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Effectiveness, accountability, and efficiency.

The individual health care practitioner writes or dictates the medical chart of each patient. Unfortunately, this clinical database is sequestered in the office or hospital, generally unavailable for authorized use by others. This not only is inefficient, but also reduces the opportunity for collaboration. Medical records are data that should be organized for quick identification of the patient, where and how he or she was cared for, and what future medical problems may arise. Simple, straightforward lists of medical information that summarize patients' histories, including visits, prescriptions, referrals, results of tests, and prevention efforts are these essential data. An appropriate database will then be used to improve comprehension and communication.

As health care becomes more coordinated and planned, accountability, effectiveness, and efficiency become critical. Medical and management leadership will be accountable for analyzing what practitioners do. Increasingly they will seek information to improve quality and reduce ineffectiveness and inefficiency. Effectiveness is perhaps the most critical and difficult new area of responsibility for the managed care industry, for it requires outcome evaluation. For this, management information systems (MISs) must be developed to:

* Comprehend health status. [1]

* Relate outcome and the antecedent process, important information for active management and planning. [2]

* Measure and monitor change over time.

Our present database is derived from claims and/or productivity data. It represents the cost of care well, but the medical logic used in the care of patients poorly.

* If it has any clinical relevance, it is not because it is information; i.e., billing or productivity data do not help us comprehend process. Where, for example, does cost reliably and sufficiently help us define a clinical context? How can a view of the costs inform us about logic or varieties in pathophysiology, disease etiology, and risk predictions? Finally, how can it help us deal with impersonal health care, variation in practice, and increased litigation?

* It is prone to error. It is unreliable. In fact, it can be misleading. It ignores patient education and evolving and changing circumstances. For example, billing data will not tell us when or if acute wheezing episodes actually represent the more chronic manifestation--asthma.

Furthermore, insurers are calling attention to the coding problems of "upcoding," "unbundling," and "exploding"--upcoding, the tendency to increase the rating of severity of illness in order to maximize reimbursement; unbundling, charging separately for the components of an operation, such as adding the charge for an incidental appendectomy in the exploration of an abdomen; and exploding, the itemization of a series of tests done from a single sample of blood. Obviously, the ethics of such practices is questionable.

* There is no clinical sense to the charge structure, which simply reflects the cost of care. The lack of evidence of the interaction of diseases existing in the same patient is different.

* Different claims-tracking data or coding methods are used by health care institutions. Some may employ procedure codes, others diagnostic or disease classifications. These unlike methods do not always tell the same story.

* In caring for patients, billing data are either irrelevant, incomprehensible, or inaccessible. What kind of information, for example, do billing data provide to the emergency department physician or to medical coverage after hours?


A clinical summary can improve our understanding of both the patient and the cost of his or her care. Properly authorized persons should be able to quickly learn who the patient is and where he or she has been cared for. [3] It is difficult to appreciate a patient's history with our database in its present form. For example, data on present and potential health problems are either sequestered in the bulky medical chart or so disorganized that they remain largely unknown. Sundry dtat may be found in diagnoses on hospital and referral forms )e.g., in claims data, diagnosis-related groupings, etc.); withinproductivity assessments; and, occasionally, even in specialized databases, such as health risk appraisals.

We must produce a comprehensive, accessible, available-at-all-hours medical record. It should take the form of a succinct and reliable database.

Moving from Data to

Two sets of dta are required: (1) a summary [4] of past and present illness history and the potential for disease (as risk factors of life-style) and (2) recent medical activity (diagnosis and treatment). A summary list and chronology creates a clinical context. This background will help us use standards and clarify expectations. From a complete picture, we improve quality management and effectiveness. [5] (See figure 1, right)

A medical database that is linked to the cost of care provides data about continuity, efficiency, efficacy, [6] and effectiveness. From it we actually see how to modify performance or manage care and adjust and/or reduce risk. Prerequisites for medical informatics are medical data management systems that are always available in the computer, day or night; that are confidential; and that summarize each patient's past and present disease history and potential for health.

Data for Managing Care:

The Objective of Clinical


Anyone properly authorized, from the telephone operator to the nurse, technician, social worker and physician, will be able to know both the patient and his or her clinical story. Many people should be sharing the same data, and the storage of the data can become expensive and unwieldy. Fortunately, there are now computer systems available with extensive and reasonably priced storage capacity. To achieve the broad objectives of the next generation of data management systems for the health care industry, one should have this hardware capacity, plus:

* Constant availability of information.

* Medical data that reflect a continuum of care from the past to the present, extending to the future.

* Continuity of data among physicians and institutional providers.

* Standardized and comparative data sets.

* Data that relect the clinical logic and can be used concurrently to help determine the validity of the data, the appropriateness of the care, the severity of illness, and the intensity of service; track patients from the point of contact to outcome, independent of costs and charges; indicate how we are spending our health care resources as they are spent; and validate clinically that we are doing what we say we are doing.

Because cost information drives our present medical systems, the work of managing care with data must begin by modifying the claims database. Standardizing and improving the content of the billing data can be accomplished by linking it to clinical information. This enhanced longitudinal medical and cost picture creates a clinical trail that will simultaneously solve several health care management problems.

Getting Cooperation

No one in medicine can ignore the recent phenomenon--loss of control. Interactive patient management systems can restore this. Management is direction, supervision, and control. Perhaps the most salient point to make about medical informatics is that it will help us manage care to improve accountability, effectiveness, and efficiency. Only a small amount of additional data gathering is involved. The more advanced, on-line, direct access systems will handle the patient at every contact [7] (phone, visit, etc.) and help to create an "episode of care or illness."

There are many examples of where an enhanced database can be invaluable. Triage is one. Malpractice another. To achieve more personalized health care, the quality issue may revolve around knowing the patient. A better informed doctor may better relate to his or her patient.


Good management of health care depends not only on supervising costs, but also on understanding medical management. Howard Berry, a futurist, urged using computer systems to facilitate health care. [8] This requires that we supply accurate and more comprehensive data. Lists of the clinical problems--past, present and potential--along with diagnosses and treatments and costs, will serve us well in this regard. These data (see figure 2, above) should be made available to health care providers and to authorized management personnel on a full-time basis.

Physicians, patients, and payers can be better served and retained if computer technology helps us manage data. They can be used to provide assistance for patients about their health needs, benefits, and costs. Similarly, as there will be increased use of computer-based expert systems and diagnostic tests, we will become more efficient at screening and helping patients. Communications systems will also link health professionals. Thus, effective computer technology will be critical to the managed care organization of the future. [8]

Data collection and presentation can be facilitated by computer-assisted methods that recognize the special needs of the health care industry. Outcome studies will become more common as we track care from the initial request for care to both intermediate and long-term results. [7] As the claims and the clinical trails become linked, monitoring and management will be more relevant to the patient care process and more supportive of appropriate data collection and use. Data management systems will help us define our terms in the interest of clarification, communication, and standardized reporting. [9]


[1] Kaplan, J. "Wellness Is an Interface Issue for the Disciplines of Marketing and Medicine." Medical Interface 1(11):1-34, Nov. 1988.

[2] Donabedian, A. Explorations in Quality Assessment and Monitoring, Volume 1: The Definition of Quality and approaches to its Assessment. Ann Arbor, Mich.: Health Administration Press, 1980.

[3] Kaplan, J. "The Interface of the Disciplines of Marketing, Medicine, and Management." Medicine Interface 1(7):21-3, July 1988.

[4] Weed, L. Medical Records, Medical Education and Patient Care. Chicago, Ill.:The Press of Case Western Reserve, 1970.

[5] Kaplan, J. "A Schematic Representation of Optimal Medical Care." Medical Interface 2(8):11-3, Aug. 1989.

[6] Kaplan, J. "Efficacy: The Real Bottom Line in Health Care." HMO Practice 3(3):108-11, May-June 1989.

[7] Kaplan, J., and others. "An Argument for a Point-of-Contact Data Management System." Medical Interface 2(2):23-8, Feb. 1989.

[8] Berry, H. "Managed Care's 4th Generation." Group Practice Journal 30(4):18-23, July-Aug 1989.

[9] Kaplan, J. "Accountability, Efficiency, Effectiveness." Medical Interface 3(5):13-7, May 1990.

Further Reading

The following additional sources of information on computerized patient data-bases were obtained through a computerized search of databases. Copies of the articles cited are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000.

Barnett, G., and Winickoff, R. "Quality Assurance and Computer-Based Patient Records." American Journal of Public Health 80(5):527-8, May 1990.

Demorsky, S. "Automation of Medical Records Can Boost Cash Flow." Healthcare Financial Management 44(10):20-4,26,28, Oct. 1990.

Harrington, J. "The Networking Standards Evolution. Toward a Real Electronic Medical Record." Computers in Healthcare 11(2):18-21, Feb. 1990.

Jeffrey G. Kaplan, MD, MPS, can be found at 105 Enderberry Circle, Syracuse, N.Y. 13224. He is Vice Chair of the College's Forum on Computers and Information Technology and an associate members of its Society on Managed Care Organizations.
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Title Annotation:medical care management information systems
Author:Kaplan, Jeffrey G.
Publication:Physician Executive
Date:Jul 1, 1991
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