Expansion into the future: healthcare and information systems technology.

Malley, John ; Griffin, Ken

INTRODUCTION

In a world where the local "discount city" maintains an on-line, real-time inventory system, where current stock quotes are just a click away on everyone's web-browser, and where practically anyone and everyone can become an instant "expert" on nearly anything simply by playing around on the Internet, it seems as though the U.S. healthcare system could do something more with information. The United States has some of the top healthcare facilities in the world. But, as far as information goes, it has been slow to institute automated systems.

Today's healthcare information system has not keep up with information science. However, slowly but surely, this status is changing. Many, but not yet most, healthcare providers and insurers have begun to maintain electronic records; healthcare intranets are becoming more common occurrences around the country; even the Internet is becoming a strategic healthcare tool in some areas. But still something is lacking. All of the healthcare players do not have an information system, and those that do are not truly linked. The American healthcare system needs something well-constructed, operationally efficient information system that connects providers, insurers, and patients around the country and can drive American healthcare to the bounds of its capabilities.

This system is needed to provide more enhanced service through offering providers, insurance carriers, and patients advantages in care, billing, and planning. The advantages this system would offer are vital for the growth and continued development of the healthcare system.

However, this information system will not be without limitations. Problems with security, provider use, cost, time, standardization and the continued need for some paper-based records would all place pressure on this information system. However, with the possibilities offered by technology, these limitations can be overcome.

Despite the fact that most areas of business and industry throughout the United States place focal emphasis on information technology, the healthcare industry simply does not. Although high tech proliferates in almost every other area of clinical practice, information technology is often only found in isolated "islands of information" within provider and insurance institutions (Bringing healthcare online, Internet). Working toward an on-line, integrated healthcare information system should be a primary objective of the healthcare industry in the next century.

HEALTHCARE AND INFORMATION TECHNOLOGY--THE PRESENT STATE

Across the Unites States today, one does not find a healthcare information system that is integrated and automated. Rather, one finds, amid a sea of relative confusion, a few isolated "islands of automation" which combine with manual, paper-supported operations to create a larger healthcare system. This system can principally be segregated into three, hierarchal levels: level one, local isolated; level two, local integrated; and level three, system-wide integrated.

Local Isolated

A healthcare information system that functions in an integrated, responsive manner, must, at its most basic level, consist of components that operate with a high degree of automation. Today, in the American healthcare information system, this is simply not the case. According to a 1998 survey by the Healthcare Information and Management Systems Society, only two-percent of 1,700 healthcare information executives have a fully operational computer-based patient record (CPR) system in operation, and nearly twenty-five percent have not even begun to plan for CPR systems (Serb, 1998). A separate survey indicates that only slightly more than one-third of the nation's healthcare networks have some sort of electronic patient record system in operation (Menduno, 1998). Providers receive little incentive from insurance companies to become electronic; the majority of insurance companies do not accept electronic claim filing (Moynihan & McLure, 1998). Without automated records, at the local, isolated level, it is difficult, if not impossible, to exchange up-to-date information within each system itself, let alone with other healthcare entities. However, for those who are automated, advancement to the next level, local integration, is possible.

Local Integrated

Considering how few local healthcare systems operate with automation, it is no surprise how few operate on the next level, integrating within the organization and with other local healthcare systems. However, there are healthcare organizations who are constantly pushing forward to make this possibility a reality. Use of both intranets, which most commonly link doctors within organizations, and remote access capabilities, which allow doctors "unconventional" access to patient information (such as after hours from their homes), is on the rise throughout the country (Serb, 1998). Some geographic locations have even gone so far as to implement community health information networks (CHIN). CHINs connect hospitals, medical clinics, physician offices, insurance companies, pharmacies, and other related organizations within a specific geographic region. They provide each of these entities patient clinical and financial information via integrated computer and telecommunications capabilities (Lassila, Pemble, DuPont & Cheng, 1997). One example of a CHIN is the Minnesota Health Data Institute's "MedNet." MedNet is a secure "network of networks" which links major health plans' networks with other healthcare parties within the state (Starr & Starr, 1997). Even given these advances, no healthcare organization has truly integrated with, and few have even explored the next level of system wide integration.

System-Wide Integrated

At the present time, the U.S. healthcare system is anything but integrated. Few, if any healthcare organizations have even explored the possibility of using a system with nationwide access, such as the Internet, in their information pursuits. Some of the systems which do allow national access, such as the government funded Patient Centered Access to Secure Systems Online research project (PCASSO) primarily only address one area of the healthcare information problem-the need for patients to have ready access to their own health records. The issues of linking providers and insurance carriers has not been a forefront issue. Although few healthcare entities have explored this encompassing level of the healthcare information structure, this is the area where ultimate expansion needs to be aimed. It is at this level in which an integrated, efficient healthcare information system must be developed.

CONCEPTUAL MODEL NATIONALLY INTEGRATED HEALTHCARE INFORMATION SYSTEM

If the healthcare information systems of this country are to be utilized to their fullest potential, eventually, the U.S. will operate with a nationwide, integrated information system. Through this system, each of the healthcare industry's primary sectors, providers, insurers, and patients, will have access to patient clinical data. For this system to exist, several changes will quite obviously have to be made.

All local systems must first develop fully electronic records. These records must be of the type that exist within a "virtual" healthcare information department-authorized users will have system wide, immediate electronic access to patient information (Odorisio 306). Second, a nationwide framework must be made available in which a system to input, store, and retrieve data may be developed. Third, a system must be developed in this framework through which each of the three sectors can input data and access its processed output--usable, accessible information.

Obviously, the first stage, developing a fully automated record system, is under way, but potentially years from completion. The completion of this first stage necessitates a committed effort on the part of healthcare insurers and providers to make this ideal a veritable reality.

The second stage of this process, creating a nationwide framework, could be achieved through establishing a new network that physically connects each authorized sector participant to a main database. While providing a great amount of security, the implementation of such a system would likely be both physically and financially impossible. A more viable solution would be to use what is already in place, the Internet.

Utilizing the Internet would still entail creating a database into which the information from the three sectors could be inputted, stored, and received. Ideally, all information would be stored in a central database, securing the integrity and completion of patient records. However, such an expansive creation would likely be impossible in realistic form. The creation of this database would result in somewhat of a problem with regard to its originator and manager. A privately managed database would create a necessary monopoly, not likely to be viewed with high esteem by federal regulators. A government managed system, through adding another layer of typically inefficient bureaucracy would create what many dislike, too much oversight and, most likely, inefficient operation. Perhaps the best solution would be to adopt a set of standards with which each sector could input and access information, and allow intranets encompassing states or even regions to maintain data warehouses for the input information. Authorized users would be given access to any of these databases through use of a web-browser.

By utilizing the Internet, a viable healthcare information system can be developed to manage the electronic patient records of individual providers and insurers, through participation in geographic intranets. Such a system would offer the healthcare industry the ability to overcome current obstacles and expand with new opportunities.

ADVANTAGES OF INTEGRATED HEALTHCARE INFORMATION SYSTEMS

An integrated, nationwide healthcare information system will benefit its three primary sectors, healthcare providers, insurers, and patients, in a number of ways. These benefits will primarily be recognized in patient care and cost savings. All of the benefits and uses described below are not obtained solely from the large, integrated information system itself. Some of them will be brought about through utilizing the systems and improvements created as a base for the larger, integrated system (such as electronic records and local intranets).

Patient Care

With the use of an integrated healthcare information system, physicians will be provided with easier and more effective access to their patients' clinical data and to relative, possibly critical information.

If an expert system were integrated into the information system, it could potentially save millions of dollars, and possibly quite a few lives. According to the Journal of the American Medical Association, adverse drug reactions fall between the nation's fourth to sixth leading cause of death (Menduno, 1998). Not a fact to be taken lightly. With the ability to connect healthcare providers through networks, smaller providers could conceivably have access to resources that have previously been out of their reach.

Even if an expert system is not added to the network, care providers will be able to offer patients better service as their status will be measured by much more efficient means. With such a system, doctors will be capable of updating and accessing patient records after hours, gaining a colleague's opinion on a patient's condition (even if they are thousands of miles apart), or reviewing a patient's entire medical history before prescribing treatment.

With an information system that can be accessed via the Internet, even patients can gain passage to their own medical records. In an era where patients, especially those with potentially terminal or lifelong illnesses, are choosing to become more educated about their health, an information system that provides needed details could become invaluable. The PCASSO system already has a security system that would allow patients to utilize such an information system to further their education about their illness. This system classifies each piece of a patient's record into one of five security categories:

* Low: anonymous or "nonpatient-identifiable" data (can be used by researchers, etc.)

* Standard: regular patient information without special sensitivity

* Public Deniable: information that demands extra security, such as HIV status, mental-health records belonging to celebrities

* Guardian Deniable: teenage abortion or other records that can be kept from parents or guardians

* Patient Deniable: information that could cause harm to the patient if known (such as confidential information provided by a relative)

Classification such as this protects the security of patient records, while at the same time, allows individuals the opportunity to monitor their own treatment process. This facet of the information system could potentially become one of the most valuable. As Dr. Dan Masys, director of Biomedical Informatics and associate clinical professor of medicine at the University of California, San Diego stated:

"In America, to some extent, we still have the Norman Rockwell view of health care, with the physician who knows all and the patient not having to worry about it. But the reality-especially when you become seriously ill-is that there are some very complicated and not-so-black-and-white issues and lots of choices to be made. The better educated you are, the better able you'll be to participate in taking care of your own health (Breckinridge, online, 4)."

Cost Savings

With the cost of healthcare perpetually on the rise, any cost savings are welcome. An integrated, up-to-date healthcare system would offer many such savings.

Saving to Providers. Historically, adverse drug events have cost hospitals $2,200 to $3,500 per ease; the use of a network expert system could eliminate many of these, potentially saving millions of dollars per year (Menduno, 1998). With such a system, doctors eventually will be able to order prescriptions and check insurance eligibility almost instantaneously, saving valuable time, effort, and hence, money (Serb, 1998). Further, administrators should also be able to utilize such data to improve operational performance and obtain information to -support crucial decisions (Scheese, 1998). Utilizing this system, providers should be able to operate in a more effective manner, saving insurance carriers and patients the cost of needless treatment. This advance should conceivably allow care to be evaluated more for performance rather than price (Millenson, 1998).

Savings to Insurance Providers. An integrated information system should also greatly benefit insurance providers with many cost savings. Currently, insurance premiums are often based on out-of-date or incomplete data--there simply is not an effective means to gain the current data quickly enough. This delay sometimes translates into significant losses-an anticipated $75 to $105 million loss for Aetna and nearly $70 million loss for Oxford, in 1998 alone (Haugh, 1998). Further, with an inside track on patient records, health management organizations can monitor the effectiveness of contracted, network physicians within the organization. By monitoring performance in terms of cost and results per-episode, improvement in outcomes and competitiveness can be realized (Breckinridge, online, 1). As mentioned above, insurance carriers should also be spared the cost of much patient treatment that is unnecessary.

Savings to Patients. In addition to the more advanced care that an integrated information system will offer, patients should also receive substantial cost benefit. By possessing the capability to access their own records, patients could possibly customize their treatment to meet individual needs, thus avoiding duplicated and unnecessary treatment. Also, as mentioned above, with healthcare providers' possession of a wider base of clinical data, unnecessary treatment will hopefully almost be eliminated.

An integrated, nationwide system should benefit each sector of the healthcare industry sufficiently to justify its implementation and use. However, such a system is not without problems and limitations.

PROBLEMS AND LIMITATIONS OF THE INTEGRATED INFORMATION SYSTEM

In order to be effectively used by the healthcare industry, the information system discussed would be faced with at least five problems and limitations that it must overcome or compensate for in order to become a success. These factors are: security, doctor utilization, cost and time to implement, standardization, and the still present need for some manual records.

Security

As everyone surely realizes by now, the world wide web is not a foolproof, totally secure method of communication. However, enough systems are in place today that protected communication can be accomplished fairly easily. The problem which still exists, however, mainly lies in limiting access to this protected information. Through the use of passwords, as well as limited physical access, electronic records should be provided the utmost security. This qualification is necessary from both a legal and ethical standpoint (Fotsch, 1998a). However, with the use of the Internet, the possibility for unauthorized use of the information system will most certainly always be present.

Doctor Utilization

When a system such as this is in place, office staff will be forced to use it-it will be part of their job description, they will not have a choice. But what about the physicians who are defiant to the use of the system? Possibly due to resistance to change, fear that ethical standards will be compromised, fear that the new system will create more work, or other reasons, physician resistance to the use of networks for clinical purposes could be very much a reality.

A 1998 survey by Healthcare Financial Management revealed that forty-percent of the polled physicians stated "that they probably would not use computers or networks for clinical purposes even if training were provided and services were made available free or at a very low cost (Fotsch, 1998a, 27)." Quite obviously, this reveals but one thing-doctors must be considered in the design of this network. It is absolutely imperative that physicians feel they are gaining an advantage by using the system.

Perhaps through emphasis on the idea that the physician's office becomes virtually boundless with this system, or through emphasis on the idea that this system will make a doctor's life easier-the benefits of the system must be stressed. Because, quite obviously, if the doctors do not input data, the system has nothing to process, and it becomes a failure.

Cost and Time to Implement

For a provider or insurer that has limited or missing electronic data banks, conversion to an information system such as this will be both time consuming and costly. The key to overcoming this limitation is in discovering the cost benefit that such a system can offer. Simple cost-benefit analysis cannot readily apply to a system such as this. Such a system is not traditional, and requires an alternative method of valuation. To justify the cost that conversion will entail, each sector must come to view information "as a valuable resource that increases individual, departmental, and organizational performance and productivity ... a competitive advantage (Scheese 57)." It is only by this means that such a large expenditure will stand the chance of acceptance ill any organization.

Standardization

Around the country, each individual healthcare provider and insurance carrier has its own method of storing patient data. One might link patient records by social security number, another by an internally assigned identification number, and still another by last name. The point is, there are few, if any, standards that govern the form of medical records. In this current state, a massively integrated information system could never function. Standardization is necessary.

To facilitate the exchange of patient information among applications on a network, users must be able to exchange and correctly recognize unique "patient identifiers" (Fotsch, 1998c, 26). In order for this to be accomplished, a patient indexing system must be developed, one which will allow management of discrete clinical data from various systems in a manner that insures all entered information will remain associated with the correct patients and providers (Fotsch, 1998b, 27). The Health Insurance Portability and Accountability Act of 1996, which requires nearly all claims payers to support electronic claims processing and uniform national standards for code sets and identifiers by the year 2000 is definitely a step in the right direction (Moynihan, 1998). Clearly, standardization is not merely a limitation that can be compensated for, but an obstacle that must be overcome before any information system such as this can be installed.

Paper Records

Even if a seemingly full-fledged electronic record system is placed within an organization, the need for some paper records does not entirely disappear. Doctors' notes and observations, often recorded on patient charts, still must be consulted for immediate analysis, audits of prescribed treatments, and research (Beckham, Englert, Davis & Koch, 1998). Until physicians stop using pens and pencils entirely, this need will likely never be overcome--it must simply be dealt with.

CONCLUSION

With the healthcare industry spending $7 billion dollars on information technology annually, and with an expected doubling of this figure by the end of the decade, serious potential for improvement in the way healthcare information systems operate exists (Lassila et al., 1997). However, according to Health Care Investment Visions, most makers of healthcare software are not basing their business foundation on "new-generation technologies" such as the Internet (Tech tomorrow, 1998). Certainly something can be done with the U.S. healthcare information system. But, will this something ever be accomplished?

The current healthcare information systems in this country are limited by a number of factors. All patient records are not electronic. Without electronic records, exchange of information within an organization and among organizations can hardly be accomplished in a timely and efficient manner. Further, the healthcare information systems of today exist in relative isolation. Few are connected through shared networks, and those that are link at the local level, not in a nationwide system. For the healthcare industry to take full advantage of the potential of information technology, a nationwide, integrated healthcare information system should be developed.

Such a system would offer numerous advantages to each sector of the healthcare industry. This system will allow healthcare providers to offer better care through more efficient dissemination of knowledge to physicians, via expert systems, colleague evaluation, and patient opinion. Further, this system will offer cost benefits to the healthcare provider, insurer, and patient. Combined, these two areas of potential advantage should create a more accepted and productive healthcare system.

Although this system would offer its users a number of advantages, it is not without limitations. Problems with security, usage, cost, standardization, and the ever-lasting presence of paper records would have to be overcome or dealt with in order for the system to operate with any degree of success. However, given the advantages such a system would offer, these limitations seem to be surmountable obstacles.

An integrated, nationwide healthcare information system would provide everyone with a more efficient, affable operation: Although the benefits well-justify this endeavor, reaching this point will be a long, hard struggle. There is no doubt the healthcare system in the United States will eventually reach this point, but how, and when, are far different questions.

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John Malley, University of Central Arkansas

Ken Griffin, University of Central Arkansas