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Working Group: Health Informatics

Position paper

Slide Show

Healthcare Informatics towards 2020

Øystein Nytrø¹, Arild Faxvaag²

¹Dept. of computer and Information Science, ²Dept. of Neuroscience

nytroe @ idi.ntnu.no, arild.faxvaag @ medisin.ntnu.no

Abstract. This paper discusses the future role of information technology in healthcare. It describes present and future challenges of health care, gives a status with regard to penetration and usefulness of healthcare information systems and presents elements in a strategy for future research and education in the field of healthcare informatics.

1.Background

To describe healthcare informatics in an engineering context, it is convenient to start with the basic phenomena: Diseases induce subjective discomfort and shorten life spans. Medicine as a discipline is at the intersection between three areas:

The natural sciences: Medicine studies diseases as natural phenomena in organisms.

Engineering: Medicine relies on development and use of and diagnostic and therapeutic tools.

Humanities: Medicine must interpret and consider subjective, individual experiences of diseases, treatment and exposure to processes and technology. Medical problems are often closely connected to social and psychological phenomena.

Healthcare is a service provided by health care personnel to patients. Healthcare services can roughly be divided into;

Diagnosing: exploring and classifying problems which might be associated with a disease

Intervening: using medical technology and other remedies in a disease or problem process to reach a more favourable situation.

Nursing: alleviate the needs and discomfort of patients suffering from disease or effects of interventions.

Healthcare is sometimes but not always provided by health care personnel employed in larger health care organisations. Hospital services often involve very specialized, advanced, new or expensive medical technology or coordinated efforts from multidisciplinary teams. Primary care is characterized by a very large scope of diseases and problems, often with emphasis on life-long treatment and chronic diseases. An important part of healthcare is research and education.

In this context, healthcare informatics can be defined as [12]:

“A scientific discipline that concerns itself with the cognitive, information processing and communication tasks of health care practice, education and research, including the information science and technology to support these tasks”

2. Challenges and trends in healthcare

Predicting the future of information technology in healthcare is a challenging task. Many independent trends will influence the future:

reliance on well developed methods for evaluating outcomes of interventions and technology and consequently aggressive marketing of “successful” new and costly medical technology.
little interest in evaluating cost-effectiveness and clinical usefulness of interventions in real life and corresponding discrepancy between cost and usefulness.
increased global discrepancy in healthcare service quality, spending and availability.
a chronic discrepancy between the amount of resources that could be spent on health care and the resources actually used (the consequences of which are most catastrophic in poor countries).
a rapidly growing and increasingly mobile population that may spread diseases (e.g HIV/AIDS, Ebola and SARS) .
lack of will or ability to use well established medical knowledge and cheap, highly cost-effective preventive or curative regimens (for example the use of vaccines, prevention of smoking and the use of condoms to prevent transmission of HIV)
a large increase in the number of elderly people in some developed countries (as a result of the successful prevention of accidents and of wars, progress in medicine and health care, and the successful implementation of technologies and methods for avoiding unwanted pregnancies)
development and global dissipation of cheap information and communication technology and resulting efficient global distribution of knowledge and information within medical communities and between providers and users of health care services.
consumerism, patients seeing themselves as demanding and critical consumers of health care services.
the rapid growth of biomedical knowledge and the emergence of new medical technologies on the basis of this new insight.

3. Present situation of IT in healthcare

Information systems have been introduced into healthcare in fairly distinct phases, motivated primarily by government, financial, legal and management needs (e.g. systems for accounting, patient management, order entry, process planning etc.). Other systems have been introduced as part of tools and technology (e.g. systems for logistics, laboratory, X-ray and other imaging). Coding systems were developed mainly for accounting and research purposes. Clinical department systems are usually developed for the purposes of quality development and research. "Electronic" medical and patient record systems have developed out of plain text editors, with little functionality and structure. In many respects, healthcare has not seen the same computer revolution as most other knowledge-intensive areas of the society.

Healthcare is worthy of special attention from an IT research and education perspective for many reasons:

Healthcare is a major part of our economy, and even small improvements are important [5]:

Healthcare averages 9% og GDP in the OECD countries, and is expected to rise with 3-4% the next 40 years. Private healthcare will increase spending considerably (The US used 13,9 % of GDP for healthcare, half of which was through public programmes only covering about 10% of the population.).

The delivery of health care is an enormously information-intensive activity.

Information handling is a major part of all clinical work. A study at St. Olav hospital found that approximately 25% of total time was used on record, notes and meetings (morning, X-ray). This is more than the time spent with patients [9].

Relevant knowledge is difficult to find, adapt and apply [8]:

One important aim of healthcare is to make clinical decisions on the basis of the best possible knowledge (Evidence-based medicine (EBM)). Systems for efficient and timely delivery of appropriate knowledge remains to be developed. A wealth of abstracted knowledge, electronic publications, internet portals and local procedures are available "point-and-click". Availability is not an issue. The challenge is quick retrieval and adaptation of recommendations and guidelines to a specific healthcare problem. One way of acheiving this is to use the same conceptual organization, structure and terminology for both user interface, computerized record content and knowledge repositories. A part of this solution is to organize information around care and patient processes and pathways.

Current clinical information systems fail to support interdisciplinary work and asynchronous communication between members of a team

Lack of support for asynchronous communication increases the possibility of making mistakes during handling over of responsibilities from one team to another.

Current clinical information systems fail to support the delivery of safe health care.

Medical errors in USA has been estimated to be responsible for 98.000 deaths each year, and the cost of preventable errors estimated to lie between 17 and 29 GUSD per year [8]. Although the literature suggests that Computerized physician order entry (CPOE) have the potential to improve patient outcomes through decrease of adverse drug events, actual improvements in medical outcomes have not been documented. Installation of such systems could actually increase the number of adverse drug events and result in higher overall medical costs, particularly in the first few years of their adoption [11]

Current clinical information systems does not support the development of high quality and efficient health care [6]:

Even with so-called electronic record systems, most Norwegian hospitals are intensely dependent upon paper records, informal communication, meetings, dictation etc. - Because the record systems are inconvenient for entering, finding and presenting information. The most prominent projects to go "electronic" have put huge effort into digital photographic representation of record documents.

Current clinical information systems contains multiple representation of the same information and do not support continuity of care [7]:

Information is entered repeatedly for different purposes and in different systems, leading to inconsistency and waste of time. A recent study shows that as much as 35% of a general practitioners time is spent on reporting information already in the EHR. Information is kept local to service providers and organization, in some cases also local to a ward or department, and is only shared through more or less formal and delayed communication and messaging. The patient, contrary to common belief, is not a reliable source of information about own health history and medication.

Information and knowledge has no value:

Healthcare economy relies on counting procedures, persons, encounters, diagnoses, hours and days. Efficient, correct, available and reliable information is not measured and valued. General practicioners in Norway are almost completely reliant on electronic patient record systems, and this may well be because the user and producer of information is the same person. Thus the information is directly relevant for their own efficiency and service quality. Timely and relevant information should be regarded as an important and valuable asset.

4. Relevant trends

Many events and trends may influence the needs for informatics in healthcare in the future. Some of the more relevant factors within healthcare, society and government, and healthcare informatics are outlined underneath:

Healthcare [1]

Expanding market and increased investment in technology-intensive, expensive healthcare in the rich parts of the world.
Increased risk of pandemic diseases.
Lack of reliable and competent healthcare personnel, medicine, technology and infrastructure in developing countries.
Growing awareness that systematic management, distribution, dissipation and use of knowledge and information is paramount to efficient high-quality care.
A renewed perception of disease as an individual process, and methods integrating subjective and objective parameters.
More information and knowledge may lead to more conditions being treated
A broader and more specialized spectre of conditions will be treatable, and thus increase overall spending.
Increased focus on self-treatment, lifestyle and disease prevention in the rich world.

Government and society

Privatization and individualization of responsibility for healthcare.
Research and technology development focused on areas of high-profit and not on areas of global importance.
Healthcare as coming provider of "life content" in the same arena as entertainment, sports and gaming.
A change in perspective from healthcare as production systems to supporter of the patient and disease processes.
Much more service-aware and knowledgeable public.
The age distribution, and growing percentage of elderly, will increase the need for both long-term and labour-intensive healthcare.

Healthcare informatics

Focus on patient involvement and control.
Focus on the needs of the healthcare professional.
Global, shared, replicated, information spaces and storage with easily managed distributed access control.
New methods for analyzing and combining information in healthcare records and biodata.
Methods for making information, computerized support and knowledge relevant and usable for the real users, namely patients and healthcare personnel.
Progress in representing, analysing and using relevant knowledge.
"Knowledge-based" record systems and renewed interest in integrated decision support.
Ubiquitous computing for both healthcare personnel and patient.

5. Challenges

The challenge for future healthcare informatics is to enable the healthcare services and professionals to ask the relevant questions. So far, the answer has not been clinical information systems, but infrastructure, computers, web portals and information systems as part of equipment. The nucleus of a safe, effective, patient-centred, timely, efficient and equitable healthcare service is the patient and care professional. Software engineers must in turn be able to answer future questions from the patient and the care professional about the functionality and effect of their systems. The development of new and exciting information technology should be driven by such questions, and not by ability and profitability alone. Some relevant questions (and examples) that may be asked with respect to current and future systems are [4]:

1. For what purpose and whom was the system designed? (Are electronic procedure-books efficient during patient encounters? Do their increase compliance? Do they increase the patients experienced quality of care? )

2. Does the system work as designed? (Are the alerts and reminders generated for a specific patient correct and "of use" to the clinician?)

3. What is the impact of various system enhancements or modifications? (Does the new patient summary display screen help clinicians quickly understand the patient's past medical conditions and treatment and allow more meaningful discussion of the current reason for the visit?)

4. Is the system used as anticipated?
After implementation of a physician order entry (POE) system, the percentage of orders entered by physicians could be examined.

5. Does the system produce the desired results?
Does the new POE system actually reduce occurrence of adverse drug events?

6. Does the system work better than the procedures it replaced? How and why?
Does the new clinical laboratory alerting system reduce the time patients spend in a critically abnormal physiologic state compared with the previous telephone notification system?

7. Is the system cost-effective?
Does the increased time clinicians spend entering data during the patient visit lead to efficiency or improvement in quality within the overall health care system and thus justify its continued use of this practice?

8. How well have individuals been trained to use the system?
What percentage of clinicians can successfully perform a series of tasks required to manage a simulated patient encounter?

9. What is the anticipated long-term impact on how departments and organizations interact?
When routine drug/drug-interaction checking is moved out of the pharmacy and onto the clinician's desktop machine, what is the impact on the pharmacy department's morale and productivity? Will the general practitioner and hospital avoid all inconsistent medication?

10. What are the long-term effects on the delivery of medical care?
Does provision of regular health maintenance reminders to clinicians at the point of care improve the long-term health outcomes of chronically ill patients?

11. Will the system have an impact on management of healthcare?
Does incorporation of real-time reminders about the current drug formulary decrease variability in prescribing behavior and thus reduce costs of managing the organization?

12. To what extent does impact depend on the practice setting?
Can the same data entry and review screens be used by both primary care and specialty care clinicians?

13. Does the increasing complexity of modern medicine and the CIS required to implement it help or hinder clinicians and their patients? And how does use of the CIS affect the patient-provider relationship?

6. IME, the future and healthcare informatics

With an IT-perspective, the need of healthcare seems endless. Superficially, even the most obvious problems such as common conceptual models, information sharing, access control, a modular service-wide software architecture and good user interfaces have not been properly addressed. Looking closer, healthcare unfolds as the ultimate challenge for all areas of research and education within information technology. Areas like software engineering, artificial intelligence, mobile computing, user interfaces, information retrieval, data and information storage, system and software architecture and computer-supported cooperative work will have to cope with intertwined problems of a new order of magnitude in both complexity and size. Solving problems for healthcare is justified both by its importance to society, and also the catalytic effect it will have on all areas of our discipline.

R. Haux & al. in "Health care in the information society. A prognosis for the year 2013" [3] writes::

The three main goals:

patient-centered recording and use of medical data for cooperative care,
process-integrated decision support through current medical knowledge,
comprehensive use of patient data for research and health care reporting

... The research environment can expect various topics to remain of utter importance:

Structuring and testing comprehensive electronic patient records, which support the casuistic use of patient data for direct patient care, and which allow patient group analyses and use of data for research and reporting.
Conception and testing of suitable information system architectures that support cooperative, patient-centered and cross-institutional care.
Conception and testing of system architectures for `knowledge centers' offering specialized medical knowledge world-wide via the Internet.
Conception and testing of methods for medical data analysis (`medical data mining') based on modern information system architectures and electronic patient records and aimed at clinical and epidemiological research, as well as health reporting.
Integration and testing of comprehensive, practical, useful and mobile ICT tools for patient care.

Successful research in these areas, and the successful implementation of the frameworks mentioned, will set patient care and medical research on new, future-oriented foundation and will help strengthen financial developments. The term `information society' would then, most probably, apply to health care.

In summary, healthcare can be envisioned as a major driving force and justification for research and education in most disciplines of informatics. So far, healthcare informatics has had comparably little impact. Healthcare is a very knowledge- and information-intensive arena, and the sheer size, complexity and importance of the information that drives healthcare has prevented development of information systems that can actually improve efficiency and quality for healthcare personnel and patients. The people that produces and uses the information is stuck with partial and disintegrating information systems and communication solutions.

Healthcare professionals, and patients, are realizing that a major part of healthcare is producing, using and managing information. The shared information and knowledge must be organized around the patient and the disease, and must be made available through user-specific system interfaces, with functionality, relevance and perspective suiting the role, situation and need of the different users.

A major factor for enabling an efficient, effective, safe, patient-centered, cost effective and high-quality healthcare through informatics is by establishing and maintaining an arena between healthcare professionals and technology developers: This requires close cooperation around multidisciplinary research projects and not least mutual and shared knowledge about problems and solutions, objectives and limitations.

References

1. The world health report - shaping the future