Standards used by Quality Oversight Organizations (see Chapter 9) for health care organizations should address health care information systems, including the automation of clinical information, improvement of data quality, and participation in regional and/or national health information networks.
National standards for the structure, content, definition, and coding of health information should be established to support improvements in information systems. The Federal Government should consult with public and private stakeholders to assess what additional standards may be necessary to support such improvements. Whenever possible, this effort should encourage the widespread adoption of existing standards and build on the work of existing public and private entities rather than creating additional layers of oversight. The need also exists to consider standards as they are developing in the international marketplace to facilitate the global exchange of medical and health care information and to drive the development of international standards.
Solo practitioners in rural areas, small group practices, and some safety net providers may face significant financial barriers to making necessary investments in information systems. This is an area where government action (e.g., subsidies, purchasing cooperatives, tax credits) may be needed, although the specific form of such action may well vary between localities.
Private and public health care organizations should protect the confidentiality of individually identifiable health care information by implementing comprehensive security programs that include employee training, security audits, and well-defined policies regarding access to different types of information.
The training of health care professionals should include the use of information technology in clinical settings. Graduates of professional schools should be experienced in the use of automated patient records and computerized decision-support tools. Education programs for paraprofessionals and other health care workers should also incorporate training in the use of information technology. There is a need for continuing education programs to train the existing health care workforce in the use of these systems.
The health care industry and the public sector should provide support to demonstration projects that can support information system improvement and create links between various sources of health care information at both the local and national levels. The success of community health information networks in California, Wisconsin, Utah, and other States suggests that this is a fertile area for additional research and action. Care needs to be taken to model success factors of community health information networks because there have also been numerous failures.
Consumers, group purchasers, policymakers, and others need information on health care quality and the individual and relative performance of health plans, facilities and systems of care, and individual practitioners. Such information is critical to support market-based efforts to improve quality (see Chapter 6 and Chapter 7). In many cases, however, much of the information needed to make risk-adjusted assessments of performance is scattered in dozens of different places in both computer and paper records, making it difficult to aggregate. Creating valid performance measurements will also require data that have not been routinely collected for patient care or payment purposes, such as information on the experiences and perspectives of patients and health care professionals; clinically detailed data of the type needed to measure quality for chronic care; and information on health care outcomes, including functional status.
While existing information systems increasingly are designed to provide the kind of quantitative information that can guide quality improvement activities, more is needed. While report cards and other quality measurement tools can provide guidance to consumers and group purchasers, as well as setting industry benchmarks, they do not give the reporting organization a great deal of guidance on how to improve their performance. Berwick and colleagues (1990) have noted that while health care organizations collect a significant amount of information in the course of their daily activities, only rarely is this information brought together in a way that can shed light on how variations in the process of care affect outcomes. This kind of information needs to be recorded, stored, and made available to frontline staff if unintended variation is to be identified and controlled.
As the body of health care knowledge continues to increase (see Chapter 1 and Chapter 11), information systems are also being called on to provide practitioners with tools to manage this flood of new information. A number of health care organizations have experimented with computerized decision-support systems that can assist practitioners by issuing reminders, offering a menu of options, or providing links to relevant journal articles. Such decision-support systems are important tools in moving toward evidence-based practice and can enhance the ability of the health care system to encourage the adoption of care techniques of demonstrated effectiveness. A study by Safran and colleagues (1996), for example, found that clinicians who receive computerized alerts and reminders tend to respond much faster to changes in their patient's condition. Studies of computerized decision support for nursing practice have found that such programs can improve nursing care in a range of areas, such as the care of incontinent patients and prenatal care (Petrucci et al., 1992; Marin et al., 1994).
Improvements in information systems also are needed to support the coordination of care. Health professionals and providers need access to a patient's treatment history, test results, and related information if they are to provide effective care. Putting all this information together is increasingly difficult as health care delivery systems become more complex and involve multiple organizations. In most cases, the patient records these organizations maintain are paper records that cannot be easily transferred between organizations. Even in cases where computer records are kept, the use of different hardware and software configurations makes file sharing difficult.
Improved information systems must also be able to generate population-level data that can assess the performance of the health system in caring for discrete populations as well as serving as a tool for researchers seeking to assess the long-term effectiveness of interventions. Public health officials also perceive the benefit of this kind of databases, which would allow them to improve the monitoring of disease outbreaks or the adverse effects of medications, procedures, or other products. Most existing information systems are not designed for these purposes. Patient identifiers vary between different health plans and sometimes even between different providers within a plan. In many cases, plans and providers are unable to determine how many patients with a given disease or condition they are treating, making it difficult to do population-level analysis. Even when technical barriers can be overcome, some health care organizations fear that sharing data may lead to the loss of competitive advantage in a highly uncertain market climate.
The health care industry is on the threshold of change. Consumers and group purchasers are beginning to set higher expectations for health plans, providers, pharmacies, and others. To manage and account for resources and outcomes, health care organizations require information systems that can provide timely data on actual versus expected expenditures, utilization, and clinical outcomes. To keep pace with state-of-the-art developments in telemedicine, operating room systems, disease management systems, and other areas, increasingly sophisticated information system capabilities are required and must rely on "real-time" data.
There is a critical need for substantial investments in information systems, and some health care organizations are already confronting this challenge. Fallon Health Plan in Worcester, Massachusetts, and Allina in Minneapolis, Minnesota, are earmarking $50 million to $100 million annually in capital and operating expenditures over the next 10 years. Kaiser Permanente Northern California region is projecting that it will invest $1.2 billion in clinical information systems over the next 5 years (Council on Competitiveness, 1996).
Health care organizations expect that these investments will yield significant returns over the long run. Kaiser estimates that it will break even on its investment in 6.5 years, with a 200 percent benefit payback on investment achieved in 10 years (Council on Competitiveness, 1996). Holy Cross Health System, based in South Bend, Indiana, found that data generated from its information system allowed it to save $4.5 million in one of its markets by eliminating unnecessary variation in the resources used for 36 common procedures (Appleby, 1997).
The weight of the evidence, however, is that, compared with other information-intensive industries, the health care industry has underinvested in information technology. The 1997 Healthcare Information and Management Systems Society (HIMSS) Hewlett-Packard Leadership Survey, for example, found that 58 percent of surveyed health care organizations were spending less than 4 percent of their budget on information technology, and only 11 percent were spending 5 percent or more. The financial industry, by contrast, spent about 7.5 percent of its revenue on information technology, and the banking industry about 5 percent (Council on Competitiveness, 1996). Because the HIMSS survey sample is weighted toward larger hospitals and health systems, it may in fact overrepresent the true level of investment in the industry as a whole. This is a very large differential -- a conservative differential of 5 percent for an $8 billion company equals a difference of $400 million. Taken globally and compounded for all health care organizations, this amounts to a huge underinvestment in an industry plagued by decentralized processing and lack of standardization.
There are signs that this situation may change. The 1997 HIMSS survey also revealed that 51 percent of the surveyed organizations planned to increase their information technology budgets by 20 percent or more over the next 2 years, with 15 percent of the organizations planning increases of more than 50 percent. A survey of 231 chief information officers (CIOs) by the College of Healthcare Information Management Executives (1997) found that 1996 information technology budgets were up nearly 30 percent above 1995 levels, an average of $2 million per facility.
Part of the reason for this change is that health care organizations recognize the substantial benefits of high-quality information systems. Public programs, group purchasers, and health plans increasingly are choosing to contract with organizations that can prove they can hold the line on costs while improving quality and ensuring access to appropriate care.
At the same time, many health care organizations still will face significant financial barriers to increasing their investment. Large organizations may have sufficient purchasing leverage to acquire and adopt computerized systems, but smaller organizations often lack access to capital and feel increasingly financially constrained. This may be a particular problem for safety net providers serving vulnerable populations, solo practitioners, and providers in rural areas. Colorado's Medicaid program tried to address this problem by supplying computers and software at no cost to providers who needed them in order to participate in a mandatory electronic claims processing system. Many European nations offer substantial subsidies to providers, especially smaller providers, to encourage them to automate clinical information (IOM, 1997).
One step that could be taken is for purchasers of health care services to insist that providers and plans be able to demonstrate that the care they provide is of high quality. Given the widespread variation in the quality of care that currently exists, there is no reason for purchasers to take assertions of quality at face value. A decision by the purchasing community to demand quantitative evidence of quality would be one effective device to encourage investment in information systems.
Another barrier to investment in improved information systems is the cost associated with fixing the so-called Year 2000 problem. Many existing computer systems use only two digits, rather than four, to record the year. Unless this problem is fixed, many computer experts predict widespread chaos in the Nation's computer systems. This problem is consuming the attention of CIOs in the health care sector, and many are devoting significant resources toward solving the problem -- resources that will therefore be unavailable for investment in other information system improvements. Perhaps even more disturbing, however, is that many smaller organizations have not yet begun Year 2000 planning and may even be unaware of how vulnerable their current systems are.
Unfortunately, health care data often suffer from a variety of quality problems. Existing information systems, designed primarily for billing purposes, often fail to record important information about a patient's condition. A study by Jollis and colleagues (1993) that compared claims and patient records found that claims did not accurately reflect over half of the clinically important patient conditions.
Even when information system software allows for the entry of additional information, that information often is incorrectly entered. The National Committee for Quality Assurance's audits comparing reported performance data with patient records have uncovered average error rates as high as 20 percent. These audits have uncovered a number of data quality problems, including missing encounter data, homegrown codes, incorrect software, missing information in patient records, and inaccessibility of mental health records (NCQA, 1997).
Recent research suggests that automation can be used as a tool to improve data quality. A study by Hohnloser and colleagues (1996) tested the use of a computer program that allowed users to quickly browse and select diagnosis codes. While clinicians coding manually left half of diagnoses uncoded, the rate for clinicians using the utility program was significantly higher. A study by Rossi and colleagues (1993) found that automatic coding of patient-record statistical cards in a university hospital virtually eliminated coding errors.
The HL7 standards organization has undertaken a project to define the authentication and verification facilities needed to ensure the accuracy, consistency, and completeness of quality measurement data within health care organizations. These facilities will cover the entire sequence of processes through which the data pass from their primary point of collection, through all intermediate processing steps, and the electronic transmission of the information to external quality monitoring. Because HL7 standards are widely used in the health care industry, this initiative could make a significant contribution to improving data quality.
Not every solution to the data quality problem needs to be high-tech, however. In 1991, Harvard Community Health Plan (HCHP) in Boston, Massachusetts initiated discussions with its affiliated hospitals about problems in data quality. HCHP had noted that there were discrepancies between claims data submitted by physicians and hospitals for the same patients, especially for obstetrics cases and individuals admitted to the hospital through the emergency room. In general, HCHP has found that merely making hospital administrators aware of these problems can lead to substantial improvements in data quality. HCHP also has changed its reimbursement policies, both to create incentives for accurate data and to remove disincentives (Coltin, 1998).
A number of steps can be taken to improve data quality. Plans and providers should build data quality into the primary point of collection. Computer systems should include automated edits that prevent errors and procedures for segregating records that are incomplete or have errors to prevent them from entering the system. Public programs, such as Medicare, and private health plans should incorporate incentives for data quality into provider reimbursement rates. Plans and providers should also consider making data quality a key aim for improvement.
Other actors in the health care system also can support measures to improve data quality. Group purchasers should incorporate incentives for data quality into their contracts with health plans. Quality oversight organizations also can make data quality a key element of their accreditation and oversight activities.
While health care organizations have access to an ever-increasing number of information technology products, linkage remains a serious problem. A single health provider, such as a hospital, may need to link separate databases that handle admitting, laboratory services, and pharmacy services. An integrated delivery system may need to link data from various health service sites, including hospitals, practitioner offices and clinics, nursing facilities, and home health agencies. Health plans may need to link data from the different providers and delivery systems under contract to the plan. Finally, a more global view of linkage envisions regional or even national information systems that can link data from many different health plans and providers to public health databases and other sources of information. Ideally, consumers also would be able to access this information, which would improve their ability to manage their own health.
Regardless of how ambitious the goal, linkage is not easy. Health care programs, plans, and providers, both public and private, may use different software packages for different requirements (e.g., claims processing, utilization management, and provider credentialing). Providers may serve many different programs and plans and may not wish to adopt a single program's or plan's hardware or software configuration. The lack of comprehensive national standards for health information makes it harder for the various actors in the system to agree on a common format for data. The experience of initiatives to create regional networks, such as the Community Health Management Information System (CHMIS) programs of the early 1990s, suggest that bringing all of the relevant stakeholders together can be a daunting task (Starr, 1997).
Despite these barriers, there have been a number of attempts to establish regional networks that would link various sources of health information. In 1993, for example, the Aurora Health System and Ameritech founded the Wisconsin Health Information Network, linking 16 hospitals (representing nearly 40 percent of the beds in the Milwaukee area), 8 clinics, 3 nursing homes, 7 insurers, 4 billing services, and more than 1,300 physicians. Besides transmitting claims and other administrative data, the system enables physicians connecting by modem to check on the status of patients at local hospitals and obtain laboratory results. Similar networks exist in Utah and California (Starr, 1997). A number of hospitals and health systems also are exploiting the new technology of the World Wide Web to develop networks that can link sources of information that use different data formats (IOM, 1997; Kohane et al., 1996; van Wingerde, 1996).
Continued progress in establishing health networks will depend on certain actions, including the establishment of information standards, protection of the confidentiality of health information, and computerization of patient records. Creating an environment that rewards providers, plans, and other entities for undertaking the burden of creating health information networks will be critical. Group purchasers can make participation in such networks a component of their value-based purchasing strategy. Quality oversight organizations may want to make a plan's or provider's ability to participate in health information networks a component of their accreditation and oversight activities.
The emergence of the Internet as an enabling technology for industry-specific, community-wide electronic commerce has been a significant development. The Internet is stimulated by standards. It creates and persuades compliance to a plethora of standards. International Data Corporation recently projected tremendous growth in electronic commerce, increasing from $2.6 billion in 1996 to $200 billion in 2001. Electronic commerce may be the panacea for an inherently decentralized health care industry, allowing it to communicate securely and cost-effectively with its partners.
Many current information systems lack sufficient controls to guarantee the confidentiality of individuals' health information. Not all systems have the capacity to restrict a user from accessing specific records or specific data types within an application, such as claims or authorizations. Transaction logs may not track the user who viewed or updated a record, making it impossible to identify confidentiality breeches. Many health care organizations, both public and private, lack a comprehensive security program that includes employee training, security audits, and well-defined policies and procedures.
Licensure and accreditation standards for health care facilities, insurers, health plans, and other health care organizations and providers generally require the accredited organization to have procedures in place for protecting the confidentiality of patient information, although these standards usually do not call for particular protocols to be used. There may be a need for Federal and State governments, licensing bodies, and accreditation organizations to strengthen their standards in this area.
The nature of organizational relationships in the current health system also may create some disincentives for investment in information systems. Most hospitals and practitioners have contracts with multiple health plans. Adopting the reporting standards and protocols for any single plan could complicate relations with others. While hospitals, practice groups, and other providers are entering into "integrated" relationships, such integration often is very loose (see Chapter 2). Rarely does such integration provide a basis for integrating information systems.
A related problem is that existing coding schemes are not sufficiently rich to provide the level of clinical precision needed for quality measurement. A recent study that applied four existing coding schemes (ICD-9, ICD-10, CPT, SNOMED) to textual data obtained from patient records found that "the major clinical classifications in use today incompletely cover the clinical content of patient records; thus analytical conclusions that depend on these systems may be suspect" (Chute et al., 1996).
An important recent advance in this area was the passage of HIPAA. Under this law, the U.S. Secretary of Health and Human Services (HHS) is charged with establishing standards for a broad range of health information, including health insurance claims and encounters; health insurance enrollment and eligibility; health identifiers for providers, health plans, employers, and individuals; code sets and classification systems; security standards and safeguards; and information. The law will be implemented over the next few years (Department of Health and Human Services, 1997).
HIPAA gives an important role to the National Committee for Vital and Health Statistics (NCVHS), HHS's public advisory committee in health data, standards, privacy, and health information policy. In establishing standards, the Secretary is required to rely on NCVHS's recommendations. NCVHS will draw on the work of existing ANSI-accredited, standard-setting bodies and is likely to recommend universal adoption of industry standards already in wide use. NCVHS also will monitor implementation of the standards, reporting annually to Congress (Department of Health and Human Services, 1997).
While the HIPAA standards will greatly facilitate financial transactions between individuals and organizations in the health care system, they only scratch the surface of what is needed to build health care information systems that will allow the industry to understand and improve the organization and delivery of health care at both the individual and population levels. In 1997, the Institute of Medicine took the unusual step of releasing a revised edition of its 1991 report, The Computer-Based Patient Record. In a new preface, Paul Tang and Ed Hammond, past chairs of the Computer-Based Patient Record Institute, wrote:
While Federal leadership remains necessary, an effective standard-setting process must involve the wide range of public and private stakeholders in this issue. As part of its implementation of the standards called for under HIPAA, the Federal Government must consult with public and private stakeholders to assess what additional standards may be necessary. To the extent possible, this effort should build on the work of existing public and private entities, including ANSI-accredited standard-setting organizations, rather than creating another layer of oversight.
Systems Must Support the Efforts of Health Professionals To Improve Quality
The concerns of health professionals about the expanded use of information technology in clinical settings must be addressed if that technology is to be a useful tool for health professionals seeking to improve the quality of care. Some of these concerns are common to all users of information systems, such as the need for adequate training and technical support. Others arise out of the fear that improved information systems may be used as a tool of judgment rather than learning or that such systems will be used to limit professional autonomy inappropriately.
Improved information systems will greatly enhance the capability to report and track errors and other problems with care, a critical first step to improving the health system's performance. If, however, this information is primarily used to identify "poor performers" rather than to guide improvement efforts, health professionals may come to view the system with suspicion. The experience of other industries that have tried to reduce error and improve quality is that a "blame-free" environment must be created to encourage the reporting of problems. Unless organizations can create such an environment, they are likely to find that increasing their investments in information technology is not likely to yield significant returns (see also Chapter 12).
The concerns of health professionals also have played a role in the relatively slow diffusion of computerized patient records. While many observers have enumerated the failings of paper records, such records may have a number of positive features from the perspective of clinicians, including familiarity, portability, and considerable flexibility in recording data (IOM, 1997). Only recently has the computer interface approached the ease of using pencil and paper. Where supporters of automation see great potential in using computer-generated "reminders" to prompt clinicians to ask patients certain questions or run particular tests, some clinicians may see this as "cookbook medicine" that limits their professional autonomy (Dowling, 1987).
On the other hand, the experience of hospitals and other providers that have experimented with computerized decision-support systems is that, if well designed, such systems can overcome these cultural barriers, win the strong support of the health professionals who use them, and significantly improve the quality of care. Evans and colleagues (1994) evaluated a computerized antibiotic "consultant" to assist physicians in the selection of appropriate antibiotics. Physicians who used the computer consultant suggested an antibiotic to which all isolated pathogens were susceptible 94 percent of the time, compared with 77 percent of the physicians who did not employ the consultant. The use of the consultant also decreased the elapsed time between the collection of culture specimens and the ordering of the antibiotics. Moreover, 88 percent of the physicians who used the consultant stated that they would recommend the program to other physicians, 85 percent said the program improved their antibiotic selection, and 81 percent said they felt use of the program improved patient care.
While dialog between clinicians and administrators will play a critical role in addressing many of these concerns, changes in the education and training of health care professionals also will be critical. The educational experience of health care professionals can shape attitudes toward, and provide the skills for, using health care information systems. For example, the Association of American Medical Colleges' Medical Schools Objectives Project has identified "the ability to retrieve (from electronic databases and other resources), manage and utilize biomedical information" as a key skill that medical students should possess at the time of graduation (AAMC, 1997). A number of medical schools have established courses in evidence-based medicine that train students to evaluate the increasing volume of medical literature (Tierney, 1996). Nursing colleges are increasingly including informatics and the use of information technology into the nursing curriculum, especially at the master's and Ph.D. levels.
Another key concern of many health professionals and providers is the financial burden of collecting the information that is being sought by consumers, group purchasers, health plans, accreditation agencies, and others. While the collection of information is necessary to assess performance and guide improvement, there is a need to be mindful of the financial burden involved (see Chapter 4).
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