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Information Flows and Needs in a Healthcare System

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Title: Information Flows and Needs in a Healthcare System


1
Information Flows and Needs in a Healthcare System
  • Yair Babad
  • IDS Department, UIC
  • June 14, 2002

with E. Geisler and T. Horev
2
Overview
Welcome at all times
  • Introduction and motivation
  • Current medical IT systems - illustrations
  • The healthcare system concept
  • The healthcare framework
  • Conclusion and summary

3
Motivation
  • Impossibility to practice modern medicine and
    healthcare without IT
  • Information management pervasive throughout
    activities
  • The related data
  • Complex
  • Uncertain
  • Abundant
  • Scope and needs change rapidly
  • Dissatisfaction with existing medical and
    healthcare IT
  • Feeling of incomplete / inadequate / missing
    information
  • Plethora of systems of varying scope and
    complexity
  • Difficulty of integration
  • The emphasis is IT and information rather than
    IS

4
The Big Questions
  • Is it possible to create an integrated,
    satisfactory medical / healthcare IT system?
  • Is it desirable to create such a system?
  • If the answer is
  • YES how to approach this objective?
  • NO why? what can we expect? How to approach
    healthcare systems?

5
Possible Answering Approaches
  • Experimental traditional approach to systems
    development
  • Specific (complex) systems - goals, needs, users,
    constraints, reliance on existing systems and
    processes, etc.
  • Synthesis
  • The combining of separate elements or substances
    to form a coherent whole
  • Generalize from study of existing systems
  • Analysis
  • The separation of an intellectual or substantial
    whole into its constituent parts for individual
    study
  • From world of medicine to specific systems

6
In This Presentation
  • Demonstrate the futility of the synthesis
    approach
  • This will be a fast-moving illustration of the
    plethora of hardly related existing medical and
    healthcare systems
  • Present a concept of a healthcare system
  • Emphasize the analytic healthcare framework
  • Including information use and flows within the
    framework
  • Conclude with implications to healthcare systems
    development and implementation
  • Including how the concept was used in a
    particular HMO

7
Overview
Welcome at all times
  • Introduction and motivation
  • Current medical IT systems - illustrations
  • The healthcare system concept
  • The healthcare framework
  • Conclusion and summary
  • ?Glance only no discussion of explanation

8
The Synthesis Approach
  • Illustrations of systems reported in the
    literature
  • (Partially) present scope of existing medical IT
    systems
  • Eventually identifying common features,
    generalizing, creating a framework of these system

9
Enterprise Healthcare System
Enterprise Intranet
Enterprise Internet
10
Computer-Based Patient-Record System
11
Healthcare Information System Architecture
12
Patients Data Record
13
Clinical Data Repository
Lab servers
Interface Engine
DB Servers (LOINC and other coding standards)
App Servers
Web Servers (HTTP)
14
Case Mix Roles
15
Technology-Enabled Online Connectivity
16
Integrated Delivery Network
17
Information Delivery Network Environment
18
Integrated Delivery Network Governance Structure
19
Intensive Care Unit Interactions
20
Distributed Intensive Care Unit
21
Radiologic Process
22
Picture Archiving and Communication System
23
PACS interoperability
Web Servers (IIS)
App Servers, e.g ASP
Presentation
DB Servers
XML query/response
Image servers
App Servers, e.g JSP
RadiologyWeb Servers
24
Imaging Workstation Application
25
VPN Diagram
26
Medical Research and Technology
  • Todays technological advances generally increase
    costs
  • Medical research holds out long term (30 50
    years) hope for inexpensive medical interventions
  • Health care in 2050 might be significantly
    different and less costly as a of GDP than today

Per Capita Cost
Today
Future
Diagnosis
Palliative Care
Prevention and Curative Interventions
Polio Paradigm
P
27
Medical Informatics
28
Fraud Detection
29
IBM makes move into health care market
(Computerworld, 6/13/2002)
  • Empire Blue Cross and Blue Shield and IBM entered
    into a 10-year agreement to develop an automated
    claims reading and processing service, using
    software from deNovis Inc. running on an IBM
    e-business infrastructure.
  • Allows English-language business rules,
    regulations and benefits to be read by the
    machines, which will speed up claims processing.
  • The software contains more than 20,000 fields
    that cover contracts, regulations, benefit
    packages and business rules. This allows the
    program to find the contracts, agreements and
    regulations that pertain to a transaction and
    give the user the correct results on the first
    pass.
  • There are hundreds of thousands of processing
    rules involved in these transactions. Empire has
    been working to streamline Web-based transactions
    for doctors and patients for the past two years.
    The package is for the back end of the health
    insurer's operation and will allow for customized
    benefit plans and enhanced customer-service
    systems.
  • Empire will be able to retire 22 million lines of
    legacy code.
  • The software is built on an open-systems
    environment that runs on high-end IBM machines
    and is "100 pure Java."
  • IBM is in the process of porting the software
    onto its Z-series mainframes.

30
Platform Overview (by a major HMO)
  • Multi-Tier environment, emphasizing proper
    coupling between presentation, application logic
    and data
  • Various interoperability techniques are employed
    when bridging heterogeneous platforms flexible
    middleware is key
  • Invested nearly billion dollars over 7 years
  • Not all data and applications are integrated,
    although we do strive for maximum feasible level
    of integration

31
The Conclusion
  • What is a medical or healthcare system?
  • Who owns the system?
  • Who owns the information?
  • Common to all systems
  • Function and technology oriented
  • Often a duplicate of an older system
  • Local view of the world
  • CHAOS !!!

32
Overview
Welcome at all times
  • Introduction and motivation
  • Current medical IT systems illustrations
  • The healthcare system concept
  • The healthcare framework
  • Conclusion and summary
  • ?Defines the world in which healthcare systems
    function, the actors, and their information
    environment, needs and use

33
Ultimate Goal Hope for Full Life
  • Health can be seen as a means, a foundation for
    achievement, as a first achievement itself , and
    a necessary premise for further achievement…..
  • The sick individual suffers isolation, loss of
    wholeness, loss of certainty, loss of freedom to
    act, loss of the familiar world the future is in
    doubt and all attention is concentrated on the
    present….
  • When ill, we no longer trust our bodies and …we
    no longer trust life.
  • Roberto Mordacci and Richard Sobel

34
(Some) Factors Influencing Health
Source Institute of Directors
35
Health Ideal
  • A state of complete physical, mental and social
    well-being, and not merely the absence of disease
    or infirmity
  • WHO Preamble to its Constitution, 1946

36
Healthcare Systems
  • The means by which societies provide support for
    citizens to maintain their good health

37
Healthcare Systems Goals (not necessarily
achieved)
  • United States
  • Universal access to high-quality, comprehensive,
  • cost-effective healthcare
  • United Kingdom
  • Comprehensive, high-quality medical care to all
    citizens on a basis of meeting professionally
    judged medical needs and without financial
    barriers to access
  • World Health Organization New Universalism
  • Delivery to all of high-quality essential care,
    defined by criteria of effectiveness, cost, and
    social acceptability

38
Healthcare Systems Criteria
  • Effectiveness - Quality
  • Improving population health
  • Social Acceptability - Responsiveness
  • Responding to peoples expectations
  • (needs and wants)
  • Cost
  • Fair financing of healthcare
  • Providing financial protection against costs of
    ill-health

39
Ideal Healthcare System
  • Enlightened government stewardship
  • Effective public health programs
  • Universal core healthcare program covering most
    healthcare needs (social solidarity)
  • Private sector non-core insurance allowing
    coverage of additional healthcare wants
    (autonomy and negative liberty)
  • Seamless, non-duplicative interface between
    universal core and private non-core programs
  • Adequate healthcare personnel, capital and
    resources
  • Effective process for medical research and
    introduction of appropriate new knowledge and
    technology
  • Adaptive system allowing for continuous
    improvement in effectiveness and efficiency
  • Maintains privacy, dignity, and need to know of
    patients and public

40
Factors Shaping Healthcare Systems
  • Social and family ethics and ethos
  • Medical decision-making ethics
  • Political-economical ideology
  • Political power centers and decision-making
    process
  • Economics (infra)structure
  • Technical capability

Social Solidarity
Personal Autonomy
Patient Autonomy
State Paternalism
Professional Paternalism
Social Democracy
Collective - Socialist
Free Market
Consumer
Providers
Bureaucrats
41
Issues Implementing an Ideal Healthcare System
  • Recognize and satisfy population needs and
    wants
  • Identify, design and implement effective public
    health interventions
  • Create incentives for efficiency and improve
    effectiveness of public healthcare resources
  • Define public program core healthcare needs
  • Psychological services __ Quality of
    life interventions
  • Preventive care __
    Responsiveness
  • End of life treatments __ Marginal
    improvements
  • Technology dissemination __ Sub-acute care
  • Design, implement and manage a rational, seamless
    interface between public core and private
    non-core programs
  • Design, implement and manage public oversight of
    private non-core health insurance programs
  • Rationalize public vs. private resource and
    medical decision making

42
Healthcare Systems Overview
Functions the system performs
Objectives of the system
Stewardship
Responsiveness
Creating resources
Delivering services
HEALTH
Fair financial contribution
Financing
Source World Health Report 2000 (WHO)
43
Healthcare Systems - Challenges
  • Costs continue to increase
  • Drive to optimize operations
  • Consumers demand more for less
  • Balancing act of cost vs. service
  • Regulatory compliance is not optional
  • HIPAA
  • Application suites are outdated and not
    integrated
  • Payers and providers must do more with existing
    infrastructure and applications

44
Overview
Welcome at all times
  • Introduction and motivation
  • Current medical IT systems illustrations
  • The healthcare system concept
  • The healthcare framework
  • Conclusion and summary
  • ?This is the heart of the presentation

45
The Analysis Approach
  • A framework actor producer and/or user of data
    and/or information
  • Identify and classify the actors
  • Repeat to nth level
  • Characterize the informational needs and usage of
    the actors
  • Identify relationships between (sets of) actors
  • A system is associated with or required for the
    information of
  • An actor
  • A relationship
  • The scope and functionality of a system are
    determined by its actors and relationships
  • The approach provides an overview of the
    information and participants
  • Does not specify owners and stewards of
    information or systems
  • Is technology independent

46
Analysis Approach Goals and Caveats
  • For individual systems
  • Sets scope, functionality, information used,
    boundary and interfaces
  • Guides the current and future state of each
    system
  • Provides framework for information, actors, and
    systems sharing
  • Enables multiple systems integration
  • Frames the overall expectations and limitations
    of healthcare IT systems
  • But specific systems specs (and detailed
    informational flows) require analysis to a low
    level
  • ? Beyond the scope of this presentation

47
The Actors an Eagles View
48
The Consumers
49
The Providers
50
The Public
51
The Infrastructure
52
The Combined Framework Context
  • Set of actors and relationships not included
  • Ownership and stewardship not included
  • Physical proximity and locality not included

53
Concept Illustration Physicians Office
  • From the turn of the 20th century to the
    office of the future
  • All actors and relationships vis-à-vis
    physician-patient relations
  • Selected illustration because
  • All know what is a physician office
  • Relative Simplicity
  • Personal interest of (at least) some participants

54
Turn of the 20th Century Office
  • Actors relationship
  • Physician as healer and counselor
  • Extended Patient
  • Patient, family, community
  • Local, long-term summaries information
  • Acute ailments
  • Ambulatory service only
  • All needs
  • Functions
  • Diagnosis, prognosis, treatment
  • Patient records, billing
  • Face-to-face-interaction
  • Record keeping
  • Manual
  • Intuitive

55
Mid 20th Century Office (changes in red)
  • Actors relationship
  • Physician (healer only)
  • Patient (alone)
  • Short-term hospitalization
  • Local, long-term summaries information
  • Acute and chronic ailments
  • Ambulatory service only
  • Physical needs only
  • Functions
  • Diagnosis, prognosis, treatment
  • Patient records, billing
  • Appointments
  • Face-to-face-interaction
  • Record keeping
  • Manual
  • Formal

56
End 20th Century Independent Office I
  • Actors relationship
  • Physician
  • Patient (alone)
  • Nurse
  • Professionals
  • Laboratories
  • Short-term hospitalization
  • Government (supervisor)
  • Local, long-term trends, summaries and medical
    and legal information
  • Acute and chronic ailments
  • Ambulatory and preventive services
  • Physical needs only
  • Educational (CPE)
  • Ignoring Medicare, Medicaid, HMO relationships
  • Functions
  • Prevention, diagnosis, prognosis, treatment,
    follow-up
  • Patient records, billing
  • Appointments
  • Support interaction
  • Office management
  • Face-to-face-interaction
  • Roles
  • Physician healer, monitor, information
    intermediary, decision maker, life-long student
  • Patient monitor, decision maker
  • Emergence of empowered patient
  • Record keeping
  • Electronic, local
  • Formal

57
End 20th Century Independent Office II (new
relationships in red)
58
21st Century Independent Office
  • Same as end of 20th century
  • Major change
  • Remote communications and Internet
  • Genetics and bio-medicine
  • Enables
  • Telemedicine
  • Real-time monitoring and follow-up
  • Maintenance of transient data
  • Home healthcare
  • Minimizing location and proximity issues
  • Physician as counselor
  • (Internet as) information intermediary
  • (Internet as) counseling intermediary
  • Paperless environment
  • Integration of information sources
  • Life-long, family and community data
  • Universal access
  • Change in roles of physician and patient
  • Empowered knowledgeable patient
  • Remote relationships
  • Evidence-based interaction
  • Raises privacy (and security), ethical, and
    social issues
  • Quality new capabilities, levels and control
  • New level of regulatory involvement
  • In effect elimination of the independent office

59
Overview
Welcome at all times
  • Introduction and motivation
  • Current medical IT systems illustrations
  • The healthcare system concept
  • The healthcare framework
  • Conclusion and summary
  • ?My conclusions and expectations
  • ?The use of this approach for an HMO systems

60
The Actors
  • We hardly know all current actors
  • New actors join continuously
  • Partial knowledge of the data and information
    elements produced / used by actors
  • Partial knowledge of the data quality and
    intensity produced / used by actors
  • Partial knowledge of the actors readiness to
    share information

61
The Relationships
  • Do we know all the participants in a
    relationship?
  • Participants interests
  • e.g., turf, privacy, proprietary concerns,
    professional differences, healthcare concept,
    political, institutional…
  • Balancing what are participants ready to give
    vs. what are participants requesting in return
  • Direction and intensity of information flows
    between participants
  • Ownership and stewardship are not defined. Should
    they?

62
Dynamics of Change
  • All elements of the healthcare framework change
    dynamically
  • Change is often unpredictable
  • Technology
  • Scientifically
  • Socially
  • Volume, frequency and quality
  • Rate of change is unpredictable
  • Complexity and scope of systems ? framework at
    start and end of development may be very
    different
  • Implementation of a system changes the framework

63
Expectations and Limitations
  • An integrated, comprehensive system is
    essentially unachievable
  • Local effective systems
  • Importance of interfaces to other (unknown)
    systems
  • Relatively short systems life horizon

64
Do and Dont Do
  • Use an open-ended design strategy
  • Design should allow for future growth and changes
  • Developers are partners for life of the system
  • Minimize reliance on current systems definitions
  • Importance of non-immediate users
  • ?Impacts on system development
  • Overall perspective prior to individual system
    development
  • Technology becomes constraint and enabler only
  • Continuous monitoring and development throughout
    system life
  • In contrast to thrust on maintenance

65
Personal Experience HMO Systems - I
  • Traditional legacy systems organization
  • Lack of information, delay in reporting,
    inefficiencies, dissatisfaction, lost
    opportunities
  • IS manager and key players as owners of
    information and systems
  • Request how to enter the 21st century?

66
Personal Experience HMO Systems - II
  • Initially ignored current systems
  • Concentrated on internal actors
  • Determined for each actor
  • Wishes and dreams
  • Information available, quality, frequency,
    accessibility,….
  • Lacking desired information and its impact
  • Information provided to other within HMO
  • Information provided to outside agencies
  • Main other actors contacted, in what roles,
    information provided and information received

67
Personal Experience HMO Systems - III
  • Used results
  • To map informational framework
  • To identify blocking actors
  • To identify key actors and relationships
  • To identify location and availability of
    information
  • Only then analyzed existing systems
  • What they do
  • How they fit the informational framework
  • What information do they have
  • What information do they have but do not provide
    to needing actors
  • What information are they missing

68
Personal Experience HMO Systems - IV
  • Resulting system strategy
  • Determined required systems
  • Determined priority of implementation and
    schedule
  • Determined technology needs and platform
  • Resulting organizational strategy
  • Structure to match informational framework
  • Stewardship of systems

69
Conclusion Where Are You?
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