Information Management and Information Technology (IM/IT) for Integrated Care

• Introduction
• Operational Effectiveness and Strategy
• Integrated Care – A Systems Approach
• IM/IT Building Blocks for Integrated Care
• The Importance of Architecture
• The Advantages of a Common Coding System
• Data Sets and IM/IT Strategies
• Information Access and Security and Consent
• IM/IT Tools for Integrated Care
• The Cost Benefit Equation
• Summary
• References

Introduction

Over the past 10 years the health industry’s “Information Management and Information Technology” (IM/IT) strategy has been constantly re-invented, in a frantic effort to support, and often mirror, an ever-changing health care delivery landscape.

As departmental systems such as Pharmacy, Laboratory and Admissions were implemented they offered some administrative gains. These early steps were soon followed by a slow and incremental development of systems supporting operational efficiencies including scheduling and waiting list or booking systems.

These developments rarely provided the promised gains and, looking back, it is not surprising because they were generally a series of unco-ordinated steps whose benefits were isolated, incremental and soon overshadowed by the negative effects of poor information flow.

To improve information flow and attempt to gain further productivity in the delivery of health care, IM/IT strategy moved from simply providing a view of departmental information, such as pharmacy or laboratory, to one that better reflected the overall delivery of care. The concept of “seamless connectivity” was introduced and was implemented in health care IM/IT by interfacing disparate health care departmental systems.

Interfacing health care IT systems with one another gave health care administrators the ability to link financial, administrative and departmental information. This gave a better view of the productivity of health care delivery. but did not achieve an integrated view of patient-oriented information. Also, while interfacing health care delivery did support the optimisation of departmental resources, it did little to support clinical decision-making or enhance patient care. However, the interfacing strategy did meet with partial success, providing the basis for a collection of hospital-centric transaction-level data.

The data were standardised, defined in specific data sets such as clinical records, coded and built around a proprietary model or architecture. The development of an IM/IT hospital architecture provided the overview or plan that could be followed when buying or building IM/IT systems and was an important step in highlighting the need for a similar planned architecture approach to IM/IT for integrated care. In essence, this was the beginning of the development of the fundamental IM/IT principles that would be required to support the advent of integrated care.

Today, this legacy of IM/IT investment, for better or worse, forms the basis on which future IM/IT strategies are implemented.

Operational Effectiveness and Strategy

Early development of health IM/IT systems supported the goals of improved service productivity and quality. While useful, and resulting in initial health care delivery operational improvements, the approach struggled to provide improvements that were more than just one-time gains. Operational effectiveness was understood as performing the same or similar activities better, and once operational effectiveness was optimised, this proved ultimately limiting in that ongoing gains were not realised.

The concept of leveraging IM/IT investments for strategic change offered significantly more promise, as it presented the opportunity to create new and improved activities or to perform old activities in different ways.  ¹  

The introduction of integrated care provides IM/IT strategists with the opportunity to develop a more strategic approach to supporting the delivery of health care. This will mean the development of a new set of IM/IT priorities. Unlike past IM/IT commitments, which focussed on technology as a means of automating administrative and operational areas, the new IM/IT priorities required to support integrated care will need to provide far more support for decision-making in the clinical delivery areas.

The introduction of more strategic opportunities such as the development of integrated care does not in itself ensure that the old ways will be abandoned or forgotten. The pursuit of operational effectiveness is seductive because it is concrete and more easily implemented. Health care managers remain under increased pressure to deliver short-term, tangible, measurable, improvements in performance. For this reason, there is always likely to be a tension between the ability to provide investment and skills to leverage IM/IT for strategic long-term gain and investment and skills leading to incremental operational efficiencies. This tension means that a rapid development in technology to support integrated care is unlikely without a change in management incentives.

Integrated Care – A Systems Approach

Integrated patient care is a health care delivery model that takes a “systems” approach, centred on the patient, to organising the entire continuum of health care products and services delivered to an individual over a persistent time period. In the US the “persistent time period” is often associated with the length of time with an employer, as it is often the employer who purchases the health plan on behalf of the individual employed. When the individual moves to a new employer, the organisation may have a different health care plan and therefore it is difficult to integrate care across organisations’ health plans. In New Zealand the persistent time period could be associated with the length of time an individual remains on a population register of an integrated care entity.

To support the concept of a patient being associated with an integrated care group over a persistent period of time, the concept of “patient registration” needs to move from an “event view”, such as a hospital admission or GP visit, to a “population view” of enrolled patients. This population view is usually based on a register of enrolled patients. A developing example of this is the age-sex registers of laboratory and pharmaceutical budget-holding GPs in New Zealand.

A population register that only accounts for patients in a primary care setting has significant weaknesses as a basis for integrated care because it only provides a fragmented view of the integrated care continuum. It does not provide a good basis from which to understand the dynamics of cost and care. In an integrated care system, there is a need to monitor discrete patient data flows between and within provider components and to make this information transparent, with appropriate security and privacy considerations, to the rest of the providers in the integrated care group.

A systems approach involves viewing the components of the integrated care delivery system as having inter-dependence, placing IM/IT in a much wider and more open context. This view of information is essential for assessing quality, allocation of costs, cost shifting and other measures which need to be monitored to successfully implement integrated care. It also provides a far more valuable information base from which to understand the relationships between the inputs, outputs and outcomes of the integrated care system with respect to patient(s). By using information to understand the system interdependencies, better decisions can be made about the most effective way to utilise resources to improve the health of the population.  ²  

A systems approach represents a significant challenge for IM/IT. New systems will have to offer a whole new set of enabling capabilities. In addition, existing systems will need to be replaced or be realigned from a provider-centric to a patient-centric approach.

The realignment and redevelopment of IM/IT for integrated care will also rely on priority spending on information technology, particularly as health care delivery shifts from inpatient to outpatient services, from specialty care to primary care, and from episodic care to population-based care.

The acceptance of greater financial risk under an integrated care model will also drive the need for more robust IM/IT systems capable of yielding measurable data across populations. To limit financial risk a broader set of information will be required and the information will need to be more readily available. All this demands an IM/IT strategy or implementation plan that is far more tuned than ever before to the business plans of both the health care providers and management organisations.

The integrated strategy for treating acute and chronic illness through the case management processes provides an excellent example of how reliant integrated care is likely to become on the new IM/IT tools.  ³  

Case management promotes a balance between high quality health care and cost-effective patient outcomes. In harmony with this delicate balance of quality and cost is the need to have access to “real-time” information, ie access to information as it is created, which can then be shared at every point of the care cycle to support:

• Health needs assessments
• Functional status assessments
• Standard protocols/guidelines for care
• Clinical pathways
• Variance tracking for outcomes reporting
• Wellness education for providers and health care consumers.

The care of a single patient could at any given time be reviewed/co-ordinated by a case manager in the acute care setting, home care setting, primary care physician’s office and the funder setting.

All four case managers will need real-time information about the care received in each setting within the integrated delivery system to ensure optimal treatment outcomes. It is the use of IM/IT in the capture, sharing and analysis of information that will be critical to integrated care strategies.

Focussing on chronic diseases is a common theme for systems integrating computer-based patient records. The Australian Commonwealth Government has recently introduced a range of co-ordinated care trials.  ⁴   The largest trial is within South Australia under the control of the SA Health Plus Unit of the South Australian Health Commission, with some 4,000 patients enrolled. The research/development goal of this trial is to leverage the administrative, financial and technical aspects of SA Health Plus by integrating the relevant information flows on GPs’ desktops such that GPs provide informed and appropriate care. The paper notes that “at the heart of the co-ordination of care is the interchange of information, and thus it is natural to expect electronic patient records and related data networks to play a major role”.

IM/IT Building Blocks for Integrated Care

Integrated care will require IM/IT to provide a more sophisticated set of enabling capabilities supporting a more demanding set of IM/IT goals such as:

• Supporting the collection of patient focussed data components containing a broad array of clinical, patient and financial information from across the continuum of care
• Providing a sound basis for analysis of the data
• Allowing the dissemination of the appropriate information in a timely and cost-effective manner leading to “information empowered behaviour”.

These IM/IT goals are not an exhaustive list, but do represent some of the fundamental requirements for IM/IT to meet the challenge of integrated care.

How will the above IM/IT deliverables be met? How far has progress advanced already? Are existing IM/IT systems primed for integrated care? Under an integrated care strategy, the individual providers cannot answer these questions in isolation; each member will be dependent on the other for information. In order to collect and share information effectively, the providers will need to have common agreements on some parts of their individual IM/IT strategies particularly in the areas of:

• An overall systems architecture
• Coding systems
• Data sets and definitions
• Management of information access by systems members and outside parties
• Privacy and security/communication and data encryption standards
• Guidelines for patient consent to information gathering and use
• Consideration on how best to meet the information needs of different cultural groups
• How to best align information strategy with a diverse set of business goals
• An understanding of the likely cost/benefits.

In essence, integrated care providers must now agree on some common basic principles for information management.The group governing each integrated care organisation will have an important role in endorsing and seeking compliance on these common agreements. It is likely that IM/IT requirements will need to be continually addressed to support evolving IM/IT requirements, particularly with respect to the shared components of the IM/IT infrastructure. Lack of appropriate leadership or governance is as much an inhibitor to IM/IT capabilities as it would be to the effective development of integrated care.

Governments can also play an important role in the development of basic building blocks for integrated care. In New Zealand there has been Government recognition of the need to ensure quality collection and transfer of data. New Zealand has in place standards for the transportation of health information (HL7, EDI) and data standards for national minimum data sets. Some progress has also been made toward the development of architecture based on the Good Electronic Health Record (GEHR). However, there is still significant development required to implement the comprehensive set of standards that would be required to support integrated care. As with most standards, compliance relies on the correct incentives. IM/IT should not be seen as a solution in its own right, but as an enabler or tool supporting the health sector’s business goals and objectives.

The Importance of Architecture

Architecture, from an IM/IT perspective, serves the same purpose as the architecture or blueprint for the construction of a building. The blueprint defines the end point – what the building will look like when completed – and the standards to be used during construction.

When an architecture is in place in an integrated care setting, individual provider IM/IT strategies can be implemented with confidence because the individual strategies will fit together, enabling the collection storage and sharing of information across provider groups. In an integrated care setting the architecture usually describes a form of electronic health record.

Many systems implemented prior to the development of integrated care may not have anticipated or incorporated the concepts of the new architecture requirements, limiting their longevity and usefulness in the new environment. Legacy system adaptability is an important issue; its consideration addresses the existence of the ongoing use and availability of historic data. The inability to integrate many heterogeneous legacy solutions within an integrated health care system continues to be a major inhibitor in providing an overall view of a patient’s continuum of care.  ⁵  

Currently, few integrated care IM/IT architectures exist which are “fully implementable”. The GEHR,  ⁶   although yet to be endorsed as a formal standard, offers the most potential and is currently being applied in the primary care setting.

Integrated care ideally requires an architecture that is not limited to primary care and allows for data to be shared from all points of care delivery and management. There has been a lack of investment in systems in the primary care setting to date. It is likely that as investments are made, they will be in systems that adhere to a GEHR or GEHR-like architecture. In the secondary care setting however, there has been considerable investment in IM/IT systems. These systems are generally continuing to use their own non-GEHR compliant proprietary architecture. To “GEHR enable” the secondary IM/IT systems would be an expensive and difficult exercise.

While GEHR can be applied to the secondary care setting, the investment in legacy non-GEHR compliant IM/IT applications by multinationals makes it unlikely to be adopted in the very near future. Despite this, GEHR currently provides the best option for the development of a comprehensive integrated care IM/IT architecture. This is largely due to the trend for integrated care systems to be based on delivery strategies that emphasise primary or community care more than hospital-based care.

The Advantages of a Common Coding System

Where data are to be aggregated, exchanged, abstracted, shared or compared, it is vital that they are collected using a “common” language, using a standard system of classification. Using different ways of classifying and measuring data makes it difficult to share data because of the problems of mapping one system of coded terms on to another.

For integrated care purposes, consistent coding becomes essential to support the implementation of quality, outcome and productivity measures. While secondary care has a long history of coding based on ICD and DRG type codes, primary care is in the early stages of adopting a coding based on READ and, in some systems, ICPC Plus.

The differing coding systems and philosophies adopted by the primary and secondary care sectors present another issue for IM/IT strategies for integrated care. Information needs to be viewed as a continuum and compared across systems; this requires consistent data definitions standards and coding practices.

Synergies between coding systems do exist, but not to the extent of being able to map one directly onto another. Coding philosophies also differ. In the hospital setting, all diagnoses are coded on patient discharge whereas a GP generally codes some of the diagnosis at the time of consultation and, as is possible with READ codes, this may be an entry under “reason for visit” rather than “diagnosis”. Primary care based on a population view relies on coding to identify the features of the population under care. Primary care based on individual consultations survives happily without coding as it arguably adds little to the process of care at the time of consultation.

The adoption of a clearly defined coding strategy for primary care is essential for the implementation of integrated care. Such a strategy would need to include agreement on the coding system to be used and the conditions that were to be coded. To be effective the strategy would need to be consistently adopted across the provider network and be supported with an adequate information transport strategy to ensure information did not remain trapped in individual practices. Support for coding on the GP’s desktop would need to be supportive of the process of care and not a barrier to doctor–patient interactions.

Data Sets and IM/IT Strategies

Agreement on what data are to be collected and coded is an important consideration for the IT support of integrated care. The uniform collection and coding of information is essential in order to standardise and present data in a meaningful way.

Collection of all possible data, as insurance for the future, is not a practical undertaking. The concept of a minimum data set is often used as a way of agreeing on basic data elements to be collected by a group. Minimum data sets define minimum sets of items of information, with uniform definitions and categories concerning the specific health care dimension, which meet the needs of multiple users in the health care system.  ⁵  

While a minimum data set traditionally has provided a base of comparable data across practice settings, additional data elements, other than those defined already, would need to be developed for integrated care. For example, the collection of information relevant to the contracting and monitoring processes unique to integrated care.

All care delivery strategies would rely on the ability to uniquely identify an individual as a patient. Unique patient identifiers become more critical under integrated care as a patient moves between components of the system, and outside the system, to receive care. The National Health Index (NHI) in New Zealand has for some time supported the sharing of information within the secondary care setting. Extending NHI use in a uniform way to the primary care setting would support the development of population registers and enable the linking of data elements by a unique patient identifier, providing the basis for a patient-centric integrated care architecture.

Information Access and Security and Consent

Providing information as a “by-product” of care is an important feature of efficient data collection in any health care delivery setting. Patient trust in a practitioner to deliver appropriate care extends to the practitioner’s appropriate use of patient information. It is not an area often well articulated by those requiring the information or those collecting it, but there remains an obligation to inform the patient on issues relating to the use and collection of information.

Poor performance in the area of informed consent will erode public confidence, lead to less co-operation in the provision of information, and form an impediment to delivery of integrated care.

Given the sensitivities in the use and collection of information, this is an area that is best dealt with up front by the development of agreed procedures to guide the doctor-patient discussion or IPA-funder discussions. This usually includes development of practice guidelines for information and standard pre-agreed templates for releasing information.

New Zealand is fortunate in having a well-developed and implemented Privacy Act and Health Information Code, which provide adequate guidance on such issues. The Privacy Act 1993 is based on the aim that the collection, storage, use and disclosure of personal information should be carefully considered and that all activities in this area should be as transparent as possible.  ⁷  

It is unlikely that integrated care could function well without some sort of Health Information Network (HIN). Prior to the growth in use of the Internet, the cost of moving health transactions in a low volume market was likely to be disproportionate to the actual value of the information. Now that the Internet provides a more economical platform for the transfer of health information, there has been a renewed focus on ensuring that information is moved across the integrated care delivery system in a secure environment that can provide:

• Authentication (are you who you claim to be?)
• Non-repudiation (can you prove this data is yours?)
• Integrity (has this information been altered?)
• Confidentiality (are the data sent and stored securely?)
• Authorisation (are you allowed to do what you are asking to do)
• Is there an auditable log of the key transactions (can you log who, what, where, when?).

Health claims, laboratory results and NHI numbers are electronically transported within New Zealand, although they are not yet transported across the Internet. The transactions are subject to various approaches to security and encryption. The development of national standards related to security and encryption for health information is under discussion and remains an ongoing issue.

IM/IT Tools for Integrated Care

In an integrated care setting, large quantities of data will be needed for decision-making and support purposes. These data will need to be accessed by a number of different people, possibly for different purposes, at the same time. Furthermore, the lead-time for fulfilling data needs must decrease while real-time availability of information must increase.  ⁸  

Decision-making support tools tend to play a greater role in integrated care setting because the responsibility for care is more likely to be shared across provider settings and more likely to be standardised in its approach. A medical-based decision support system (DSS), is a computer-based decision support system that is designed to help health professionals make clinical decisions.  ⁴   This broad definition allows one to include medical DSSs that range in functionality from those that merely display relevant medical data to the most advanced expert systems. A passive DSS provides the right information at the right time. In contrast, an active DSS applies medical knowledge to a specific patient’s data and recommends a specific conclusion or course of action.

Clinical guidelines have existed for some time in printed form but have recently been integrated into DSS-type systems. In this way, the guidelines can be integrated into physicians’ daily decision-making processes, increasing the probability of effective implementation, particularly as the decision support is provided at the time and place of consultation.

Other technologies that have also recently been applied successfully to the integrated care setting include:  ⁸  

• Data warehousing – facilitating easier access to information
• Document imaging – online storage, retrieval and management of electronic images of documents
• Integrated voice response and workflow management systems – automating customer-oriented services
• Home monitoring – enabling the tracking of health status in a patient’s home
• The Internet – used as a medium for wellness information.

The Cost Benefit Equation

Putting information at the fingertips of clinicians and funders in support of integrated care has the potential for tremendous impact. While this impact can be quantified in terms of a business case for integrated care, the direct benefits are not always as transparent for IM/IT.

The Healthcare Financial Management Association of America (HFMA) launched an initiative in 1996 to determine whether significant cost savings are made possible by using information systems that merge clinical and financial data in integrated health care networks.  ⁹   After in-depth interviews with chief financial and information officers at 17 selected health care delivery or managed care networks, HFMA found that the benefits accrued from such data integration have been ‘soft’ benefits – not the kind that translate easily into a dollars-and-cents return on investment.

Because of the difficulty of measuring the direct benefits of strategic IM/IT investments for integrated care, there is some support by managed care finance executives in the United States for measuring the success of the process the information system supports rather than looking for measurable IM/IT gain.  ¹⁰   In the context of measuring the process rather than the IT system, the potential gains for IM/IT investment in integrated care could include a reduction in health care resource utilisation from the ability to use information to more appropriately target health care services, and improved health outcomes resulting from the availability of clinical information.

Summary

The introduction of integrated care offers IM/IT the opportunity to develop a more strategic approach to supporting the delivery of health care; this new approach will result in the development of a new set of IM/IT priorities. Unlike past IM/IT commitments, which used technology as a means of automating administrative and operational areas, new IM/IT priorities required to support integrated care will provide far more support for decision-making in the clinical delivery areas.

Implementing IM/IT requirements for integrated care will require a leadership or governance structure that can provide collective agreement on evolving IM/IT requirements, and can make decisions regarding ongoing capital to support shared components of the IM/IT infrastructure.

Lack of appropriate leadership or governance is an inhibitor to integrated care, as it can often make it difficult to put in place the IM/IT system building blocks required for effective IM/IT management.

When an IM/IT architecture is in place in an integrated care setting, individual provider IM/IT strategies can be implemented with confidence that the individual strategies will fit together enabling the collection storage and sharing of information across provider groups.

In addition to IM/IT architecture, there is the need to standardise the management of information. Implementing a coding strategy becomes essential to support the implementation of quality, outcome and productivity measures.

Public confidence in the management of information by integrated care providers is essential to ensure the ongoing provision of patient information. Clearly defined protocols for information collection, storage, use and access are necessary components of any IM/IT strategy; however, their relevance in integrated care setting becomes significant as considerably more information is likely to be collected and transported around the system.

In transporting information across the continuum of care, it is unlikely that integrated care could function well without some sort of HIN. While local and wide-area networks are a common feature of current provider IM/IT strategies, to support the multiple provider environment of integrated care a more robust network infrastructure would be required, addressing such issues as security and privacy.

The benefits of an IM/IT strategy for integrated care have proven difficult to measure. There is some support for measuring the success of the process the IM/IT supports rather than looking for measurable IM/IT gain. While the benefits of integrated care are more transparent and quantifiable, these would become less so without adequate IM/IT support for integrated care.

References