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The technology hierarchy.

To take advantage of computer-based patient records and communicate data electronically about patients to other practice sites and insurers, physicians, offices need to invest in an information architecture based on the standards of the Internet's World Wide Web. These standards - transmission control protocol/Internet protocol (TCP/IP) - can be the foundation for local area networking in a physician's office or for wide area networking in a health care enterprise. If they are adopted for local and wide-area networking, they can be linked to the Internet with digital telephone connections with fast data rates (128,000 bps with ISDN, or 1,500,000 bps with DS-1 service) still giving individual workstations on those networks Internet access.

Installing firewall - computers that filter the communication between private networks and the Internet - will protect an office practice's local area network and a hospital or health care system's wide-area network from unwanted hackers. Private networks can be secure and still have access to the internet.

The first layer

At the bottom. so to speak, are the local and wide area networks moving private data about patients between workstations and servers within the organization. They need to adhere to open standards, including TCP/IP consistent in the way data are distributed into electronic packets, addressed, and moved over the Internet. Above the standardized networks are end-user functions, such as electronic medical records, scheduling, patient accounting, inventory, payroll, financial management and personal productivity tools, for example, decision support systems for retrospective analysis of patient outcomes. Those functions interact with a corporate database which, ideally, uses a data model and data definitions that are shared among group practices so patient information can flow electronically from one practice to another.

The second layer

When practices are acquired or merged into a common entity, or collaborate on managed care contracts, they will want to share applications and "umbrella" databases to permit each of them to access patient data and medical records. Standardization is the key - without it, data cannot be shared electronically. Physicians need to plan for office practice information systems in common, with an eye to conveying data electronically between all the locations of care and all the providers involved in caring for defined populations of people.

Sharing data brings such enormous economies of scale that it behooves practices that work together to standardize and integrate their information systems. On the other hand, this process takes tens of thousands of dollars per physician, and most group practices that are not actually integrated into a single economic unit do not have the political will or organization means of shouldering such large investments.

At the local and wide-area network level of technology, cooperating providers can standardize the system, so the same graphical user interface is accessed at every location of care, and for every application, both clinical and financial, reducing the training costs and maximizing the ease of using various workstations. Clinicians moving between office practice to hospital, and within the hospital to multiple nursing units, and, perhaps, to several hospitals within a common system within a single day, benefit most from standardized screens and commands.

The shared data-base will probably depend on a distributed relational data-base management system. Work stations accessing it over the wide-area network will have a graphical user interface and tools for simple extraction of information from that database for retrospective analysis. The database will become the most important asset of the collection of providers who make up the delivery system that creates it.

The delivery system will have to spend countless hours protecting the integrity, of the data model and database, by making certain that the meaning of data elements collected for it at all locations of c re are standardized. If the political structure of the delivery system is not sound, and if the organization cannot set policies for data definitions and data collection for all its operating units, then there will be chaos instead of standardization, and the organization will never achieve its full potential of an integrated, shared computer-based record for all patients seen in any location of care.

The third layer

Above the shared databases of patient information are networks linking the providers to the outside world and, without question, they will be based on the Internet. So, the internal and external networks will have the same architecture, and define, package, address, and move data in the same ways. Electronic communication and opportunities for distance learning, telemedicine, and extending the reach and influence of highly-regarded experts will emerge with this universal standardization. The era of the networked society - and medical care depending on networked intelligence - is dawning.

This next level is the external regional and national telecommunication networks, with which financial transactions move electronically from providers within the delivery system to payers and employers outside of it. Electronic claims, eligibility verification, and credit card transactions are standardized by EDI (Electronic Data Interchange). Access to clinical and research information over public networks, such as the Internet, has become indispensable for most health care organizations. Physicians and their patients will benefit if the wide-area network of the health care delivery system connects easily with the Internet and the National Library of Medicine Medline database. The NLM has a Medline service on the World Wide Web.

Another electronic library makes itself available to users of the World Wide Web daily. Research and library searching have never been easier than they are now. Ideally, physicians and other clinicians working in a health care organization will have access via their local area networks to high-speed (ISDN or DS-1) digital telephone connections to Internet service providers and the World Wide Web, with much faster data rates than they can obtain with modems over the plain, old telephone system (POTS).

Marshall Ruffin, MD, MPH, MBA, FACPE, is President of The Informatics Institute, Falls Church, Virginia. He may be reached at 810 Gatehouse East, #401 East, Box 11, Falls Church, Virginia 22042, 703/205-3901, fax 703/205-2301. You can also reach Dr. Ruffin online at Marshall@

Payers are Pushing Clinicians

To Automate their Office Practices

The mandate to share data electronically among physicians and health care facilities in a regional area is growing rapidly. Consider the decisions being made by the National Committee for Quality Assurance (NCQA) and by U.S. Healthcare, an aggressive manager of IPA health maintenance. organizations on the northern and central East Coast.

NCQA is developing the Health Employer Data and Information Set (HEDIS), which employers and their benefits managers ask health plans to submit as a standardized measure of outcomes for their populations of members. The HEDIS data set includes questions about how frequently screening procedures are performed, measured either by retrospective chart review, which is expensive, or by data stored in electronically medical records in physicians, offices, submmitted inexpensively to employers and their representatives electronically, right into databases used to compare the performance of health plans. U.S. Healthcare pays providers bonus, on top of their base reimbursement, provided they can collect medical record details, and submit claims electronically to US Healthcare's offices in Blue Bell, Pennsylvania.

HEDIS data include these titles: Quality of Care, Member Access and Satisfaction, Membership and Utilization, Finance and Health Plan Management and Activities. Quality of Care primarily includes data on the timeliness and completeness of screening procedures for various age and sex cohorts most at risk for preventable common diseases. For instance, the proportion of women between ages 52 and 64 who have had a screening mammogram in the past two years; the cesarean section rate@ the cervical cancer screening rate; the proportion of diabetics aged 31-64 who had at least one retinal examination during the preceding year.

Many of the HEDIS statistics were adopted by the NCQA from work performed by U.S. Quality Algorithms, a subsidiary of U.S. Healthcare devoted to analyzing claims data to develop report cards on physician practices. U.S. Healthcare prefers to pay physicians based on a formula that includes a base amount and a bonus for performance, with criteria such as member satisfaction, measured by a standardized satisfaction survey case-mix and severity-of-illness of members assigned to each physician, measured by a standardized set of criteria from claims data; and structural support for managed care operations, which translates into a physicians' ability to send all data to U.S. Healthcare electronically, including claims. HEDIS statistics for the practice, and severity indicators for individual patients. U.S. Healthcare wants group practices with which it contracts to automate their data processing and communicate electronically with the payer, and it gives physicians' practices a financial incentive to automate their business and clinical records.
COPYRIGHT 1996 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1996, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:contains related information; the use of computers in healthcare; Information Technology, Part
Author:Ruffin, Marshall
Publication:Physician Executive
Date:Sep 1, 1996
Previous Article:What employers are looking for right now.
Next Article:Integrating medical and operational management.

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