Chapter IV

Information Technology: Cost-Effective Application
to the Delivery of Health Care

Primary care physicians are in many ways sophisticated data managers as they collect information, record, process and disseminate it in a myriad of forms. Informatics refers to the use of computing and advanced communication technology in the management of this medical data.

Although a host of computer-based information systems have been developed and implemented in the health-care environment, numerous articles in the literature caution that they are not the panacea. There is now an assumption that a cost-benefit impact has not been shown to be effective in all cases, and yet it is critical, as in all situations, to have a systems evaluation.

A case can be presented for computer-based information systems to support the delivery of primary health care because the collection, sorting and retrieval of information data is currently labour-intensive and cumbersome.

Health care is by far the largest industry in Ontario, with expenditures of approximately $23 billion, and yet the present information system lags behind the state-of-the-art systems utilized in the private business sector. There are four reasons cited for this information lag:

  1. The system is largely controlled by bureaucracy. This situation in the past had relatively little interest in contemporary technology; particularly since it has the potential to result in restructuring and job loss.

  2. Health providers, including physicians, have been preoccupied with professional work and in the past have expressed little interest in management and administration of technology.

  3. Although it is no longer a correct assumption, the perception exists that the computerization of health records is an extremely complex and costly task.

  4. Privacy protection remains a critical factor and is problematic from the public's perspective.
Nevertheless, substantial progress has been made in the area of informatics with the introduction of the Ontario Drug Benefit Program project in October 1993. For this reason, the OMA Primary Care Reform Physician Advisory Group recommends that the application of technology be considered with the following underlying principles:

  1. that there be incremental change encompassing existing computer hardware and software businesses be reviewed, and that no unnecessary 're-invention of the wheel' occur;

  2. physicians will not rely on computer tools that restrict their ability to practice, that is, information technology must be better than what physicians currently accomplish manually;

  3. capital expense for physicians and government in partnership must be minimized;

  4. improved quality of care, overhead reduction in office settings occur, and reduction of expenditures for government have been designated as key targets for the implementation strategies.

  5. the most appropriate location for the cumulative patient record is the primary care provider's practice location, regardless of the degree to which the record is automated.
The Physician Advisory Group recommends a three-stage implementation process for informatics:

Stage 1: Utilization of Existing Technology

The first stage involves utilizing current deployed technology that is already proven to be reliable. The following topics should be considered for inclusion in the first stage of this process:

  1. health card validation;
  2. bi-weekly direct deposit;
  3. implementation of prevention and promotion targets such as influenza, pneumococcal vaccine and appropriate immunization for children;
  4. ODB patient drug summaries and prescriptions provided to physicians' offices;
  5. facilitate the use of a 1-800 Internet to access CME for rural and isolated physicians.
Stage 2: Implementation of the electronic patient record

It is not within the scope of this report to review the extensive literature available on the electronic patient record (EPR). However, implementation of the EPR in the primary care office setting has four driving forces:

  1. cost-reduction, both for the provider and purchaser;
  2. enhancement of quality provision and collection of data;
  3. enable knowledge of what services have been provided and be able to transmit this information rapidly to others while recognizing patient confidentiality;
  4. appropriate interaction with, and enhancement of, timely return-to-work.
The key features of the electronic patient record in primary care are listed below:

  1. it must enhance workflow automation;
  2. accessibility must be easy and timely;
  3. it must have flexible data entry;
  4. information must be stored such that it will allow data to be available for quality outcomes measurement, irrespective of the method of data entry or language;
  5. it must be adaptable to support decision guidemaps and algorithms;
  6. a communications infrastructure to allow linkage of the EPR should be supported.
In keeping with the policy direction of the Physician Advisory Group, the electronic patient record could initially be simply "a mini-medical record system," as described by Timothy S. Carey in the article, Half a loaf is better than waiting for the bread truck: a computerized mini-medical record for outpatient care. This system produces a typed face-sheet prior to each visit, with a minimum of information including:

According to Carey, because partially computerized systems can be developed inexpensively, they are also well-received among the multi-specialty practices where inter-physician communication is vital.

An integrated clinical information record could allow a system of continuous quality assurance by collecting data pertaining to the daily treatment encounters, and it could allow analysis for decision-makers. In its simplest application, such a system could generate quickly an immunization record at any time for a particular patient. At a more complex level, such a system will allow the physician to know the health status and risk of any particular segment of his or her patient roster.

Nevertheless, the EPR cannot replace the face to face clinical encounter, and therefore must be approached with caution. Evidence suggests that the use of clinical information alone without direct personal interaction has been shown to neither enhance the management of patients in a number of different settings, nor reduce costs. Without a direct doctor/patient exchange, the physician is not afforded the opportunity to glean from the information provided many of the more subtle details that traditionally emerge in the patient interview. Consequently, an integrated clinical patient record will enhance the information-gathering process, but cannot replace talking to the patient.

Guidelines have been introduced to change practitioners' knowledge base and ultimately to alter behaviour to a mode of practice that peers would term ‘best practice pattern.' However, guideline dissemination alone has been seldom sufficient to sustain the desired practice pattern alterations to ‘best practice.'

The Physician Advisory Group cautions that until the technical difficulties are overcome, the increasing focus on the medical record be balanced with both the standard paper record as well as the mini-medical record described earlier. It is recognized that this will be an evolutionary step to the fully computerized electronic record.

Stage 3: The Integrated Clinical Information System

The goal of the exercise in medical computer technology is the development of a communications backbone for the health-care delivery system. As cars and highways connect us in the physical universe, so computers and modems will do in our practice universe. Realizing that the practice of medicine is a time and energy-consuming endeavour, there will be a realized need to link the hospital, the community office, the ambulatory clinic and even the patient's home.

Currently there are a number of projects underway to develop this integrated system and the Physician Advisory Group is confident that the problems of reliability and security can be addressed. It is critical that such a network be established and that physicians play a role in its evolution. This could be a main feature in the effort to reduce duplication and inefficient practice.

The implementation of the electronic patient record and management system will afford the opportunity to collect data and analyze it to allow the development of guidelines. This is an enormous ongoing task that is critical for the development of cost-effective management tools in primary care.

Many community-based primary care physicians also work in hospital settings. The Physician Advisory Group encourages these physicians to participate in and guide hospital information restructuring so that coordination of the system does not ignore the community component. Hospital committees are currently developing protocols and guidelines; physicians who will be dealing with speedy discharges must be concerned with this process and involve themselves in these guideline development groups. In this manner, harmonization will occur between hospital and community-based practices. The integrated clinical information system will become the engine of the health system and the primary care physician is often the driver of that engine.

Overcoming Resistance to Change

"You do not have to change: survival is not mandatory."
J. Edward Deming

No matter how good the information technology system may appear to be, the Physician Advisory Group recognizes that realistic expectations for its impact and initial productivity must be set. Initially, productivity will doubtless diminish until the provider learns to use the system and the patient becomes comfortable with its implementation. It is crucial that physicians participate in the planning process and that they along with their support staff receive timely training. Implementation of such programs should provide extensive support following the training period, including written support tools in a clear, understandable format.

There must be an expectation of initial difficulties and a period of time where modification will be required. Success for large informatics projects has been best when there is a good strategy to implement the change as quickly as possible.

Following the implementation, steps must be taken to assess the cost benefits and answer the very serious question that those participating will have insured benefits for implementing informatics. The implementation of information technology and a systems management program must be done in partnership with government, the private sector, and physicians. It is extremely important to have a positive organizational climate in this respect. Above all, implementation of informatics requires champions at a local level who are medically-respected physicians who are able to fulfill this role. Such individuals must be integrated into the planning process at all stages and be prepared to deal with trouble spots as they arise.

The cost-effective application of informatics is crucial to primary care reform. With the reliance on proven technology introduced in incremental stages using appropriate tools with minimization of capital expense, the Physician Advisory Group is optimistic that there will be an improved quality of care as well as significant savings to the health-care system. Pilot studies in this area are strongly supported.

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Referrals

(...panacea)19th Annual Symposium on Computer Applications in Medical Care; Toward cost-effective clinical computing, Oct. 28, 1995, New Orleans Conference.
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(...systems evaluation) Journal of Medical Systems Vol. 13, no.2, 1989.
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(...private business sector) Macintosh, RM, Information technology in Ontario, Backgrounder, CD Howe Institute, Jan. 12, 1995,
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(...outpatient care) Arch Int Med, 1992: 152;1845-1849.
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(...nor reduce costs) Annals of Internal Medicine, March 15, 1995: 122; 34-437.
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(...best practice) Arch, Fam Med vol. 4, August 1995.
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(...record described ealier) Ann Int Med, 1989: 110, 482-484.
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(...strongly supported) For additional information, please refer to the appended report by Dr. Jay Mercer.
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