Health Information Management: Integrating Information Technology ...

84 MEETING THE CHALLENGE
treatment: patients also happen to have individual desires, needs, complications,
social histories and so forth. As a consequence, the delivery of health care is
traditionally organized to meet this need for high flexibility: every patient
follows his or her own trajectory, which is decided upon on a step-by-step basis.
You see a doctor, who decides, for example, that tests need to be done. These
tests are subsequently arranged for you, and upon the evaluation of their results,
the next step to be taken is decided upon and organized.
This step-by-step organization of health care work may result, in principle, in
a health care trajectory that is optimally geared to the individual patient’s needs
and desires. As a corollary, this organization also affords the individual health
care professionals a relatively large autonomy over their own work processes.
The gynaecologist, organized in an organizational unit with other
gynaecologists, decides when to receive a patient and how to deal with her just
like the surgeon does for his patients, the x-ray department does for its clients,
physiotherapists do for their patients and so forth.
Yet in the highly specialized environments of current Western health care, this
mode of organization now rather results in a very fragmented experience. The
lack of coordination between the individual steps and decisions has become deeply
ineffective, as we have argued above. In addition, it has also become very
inefficient (for both health care provider and recipient). Outweighing the pros
and cons of a decision and organizing the next step to be taken every time anew
takes up much time. In addition, the lack of overview over the use of all the
required facilities (nurses, specialists, laboratories, MRI equipment) guarantees a
suboptimal utilization of these facilities.
The result of these modes of organizing the work is a high variability in the
course of patient trajectories, even between physicians within health care
institutions, and the subsequent impossibility to be transparent about the care
processes in the health care institution (let alone its outcomes). This variability
and lack of transparency (and consequent inability to learn from and improve
upon their own approaches) is painful even to those that are critical of the ideals
of evidence-based medicine.
Given all these problems, the basic organization of health care work as a oneby-one,
step-by-step processing of individual patients’ problems needs to
be revisited. Indeed, on the level of the individual patient trajectory, every
trajectory is unique, and no predictions can be certain. Yet on the aggregate
level, of categories of patients—such as ‘heart failure’, or ‘monitoring of diabetes
type II’—what has to be done, and how patients will react is predictable. As a
rough guiding figure, one can say that 70–80 per cent of the patient flows in any
given health care sector can be made predictable enough to warrant the
production of care paths. Within these care paths, 70–80 per cent of the steps and
decisions can be explicated. These paths are multidisciplinary: tying in the
activities of doctors and nurses, of different specialties, and explicating a central
role for the patient whenever possible. When one organizes these categories
around the problems with which patients present themselves to the health care