Abstract
Despite decades of research, healthcare information systems have been characterised by cost over-runs, poor specifications and lack of user uptake. A new approach is required which provides organisations with a reason to invest in this type of software. W Edwards Deming argues that quality is not an entity but derives from using feedback, iteratively to seek improvement to processes, in order to increase productivity and to make better use of resources. The authors propose that supporting this form of quality assurance (QA) using information systems (IS) has the potential to deliver a return on investment. An object-oriented analysis, where healthcare is viewed as the delivery of interdependent processes to which Deming’s form of QA is applied, results in a class model of data types that has some useful characteristics. It is able to store data about medical and nonmedical events; to save descriptions of procedures and to represent the QA process itself. With software based on the model, organisations will have a memory of previous attempts at making improvements as well as data about feedback from patients and staff to drive future change. A critical research in information systems (CRIS) analysis of this model proposes a number of criticisms deriving from theories about rationality; concepts of technology; politics and hidden agendas, as well as the social consequences of technology. The view that QA is a standardised, ongoing conversation about the important characteristics of a process pre-empts many of these counter arguments. The CRIS critique also highlights the need to ensure that development is in harmony with the needs of the many stakeholders in healthcare IS. These concepts lead to new directions in healthcare IS research. The class model needs to be tested against clinical and non-clinical use-cases for its viability not only as support for QA but also as an electronic patient record. A standard terminology is required for processes and for how objects from the model should be used to represent them. The model predicts that user interfaces will have to collect more detailed data than hitherto. Also use of the software should be tested in controlled trials to demonstrate whether the required improvements in quality not only benefit the patient but also the organisations managing their care.
TopBackground
Reviews of individual health information systems for the management of patients with chronic diseases are positive (Dorr et al., 2007) as are those of computer based nurse documentation (Ammenwerth et al., 2001). There is agreement that the overall costs and benefits have rarely been fully assessed (Herbst, Littlejohns, Rawlinson, Collinson, & Wyatt, 1999; Shekelle, Morton, & Keeler, 2006) but none-the-less Shekelle (2006) states that:
“Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from [Electronic Health Record implementation.] The quantifiable benefits are projected to outweigh the investment costs. However, the predicted time needed to break even varied from three to as many as 13 years.”
This conclusion is open to question because an understanding is required of how different research methods influence results (Moehr, Anglin, Schaafsma, Pantazi, & Grimm, 2006; Wyatt & Wyatt, 2003; van't Riet, Berg, Hiddema, & Sol, 2001). Consequently some authors have suggested the need for a broadly accepted, standard evaluation framework (Rahimi & Vimarlund, 2007; Ammenwerth, Graber, Herrmann, Burkle, & Konig, 2003; Ammenwerth et al., 2004).
An overview of academic medical informatics (Jaspers, Knaup, & Schmidt, 2006) suggested that:
“The computerised patient record ... is playing a growing part in medical informatics research and evaluation studies, but the goal of establishing a comprehensive lifelong electronic health record ... is still a long way off.”
Why should healthcare organisations invest in information systems that are yet to provide an electronic health record and which offer, at best, a modest economic benefit? We propose that they are most likely to gain if they establish a QA process and use software to support it.
Key Terms in this Chapter
Electronic patient record (EPR): allows health care providers, patients and payers to interact more efficiently and in life-enhancing ways. It offers new methods of storing, manipulating and communicating medical information of all kinds, including text, images, sound, video and tactile senses, which are more powerful and flexible than paper based systems. The policy of governments appears to favour a national healthcare infrastructure with a longitudinal patient record covering a patient’s complete medical history from the cradle to the grave. (Rogerson, 2000)
Object-Oriented Programming: A programming paradigm that uses “objects” and their interactions to design applications and computer programs. Programming techniques may include features such as encapsulation, modularity, polymorphism, and inheritance.
Object-Oriented Programming: A programming paradigm that uses “objects” and their interactions to design applications and computer programs. Programming techniques may include features such as encapsulation, modularity, polymorphism, and inheritance.
Quality Assurance: W Edwards Deming defined quality assurance as the continuous, systematic, iterative improvement of processes by obtaining feedback from clients and from staff. It may be viewed as a standardised, ongoing conversation about the important characteristics of a process.
Healthcare Information Systems: An information system (IS) is a system of persons, equipment and manual or automated activities that gather, process and report on the data an organization uses. A healthcare information system is one used by an organisation involved in the delivery of health care.
Quality Assurance: W Edwards Deming defined quality assurance as the continuous, systematic, iterative improvement of processes by obtaining feedback from clients and from staff. It may be viewed as a standardised, ongoing conversation about the important characteristics of a process.
Stakeholder: A person, company, etc., with a concern or (esp. financial) interest in ensuring the success of an organization, business, system, etc. (taken from OED Online: http://dictionary.oed.com/).
Critical Research in Information Systems (CRIS): An approach that draws from critical theories in the social sciences and attempts to discover angles typically overlooked by traditional research. A main aim of CRIS is to promote emancipation, understood as the ability of individuals to live a self-determined life.
Rationality: Best exemplified by the autonomous individual on whom neoclassical economic theory is built. Such an individual is rational because she has a complete set of preferences and acts in order to maximise her utility according to these preferences.
Electronic patient record (EPR): allows health care providers, patients and payers to interact more efficiently and in life-enhancing ways. It offers new methods of storing, manipulating and communicating medical information of all kinds, including text, images, sound, video and tactile senses, which are more powerful and flexible than paper based systems. The policy of governments appears to favour a national healthcare infrastructure with a longitudinal patient record covering a patient’s complete medical history from the cradle to the grave. (Rogerson, 2000)
Continuous Quality Improvement (CQI): The application of Deming’s form of QA to healthcare (see Quality Assurance below).
Healthcare Information Systems: An information system (IS) is a system of persons, equipment and manual or automated activities that gather, process and report on the data an organization uses. A healthcare information system is one used by an organisation involved in the delivery of health care.
Rationality: Best exemplified by the autonomous individual on whom neoclassical economic theory is built. Such an individual is rational because she has a complete set of preferences and acts in order to maximise her utility according to these preferences.
Stakeholder: A person, company, etc., with a concern or (esp. financial) interest in ensuring the success of an organization, business, system, etc. (taken from OED Online: http://dictionary.oed.com/).
Continuous Quality Improvement (CQI): The application of Deming’s form of QA to healthcare (see Quality Assurance below).
Critical Research in Information Systems (CRIS): An approach that draws from critical theories in the social sciences and attempts to discover angles typically overlooked by traditional research. A main aim of CRIS is to promote emancipation, understood as the ability of individuals to live a self-determined life.