Credit Card Know More About You Than Your M.D.?
Karl Brown, Dave A. Ross, and David Lubinski
One of the biggest challenges facing health systems around the world might come as a surprise, because it's not about doctors, drugs or money. From Boston to Beijing to Bamako, governments and health systems face an information challenge - specifically the lack of information.
In a world where business is transacted at the speed of light, where supplies can be ordered, inventories managed, and production quotas established on a daily basis, many countries, including highly developed economies, struggle to know basic facts about births, deaths, emerging threats to health or even the status of changing health systems.
The scope of information needs is immense, but the opportunity to revolutionize the use of information in health, especially in developing countries, has never been greater. This is thanks to advances in low-cost computing, widespread access to broadband Internet connections, the incredible growth of mobile phones and wireless connectivity, as well as 30 years' experience in health informatics in the industrialized world.
A simple story will demonstrate the incredible disparity in how information is used in two of the world's largest industries: health and finance. Let's imagine you're on vacation in Las Vegas. You go to the casino, approach the banker, hand him your credit card, and shortly thereafter, he agrees to loan you $5,000. Within a matter of seconds, from a piece of plastic in your pocket, the banker knows your name, date of birth, address, and has access to your up-to-date bank account balance, credit line, credit history, risk rating, and so on - everything he needs to decide how much money to lend you. The casino's informed decision - and indeed, its business - is based on rapid and secure access to reliable financial information.
So how is health information handled? Money in hand, you head to the roulette wheel and put down $5,000 on black. Unfortunately, the ball lands on red, your world starts spinning, and you collapse, clutching your heart. The ambulance arrives. Your life is now on the line - the decisions taken over the next few minutes are critical. Like the banker, the paramedics need rapid and secure access to reliable information: Are you on any medication? Do you have a history of heart disease? Have you had any recent surgery?
Unfortunately, this information is not available; there is no card they can scan, no database they can consult. The medical records that might save your life are confined to the filing cabinets among your doctors' offices a thousand miles away. Aside from an insurance card to identify who will be paying for your care, the paramedics know absolutely nothing about you or your health history.
The financial services industry has figured out how to solve the problem of distributed access to information. Every day, financial institutions rapidly and securely move massive amounts of information, research and money, around the country and around the world, using information and communication technologies (ICTs). Networks (mechanisms for transporting information) and standards (common formats for representing information) are at the core of how the financial world manages its information. Unfortunately, health is a different story.
Despite the potential for ICT's impact on health, the health industry has lagged behind many other industries in the adoption of information technology. For example, a recent study found that fewer than 8 percent of hospitals in the U.S. have electronic health records (EHRs) in place for even one department, and only 1.5 percent have an electronic system in place for all departments. When we look at health information exchanges (the ability to move EHRs from one place to another), the picture is even worse, even among advanced institutions. A few years ago, two of the hospitals voted "most wired in the U.S." were in New York City, only a few blocks apart. The only way to get patient records from one "wired" hospital to another was to print them out and carry them on foot! So why have banks digitized all of their records, but the hospitals have not?
There are many explanations for the slow adoption of ICT in health. Health information is complex and needs standardized vocabularies and coding structures. Patients have legitimate concerns about privacy that must be met with satisfactory legal frameworks. Health IT systems are expensive to procure and support. In third-party payer systems like the U.S., perverse financial incentives can actually discourage more integrated approaches to care, thereby limiting the impact information systems can have. And, the collective failure to articulate commonly held requirements for how information systems must support health care and community health protection leave those in need of help wondering which systems to buy and what to expect out of an ICT investment.
Nonetheless, there is a growing global movement to leverage eHealth, or the use of information technology in health, through systematically defined standards, expanded collaboration to share treatment and prevention knowledge, and a more unified global approach to strengthening health systems through integrated, accurate and timely information. The global eHealth arena promises innovations around every aspect of personal care, population health, and environmental risk-factor management.
During the Rockefeller Foundation's "Making the eHealth Connection" conference held in July 2008, health and technology leaders from all over the world declared a vision for reshaping health through a coordinated and collaborative approach to stimulating and sharing ehealth solutions to the most pressing problems. Building upon information architecture standards evolving through global standards organizations, like the International Organization for Standardization (ISO) and Health Level 7 (HL7), these leaders envision a new generation of integrated health information systems capable of directing resources where they are needed, informing individual care, and intervening in the complex web of social and environmental influences that impact health outcomes.
This is not an unrealistic vision, and developing countries will likely achieve it faster, and at lower cost, than richer nations. This is because legacy (i.e. old) information systems, which have bedeviled efforts for integration in the wealthy countries, are much less entrenched in the emerging economies. Just as many African nations moved directly to fiber and wireless communications instead of laying down copper wire, the possibility for many countries to leapfrog to best-of-class integrated health information systems is quite real. There are already examples, like Belize, which recently installed a fully-integrated nationwide health information system, or the city of Sao Paolo, Brazil, which has developed an integrated system connecting all of the health posts in a city of 14 million people.
From Silos to Systems
In the past, information systems were often developed to address narrowly defined vertical disease treatments or health programs - resulting in what are called data silos. Because such systems were designed for a single purpose within a single context, they have built-in limitations to the use and accessibility of the data. What is worse, due to the lack of coordination, these efforts often recreate the common building blocks of a health information system, such as patient identification, storage, security, authentication, and backup. All around the world, health information systems are fragmented and more expensive than they need to be, and do not easily share data. For example, in 1993 during a hantavirus outbreak in the U.S., officers from the Centers for Disease Control and Prevention had to compare information from several public health databases by hand.
Integrating requests for data and creating information that informs action on a range of problems have been barriers to better use of resources and to patient care. As the power of computing devices increases, there is the potential to leapfrog today's integration barriers, and open a world of information to even the remotest locations.
The power of integrating multiple streams of data is witnessed daily by anyone who uses Google Earth to zoom into an address or by those who view a weather forecast that combines satellite data with ground monitoring data to warn of advancing weather events. Similarly, information systems that accurately predict epidemic trends or spot environmental threats will influence the health of every society in the future. As a hint of things to come, Google recently released a tool that is able to detect flu outbreaks weeks before official reporting systems, based on search keyword analysis. We believe that moving from silos of data to integrated information systems (which combine multiple streams of official and unofficial data) will fundamentally transform the practice of health.
What would a future health system, supported by timely and accurate information, look like? Here is one possible scenario: imagine that the South African minister of health has a dashboard that shows her, on a daily basis, the number of patients receiving antiretroviral (ARV) treatment, how predicted future needs map to existing stock levels of ARVs, the number of new cases of HIV, TB, malaria, and other major infectious diseases detected (and where those cases are), case reports on new and emerging infections, statistics on chronic diseases, the number of doctors and nurses per capita on a per-district basis, how many doctors and nurses are currently in the training pipeline, the latest statistics on births and deaths, the latest environmental monitoring trends, and so on.
When the minister of health makes a decision, it is based on live data instead of reports from 3 months or 1 year ago, and she can now watch the results of her decisions as they unfold, and adjust her interventions in real-time. In addition, just as your bank is alerted immediately when strange spending behavior occurs, public health officials are alerted when unusual health conditions occur - odd patterns of drug prescription, increases in emergency room visits, an outbreak of an unknown disease, and so on.
One could also imagine that a subset of this information, targeted at the local needs, is available to district health managers, hospital directors, community health workers, and the public. The vision we should aim for is that every person who makes decisions in the health system, whether the minister of health, a surgeon, a rural community worker, or a patient, has access to all of the information he or she needs in order to make an informed decision.
The Way Forward
The health and technology leaders convened at the "Making the eHealth Connection" conference all agreed that we need to move from silos of health information to more coordinated and aligned eHealth systems. The promotion of standards, which are sorely lacking in many health information systems, was underlined as a particular need.
The Rockefeller Foundation, International Development Research Centre, and others will be supporting processes to develop reusable national blueprints and architectures for health information systems, foster agreement on common standards for exchange of health information, develop human capacities to design and manage eHealth systems, and deploy eHealth systems to low-income countries.
Through funding from the Bill & Melinda Gates Foundation and other donors, the World Health Organization supports the Health Metrics Network, an international network devoted to giving developing countries a framework for how health information systems can inform better health resource allocation, improve patient services, and impact community health. This effort has led a global movement among more than 100 countries that have adopted the HMN Framework to guide improving national health information systems. Many countries are already developing plans and strategies for integrating their information systems, and some have advanced considerably towards implementation.
The conditions are ripe for suppliers of health information technologies, the countries that require these systems, and donors and supporting agencies to align in support of health information systems that are supportive of the health system as a whole (and not just a priority disease or program), affordable and sustainable. Most importantly, this must be done quickly, before today's pilot projects become tomorrow's isolated data silos.
Karl Brown is associate director at the Rockefeller Foundation and focal point for eHealth.
David Ross is the executive director of the Public Health Informatics Institute.
David Lubinski is a consultant for PATH, and was previously the chief technology officer for the Health Metrics Network.
All three helped organize the "Making the eHealth Connection" conference and are signatories to the Bellagio call to action.
An extensive literature review today, regarding the slow adoption of EHRs by Physicians in the U.S., will only validate Kaplan’s review of 1987. She concisely summarized the main barriers facing physicians’ adoption of EHR. These are:
1. Barriers of insufficiency: lack of funding, technology, staffing, training, and effort;
2. Poor management, including: difficulties of interdisciplinary teams, planning and approach, and lack of attention to human factors and methodologies;
3. Barriers inherent in medicine, including: insufficient knowledge, the difficulty of translating medical knowledge into a form suitable for computing, institutional constraints; and
4. Physician resistance.
In addition to the aforementioned factors, as primary reasons for the slow adoption of EHR, culture (the basic tenet that informs who the individual is and how he/she behaves) has been largely overlooked as an important factor in the literature.
A cultural typology can be defined in relation to the values and beliefs that inform physicians’ behaviors and their practices in their decision to adopt or not adopt the EHR.
1. Medicine as an art
2. Medicine as a technological endeavor
3. Professional autonomy and leadership
4. Physician Resistance
5. Personal relationship with the patient
6. Provision of quality services reflecting professional competence
7. Sense of belonging to a professional class
a. Medical specialties as subcultures
8. Medicine as a meaningful professional practice for health care justice
9. Other socio-demographic variables
a. Age as a definer of generational subcultures
b. Practice in educational settings as an academic subculture
The role of medical culture, practices and social structure in the process of adoption or non-adoption of medical computer applications helps explain the differences in adoption between medical computer applications. Physicians’ acceptance of technology has to do more with physicians’ cultural values such as quality of patient care, medicine as an art, personal relationship to the patient and professional autonomy. Computers infringe on their roles as chief architect of a patient’s management. Physicians consider themselves as autonomous, responsible, and self governing, believing that no one but other physicians are competent to judge their actions.
Technologies rooted in practical applications that do not disrupt nor change the medical practice, as defined by physicians, are readily accepted, while technologies that could change the physicians’ role and work are not accepted and are even sabotaged. As Bria and Rydell (2004) argue, how slow the physician-computer connection has occurred in the U.S. has to do with the great emphasis placed in the technology itself and the failure of system implementation by and for health care providers, physicians in particular.
As Stinson (2007) pointedly also asserts, “No amount of incentive short of a double-digit percentage figure is going to aid in convincing those practices that are uninitiated to join the ranks of EHR implementers.” The fact is that sociological, cultural, and financial issues have as much to do with the success or failure of a system as do technological aspects because IT are embedded within a complex social and organizational context. Roughly 75% of all large health information technology (HIT) fails basically due to inattention to the problems associated with the introduction of computer technology into complex work environments. The many unintended and undesired consequences of HIT flow from interactions between the HIT and the health care organization’s socio-technical system- its workflow, culture, social interactions and technologies.
These socio-technical interactions have been richly documented in the literature but, unfortunately, many information technology (IT) users and even IT specialists, are unfamiliar with these or their practical implications. In particular, it is ultimately the physicians (as the major determinants of the health care social environment) who will drive the success of.
What to do? Recommending policies to address cultural factors could be problematic given the nature of the American culture because, as Bosso (1994) notes, it is built around core beliefs of individual liberty. Americans traditionally resent anybody with authority regulating or mandating limits to what could be understood as an individual choice. In the U.S. health care is usually considered a market commodity to be accessed as the individual prefers, and is able to pay, rather than a social good dispensed as per social contract.
In addition, since culture is usually understood as a matter out of the realm of government or any particular institution or organization, these recommendations could be seen as social regulatory policies.
On the other hand, culture itself is not amenable to direct regulation. An activity intended to modify culture will only have results as long as the individuals or institutions whose cultures are affected react to such activities. Since medicine is a cultural construct in which people are constantly creating, negotiating, revisiting, internalizing, and externalizing their understandings of it, and these people live within organized communities and institutions, that themselves have a culture, any recommended policy will be considered by individuals, organizations, and institutions from their very particular world view, that is to say their culture. Its acceptance and/or implementation will depend on how well any recommendation makes sense, or is desirable, and is in the purview of anyone’s capacity and/or authority to act upon it in the broader societal context.
In the absence of a clear understanding of what it is in the culture of the physicians that informs them into what they are, preeminent practitioners of medicine, the most important and overarching policy recommendation would be the development of a comprehensive research agenda to explore the culture of physicians and medicine as it relates to EHR, the epitome of HIT. As Menachemi (2006) lucidly asserts, little is known about physicians who are likely to adopt EHR imminently, and if efforts to promote EHR adoption are to be successful, these have to be targeted with priority to create the critical mass that would create “waves” of further adoption. In order to finance this effort I would recommend that funding be pursued from private and public institutions interested in developing human capital.
Finally, in paraphrasing the authors of this article I would argue that the time is also ripe to review the social contract of society with physicians.
— Angel Rafael Braña, MD, MPH on 2009-05-14
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— Gadema Korboi Quoquoi on 2009-09-11