Health Information Management: Integrating Information Technology ...

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WAITING FOR GODOT 29 organize their data entry according to the SOAP structure, and whether or not they code diagnoses, for instance. One problem has been that GPs feel it takes too much time to register data this way, not the least when ‘insignificant’ problems such as small infections are at stake. While the Dutch GPIS ‘diffused’ into Dutch GP practices very rapidly during the 1990s, the success story has turned into a near-disaster during the last few years. Due to sharply increased development costs, high existing functionality and uncertainty about future directions for development, many vendors have left the highly fragmented and small Dutch GPIS market. This has left the Dutch GPs with unsupported, often 10–20 year old systems, with no clear perspective what the future will bring. Some observers hope for international convergence in GPIS development, others see more future in integrated information systems for integrated health delivery organizations (that is to say: no more separate GPIS). Still others plead for Open Source GPIS development. What the future will bring is as yet difficult to predict. The Danish situation: scaling up a local initiative Just like in the UK and in the Netherlands, developing an EPR for Danish general practice has been closely connected to standardization of GP work. In Denmark in 1984 the Danish GP Association (PLO) decided in principle to support an intensification of ICT in general practices. Quite detailed specifications were developed for what the systems should look like, and several GPs were active in this work. The vision, primarily, was a GPIS that would make the financial administration of GP practices easier and—later on—enable electronic transfer between different ICT systems embedded in the different health care sectors. The GP Association developed a system called Apex, which was offered to all GPs. One of the immediate benefits for the health authorities in supplying electronic support for administration was that the GPs would begin to settle accounts electronically. This saved much administration for the state driven health insurance (Sygesikringen). As a result several of their staff members were laid off in the mid-1980s. To stimulate electronic accounting GPs were also offered a one-time amount of 1,350 Euro. The GPs were pleased with the possibility of using ICT for administration as well. Like the Dutch GPs they were used to spending their evenings on bookkeeping. The electronic system saved time and it even helped them remember to bill ‘small things’ like phone consultations, which they would sometimes forget. In the late 1980s the GP Association had to close down the Apex system, since it could no longer afford the cost of its maintenance. Its users felt it was ‘heavy’ and not very ‘user-friendly’, and its ‘diffusion’ had been disappointing. This kicked off several small projects, started by enthusiastic GPs who were eager to improve their EPRs. One of the
30 STARTING POINTS successful initiatives was the FynCom project. Its participants aimed at developing a system that would enable GPs to send and receive lab results, specialist letters and prescriptions using the EDIFACT standard. One of the GPs, who was part of the project from its beginning, explains: In 1990 we got the ‘informatics scheme’. It was about how the politicians wished to develop health care ICT until the year 2000. The scheme consisted of 120 pages and on page 117 it said that perhaps one could imagine that in year 2000 primary and secondary health care organizations would be able to communicate with each other. We had tasted blood and agreed that we could not wait for that long. (Interview, GP, 1101) In 1994 the standards developed by the FynCom group were transferred into a new project called MedCom, whose aim it was to make the protocols work on a national level. At that time, the extended possibilities for data exchange implemented by means of a number of locally based pilot projects had become a major incitement for non-computerized GPs to start working with an EPR. New possibilities of sending and receiving data also meant that the content of the EPR was suddenly experienced by the GPs as very unorganized; it was basically one ever-expanding ‘toilet roll of text’. They needed some organizing principles in order to keep an overview of their notes. Simultaneously, as elsewhere in Europe, health authorities felt a growing need to monitor GP practices to be able to better control health care expenditure. In the late 1990s diagnostic codes were integrated in updated versions of the GPIS available on the market. The classification used was the International Classification of Primary Care (ICPC), which was developed to register not only end-diagnoses, but also, for instance, a patient’s reasons for encounter (the Dutch GPIS uses the same classification). At present day health authorities are searching for ways to use data from GPs databases for research purposes. This is no easy task. First, GPs easily feel that they become subject to external control, and many do not feel it is their job to register for ‘external’ purposes. Second, comprehensive policy aimed at protecting patient privacy is felt to stand in the way of such external use of data. The ministry of health has now put forward suggestions to reinterpret the strict rule that patients must give a written consent before anyone can exchange patient information. Recently, within the ministry of health, the problem-oriented medical record has been put on the agenda. The aim is to enable more detailed registration of chronic diseases and subsequent transfer of this data into clinical databases. A National Indicator Project launched to develop
Page 2 and 3: Health Information Management In al
Page 4 and 5: Health Information Management Integ
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
Page 26 and 27: WAITING FOR GODOT 11 KEY TERMS ■
Page 28 and 29: WAITING FOR GODOT 13 Netherlands an
Page 30 and 31: WAITING FOR GODOT 15 facts to show
Page 32 and 33: WAITING FOR GODOT 17 (Lewinski-Corw
Page 34 and 35: WAITING FOR GODOT 19 In most cases,
Page 36 and 37: WAITING FOR GODOT 21 (Anonymous 191
Page 38 and 39: WAITING FOR GODOT 23 Because of the
Page 40 and 41: WAITING FOR GODOT 25 they simply sa
Page 42 and 43: WAITING FOR GODOT 27 expected. Stil
Page 46 and 47: WAITING FOR GODOT 31 performance in
Page 48 and 49: WAITING FOR GODOT 33 different HIS
Page 50 and 51: WAITING FOR GODOT 35 CONCLUSION: TH
Page 52 and 53: WAITING FOR GODOT 37 assumption tha
Page 54 and 55: WAITING FOR GODOT 39 Anonymous (191
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
Page 78 and 79: 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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