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  • 1. IntegratingHealthCare CommunitiesofPractice:TheCase of Uruguay CMECONGRESS 29-31 May, 2008 Vancouver AnnSrorMBA, PhDeResearch Collaboratory, Quebec City, QC, Canada Email: annseror,

2. IntegratingHealthCare CommunitiesofPractice:TheCase of Uruguay

  • Todevelop a theoretical framework Communities of practice (Wenger) Knowledge ecology(Trist,Nonaka)
  • To consider methodological strategies Qualitative case analysis (Yin) Virtual infrastructure mapping (Carley, 1998)
  • To identify the configuration ofvirtual infrastructures. National Health Care System of Uruguay - CMEKnowledge 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 Lancet1999;354:20

INTRODUCTION 4. HealthCareSystems

  • 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.

5. VirtualInfrastructures

  • 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.

6. HealthCareSystemTransformation

  • 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.

7. Communities of Practice

  • Communities 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.
    • Shared domain of interest.
    • Community relationships for learning.
    • Shared repertoire of resources for practice.
    • Tools for translation of information into knowledge.
  • Source: Wenger, E. :

8. Information Translation to KnowledgeKnowledgeEcology:BASource: Nonaka (1998) available at Data Sense-Making Knowledge 9. 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
  • 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.

10. Research ProgramNational Health Care Systems

  • Infomed Cuban national health care network and portal, Ministry of HealthSee Sror AC A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and Portal Journal of Medical Internet Research, 2006;8(1):e1
  • Ministry of Health and Family Welfare - India
  • Ministry of Health Online Uganda
  • Kaiser Permanente USA
  • British National Health Service NHS UKSee Sror AC Internet Infrastructures and Health Care Systems: a Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser Permanente J Med Internet Res 2002;4(3):e21
  • Uruguay Integrated National Health Care System

11. COMPARATIVECOUNTRYCONTEXT 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 97.2/96.979.5/60.499/99 99/9999/99 59.5/48.3Internet Penetration % (ITU 2007) 33.6 2.1 2.6 67.8 66.4 71.4 5.3 12. . 13. Characteristics of Health Care Culture

  • Strong institutional structureProfessional associationsSindicato Mdico 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.

14. 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 Mdico Continuo en el Uruguay de Cara al Siglo XXI,Rev. Panamericanade Salud Publica, 2003. 15. Virtual Knowledge Ecology: National Institutions

  • Ministry of Public Health
  • Government Commission on Oncology
  • University of the Republic of Uruguay Faculty of Medicine
  • National Library of Medicine
  • Medical Associations Sindicato Mdico del Uruguay
  • Private Enterprises( EviMed )
  • International Organizations-Bireme , PAHO

16. Regional Virtual Infrastructures

  • BIREME - Latin American and Caribbean Health Sciences Systemcreated 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
  • ThePan American Health Organization (PAHO)created the Virtual Campus for Public Health (VCPH) in 2003:
    • Virtualcollaboration.
    • 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

17. 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 Mdica del Uruguay
    • Measuring their usage and impact