Health Information Management: Integrating Information Technology ...

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WAITING FOR GODOT 23 Because of the increase in the amount of registered information, the number of health care providers, and the number of pre-structured forms to be filled out, the patient record had grown substantially thicker. Its basic format, however, had not changed along. As is still the case today, the information was mostly arranged by ‘source’. The x-ray forms, the bacteriology results, the progress reports of the physicians, the blood test results, clerical information—everything had its own section in the record. Within each section, the pages were arranged in a chronological order. Even the criticism of the content of the patient record still sounded the same as fifty years earlier—only louder. Critics claimed that the ‘progress of medicine’ was impeded by the fact that the patient records were ‘prejudiced, incomplete or noncomparable’ and that they were catalogued, crossreferenced, and integrated only ‘loosely’ (Anonymous 1950a; 1950b). As a result, they could hardly be used for studies of the clinical progress of pathologies or for studies of the results of intervention strategies. As the historian Reiser suggests, the source-based patient record was rapidly becoming a ‘dinosaur’: it remained a pastiche of laboratory reports, X-ray reports, nurses’ notes, social workers’ notes, statements by patients, objective facts, and subjective narratives. [It was] the endpoint of the network of communications that bound together the specialties dividing medicine… [and a] fragmented almanac of [the patient’s] total medical experiences. (1978) In fact, one of the first functions people had in mind for the computer involved medical reporting: It could accumulate and store complex medical records, which could subsequently be interrogated and manipulated for research and retrieval of medical history. (Anonymous 1960) Already in 1963 it was argued that EPRs were ‘inevitable’ and that possibly they would compensate for some of the shortcomings of paper records: the medical record is changing in bulk and character, and…the demands on the medical record system are increasing [due to] (a) the shift from acute infectious diseases to chronic disorders, (b) the increased life span of patients…, (c) the complexity of modern medical treatment, (d) scientific advances which have made it possible to observe more patient variables, and (e) the constant geographical migration characteristic of modern life. (Anonymous 1963)
24 STARTING POINTS How was the EPR introduced? Who were the important, steering actors in this development? In this section we will (rather patchily) outline the development of PICS from the 1960s up to the present. It is not our aim to provide an exhaustive historical account but merely to introduce a number of essential developments and actors as a context for the issues that will be discussed later on in this book. The first computers actually implemented in Western health care practice were large, centralized mainframes for the financial and patient administration of hospitals. The design and development of these systems was strongly stimulated by the Medicare Program, set up in the United States in 1965. This programme required hospitals to provide extensive, aggregated patient care information. Such systems did not play a role in the working life of physicians and nurses: during the 1950s and 1960s, they continued to work with the familiar paper records. The first EPRs used by health care professionals were developed in the 1970s in US outpatient clinics and general practices. One example of such a system was COSTAR, developed by the Massachusetts General Hospital. For each consultation, the physician was given a printout of the patient record, whereas during the consultation he would fill out a pre-printed form. Physicians themselves had no contact with the computer: clerical staff had to be present to produce printouts and to enter the data from the filled-out forms into the computer. The much cheaper ‘mini computers’ that entered the market in the 1970s made it possible for hospitals and clinics to experiment with computerized forms of medical data processing. Small experiments started up, such as the Artemis project in Paris, which supported care and research for patients in the Hypertension Clinic of Saint Joseph Hospital in Paris, or the ‘computer aided diagnosis’ system that helped detect acute appendicitis patients in the Department of Surgery at the University of Leeds. A project that started similarly small was the Nobin-HIS project, started in 1972 at the Dutch University Hospital of Leiden. This project was co-sponsored by the Dutch government. This computerized Hospital <strong>Information</strong> System (HIS) was aimed at streamlining the flow of information within the hospital, while a more general goal of the project was to develop an operating system specifically designed for hospitals. The Nobin-HIS project resulted in BAZIS, in which initially only university hospitals participated, though after 1980 general hospitals in the Netherlands joined as well. Each hospital that decided to purchase the BAZIS system was allowed to pass on its cost to its general nursing fee. In this way, a close connection was established between the software company, whose design was indirectly funded by government money, and the medical field: As a result of this whole scheme, a critical mass was generated: these first three university hospitals—Leiden, Rotterdam, Utrecht—were soon joined by Groningen and Amsterdam, and so forth. Critical mass was developed among the user group, for [BAZIS] was still a nonprofit foundation where
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Page 6 and 7: Contents List of illustrations vii
Page 8 and 9: Illustrations FIGURES 3.1 Medicatio
Page 10 and 11: Contributors Marc Berg is a physici
Page 12 and 13: Series preface In almost all Wester
Page 14 and 15: Acknowledgements I would like to th
Page 16 and 17: Chapter 1 Introduction In all Weste
Page 18 and 19: INTRODUCTION 3 touch upon the deplo
Page 20 and 21: INTRODUCTION 5 can draw upon to mai
Page 22 and 23: INTRODUCTION 7 Physician Order Entr
Page 24 and 25: Part I Starting points Understandin
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Page 34 and 35: WAITING FOR GODOT 19 In most cases,
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Page 56 and 57: WAITING FOR GODOT 41 Berg, M. (1997
Page 58 and 59: Chapter 3 Health care work and pati
Page 60 and 61: HEALTH CARE WORK AND INFORMATION SY
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THE CONTEXTUAL NATURE OF INFORMATIO
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Chapter 5 Meeting the challenge Int
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STARTING POINTS 81 ‘gender, race,
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STARTING POINTS 83 Now, imagine an
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STARTING POINTS 85 organization,
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STARTING POINTS 87 Figure 5.2 Incre
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STARTING POINTS 89 already overflow
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STARTING POINTS 91 responsibilities
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STARTING POINTS 93 answer the quest
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STARTING POINTS 95 Kohn, L.T., J.M.
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Chapter 6 Designing interactions En
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DESIGNING INTERACTIONS 99 the way t
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DESIGNING INTERACTIONS 101 1 Identi
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DESIGNING INTERACTIONS 103 the deve
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DESIGNING INTERACTIONS 105 communic
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DESIGNING INTERACTIONS 107 Figure 6
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DESIGNING INTERACTIONS 109 ■ Figu
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DESIGNING INTERACTIONS 111 measurem
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DESIGNING INTERACTIONS 117 Covell D
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Part II Information strategy, imple
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INFORMATION STRATEGY: AN INTRODUCTI
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Chapter 8 Developing the informatio
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STRATEGY, IMPLEMENTATION AND EVALUA
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Guidelines for information system d
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Chapter 9 Implementing information
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IMPLEMENTING INFORMATION SYSTEMS 16
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Chapter 10 Project management of in
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Index accumulation 53-4, 61, 73-4,
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INDEX 223 contingent and emergent c
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INDEX 225 satisfaction 176 patient
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INDEX 227 support 164 technology de
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