Sam Heard

Specialist outreach to isolated and disadvantaged communities: a population-based study

BACKGROUND Visiting-specialist clinics (specialist outreach) have the potential to overcome some of the substantial access barriers faced by disadvantaged rural, remote, and Indigenous communities, but the effectiveness of outreach clinics has not been assessed outside urban and non-disadvantaged settings. We aimed to assess the effects of outreach clinics on access, referral patterns, and care outcomes in remote communities in Australia. METHODS We undertook a population-based observational study of regular surgical, ophthalmological, gynaecological, and ear, nose, and throat outreach visits, compared with hospital clinics alone, on access, referral practices, and outcomes for the populations of three remote Indigenous communities in northern Australia for 11 years. We assessed all new non-emergency potential specialist surgical cases who presented initially between Jan 1, 1990, and Jan 1, 2001. The effects of outreach clinics on the proportion of patients referred, the time from referral to initial specialist consultation, and the rates of community-based and hospital-based procedures were analysed using logic regression and Cox proportional hazard models. FINDINGS 2339 new surgical problems presented in 2368 people between 1990 and 2001. Outreach improved the rate of referral completion (adjusted hazard ratio 1.41, 95% CI 1.07-1.86) and the risk of timely completion according to the urgency of referral (adjusted relative risk 1.30, 1.05-1.53). Outreach had no significant effect on initiation of elective referrals, but there were 156 opportunistic presentations on outreach clinic days. Specialist investigations and procedures in community clinics removed the need for many patients to travel to hospital, and outreach consultations were associated with a reduced rate of procedures that needed hospital admission (adjusted hazard ratio 0.67, 0.43-1.03). INTERPRETATION Specialist outreach visits to remote disadvantaged Indigenous communities in Australia improve access to specialist consultations and procedures without increasing elective referrals or demands for hospital inpatient services.

Exploiting ebXML registry semantic constructs for handling archetype metadata in healthcare informatics

Using archetypes is a promising approach in providing semantic interoperability among healthcare systems. To realise archetype based interoperability, the healthcare systems need to discover the existing archetypes, based on their semantics; annotate their archetypes with ontologies; compose templates from archetypes and retrieve corresponding data from the underlying medical information systems. In this paper, we describe how ebXML Registry semantic constructs can be used for annotating, storing, discovering and retrieving archetypes. For semantic annotation of archetypes, we present an example of an archetype metadata ontology and describe the techniques to access archetype semantics through ebXML query facilities. We present a GUI query facility and describe how the stored procedures, which we introduce, move the semantic support beyond what is currently available in ebXML registries. We also address how archetype data can be retrieved from clinical information systems by using ebXML web services. A comparison of web service technology with the ebXML messaging system is provided to justify the reasons for using web services.