The use of information technology in improving medical performance. Part I. Information systems for medical transactions

Investment in medical information technologies reached $15 billion in 1996. However, these technologies have not had the wide impact predicted in streamlining bureaucracy, improving communications, and raising the effectiveness of care. In this series, we identify how such technologies are being used to improve quality and performance, the future directions for advancement, and the policy and research developments required to maximize public benefit from these technologies. Each of these articles focuses on a different type of information technology: (1) information systems to manage medical transactions; (2) physician-support technologies to improve medical practice; and (3) patient-focused technologies designed to change how people manage their own care. This first article of a 3-part series examines the successes of and opportunities for using advanced information systems that track and manage medical transactions for large populations to improve performance. Examples of such systems include: HEDIS, which gathers standardized data from health plans on quality of care; the USQA Health Services Research Program, which tracks treatment patterns and outcomes for 14 million insurance members; Ford's program to collect medical data for over 600,000 employees; and Harvard Pilgrim Health Care's system of computerized laboratory, pharmacy, ambulatory, and hospital admission records for its 1.5 million members. Data from these systems have led to modest improvements in knowledge and practice patterns for some diseases. Significant barriers are slowing efforts to add outcomes data to these databases and broaden the databases to cover larger populations. Nonetheless, existing data in currently evolving systems could be used to greater benefit in tracking public health and in identifying more effective treatments and causes of diseases.     

Medical direction and control of emergency medical services in Canada.

OBJECTIVE: To determine the level of physician involvement in prehospital emergency medical services (EMS) in Canada, as compared with published principles of medical control and direction. DESIGN: Mail and telephone survey by means of a questionnaire from March to November 1991. SETTING: All Canadian provinces and territories. PARTICIPANTS: Fifty-six key prehospital EMS physicians, senior government administrators and senior representatives of the agencies responsible for licensing physicians in each province or territory. MAIN OUTCOME MEASURES: Responses to questions regarding the legislation, organization, administration, practice and regulation of medical direction and control by physicians in each province or territory. RESULTS: EMS legislation describing medical direction and control was completely lacking in five provinces and both territories and was incomplete in the remainder. Provincial guidelines written by physicians for prehospital patient care were present in only four provinces. Formal organization of medical directors varied from none to partially remunerated networks. Regional medical-director systems were present in three provinces, and local medical directors were required for all communities in three. Most rural ambulance services were found to engage physicians only when there was local interest. CONCLUSIONS: The level of physician involvement in the medical direction and control of EMS appears to be inconsistent across Canada and insufficient in most jurisdictions, as compared with accepted principles.     

Improving the quality of care via maintenance of certification and the Web: an early status report

Few question the need for continuous professional development throughout a physician's career, but rapid changes in health care are creating demand for physicians to acquire new knowledge, skills, and attitudes to implement quality improvement in clinical practice. The Internet and World Wide Web are technologies that have the potential to facilitate deep change in physician practice and lifelong learning. This paper describes how the American Board of Internal Medicine (ABIM) has utilized the Web and the Internet to engage physicians in the competencies of practice-based learning and improvement and systems-based practice. Specifically, we describe how the ABIM developed and implemented Web-based practice improvement modules (PIMs) to help physicians measure and improve their clinical practice.     

Information retrieval for patient care.

Doctors need clinical information during most consultations with patients, and much of this need could be satisfied by material from online sources. Advances in data communication technologies mean that multimedia information can be transported rapidly to various clinical care locations. However, selecting the few items of information likely to be useful in a particular clinical situation from the mass of information available is a major problem. Current information retrieval systems are designed primarily for use in research rather than clinical care. The design, implementation, and critical evaluation of new information retrieval systems for clinical care should be guided by knowledgeable clinical users.     

Primary and managed care. Ingredients for health care reform.

The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.     

Aspects of audit. 5: Looking forward to audit.

Whatever the misgivings of individual doctors, the formal support being given by professional bodies suggests that medical audit will become established in Britain. It is therefore appropriate to heed the advice of pioneers in the field in choosing methods and topics for audit. Practical problems can be anticipated because of the inadequacy of medical records, retrieval systems, and comparable information on practice patterns and evaluation of traditional processes of patient care. The criterion system of audit may provide a common standard for effective review. This can be used for any group of patients with some characteristic in common. It requires good records and a good records staff. Whatever method is adopted, central support should come from the royal colleges, with community physicians and clinical tutors assisting clinicians at the local level.     

A report from Japan: choices of Japanese patients in the face of disagreement

Background: Patients in different countries have different attitudes toward self-determination and medical information. Little is known how much respect Japanese patients feel should be given for their wishes about medical care and for medical information, and what choices they would make in the face of disagreement.
Methods: Ambulatory patients in six clinics of internal medicine at a university hospital were surveyed using a self-administered questionnaire.
Results: A total of 307 patients participated in our survey. Of the respondents, 47% would accept recommendations made by physicians, even if such recommendations were against their wishes; 25% would try to persuade their physician to change their recommendations; and 14% would leave their physician to find a new one.
Seventy-six percent of the respondents thought that physicians should routinely ask patients if they would want to know about a diagnosis of cancer, while 5% disagreed; 59% responded that physicians should inform them of the actual diagnosis, even against the request of their family not to do so, while 24% would want their physician to abide by their family's request and 14% could not decide. One-third of the respondents who initially said they would want to know the truth would yield to the desires of the family in a case of disagreement.
Interpretations: In the face of disagreement regarding medical care and disclosure, Japanese patients tend to respond in a diverse and unpredictable manner. Medical professionals should thus be prudent and ask their patients explicitly what they want regarding medical care and information.     

Expert systems in treating substance abuse.

Computer programs can assist humans in solving complex problems that cannot be solved by traditional computational techniques using mathematic formulas. These programs, or "expert systems," are commonly used in finance, engineering, and computer design. Although not routinely used in medicine at present, medical expert systems have been developed to assist physicians in solving many kinds of medical problems that traditionally require consultation from a physician specialist. No expert systems are available specifically for drug abuse treatment, but at least one is under development. Where access to a physician specialist in substance abuse is not available for consultation, this expert system will extend specialized substance abuse treatment expertise to nonspecialists. Medical expert systems are a developing technologic tool that can assist physicians in practicing better medicine.     

Evaluating online direct-to-consumer marketing of genetic tests: informed choices or buyers beware?

Commercialization of genetic technologies is expanding the horizons for the marketing and sales of genetic tests direct-to-consumers (DTCs). This study assesses the information provision and access requirements that are in place for genetic tests that are being advertised DTC over the Internet. Sets of key words specific to DTC genetic testing were entered into popular Internet search engines to generate a list of 24 companies engaging in DTC advertising. Company requirements for physician mediation, genetic counseling arrangements, and information provision were coded to develop categories for quantitative analysis within each variable. Results showed that companies offering risk assessment and diagnostic testing were most likely to require that testing be mediated by a clinician, and to recommend physician-arranged counseling. Companies offering enhancement testing were less likely to require physician mediation of services and more likely to provide long-distance genetic counseling. DTC advertisements often provided information on disease etiology; this was most common in the case of multifactorial diseases. The majority of companies cited outside sources to support the validity of claims about clinical utility of the tests being advertised; companies offering risk assessment tests most frequently cited all information sources. DTC advertising for genetic tests that lack independent professional oversight raises troubling questions about appropriate use and interpretation of these tests by consumers and carries implications for the standards of patient care. These implications are discussed in the context of a public healthcare system.     

Profiles

The Canadian Medical Association (CMA) recognizes that there is justification for abortion on medical and nonmedical socioeconomic grounds and that such an elective surgical procedure should be decided upon by the patient and the physician(s) concerned. Ideally, the service should be available to all women on an equitable basis across Canada. CMA has recommended the removal of all references to hospital therapeutic abortion committees as outlined in the Criminal Code of Canada. The Criminal Code would then apply only to the performance of abortion by persons other than qualified physicians or in facilities other than approved or accredited hospitals. The Canadian Medical Association is opposed to abortion on demand or its use as a birth control method, emphasizing the importance of counselling services, family planning facilities and services, and access to contraceptive information.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Attitudes of consultant physicians to the Calman proposals: a questionnaire survey. North West Thames Diabetes and Endocrinology Specialist Group.

OBJECTIVE--To determine the views of a large and representative group of consultant physicians on the Calman proposals, in which acute general medical services will change from being primarily consultant led to consultant provided. DESIGN--Postal questionnaires. SUBJECTS--All 236 consultant physicians in acute hospitals in North West and South West Thames regions. RESULTS--Replies were received from 179 (76%). One hundred and thirty seven (77%) indicated that they would not resume emergency residential duties, and 126 (71%) indicated that they would probably withdraw from general medical duties under these circumstances. One hundred and twenty six (70%) and 137 (77%) had not inserted a central venous line or temporary pacemaker, respectively, within the previous five years. Of 157 answering a question on the impact of the Calman proposals on the quality of patient services, 125 considered that it would be detrimental, and only 18 (11%) thought that it would be beneficial. CONCLUSION--Most consultant physicians are not prepared to resume emergency duties and could not do so without retraining in practical procedures. There is widespread antagonism to the Calman proposals, and most physicians consider that their impact on the quality of patient services will be detrimental.     

Medical ethics and education for social responsibility.

The physician, said Henry Sigerist in 1940, has been acquiring an increasingly social role. For centuries, however, codes of medical ethics have concentrated on proper behavior toward individual patients and almost ignored the doctor''s responsibilities to society. Major health service reforms have come principally from motivated lay leadership and citizen groups. Private physicians have been largely hostile toward movements to equalize the economic access for people to medical care and improve the supply and distribution of doctors. Medical practice in America and throughout the world has become seriously commercialized. In response, governments have applied various strategies to constrain physicians and induce more socially responsible behavior. But such external pressures should not be necessary if a broad socially oriented code of medical ethics were followed. Health care system changes would be most effective, but medical education could be thoroughly recast to clarify community health problems and policies required to meet them. Sigerist proposed such a new medical curriculum in 1941; if it had been introduced, a social code of medical ethics would not now seem utopian. An international conference might well be convened to consider how physicians should be educated to reach the inspiring goals of the World Health Organization.     

Automation of in-silico data analysis processes through workflow management systems

Data integration is needed in order to cope with the huge amounts of biological information now available and to perform data mining effectively. Current data integration systems have strict limitations, mainly due to the number of resources, their size and frequency of updates, their heterogeneity and distribution on the Internet. Integration must therefore be achieved by accessing network services through flexible and extensible data integration and analysis network tools. EXtensible Markup Language (XML), Web Services and Workflow Management Systems (WMS) can support the creation and deployment of such systems. Many XML languages and Web Services for bioinformatics have already been designed and implemented and some WMS have been proposed. In this article, we review a methodology for data integration in biomedical research that is based on these technologies. We also briefly describe some of the available WMS and discuss the current limitations of this methodology and the ways in which they can be overcome.     

Poverty in the United States as Defined by Federal Standards—Report of the Bureau of Research and Planning

The subject of this Socio-Economic Report is of tremendous importance to the medical profession because physicians should be aware that future programs for the expansion of health care services will be based and, in fact, are being based upon information which this Report contains. The relationship between poverty and accessibility of health care services is therefore quite direct. So, too, will be the impact upon the profession and the organization of medical practice.The 1966 amendments to the Poverty Act are concerned with neighborhood health centers and a vast array of other programs which will touch every physician and every community which can be identified by the standards indicated in this Report as low income, poor, or near poor. For this reason the California Medical Association Committee on Welfare Medical Programs, among several others concerned with aspects of this problem, is trying to alert every county medical society of developments as well as of the responsibilities they should assume in working with the Office of Economic Opportunity and other community organizations in providing guidance and leadership in structuring programs compatible with the interests of the public and the health care professions.This Report on poverty presents a current and prospective view of the problems and issues to be faced. Unless physicians see the relationship and join in a community effort to aid in resolving an issue which underlies public policy, we shall be looking back five or ten years from now to point out that we failed to take advantage of opportunities to assist in the development of a rational system of medical care for low-income groups.Individual physicians, component medical societies on a grass-roots level and CMA as a state organization should all be concerned with and aware of the facts.     

Cancer: improving early detection and prevention. A community practice randomised trial.

OBJECTIVE--To test the impact of physician education and facilitator assisted office system interventions on cancer early detection and preventive services. DESIGN--A randomised trial of two interventions alone and in combination. SETTING AND SUBJECTS--Physicians in 98 ambulatory care practices in the United States. INTERVENTIONS--The education intervention consisted of a day long physician meeting directed at improving knowledge, attitudes, and skills relevant to cancer prevention and early detection. The office system intervention consisted of assistance from a project facilitator in establishing routines for providing needed services. These routines included division of responsibilities for providing services among physicians and their staff and the use of medical record flow sheets. MAIN OUTCOME MEASURES--The proportions of patients provided the cancer prevention and early detection services indicated annually according to the US National Cancer Institute. RESULTS--Based on cross sectional patient surveys, the office system intervention was associated with an increase in mammography, the recommendation to do breast self examination, clinical breast examination, faecal occult blood testing, advice to quit smoking, and the recommendation to decrease dietary fat. Education was associated only with an increase in mammography. Record review for a patient cohort confirmed cross sectional survey findings regarding the office system for mammography and faecal occult blood testing. CONCLUSION--Community practices assisted by a facilitator in the development and implementation of an office system can substantially improve provision of cancer early detection and preventive services.     

Relationships in consultation

The cause of medicine is advanced by the proper exchange of services between general practitioners and specialists. As a medical group and singly, physicians stand to benefit by strengthening their relationships; and the one to benefit most of all by this combination of services is the patient. Any physician of integrity admits that it is impossible for one physician to know all there is to know about every medical subject. The establishment of rules of conduct to be followed by those who get together to solve a medical problem will promote the use of advisory practice.     

RELATIONSHIPS IN CONSULTATION

The cause of medicine is advanced by the proper exchange of services between general practitioners and specialists. As a medical group and singly, physicians stand to benefit by strengthening their relationships; and the one to benefit most of all by this combination of services is the patient.Any physician of integrity admits that it is impossible for one physician to know all there is to know about every medical subject. The establishment of rules of conduct to be followed by those who get together to solve a medical problem will promote the use of advisory practice.     

Nuclear medicine in district general hospitals.

Nuclear medicine is a recognised clinical specialty both nationally and internationally. Compared with other countries, it is inadequately developed in Britain, particularly in district general hospitals. To create clinical radioisotope services at district level physicians or radiologists with experience in nuclear medicine need to be trained and appointed. Such appointments would allow facilities to evolve that would provide either a comprehensive nuclear medicine service formed around a physician or an imaging service based on a radiologist. Such units would improve the care of patients at a reasonable recurring cost of 15 pounds--30 pounds per investigation.