The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente.

BackgroundPatient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited.MethodsThis paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development?ResultsWe identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design.ConclusionsThese findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs

Magnetic transport in a straight parabolic channel

We study a charged two-dimensional particle confined to a straight parabolic-potential channel and exposed to a homogeneous magnetic field under influence of a potential perturbation $W$. If $W$ is bounded and periodic along the channel, a perturbative argument yields the absolute continuity of the bottom of the spectrum. We show it can have any finite number of open gaps provided the confining potential is sufficiently strong. However, if $W$ depends on the periodic variable only, we prove by Thomas argument that the whole spectrum is absolutely continuous, irrespectively of the size of the perturbation. On the other hand, if $W$ is small and satisfies a weak localization condition in the the longitudinal direction, we prove by Mourre method that a part of the absolutely continuous spectrum persists

Phenotypic plasticity and population viability: the importance of environmental predictability

Phenotypic plasticity plays a key role in modulating how environmental variation influences population dynamics, but we have only rudimentary understanding of how plasticity interacts with the magnitude and predictability of environmental variation to affect population dynamics and persistence. We developed a stochastic individual-based model, in which phenotypes could respond to a temporally fluctuating environmental cue and fitness depended on the match between the phenotype and a randomly fluctuating trait optimum, to assess the absolute fitness and population dynamic consequences of plasticity under different levels of environmental stochasticity and cue reliability. When cue and optimum were tightly correlated, plasticity buffered absolute fitness from environmental variability, and population size remained high and relatively invariant. In contrast, when this correlation weakened and environmental variability was high, strong plasticity reduced population size, and populations with excessively strong plasticity had substantially greater extinction probability. Given that environments might become more variable and unpredictable in the future owing to anthropogenic influences, reaction norms that evolved under historic selective regimes could imperil populations in novel or changing environmental contexts. We suggest that demographic models (e.g. population viability analyses) would benefit from a more explicit consideration of how phenotypic plasticity influences population responses to environmental change

Liver transplantation for type IV glycogen storage disease

TYPE IV glycogen storage disease is a rare autosomal recessive disorder (also called Andersen's disease1 or amylopectinosis) in which the activity of branching enzyme alpha-1, 4-glucan: alpha-1, 4-glucan 6-glucosyltransferase is deficient in the liver as well as in cultured skin fibroblasts and other tissues.2,3 This branching enzyme is responsible for creating branch points in the normal glycogen molecule. In the relative or absolute absence of this enzyme, an insoluble and irritating form of glycogen, an amylopectin-like polysaccharide that resembles plant starch, accumulates in the cells. The amylopectin-like form is less soluble than normal glycogen, with longer outer and inner chains. © 1991, Massachusetts Medical Society. All rights reserved

906-61 Acoustic Quantification in the Infarcted Ventricle: Comparison with Electron Beam Computed Tomography

Assessment of LV size and function by acoustic quantification (AQ) correlates well with other techniques in patients with normally contracting ventricles. This prospective study examined the correlation between AQ and electron beam computed tomography (EBCT) volume measurements in patients with first anterior Q-wave MI and abnormally contracting ventricles. End-diastolic (EDV) and end-systolic (ESV) volumes by AQ were determined from standard four-chamber (4ch) and two-chamber (2ch) apical windows. The AQ tracings were transformed to volumetric measurements using the area-length (AL) and the modified Simpson's (mod.S) methods. EDV and ESV by EBCT were obtained conventionally by summation of manually traced LV areas on each short axis tomograms using Simpson's rule. Thirteen patients were imaged by both EBCT and echocardiography within 24 hours. EBCT-EDV ranged from 129–234ml (mean 173±34 ml and ESV from 58–109ml (mean 82±19 ml). The EDV and ESV by AQ, their correlation to EBCT and the accompanying pvalues are shown below:EDV-2chEDV-4chESV-2chESV-4chVol (ml)88±3097±3043±2050±22ALr0.760.560.580.34p0.0060.0490.0610.258Vol (ml)80±3390±3140±2145±20mod.Sr0.760.700.720.58p0.0060.0080.0120.037Conclusions[1] AQ underestimates absolute EDV and ESV measured by EBCT. [2] AQ-EDV correlates well with EBCT, particularly using the mod.S method. [3] AQ-ESV correlation to EBCT drops due to the asymmetric contraction pattern of infarcted ventricles. [4] The AL method's accuracy is particularly susceptible to asymmetric contraction in distorted ventricles. [5] Correction factors can be applied to account for the offset of EDV and ESV measurements by AQ

Opportunities for and Limitations of Private Ordering in Family Law (Symposium Roundtable)

Symposium: Law and the New American Family Held at Indiana University School of Law - Bloomington Apr. 4, 199