About 98.000 people die every year in the hospitals in the USA due to medical errors. The experts calculated this in 1997, after they studied reported adverse occurrences in hospitals in New York, Utah and Colorado in previous years. The data for the rest of the world is not available. If we assume similar incidence in the world and extrapolate, it turns out, every year over 2.1 million people would die in the world, or over 42 million people may have died in the past 20 years because of medical errors. (This shocking number is not based on any hard statistical evidence. The purist may ignore this extrapolation and the cynic can argue that in many countries people die due to lack of medical care and not because of it.)
Most errors occur due to fault in the “process” of care: switching two similar sounding medications (Hydralazine/ Hydoxyzine), wrong dosage units (mcg/mg), confusing two patients with identical names. Extensive use of information technology (IT) can minimize this tragedy and also provide many other tools to improve the processes of health care in the hospitals, local community and the country. Some such benefits are: avoiding repetitive tests on patients, cost containment, early warning of epidemics, post market drug surveillance, disaster management, health care planning and long distance tele-medicine.
The driving component of the health IT – you could call it the ‘operating system’ of the health care universe — is the electronic health record. (EHR), which is a digitized equivalent of a patient’s chart in the hospital or a doctor’s office. An ideal EHR would record each health care encounter and transaction in the life of an individual, from birth to death. This EHR could reside in doctor’s office, a hospital or a central repository, which can allow secure access to pre authorized persons through the Internet.
Why hasn’t it happened? The use of computers in health care is primitive compared to other industries like banking and airlines. IT entered the hospitals through the back door: financial software, including billing and collections settled in the hospital first without any significant linkage to the clinical work, and within clinical disciplines each department procured software to run only its own functions without any electronic data exchange with other departments. The use of IT in healthcare grew by installation of independently functioning modules in enclosed silos and the unintended result was that the departments could not communicate. Medical fraternity learned the hard way that computers are not amenable to behavior modification and software is like a stern nurse: it may do what you ask but not what you want.
What is true of hospital departments is true of institutions; even neighboring hospitals serving the same population cannot communicate with each other. Since health IT has grown in bits and pieces over the past few years, one will have to first dismantle the current system to install the new interoperable information applications.
Five components are essential for the successful operation of a health information network:
- Common interoperable health IT standards.
- Uniform medical nomenclature.
- Policy and regulations to promote the use of e-health platforms.
- User-friendly interface for clinical workers.
- Early involvement of the end users in development and implementation.
The problem of IT standards and clinical nomenclature is nearing resolution. Over the past few years many voluntary and professional institutions have done remarkable work to delineate IT and clinical standards. For instance, we have Health Level-7 (HL-7) protocols for messaging; Digital Imaging and Communication in Medicine (DICOM) for digital images (x-rays) and many other standards have been accepted and vetted. In clinical semantics, Systematized Nomenclature of Medicine (SNOMED) is gaining popularity as the standard nomenclature, which complements the preexisting nomenclature: International Classification of Diseases (ICD-10) and Current Procedure Terminology (CPT codes). These common standards will go a long way to solve the problem of interoperability.
In the past, clinical user interfaces were friendly only to the friends of the programmer. In recent times, the EHR has considerably improved, but the medical world is still waiting for the ideal interface — one which would save time compared to a paper chart, make data entry and retrieval faster, connect with ancillary services, provide alerts and prompts, enhance the business processes and provide frequent updates about advances in the medical sciences. In short, it should be convincingly more efficient than the paper chart to ensure easier acceptance by the clinical workers. We are getting there, but slowly and adequate regulations should accelerate the pace.
The regulations have to address three issues about the data of patients:
- Ownership of data and its authenticated flow to users.
- Secure and need based access to slices of data.
- Security, privacy and confidentiality of data.
These policies have to be in place for transaction of data. At present, the patient owns her health information and it resides in the hospital or insurance company’s servers. These institutions have no incentive to share this data with other competing organizations and would rather keep the information to themselves for business advantage.
The US government envisioned in1994 that the communication between the health care entities and the federal government would be streamlined by electronic communication by 2014. A recent survey of the ambulatory medical care revealed that 25 % of doctors’ offices have either a simple or an advanced IT system. Another survey of the hospitals revealed that implementation of an upgraded EHR was a high priority to improve clinical outcomes and cut costs. A study done by the Health Care Information and Management Society (HIMSS) has found “About 62% of the healthcare organizations based in the U.S. have already made a decision about their (EHR) vendors and are starting an implementation or already have a part of an EHR in place, at least the foundation of it.” Recently adopted regulations in the US will ensure that health IT systems become more prevalent in next ten years.
Many developed countries, with mature health care systems, are in some stage of implementing interoperable health information grids. Some counties like Sweden and Finland are ahead and others like UK and Australia are in the process. European Union is planning to connect all the members on a health grid.
Installation of health IT system has proven to be expensive and slow in almost all countries. Starting in 1998, the National Health Service (NHS) in UK began to implement an electronic patient record in all NHS institutions. The target date was 2005 but by early 2007 the venture was still incomplete and had cost £12.4 billions. Now, the revised completion date is 2008.
In Canada, a not-for profit organization, “Canada Health Infoways”, is leading the implementation of an interoperable health information system, with the participation of federal and provincial health departments. The federal government has invested 1.2 billion Canadian dollars and they aim to have EHR systems operational for 50% of the population by 2009.
For the developing nations, lack of any legacy IT systems may be a blessing; they can leap frog to the latest standards and technology without the burden of dismantling the old. Connectivity and costs will, however, remain big challenges.
India has recently started with a vision of connecting the entire country in one interoperable health IT grid to manage health care and medical knowledge. The vision is to capture most health care transactions, when the system is operational in a few years. The proposed grid will be a hub-and-spoke network with interconnected data repositories stationed through out the country. The project is still in the preliminary stages and probably will gather steam in coming years. Other Asian countries, including China, are also in various stages of developing health IT networks.
On the technology side, many new applications will enhance the capabilities of an EHR system. Mobile platforms like the PDAs and cell phones will access clinical data; personal devices like pacemakers and heart monitors will communicate with the EHR; administrative paper work will be streamlined. If and when individual genomic structure becomes part of the EHR, one would be able to predict disease trends and possible preventive measures for individuals and families. Genetic data would guide the choice of therapy; predict the outcome and even help in new drug development research.
Future of health IT systems is exciting. Once we have strong regulations, interoperability of data and efficient user interface, the EHR becomes scalable. Health care institutions, communities, and even whole country can transact health care information and related business on a web based health grid. It is feasible that in next 30 years we could have a worldwide interoperable health IT network.
Imagine this future scenario: Ms Sally, a 49 years old executive from London has traveled to New York for an urgent meeting. She experiences chest discomfort and is rushed to the emergency room. The doctor suspects a heart attack and advises emergency cardiac catheterization. She declares that a coronary angiogram had been done recently in London for similar symptoms and she believed “it was not that bad.” She had received no treatment as she was in a rush to travel.
It is nighttime in London and her personal doctor is not available. She gives the New York doctor access to her EHR on the Internet, who downloads the angiogram. It is perfectly normal.
The ER doctor looks for another reason for her chest pain and orders a CT scan of the chest, which reveals a large life threatening blood clot in the lung. She receives urgent treatment to dissolve the clot.
Immediate access to the EHR helps avoid an error. It prevents an unnecessary procedure, and saves time and probably her life.