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Digital health technology is already playing a larger role in how healthcare consumers receive information about health concerns and how patients manage wellness and disease. The influence of mobile apps, wireless medical devices and other tools for patient monitoring will soon be felt in almost every physician practice. In an environment where regulatory standards are still in flux, some of these technologies are validated and reliable, others are not. We present the first in a series of systematic guidelines to assist physicians in navigating digital health technologies that they will encounter in the office setting.

Objective To determine how Community Health Centers (CHCs) perform relative to other primary care providers. Research design A retrospective cohort study of Medicaid claims comparing provider groups on the basis of avoidable hospitalizations and costs. Results Avoidable hospitalization rates did not differ significantly across care settings. Hospital outpatient departments and CHCs had comparable total costs, whereas physicians had slightly but significantly lower total costs. Conclusions Understanding determinants of care cost differences could inform future performance improvement initiatives. Care quality variance within provider groups may be more significant than care quality performance across care settings.

The Maryland Health Services Cost Review Commission (HSCRC or the commission) is a government agency with the authority to establish rates for both inpatient and outpatient services for all general acute care hospitals in the state. By law and consistent with the state's unique Medicare waiver, all payers (including Medicare and Medicaid) must pay hospitals on the basis of these rates. The HSCRC has used diagnosis related groups to set case-mix-adjusted limits on the revenue per discharge for inpatient services (similar to Medicare inpatient prospective payment nationally) yet, the Maryland rate-setting system for outpatient services has not embodied incentives to control utilization of services. Beginning in the state's fiscal year 2008, the HSCRC is implementing regulation of ambulatory surgery services using ambulatory patient groups to provide better incentives to control utilization, and to facilitate comparisons of the case-mix-adjusted charges per ambulatory surgery case across hospitals. Maryland has been an innovator in the design and successful implementation of payment systems and other incentive mechanisms to constrain hospital cost, maintain payment equity, and ensure access to needed hospital care. The HSCRC's adoption of all patient refined diagnosis related groups and the hospital-specific relative value method for establishing diagnosis related group weights in 2005 was relevant to the Centers for Medicare and Medicaid Services' decision to move to Medicare severity diagnosis related groups beginning in federal fiscal year 2008, and to consider the use of hospital-specific relative value weights. The HSCRC's decision to use ambulatory patient groups for ambulatory surgery is an attempt to apply the most effective features of inpatient payment systems, prospective payment, including incentives to control service volumes. As such, it represents a radical departure from prevailing payment arrangements in that it seeks to remove the traditional distinction between inpatient and outpatient surgical services, a distinction that has blocked the development of effective and well-integrated outpatient payment systems for decades. This article describes the policy rationale for this system, the analysis that was performed, and the methods that will be used to control the revenue per case and compare the relative charges of the hospitals.

Timeliness, one of the Institute of Medicine's six aims for improving the quality of health care, is an important yet understudied aspect of health care. It has been well documented as a factor influencing satisfaction in many other service industries but not as frequently in health care, especially outside of the emergency department. This article examines current trends with wait times and their effect on overall satisfaction with care in physician's offices and outpatient test and treatment facilities offering both analysis of the current situation and recommendations for improvement in the future.

Over the next decade, the Internet and related technologies will revolutionize the administrative and clinical practices of ambulatory care, enhancing the ability of physicians to provide quality care, enabling "virtual care teams" to help patients deal effectively with acute episodes and chronic conditions, and reducing the cost of care. Like any major paradigm shift, this change will not happen overnight. Nor will it be without cost. The explosion of venture capital and meteoric rise of the Nasdaq in 1999 reflected the promise of the Internet to revolutionize many aspects of American business. The Nasdaq's equally rapid descent in 2000 reflected a growing realization that this change will not be free--that "creative destruction," to use Schumpeter's term, will inevitably require significant investment and produce substantial losses. This article takes a longer term view than the ups and downs in the stock market. We believe the forces unleashed by the Internet are inexorable and that 10 years from now we will look back at the millennium's first decade as a period when the practice of ambulatory medicine was transformed by communication technology.

Ambulatory care providers are being challenged to deliver high-quality care at low cost with easy access. Patient satisfaction with services hinges on the ability of providers to meet these often elusive benchmarks. This article focuses on the barriers to benchmarking patient relations in ambulatory care organizations and strategies for improving patient relations through internal benchmarking that encourages service innovation and performance emphasis. A case study of programmatic benchmarking in the Lovelace Health System is used to illustrate how patient relations can benefit from establishing internal performance thresholds that guide service delivery. Examples from Lovelace's High Risk Pregnancy Program demonstrate the value of benchmarking efforts. The implications for patient relations benchmarking in other ambulatory care settings are discussed.

As rural community hospitals continue their transition of health care delivery to predominantly outpatient and ambulatory services, many factors are being considered in design, planning, and operations to enact this change both efficiently and effectively. The following examines strategies that allow these changes to be incorporated successfully while maintaining the flexibility for the continued transition that these organizations will experience in the future.

The Germany multipayer universal health insurance plan in 1992 consumed 8.7% of its nation's total expenditures. Nevertheless, its macromanaged approach has allowed until recently for pluralism, decentralization, and self-regulation among providers and sickness funds (not-for-profit, third party payers). With 34.8% more physicians per 1,000 persons, German doctors provided twice as many patient contacts per capita than in the United States. Due to economic constraints and increases in payroll taxes, the Federal Republic of Germany's parliament, with its 1993 health reform plan, virtually froze all payments to providers for a 3-year period. Among other contentious provisions were the following: (1) limiting the entry of new physicians into municipalities that are considered by government health manpower planning experts to be oversupplied in that specialty; (2) requiring community-based physicians to participate in controlling pharmaceutical costs; and (3) eliminating some of the German traditional barriers between their in- and out-of-hospital physicians. This article focuses on how the Germans now micromanage their physician and other ambulatory care services within a macromanaged system that, in terms of patient access, benefits, quality, and cost, should be the envy of the Americans.

Health care is a service industry. A fundamental attribute of many successful service industries is the "small replicable unit (SRU)." There are three essential elements of an SRU: (1) the smallest core unit of activity, (2) micromeasures designed to help manage the core activities, and (3) combinations of the activities and measures to match local customer needs. In this article, we describe a model for geriatric care based on "SRU thinking." We demonstrate how this approach places measurement of patient values, clinical improvement strategies, and research objectives into day-to-day health care delivery.

The leaders of health care organizations across the country are facing significant pressure to improve the quality of their services, reduce operating costs, and adjust to decreases in reimbursement. Survival of a surgery center is achieved when physicians work together to decrease their vulnerability to outside forces and increase their ability to reach desired objectives. Improved communication, operational efficiency, and cost effectiveness are the strategic imperatives. As competition for patient referrals increases among providers, in the midst of a national trend, a surgery center marketing program must be well organized and carefully designed to meet the needs of all its customers. A surgery center that can strategically place itself as a critical link between the surgical specialist and the gatekeeper will survive and prosper in the current health care world.

This article explores case-mix adjustment systems in the ambulatory care environment as applied by managed care firms. An overview of ambulatory care groupings or ambulatory case-mix systems is given, and the special case-mix adjustment needs of managed care companies are reviewed. Generally, two types of ambulatory care grouping systems are available: encounter-based and population-based. Case examples of three managed care companies that are currently investigating the use of population-based case-mix systems are used to demonstrate the possible use of such systems in the managed care environment such as physician profiling and capitation rate setting.

Prospective payment for ambulatory surgical services offers the opportunity to achieve a number of operational efficiencies in the health care delivery system by incorporating incentives for both physicians and facilities to reorganize care. The risk associated with this opportunity is the creation of additional bureaucratic infrastructure.

In summary, by being aware of the characteristics of their physicians and patients, ambulatory care managers might be able to influence their physician productivity. Specifically, managers may wish to hire physicians who are board certified or foreign medical school graduates. Similarly, managers may seek to attract patients with acute, nonsevere, nonurgent conditions. Managers seeking to enhance physician productivity should consider these characteristics regardless of the reimbursement or proprietary nature of their ambulatory care organizations.

Classification issues in ambulatory care nursing present an exciting area for future research and development that is only beginning to be tackled. It will be important to validate both the conceptual basis of the nursing workload model and the tools and methods used to measure workload. Comparative studies are needed in a variety of settings to reach consensus about the variables affecting workload in ambulatory nursing, and ways to measure them. Timed observation and validation studies are needed as new reporting and evaluation instruments are developed. At NIH a validation study looking at a modification of the taxonomy of ambulatory nursing practice (Verran, 1981) is underway, using a national sample of nursing administrators (Hastings, 1984). Studies to establish interrater reliability and to refine criteria for classifying patients and nursing activities are also needed.