Blockchain Papers

A. Taborga Echevarría

No abstract is available for this record.

Peter Haastrup, Anne Møller, Jette Kolding Kristensen, Linda Huibers

Denmark is known for its good population health, largely attributable to its effective healthcare system. This analysis of the Danish primary healthcare system with focus on general practice describes the system's overall structure, function, and financing. Further, it reviews some of the recent developments in organization and decentralization from secondary to primary care. Finally, we discuss some of the key challenges that primary care faces and potential areas for improvement to ensure a sustainable Danish healthcare system of high quality.

Maria Gabriella Melchiorre, Roberta Papa, Sabrina Quattrini, Giovanni Lamura · 5 authors

INTRODUCTION: eHealth applications have the potential to provide new integrated care services to patients with multimorbidity (MM), also supporting multidisciplinary care. The aim of this paper is to explore how widely eHealth tools have been currently adopted in integrated care programs for (older) people with MM in European countries, including benefits and barriers concerning their adoption, according to some basic health system characteristics. MATERIALS AND METHODS: In 2014, in the framework of the ICARE4EU project, expert organizations in 24 European countries identified 101 integrated care programs. Managers of the selected programs completed an online questionnaire on several dimensions, including the use of eHealth. We analyzed data from this questionnaire, in addition to qualitative information from six innovative programs which were studied in depth through case study methodology, according to characteristics of national health systems: a national health model (financing system), overall strength of primary care (PC) (structure/service delivery process), and level of (de)centralization of health system (executive powers in a country). RESULTS: 85 programs (out of 101) adopted at least one eHealth tool, and 42 of these targeted explicitly older people. In most cases, Electronic Health Records (EHRs) were used and some benefits emerged like improved care management and integration, although inadequate funding mechanisms represented a major barrier. The analysis by health system characteristics showed a greater adoption of eHealth applications in decentralized countries, in countries with a National Health Service (NHS) model, and in countries with a strong/medium level of PC development. CONCLUSIONS: Although in the light of some limitations, findings indicate a relation between implementation of care programs using eHealth tools and basic characteristics of health systems, with decentralization of a health system, NHS model, and strong/medium PC having a key role. However adaptations of European health systems seem necessary, in order to provide a more innovative and integrated care.

Yu-Sheng Lo, Cheng-Yi Yang, Hsiung‐Fei Chien, Shy-Shin Chang · 6 authors

BACKGROUND: Medical referral is the transfer of a patient's care from one physician to another upon request. This process involves multiple steps that require provider-to-provider and provider-to-patient communication. In Taiwan, the National Health Insurance Administration (NHIA) has implemented a national medical referral (NMR) system, which encourages physicians to refer their patients to different health care facilities to reduce unnecessary hospital visits and the financial stress on the national health insurance. However, the NHIA's NMR system is a government-based electronic medical referral service, and its referral data access and exchange are limited to authorized clinical professionals using their national health smart cards over the NHIA virtual private network. Therefore, this system lacks scalability and flexibility and cannot establish trusting relationships among patients, family doctors, and specialists. OBJECTIVE: To eliminate the existing restrictions of the NHIA's NMR system, this study developed a scalable, flexible, and blockchain-enabled framework that leverages the NHIA's NMR referral data to build an alliance-based medical referral service connecting health care facilities. METHODS: We developed a blockchain-enabled framework that can integrate patient referral data from the NHIA's NMR system with electronic medical record (EMR) and electronic health record (EHR) data of hospitals and community-based clinics to establish an alliance-based medical referral service serving patients, clinics, and hospitals and improve the trust in relationships and transaction security. We also developed a blockchain-enabled personal health record decentralized app (DApp) based on our blockchain-enabled framework for patients to acquire their EMR and EHR data; DApp access logs were collected to assess patients' behavior and investigate the acceptance of our personal authorization-controlled framework. RESULTS: The constructed iWellChain Framework was installed in an affiliated teaching hospital and four collaborative clinics. The framework renders all medical referral processes automatic and paperless and facilitates efficient NHIA reimbursements. In addition, the blockchain-enabled iWellChain DApp was distributed for patients to access and control their EMR and EHR data. Analysis of 3 months (September to December 2018) of access logs revealed that patients were highly interested in acquiring health data, especially those of laboratory test reports. CONCLUSIONS: This study is a pioneer of blockchain applications for medical referral services, and the constructed framework and DApp have been applied practically in clinical settings. The iWellChain Framework has the scalability to deploy a blockchain environment effectively for health care facilities; the iWellChain DApp has potential for use with more patient-centered applications to collaborate with the industry and facilitate its adoption.

Alberto Infante Campos

The Spanish National Health System (SNHS) was legally defined in 1986. There are many well documented studies on how its basic traits (universality, accessibility, decentralization, integrated public health networks, public and private provision, financed by taxes, social premiums and copayments, etc.) have evolved since then. This paper explains how the SNHS facilities and functions are deeply decentralized and how the recent economic crisis has changed this picture, with central health planning basically located into the Ministry of Finance and mainly guided by deficit control considerations.

Cristianne Maria Famer Rocha, Silvia Helena De Bortoli Cassiani

In recent decades, health care networks in diff erent parts of the world have incorporated new forms of social organization that involve extensive use of technology to produce and disseminate information and are based on the autonomous, non-hierarchical and decentralized cooperation and collaboration of those within these networks. In Latin American countries, Nursing Networks were created in the 2000s on the initiative of professionals seeking to exchange knowledge and experiences. Over time this initiative gained ground with the support and leadership of the Regional Council for Nursing and Health Technicians of the Pan American Health Organization (PAHO) and, in 2007 and, in 2007, the 1 st International Nursing Network Conference was held in Toledo (Spain), during the 9 th Ibero-American Conference of the Latin American Association of Nursing Schools (ALADEFE). These networks operate as a communication strategy, stimulating cohesion and cooperation between nurses interested in developing nursing care, management, research, information and education with a view to supporting the advancement of the profession and help countries achieve universal health care coverage and access to health services. There are currently around 25 International Nursing Networks in the Americas, which together form Rede EnfAmericas and consist of more than 3000 nurses in Latin America. Information on each of these networks is available at: http://www.

Joseph Bernstein

The practice of orthopaedic surgery has become highly specialized. According to a recent American Academy of Orthopaedic Surgeons (AAOS) census, 77% of members reported a specialty interest [1]. Along those lines, Morrell et al. [12] estimate that at least 90% of graduating orthopaedic surgery residents pursue fellowship training. It would be no surprise, therefore, to discover that the AAOS Board of Specialty Societies boasts 22 member groups. To some, greater specialization is no doubt a step in the wrong direction. Back in the days of the giants, this nostalgic argument goes, a “real” surgeon would be happy to fix a femur fracture and straighten a spine on the same day. (In fact, the true giants would fix a fracture and straighten a spine only after removing an appendix and delivering a baby or two.) Today's orthopaedic surgeons, by contrast, are feckless and feeble. A more reasonable view acknowledges the benefits of specialization. For one, surgeons who do only one procedure are apt to become quite efficient [6]. Better still, the high-volume specialist-surgeon will produce superior results [7]. Specialization similarly enhances career prospects: The Top Doctor lists are filled almost exclusively with specialists and academic advancement criteria emphasize depth over breadth. Of course, a reasonable view would also acknowledge the costs of specialization. Specialists—like all of us—see the world through the prism of experience. As such, they can easily overlook or discount important findings. This so-called “availability bias” would spur a neurosurgeon to attribute index finger pain to a cervical radiculopathy and a hand surgeon to blame the median nerve—with both of them relatively blinded to the possibility that a metabolic abnormality, say, is the true cause. Yet even if specialists could break free of their cognitive constraints, patients may still pay as they shuffle from expert to expert in search of total care. This cost comprises not only hassle and dollars, but a potential for poor communication and other forms of uncoordinated care [3]. There is, furthermore, a problem of distribution. Specialists quite rationally tend to congregate in larger urban areas: Places with enough patients to keep them busy in their own narrow practice enclaves. Hence, specialization can lead to a manpower shortage (and impeded access to care) in small towns and a glut (with overtreatment) in big cities. In addition, too much specialization within a surgeon's practice exposes that surgeon to the risk his or her practice might implode if the demand for a particular service disappears. Simply put: The surgeon who knows how to do only knee replacements will be out of work if a medical cure for arthritis is discovered. Of course, it is highly unlikely that a medical cure for arthritis will be discovered so quickly that the surgeon will be unable to adapt, but the risk is not zero. (Those who place the risk at zero have never witnessed a cardiothoracic surgeon crying about the discovery of coronary stents). Maintaining mastery over many surgical procedures is an excellent hedge against the possibility that one of these procedures falls out of favor. But there is an even more pressing reason for surgeons to resist too much specialization: It just might be bad for the soul. In his classic book The Wealth of Nations, Adam Smith noted that the division of labor leads to “universal opulence.” Smith clearly recognized the benefits specialization and is rightly considered one of its greatest champions. But Smith went on to assert “The man whose whole life is spent in performing a few simple operations … generally becomes as stupid and ignorant as it is possible for a human creature to become.” According to Smith, repeatedly doing the same operation (a word we may want to take in its modern medical sense) creates a “torpor of [the] mind.” This torpor, Smith claims, is a state in which the specialist becomes unable to conceive of any “generous, noble, or tender sentiment, and consequently of forming any just judgment concerning many even of the ordinary duties of private life.” In modern parlance: Burnout. So what to do? Because specialization imposes costs on patients, it may be reasonable to insist on professional rules to limit it somewhat. (The broad ABOS recertification examination can be considered such a step, as are normative standards that ask orthopaedic surgeons to provide general emergency room coverage in their community). In addition, our leaders should educate young orthopaedic surgeons about specialization's hidden costs. This knowledge will let enlightened self-interest—what Smith called the “invisible hand”—motivate the correct course of action. Pierre J. Hoffmeyer MD Professor of Orthopaedic Surgery University Hospital of Geneva Hyperspecialization in orthopaedic surgery is here to stay. This is especially true in economically favored regions benefitting from high levels of resources [4]. Hyperspecialization has political support because of increasing public pressure stemming from the needs and demands of an aging and active population [2]. In this setting of economic affluence, orthopaedic surgeons have been able to narrow their surgical practice to one joint, to one disease process, or even to one technique. The corollary is that as the number of hyperspecialized experts increases, the quality of the holistic approach towards musculoskeletal care diminishes. How this situation of increasing hyperspecialization will progress will depend on many issues touching on education, legal environment, and economics. Young surgeons training in academic centers are educated by teachers who themselves are highly specialized. These specialists serve not only as mentors but also as role models. It is likely that trainees will follow in the footsteps of their teachers. It is doubtful that this situation is likely to change soon given the structure and organization of most major teaching institutions. The legal environment plays a major role in the molding of surgical practice. In fact, the first question facing a surgeon entangled in a medicolegal issue is how competent he or she is in performing a given procedure. A diploma attesting to the completion of a general orthopaedic education is no longer sufficient to demonstrate competence. Today, proofs of fellowship training as well as the performance of the appropriate numbers of specialized interventions have become mandatory if the surgeon is to convince opposing parties that he or she is competent to safely and effectively perform a given operation. This vision of capability embodied by the high-volume surgeon specialist will undoubtedly persevere [2, 8]. Arguably, regional economics differentiate surgical practice in affluent constituencies from less-prosperous areas. Well-equipped regions with high-quality infrastructures allowing rapid travel to centers of highly specialized expertise will have a large range of hyperspecialized surgeons providing expertise in all the domains of orthopaedics and traumatology. For the individual patient, this could mean better care, fewer complications, and improved efficiency for a given procedure [8, 11]. Conversely, hyperspecialization will entail higher costs because of the increased number of specialists working in a technology-rich environment. For less-favored regions, one surgeon will have to tackle a broad spectrum of diseases, master many techniques, and be knowledgeable in many areas. He or she will have to deal with a variety of situations, but perhaps not as efficiently or complication-free for a given procedure as the hyperspecialized surgeon. Although a generalist approach might appear to be cheaper in the short-term, patients may not always benefit from the latest, safest, and most efficient techniques [2, 11]. Since it appears hyperspecialists are here to stay, solutions must be found. The obvious answer lies in education. All practitioners of orthopaedic surgery, regardless of specialization, must possess a broad base of knowledge in the musculoskeletal field. One should not confound technical and procedural skills with overall expertise and knowledge [13]. The education of surgical trainees and fellows needs to emphasize the necessity of a broad culture in terms of diseases and trauma of the musculoskeletal system regardless of the field of hyperspecialization. This knowledge should be controlled in the recertification process, specializing on the joint, technique, or disease in which the surgeon is focused as well as on his or her general level of knowledge in the broader field of orthopaedics and traumatology. Augusto Sarmiento MD Professor and Chairman Emeritus University of Miami Dr. Bernstein identifies several important issues concerning exaggerated subspecialization in medicine and does not hide his personal concerns regarding its uncontrolled explosion. However, his attempts to propose solutions to the problem do not match his clear exposure of the unhealthy consequences of failure to arrest the progression of the trend. His suggestions along this line are rather timid and sometimes even unrealistic, such as “asking orthopaedic surgeons to provide general emergency room coverage in their community.” This suggestion falls in shallow water even if the fear of litigation could be eliminated. Dr. Bernstein further suggests, “In addition, our leaders should educate young orthopaedic surgeons about specialization's hidden costs.” In this instance, who will educate the “leaders” who have been the ones primarily responsible for the creation and perpetuation of the problem? I commend CORR® for publishing this thoughtful article on a subject that needs a forceful and aggressive debate. However, in his column, Dr. Bernstein underestimates the fact that greed has crept into our profession to the point where many consider it as being primarily a profitable business. Unfortunately, greed is at the very essence of the subspecialization problem. The current situation will not be assuaged with warm compresses and a few aspirins. The entire issue of education of the physician must be brought to the frontline [14-16]. This is a golden opportunity for orthopaedics, as a major and instrumental profession, to provide leadership to a force that requires active input from a variety of disciplines within the medical establishment as well as from other social and political bodies. Harmful, exaggerated fragmentation of our discipline has allowed several traditional medical and paramedical professions to assume the care of musculoskeletal conditions, long a territory exclusively managed by the orthopaedist. For example, podiatrists and chiropractors have expanded the scope of their disciplines into orthopaedic territory, and more recently, nurse practitioners and physician assistants have claimed the right to provide care for conditions they consider themselves qualified to treat. If we cannot appropriately correct the already ridiculous degree of fragmentation in orthopaedics, the overall situation will continue to deteriorate to a degree that could seriously compromise the vitality of our profession. K. Daniel Riew MD Professor, Department of Orthopaedic Surgery Washington University in St. Louis Dr. Bernstein's article is an excellent summary of the benefits and risks of overspecialization. His arguments against specialization are all valid. I would add what Konrad Lorenz said about scientists, (even more appropriate for specialists): They “are people who know more and more about less and less, until they know everything about nothing” [5]. But as a hyperspecialist who specializes only in cervical spine, I have to respectfully disagree with the final message. In my opinion, not only is specialization inevitable, it is the correct path for science, education, and patient benefit. The history of medicine has demonstrated an inexorable path towards subspecialization. In The Evolution of Orthopaedic Surgery [9], author Leslie Klenerman tells us how orthopaedics became a specialty and seceded from general surgery: “It is little more than a generation since orthopaedic surgery began its astounding and near exponential ascent from relative obscurity under the dominance of general surgery to itself become a major influence.” But Klenerman notes that the forces are inexorably pushing the subspecialties away from orthopaedics: “How much longer will the interests of specialization within it, allow it to remain united before it too falls victim to the fragmentation that destroyed the supremacy of its erstwhile master?” The desire to subspecialize is driven by at least three factors. First, we live in a world of information overload. MEDLINE adds more than 5000 articles per weekday. Even if we assume that only 1% of these pertain to orthopaedics, it is nearly impossible for most busy physicians to stay current with all the articles. Would we want the next generation of surgeons to be trained by generalists who cannot keep up, or specialists, current with the literature in their area? Second, legally, general practitioners are held to the same standards as subspecialists. Therefore, if a generalist mismanages a cervical spine fracture, they will be held to the same standards as a cervical spine surgeon. Unless they are current with all aspects of cervical spine care, they are placing themselves at medicolegal risk. Third, in surgery, volume drives success, improves outcomes, shortens operative times, decreases complications, and improves efficiency. We are the cognoscenti when it comes to orthopaedic problems. Who among us would choose to have a delicate tumor removed from our dominant hand by a general orthopaedic surgeon, instead of a hyperspecialized hand surgeon who has great experience with such tumors? Knowing that the results would be highly likely to be better, would we not want the same for all of our family and friends? If we would want these for our loved ones, do our patients deserve any less? A generalist still serves a useful purpose and there are many downsides to everyone becoming a hyperspecialist. However, in my opinion, this is not an adequate reason to recommend that we remain a “jack of all trades and a master of none.”

Matthew S. Murphy, Alberto Fernápndez, Antonio Daponte

the death of General Francisco Franco on 20th November 1975 and the subsequent transition to democracy was a seminal moment in Spanish history, laying the groundwork for important administrative and institutional changes. one of the most important changes during this time period was the establishment of a right to health care in the Constitution of 1978. previously, the Spanish health system had granted access based on employment status, with financing via payroll taxes managed by the Social Security Administration. With the passage of the Constitution of 1978 and subsequently the General Health Law of 1986, Spain developed a national health system which guaranteed universal access to the population and was financed through general taxation. At the same time, the country began to move away from a strongly centralized administration through a devolution process which granted administrative responsibility for governing areas such as education and health to the 17 autonomous communities of Spain. the process began with Cataluna in 1981, followed several years later by Andalucia and was completed in 2002.Both of these elements are essential to understanding the role and organization of the country's public health workforce. the universal nature of the Spanish health care system is regarded as the most significant guarantor of the country's health and wellbeing. At the same time, the central government has a very limited role in the management and organization of the health system. in fact, during the process of devolution, the field of public health was the first administrative element that was turned over to the autonomous communities. As it involved limited financial resources and infrastructure at the time, it was viewed as easily transferable. However, the government has struggled since then to organize and coordinate public health initiatives between the different autonomous communities. the principal coordination mechanism for health- related issues is a body called the Consejo Interterritorial de Salud where the 17 health ministers from the different communities as well as national professional groups meet with the national Minister of Health. Here, they plan the response to disease outbreaks or discuss the effects of new legislation on regional health systems. one of their major initiatives now is standardizing national preventive programs such as population screening procedures and the paediatric vaccine calendar in response to important intercommunal variations in initiatives and resources. ultimately, the Consejo has little legal authority and acts more as a facilitator for collaboration than a regulatory agency.As a result of the decentralization of the administration of health services and the early devolution of the responsibility to ensure public health reaches the autonomous communities, it is difficult to discuss a national public health workforce. there are no national databases or registries of the public health workforce in Spain. each community has developed its workforce based on its history, political philosophy and perceived health needs. Additionally, there is no national accrediting body for public health professionals in Spain, something that is essential for professional regulation and political importance in the workplace. However, there are important professional associations at the national and regional level that fall under the umbrella group SeSpAS, or the Spanish Society of public Health and Health Administration. these associations include groups such as the Spanish Network of primary Healthcare, the Spanish Association of epidemiology and the Spanish Society of environmental Health among others.the national government does play a central role in insuring compliance with european legislation and regulations, particularly in areas of occupational health, environmental health and food safety. As a result, the public health workforce is organized around these areas and usually includes a diverse set of professional profiles. …

Juan Ventura, Eduardo González

The aim of this chapter is to critically describe the evolution of the Spanish National Health System (NHS) in the last 25 years and its current situation. We will also revise the main reforms which are currently under debate. During these years, even with its ups and downs, the NHS has become a cornerstone of the Spanish welfare state. Mostly financed through taxes and with the predominance of public provision, the system has been able to incorporate the latest medical advances, offering quality health services almost universally. At the same time, in an ad hoc and rather hasty manner, the system has gone through a decentralization process that started with the devolution of health competences to the so-called historical regions, and was finally extended in 2002 to the 17 Spanish Autonomous Communities (ACs). These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

César Sánchez, Edwin Triana, Eduardo Romero

This article presents a web oriented telehealth platform adapted to the social and economic conditions of a developing country like Colombia. The platform aims to satisfy health care needs integrating modules for telemedicine, where medical processes are modelled following the HL7 Reference Information Model which has allowed easy inclusion of many specialities such as dermatology, radiology, cardiology, pathology and infection diseases, among others. The system implements many security mechanisms such as Digital Signature and Zero Knowledge Proof for authentication. A telecare real-time module measures patient's vital signs such as blood pressure, electrocardiogram, oxygen saturation and sends them over the network to monitor patient's health. After 19 months of service, the system processed 4.751 actual telemedicine cases from 31 remote stations with an average response time of 1, 3 days, showing flexibility, security and scalability.

José Miguel Fernández-Mastro, José Manuel Pajuelo-Morán, Juan María Benegas-Capote, María Isabel Enciso-Arjona · 7 authors

No abstract is available for this record.

Sven-Eric Bergman

Resource constraints and the necessity to improve efficiency and effectiveness have provided challenges for the Swedish health care system during the 1990s. Whereas there are no comprehensive reforms of funding and organization, measures have been taken at both national and regional level to meet these challenges. Decentralization has been a core issue in long-term reforms and current changes can be seen as continuing this pattern. As a consequence different solutions are sought in the various county councils (locally elected self-government bodies financing and procuring health services). In about one third of these county councils some sort of purchaser–provider models have been introduced. Emerging evaluation reports claim that the models have succeeded in improving efficiency; making the system more patient-oriented; and enhancing cost-consciousness. The roles of politicians, managers and professionals are also more clear, according to the proponents. However, there are also problems with more difficulties in controlling costs, and with inadequate remuneration systems. Over time the purchaser–provider schemes have matured, developing from emphasizing short-term tendering, negotiations and detailed contracts to more comprehensive agreements based on mutual commitments to improve health services. Rhetoric has changed; competition has been replaced by co-operation. The lure of the market concept has diminished. Similarities can be seen between county councils with and without purchaser–provider models. © 1998 John Wiley & Sons, Ltd.