenberg E, Burdick E, Seger DL, Vander Vliet M, and Bates DW, Identifying Adverse Drug Events: Development of a Computer-Based Monitor and Comparison with Chart Review and Stimulated Voluntary Reporting, Journal of the American Medical Informatics Association, 5(3):305-314 (1998) Teich J, PR M, Schmiz J, Kuperman G, Spurr C, Bates D. Effects of computerized physician order entry on prescribing practices. Archives of Internal Medicine. 2000;160:2741-47. Bates, D. W., Boyle, D. L., and Teich, J. M. Impact of Computerized Physician Order Entry on Physician Time. Proceedings of the Annual Symposium on Computer Applications in Medical Care, 1994, 11(1), 996. Sincerely yours, Tim Tim Flewelling Information Architect/Architecte de l'informatique Health and Wellness/Santé et Mieux-être Government of New Brunswick/Gouvernement
RE: physician prescribing tool development
Dan: You wrote Studies have shown approximately a 20-30% loss of physician efficiency during visits with the use of EHR software. Any links handy? David D Derauf MD MPH Executive Director Kokua Kalihi Valley -Original Message- From: Daniel L. Johnson [mailto:[EMAIL PROTECTED] Sent: Friday, October 01, 2004 11:41 AM To: OpenHealth List Subject:physician prescribing tool development Dear All, First of all, this is not an announcement; this is merely conversation, because Gunther Schadow does not want to make any announcements until there is something to announce. I am conversing with this list simply because I thought you would all be encouraged to know that the US Agency for Healthcare Research and Quality has awarded a grant to Indiana University-Purdue University at Indianapolis for development of an open-source computerized physician order entry system, to be led by Gunther Schadow, MD, of the Regenstrief Institute. Dr. Martha Adams of Duke University and myself have volunteered to test the implementation of this software. Design begins now; implementation is to begin in about a year. The plan is to develop a software tool that will provide decision support for physician e-prescribing. This tool will live on a Linux server and be accessed by users through a browser. The formal goals of this project are: 1: to test the utility of the new FDA-mandated computerized package insert (Dr. Schadow was an FDA consultant in its design). 2: to use HL7 v3 tools to deliver decision support to prescribing: default dosing, dosing correction for height, weight, and renal function, dose checks, contraindication checking, allergy checking, and drug-interaction and food-drug interaction checking. 3: to evaluate whether physician efficiency is gained by its use. Studies have shown approximately a 20-30% loss of physician efficiency during visits with the use of EHR software; a design goal of this project is to have the opposite effect. A time-motion study of physician work during office visits is an important feature of this project. 4: Medication errors are the leading cause of adverse medical events. About half of these occur in prescribing: approximately half of these involve dosage or frequency errors, half involve prescribing against contraindications or known interactions or allergy. This tool will be designed to specifically remediate these errors, estimating that it could reduce about 2/3 of prescribing errors. 5: The goal is to have a fully functional tool available for deployment and use beginning October, 2006. 6: Gunther is aiming at making this open source. He is interested in collaborative development, but of course must balance the need to stay on track with the grant timeline against the ideal of distributed development. I will of course encourage him to allow collaboration in development, but for now he's hunkered down in full Project Organization Mode. To repeat: This is *not* an announcement. If there were something to announce it could be an announcement, but as there is now no meat on the barbecue, no one is currently invited to dine. Best wishes, Dan Johnson md Menomonie, WI
Re: time and actions
I'm not convinced that like is compared with like. With handwritten records I've met many doctors and others who assert they read the record before seeing the patient, and I beleive that some occasionally do. WIth typed records, whcih usually now is computer displayed records, it is hard not to... but althugh it takes less time since it actually happens the total time used is likely to be longer. There is also the almost unstoppable temptation to actually act on some of the reminders and prompts. I would like to get some of what I do out of this room and into the front desk, and I'm working on it. Sadly, with closed source software at present. -- AKM Homefield Surgery Heavitree Exeter 01392 214151
Re: Re: time and actions
Sorry to jump-up as I am mostly a lurker on this list, We are piloting OpenEMR at a clinic here in Santa Fe, My guess is an EMR won't cut visit time or save provider's time at all, as they have to write down stuff or check boxes anyway, but I agree with Adrian M., information and reminders are pushed and it's difficult not seeing them,. EMR will save tons of assistant's administration time. I am foreseeing (with observation and role playing) more than %50 time saving as they don't have to go pull a chart insert a phone call comment, go check faxes for lab results, check with the provider for a refill request, send that fax to pharmacy, etc. etc. And of course relaxed assistants help improve patient's experience. David Derauf wrote: Dan: You wrote "Studies have shown approximately a 20-30% loss of physician efficiency during visits with the use of EHR software". Any links handy? David D Derauf MD MPH Executive Director Kokua Kalihi Valley -Original Message- From: Daniel L. Johnson [mailto:[EMAIL PROTECTED]] Sent: Friday, October 01, 2004 11:41 AM To: OpenHealth List Subject: physician prescribing tool development Dear All, First of all, this is not an announcement; this is merely conversation, because Gunther Schadow does not want to make any announcements "until there is something to announce." I am conversing with this list simply because I thought you would all be encouraged to know that the US Agency for Healthcare Research and Quality has awarded a grant to Indiana University-Purdue University at Indianapolis for development of an open-source computerized physician order entry system, to be led by Gunther Schadow, MD, of the Regenstrief Institute. Dr. Martha Adams of Duke University and myself have volunteered to test the implementation of this software. Design begins now; implementation is to begin in about a year. The plan is to develop a software tool that will provide "decision support" for physician e-prescribing. This tool will live on a Linux server and be accessed by users through a browser. The formal goals of this project are: 1: to test the utility of the new FDA-mandated computerized "package insert" (Dr. Schadow was an FDA consultant in its design). 2: to use HL7 v3 tools to deliver decision support to prescribing: default dosing, dosing correction for height, weight, and renal function, dose checks, contraindication checking, allergy checking, and drug-interaction and food-drug interaction checking. 3: to evaluate whether physician efficiency is gained by its use. Studies have shown approximately a 20-30% loss of physician efficiency during visits with the use of EHR software; a design goal of this project is to have the opposite effect. A time-motion study of physician work during office visits is an important feature of this project. 4: Medication errors are the leading cause of adverse medical events. About half of these occur in prescribing: approximately half of these involve dosage or frequency errors, half involve prescribing against contraindications or known interactions or allergy. This tool will be designed to specifically remediate these errors, estimating that it could reduce about 2/3 of prescribing errors. 5: The goal is to have a fully functional tool available for deployment and use beginning October, 2006. 6: Gunther is aiming at making this open source. He is interested in collaborative development, but of course must balance the need to stay on track with the grant timeline against the ideal of distributed development. I will of course encourage him to allow collaboration in development, but for now he's hunkered down in full Project Organization Mode. To repeat: This is *not* an announcement. If there were "something to announce" it could be an announcement, but as there is now no meat on the barbecue, no one is currently invited to dine. Best wishes, Dan Johnson md Menomonie, WI -- Andres Paglayan [EMAIL PROTECTED] Ph: (505) 986-1561 Santa Fe, NM USA Open Source is like Love. The more you share it the better it gets.
CPOE time studies.
-BEGIN PGP SIGNED MESSAGE- Hash: SHA1 I have two references, thanks to Tim's Flewelling research. Both of these indicate far more than a 20-30% decrease in efficiency, more like a doubling of time spent by physicians. This time can partially be recovered elsewhere in the system, but not completly by the physicians directly. I don't have full text access to either article, so I cannot pursue other references. It is really these studies that validate and personal experience that lead Dr. Wenner to apply computer power elsewhere in the patient visit chain to the physician. Title: Impact of computerized physician order entry on physician time. Source: Proceedings - the Annual Symposium on Computer Applications in Medical Care. :996, 1994. For both medical and surgical house officers, writing orders on the computer took about twice as long (p 0.001), or 44 minutes for medical and 73 minutes for surgical house officers. Medical house officers recovered about half this time because some administrative tasks--e.g. looking for charts--were made easier. Authors: Shu K. Boyle D. Spurr C. Horsky J. Heiman H. O'Connor P. Lepore J. Bates DW. Institution: Information Systems, Partners HealthCare System, Boston, MA, USA. Title: Comparison of time spent writing orders on paper with computerized physician order entry. Source: Medinfo. 10(Pt 2):1207-11, 2001. Key findings were that interns spent 9.0% of their time ordering with CPOE, compared to 2.1% before, although CPOE saved them an additional 2% of time, so that the net difference was 5% of their total time. However, this is counterbalanced by decreased time for other personnel such as nursing and pharmacy, and by the quality and efficiency changes. -BEGIN PGP SIGNATURE- Version: GnuPG v1.2.4 (GNU/Linux) Comment: Using GnuPG with Thunderbird - http://enigmail.mozdev.org iD8DBQFBYZtzY+HG7UEwVGERAn2CAJwNuo8hHoBIzkWULdMCKJdgRE8GqACgvA9v esrR7mzazDpIM5rmw4UEkSA= =MrvA -END PGP SIGNATURE-
Re: physician prescribing tool development
On Fri, 2004-10-01 at 16:54, Joseph Dal Molin wrote: Dan...what will be context...primary care/clinics or acute care?? On Mon, 2004-10-04 at 14:41, Joseph Dal Molin wrote: what I was wondering was whether the application is primarily intended for use in non-hospital environments e.g. clinics and family practice. Ah! Non-hospital environments. However, our little hospital seems like a good place to try to extend this, and Gunther has promised that we shall be able to print the Kardex medication-administration record for the hospital nurses, and the hospital pharmacist will of course have access to the patient data within our institution.
Re: CPOE time studies.
even without reading it, i won't take the 1994 study very seriously, just because the interfaces that were and weren't available at that time and the general illiteration around computers then. Wayne Wilson wrote: Title: Impact of computerized physician order entry on physician time. Source: Proceedings - the Annual Symposium on Computer Applications in Medical Care. :996, 1994. -- Andres Paglayan [EMAIL PROTECTED] Ph: (505) 986-1561 Santa Fe, NM USA Open Source is like Love. The more you share it the better it gets.
Re: CPOE time studies.
Andres, even without reading it, i won't take the 1994 study very seriously, just because the interfaces that were and weren't available at that time and the general illiteration around computers then. There might have been some improvement in interfaces during the last 10 years, but I haven't noted anything really revolutionary (unless the study referred to looked and command-line stuff). Computer illiteracy in the north anno 1994 was probably on par with or better than the computer literacy you find in most developing countries today. One example: A collegue of mine (computer literate TB specialist) noted a year ago or so that she spent an average of 1.5 minutes to enter one TB patient into an electronic TB register application. The app was a bit slow when saving, but she had no problem with that 10-12 second delay because she used it to prepare the next patient folder for data entry. Nurses with negligible IT experience, on the other hand, spent 16 minutes (typing one finger, looking for each key, etc) on capturing a similar record - AND they complained about the 10-12 second delay because their eyes were glued to the progress bar during saving So it's crucial to consider the applicability of various experiences and studies not only to health workers in countries where computers have penetrated deeply during the last 30 years, but also to health workers in areas with less or negligible penetration. My guess is that a clear majority of health workers world-wide never have been systematically trained in computer use, probably not even in how to type with reasonable speed and accuracy (how many subscribers on this list type with all 10 fingers, I wonder) Otherwise, I've just read the last annual HIV prevalence survey (survey in November 2003) for pregnant women: On average 27.5% for South Africa, with provincial rates ranging from about 13% to 37%. Add to that the fact that UK, Canada, Australia and other countries systematically poach doctors and nurses from SA (we have over 30,000 vacant nurse positions now) - the impact on workload should be obvious. Regards calle Wayne Wilson wrote: Title: Impact of computerized physician order entry on physician time. Source: Proceedings - the Annual Symposium on Computer Applications in Medical Care. :996, 1994. -- Andres Paglayan [EMAIL PROTECTED] Ph: (505) 986-1561 Santa Fe, NM USA Open Source is like Love. The more you share it the better it gets.
Re: CPOE time studies.
Sounds to me like a job for Tablet Computers! Don Grodecki openhre.org - Original Message - From: Wayne Wilson [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Monday, October 04, 2004 1:50 PM Subject: CPOE time studies. -BEGIN PGP SIGNED MESSAGE- Hash: SHA1 I have two references, thanks to Tim's Flewelling research. Both of these indicate far more than a 20-30% decrease in efficiency, more like a doubling of time spent by physicians. This time can partially be recovered elsewhere in the system, but not completly by the physicians directly. I don't have full text access to either article, so I cannot pursue other references. It is really these studies that validate and personal experience that lead Dr. Wenner to apply computer power elsewhere in the patient visit chain to the physician. Title: Impact of computerized physician order entry on physician time. Source: Proceedings - the Annual Symposium on Computer Applications in Medical Care. :996, 1994. For both medical and surgical house officers, writing orders on the computer took about twice as long (p 0.001), or 44 minutes for medical and 73 minutes for surgical house officers. Medical house officers recovered about half this time because some administrative tasks--e.g. looking for charts--were made easier. Authors: Shu K. Boyle D. Spurr C. Horsky J. Heiman H. O'Connor P. Lepore J. Bates DW. Institution: Information Systems, Partners HealthCare System, Boston, MA, USA. Title: Comparison of time spent writing orders on paper with computerized physician order entry. Source: Medinfo. 10(Pt 2):1207-11, 2001. Key findings were that interns spent 9.0% of their time ordering with CPOE, compared to 2.1% before, although CPOE saved them an additional 2% of time, so that the net difference was 5% of their total time. However, this is counterbalanced by decreased time for other personnel such as nursing and pharmacy, and by the quality and efficiency changes. -BEGIN PGP SIGNATURE- Version: GnuPG v1.2.4 (GNU/Linux) Comment: Using GnuPG with Thunderbird - http://enigmail.mozdev.org iD8DBQFBYZtzY+HG7UEwVGERAn2CAJwNuo8hHoBIzkWULdMCKJdgRE8GqACgvA9v esrR7mzazDpIM5rmw4UEkSA= =MrvA -END PGP SIGNATURE- My Inbox is protected by SPAMfighter 16205 spam mails have been blocked so far. Download free www.spamfighter.com today!
Re: CPOE time studies.
On Mon, 4 Oct 2004, Don Grodecki wrote: Sounds to me like a job for Tablet Computers! Don, As far as I know, lack of full-size keyboard dramatically diminishs the utility of tablet computers for applications that require text data entry. Best regards, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: CPOE time studies.
On Tue, 2004-10-05 at 08:01, Calle Hedberg wrote: Otherwise, I've just read the last annual HIV prevalence survey (survey in November 2003) for pregnant women: On average 27.5% for South Africa, with provincial rates ranging from about 13% to 37%. Not the first time I've seen such figures, but I am nevertheless dumbstruck by the size of the tragedy and enormity of the task ahead each time I am confronted with these data. This web site also helps to put things in perspective: http://costofwar.com/index-aids.html (the cost of Australia's direct participation in the Iraq war is thought to be about AUD$500 million over an 18 month period - a small proportion of the US cost, but nevertheless 25% of the total annual Australian foreign aid budget - which itself is way too small at just 0.25% of GDP). Add to that the fact that UK, Canada, Australia and other countries systematically poach doctors and nurses from SA (we have over 30,000 vacant nurse positions now) - the impact on workload should be obvious. Yes, and it is a totally unconscionable trade in human resources. It's okay for rich countries to fight amongst themselves for trained health staff, but plain wrong for them to actively drain such resources from countries with enormous needs. Just another aspect of the enormous rich/poor imbalance in the world. -- Tim C PGP/GnuPG Key 1024D/EAF993D0 available from keyservers everywhere or at http://members.optushome.com.au/tchur/pubkey.asc Key fingerprint = 8C22 BF76 33BA B3B5 1D5B EB37 7891 46A9 EAF9 93D0
Issue of freedom and migration, Re: CPOE time studies.
On Mon, 5 Oct 2004, Tim Churches wrote: On Tue, 2004-10-05 at 08:01, Calle Hedberg wrote: ... Add to that the fact that UK, Canada, Australia and other countries systematically poach doctors and nurses from SA (we have over 30,000 vacant nurse positions now) - the impact on workload should be obvious. Yes, and it is a totally unconscionable trade in human resources. Calle and Tim, Why is it unconscionable to freely trade human resources? Have you interviewed individuals who chose to migrate? I have. - begin quote The German free-market economist Wilhehm Roepke once suggested that modern nationalism and collectivism have, by the restriction of migration, perhaps come nearest to the servile state . Man can hardly be reduced more to a mere wheel in the clockwork of the national collectivist state than being deprived of his freedom to move - end quote from In Defense of Free Migration, Richard Ebeling, The Future of Freedom Foundation http://www.fff.org/freedom/0691b.asp It's okay for rich countries to fight amongst themselves for trained health staff, I see. There are different kinds human beings: those born to rich countries and those born to poor countries? And it is _harmful_ to offer the same opportunities to individuals from poor countries? As we all know, major motivation for free software is to increase freedom and lower costs. If vendor lock-in impedes progress and adds to information costs, country-of-birth lock-in carries even higher human and economic costs. Best regards, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: Issue of freedom and migration, Re: CPOE time studies.
On Tue, 2004-10-05 at 09:47, Andrew Ho wrote: On Mon, 5 Oct 2004, Tim Churches wrote: On Tue, 2004-10-05 at 08:01, Calle Hedberg wrote: ... Add to that the fact that UK, Canada, Australia and other countries systematically poach doctors and nurses from SA (we have over 30,000 vacant nurse positions now) - the impact on workload should be obvious. Yes, and it is a totally unconscionable trade in human resources. Calle and Tim, Why is it unconscionable to freely trade human resources? It is unconscionable because the rich countries do not pay a fair price for the very valuable human resources they are encouraging (and helping) to migrate to their countries. For example, it probably costs the South African government (and hence the South African people) between US$50,000 and US$150,000 to train a medical student through to being a specialist physician or surgeon. When the UK, Canada or Australia recruits such a person to work in the UK, Canada or Australia, do they reimburse the South African government for the cost of that training, plus the much greater opportunity cost of having to train a replacement over a ten year period? No, they don't. That situation seems unconscionable to me, especially when the relative need for trained health staff in South Africa is so much greater than in the UK, Canada and Australia. - begin quote The German free-market economist Wilhehm Roepke once suggested that modern nationalism and collectivism have, by the restriction of migration, perhaps come nearest to the servile state . Man can hardly be reduced more to a mere wheel in the clockwork of the national collectivist state than being deprived of his freedom to move - end quote from In Defense of Free Migration, Richard Ebeling, The Future of Freedom Foundation http://www.fff.org/freedom/0691b.asp Sorry, all that laissez-faire, totally free-market, right-wing libertarianism stuff is wasted on me. I unapologetically believe that the state has a role and responsibility to help redistribute wealth from the rich to the poor. It's okay for rich countries to fight amongst themselves for trained health staff, I see. There are different kinds human beings: those born to rich countries and those born to poor countries? That's the unfortunate but undeniable reality of the world today. The key is for governments and individuals to act in ways which reduce those disparities, not increase them. And it is _harmful_ to offer the same opportunities to individuals from poor countries? It is harmful for governments of rich nations to actively recruit and to facilitate the migration of desperately needed, expensively-trained individuals from poor countries. As we all know, major motivation for free software is to increase freedom and lower costs. If vendor lock-in impedes progress and adds to information costs, country-of-birth lock-in carries even higher human and economic costs. Neither Calle or I, or anyone else, have suggested that people be prevented from migration. The argument is against active recruitment and facilitated, preferential immigration programmes for skilled health care personnel from poorer countries to richer countries. It is morally wrong. -- Tim C PGP/GnuPG Key 1024D/EAF993D0 available from keyservers everywhere or at http://members.optushome.com.au/tchur/pubkey.asc Key fingerprint = 8C22 BF76 33BA B3B5 1D5B EB37 7891 46A9 EAF9 93D0
Re: CPOE time studies.
- Original Message - From: Andrew Ho [EMAIL PROTECTED] Don, As far as I know, lack of full-size keyboard dramatically diminishs the utility of tablet computers for applications that require text data entry. Andrew, Why not capture the Doctor's input as a handwriting image? That's what happens on paper systems. - Don My Inbox is protected by SPAMfighter 16250 spam mails have been blocked so far. Download free www.spamfighter.com today!
Re: Issue of freedom and migration, Re: CPOE time studies.
On Mon, 5 Oct 2004, Tim Churches wrote: ... Yes, and it is a totally unconscionable trade in human resources. Calle and Tim, Why is it unconscionable to freely trade human resources? It is unconscionable because the rich countries do not pay a fair price Tim, The concept of trading freely includes mechanism for establishing fair pricing that is acceptable by both seller and buyer. ... For example, it probably costs the South African government (and hence the South African people) between US$50,000 and US$150,000 to train a medical student through to being a specialist physician or surgeon. So what? It probably costs the same or more to train an U.S. medical student. Does that mean it is unconscionable for the people of France or South Africa to offer a position to this physician? When the UK, Canada or Australia recruits such a person to work in the UK, Canada or Australia, do they reimburse the South African government for the cost Double standard you use. If I decide to move to South Africa, would South Africans reimburse the U.S. government? ... That situation seems unconscionable to me, especially when the relative need for trained health staff in South Africa is so much greater than in the UK, Canada and Australia. Needs typically exheed the ability to fill the need; this is called scarcity in economics, please read: http://www.socialstudiesforkids.com/articles/economics/scarcityandchoices1.htm With greater scarcity, each unit of goods/service will command a higher price. In a free market, the higher price will eventually cause increased availability of the goods/services and reduction of scarcity. On the other hand, if price-control is instituted, then the relative shortage will never be resolved. ... And it is _harmful_ to offer the same opportunities to individuals from poor countries? It is harmful for governments of rich nations to actively recruit and to facilitate the migration of desperately needed, expensively-trained individuals from poor countries. It is not as simple as that. Most expensively-trained and talented individuals choose to migrate even in the face of active discouragements and barriers. As we all know, major motivation for free software is to increase freedom and lower costs. If vendor lock-in impedes progress and adds to information costs, country-of-birth lock-in carries even higher human and economic costs. Neither Calle or I, or anyone else, have suggested that people be prevented from migration. ... ok - as long as you are not advocating discrimination based on country-of-origin. Best regards, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: CPOE time studies.
On Mon, 4 Oct 2004, Don Grodecki wrote: - Original Message - From: Andrew Ho [EMAIL PROTECTED] Don, As far as I know, lack of full-size keyboard dramatically diminishs the utility of tablet computers for applications that require text data entry. Andrew, Why not capture the Doctor's input as a handwriting image? That's what happens on paper systems. Don, Good point, maybe that's exactly what we aim for. With sufficient digitizer resolution, network bandwidth, and storage capacity, this might become feasible. Have you tried current generation of tablet PC? I am interested to know whether you think they are sufficient for capturing handwriting image. Best regard, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
Re: Issue of freedom and migration, Re: CPOE time studies.
On Tue, 2004-10-05 at 14:21, Andrew Ho wrote: Needs typically exheed the ability to fill the need; this is called scarcity in economics, please read: http://www.socialstudiesforkids.com/articles/economics/scarcityandchoices1.htm With greater scarcity, each unit of goods/service will command a higher price. In a free market, the higher price will eventually cause increased availability of the goods/services and reduction of scarcity. Yes Andrew, eventually, and in theory, but in the meantime who provides health care for the huge numbers of HIV +ve people in Africa? Neither Calle or I, or anyone else, have suggested that people be prevented from migration. ... ok - as long as you are not advocating discrimination based on country-of-origin. No, we are against active recruitment and facilitated migration of trained health professionals from needy countries to wealthy countries. -- Tim C PGP/GnuPG Key 1024D/EAF993D0 available from keyservers everywhere or at http://members.optushome.com.au/tchur/pubkey.asc Key fingerprint = 8C22 BF76 33BA B3B5 1D5B EB37 7891 46A9 EAF9 93D0
