Description

Integrated health information systems will be at the heart of the decision support systems needed to enable physicians, payers, and patients to choose among an array of evolving alternatives.

Special Characteristics

Integrated health information systems will also be essential to the decision support systems needed to enable community, state, and national public health officials to detect emerging health threats and to allocate resources among competing public health problems that affect the populations as they age.

Impact on Economy

To capitalize on the natural experiments occurring in health care settings and to identify and evaluate potential cost-effective alternatives for improving the personal and public health care systems is an ongoing challenge. Clinical decision making must be improved, and this could be done by computer-aided diagnostic systems enabling efficient selection by physicians and patients among an increasingly complex range of alternatives in diagnosis and treatments. Improved outcome data on comparable and competitive approaches will provide the basis for informed patient management and the evaluation of alternative services structures.

Impact on Security

Under development.

Worldview

The breadth of the U.S. artificial intelligence/knowledge based support systems, often developed at universities with close working relationships to major medical research centers, has led to the United States having an unsurpassed base of experienced researchers and demonstration projects. Networking and communications infrastructure will play a significant role in wide-spread application, again an area benefiting from U.S. leadership. European interest in Medical Informatics has also been strong for more than 20 years, with a history of involvement with artificial intelligence decision support research. While the Japanese have shown a strong interest in quantitative medicine and the application of their biosensor technologies, they have not had the extensive development of artificial intelligence decision support systems and have been further limited by user interface, networking and institutional issues.

What’s the use?

While many isolated systems have been developed and demonstrated in well-bounded settings, the availability of an integrated system of information on clinical practice, patient management and outcomes is still on the far horizon. Because most data bases are administrative in nature, few contain any meaningful clinical or outcome information; and because of the nature of our health insurance system, they do not contain population-based or longitudinal data. Emphasis must be placed on linking the ultimate outcome and health status changes for many patients over time with data regarding the specific preventive/clinical intervention/treatment as well as effects of financing structures, organization, demographics, procedures, guidelines, and care processes. Cost-effective public health surveillance requires the ability to link aggregate data obtained from the personal care system to regional, state, and local data on environmental pollution, occupational hazards, disease vectors, etc.

Such work is dependent upon development of data systems, agreement on standardized data elements to be collected for computer-based patient records, and administrative data files as well as consumer surveys. A major focus of activity also needs to be the linkage of existing personal care and public health data systems and incorporation of meaningful clinical and outcomes data (measures and reporting formats) that can be electronically exchanged. The results should improve the ability of physicians to stay abreast of state-of-the-art treatments and outcomes in specific circumstances, and enable patients to take a more actively informed role in their own health care. The broader acceptance of telemedicine and the emergence of virtual medical groups may enable more fully informed decisions to be made in remote clinics or community hospitals. These systems would also provide increased national security by allowing the military to minimize battlefield casualties by facilitating out-of-theater support for limited forward medical teams.

The United States has developed a broad technology base at the sub- systems level in both hardware and software, but has not yet been able to benefit from the synergy of decision support systems, networking and communications, and large scale data storage and retrieval capabilities. The development of standards for data exchange is in progress to provide commonality of definitions, messaging and data formats which will be necessary to link large, presently independent systems. As part of the High Performance Computer Consortium (HPCC) program, health care related systems include test bed networks and collaborative applications to link remote and urban patients and providers to the information they need. This includes database technologies to collect and share patient health records in secure, privacy assured environments, advanced biomedical devices and sensors, and the system architectures to build and maintain the complex health information network. Virtual reality technology is being used to simulate operations for medical training, and combined with teleoperator technology for remote surgical procedures. Graphic image reconstruction software and visualization techniques are being combined with high resolution serial sections and CT and MRI imagery to development a virtual atlas of human anatomy for training and education.

Yet, the history of further development into commercial products with multi-institutional adoption has not been encouraging, encountering a host of non-technical barriers which have not been related to the system's ability to improve patient management and outcomes, reduce length of stay and related health care costs. The barriers include physician resistance, cultural differences, and conflicts between societal values. Confidentiality, privacy, and security issues may be an ongoing challenge to systems implementers because a patient's right to privacy has been defined by the U.S. Court of Appeals as a constitutional right which is more compelling than "just" a statutory right, and administrative convenience was not deemed to be a defense against compromising patient privacy. To benefit from the capabilities of integrated health care information systems, these systems will have to bridge a multiplicity of medical institutions, third party payer reporting requirements, and even widely varying public health reporting requirements on a state- by-state basis. Telemedicine and the interstate transfer of medical decision support software have already met regulatory challenges that demonstrate that 60-year-old policies need to be revised.

Universal solutions are unlikely as an integrated system must encompass patient and physician education, medical diagnosis and patient management, third party payers and national public health data acquisition needs while complying with individual privacy rights. Implementation will be incremental, modules will be developed, certified and integrated locally and regionally; while there will be strong economic incentives for commonality, cultural differences will play an enormous role in actual utilization.