Working the truth and perfecting the moment for physicians and patients: a serious challenge for information systems.

Most of us looking at the field of computers, systems, applications and the like are struck, if not turned off by, the flurry part of the activity. There is often little there that bespeaks of working the truth. This is particularly true in health care computing. For most who have come in contact with patient care systems, there has been disappointment, decoupling of cost and value (a nice way of saying: pay a lot, get little), and a sense of yet another "solution" being forced into place, taking the physician and clinical team farther away from "just being able to take care of patients." More times than not, systems are lumped into the hassle factor we all know too well.

From the patient point of view, systems are often equally frustrating in our health care environments. Lost test results, faulty appointment systems, and so forth. More and more, the patient is given the excuse that "the system lost it," or "the system is down."

The report of the Institute of Medicine Committee on Improving the Patient Record has stated clearly that there is no need for new technology breakthroughs to establish the computerized patient record.[1] New and efficient programming environments are available. Hardware is cheaper and more powerful. The stars are lining up, and systems can now be built and implemented that serve the care process as it has never been served before.

From time immemorial, the basic activity of health care has remained unchanged. I represent it with the simple Venn diagram of "health-caring" figure 1, page 11). Someone with a disease or an "owie" would seek help from someone with skill and knowledge to alleviate the problem. Whether this has been a witch doctor, a barber surgeon, a country doc, or our current array of generalists and specialists, the interaction has remained basically the same. Health care and support have always passed from the healer into the shared space with the patient. Equally important is what passed from the patient into that space. History, physical (each patient owns one physical), and some form of payment.

It is in the shaded area in the diagram that all things come together. This is where the art of medicine is applied; it is here that physician trust is born; it is here that a unique, interhuman, professional relationship is held sacred. It was here that money or barter took place as the patient paid for the help rendered. In recent years, the payment part of the relationship has been lifted out through insurance, employment benefits, and entitlement programs. The "third-partizing" of the barter has, of course, opened the door for payers to ask questions about services provided within that sacred space. The interchange has become very complicated and political, because the health component still needs to flow into the shared space. Because others are now financing it, questions of quality, value-added service, and resource management are thrust into the space. When this happens it's likely physicians will be heard asking: "Who's treating this patient, anyway?" It's equally likely patients will be heard asking: "What about me? I'm the one naked under this gown, and I'm worried about my health and well-being. Is anyone else?"

How does this all relate to information systems? Information systems must be aligned with one mission: to help perfect the shared space between the healer (physician, clinician, provider) and the patient. Information systems must support both stakeholders in that interaction. Let me approach this concept further with a series of algebraic equations.

Clinical Information System = Customer Information System: CIS (or Computerized Patient Record, CPR)

The computerized patient record must serve both sides of the health care interchange by being a complete clinical information system for the providing side and a complete customer information system for the patient side.

Working the truth, I have found that four basic equations need to be addressed when evaluating whether computer systems are aligned to perfect the basic unit (business and clinical unit together) of health care:

Equation #1: S = P - E (Satisfaction equals Perception minus Expectation)

If we are to place systems into an effective role in the shared space between patient and doctor, we must manage the "S" equation very carefully. Because system planners have often not come from a strong clinical background (often from a financial background), the pictures that are painted on blue sky, representing large expectations, have often been met with much weaker perceptions of actual system capability, ease of use (friendliness), and user value. In the equation, then, the "S" is negative. Therefore understanding, rather than setting, of expectations is needed to perfect the moment between patient and doctor and is a key way to work truth with information systems.

What information do physicians need at the moment of clinical interaction with their patients, and in what form? If the reality (perception) is that they must be computer wizards to get a lab value out of a system, and they were led to expect "information at their finger-tips," what's happened to their satisfaction levels? What do physicians expect of the actions (orders, prescriptions) they must make during that shared moment with patients? You'd have to be accomplished on the computer to beat the pen and pad with a key board and a set of computer-generated screens. What do physicians expect in terms of appointment scheduling, billing, or claims filing, which should come out of the shared moment? Once systems start to roll out and computers start landing on physicians desks, it's perception time. It's "S" time. If expectations have not been properly managed by thorough understanding of the information needs and timing requirements within that shared doctor-patient space, if proper training and attention to practice processes have not taken place, the hoped for large positive "P" factor can diminish toward zero in the face of huge and ill-focused expectations. The low and mounting rumble that emerges in the organization, often coming out of the doctors lounge, is a growing negative "S" factor.

Negative satisfaction among physicians is extremely difficult to turn around, especially when it comes to technology adoption. The literature on change management is very convincing on this subject. Therefore, who's in charge of this first equation? It had better not be a "techy" or a finance person when you're thinking about clinical systems and the sacred shared space. It won't work and truth won't be worked. Clinical leadership is the only way in health care to set the E, shape the P, and harvest the positive S.

Equation #2: S/0 > 1 (Strategic Influence over Operational Influence should be equal to or greater than One)

Basically, what this equation says is there must be a significant shift in the way we think about computer systems. It has probably been most clearly stated by Moriarty.[2] Most systems, because they are from financial origins or production environments such as manufacturing, have had a very strong operational focus. How can the system increase worker productivity? How can the system cut staff through automation? These are operational questions. They aren't bad questions, but they are "cart-before-horse" questions for health care. In planning systems, in evaluating system capability, in creating the place for information management within the health care environment, taking an operational approach will more times than not miss supporting the physician and patient as the basic health care unit of action. By taking a strategic approach, we are driven to working truth and looking at the mission of the organization. We must reflect on the best way to succeed at the mission. If high-quality health care delivery at an appropriate cost is the mission, how do systems support it? Are we installing systems to make physicians more productive, so we can hire fewer docs? Or are systems being shaped and installed that are supportive of physicians in their role of delivering high-quality, cost-effective care. Do we justify systems because physicians have poor handwriting--i.e., improve the situation operationally for nurses, clerks, and so forth? Or do we justify systems because they assist physicians in their communication of key decisions, be those orders or charting? The latter is of strategic importance to the health care delivery mission.

Therefore, to get the truth worked out of this equation is to lead with the strategy of perfecting that shared moment between physician and patient. Succeeding at the bottom line business of health care delivery will be very competitive. If the approach is the traditional one of operational improvements, the organization will miss the golden opportunity to focus on a strategic goal. This means raising performance requirements and then using information systems to bridge the performance gap between what might have been just an operational improvement of some merit and a new strategically competitive and effective position (figure 2, above).

Equation #3: C/A = 1 (Control over Accountability equals One)

This is more than an expanded "CYA" maneuver. It is really a basic unity equation for all of us. Systems must provide the information necessary at the time and place necessary to allow physicians to operate successfully within this equation. Clearly, physicians cannot be held accountable when the gods and the patient protoplasm finally decide to shut down the flow in that left anterior descending artery. However, physicians are held accountable for patient care issues over which, owing to lack of information, they have little control. For instance, there is charting of increasing severity of hypertension in the blood pressure clinic for one of your patients, and no one notified you that pressures were going off the map? Your C/A is less than one on this one. This could mean an unnecessary hospitalization, or an uncomfortable departmental quality review, or even uncomfortable and costly time on the witness stand.

Information systems must support accountability. Information needs to be available to those who are responsible for the matter at hand. The person responsible is usually the physician. Going back to Equation #2, it is of strategic, not operational, importance to support the ultimate person accountable for patient care. In short, if you make physicians' C/A equations equal to one, you've worked the truth of unity in responsibility allocation and you've added tremendous, well-directed value, through automation. "Physicians are more likely to alter divergent behavior if they are involved in the process of assessing their own practices."[3] How better to do this than through well-targeted supporting information systems supplying meaningful data. This applies here and in the next equation.

Equation #4: II = TR - TC (Profit equals Total Revenue minus Total Cost)

This is the most basic accounting equation in business. When applied to health care, it takes on a very charged nature. Human life and limited resources are involved. Health care is a marketplace for most. It is not lost on anyone that the market is getting very competitive and consumer-oriented. The federal government, through Clinton Health Reform, will be in that marketplace in a very powerful way. Spending caps, managed care, and health care reform will first attack and attempt to hold in check the total revenue side. What can be the role of information systems in supporting physicians and health care providers in this equation?

Systems need to focus on total costs (TC = VC + FC). Total costs (TC) are made up of variable costs (VC), which are incurred each time you perform a service (a tongue blade is a variable cost when working up a sore throat), and fixed costs (FC), which are incurred whether you perform any particular service or not (office rent). Cost controls usually focus on variable costs over the short run. For example, buying tongue blades in quantity will make each unit's variable cost less per sore throat seen. Some fixed costs can be attacked over the longer haul, such as renting cheaper office space next time. In general, cost controls focus on variable costs.

So for the physician taking care of patients, what defines fixed costs besides the basic plant and equipment? I like to suggest that practice patterns, self-imposed protocols, and the like make up a lot of the fixed costs associated with the shared space between the physician and the patient. In some ways, even though we are examining an accounting equation, we are really looking at a clinical equation. We can see that total cost could be seen as a diagnosis with all its associated costs. What are the fixed costs of any diagnosis? Aren't they driven by clinical knowledge and activity? Systems must help physicians translate the clinical data associated with the fixed cost portion of their care activities into variable costs that they can manage. Physicians must know that some of these variable costs are ripe for cutting and some of them are appropriate for increasing. The direction varies with each patient and with different patient groups.

How do we enhance physicians' ability to manage the accounting equation of health care? Information systems focused on the necessary detail of clinical data associated with the care process are a very real answer. Putting aggregate care data into physicians' hands to allow those responsible for care outcomes to understand the factors affecting outcomes is the only way to get to the heart of the challenge. Managed care that attempts to manage physicians with data of coarse granularity garnered from distant claims data, DRGs, etc. will always create a tension between those in the shared space--the physician and the patient--and those paying for the care. Those paying for the care are trying to work the cost equation, not the clinical equation. With distant data, such as claims data, they appear to be doing brain surgery with a jack hammer.

Management of the care process in a cost-controlling manner must be delicate and focused on aspects of care whose cost can be reduced with no worse than an indifferent outcome. The fine and delicate data needed for turning some fixed costs into variable costs in our thinking will necessarily be gathered from the care process itself and will be seen as a whole for the patient. Making this type of well-differentiated and detailed data available first to physicians and allowing them to ask how they are doing with outcomes when they have kept track of all the inputs creates a very strong and supportive environment for physicians to adjust practice patterns and share best practices. It gets us past the point of "I've always done it that way," or "That's the way I was trained." It also takes us to the point where clinical systems are a very sophisticated cost accounting system supporting the ultimate clinical manager--the physician. The trick is to manage physicians with clinical data consistent with and balanced against the numbers, not the reverse.

The idea that new systems must support the patient side of the Venn diagram is very important and often is paid only lip service. Successful information systems perfect encounter moments for both participants equally. Therefore, we must apply the same four equations for the patient. We must think of the same CIS, but focus on the customer information system aspects and less on the clinical information system aspects to balance the moment.

The patient will be satisfied (S = P - E) only if expectations of care and service are met with perceptions that equal or outshine those expectations. Patients are often very dissatisfied because the perception of service is so much less than expected. Information systems must support the service component of health care organizations. At any point of service, patients must not feel they are fighting for their sanity to make sure we, on the providing side, all know at least their names, not to mention their correct insurance numbers, correct demographics, correct employer grouping, and so forth. They expect that providers know them, haven't lost information about them, and haven't confused them with someone else. Yet we all know the truth about working this equation. The journals are full of it, the popular press is full of it, and so are the malpractice courts. "S" levels are intolerably low for health care information management. We have failed to deliver because we have not focused systems on patient and physician needs, and therefore "P" hits new lows along with "S" each day.

How can the customer information system (aka the clinical information system) be strategically focused for the patient (the S/O > 1 equation)? Isn't the "strategic" significance of health for people at the very core of living happy and prosperous lives? If health is approached as an operational paradigm from the patient point of view, we are only looking at the chronic illness model, whereas a strategic focus speaks of health maintenance, prevention, and proactivity. A strategic, patient-focused CIS has health maintenance as its number one goal. How much can we reduce health care expenditure dollars if the CIS has, as proactive components, patient-specific health care alerts, reminders, and readily available self-care and maintenance information?

Consider the new wave of interactive TV and the potential of alerts and reminders being available to the patient through a different type of "chart"--the patient's chart channel. It is not too far out to consider that a large accountable health care organization will be offering a health channel to its members, through which they could access patient-specific information along with regular health-related programming. The technology is not a problem. The focus has been.

We must address the performance gaps and reach for the strategic goal for our patients. Patients need information to share in the management of their health. This leads to the next algebraic equation for the patient.

Accountability and control (C/A = 1) from the patient point of view has often been the place where managing the best outcomes of care has been a problem. Patients often don't understand their diseases (or disease prevention) and don't understand their part in monitoring their own progress in therapy. Because of the intensity and pace of modern medicine, the inclusion of the patient in the care management process has fallen further and further out of step. Yet even malpractice data show that informed patients, patients included in the process of their care decisions, are less likely to sue, even if there is an iatrogenic event. At some basic level, most people know they are accountable for their own lives and well-being, but health care delivery has assumed a very controlling position in that process.

Many patients are almost decoupled from their physical selves by our delivery systems, as we take their diseases from them, appear to take responsibility for them, diagnose and treat their diseases, and give them back the new square on the monopoly board (their outcome) where they must take up living their lives again. Some of the time, this works, and people are eternally grateful that they have been cured and fixed. But we are learning that there is a price for that dependence, manifested by lack of commitment to and nonunderstanding of treatment plans, malpractice litigation, and patients' not liking what we ultimately handed them. Information availability supported by information systems focused on patient participation, knowledge, and partnering in that shared space works the truth toward accountability and responsibility on their part.

Finally, in the accounting equation from the patient point of view (Profit = TR - TC), patients must be made managers of their own cost structure. Ultimately, for the delivery system, they supply the revenue through their hard work supporting benefit programs and through taxes supporting government programs. Although it would be stretching to say that patients are concerned about maintaining a large profit for the provider world, they do in general subscribe to the democratic marketplace and want successful physicians and organizations to be available to serve their health needs. Patients don't want the health care system to go out of business, but they and their employers want to bring down total revenue. Like physicians, patients need to be allowed to be a part of the decision process to lower fixed costs.

Again, I am addressing fixed costs as clinical factors. Probably the best example is the well-known work being done on informed choice for transurethral prostatectomies (TURPS). The procedure used to be a fixed cost: you were male, you aged, you started getting up 3 or 4 times a night to relieve yourself, and you and your doctor determined a TURP was a fixed cost of your benign prostatic hypertrophy diagnosis. By applying information to the shared moment, the TURP fixed cost has become a variable cost, manipulated by the clinical decision-making partnership between patient and physician. A surprising number of men, when presented with clear, customer-focused information, choose to pass on the surgery. Through more informed patient choice, costs went down; patient self-control went up; and, without an increase in revenues, profitability for the managed health care delivery system was improved.

The world is changing and physicians must manage the best and most cost-effective outcome for our patients and demand that both we and our patients have good information or it will be taken from us a our patients. We must work the truth with good information made available to both "managers" in the shared space. We all look forward to a day when this new technology will play its expected role in maximizing positive outcomes of that sacred interaction.

References

[1.] The Computer-Based Patient Record: An Essential Technology for Health Care. Dick, R., and Steen, E., Eds. Washington, D.C.: National Academy Press, 1991. [2.] Moriarty, D. "Strategic Information Systems Planning for Health Service Providers." Health Care Management Review 17(l):85-90, Winter 1992. [3.] Greco, P., and Eisenberg, J. "Changing Physicians' Practices." New England Journal of Medicine 329(17):1271-4, Oct. 21, 1993.

Further Reading

The following additional sources of information on the computerized patient record were obtained through a computerized search of databases. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000. Adineh, M., and Zamczyk, R. "Charting a Course toward the Electronic Medical Record at Stanford." Healthcare Informatics 10(4):86-8,90, April 1993. Ball, M. "Aspects of CPRs (Computerized Patient Record) & Organizational Redesign." Healthcare Informatics 10(6):28,30, June 1993. Bergman, R. "Electronic Medical Record Makes Life Simpler for Clinic Physicians." Hospitals and Heal Networks 67(14):60, July 20, 1993. Braunstein, M. "The Electronic Patient Records Solution." Caring 12(7):30-3, July 1993. Bria, W. "Person-Side Terminals: The Missing Link in Patient Care Information Systems. Look Doc, No Wires..." Healthcare Informatics 10(5):50-2,54, May 1993. Davis, M. "Reaping the Benefits of Electronic Medical Record Systems." Healthcare Financial Management 47(6):60-2,64,66, June 1993. DeHart, K, and Holbrook, J. "Emergency Department Applications of Digital Dictation and Natural Language Processing." Journal of Ambulatory Care Management 15(4):18-23, Oct, 1992. Dittbrenner, H. "CPR Systems -- Resuscitation for Health Care Records." Caring 12(7):24-6,28, July 1 Fitzmaurice, J., and others. "Patient Identifiers: Stumbling Blocks or Cornerstones for CPRs (Comput Based Patient Records)?" Healthcare Informatics 10(5):38-40,42, May 1993. Gabrieli, E. "Aspects of a Computer-based Patient Record." Journal of the American Health Informatio Management Association 64(7)70-82, July 1993. Gleser, M. "Benefits and Obstacles for Hospital Executives of the Electronic Medical Record." Health Information Management 7(l):32-4, Winter 1993. Marcoux, K "Opportunities Abound for Automating the patient Record." Medical Group Management Journal 39(6):46-8,54-5, Nov.-Dec. 1992. Martin, A." The Development of a Computerized Information System for Clinicians." HMO Practice 7(2):56-60, June 1993. Martin, G., and Baker, G. "Measuring the Benefits of Bedside Systems." Healthcare Informatics 10(5):26,28,30, May 1993. Merriman, W., and others. "Chart Tracking Systems: Prerequisite to Medical Records Automation." Healthcare Informatics 10(4):58,60, April 1993. Neame, R. "Making the Case for Healthcare Smart Cards." Healthcare Informatics 10(6):16,18,20, June Pace, K, and Dittbrenner, H. "Electronic Data Interchange--A Vision for Health Care." Caring 12(7):1 6,19-20,23, July 1993. Paige, L. "Implementing a Mainframe Coding/Abstracting System." Topics in Health Information Management 13(l):27-34, Aug. 1992. Rollins, P. "Converting to an Optical Disk System." Topics in Health Information Management 13(3):30 44,Feb.1993. Schoenleber, M., and Elias, S. "The Patient Profile System: Group Health's First Iteration of the Automated Medical Record." HMO Practice 7(2):67-72, June 1993. Smith, W., and others. "Developing a Computerized Ambulatory Medical Record to Document Health Promotion and Disease Prevention Activities during the Clinic Encounter." Journal of Ambulatory Care Management 15(4)9-17, Oct. 1992. Speer, S., and Cowen, S. "Operations Analysis and the CPR (Computer-based Patient Record) Team." Healthcare Information Management 7(1):15-21, Winter 1993. Tape, T., and Campbell, J. "Computerized Medical Records and Preventive Health Care: Success Depends on Many Factors." American Journal of Medicine 94(6):619-25, June 1993. Valentine, C. "From the Basement to the Penthouse and towards CPR (Computer-based Patient Records)." Journal of the American Health Information Management Association 64(2):61-2, Feb. 1993. Waller, A., and Fulton, D. "The Electronic Chart: Keeping It Confidential and Secure." Journal of He and Hospital Law 26(4):104-9, April 1993.