Integrating Health Care Communities of Practice:

The Case of Uruguay

CME CONGRESS – 29-31 May, 2008Vancouver

Ann Séror MBA, PhD eResearch Collaboratory, Quebec City, QC,

CanadaEmail: annseror,@eresearchcollaboratory.com

Integrating Health Care Communities of Practice:

The Case of UruguayOBJECTIVES To develop a theoretical framework

Communities of practice (Wenger)Knowledge ecology (Trist, Nonaka)

To consider methodological strategiesQualitative case analysis (Yin)Virtual infrastructure mapping (Carley, 1998)

To identify the configuration of virtual infrastructures.National Health Care System of Uruguay - CME Knowledge management for evidence-based medical practice

To formulate some conclusions and recommendations.

Economic analysis of national health care systems shows that the important positive correlation between gross national product and indicators of health care quality such as life expectancy is mediated by variables related to equitable distribution of wealth as well as rates of public expenditure in the healthcare sector.

Source: Sen A. Economics and Health. The Lancet 1999;354:20

INTRODUCTION

Health Care Systems• A health care system is a dynamic set of interconnected

individuals, institutions, organizations, and projects offering products and services in health care markets. (Alliance for Health Policy and Systems Research, 2004) p. 1

• The functions of the health system include all categories of

service delivery, financing and other resource generation and allocation, and governance. Governance includes both policy making and regulation at all levels of the system.

• Service delivery is here broadly defined to encompass information, research, and education services as well as public health and delivery of patient care, both preventative and curative.

Virtual Infrastructures

• Overlapping distribution networks, systems brokerage functions emphasizing the devices and channels through which information is processed and distributed.

• Accessibility through Internet websites and gateways designed to facilitate integrated use of the resources.

• “VIRTUAL” describes any web-based service, organization or institution arising from the technical infrastructure defined above.

Health Care System Transformation

• Pressures for collaboration, data-sharing and access to distributed resources increase the focus on interconnection of services both within and across institutions. (Foster, 2002)

• Technological trends and commercial pressures foster service decomposition and distribution through networks rather than host-centric systems.

Communities of PracticeCommunities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.

o Shared domain of interest.o Community relationships for learning.o Shared repertoire of resources for practice.o Tools for translation of information into knowledge.

Source: Wenger, E. : http://www.ewenger.com/theory/

Information Translation to Knowledge

Knowledge Ecology: « BA » Source: Nonaka (1998) available at

http://home.business.utah.edu/actme/7410/Nonaka%201998.pdf

Data Sense-Making Knowledge

Qualitative Case Analysis• Technological innovation and economic globalization drive

rapid changes rendering nomological model identification elusive.

• Need for inquiry into the cognitive mapping of large scale socio-ecological systems characterized by network structures expressing negotiated rather than bureaucratic order. Source: Trist, E. (1977) available at http://www.agsm.edu.au/~eajm/7710/trist.html

• Idiographic case research methods offer tools for descriptive analysis and assessment of complex health care management systems within their social, economic, and cultural contexts. Source: Yin RK. Enhancing the quality of case studies in health services research. Health Services Research, 1999 ,34(5 Pt 2):1209-1224.

Research Program National Health Care Systems

• Infomed – Cuban national health care network and portal, Ministry of Health See Séror ACA Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and PortalJournal of Medical Internet Research, 2006;8(1):e1<URL: http://www.jmir.org/2006/1/e1/>

• Ministry of Health and Family Welfare - India• Ministry of Health Online – Uganda• Kaiser Permanente – USA• British National Health Service – NHS – UK See Séror AC

Internet Infrastructures and Health Care Systems: a Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser PermanenteJ Med Internet Res 2002;4(3):e21<URL: http://www.jmir.org/2002/3/e21/>

• Uruguay – Integrated National Health Care System

Country Uruguay Cuba Uganda Canada UK USA India

Population (millions)

3.5 11.3 28.8 32.3 59.7 298.2 1,103.4

Total Health Expenditure per

capita (Int. $-2004

784 229 135 3,173 2,560 6,096 91

External Resources (% of total health exp.)

0.3 0.2 28.5 0.0 0.0 0.0 1.6

Private exp. (% of total health

exp.)

56.5 (2004) 13.2 (2003) 69.6 (2003) 30.2 14.3 (2003) 55.4 (2003) 75.2 (2003)

Out-of-pocket exp.-percentage of private exp.

31.1 (2004) 75.2 (2003) 52.8 (2003) 49.4 76.7 (2003) 24.3 (2003) 97.0 (2003)

Life expectancy (m/f –WHO

2004)

71/75 75/80 48/51 78/83 76/81 75/80 61/63

Child Mortality (m/f per 1000

population-WHO 2004)

16/12 8/7 144/132 6/5 6/5 8/7 81/89

Physicians per 1000 population

(WHO 2004)

3.65 5.91 0.08 2.14 2.30 2.56 0.60

Literacy(CIA World

Factbook 2003)

97.6/98.4 97.2/96.9 79.5/60.4 99/99 99/99 99/99 59.5/48.3

Internet Penetration %

(ITU 2007)

33.6 2.1 2.6 67.8 66.4 71.4 5.3

COMPARATIVE COUNTRY CONTEXT

.

Characteristics of Health Care Culture

• Strong institutional structure Professional associations – Sindicato Médico del Uruguay

• Strong collectivism.• Face-to-face communication, presence.• High literacy rate.• High public health attainment.• Strong commitment to a social medicine ideology.

– Universal access to health care services.– Equitable financial contributions.– Emphasis on primary care and preventive medicine.– Medicine and health sciences education.

Strategies for Development of CME in Uruguay

• Creation of a national CME system.• Promotion of access to databases for evidence-

based medical practice.• Training of human resources in specialties of

CME.• Accreditation of CME institutions and activities.• Promotion of culture required for continuing

education and evaluation.• Application of new technologies and

methodologies for medical education. Larre Borges, U., et al.,El Desarrollo Profesional Médico Continuo en el Uruguay de Cara al Siglo XXI, Rev. Panamericana de Salud Publica, 2003.

Virtual Knowledge Ecology: National Institutions

Ministry of Public Health http://www.msp.gub.uy/ Government Commission on Oncology http://www.urucan.org.uy/ University of the Republic of Uruguay – Faculty of Medicine

http://www.fmed.edu.uy/ National Library of Medicine http://www.biname.fmed.edu.uy/ Medical Associations – Sindicato Médico del Uruguay

http://www.smu.org.uy/ Private Enterprises(EviMed) http://www.evimed.net/

International Organizations - Bireme http://www.bireme.br/php/index.php , PAHO http://www.ops-oms.org.uy/

Regional Virtual Infrastructures BIREME - Latin American and Caribbean Health Sciences System created

the Virtual Health Library (VHL) in 1998 : – Production and distribution of health information resources through the

Internet. – Development of common methodologies for creation and distribution of

electronic publications in Portuguese and Spanish – SciELO Publication Model – Management of the transition from paper to open access electronic

publication media. See the VHL website at http://regional.bvsalud.org/php/index.php?lang=en

The Pan American Health Organization (PAHO) created the Virtual Campus for Public Health (VCPH) in 2003:– Virtual collaboration.– Creation and sharing of learning content .– Development and reuse of resources. – Integration of the VHL for networked learning in the domain of public health. See the VCPH at http://www.campusvirtualsp.org/en

SciELO – Uruguay (2005)

SciELO integrates the scientific literature published in the Latin American region in the international flow of health information: Promoting an open access model. Selecting those journals that meet internationally recognized

standards: Revista Médica del Uruguay Measuring their usage and impact Linking published articles with national and international

information sources, references cited, forums for discussion, blogs and tools for resource sharing. (Packer, A. 2007)

See the website at http://www.scielo.edu.uy/scielo.php?script=sci_home&lng=en&nrm=isoSee an article portal at http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-

49892008000100008&lng=en&nrm=iso&tlng=es

URUGUAY: HEALTH CARE KNOWLEDGE ECOLOGY

HEALTH CARE KNOWLEDGE ECOLOGY

• Institutional Communities of Practice– Faculty of Medicine, SMU, PAHO-Uruguay, Commission on Oncology, Ministry of Public Health

• Emerging Collaborative Spaces.– Virtual Classroom – Repository, Wiki– Blog

• Market Dynamics in Knowledge EcologyNATIONAL REGIONAL GLOBAL

– National and regional infrastructures, standards, tools for system integration.

– Local data collection and research capacity.

Future Research• Institutional roles:

– Virtual infrastructures– System design.– Human resource motivation and evaluation

• Physician roles: – Tools for interdisciplinary community interaction– Research Methodology

• Ideological diversity• Time and space:

– Co-location.– Co-evolution.

EviMed ArchitectureSource: http://www.evimed.net/

URUGUAY: HEALTH CARE KNOWLEDGE ECOLOGY