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Health care in the information society: evolution or revolution?
International Journal of Medical Informatics 66 (2002) 25 /29 www.elsevier.com/locate/ijmedinf
Health care in the information society: evolution or revolution? Jane Grimson a,*, William Grimson b a b
Centre for Health Informatics, O’Reilly Institute, Trinity College, Dublin 2, Ireland Management Information Systems, Dublin Institute of Technology, Dublin, Ireland
Abstract This brief article is a commentary on the Haux et al. paper on Health Care in the Information Society: a prognosis for the year 2013. The commentary concentrates in particular on the underlying assumptions, which are at the core of the Haux et al. vision for healthcare in 2013. They assume that while there will be a shift towards increased patient-centred, community-based shared care, the underlying healthcare system will remain essentially the same. This commentary suggests that this is a conservative view and indeed questions its validity. Radical financial pressures to control costs as well as demands for equity fuelled by more knowledgeable and better informed patients have the potential to bring about fundamental changes, with consequences for the way in which healthcare is delivered and in turn in how information and communications technologies are utilised. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Electronic health records; Health information systems
1. Introduction Predicting the future has always been a risky business as many eminent scientists and engineers have discovered to their cost. For example, Lord Kelvin predicted in 1895 that ‘heavier than air flying machines are not possible’, while Thomas J. Watson, Chairman of IBM, assured the world in 1945 that ‘there is world market for 15 computers’. Even as recently as 1977, Ken Olson, President of Digital, stated that ‘there is no reason to. . .
* Corresponding author. Tel.: /353-1-608-1780; fax: /3531-677-2204 E-mail address: [email protected] (J. Grimson).
have a computer at home!’. And in more recent times it should be noted that more human knowledge has been created in the last decade of the 20th century than in all previous human history [1]. So given the speed of change and the phenomenal growth in knowledge, the margin of error today in such predictions is likely to be even greater than applied when Kelvin, Watson and Olson made their forecasts. Reinhold Haux and his colleagues, therefore, show great courage in making specific predictions about the state of health care in 2013 in the form of 30 theses with associated quantified predictions (prognoses) for each of the theses. Their fascinating and entirely
1386-5056/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 3 8 6 - 5 0 5 6 ( 0 2 ) 0 0 0 3 2 - 1
26
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29
plausible vision of the future, however, is based on an evolution from where we are today rather than the sort of revolutionary shift in technology predicted, for example, by Vannevar Bush in his seminal paper ‘As we may think’ in which he foresaw the advent of digital multimedia [2]. The Haux et al. theses are, therefore, likely to be relatively conservative. The impact of the Web, for example, was not predicted, and nor was it developed for the many purposes for which it is now used. Is it not likely that another ‘web’ will inject a new dynamic into ICT and its applications in Healthcare? So it could be that Haux and his colleagues have underestimated change by essentially extrapolating technological progress, and assuming that ICT will simply just become cheaper, faster, smaller, more reliable, and ubiquitous. They foresee that the healthcare system in 2013 will place much greater emphasis on shared community-based care (T2, T3, T8, T9) with the associated need to be able to share information efficiently (T16, T17, T18, T19), with such electronic communication increasingly taking place via mobile device and greater use of wireless technology (T28). An underlying assumption is that care in 2013 will be patient* rather than institutioncentred (goal one). This might well be viewed as desirable but does the evolutionary-style evidence not support the contrary? Such a change from the current institution centric model would require a revolution rather than an evolution, and if that is true, what would be the catalyst for major change between now and 2013 and what would be the consequences for ICT in healthcare let alone organisational change? Another major assumption, which could be called into question, is the assertion that ‘‘the health care sector represents a. . . financially attractive area(s) for . . . ICT industry’’. The health information systems market is in fact very fragmented undermining /
competition, best of breed and profitability [3]. How is this likely to change in the next decade? Many of the theses are uncontroversial and the quantitative predictions appear credible and are supported by data from other reports such as [4]. The underlying methodology by which Haux and his colleagues have developed their vision of the future is not explicitly stated but appears to be based on a direct extrapolation of the current situation in Germany and an intuitive feel for likely future developments in technology. Crucially, they explicitly exclude the context in which these developments are taking place. Technology is an agent for change and cannot be considered in isolation from the environment in which it works. Of course, there is an element of ‘chicken and egg’ here; organisational change often demands the introduction of new technology, but the introduction of new technology itself generally can bring about or necessitate organisational change. The important point, however, is that they cannot be considered in isolation from each other. The selection of the particular theses and their groupings under four main headings is designed to be comprehensive but in a sense is somewhat arbitrary leading to potential contradictions, especially when the context is ignored. Haux et al. assert (T5) that financial pressures and increased demand will inevitably lead to the introduction of accreditation of healthcare service providers, and indeed this trend can already be observed. Furthermore, they predicted quite reasonably (P5.2), that the performance indicators associated with this accreditation will be publicly available. What is the nature of these performance indicators likely to be; surely more than simply the length of waiting lists? Given the social and political pressures for equality of access and treatment, outcomes are likely to feature prominently. Health service providers
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29
will be required to show that they are following evidence-based best practice, perhaps under pressure from funding agencies such as public or private health insurance bodies. P20.1 indicates that this evidence-based best practice will be available on the Internet, but unless it is encoded in the form of clinical guidelines, which are directly linked to the record, there is little chance that they will be widely followed [5]. Haux et al. predict that clinical guidelines will be integrated with Electronic Patient Records in little more than 10% of hospitals, which seems too low, given that they also predict that over 40% of hospitals will be accredited. Why would the accreditation process not in fact demand the integration of clinical guidelines with the Electronic Patient Record? With the demand for best practice and the demand to see evidence that it has been applied it is not beyond the bounds of possibility that the patient-citizen and fund providers will insist on computerised records which will show how clinical guidelines were used. The role and impact of clinical audits need to be considered. Carrying this argument further, clinical guidelines even if they are optional inevitably change the way healthcare is delivered (otherwise, why bother?), and if they are embedded in an overall workflow management system, the impact on the healthcare system as a whole will surely be substantial. Far from undermining the skill and expertise of the physician, the use of ICT will enhance and strengthen their role, ensuring that they have the information they need in the right format and at the appropriate time, and allow them to concentrate on providing healthcare. And indeed their pre-eminent role will be of providing the knowledge management that will include the design and authorising the use of guidelines and protocols. Turning to more general decision support tools, Haux et al. predict (T21) that ‘tools /
/
27
which actively give diagnostic and therapeutic advice will not yet have established themselves’ by 2013. Based on the huge numbers of such tools, which have been developed over the past four decades, many of which have never made it beyond the confines of the research laboratory, Haux and his colleagues are at first glance being very realistic. However, theses T28 and T29, under the heading of ICT tools, predict a considerable increase in the use of intelligent monitoring devices and sensors. Surely these should be regarded as embedded decision support tools which are used to contribute to formulating therapeutic advice? And this is borne out by the reference in the scenario, which indicates that Dr Bright will be able to receive real-time alerts from Adam’s heart monitor. Clearly if Dr Bright is not be overwhelmed by a stream of monitoring data from all her patients, she will have to make use of intelligent filters (cf. the modest use of filters to eliminate SPAM emails today) which will be based on standard accredited protocols. So what does this alternative vision of the future mean for ICT and its application in healthcare?
2. Electronic patient records Haux et al. assert that over 90% patient data will continue to be stored locally by the healthcare provider (P12.1) in 2013. They do not support the view that the single, integrated, life-long record will be commonplace by 2013, although there is the suggestion that smart (chip) cards will be increasingly used to store relevant data for chronic conditions (the domain-specific record). Past history (four decades of research into electronic patient records) would suggest that such pessimism may well be justified. However, this does not take into account the potential impact of
28
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29
patient empowerment, a theme that underpins a number of Haux’s theses (e.g. T10, T11). Patient empowerment involves informed and knowledgeable patients taking more responsibility for their own healthcare. Health surfers already form one of the largest identifiable group of Internet users. While healthcare organisations may not be able to come together and agree standards to achieve the life-long longitudinal record, there is every possibility that consumers will take control and do it themselves. Consumer (personal) health records which are created and managed by the individual citizen and stored on secure web-sites accessible over the Internet are becoming increasingly common [6,7]. The simple view could be that these patient controlled records will simply co-exist beside the patient data controlled by the healthcare professionals. But a more rational view would be that convergence to a single record would occur, possibly encouraged by the envisaged need to share patient data between a multitude of healthcare providers. This convergence would of course pose all sorts of technical challenges in relation to standards, terminology, data provenance, as well as ethical and security ones. Nevertheless how patients will in the future interact with their own records is a topic that will require much research and debate by all concerned. The PCASSO project explores some of the issues and points to the potential of a ubiquitous national information infrastructure (NII) with a key theme being individual empowerment [8].
self-evident. Even most developed countries suffer from a two-tier system with those who can afford to pay or have insurance receiving better and more timely healthcare. Ensuring equitable access to healthcare for all citizens is likely to become a major political issue over the next decade which must inevitably bring with it fundamental changes in the healthcare system. Haux et al. have concentrated on ICT-related aspects of healthcare* the system itself, the people involved (patients and healthcare professionals), health information systems, and ICT tools without considering some of the larger issues. Probably the single biggest external factor that will influence the evolution or indeed revolution in healthcare concerns the need to balance public and personal expectations with the cost of delivering them, and the evidence is that Finance and Health ministries are on a collision course in many countries. Another issue, and not unrelated to the above, is the need for global equity, and in today’s world equity within our own borders may not be sufficient to ensure peace and harmony: commercial globalisation carries sooner or later inevitable social obligations. In any case, it is hard to believe that major changes to the way healthcare is governed and delivered will not be necessary in the next decade and the way information technology is utilised will be shaped by these changes. And advances in information technology will itself contribute to these changes. /
References 3. Conclusions The main difficulty, perhaps, with Haux’s paper is the underlying assumption that society and the healthcare system will remain largely the same (T2). This is by no means
[1] M. Kaku, Visions: How Science will Revolutionise the 21st Century and Beyond, Oxford University Press, Oxford, London, 1998. [2] V. Bush, As we may think, Atlantic Monthly, 1945. [3] The emerging European Health telematics industry; market analysis. Prepared for the European Commission-Directorate General Information Society, Deloitte and Touche, 2000.
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29 [4] PriceWaterhouseCoopers, HealthCast 2010; smaller world, bigger expectations (1999). [5] R.N. Shiffman, Y. Liaw, C.A. Brandt, G.J. Corb, Computer-based guideline implementation systems: a systematic view of functionality and effectiveness, J. Am. Med. Inf. Assoc. 6 (2) (1999) 104 /114. [6] M.I. Kim, K.B. Johnson, Personal health records: evaluation of functionality and utility, J. Am. Med. Inf. Assoc. 9 (2002) 2.
29
[7] C. Safran, Electroni patient records */an opportunity to reengineer physician /patient communication, Irish J. Med. Sci. 171 171 (Supplement 1) (2002) 9 /12. [8] D. Masys, D. Baker, A. Butros, K. Cowles, Giving patients access to their medical records via the Internet, J. Am. Med. Inf. Assoc. 9 (2) (2002) 181 /191.
Health care in the information society: evolution or revolution? Jane Grimson a,*, William Grimson b a b
Centre for Health Informatics, O’Reilly Institute, Trinity College, Dublin 2, Ireland Management Information Systems, Dublin Institute of Technology, Dublin, Ireland
Abstract This brief article is a commentary on the Haux et al. paper on Health Care in the Information Society: a prognosis for the year 2013. The commentary concentrates in particular on the underlying assumptions, which are at the core of the Haux et al. vision for healthcare in 2013. They assume that while there will be a shift towards increased patient-centred, community-based shared care, the underlying healthcare system will remain essentially the same. This commentary suggests that this is a conservative view and indeed questions its validity. Radical financial pressures to control costs as well as demands for equity fuelled by more knowledgeable and better informed patients have the potential to bring about fundamental changes, with consequences for the way in which healthcare is delivered and in turn in how information and communications technologies are utilised. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Electronic health records; Health information systems
1. Introduction Predicting the future has always been a risky business as many eminent scientists and engineers have discovered to their cost. For example, Lord Kelvin predicted in 1895 that ‘heavier than air flying machines are not possible’, while Thomas J. Watson, Chairman of IBM, assured the world in 1945 that ‘there is world market for 15 computers’. Even as recently as 1977, Ken Olson, President of Digital, stated that ‘there is no reason to. . .
* Corresponding author. Tel.: /353-1-608-1780; fax: /3531-677-2204 E-mail address: [email protected] (J. Grimson).
have a computer at home!’. And in more recent times it should be noted that more human knowledge has been created in the last decade of the 20th century than in all previous human history [1]. So given the speed of change and the phenomenal growth in knowledge, the margin of error today in such predictions is likely to be even greater than applied when Kelvin, Watson and Olson made their forecasts. Reinhold Haux and his colleagues, therefore, show great courage in making specific predictions about the state of health care in 2013 in the form of 30 theses with associated quantified predictions (prognoses) for each of the theses. Their fascinating and entirely
1386-5056/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 3 8 6 - 5 0 5 6 ( 0 2 ) 0 0 0 3 2 - 1
26
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29
plausible vision of the future, however, is based on an evolution from where we are today rather than the sort of revolutionary shift in technology predicted, for example, by Vannevar Bush in his seminal paper ‘As we may think’ in which he foresaw the advent of digital multimedia [2]. The Haux et al. theses are, therefore, likely to be relatively conservative. The impact of the Web, for example, was not predicted, and nor was it developed for the many purposes for which it is now used. Is it not likely that another ‘web’ will inject a new dynamic into ICT and its applications in Healthcare? So it could be that Haux and his colleagues have underestimated change by essentially extrapolating technological progress, and assuming that ICT will simply just become cheaper, faster, smaller, more reliable, and ubiquitous. They foresee that the healthcare system in 2013 will place much greater emphasis on shared community-based care (T2, T3, T8, T9) with the associated need to be able to share information efficiently (T16, T17, T18, T19), with such electronic communication increasingly taking place via mobile device and greater use of wireless technology (T28). An underlying assumption is that care in 2013 will be patient* rather than institutioncentred (goal one). This might well be viewed as desirable but does the evolutionary-style evidence not support the contrary? Such a change from the current institution centric model would require a revolution rather than an evolution, and if that is true, what would be the catalyst for major change between now and 2013 and what would be the consequences for ICT in healthcare let alone organisational change? Another major assumption, which could be called into question, is the assertion that ‘‘the health care sector represents a. . . financially attractive area(s) for . . . ICT industry’’. The health information systems market is in fact very fragmented undermining /
competition, best of breed and profitability [3]. How is this likely to change in the next decade? Many of the theses are uncontroversial and the quantitative predictions appear credible and are supported by data from other reports such as [4]. The underlying methodology by which Haux and his colleagues have developed their vision of the future is not explicitly stated but appears to be based on a direct extrapolation of the current situation in Germany and an intuitive feel for likely future developments in technology. Crucially, they explicitly exclude the context in which these developments are taking place. Technology is an agent for change and cannot be considered in isolation from the environment in which it works. Of course, there is an element of ‘chicken and egg’ here; organisational change often demands the introduction of new technology, but the introduction of new technology itself generally can bring about or necessitate organisational change. The important point, however, is that they cannot be considered in isolation from each other. The selection of the particular theses and their groupings under four main headings is designed to be comprehensive but in a sense is somewhat arbitrary leading to potential contradictions, especially when the context is ignored. Haux et al. assert (T5) that financial pressures and increased demand will inevitably lead to the introduction of accreditation of healthcare service providers, and indeed this trend can already be observed. Furthermore, they predicted quite reasonably (P5.2), that the performance indicators associated with this accreditation will be publicly available. What is the nature of these performance indicators likely to be; surely more than simply the length of waiting lists? Given the social and political pressures for equality of access and treatment, outcomes are likely to feature prominently. Health service providers
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29
will be required to show that they are following evidence-based best practice, perhaps under pressure from funding agencies such as public or private health insurance bodies. P20.1 indicates that this evidence-based best practice will be available on the Internet, but unless it is encoded in the form of clinical guidelines, which are directly linked to the record, there is little chance that they will be widely followed [5]. Haux et al. predict that clinical guidelines will be integrated with Electronic Patient Records in little more than 10% of hospitals, which seems too low, given that they also predict that over 40% of hospitals will be accredited. Why would the accreditation process not in fact demand the integration of clinical guidelines with the Electronic Patient Record? With the demand for best practice and the demand to see evidence that it has been applied it is not beyond the bounds of possibility that the patient-citizen and fund providers will insist on computerised records which will show how clinical guidelines were used. The role and impact of clinical audits need to be considered. Carrying this argument further, clinical guidelines even if they are optional inevitably change the way healthcare is delivered (otherwise, why bother?), and if they are embedded in an overall workflow management system, the impact on the healthcare system as a whole will surely be substantial. Far from undermining the skill and expertise of the physician, the use of ICT will enhance and strengthen their role, ensuring that they have the information they need in the right format and at the appropriate time, and allow them to concentrate on providing healthcare. And indeed their pre-eminent role will be of providing the knowledge management that will include the design and authorising the use of guidelines and protocols. Turning to more general decision support tools, Haux et al. predict (T21) that ‘tools /
/
27
which actively give diagnostic and therapeutic advice will not yet have established themselves’ by 2013. Based on the huge numbers of such tools, which have been developed over the past four decades, many of which have never made it beyond the confines of the research laboratory, Haux and his colleagues are at first glance being very realistic. However, theses T28 and T29, under the heading of ICT tools, predict a considerable increase in the use of intelligent monitoring devices and sensors. Surely these should be regarded as embedded decision support tools which are used to contribute to formulating therapeutic advice? And this is borne out by the reference in the scenario, which indicates that Dr Bright will be able to receive real-time alerts from Adam’s heart monitor. Clearly if Dr Bright is not be overwhelmed by a stream of monitoring data from all her patients, she will have to make use of intelligent filters (cf. the modest use of filters to eliminate SPAM emails today) which will be based on standard accredited protocols. So what does this alternative vision of the future mean for ICT and its application in healthcare?
2. Electronic patient records Haux et al. assert that over 90% patient data will continue to be stored locally by the healthcare provider (P12.1) in 2013. They do not support the view that the single, integrated, life-long record will be commonplace by 2013, although there is the suggestion that smart (chip) cards will be increasingly used to store relevant data for chronic conditions (the domain-specific record). Past history (four decades of research into electronic patient records) would suggest that such pessimism may well be justified. However, this does not take into account the potential impact of
28
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29
patient empowerment, a theme that underpins a number of Haux’s theses (e.g. T10, T11). Patient empowerment involves informed and knowledgeable patients taking more responsibility for their own healthcare. Health surfers already form one of the largest identifiable group of Internet users. While healthcare organisations may not be able to come together and agree standards to achieve the life-long longitudinal record, there is every possibility that consumers will take control and do it themselves. Consumer (personal) health records which are created and managed by the individual citizen and stored on secure web-sites accessible over the Internet are becoming increasingly common [6,7]. The simple view could be that these patient controlled records will simply co-exist beside the patient data controlled by the healthcare professionals. But a more rational view would be that convergence to a single record would occur, possibly encouraged by the envisaged need to share patient data between a multitude of healthcare providers. This convergence would of course pose all sorts of technical challenges in relation to standards, terminology, data provenance, as well as ethical and security ones. Nevertheless how patients will in the future interact with their own records is a topic that will require much research and debate by all concerned. The PCASSO project explores some of the issues and points to the potential of a ubiquitous national information infrastructure (NII) with a key theme being individual empowerment [8].
self-evident. Even most developed countries suffer from a two-tier system with those who can afford to pay or have insurance receiving better and more timely healthcare. Ensuring equitable access to healthcare for all citizens is likely to become a major political issue over the next decade which must inevitably bring with it fundamental changes in the healthcare system. Haux et al. have concentrated on ICT-related aspects of healthcare* the system itself, the people involved (patients and healthcare professionals), health information systems, and ICT tools without considering some of the larger issues. Probably the single biggest external factor that will influence the evolution or indeed revolution in healthcare concerns the need to balance public and personal expectations with the cost of delivering them, and the evidence is that Finance and Health ministries are on a collision course in many countries. Another issue, and not unrelated to the above, is the need for global equity, and in today’s world equity within our own borders may not be sufficient to ensure peace and harmony: commercial globalisation carries sooner or later inevitable social obligations. In any case, it is hard to believe that major changes to the way healthcare is governed and delivered will not be necessary in the next decade and the way information technology is utilised will be shaped by these changes. And advances in information technology will itself contribute to these changes. /
References 3. Conclusions The main difficulty, perhaps, with Haux’s paper is the underlying assumption that society and the healthcare system will remain largely the same (T2). This is by no means
[1] M. Kaku, Visions: How Science will Revolutionise the 21st Century and Beyond, Oxford University Press, Oxford, London, 1998. [2] V. Bush, As we may think, Atlantic Monthly, 1945. [3] The emerging European Health telematics industry; market analysis. Prepared for the European Commission-Directorate General Information Society, Deloitte and Touche, 2000.
J. Grimson, W. Grimson / International Journal of Medical Informatics 66 (2002) 25 /29 [4] PriceWaterhouseCoopers, HealthCast 2010; smaller world, bigger expectations (1999). [5] R.N. Shiffman, Y. Liaw, C.A. Brandt, G.J. Corb, Computer-based guideline implementation systems: a systematic view of functionality and effectiveness, J. Am. Med. Inf. Assoc. 6 (2) (1999) 104 /114. [6] M.I. Kim, K.B. Johnson, Personal health records: evaluation of functionality and utility, J. Am. Med. Inf. Assoc. 9 (2002) 2.
29
[7] C. Safran, Electroni patient records */an opportunity to reengineer physician /patient communication, Irish J. Med. Sci. 171 171 (Supplement 1) (2002) 9 /12. [8] D. Masys, D. Baker, A. Butros, K. Cowles, Giving patients access to their medical records via the Internet, J. Am. Med. Inf. Assoc. 9 (2) (2002) 181 /191.