Information Management to Improve Performance
Paul A. MacLennan
E. Lanette Milligan
Information management is a vast and important endeavor in the care of trauma patients. Their care often relies on a multitude of interrelated surgical and medical specialties, diagnostic tests, and therapeutic interventions that are time and resource intensive as well as costly. Health care delivery is inherently fragmented and poor documentation and miscommunication can lead to errors, duplicate testing, inappropriate care, increased costs, and reduced timeliness of care. Information management and health information technology have the potential to enhance timely care that is well organized and efficient through planning and communications while decreasing complications, lengths of stay, and adverse events. However, research shows that adoption of new technologies that contribute to quality and safety has not occurred as quickly as had been anticipated.1
A number of stakeholders, both inside and outside of medicine, are pushing for more integrated and sophisticated information management systems. This new emphasis is most always linked to the desires of health care facilities, providers, and third party payers to improve the overall quality of care and cost-effectiveness by streamlining bureaucracy, catching and correcting errors, assisting with decisions, and improving communications. A report in 2000 from the Institute of Medicine (IOM) dramatized the need for greater attention to quality. In their report, the IOM estimated that adverse events occurred in 2.9% to 3.7% of all hospitalizations and in light of approximately 34,000,000 hospital admissions per year, the number of deaths that resulted were between 44,000 and 98,000.2
Health care is an information intensive industry with an estimated annual 30 billion transactions.3 Although it would seem important for health care to rely heavily on information management, the industry has historically underinvested in information systems, as compared to other industries.3,4 Unlike other sectors of the economy, health care is very complex, making computerization of medical tasks very difficult. In addition, doctors have traditionally controlled decision making in health care and when lives are at stake, they are understandably conservative about changing the way they practice medicine.5 Furthermore, introduction of information technology can produce stress among an entire organization because its integration often interferes with the existing workflow.6 However, there is a serious need to overhaul the information system that has historically relied on paper, telephone, fax, and Electronic Data Interchange media to create a system that is often inefficient in communications within and between organizations.7 The shift from paper-based processing and storage to electronic-based processing and storage has brought some disadvantages due to higher technologic complexity and advantages because of higher functionality and greater opportunities in using patient information and medical knowledge.8
Information is stored in many ways and in many locations with inherent fragmentation that often results in incomplete, inaccurate, and unclear communications based on which clinical decisions have to be made. The expected information technology overhaul is likely to be very
expensive and many providers will need financial assistance for investments as well as a nudge from payers in how they pay for health care.3 For example, Kaiser Permanente, an integrated managed care organization operating in nine US states, plans to spend approximately $3.2 billion on a paperless system over 10 years.3 In the past, hospitals’ boards of trustees have held medical staff responsible for developing and implementing activities and mechanisms for monitoring and evaluating patient care and to identify opportunities to improve patient care by recognizing and then resolving patient care problems; but with the impeding pay for performance standards the approach to information management may begin to be addressed strategically from the top levels of administration.9,10
expensive and many providers will need financial assistance for investments as well as a nudge from payers in how they pay for health care.3 For example, Kaiser Permanente, an integrated managed care organization operating in nine US states, plans to spend approximately $3.2 billion on a paperless system over 10 years.3 In the past, hospitals’ boards of trustees have held medical staff responsible for developing and implementing activities and mechanisms for monitoring and evaluating patient care and to identify opportunities to improve patient care by recognizing and then resolving patient care problems; but with the impeding pay for performance standards the approach to information management may begin to be addressed strategically from the top levels of administration.9,10
Health care information is health care data that has been processed. Therefore, in order to have high quality health care information the data input must also be of high quality. Data is utilized for billing, research, decision making across professions, and for comparisons for health care issues. Poor data can result in diminished quality in patient care, poor communication among providers and patients, problems with documentation, reduced revenue generation due to problems with reimbursement, and a diminished capacity to effectively evaluate outcomes or participate in research activities.3
The Medical Records Institute identified five areas in which poor data can affect poor health care outcomes:
Patient safety
Public safety
Continuity of patient care
Health care economics
Clinical research and outcomes analysis3
HISTORY OF HEALTH CARE INFORMATION SYSTEMS
The evolution of information systems in health care was primarily shaped by the needs of organizations to be reimbursed and external technologic developments.3 Health care organizations began to seek out systems that could automate billing and process accurate cost reports in response to the payment systems established by Medicaid and Medicare in the 1960s. During this period, the Hill-Burton Act encouraged tremendous growth of new hospitals throughout the United States and provided access to capital for organizations to grow and expand. Driven by Medicare and Medicaid reimbursement practices that paid a little higher than the costs of services, known as costs plus reimbursement, and by demands to access capital through Hill-Burton, organizations needed a way to keep track of their accounting and finances, and patients. During the period of cost plus reimbursement practices, the larger the number of patients that organizations served, the more they grew, and the more money they were reimbursed. Computers of this period were very large and needed a great deal of space for storage and maintenance. They were also quite expensive and typically only available to very large medical centers.3 Centralized large mainframe computers were typically utilized for automating administrative functions such as accounting and financial services.6
The 1970s can be characterized by escalating costs in health care and the development of minicomputers and departmental information systems. It became necessary for departments (e.g., laboratory, radiology) to address efficiency of care and minicomputers were smaller and often more powerful than mainframe computers.3 During this period turnkey systems were developed and marketed by vendors toward departments within health care facilities. Software systems could be put into functional operation in a department simply by being turned on, therefore the turnkey terminology.3 The turnkey systems were limited in their inability to be adaptable to specific institutions.3 However, the advent of the minicomputer allowed for technology to find its way into clinical applications rather than just administrative functions.
Health care costs continued to increase in the 1980s and Medicare transformed its reimbursement policies from the cost plus reimbursement to a prospective payment system based on diagnosis-related groups (DRGs). Health care organizations were now paid a specific amount for a specific diagnosis as opposed to being paid the costs determined by organizations to treat their patients. This new reimbursement system forced health care organizations to implement cost-reducing processes and policies and to strive for more efficiency in delivery of care. Also in response to increase costs, health insurance companies began to move from fee-for-service models toward managed care plans. The 1980s also saw privatization and integration of health care organizations and health care services were merged into one system to offer a range of services from ambulatory care to long-term care. The dramatic changes of this period welcomed the advent of the microcomputer, better known as the personal computer (PC).3 The PC was powerful and small and could be utilized at workstations in departments. It was typical of this period for computers to be specific to departments, for example pharmacy or laboratories, and rarely were the systems integrated to enable different departments to communicate with one another. However local area networks (LAN) did allow for multiple computers to share pertinent information.3 The microcomputer allowed for health care organizations other than large hospitals to acquire computer technology.
The 1990s were a dynamic era for health care and information technology. The success of DRGs ushered in similar changes of reimbursement policies for providers based on managed care models. The new system supported on resource-based relative value scale intended to put decisions into the more efficient and less costly primary
care providers and therefore reimbursed them at better rates than specialist; however, the changes required good information management to administer these new reimbursement practices.3 Other managed care components called for physicians to become better at disease management, and technology offered a mechanism to do so. In 1991 the IOM called for a gradual phase out of paper records, citing numerous problems and recommended the adoption of computer-based patient record (CPR).3 In 1996 the Health Insurance Portability and Accountability Act (HIPAA) was signed into law and was designed to make insurance more affordable and accessible; however, the real impact of the law resides in its provision to protect the confidentiality of patient health records.11 Up to this point, there was no federal legislation addressing the confidentiality of patient records. HIPAA ushered in the most sweeping change to the US health care system since Medicare and Medicaid.10 During this time computers were becoming much more prevalent, with many households now owning PCs. The impact of the microcomputer in the 1980s parallels the introduction of the Internet in the 1990s as the single greatest technologic achievement of this era. The Internet impacted health care in a multitude of ways, from how health care professionals communicated, accessed information, and conducted business. Providers can access vast amounts of information quickly, patients and providers communicate through e-mail efficiently and in a timely manner, and organizations can share information internally and externally to improve business processes.3
care providers and therefore reimbursed them at better rates than specialist; however, the changes required good information management to administer these new reimbursement practices.3 Other managed care components called for physicians to become better at disease management, and technology offered a mechanism to do so. In 1991 the IOM called for a gradual phase out of paper records, citing numerous problems and recommended the adoption of computer-based patient record (CPR).3 In 1996 the Health Insurance Portability and Accountability Act (HIPAA) was signed into law and was designed to make insurance more affordable and accessible; however, the real impact of the law resides in its provision to protect the confidentiality of patient health records.11 Up to this point, there was no federal legislation addressing the confidentiality of patient records. HIPAA ushered in the most sweeping change to the US health care system since Medicare and Medicaid.10 During this time computers were becoming much more prevalent, with many households now owning PCs. The impact of the microcomputer in the 1980s parallels the introduction of the Internet in the 1990s as the single greatest technologic achievement of this era. The Internet impacted health care in a multitude of ways, from how health care professionals communicated, accessed information, and conducted business. Providers can access vast amounts of information quickly, patients and providers communicate through e-mail efficiently and in a timely manner, and organizations can share information internally and externally to improve business processes.3
In trauma care currently, hospital information systems are just one component of health information. The importance of information management begins at the time of injury in the prehospital setting and follows patients’ continuum of care through the emergency department (ED), surgery, the intensive care unit (ICU), and hospital stay, until discharge and rehabilitation.
PREHOSPITAL INFORMATION
Enhanced information technology, information management, and communications are critical to trauma systems providing seamless transition between each stage of patient care. Efficient and rapid movement of patients through the system (prehospital assessment and treatment, transport, hospital resuscitation, evaluation, and care) results in maximum outcome potential and trauma survival.12,13 Effective communication enables the systems to vary resource utilization and allow for maximum preparation from receiving trauma centers.14
To attain high performance and quality assurance, emergency medical service (EMS) systems must monitor the effectiveness of patient care delivery. Prehospital information is used to bridge the gap between education and competency. Reliable information can be used for educational reinforcement based on actual patient care for the purpose of improving patient care. Current activities include the National Emergency Medical Services Information System (NEMSIS), a nationwide electronic EMS documentation system.15 The NEMSIS will eventually be used for EMS education, to examine outcomes and evaluate trauma systems, and to generate research questions and evaluate cost-effectiveness.
AUTOMATIC COLLISION NOTIFICATION
Motor vehicle collisions (MVCs) are a significant cause of morbidity and mortality throughout the world. Trauma centers and systems have decreased mortality rates by providing MVC victims with appropriate and timely trauma care.13 Currently available automotive technology represents an opportunity to further enhance patient survival in the prehospital setting. Automatic crash notification (ACN) systems utilize collision sensors and wireless technology to detect and transmit information regarding the occurrence of an MVC.16,17,18,19 ACN systems provide an opportunity for decreasing the time between injury and EMS arrival, which may be especially important in rural areas where MVCs may go unobserved and therefore result in delayed notification of EMS. Moreover, the information available from newer systems (e.g., crash severity) can be used to estimate occupant injuries and aid in the delivery of prehospital care and thereby improve patient outcomes.20 Currently, the two largest commercial providers of ACN services in the United States are OnStar and ATX Technologies.
ACN services utilize systems that are integrated with the vehicle electrical architecture. The systems are activated by in-vehicle crash sensors and the resultant crash messages are transmitted by cell phone call to the service provider call center that is operated by the ACN service. The crash location (i.e., vehicle latitude and longitude at the time of the crash) is determined using global positioning system (GPS) and reported as part of the crash message. All currently available ACN systems provide the time and location of the MVC; some of the newer systems can also provide information on the nature and severity of the crash. Potentially, future systems, utilizing available technology could also include information on the number and seating position of vehicle occupants, restraint and protection system use, and postcrash vehicle orientation (e.g., overturned, vehicle rollover, and occupant ejection). However, currently ACN systems are not integrated with EMS or public safety agencies (9-1-1 centers).
When an ACN-equipped vehicle is involved in an MVC, the vehicle automatically transmits a crash message to the national call center operated by the ACN telematics service provider (TSP) (e.g., OnStar). The TSP attempts to talk to occupants of the car and when necessary, calls the public safety dispatch organization (i.e., the 9-1-1 call center) serving the region in which the crash has occurred, and verbally provides them with crash information including
crash location. Quantitative estimates of the potential benefit of ACN systems are dependent on the level of ACN market penetration (i.e., the number of vehicles on the road with ACN equipment). A recent estimate, assuming an ideal ACN system, suggested a 1.5% to 6% reduction in MVC deaths in the United States annually.21
crash location. Quantitative estimates of the potential benefit of ACN systems are dependent on the level of ACN market penetration (i.e., the number of vehicles on the road with ACN equipment). A recent estimate, assuming an ideal ACN system, suggested a 1.5% to 6% reduction in MVC deaths in the United States annually.21
HEALTH CARE AND MEDICAL INFORMATICS
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