Diflucan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

James R. Ouellette DO

• Assistant Professor of Surgery/Associate Program Director, Division of Surgical
• Oncology, Hepatobiliary and Pancreatic Surgery Program, Wright State University
• Boonshoft School of Medicine, Dayton, Ohio

Complication codes from the body system chapters should be assigned for intraoperative and postprocedural complications fungus gnats in grass cheap diflucan 400mg without a prescription. Chapter 20: External Causes of Morbidity (V00-Y99) the external causes of morbidity codes should never be sequenced as the first listed or principal diagnosis fungus structure order diflucan cheap online. External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies fungus gnats mushrooms buy cheap diflucan 50 mg on line. In the absence of a mandatory reporting requirement garlic antifungal yeast infection order diflucan 100mg overnight delivery, providers are encouraged to voluntarily report external cause codes fungus packaging order diflucan online now, as they provide valuable data for injury research and evaluation of injury prevention strategies antifungal vitamins minerals purchase diflucan 150mg amex. General External Cause Coding Guidelines 1) Used with any code in the range of A00. Though they are most applicable to injuries, they are also valid for use with such things as infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity. Most categories in this chapter have th three 7 character values: A, initial encounter, D, subsequent encounter and S, sequela. While the patient may be seen by a new or different provider over the course of treatment for an th injury or condition, assignment of the 7 character for external th cause should match the 7 character of the code assigned for the associated injury or condition for the encounter. If only one external code can be recorded, assign the code most related to the principal diagnosis. The combination external cause code used should correspond to the sequence of events regardless of which caused the most serious injury. Place of Occurrence Guideline Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition. Generally, a place of occurrence code is assigned only once, at the initial encounter for treatment. However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence th code may be assigned. Activity Code Assign a code from category Y93, Activity code, to describe the activity of the patient at the time the injury or other health condition occurred. The activity codes are not applicable to poisonings, adverse effects, misadventures or sequela. A code from category Y93 is appropriate for use with external cause and intent codes if identifying the activity provides additional information about the event. Place of Occurrence, Activity, and Status Codes Used with other External Cause Code When applicable, place of occurrence, activity, and external cause status codes are sequenced after the main external cause code(s). Regardless of the number of external cause codes assigned, generally there should be only one place of occurrence code, one activity code, and one external cause status code assigned to an encounter. However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence code may be assigned. If the format permits capture of additional external cause codes, the cause/intent, including medical misadventures, of the additional events should be reported rather than the codes for place, activity, or external status. Multiple External Cause Coding Guidelines More than one external cause code is required to fully describe the external cause of an illness or injury. The assignment of external cause codes should be sequenced in the following priority: If two or more events cause separate injuries, an external cause code should be assigned for each cause. The first-listed external cause code will be selected in the following order: External codes for child and adult abuse take priority over all other external cause codes. External cause codes for terrorism events take priority over all other external cause codes except child and adult abuse. External cause codes for cataclysmic events take priority over all other external cause codes except child and adult abuse and terrorism. External cause codes for transport accidents take priority over all other external cause codes except cataclysmic events, child and adult abuse and terrorism. Activity and external cause status codes are assigned following all causal (intent) external cause codes. The first-listed external cause code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed above. Child and Adult Abuse Guideline Adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse. For confirmed cases of abuse, neglect and maltreatment, when the perpetrator is known, a code from Y07, Perpetrator of maltreatment and neglect, should accompany any other assault codes. Unknown or Undetermined Intent Guideline If the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent. Sequelae (Late Effects) of External Cause Guidelines 1) Sequelae external cause codes th Sequela are reported using the external cause code with the 7 character S for sequela. These codes should be used with any report of a late effect or sequela resulting from a previous injury. Do not use a late effect external cause code for subsequent visits for follow up care. More than one Y38 code may be assigned if the injury is the result of more than one mechanism of terrorism. This code should not be assigned for conditions that are due to the initial terrorist act. External Cause Status A code from category Y99, External cause status, should be assigned whenever any other external cause code is assigned for an encounter, including an Activity code, except for the events noted below. Assign a code from category Y99, External cause status, to indicate the work status of the person at the time the event occurred. The status code indicates whether the event occurred during military activity, whether a non-military person was at work, whether an individual including a student or volunteer was involved in a non-work activity at the time of the causal event. A code from Y99, External cause status, should be assigned, when applicable, with other external cause codes, such as transport accidents and falls. The external cause status codes are not applicable to poisonings, adverse effects, misadventures or late effects. Do not assign a code from category Y99 if no other external cause codes (cause, activity) are applicable for the encounter. An external cause status code is used only once, at the initial encounter for treatment. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) Note: the chapter specific guidelines provide additional information about the use of Z codes for specified encounters. Use of Z Codes in Any Healthcare Setting Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. A corresponding procedure code must accompany a Z code to describe any procedure performed. Categories of Z Codes 1) Contact/Exposure Category Z20 indicates contact with, and suspected exposure to , communicable diseases. These codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic. Category Z77, Other contact with and (suspected) exposures hazardous to health, indicates contact with and suspected exposures hazardous to health. Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit. A status code is informative, because the status may affect the course of treatment and its outcome. A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96. The status Z codes/categories are: Z14 Genetic carrier Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease. Z15 Genetic susceptibility to disease Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31. Additional codes should be assigned for any applicable family or personal history. Z16 Resistance to antimicrobial drugs this code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Z22 Carrier of infectious disease Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection. Z66 Do not resuscitate this code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence. Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis). Z93 Artificial opening status Z94 Transplanted organ and tissue status Z95 Presence of cardiac and vascular implants and grafts Z96 Presence of other functional implants Z97 Presence of other devices Z98 Other postprocedural states Assign code Z98. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter. Z99 Dependence on enabling machines and devices, not elsewhere classified Note: Categories Z89-Z90 and Z93-Z99 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent. Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. The history Z code categories are: Z80 Family history of primary malignant neoplasm Z81 Family history of mental and behavioral disorders Z82 Family history of certain disabilities and chronic diseases (leading to disablement) Z83 Family history of other specific disorders Z84 Family history of other conditions Z85 Personal history of malignant neoplasm Z86 Personal history of certain other diseases Z87 Personal history of other diseases and conditions Z91. The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination. The screening Z codes/categories: Z11 Encounter for screening for infectious and parasitic diseases Z12 Encounter for screening for malignant neoplasms Z13 Encounter for screening for other diseases and disorders Except: Z13. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code. The only exception to this is when the principal diagnosis is required to be a code from category Z38, Liveborn infants according to place of birth and type of delivery. Then a code from category Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out, is sequenced after the Z38 code. Additional codes may be used in addition to the observation code, but only if they are unrelated to the suspected condition being observed. They are for use in very limited circumstances on a maternal record when an encounter is for a suspected maternal or fetal condition that is ruled out during that encounter (for example, a maternal or fetal condition may be suspected due to an abnormal test result). For encounters for suspected fetal condition that are inconclusive following testing and evaluation, assign the appropriate code from category O35, O36, O40 or O41. The observation Z code categories: Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Except: Z04. The aftercare Z code should not be used if treatment is directed at a current, acute disease. If the reason for the encounter is more than one type of antineoplastic therapy, code Z51. For aftercare of an injury, assign the acute injury code th with the appropriate 7 character (for subsequent encounter). The aftercare codes are generally first-listed to explain the specific reason for the encounter. An aftercare code may be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. An example of this would be the closure of a colostomy during an encounter for treatment of another condition. Aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification.

But the young girl who is compelled to rise early in the morning fungus gnats everywhere order diflucan online pills, prepare breakfast zeasorb antifungal treatment powder discount diflucan online amex, assist with the family washing or ironing and prepare herself for school will lose out somewhere antifungal and antibacterial shampoo discount diflucan online. And I really believe it is ever so glad That we planted it there to grow fungus or bacteria order diflucan american express, And knows us and loves us and understands fungus amongus buy genuine diflucan online, For it claps them just like two little hands antifungal hand wash order diflucan in united states online, Whenever the west winds blow. They should be about five inches wide and twenty inches long, with the edges raw, or pinked, perhaps, but not hemmed. After the first six or eight weeks the knitted, circular band which can be bought ready made or may be crocheted at home, is substituted for the flannel binder. Their minds so ready to receive impressions should receive only the best and most beneficial, the wholesome air play in the park, or the country, not too much company, nor too much noise, nor too many toys. I hear in the chamber above me, the patter of little feet, the sound of a door that is opened, And voices soft and sweet. If the children are going out at once after the washing, use warm water with plain unscented soap, then rub a little good cold cream into the skin. This can be avoided by making a tiny sham of swiss or other similar material and basting it across the top of the coverlet. It can be pinned into place at the corners with tiny baby pins or caught with a few stitches. These shams edged with narrow lace add a really attractive touch to the coverlet, and they can be quickly removed and easily laundered. Let the mother give her children two or three oranges every day, as they possess many virtues, especially upon the action of the liver. The mother who buys plenty of oranges for the children will note the reduction in her medicine bill. When I meet a human face, Lit for me with light divine, I recall all loving eyes, That have ever answered mine. Nurses who expect to make a specialty of caring for children sometimes take a brief course in kindergarten work, and certainly such knowledge is a valuable asset. Almost all children enjoy being read to , but care must be taken not to select stories that will depress the child or so excite him as to keep him awake at night or cause unpleasant dreams. Insist upon her sharing her pleasures, even at a great sacrifice with other children. One mother whom I know has trained her baby to extend an entire box of bon-bons to her little friends with the words "Hop yourself," and she does this with a charm and spontaneity which makes her irresistible. The mother who spoils a child through weak indulgence does not truly love her child. One will carry twice more weight packed up in bundles, than when it lies flapping and hanging about his shoulders. Five light feedings are much more scientific, the first at about six-thirty in the morning since baby keeps early hours. Dinner at one-thirty might include meat broth, or soft boiled eggs, and bread and toast. They are developed mostly in linen, galatea, and less expensively still in chambray. The best colors are dark blue, brown, green, tan and natural colored linen; green perhaps is best for summer. There is always more dampness in the woods than out in the open, and summer colds are not pleasant for grown folk, much less wee tots. A few safety pins, needle and thread will not take up space in the big basket, and how often such articles are needed. Pound the bread to a powder, roll it with the rolling pin, sift and use the same as flour. It can also be used in milk as a baby food, and is often given to children with very delicate stomachs. This lot which could be sold for thousands of dollars, has been donated to the boys for a playground near their homes, the owner realized that the streets are not suitable playgrounds for the children and that accidents occur there almost daily. The streets of our cities are poor places in which to play, bad for the boys, and still worse for the community, If you have vacant lots turn them over to the boys this summer. A boy never forgets a favor, and American boys are not going to abuse good privileges. The loneliest boys are those who are not allowed to play on the beautiful lawn at home, are not allowed on the streets, and wander about from place to place to be told "Move on," every place they go. It is natural that he should feel a curiosity with regard to a dish with which he is not familiar, and ask some questions about it. A boy whose digestive organs were very delicate was taught from babyhood to sit in his high chair at the table and eat what was on his tray and was perfectly content with what he had, as he knew no other diet. As he grew older he reaped the benefit of the strict regime and his digestion was perfect. New occasions teach new duties; Time makes ancient good uncouth; They must upward still, and onward, who would keep abreast of Truth; Lo, before us gleam her camp-fires! This is not sufficiently warm to be weakening nor sufficiently cool to cause chills. Of course, when the natural heat of the atmosphere is higher than sixty degrees the temperature of the nursery cannot be kept that low, but with darkened windows during the heated portion of the day and good ventilation the room can be kept at a reasonably comfortable temperature. Backward, turn backward, O Time in your flight, Make me a child again just for to-night! Mother, come back from the echoless shore, Take me again to your heart as of yore; Kiss from my forehead the furrows of care, Smooth the few silver threads out of my hair; Over my slumbers your loving watch keep; Rock me to sleep, mother,-rock me to sleep! It is so easy to renew the overdress and under bodice as required and it is, moreover, invaluable to suit the weather changes from day to day. The serge overdress can have a little cotton or flannel blouse, just as thermometers demand. The dresses escape the floor by several inches and reveal the slippers and an inch of the colored hosiery. A Song of Long Ago: Sing it lightly-sing it low- Sing it softly-like the lisping of the lips we used to know When our baby-laughter spilled From the glad hearts ever filled With music blithe as robin ever thrilled! When the babe has finished drinking it should be unscrewed and laid in a cool place under the tap. The room should be papered in light colors, also painted in light tones, though the blinds should be the darkest shade, to darken the room when necessary. It has been her experience with children in her department who were usually awkward and who had their eyes examined that there was something wrong with the vision, which was quickly overcome when glasses were purchased. They may be made in one piece, in princess style, or may consist of a flannel skirt attached to a loose cambric waist. These are decidedly preferable for summer and are really quite warm enough for any season. Gather the rosebuds while ye may, Old Time is still a-flying; And this same flower that smiles today To-morrow will be dying. Rub the meal in as though it were soap, shake it out and rub in more meal, letting it remain in the rug for a day or two. Charcoal and tincture of myrrh are very beneficial to the teeth of the young, and both are easily procured at any drug store. Teach the children to make these useful little drinking cups from clean white paper, and there will be no danger of contracting disease from a drinking cup used by everyone who passes. If no petticoat is worn, then an extra short jacket is provided in the coldest weather, for most babes sleep best with hands and arms uncovered. Use white cotton curtain cords for the girdle and make the hood of the Turkish face cloth. A baby usually enjoys this and receives the same amount of nourishment that he would if the egg were cooked in any other way. The above is a question to be considered by parents who govern wholly by "authority. Cut the feet off and overcast neatly into the armholes; putting in a little gusset under the arms is necessary to enlarge armhole. The leg of the stocking makes the sleeves and the top fits nicely around the little wrist, Reading. Cut the material same as for princess slip, coming narrow on the shoulder and low neck back and front, and to flare at the bottom, which may be finished as desired. The flannel ones add to warmth, having flannel to neck baby needs no little jackets, the Two Symptoms of Love. The two sexes have a tendency to approach, and each assumes the qualities of the other. When fastened this will keep the bedclothes securely in place, however much the child may toss in its sleep. He will then entertain himself by the hour pushing the toys back and forth, and watching them swing above him. The busy mother will find that they grow without care if proper soil is provided and will bloom where there is too much shade for other flowers. March brings forth the lovely hepatica, and wild phlox or sweet william soon follows. Next comes the wild geranium cranes bill, but as its petals fall rapidly, it is not as effective as sweet william, which will be a mass of delicate bloom for five weeks or more. The trillium or wake robin is another desirable flower, and wild violets thrive where the cultivated kind will not grow. The Indian turnip or Jack-in-the-Pulpit is an interesting plant and a curiosity to many who never ramble in the woods to see it in its native abode. All of these bear transplanting and are satisfactory as garden plants, but choose sweet william if you wish the most desirable for color, fragrance and duration of bloom. By gently massaging this feature every day with the thumb and forefinger a tendency to broadness may be promptly subdued. The bridge should be gently pressed between the fingers in the course of an upward massage movement. He would look puzzled and only half convinced as his reason told him it could not be that late; but he had no choice but to obey. The mother relaxes her care for a day or two, and a new trick appears, or the work of weeks on an old one is undone. A tiny baby of a few months old knows very well if the habit of loud crying will procure for it what it wants, and if not cheeked will develop into the irritable whining adult we are all acquainted with. Habits of disrespect, of indifference to the rights of others, of cruelty, may all be irresistibly formed or dispelled in the first few years of life. At the same time they dislike to mar the appearance of their table with the tin waiter which is usually set before the children to protect the cloth against the depredations of dropped bread and milk. The linen is hemmed neatly so that it looks like an oblong napkin, and while it protects the cloth and the table it protects the table underneath; being white, like the cloth itself, it does not spoil the looks of the table. When soiled the oilcloth is slipped out and wiped off with a damp cloth, and the linen case goes with the tablecloth and napkin. Several of these cases will be needed, for the ordinary enterprising baby, but one piece of oilcloth will be sufficient for a long time. It can be folded up and put out of the way when not in use, and it telescopes into a small bundle when one wants to travel. The petticoats should be made the same lengths as the dresses, or perhaps a half inch shorter. We have just awakened to the fact that our daughters should receive training in those things which will best fit them for housewives and mothers. While many of our girls are earning their own livelihood, the majority ultimately settle into homes of their own. Many girls have an excellent opportunity to get the training they need as homemakers from their mothers, but many of the children in this country lack this home training. There are two reasons for this neglect on the part of the mothers: first, the mother may not know how to do these things herself; and, second, she may be a wage-earner and of necessity cannot train her daughter. The public school is expected to develop the child along these lines and consequently the cookery class, together with the class in housekeeping, has a mighty influence toward developing noble women. All the home duties are developed and made a pleasure and not a duty to the child, so that the home is looked upon with favorable eyes. Investigators who have made careful research into the divorce question, which has assumed such large proportions, state that if women knew more of the science of home making there would be fewer homes broken up. The public school aims through domestic science to teach the importance and dignity of being a good housewife. Many times debt and trouble come to homes, not through lack of sufficient funds, but through lack of knowledge on the part of the dispenser of the funds. One of the principles which domestic science emphasizes in its teaching is to show how some of our cheaper foods furnish more nutriment to our systems than do some of our more expensive articles of diet. With this fact thoroughly established and understood domestic science tries to develop new and simple methods of cooking such foods and of making them attractive and appetizing. It is a well-known fact that it is not the amount of food we eat but the amount that we digest that gives nourishment to our bodies, and it has been proven that food that is not attractive and palatable to us gives only one-half the value to our bodies as when it is made attractive and palatable. If we are going to prepare food and use it as part of our diet, why should we not obtain the most of its value For an example of this fact let us take eggs, one of our most common articles of diet. We commonly cook eggs to harden the white, or albumen, so as to make them more palatable. Through experiments it has been proven that boiling makes this albumen so hard to digest that our bodies get practically no value from it. The newer method advanced proves that the same results can be obtained by cooking eggs in water which is kept just below the boiling point, and eggs cooked this way are easily and readily assimilated by our bodies. Why should we not endeavor then to give to our bodies food so prepared that it gives the most nourishment.

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Approach: An expert Planning Committee will be appointed by the National Academies to oversee the development and conduct of an Institute of Medicine workshop to consider: measures core for insights on health care, costs, and status; existing requirements and sources of data currently available; perspectives of decision-makers and program managers using the data to guide program decisions; challenges and barriers confronted; successful pilot models to address the challenges, and strategies moving forward. Deliverable(s): A publication will be produced highlighting key themes from the discussion and identifying possibilities for collaborative and individual action, and strategies for progress. Working together in consensus committees, public forums, and collaborative efforts, invited experts carry out the technical and policy studies commissioned to produce advice on compelling health challenges, meetings and symposia convened on matters of widespread interest, and projects to catalyze recommended action. Compelling aim: Engineering principles can improve the quality, safety, and value achieved by health care, assist clinicians in managing the increasing complexity of modern care, while laying the foundation for a continuously learning health system. The Collaborative will serve to identify important opportunities for joint action; facilitate joint projects initially aimed at eliminating patient injury; foster information exchange about successful systems approaches to care improvement; and explore compelling conceptual, evaluation, and research questions. Issue: Central elements of daily life, from assuring clean water to promoting aviation safety to automobile manufacturing to developing new imaging technologies, have benefited from broader application of engineering principles. Similarly, engineering offer a powerful, yet underutilized, method of accelerating improvement in the health system. Various organizations have successfully implemented its tools and techniques to prevent health care acquired infections and promote safety, deliver best practices reliably, and optimize their general operations. Greater application of these principles can link people, processes, structures, and technology in an integrated and interdependent whole, creating reliable high-performing systems approaches that can be implemented at scale and achieve sustainably high levels of patient safety and outcomes, and improve value. Participants will come from teams already working as medicine-engineering partnerships on patient safety and related care improvements, health care institutions with active process re-engineering under way, information technology experts, and key change agents and opinion leaders who can move promising results into practice. The Collaborative will serve to steward discussion and counsel on activities under way. Deliverable(s): Systematic exchange of information on system-based initiatives underway; discussion papers on successes and challenges to tools and techniques, opportunities for improvement, and best practices; vehicles for brokering expertise and encouraging collaboration among diverse organizations; and initiation of joint projects as indicated. Presidential Executive Orders have defined the special relationship of the Academy to Government and cited its unique capacity to marshal scientific expertise of the highest caliber for independent and objective science policy advice. The mission of the National Academy of Engineering is to advance the well-being of the nation by promoting a vibrant engineering profession and by marshalling the expertise and insights of eminent engineers to provide independent advice to the federal government on matters involving engineering and technology. They provide the leadership and expertise for numerous projects focused on the relationships between engineering, technology, and the quality of life. With the increased collection of large Follow-up projects: quantities of data, the potential for methods innovation in Publish paper on approach to harmonized system research is growing. Value Incentives Increased use of innovative clinical trial methods, such as June 15, 2012 large simple trials that rely on larger, more inclusive Focus: populations, and the incorporation of optimized data collection Value incentives in health care reform systems into routine care settings could serve to speed the Methods to engage providers in improving value transformation towards a learning health system. If you would no E-mail the Team longer like to receive this mailing, please click here. June 2011 and Expectations the Common Rule and Continuous Improvement Harry Selker et al. September 2012 Evidence Core Principles & Values of Effective Team-Based Pam Mitchell, Matt October 2012 Care Wynia, et al. The Center studies ways to provide practical solutions for access, quality and financing challenges facing the U. McClellan has a highly distinguished record in public service and in academic research. He is the former administrator for the Centers for Medicare and Medicaid Services (2004-2006) and the former commissioner of the Food and Drug Administration (2002-2004). McClellan was also an associate professor of economics and associate professor of medicine (with tenure) at Stanford University, from which he was on leave during his government service. His academic research has been concerned with the effectiveness of medical treatments in improving health, the economic and policy factors influencing medical treatment decisions and health outcomes, the impact of new technologies on public health and medical expenditures, and the relationship between health status and economic well being. McClellan is a Member of the Institute of Medicine of the National Academy of Sciences and a Research Associate of the National Bureau of Economic Research. Prior to embarking on a career in health care, he taught philosophy at the college level at the University of Colorado. He is co author of the Managerial Moment of Truth, published by Simon & Schuster in 2006. Research & Development and Vice President, Therapeutic Department Head, Metabolism, Diabetes and Thrombosis in which role he was responsible for Lovenox, Lantus, and the therapeutic development portfolio. Chew was Vice-President, Global Head of Metabolism and Diabetes at Aventis Pharmaceuticals, 2001-2004. Chew was at the Bristol-Myers Squibb Company, starting in 1992 as Medical Director of Clinical Cardiovascular Development. Medical Affairs from 1999-2001 where he was responsible for Plavix, Avapro, Glucophage, and Pravachol. Chew was Assistant Professor of Medicine at the Johns Hopkins Hospital, Attending Physician in Radiology, Director of the Pacemaker Clinic and a member of the Interventional Cardiology staff. Research interests included acute interventional cardiology, cardiac biomechanics, and statistical modeling of pericardial biomechanics. Chew obtained his medical education at the Johns Hopkins School of Medicine, serving his internal medicine training and cardiology fellowship at the Johns Hopkins Hospital. Clancy, a general internist and health services researcher, is a graduate of Boston College and the University of Massachusetts Medical School. Clancy holds an academic appointment at George Washington University School of Medicine (Clinical Associate Professor, Department of Medicine) and serves as Senior Associate Editor, Health Services Research. She serves on multiple editorial boards including the Annals of Internal Medicine, Annals of Family Medicine, American Journal of Medical Quality, and Medical Care Research and Review. She is a member of the Institute of Medicine and was elected a Master of the American College of Physicians in 2004. Her major research interests include improving health care quality and patient safety, and reducing disparities in care associated with patients race, ethnicity, gender, income, and education. As Director, she launched the first annual report to the Congress on health care disparities and health care quality. Collins at the helm, the Human Genome Project consistently met projected milestones ahead of schedule and under budget. Collins was named a co-recipient of the Albany Medical Center Prize in Medicine and Biomedical Research for his leading role in this effort. He is an elected member of the Institute of Medicine and the National Academy of Sciences. Collins received the National Medal of Science, the highest honor bestowed on scientists by the United States government. As Chief Medical Officer, he had a portfolio of work focused primarily on quality measurement and links to payment, health information technology, and policy, research, and evaluation across the entire Department. He also served as Executive Director of the Federal Coordinating Council on Comparative Effectiveness Research coordinating the investment of the $1. Previously, he was a management consultant at McKinsey & Company, serving senior management of mainly health care clients on strategy projects. Its 318 members, including 66 of the Fortune 100 in 2010, purchase health and disability benefits for over 55 million employees, retirees and dependents. She was given a lifetime appointment in 2003 as a National Associate of the National Academy of Sciences for her work for the Institute of Medicine. She is on the Board of Directors of the National Quality Forum and the Congressionally-created Reagan-Udall Foundation. Earlier in her career, Darling was an advisor to Senator David Durenberger, on the Health Subcommittee of the Senate Finance Committee. She directed three studies at the Institute of Medicine for the National Academy of Sciences. An alliance of more than 2,600 hospitals and health systems and more than 90,000 non-acute care sites, Premier uses the power of collaboration to lead the transformation to high quality, cost-effective healthcare. With the ultimate goal of helping its members improve the health of their local communities, Premier builds, tests and scales models that improve quality, safety and cost of care. She is on the Board of the Healthcare Leadership Council, National Center for Healthcare Leadership as well as the Medicare Rights Center. Previously, Rich served as Vice President, Brand Strategy & Portfolio Operations, leading the development and execution of marketing strategies for all AstraZeneca brands in the United States. She founded Epic in 1979 and guided it from its modest beginnings as a clinical database company to its current place as a leading provider of integrated healthcare software. Frieden has worked to control both communicable and noncommunicable diseases in the United States and around the world. He then worked in India for five years where he assisted with national tuberculosis control efforts. As Commissioner of the New York City Health Department from 2002-2009, he directed one of the world s largest public health agencies, with an annual budget of $1. A physician with training in internal medicine, infectious diseases, public health, and epidemiology, Dr. He has received numerous awards and honors and has published more than 200 scientific articles. Gabow joined the medical staff at Denver Health in 1973 as Renal Division chief, and is known for scientific work in polycystic kidney disease, and now health services research. She received a Lifetime Achievement Award from the Denver Business Journal and from the Bonfils-Stanton Foundation; the Innovators in Health Award, New England Healthcare Institute; and the David E. Gabow was awarded honorary degrees by the University of Denver and the University of Colorado and is a Master of the American College of Physicians. He is also Associate Professor of Surgery at Harvard Medical School and Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health. His research work currently focuses on systems innovations to transform safety and performance in surgery, childbirth, and care of the terminally ill. He is also founder and chairman of Lifebox, an international not-for-profit implementing systems and technologies to reduce surgical deaths globally. He served as President of Brigham and Womens/ Faulkner Hospitals since March of 2002. Gottlieb was recruited by Partners to become the first chairman of Partners Psychiatry in 1998 and he served in that capacity through 2005. In 2000, he added the role of President of the North Shore Medical Center where he served until early 2002. Gottlieb spent 15 years in positions of increasing leadership in health care in Philadelphia. In 1983, he arrived at the University of Pennsylvania as a Robert Wood Johnson Foundation Clinical Scholar. In 1994, he became Director and Chief Executive Officer of Friends Hospital in Philadelphia. Gottlieb has published extensively in geriatric psychiatry and health care policy. He completed his internship and residency and served as Chief Resident at New York University/Bellevue Medical Center. Gottlieb also focuses his attention on workforce development and disparities in health care. The organization was founded in 1936 when advertising first flooded the mass media. Consumers lacked any reliable source of information they could depend on to help them distinguish hype from fact and good products from bad ones. Under his leadership, the organization is currently pursuing a high-profile campaign to improve the safety, quality, accessibility, and value of the health-care marketplace. This has included the successful launch of several new initiatives such as ConsumerReportsHealth. Guest also is the President of Consumers International, a global federation of 250 organizations from 115 countries. Guest moved to Vermont where he served as Banking and Insurance Commissioner, Secretary of State, and Secretary of Development and Community Affairs. Over the last 20 years, he has headed several public policy and advocacy groups including Handgun Control Inc. He was also the founding Executive Director of the American Pain Foundation, a national consumer information, education, and advocacy organization for pain prevention and management. Guest credits his very first job for introducing him to one of his biggest influences in consumer advocacy. Halvorson was named chairman and chief executive officer of Kaiser Permanente, headquartered in Oakland, California in March 2002. George Halvorson has won several awards for his commitment to health technology and for his leadership and achievements in advancing health care quality. Halvorson lends his time and expertise to a number of organizations, including the Institute of Medicine, the American Hospital Association, and the Commonwealth Fund. Halvorson chairs the International Federation of Health Plans and co-chairs the 2010 Institute for Healthcare Improvement Annual National Forum on Quality Improvement in Health Care. Halvorson was president and chief executive officer of HealthPartners, headquartered in Minneapolis. With more than 30 years of health care management experience, he has also held several senior management positions with the Health Central Hospital System, Health Accord International, and Blue Cross and Blue Shield of Minnesota. Hamburg graduated from Harvard Medical School, and completed her residency in internal medicine at what is now New York Presbyterian Hospital-Weill Cornell Medical Center, one of the top-ten hospitals in the nation.

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Joint Appointment in Biophysics and Biophysical Joint Appointment in Oncology [2010] Chemistry [2002; 1994] David Joseph Sullivan, Jr. Joint Appointment in Medicine [1998] Joint Appointment in Medicine [1982], Professor of Pathology [1994] Moyses Szklo, M. Appointment in Oncology [1986; 2005] Joint Appointment in Medicine [2003] Andrea J. Joint Appointment in Pediatrics [1987] Joint Appointment in Radiology [1995], Joint Appointment in Surgery [1995; 2005] Cynda Hylton Rushton, D. Joint Appointment in Emergency Medicine [1989], Joint Appointment in Medicine [1985; 1976] Joint Appointment in Pediatrics [1984] R. Joint Appointment in Medicine [1985; 1976] Joint Appointment in Ophthalmology [1994; 1982] Mathuram Santosham, M. Joint Appointment in Pediatrics [1985; 1976] Joint Appointment in Oncology [1997] Edyth H. Joint Appointment in Medicine [1978; 1949] Joint Appointment in Health Sciences Informatics [2001] Brian S. Joint Appointment in Oncology [2000] Appointment in Oncology [1996] Amy Lynne Shelton, Ph. Joint Appointment in Neuroscience [2002] Joint Appointment in Health Sciences Informatics [1982; 2007], Joint Appointment in Medicine [1982] MacHiko Shirahata, M. Care Medicine [1990; 1988] Joint Appointment in Health Sciences Informatics [2007] Jane C. Joint Appointment in Medicine [1990], Joint Joint Appointment in Gynecology and Obstetrics Appointment in Surgery [2007] [1991] James D. Joint Appointment in Neuroscience [2001] Joint Appointment Emeritus in Pediatrics [1991; Laurie S. The circumstances attending the acceptance of this fund were as follows: At a meeting of the Board of Trustees of the University, October 28, 1890, the following letter was presented: The committee formed for the purpose of raising a fund to procure the most advanced medical educa tion for women can now place at your disposal the sum of one hundred thousand dollars for the use of your Medical School, if you will, by resolution, agree that women whose previous training has been equivalent to your preliminary medical course, shall be admitted to the school, when it shall open, upon the same terms which may be prescribed for men. There can be no doubt that women ought to be trained to act as nurses for sick women. There is as little doubt that a suffcient number of women ought to be educated and trained in such manner as to be fully able to care for sick women who may wish or ought to be treated by women. We have reason to hope that a university which proposes to found a medical school intended to teach advanced methods in the treatment of those diseases which affect mankind, will not refuse to women the opportunity of learning such methods. In order that this interest may be sustained, we ask you to consider our offer at the earliest possible period. Nancy Morris Davis, chairman of one of the committees formed for the purpose of raising a fund to procure the most advanced medical education for women, the gratifying intelligence that $100,000 has been raised for the use of their intended Medical School, and is at their disposal, if they will, by resolution, agree to the terms upon which the money was contributed by its donors. Then, and not until then, will a Medical School be opened by this University, and then, and not until then, will the gift now offered be used by this University; and then, and not until then, will the terms attached thereto be operative. That women shall enjoy all the advantages of the Medical School of the Johns Hopkins University on the same terms as men to all the prizes, dignities or honors that are awarded by competition, examination, or regarded as rewards of merit. That the Medical School of the University shall be exclusively a graduate school as hereinafter explained, that is to say: That the Medical School of the Johns Hopkins University shall form an integral part of the Johns Hopkins University, and like other departments of the University, shall be under the man agement and control of the Trustees of the said University, that it shall provide a four years course, leading to the degree of Doctor of Medicine; that there shall be admitted to the School those students only who, by examination or by other tests equally satisfactory to the Faculty of the Medical School (no distinction being made in these tests or examinations between men and women), have proved that they have completed the studies included in the Preliminary Medical Course (Group Three, Chemical-Biological Course), as laid down in the University Register (but this condition is not meant to restrict the Trustees from receiving as hearers, but not as candidates for the degree of Doctor of Medicine, those who have received the degree of Doctor of Medicine, or its equivalent, in some school of good repute); and that the degree of Doctor of Medicine of the Johns Hopkins University shall be given to no Doctor of Medicine who has not proved by examination or by other tests equally satisfactory to the Faculty of the Medical School that he has com pleted the studies included in the Preliminary Courses, besides completing the course of instruction of the Medical School of the Johns Hopkins University. The aforegoing provision shall not be construed as restricting the liberty of the University to make such changes in the requirements for the admission to the Medical School of the Johns Hopkins University or to accept such equivalents for the studies required for admission to the school as shall not lower the stan dard of admission specifed in this clause; provided that the requirements in modern languages other than English shall not be diminished, and provided also that the requirements in non-medical scientifc studies shall include at least as much knowledge of natural science as is imparted in the three minor courses in science now laid down in its University Register, the subjects and arrangements of these scientifc studies being subject to such modifcations as may from time to time seem wise to its Board and to the Faculty of the Medical School, but being at all times the same for all candidates for admission. That there shall be created a committee of six women to whom the women studying in the Medical School may apply for advice concerning lodging and other practical matters, and that all questions concern ing the personal character of women applying for admission to the School and all non-academic questions of discipline affecting the women studying in the Medical School shall be referred to this committee, and by them be in writing reported for action to the authorities of the University; that the members of this committee shall be members for life; that the committee, when once formed, shall be self-nominating, its nominations of new members to fll such vacancies as may occur being subject always to the approval of the Board of Trustees of the University. That in the event of any violation of any or all of the aforesaid stipulations, the said sum of $306,977 shall revert to her, or such person or persons, institution or institutions, as she by testament or otherwise may hereafter appoint. It will be observed that by the tenor of the aforegoing terms no university course will be in any way modi fed by any conditions attached to her gift. These conditions relate exclusively to preparation for the Medical School, and have received, in the shape in which they are now presented, the unanimous approval of the Medical Faculty of the University. The terms of admission to the Medical School of the University, as formulated and interpreted by the Medical Faculty of the University, February 4, 1893, and here subjoined, are therefore in entire accordance with the terms of her gift. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. Graduates of approved colleges or scientifc schools who can furnish evidence: (a) That they have a good reading knowledge of French and German; (b) That they have such knowledge of physics, chemistry and biology as is imparted by the regular minor courses given in these subjects in this University. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientifc school, and the knowledge of French, German, physics, chemistry and biology already indicated. By approved colleges and scientifc schools are meant those whose standard for graduation shall be considered by this University as essentially equivalent to its standard for graduation in the undergraduate department. Review Best Care at Lower Cost with Members and solicit insights on key follow-up opportunities. Discuss state of play on selected Collaborative Projects: patient demand for better value, care assessment, and shared decision-making, core metrics for the triple aim, and new research approaches to evidence generation. Consider ways in which Member initiatives, within and across organizations, might foster action supportive to Report follow-up and Collaborative projects. Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity. The full extent of these shortcomings is visible when considering how other industries routinely operate compared with many aspects of health care. Americans would be better served Builders rely on blueprints to coordinate the work of carpenters, electricians, by a more nimble health care and plumbers. Banks offer customers fnancial records that are updated in real system that is consistently reliable time. Automobile manufacturers produce thousands of vehicles that are stan and that constantly, systematically, dardized at their core, while tailored at the margins. Americans would be better served by a more nimble health care system that is consis tently reliable and that constantly, systematically, and seamlessly improves. In short, the country needs health care that learns by avoiding past mistakes and adopting newfound successes. Payers and offers its recommendations in Best Care at Lower medical product companies also should contrib Cost: the Path to Continuously Learning Health ute more data to research groups to generate new Care in America. Patients should participate in developing robust data utility; use new tools, such as personal portals, to better manage their own care; and Building an Adaptive System be involved in building new knowledge, such as through patient-reported outcomes. Because health care is complex and constantly changing, the committee set out to chart a tran sition to a system that learns, in real time and Delivering Reliable Clinical with new tools, how to better manage problems. Indeed, such opportunities now exist that were Knowledge to Patients not available just a decade ago. Vast computa Improving the data infrastructure and data utility tional power is increasingly affordable, and con would require revising and streamlining research nectivity allows information to be accessed in real regulations to improve care, promote capture of time. Human and organizational capabilities offer clinical data, and generate knowledge. Regulators expanded ways to improve the reliability and eff can clarify and improve rules governing the col ciency of health care. And health care organiza lection and use of clinical data to safeguard patient tions and providers recognize that effective care privacy while promoting the seamless use of such must be delivered by collaborative teams of clini data for better care coordination and manage cians, each member playing a vital role. By one estimate, almost 75,000 needless deaths could have been averted in 2005 if every state had delivered care on par with the best per forming state. Current waste diverts resources; the committee estimates $750 billion in unneces sary health spending in 2009 alone. Among possible actions, clinicians and health developing and testing a reliable set of measures care organizations can adopt tools that deliver of patient-centeredness for consistent use across reliable clinical knowledge to patients. And digital bility, and use of evidence-based and harmonized technology developers and health product inno clinical practice guidelines. Also, education pro vators should develop tools to assist individuals in grams should evolve so that health professionals managing their health and health care. The prevailing approach organizations that fund research should support to paying for health care, based predominantly investigations into improving the usefulness and on individual services and products, encourages accessibility of patient outcome data and scien wasteful and ineffective care. Health care delivery organi of information about the quality, price, and out zations should monitor and assess patients per comes of care, and professional specialty societies spectives and use those insights to improve care; should encourage transparency in the informa establish patient portals to facilitate data sharing tion provided by their members. Likewise, pay among clinicians, patients, and families; and make ers should promote transparency to help their high-quality tools available for shared decision members make better decisions. Health care delivery organiza President and Chief Executive Chief Quality Offcer, Offcer, California HealthCare Intermountain Health Care, Inc tions should develop organizational cultures that Foundation Craig Jones James P. Bagian Director, Vermont Blueprint for encourage continuous improvement by incorpo Professor of Engineering Health Practice, University of Michigan rating best practices, transparency, open commu Gary Kaplan Anthony Bryk Chairman and Chief Executive nication, staff empowerment, coordination, team President, Carnegie Foundation Offcer, Virginia Mason Health for the Advancement of System work, and mutual respect, and that align incentives Teaching Arthur A. Also, specialty societies, education Former Vice President, Consumers Scientifc Affairs, Eli Lilly and programs, specialty boards, licensing boards, and Eugene Litvak Company President and Chief Executive accreditation organizations should incorporate James B. Conway Offcer, Institute for Healthcare Senior Fellow, Institute for Optimization basic concepts and specialized applications of con Healthcare Improvement David O. Darling Director, Center for Health and tinuous learning and improvement into health pro President, National Business the Social Sciences, University fessionals education, licensing, certifcation, and Group on Health of Chicago T. Chairman, Department of Director, NewCourtland Center Cardiovascular Sciences, East for Transitions and Health, Carolina University University of Pennsylvania Ginger L. Redberg Conclusion Executive Offcer, Amylin Professor of Medicine, Pharmaceuticals and Former University of California, San Group Chairman, Guidant Francisco the entrenched challenges of the U. Left Chairman and Chief Executive and Technology Offcer, Palo unchanged, health care will continue to underper Offcer, Kaiser Permanente Alto Medical Foundation form; cause unnecessary harm; and strain national, Study Staff state, and family budgets. Michael McGinnis Senior Program Assistant Senior Scholar at lower cost for all Americans. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policy makers, health professionals, the private sector, and the public. Data tributed data research networks and expand the generated in the course of care delivery should be digitally availability of departmental health data resources collected, compiled, and protected as a reliable and acces for translation into accessible knowledge that can sible resource for care management, process improvement, be used for improving care, lowering costs, and public health, and the generation of new knowledge. Technology, digital technology developers, and standards organizations should ensure that the digital infrastructure captures and delivers the core data elements and interoperability needed to support better care, system improvement, and Recommendation 2: the Data Utility the generation of new knowledge. Regulatory agencies should clarify and data to research and analytic consortia to sup improve regulations governing the collection and use of port expanded use of care data to generate new clinical data to ensure patient privacy but also the seam insights. Care delivery and community-based orga waste, streamline care delivery, and focus on activities nizations and agencies should partner with each other to that improve patient health. Care delivery organiza develop cooperative strategies for the design, implemen tions should apply systems engineering tools and process tation, and accountability of services aimed at improving improvement methods to improve operations and care individual and population health. Supportive Policy Environment Recommendation 8: Financial Recommendation 6: Care Continuity Incentives Improve coordination and communication within and Structure payment to reward continuous learning and across organizations. Payers should structure payment improvement in the provision of best care at lower cost. Payment models and communication tools to ensure safe, seam should adequately incentivize and support high less patient care. Recommendation 10: Broad Leadership Expand commitment to the goals of a continuously learn ing health care system. The past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet American health care is falling short on basic dimensions of quality, outcomes, costs, and equity.

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