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

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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

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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

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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

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Enterprise Healthcare System
Enterprise Intranet
Enterprise Internet
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Computer-Based Patient-Record System
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Healthcare Information System Architecture
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Patients Data Record
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Clinical Data Repository
Lab servers
Interface Engine
DB Servers (LOINC and other coding standards)
App Servers
Web Servers (HTTP)
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Case Mix Roles
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Technology-Enabled Online Connectivity
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Integrated Delivery Network
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Information Delivery Network Environment
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Integrated Delivery Network Governance Structure
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Intensive Care Unit Interactions
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Distributed Intensive Care Unit
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Radiologic Process
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Picture Archiving and Communication System
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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
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Imaging Workstation Application
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VPN Diagram
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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
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Medical Informatics
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Fraud Detection
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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.

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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

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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 !!!

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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

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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

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(Some) Factors Influencing Health
Source Institute of Directors
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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

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Healthcare Systems

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

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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

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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

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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

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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
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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

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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)
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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

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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

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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

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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

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The Actors an Eagles View
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The Consumers
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The Providers
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The Public
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The Infrastructure
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The Combined Framework Context

• Set of actors and relationships not included
• Ownership and stewardship not included
• Physical proximity and locality not included

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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

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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

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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

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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

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End 20th Century Independent Office II (new
relationships in red)
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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

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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

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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

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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

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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

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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

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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

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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

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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

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Conclusion Where Are You?