Health Systems: Improving with Information Technology
Laxmi Chekuri & Fredrick Schumacher
Health care systems survive due to numerous reasons, but one of their most important traits is the willingness to adapt to changes caused by the flux of the industry. Healthcare issues and healthcare delivery rarely become static due to new diseases, changing patient attitudes, medical spending, and technological innovations. The need for personnel and institutions to adjust with these issues cannot be overstated. Recently the importance of technological advances has become a forerunner in revamping medical systems. High costs, shorter hospital stays, and a reduction in hospital staff have demanded new ways information can be passed to those who need it most. Advances in information technology surround us everyday through the use of pagers, cellular phones, PDAs, and computers. Healthcare systems are looking for ways to adapt these systems to lower overhead, increase production, and to keep up in a changing world. Medical informatics may a solution.
What is medical informatics?
The short answer is ‘computers in medicine’. But that would be a myopic view. Medical Informatics research is a broad and emerging specialty in medicine that deals with information, and more importantly, information management for healthcare practitioners at the point of need. Several definitions of medical informatics have been given and these take into account both the scientific and the applied sides of the field. An encompassing definition of medical informatics is:
science of using system analytic tools…to develop procedures (algorithms) for
management, process control, decision making and scientific analysis of medical
A variety of applications and sub fields comprise a diverse science like medical informatics. For example, the following lists several categories.
· Public health informatics- Information systems that track and manage medical transactions for large populations to improve performance.
One can see the broad scope medical informatics entails. One common theme among the categories is the role of computers and/or technology. This linking factor is only part of these categories. Another important link between the groups is the software needed to gather, process, manage, and redistribute the incoming data to a form that is usable.
In addition to the categories of medical informatics, certain trends have also occurred in this technological advance. The trends are focused areas that technology has been applied to better the situation for the patient, the caregiver, and the organization. The following is a few key areas.
Electronic Health Record System
What might the future hold for the typical practicing physician and their patients? No clinical computing topic is gaining more attention currently than the issue of electronic medical records (EMRs). Health-care organizations are finding their systems lacking the ability to answer questions that are crucially important for strategic planning and to better understand how they compare with other provider groups in their local or regional district. In the past, systems have been developed around encounters of care and were based on information needed to collect for bills and services. Comprehensive clinical data is important for institutional self-analysis and strategic planning. Furthermore, the inefficiencies and frustrations associated with the use of paper-based medical records have become increasingly clear [Dick & Steen, 1991 (Revised 1997)], especially when inadequate access to clinical information is one of the principal barriers that clinicians encounter when trying to increase their efficiency in order to meet productivity goals.
Clinical Work Stations
Many health-care institutions are seeking to develop integrated clinical workstations to act as entry points into the electronic record system. Such a system would provide the following:
The key for systems integration lies in the medical record. Despite the obvious need for a new record-keeping paradigm, most organizations have found it challenging to try to move to a paperless world. Companies offer medical-record software packages, but they are limited in their capabilities and seldom seem to meet the full range of needs defined within an organization. The record system must make it easy to access and display needed data, to analyze them, and to share them among colleagues and with secondary users of the record. The computer-based medical record is best viewed not as an object, or a product, but rather as a set of processes that an organization must put into place, supported by technology. The purpose is not to automate existing processes but to enable new functionality.
About one third of health care cost in the United States- some $ 350 billion-consists of the cost of capturing, storing, processing, and retrieving information such as patient records, cost accounting, and insurance claims2. By that measure, health care is a larger information industry than the “information” industry. Implementing electronic records is inherently a systems-integration task; it is not possible to buy a medical-record system for a complex organization as an off-the-shelf product. Joint development is crucial. The new technology requires clear objective, management support, and process innovation in order to demonstrate value. Without these, they are simply high cost technologies. Several products are available designed to reduce medical errors and to improve access to new knowledge.
Successful Cases of Electronic Health Record System
The Brigham and Women’s Hospital in Boston began to replace paper based ordering with computer based order entry in 1994 encompassing tasks such as the ordering of drugs, diagnostic tests, and settings of ventilators. This system automatically suggests appropriate dosages and known drug interactions. The first year of use resulted in a 55% decrease of serious medication errors.3
The digital revolution at Kaiser was embarked in 1998. The Net system has been in place for Northwest for two years. Only three of Kaiser’s six regional divisions are using Net systems so far. When a patient comes in for a visit, doctors can instantly access their records from a keyboard and a flat-panel screen in an examination room. Doctors use computers to type up notes and flip through records of previous treatments, x-rays, or charts. Information is zipped over dedicated phone lines to a central database in each region. The savings from this system are coming from the containment of pharmaceutical costs because the network automatically offers any available lower-cost alternatives. This system has helped Northwest unit cut cost by 20%.4
In the past, 10% to 15% of patient tests in Northwest had to be repeated because of lost paperwork or illegible doctor’s handwriting. Now that records are on a central database, the vast majority of those repeated tests have been eliminated. Doctors can get instant access to updates about their patients. Patients will be able to make appointments on web sites, adding up to big savings. Kaiser expects to save $400,000 annually in northern California alone with this program.
In a recent study, a neural network detected myocardial infarctions from electrocardiograms 20% more accurately than an experienced cardiologist5. Neural networks have now been developed to assist with and improve diagnosis in nearly every field of medicine. Systems have been designed to read chest x-rays, mammograms, and nuclear medicine scans. Such changes have reduced misdiagnoses.
Physicians are expected to stay apprised of medical journal articles; government-published guidelines and reports, such as those published by the National Institutes of Health (NIH) and the U.S. Food and Drug Administration (FDA); clinical alerts from pharmaceutical companies; scientific conference presentations; and even reports of unpublished findings from the popular press. The volume is overwhelming. With this enormous volume and diversity of sources, physicians cannot absorb all the information generated that is relevant to their clinical practices. Computer integrated databases assist in such endeavors.
Successful integration of Electronic Health Record System poses several challenges such as:
· The concept to use computers and the Internet as the basis for communication between patients and providers.
There has been rapid growth in the use of electronic mail as a mechanism for avoiding “telephone tag”. There are young companies that work with managed-care organizations and health-care systems to provide Web-based facilities for disease management. Patients log in to a private Web site, provide information about the status of their chronic disease (for example, blood glucose readings in diabetes), and later obtain feedback from their physician or from disease managers who seek to keep the patients healthy at home, thereby decreasing the need for emergency-room or clinic visits. Many of the concepts proposed above depend on the emergence of an Internet with much higher bandwidth and reliability, decreased latency, and financial models that make the applications cost-effective and practical. Hardware technology will continue to improve.
Developers of systems must have a through grasp of users needs to produce systems that help health care providers use these tools efficiently to deliver care. Requirements of physicians entering data are different from clerks entering patient charges. Developers must focus on specific sets of users and must define and address their unique information needs.
Standards reduces development costs and increase integration. Standards are critical because of the need to integrate applications and job functions throughout the organization. Standards facilitate integration of data between systems in supporting better data collection and improving level of patient care and data for quality improvement and policy. Legal issues, privacy, confidentiality and security are major concerns. Methods must be defined and legally enforced to protect private data. Part of the difficulty in comparing costs is inability to measure costs of using paper records. Significant resources are needed for integrating systems. Many randomized controlled studies show that computer based decision systems integrated with electronic records reduce costs and improve quality. Leaders from all segments of health care industry must work to articulate the needs, to define standards, to fund the development and to implement social change and accelerate the development and routine use of electronic patient systems. Voice recognition systems will enable physicians to dictate their notes, which will remove the keyboard barrier. Medical students, residents, and fellows have grown-up using computers and are already comfortable using electronic medical records.
To summarize, an electronic record system involves integration of large information systems. Implementation of a large-scale information system is still in its infancy but a possible reality. Organizations are experimenting with partial implementation such as decision support systems. Innovation to improve single process in medicine is less technically demanding and capital intensive. Small changes are easily accepted. Success of some organizations such as Kaiser in integrating new systems proves the feasibility and utility of such systems, providing an example to other organizations.
Public Health and Consumer Information.
The demand for tracking healthcare data and using the data in an attempt to improve health care delivery is increasing. The need for integrating health care data is dictated by:
· Cost controlling, improving quality, and cost effectiveness
· Health care data reporting for accreditation of managed care plans (HEDIS)
· Federal reporting regulations
Successful Cases of Organizations Tracking Healthcare Data
They developed specialized solutions for their specific needs.
HEDIS- (Health Plan Employer Data and Information Set). The data collected by it serves as national reference standard for evaluating health plans. Data is a source for U.S. news and World Report rankings for health care plans. HEIDS data include survey measures of patient satisfaction and indicators for quality of care. HEIDS is a tool for monitoring preventive activities of managed care plans. It is a major achievement in quality measurement. In 1997 60% of HMOs used HEIDS to evaluate performance.
USQA Health Services Research Program- It reviews treatment patterns and performance of physician and determines outcome measures for patients suffering from any of the 65 chronic diseases.
Ford- Insurance contractors for Ford have to provide real time data on patient care and outcomes. This data is collected in a single database. This system allows to track quality over time and implement improvements in care.
Integrated systems of data have potential for producing impressive findings of public health interest. The data provided by HPHC (Harvard Pilgrim Health Care) was used to establish that the effectiveness of lipid lowering agents was less in general use than in clinical trails.6
Hospitals and medical groups are gathering outcome oriented clinical data on performance of physicians.
Surveillance data- CDC maintains surveillance systems to track incidence of many conditions and database for notifiable diseases. CDC considers information processing and dissemination important. T hey developed immunization registries and integrate different systems.
There are several hospital-based projects that use the Internet to centralize patient information and provide access to providers across institutions. The electronic medical record collaborative is an example. CHINS (Community Health Information Networks) is leading to build a single network to communicate with all parties but no attempts have been made to build a national scale network.
As electronic records become a source of data, the depth and quality of data increase. Evaluating data from these sources can provide information about local medical services and disparities of care.
Public health data files contain many millions of records. They do not use keywords and have long complex questionnaires. Access to complex data should be improved. As medical practice shifts from treatment to prevention, outcome measures become more important. The electronic medical record is a valuable tool for data. Physicians can monitor and adapt care according to their patient population. Standard format for data is lacking but the Health Care Financing Administration has proposed standard format for electronic transactions about Medicare. In fragmented health care industry it is difficult for HMOs, hospitals, and physicians to accept one single standard.
Better public health information systems will improve the identification and investigation of disease outbreaks and provide information to the public. Integrated public health systems will bridge the gap between public health and private health. It places individuals in context of community and involves them and their communities in preventive and therapeutic care. The challenge to integrate comprehensive data is formidable. There are huge gains in public health using information contained in these databases. The greatest benefit of information revolution in the future might be a break down of role and geographic barriers.
Consumer Health Informatics (CHI)
A busy clinician may be able to take a few minutes to explain terms and likely consequences of procedures and treatments. CHI resources provide patients with condition and disease specific information about the problem(s) they face. Some resources are easy to understand even for a layperson. Other resources provide procedural information and explain diagnostic detail. CHI resources originate from professional and self-help groups. CHI resources developed by organizations—such as HMOs, managed-care companies, and group practices- use information resources as a service to the patient populations that they treat. Kaiser Permanente Health Facts, a program designed to help Kaiser members answer questions about common health problems and the Mayo Health Advisor, a commercially available CD-ROM that can be purchased and used to help manage health are a few examples.
. Self-help information may address daily living concerns and lifestyle issues. Computer networks not only provide patients with access to information but they also help individuals to connect with other people with similar diseases and concerns. Network-based consumer-health services include both specialty and public access networks. Specialty systems are the ComputerLink -for homebound patients and their caregivers.
Information technology shifts the balance of knowledge. Patients use the Internet to get information and to make choices. It allows patients to access personally tailored solutions. The consumerist trend will increase in health care. What is the relationship going to be between patient and doctor in the era of information revolution? There is no clear answer at the present. Analysis, policy development and implementation are critical for translating the benefits of the information revolution and to maximize benefits and minimize harm. They will have profound effect on health care when patients will compare and chose between managed care plans or physicians based on the information provided.
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3.Bates, et al Effect of computerized physician order entry…Jama 1998; 2809150:1311-1316.
4.Businessweek Kaiser takes the cyber cure by Doublas Gantenbein and Marcia Stepanek
5.Heden B Acute myocardial infarction detected in the 12-lead ECG, Circulation 1997; 96; 1798-1802.
6. Gawande AA, Bates DW. The use of information technology in improving medical performance. Part I. Information systems for medical transactions. Medscape General Medicine February 7, 2000.
7.AA Gawande, DW Bates. Use of Information Technology in Improving Medical Performance Part II. Physician-Support Tools. Medscape General Medicine February 14, 2000.
8.Gawande AA, Bates DW. The use of information technology in improving medical performance. Part III. Patient-support tools. Medscape General Medicine. February 2000.
9 Kerry Kissinger ,Sandra Borchardt. Information technology for integrated health systems.
10.picture copied from “Medical Informatics: computer applications in health care and biomedicine”edited by Shortliffe E.H.
11. Picture copied from “Medical Informatics: computer applications in health care and biomedicine”edited by Shortliffe E.H.
12. Medical Informatics: computer applications in health care and biomedicine”edited by Shortliffe E.H.