Knowledge is not constrained to national or geographic boundaries. While we must recognise cultural, national, societal and other variations, best practices are applicable everywhere.More than 1,500 health information technology professionals from 31 countries discussed on topics: clinical leadership and governance, e-health, EHR, EMR, EPR, PHR, IT strategy and innovation during HIMSS AsiaPac08 conference.
The group of healthcare leaders and professionals who gathered during this event looked at the evolution of healthcare with a unified philosophy: healthcare delivery can be improved with the use of information technology. Following are some of the basic principles that offer a picture of healthcare that applies to everyone.
Use a bottom-up approach
Dr York CHOW, SBS, JP, Secretary, Food and Health, Government of the Hong Kong Special Administrative Region and Shane Solomon, Chief Executive, Hong Kong Hospital Authority (HA) suggested four key 'factors in action' that helped transform the Clinical Management System in Hong Kong. One of them was, transformation of healthcare is bottom-up, rather than top-down, development process.
"Users are involved right from the beginning and are put in the driver's seat throughout the design, standardisation, development and implementation process," said Dr CHOW. "We engage the users from the outset and allow the whole process to be driven in a bottom-up manner by user groups-which is painstaking and time consuming." He also explained that this process is worth it because "it secures the buy-in and ownership of the users themselves to the need for change."
In countries where healthcare systems are largely centralised under a governmental authority, this concept can be a challenge. When most of the planning and IT adoption is driven by a regional health authority or federal level ministry, switching to a process that starts with the end user can be difficult. Government officials must give up certain elements of control in hope for a better outcome through the end user's commitment that is secured from the bottom-up approach.
Focus on the patient
Private sector management models have been both a source of revelation and consternation to the healthcare industry.
Dr TAN Yung Ming, Product Development Manager at Health Group, Singapore and CHEW Kwee Tiang, Chief Operating Officer at Alexandra Hospital explained 'Lean Healthcare IT Systems: The Toyota Way.' Using this business strategy from the Toyota Production System (TPS), Alexandra Hospital in Singapore has emphasised on the following principles:
- The customer is at the heart of the organisation's philosophy
- The organisation continuously reflects and learns
- The organisation sees processes end-to-end and removes silos.
Looking at healthcare delivery from the patient's perspective presents an entirely different approach to care because the focus is on the person, not the process. The TPS approach uses a value stream map that distinguishes value-added versus non-value-added activities. Thus, TPS is a management philosophy that requires the creation of an organisational culture where everyone is involved.
A study from Tefen USA found that this number may be even higher for those over the age of 65 who have more hospital stays than that of the general population. The data from this study reveals that elderly population has nearly three times as many hospital days per thousand as the general population. In addition, 62 per cent of 50-64 year-olds indicate that they have at least one of six chronic health conditions: arthritis, cancer, diabetes, heart disease, high cholesterol and hypertension.
This patient-centred approach takes on a role reversal as the population ages throughout the world. Demand increases for quality healthcare delivery to manage the health and the care of these individuals. For example, in the US, a recent report from the Centers for Medicare and Medicaid Services (CMS) predicts that unless decisive action is taken, total US healthcare spending will double to over US$ 4.3 trillion by 2017 or nearly 20 per cent of the nation's gross domestic product.
Chronic disease management is one of the primary benefits of the EHR, but the patient must truly be part of this process. Shane Solomon, Chief Executive, Hospital Authority, Hong Kong, said that "healthcare can do more," to help improve the delivery of care.
"We have created the passive, disempowered patient, waiting in hospital for the doctor or nurse to tell them what to do," said Mr. Solomon. This philosophy made sense when hospitals mainly cared for those with infectious diseases and patients were uneducated and unable to care for themselves.
He suggested a co-production approach to healthcare, where "you should not only be able to read your own health record, but you will contribute to creating it." As he explained, to do this, the patient needs information. The patient must also take an active role in recording their blood pressure, weight or blood glucose levels. "This electronic health record will link to authoritative sources of information for the condition, and other forms of patient support and education."
Mr Soloman's vision is not unrealistic and in fact, as he indicated, there are prototypes of these initiatives already emerging throughout the world.
This changing focus on the patient in regards to health information is evident. The very strong historical culture of hospital or physician 'ownership' of a patient's information is giving way to this shared ownership concept-slowly, but surely. Personal Health Record (PHR) applications are in their infancy, but there are some very powerful proponents of these applications: Microsoft and Google to name two. The increase in number of these applications will have an impact on institution-based Electronic Medical Record (EMR) systems and anticipation of the relationship between PHRs and EMRs will be important.
Come together on health IT standards
Standards make interoperable exchange of information possible and enduring. In fact, together standards and organisations are working to develop effective standards for healthcare.
Providing an update on global health IT standards development, Dr Yun Sik KWAK, Medical Informatics, Kyungpook, National University, Republic of Korea explains that there are various HL7 standards, such as V2.X and V3 that have been introduced to help establish integrated and connected health information systems. Dr KWAK is also the Chair, ISO / TC215, Health Informatics, Republic of Korea.
Dr KWAK and Audrey Dickerson, Secretary, ISO / TC215 Health Informatics (USA), and Manager, Standards Initiatives, HIMSS opined that both HL7 and ISO are separate but collaborative Standard Development Organisations (SDOs), which recognise that developing countries depend on standardisation for some of their IT infrastructure in hospitals and in their clinics, for health IT systems and devices. In addition, telemedicine has been used as a consultant network in some countries, especially China, where the network is advanced to assist local doctors with diagnosis.
Many developing countries are completing their initial work in healthcare IT, often seeing what other countries have done and how those successes can be applied in their own countries. But involvement by the healthcare community in international creation of standards is critical. As healthcare becomes more of a global business, commonality of health standards will grow. Engagement with HL7, ISO and other standards development organisations will pay dividends in the Asia Pacific and other regions as they move further down the path of IT adoption.
Looking at healthcare delivery from the patient's perspective presents an entirely different approach to care.
Quality healthcare with a local focus
While quality is the constant in patient care throughout the world, many other variables change based on location, availability of staff, medicine, hardware, software, and even a building, to provide that care.
Dr Alvin Marcelo, Director, National Telehealth Center, University of the Philippines, Manila, who dealt with the problem of shortage of health workers in the Philippines due to their increasing migration to other countries, opines that the biggest challenge in the Philippine is, 'human capacity' not 'infrastructure.' As a result, open source software and SMS / MMS telereferrals, a simplified technology that demands less tech support, were put in place. He focussed on capacity-building to eliminate the fear or avoidance of personal computers (PCs). He said that he was able to expose rural health workers to "practical applications that related directly to the nature of their work," a process that allowed them to "evaluate the quality of their data and to plan for improvement."
In healthcare, it is easy to forget, or perhaps not recognise, that learning how to manage technology takes time. Dr Marcelo found that he had to invest in the healthcare workers of his country instead of signing an expensive licensing agreement. And, he chose to invest in healthcare workers.
In Asia, workforce shortage and training issues vary from one region to another. The valuable lesson learnt in managing the labour shortage focusses on the critical need to develop a culture of continuous professional improvement, whether using expatriate workers or developing the skills of nationals with quality education and training. In either case, healthcare is a complex activity requiring many skills and extensive knowledge. Continuing education is an investment in the future.
How privacy works for EHRs?
Elisabeth Harding, Director, Legal & Governance, University Hospital, Dubai Healthcare City, United Arab Emirates, advises healthcare professionals that it is important to understand what privacy of patient health information means and how it works at the point-of-care, but so should the patient. She explained that "privacy legislation is not about keeping things 'private' or 'secret' but about ensuring that information is used consistently with the purposes for which it was obtained."
The Hippocratic Oath introduced in the 4th century BC, indicates that privacy was a concern then, and now. Physician Hippocrates stated that, "All that may come to my knowledge in the exercise of my profession or in daily commerce with men (now people), which ought not to be spread abroad, I will keep secret and will never reveal."
She advises physicians to help patients, and healthcare employees, understand why information is being collected. "If people (you and I) trust what is being done with our information, then generally there is not a problem with sharing our information in the course of providing care and treatment (in its broadest sense)," she said. She advises healthcare providers to make sure the patient understands why information is being collected because, "transparency is essential to build trust."
Andrew M Wiesenthal, Associate Executive Director, The Permanente Federation, said that his organisation, Kaiser Permanente, learnt early in its EHR implementation process that information technology is a strategy, not a goal.
Kaiser Permanente began this process in 1970s with new applications or technology introduced in certain regions throughout these years. This integrated healthcare delivery system serves eight regions that include nine states and the District of Columbia with more than 32 hospitals and medical centers and more than 435 medical offices.
In 1997, the EHR implementation process became a corporate goal of Kaiser Permanente. In 2002, Kaiser reassessed its progress and asked key questions on the system needed and on clinical and operational goals. In 2003, the organisation introduced the Kaiser Permanente HealthConnectT integrated healthcare delivery system.
Dr Wiesenthal's assessment of what worked-and didn't work-has global applications because his summation of the electronic health record at Kaiser is one of a "complete healthcare business system that will enhance the quality of patient care." That conclusion comes from understanding the following points.
- Deploying an EHR is a strategy, not a goal
- Distributed development with subsequent integration is achievable but very difficult and very expensive
- Interfaces to legacy system are always more difficult than predicted
- The organisation is a healthcare delivery system, not a software development firm.
All of us in the healthcare industry continue to strive for the best patient care that we can deliver with the 'how-to' equation differing on the basis of budget to time in the day. But technology has brought the world together in many industries, including healthcare. The six points presented here offer some guidance based on lessons learned from our peers in the field.
Stephen Lieber is President and CEO of the Healthcare Information and Management Systems Society (HIMSS). Lieber also serves on the Board of Directors of HIMSS and its two related corporations, as well as other corporate, nonprofit and coalition boards and groups. He is one of the founders of the Certification Commission for HIT and the Health Information Technology Standards Panel, which are both US federally-funded initiatives supporting the US interoperability effort.