Health Information Management

Integrating Information and Communication Technology in Health Care Work

Marc Berg

• Publisher: Routledge
• Year: 2003
• eBook ISBN: 9781134377190
• Topic: Business
• Subtopic: Business General
• Index: Business

In almost all Western countries, concerted efforts are made to stimulate the use of information and communication technology (ICT) in health care. Yet the number of success stories are few and the frustrations many. In this key textbook, readers are introduced to the challenges, the lessons learned and the new insights of health information managem

Chapter 1

Introduction

In all Western countries, concerted efforts are undertaken to enhance the use of Information Technology (IT) in health care. National, regional and institutional projects abound to bring the shared Electronic Patient Record (EPR) into being, and to support the care process with order communication and decision support techniques. IT, it is hoped, can help reduce medical errors and increase the quality of health care delivery through optimizing communication. Likewise, extensive use of Internet technologies and electronic patient records could enhance the position of the patient (provide him/her with relevant medical information and access to their own records). Simultaneously, it could provide governments, payers and patient organizations with comparable information on the performance of individual professionals and organizations.

Yet there are only a few real success stories in health care IT, and the frustrations are many. It has become clear that the design and introduction of IT in the health care sector is a complex endeavour, encompassing the simultaneous management of technological innovation and organizational change. This book will introduce the reader to the challenges, lessons learned and new insights of Health Information Management at the beginning of the twenty-first century. It focuses on some of the theoretical reasons why introducing health care IT appears to be ‘a more complex task than putting a man on the moon’ (Collen, 1995:353). Simultaneously, it attempts to provide the reader with concrete insights and lessons on how to handle these complex issues more successfully.

FOR WHOM IS THIS BOOK?

The book focuses on the development and implementation of health care IT, on making a health care IT strategy and on evaluating health care IT as part and parcel of these undertakings. Importantly, this is not a technical volume, but a text focused on the organizational processes and management of design, implementation and evaluation of such systems. Health Information Management, in our view, is the job of handling the information requirements of a health care organization. In the past century, ‘health information management’ was often a term reserved for those making and archiving the paper medical records of an institution. A book on ‘health information management’ would have been a rather specialized endeavour, focusing on how to make forms, how to archive records, the legal responsibilities of record keepers, and so forth. Not the reading material physicians or general managers would dive into.

At the beginning of the twenty-first century, however, the field of ‘health information management’ has fundamentally changed. Only 20 years ago, ‘the information systems department’ was usually a small organizational unit, part of the Finance Department, whose organizational ‘niche’ position reflected the limited strategic importance of information systems, and their small impact on the organization. Nowadays, however, ‘information management’ has become of much more strategic importance to the organization, with ‘information managers’ at work within many different departments, and a ‘Chief Information Officer’ (however labelled) who reports directly to or is often even part of the Board of Directors.

This migration ‘upwards’ and diffusion through the organizational chart is no mere fashion or management hype. Health care organizations are informationintensive industries, with at least three different types of ‘information’ that are of core importance to a professional organization such as a hospital or GP practice:

1. information about individual patients (gathered in the ‘patient record’);
2. aggregate information about the processes and outcomes of the organization (‘management’ information, which can also be for the professionals themselves to help them monitor and improve their current performance);
3. information about diagnostic and therapeutic decisions and procedures (the professional and organizational ‘knowledge’ required to handle patients optimally, often embedded in guidelines or protocols).

The Patient Care Information System (PCIS; see below) is where all these different forms of information are required and/or are generated. It is the core node in the information network of a health care organization, and, as such, of core importance to health information management.

Currently, then, health information management deals first and foremost with the challenge of integrating health information systems in health care work in such a way that the quality of that work is improved. This sounds obvious, but, as this book will show, it is not. Health information management is about the complex task of handling technical innovation simultaneously with organizational transformation. Yielding strategic benefits from PCIS, it will become clear, requires vision and basic information management knowledge for every manager or professional whose responsibilities include the (re-)organization of health care work or the generation or utilization of management information from that work. This, indeed, includes many people—but in current information-intensive organizations such as health care institutions, IT does affect many people.

This book, then, is of importance to both the (future) health information manager, and to those professionals and general managers whose responsibilities touch upon the deployment of IT in the organization—whether at the strategic or the implementation level.

A READER’S GUIDE

This book focuses on what we call ‘Patient Care Information Systems’ (PCIS): all those systems that are used primarily by health care professionals and patients, and that are primarily oriented at the support of their tasks (such as electronic patient records, order communication systems, patient cards, patient information systems). Systems that bridge the primary care process and secondary work processes in health care organizations, such as management information systems and registration systems for scientific research are included. Systems that primarily focus on financial administration, human resource management and so forth are not addressed here.

This is not an ordinary handbook. Significant parts of this book are not written in the form of ‘how to’ manuals, but are aimed at providing an understanding of the tasks of information management; of the organizational processes and management of design, implementation and evaluation of PCISs. Subsequently, these and other chapters also give concrete guidelines for (information) managers and professionals to handle these tasks.

We argue, maybe a bit counter-intuitively, that those readers whose responsibilities are not primarily oriented towards information management concentrate first and foremost on the more conceptual chapters. A core insight of this book is that many PCIS projects run to the ground because of wrong expectations of what these technologies can do (at the level of the workfloor and for the organization), and how their implementation should be managed. The book touches upon the familiar high hopes and dreams surrounding information technology, and the frustrations of professionals when these high hopes cannot be realized instantly (‘my nephew can do this in one evening!’). Since the conceptual chapters are full with concrete examples and are directly oriented towards the real-life issues that managers and professionals face in their daily, information-intensive work, these chapters (concentrated in Part I of this book) are not ‘difficult’ or ‘dry’.

Part I, then, ‘Understanding health care work and the role of IT’ attempts to underscore the strategic importance of IT, the nature of IT and its development, and the nature of health care work. It will push the reader to understand the phenomenal challenges of creating true synergy between health care work practices and PCIS systems. Simultaneously, it will set high stakes for the ambitions that can and will have to be pursued in twenty-first century health care.

Chapter 2 focuses on the nature of information technology innovation. Through a historical account of the paper-based patient-centred record, and the subsequent quest for its electronic sequel, the entanglement of information technology, information management and its social and organizational context is emphasized.

Subsequently, Chapters 3 and 4 deal with the nature of health care work and of health care information, and with the way PCIS systems can transform this work. This transformation, we will argue, can easily be a negative development: systems abound that truly ‘interfere’ with work rather than support it. Only through a thorough understanding of the nature of health care work and information can systems be developed and implemented that can help this work become more patient-oriented, more effective, more efficient, and more professional-oriented.

This last sentence, we will argue in Chapter 5, is no mere slogan. Western health care is in dire need for means to cross the ‘Quality Chasm’, as it has been labelled by recent, widely embraced reports from the US Institute of Medicine (Committee on Quality of Health Care in America, 2001). Information technology, we will argue in Chapter 5, is a sine qua non in the effort to transform health care work so that it can hope to meet the challenges facing it. Crucially, however, IT will not be able to fulfil this role in the form of yet the next IT ‘hype’. It is not more intelligent technology that we need: it is intelligent use of already existing technologies. As will become abundantly clear in this chapter and others, properly developing and implementing IT in health care practices is primarily about organizational development. Technology is crucial— but secondary.

In Chapter 6, this latter theme is picked up again in a discussion about the proper position of Information Technology in the interaction space for humans in complex organizations such as hospitals. This chapter challenges us to see even the design of systems as a shift from a focus on the technology to the people that are using it. Only in that way, the chapter argues, can information systems become truly useful.

In Part II, ‘Information strategy, implementation and evaluation’, we will build upon these insights and discuss some of the information management tasks. Here, we will dive deeper into the topics of IT strategy development, PCIS implementation and PCIS evaluation. More than in Part I, the emphasis is directed towards providing practical guidelines for the health information manager.

Chapter 7 discusses the challenges of information strategy development. It discusses the very nature of strategy and strategy formation, and it focuses on the alignment between the information strategy and the organizational strategy. The complexity of both information technology and health care organizations, the chapter argues, makes the attempt to align their mutual development a sheer impossible—yet crucial! —challenge.

Chapter 8, subsequently, sets out to give the reader some concrete instruments with which he/she can manage this process. It discusses the goals of the information strategy, gives guidelines to how it should be drafted, and, more importantly, what it should contain. These instruments do not solve the complexity, nor do they constitute a simple roadmap towards success. Yet they are the tools that health information managers—and health care organizations— can draw upon to maintain on course. They are a means to ensure that the strategy development process is seen as the vital process that it is, and to ensure that it remains focused on the tough questions that any ambitious IT strategy will certainly bring along.

Chapter 9 then turns towards the issue of the implementation of a PCIS. Arguing for the strong intertwinement of IT and work practice, it restates the point that PCIS implementation is a form of organizational development, and argues how this has consequences for the management of any PCIS implementation project. As Chapter 7, this chapter demonstrates the complexity of such projects, and argues for a knife-edge balance between intense, bottom-up user-participation and strong visionary management, and between controlling the development process and letting go of control.

Chapter 10, then, mirroring Chapter 8, brings the tools that make it feasible to run projects without the ‘control’ criticized in Chapter 9, and to have projects be both user-driven and management-led. Again, this is no magical recipe, but a set of decision points and steps that, when well handled, sets some of the conditions in place for a ‘successful’ IT implementation.

Chapter 11, finally, discusses the need for PCIS evaluation. Starting with a sketch of the PCIS evaluation field, it focuses on the so-called formative evaluations that should be part and parcel of any PCIS development. A formative evaluation, this chapter argues, is a necessary building block of successful IT development and use: only in this way can the mutual learning potential between ‘work practice’ and ‘PCIS’ be fully drawn upon. Although often omitted because of its seemingly supplementary costs, proper formative evaluation ultimately always pays itself back —and often saves the organization for expensive mistakes. The chapter outlines the different domains that a formative evaluation can focus on, and discusses the reallife steps of setting up and performing such an evaluation.

This book has a strong international orientation, comparing related developments and drawing on examples from different countries. It is an ideal handbook for Masters students, other postgraduate trainees, interested professionals and general managers, and will equally provide experienced information managers with an up to date overview of the latest developments in their area. The book will draw heavily on case descriptions and examples (in Case Study Boxes) to illustrate and enrich the main text, but also to enhance their usability for teaching purposes. Every chapter starts with a list of ‘key points’ and ‘key terms’ of the chapter, and ends with ‘discussion questions’ and suggestions for ‘further reading’.

A NOTE ON PATIENT CARE INFORMATION SYSTEMS AND TERMINOLOGY

Different authors, different countries, different vendors all use different terminologies for their health care IT products. The medical informatics literature is replete with discussions about whether an Electronic Medical Record should not rather be called an Electronic Patient Record (emphasizing the central role of the patient) or, rather, an Electronic Health Record (emphasizing the fact that there is much more than just ‘medical’ or ‘disease related’ information in a record). For others, a Medical Record is something essentially different from a Health Record—the former being limited to physician’s notes and physicianoriented information; the latter being the all-encompassing record on the ‘whole patient’.

This book does not want to take a stake in such definition quarrels. Yet it is important to realize that they exist, and that what is precisely meant at any given time by a label such as ‘medical record’ is not self-evident. Often, terminology oversells the underlying product: at best, the intelligence of ‘intelligent systems’ lies in their design and their use; at worst, ‘intelligent systems’ are an affront to any intelligent person working with it. Similarly, a ‘data warehouse’ and ‘data mining’ allude to highly lucrative activities and the ‘golden nuggets’ of information that the organization has at its fingertips. ‘Databases’ and ‘doing searches’ sound much less interesting, although that is basically what lies beneath the rhetoric.

We will use the term ‘Information Technology’ (IT) throughout this book, although some prefer the term ‘Information and Communication Technology’ (ICT). We intend no definition quarrel here either, although we do not focus on telecom applications, for example.

As said, we will here use the term ‘Patient Care Information Systems’ (PCIS) to address those systems that are used primarily by health care professionals and patients, and that are primarily oriented to the support of their tasks. Among others, the following systems that we will encounter in this book belong to this category (for more technical details, please consult a leading Medical Informatics handbook such as (Coiera, 2003; van Bemmel, 1997)).

Table 1.1 Some examples of patient care information systems

REFERENCES

Collen, M.E. (1995) A History of Medical Informatics in the Unit...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Illustrations
• Contributors
• Series Preface
• Acknowledgements
• Chapter 1
• Part I Starting points Understanding Health Care Work and the Role of IT
• Part II Information Strategy, Implementation and Evaluation