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Adaptive Health
Management
Information Systems
Concepts, Cases, and
Practical Applications
Third Edition
Edited by
Joseph Tan, PhD
Professor
Business Department
Wayne State University
School of Business Administration
Detroit, Michigan
with
Fay Cobb Payton, PhD
Associate Professor
Information Systems/Technology
North Carolina State University
College of Management
Raleigh, North Carolina
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Library of Congress Cataloging-in-Publication Data
Tan, Joseph K. H.
Adaptive health management information systems : concepts, cases, & practical applications / Joseph Tan with
Fay Cobb Payton.—3rd ed.
p. ; cm.
Rev. ed. of: Health management information systems. 2nd ed. Gaithersburg, Md. : Aspen Publishers, 2001.
Includes bibliographical references and index.
ISBN-13: 978-0-7637-5691-8 (pbk.)
ISBN-10: 0-7637-5691-1 (pbk.)
1. Information storage and retrieval systems—Health services administration. 2. Management information
systems. I. Payton, Fay Cobb. II. Tan, Joseph K. H. Health management information systems. III. Title.
[DNLM: 1. Management Information Systems. 2. Health Services Administration. W 26.5 T1608a 2009]
RA971.6.T36 2009
362.1068’4—dc22
2008054201
6048
Printed in the United States of America
13 12 11 10 09 10 9 8 7 6 5 4 3 2 1
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New to This Edition
Adaptive Health Management Information Systems, Third Edition, is for instructors who want to
keep pace with rapid changes in the field of healthcare management information systems
(HMIS) and health informatics (HI). This new edition is not simply an update of the second
edition—it is a completely reorganized, expanded, and rewritten text containing all new con-
tributions, special sections, and streamlined discussions of more established as well as hot cur-
rent topics. These are spiced with motivating scenarios; real-world examples; mini-cases;
stimulating chapter questions; illustrative graphics, tables, and exhibits; and additional read-
ings. Significant updates and complete revisions have been integrated throughout the text—so
much so that readers familiar with the previous edition would not recognize this work as a de-
rivative of the other.
Specific updates
● Content. Rich, comprehensive topics covered range from HMIS history; chief executive
officer/chief information officer roles and responsibilities; health IT and Internet use;
HMIS enterprise software; virtual communities and networks; patient-centric manage-
ment systems; HMIS interoperability; HMIS strategic planning; HMIS developments;
HMIS project management; HMIS standards, governance, and international perspec-
tives; and HMIS innovation.
● Scenarios. Realistic and real-world scenarios set the stage for topic discussion and to moti-
vate the student readers; a short reflection is also given at the end of each scenario.
● Technology Briefs. Concise briefs cover specific HMIS knowledge domains such as the
Internet and associated technologies; hardware, software, and user interfaces; network
technologies; database concepts; and data mining and data warehousing.
● Research Brief. Brief extends reading and provides supplementary research data.
● Policy Brief. Brief covers key policy issues relating to the Health Insurance Portability and
Accountability Act (HIPAA), privacy, confidentiality, and security issues.
● Mini-Cases. Short cases illustrate concepts, and related mini-case questions promote class
discussions among students.
● Chapter Questions. Long- and short-answered questions stimulate classroom discussions
and promote learning of various topics and examples discussed in the text.
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● Editor’s Notes. Appended to chapters contributed by various authors, these notes bridge
the chapter contents with the other chapters and parts of the text, thereby providing read-
ers with an overview of the intended organization of the text.
● Major Cases. Part V provides a selection of major cases to enhance understanding of
teaching materials and promote further interactions between students and instructors.
iv NEW TO THIS EDITION
56918_FMxx_Final_Tan 4/6/10 1:31 PM Page iv

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Dedication
To the memory of my parents, who brought me into this world;
to my students and colleagues, who have enjoyed my work and benefited
from my 20-year career of teaching and research in the fields of healthcare services
and administration, business information systems, and healthcare informatics;
and to my immediate family members, who have helped in every way
to mature my academic publishing and writing career.
—Joseph Tan
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Acknowledgments
Above and beyond those to whom I am indebted while putting together the earlier editions of
this text, I would like to thank those newly added academic and professional contributors, in-
cluding those who were brought on board by co-editor, Dr. Fay Cobb Payton. Dr. Payton has
personally shared in parts of the writing of this revised edition and Mr. Joshia Tan helped
make this revised edition not only a completely different kind of text, but one much more ap-
pealing and valuable for instructors and students alike. Aside from contributing his very own
case as a closure to the text and spearheading the writing of several briefs and chapters, Mr.
Tan has contributed to the repackaging of the materials in this text in such a way as to help
student readers better digest those more complex and highly technical parts of the previous
editions by rearranging and rewriting key portions of previously published materials for lighter
and easier reading.
There are two other individuals whom I must especially thank: Dr. Kai Zheng, a professor at
the University of Michigan School of Public Health and School of Information, and Mr.
Jonathan Dunford, a graduate student studying in the joint MBA–Masters in Health Services
and Administration program at the University of Michigan. Dr. Zheng has kindly—and metic-
ulously—reviewed some of the more critical chapters of this revised edition, especially Chapter
1, while Mr. Dunford has generously assisted in summarizing several of the motivating scenar-
ios appearing at the beginning of the chapters. I am also indebted to numerous Wayne State
University students, whose names would fill countless pages if I were to list them one by one; I
will choose to keep this simple for fear of missing anyone important. To date, these students
have contributed to many repeated discussions, year after year, about where they felt changes
would have made previous editions of this text more valuable in classroom teaching and during
online discussion sessions. A good number of these students have enjoyed and greatly benefited
from my teaching and have also encouraged me to elaborate on new and emerging topics, most
of which, unfortunately, I can only incorporate briefly and sparingly due to space limitation;
otherwise, we would have ended up with a four-volume introductory text if all of the research
gathered by myself, my assistants, and my students were to be incorporated, in one way or an-
other, as different chapters, briefs, and cases. Indeed, I have also taken this opportunity, with
the help of Mr. Joshia Tan, to substantially reduce the volume of words to convey the same key
56918_FMxx_Final_Tan 4/6/10 1:31 PM Page vii

messages contained in the previous editions through the innovative use of Technology, Research,
and Policy Briefs. In so doing, we have eliminated most of the dated materials.
I am grateful to all who have contributed, especially for their collaborative spirit and willing-
ness for me to revise and edit freely their submitted pieces throughout the lengthy duration of
this project. Their willingness for me to redirect their contributions to a common theme, to
conform to a set format or a particular layout, to confine and revise the writing to a particular
topic or area of research, to eliminate much of the overlapping information in earlier drafts, and
to make substantive changes when necessary—without the need to consult with them over and
over again—is highly admired because it has helped merge the different contributed pieces into
a unified whole. More importantly, a special acknowledgment is due to the generosity of the
publisher to extend the deadline for me to complete all of the revisions I wanted to see going
into this latest edition at a time when I was swamped with the parallel production of several
other major works. I would also like to take this opportunity to thank the three anonymous re-
viewers engaged by the publisher for going over the submitted drafts, pointing out any errors,
and providing various suggestions to improve the appeal of the different chapter layouts and
contents. Without the patience shown to me by key personnel at Jones & Bartlett Publishers, I
know the end product of this revised edition would have been vastly limited. I am also indebted
to Dean Homer Schmitz of St. Louis University, who kindly agreed to pen the Foreword for
this latest edition swiftly on a very tight time constraint. His mentorship and advice for advanc-
ing my academic career has always been one that I truly admire and enjoy.
All in all, I greatly appreciate and thankfully acknowledge all of the assistance, encourage-
ment, and understanding from each and every person who participated in any way, shape, or
form, in the various stages and processes involved in the production of this work, from begin-
ning to end. Once again, I am particularly grateful to my son, Joshia Tan, who took precious
time out of his extremely busy summer 2008 work schedule to help me prepare this third edi-
tion for publication. And I must certainly acknowledge the unceasing support, encouragement,
and understanding of my wife, Leonie Tan, throughout the duration of this project.
To all of these individuals and to my family members, friends, students, and relatives, I offer
my many thanks for the support provided to me. Much of the value of this work is due to their
contributions and assistance.
—Joseph Tan
viii ACKNOWLEDGMENTS
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Contents
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii
PART I Foundation Concepts of Health Management
Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1
Health Management Information Systems: A Managerial Perspective . . 3
Joseph Tan
Scenario: Key Trends Contributing to the Merging of Enterprise and
Health Information Exchange Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
II. Evolution of HMIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
III. HMIS Components and Basic Functions . . . . . . . . . . . . . . . . . . . . 8
● HMIS Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
● HMIS Basic Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
IV. HMIS Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
V. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Mini-Case: MinuteClinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ix
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Chapter 2
Health Management Information System Executives: Roles and
Responsibilities of Chief Executive Officers and Chief Information
Officers in Healthcare Services Organizations . . . . . . . . . . . . . . . . . . . 23
Joseph Tan
Scenario: Managing Waiting Time in Emergency Rooms . . . . . . . . . . . . . . . 24
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
II. Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
III. Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
IV. Execution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
V. Senior Executives in Healthcare Services Organizations . . . . . . . . 33
● A Trustworthy Leader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
● An Inspirational Manager and Motivator of Others . . . . . . . . . 36
● An Effective Communicator . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
VI. Specific CIO Role and Responsibilities . . . . . . . . . . . . . . . . . . . . . 37
VII. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Mini-Case: Predicting Future HMIS Trends by Chief Information
Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Research Brief I: Personal Digital Assistants Enhance Data
Collection Efficiency during a Study of Waiting Times in an
Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
N. Elkum, W. Greer, and A. Al-Madouj
Chapter 3
Online Health Information Seeking: Access and Digital
Equity Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Fay Cobb Payton and Joseph Tan
Scenario: A New RHIO in DC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
II. Emotional Support and Empowerment of Health
Information Seekers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
III. Profiling Health Information Seekers . . . . . . . . . . . . . . . . . . . . . . 54
IV. Accessing Health Information beyond the Internet . . . . . . . . . . . . 57
V. Alternative Means of Accessing Health Information . . . . . . . . . . . 57
VI. Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
x CONTENTS
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Technology Brief I: Fundamentals of Internet and Associated
Technologies for Healthcare Services Organizations . . . . . . . . . . . . . . . 61
Joshia Tan
PART II Health Management Information System Technology
and Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Chapter 4
Health Management Information System Enterprise Software:
The New Generation of HMIS Administrative Applications . . . . . . . . 69
Joshia Tan with Joseph Tan
Scenario: Customer Relations Management with Blue Cross Blue
Shield of Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
II. Supply Chain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
III. Customer Relationship Management . . . . . . . . . . . . . . . . . . . . . . 75
IV. Enterprise Resource Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
V. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Technology Brief II: Basic Hardware, Software, and
Interface Concepts for Healthcare Services Organizations . . . . . . . . . . 86
Joshia Tan and Joseph Tan
Chapter 5
Community Health Information Networks: Building Virtual
Communities and Networking Health Provider Organizations . . . . . . 95
Jayfus T. Doswell, SherRhonda R. Gibbs, and Kelley M. Duncanson
Scenario: Designing an Intelligent Community Health
Information Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
II. Previous Community Health Information Networks . . . . . . . . . . 98
III. From CHIN to RHINO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
IV. Prospects for RHINO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
V. HL7 Standard Health Data Exchange . . . . . . . . . . . . . . . . . . . . . 101
● Community Management Systems . . . . . . . . . . . . . . . . . . . . . 102
VI. Mayo Clinic CASE Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
VII. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
CONTENTS xi
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Technology Brief III: Telecommunications and Network
Concepts for Healthcare Services Organizations . . . . . . . . . . . . . . . . . 109
Joseph Tan
Chapter 6
Trending toward Patient-Centric Management Systems . . . . . . . . . . . 117
Joseph Tan with Joshia Tan
Scenario: Google Health, a Portal for Personal Health Records
and Health Decision Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
II. Definitions of EHR, CPOE, and CDSS . . . . . . . . . . . . . . . . . . . 120
III. Historical Evolution of EHR, CPOE, and CDSS . . . . . . . . . . . . 121
IV. Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
V. Computerized Physician Order Entry . . . . . . . . . . . . . . . . . . . . . 125
VI. Clinical Decision Support Systems . . . . . . . . . . . . . . . . . . . . . . . 125
VII. Benefits and Challenges of EHR, CPOE, and CDSS . . . . . . . . . 126
● Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
● Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
VIII. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Technology Brief IV: Database, Data-Mining, and
Data-Warehousing Concepts for Healthcare Services Organizations . . 133
Joshia Tan and Joseph Tan
Chapter 7
Health Management Information System Integration: Achieving
Systems Interoperability with Web Services . . . . . . . . . . . . . . . . . . . . 143
J. K. Zhang and Joseph Tan
Scenario: The SAPHIRE Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
II. Current HMIS Interoperability Issue . . . . . . . . . . . . . . . . . . . . . 148
III. Web Services: The Interoperability Solution . . . . . . . . . . . . . . . . 150
IV. WSIHIS Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
● Background of WSIHIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
● WSIHIS Interoperability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
● Web Service–Based Solution for WSIHIS Interoperability . . . 154
● System Assessment on WSIHIS Interoperability . . . . . . . . . . . 157
V. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
xii CONTENTS
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PART III Health Management Information System
Planning and Management . . . . . . . . . . . . . . . . . . . . . . . 163
Chapter 8
Health Management Strategic Information System Planning/
Information Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Jon Blue and Joseph Tan
Scenario: Open Health Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
II. The Essence of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
III. The PODC Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
IV. HMSISP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
V. Information Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
● Information Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
● Business Systems Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
● Critical Success Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
● In-Depth Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
VI. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Chapter Appendix: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Chapter 9
System Development: Health Management Information
System Analysis and Developmental Methodologies . . . . . . . . . . . . . . 191
Joseph Tan
Scenario: Richmond Township . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
II. HMIS Analysis and Development Methodologies . . . . . . . . . . . . 196
III. SDLC-Based Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
IV. Structured Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
V. Prototyping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
VI. Contemporary Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
● Computer-Assisted Software Engineering
(CASE) Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
● Multiview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
● Open-Source Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
VII. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
CONTENTS xiii
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Chapter 10
Data Stewardship: Foundation for Health Management Information
System Design, Implementation, and Evaluation . . . . . . . . . . . . . . . . 217
Bryan Bennett
Scenario: The Metropolitan Medical Group . . . . . . . . . . . . . . . . . . . . . . . 218
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
II. The Change Continuums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
● Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
● Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
● People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
III. Data Stewardship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
● Data Quality Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
● Data Management Implications . . . . . . . . . . . . . . . . . . . . . . . 223
● Data Security Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
● Business Intelligence Implications . . . . . . . . . . . . . . . . . . . . . . 224
IV. Implementation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
● Step 1: Assessing the Available Resources . . . . . . . . . . . . . . . . 225
● Step 2: Assessing Data and Data Inventory . . . . . . . . . . . . . . . 226
● Step 3: Profiling Data and Determining the Valid Values
for Each Attribute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
● Step 4: Reviewing Processes . . . . . . . . . . . . . . . . . . . . . . . . . . 226
● Step 5: Reviewing Personnel Responsibilities . . . . . . . . . . . . . . 228
● Post-Implementation Review . . . . . . . . . . . . . . . . . . . . . . . . . 229
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Mini-Case: The Metropolitan Medical Group (MMG) . . . . . . . . . . . . . . 230
Chapter 11
Managing Health Management Information System Projects:
System Implementation and Information Technology
Services Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Joseph Tan
Scenario: Louisiana Rural Health Information Exchange . . . . . . . . . . . . . 232
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
II. Critical Success Factors for Systems Implementation . . . . . . . . . . 234
● User Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
● Systems Design Characteristics . . . . . . . . . . . . . . . . . . . . . . . . 236
● Organizational Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 237
III. Strategic Planning and Management Issues . . . . . . . . . . . . . . . . . 238
● Staffing Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
● Organizational Project Management . . . . . . . . . . . . . . . . . . . . 240
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● Reengineering Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 242
● End-User Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
● Vendor Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
● Additional Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
IV. Systems Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
● Pre-Implementation Preparation . . . . . . . . . . . . . . . . . . . . . . . 245
● Proposal Evaluation and Selection . . . . . . . . . . . . . . . . . . . . . . 246
● Physical Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
● Post-Implementation Upkeep . . . . . . . . . . . . . . . . . . . . . . . . . 251
V. IT Services Management Concepts . . . . . . . . . . . . . . . . . . . . . . . 253
VI. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
PART IV Health Management Information System
Standards, Policy, Governance, and Future . . . . . . . . . . . . 259
Chapter 12
Health Management Information System Standards:
Standards Adoption in Healthcare Information Technologies . . . . . . . 261
Sanjay P. Sood, Sandhya Keeroo, Victor W. A. Mbarika, Nupur Prakash,
and Joseph Tan
Scenario: HHS to Form Standards, Operability Group to Spur
Health IT Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
II. HMIS Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
III. HIPAA to Spur Data Standards Adoption . . . . . . . . . . . . . . . . . . 266
IV. HL7: Health Level Seven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
● The Vocabulary Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
● HL7 Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
● HL7 Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
V. DICOM: Digital Imaging and Communication
in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
● Purpose of DICOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
● Adoption of DICOM Standards . . . . . . . . . . . . . . . . . . . . . . . 274
VI. Web Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
VII. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
CONTENTS xv
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Policy Brief I: HIPAA, Privacy, and Security Issues for
Healthcare Services Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Joseph Tan and Fay Cobb Payton
Chapter 13
Health Management Information System Governance, Policy, and
International Perspectives: HMIS Globalization through E-Health . . 291
Anantachai Panjamapirom and Philip F. Musa
Scenario: TriZetto and TeleDoc Alliance . . . . . . . . . . . . . . . . . . . . . . . . . 292
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
II. Tele-Care, Telemedicine, Tele-Health, and E-Health . . . . . . . . . . 295
III. Types of Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
IV. The Economic Perspectives of ICT and E-Health . . . . . . . . . . . . 298
● Production Possibility Frontier . . . . . . . . . . . . . . . . . . . . . . . . 300
● Positive Externality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
V. Factors Influencing the Adoption of E-Health . . . . . . . . . . . . . . 302
● Technology Acceptance Model . . . . . . . . . . . . . . . . . . . . . . . . 302
● Theory of Planned Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . 303
● Diffusion of Innovation Theory . . . . . . . . . . . . . . . . . . . . . . . 303
● Technology-Organization-Environment Model . . . . . . . . . . . . 304
VI. Barriers to E-Health Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . 304
VII. Stakeholder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
VIII. WHO’s Strategic Framework for E-Health Development . . . . . . 308
IX. Flow of Resources between Developed and
Developing Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
X. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
Mini-Case: M&P Cardiovascular Center Inc. . . . . . . . . . . . . . . . . . . . . . 316
Chapter Appendix: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Chapter 14
Health Management Information System Innovation: Managing
Innovation Diffusion in Healthcare Services Organizations . . . . . . . . 319
Tugrul U. Daim, Nuri Basoglu, and Joseph Tan
Scenario: MedeFile International . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
II. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
III. Complex Adaptive Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
● General Systems Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
● Complex Adaptive Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
● Handling Complexity in Healthcare Services Organizations . . 328
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IV. Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
V. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Chapter Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
PART V Health Management Information Systems
Practices and Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Case 1
Emergency Medical Transportation Resource Deployment . . . . . . . . . 339
Homer H. Schmitz
Case 2
The Clinical Reminder System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Kai Zheng
Case 3
Integrating Electronic Medical Records and Disease
Management at Dryden Family Medicine . . . . . . . . . . . . . . . . . . . . . . 359
Liam O’Neill and William Klepack
Case 4
Delivering Enterprisewide Decision Support through
E-Business Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Rajiv Kohli and Henry J. Groot
Case 5
Mapping the Road to the Fountain of Youth . . . . . . . . . . . . . . . . . . . 385
Joshia Tan
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
CONTENTS xvii
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About the Editors
Primary author and editor Joseph Tan, PhD, is a professor of business information systems/
information technologies (IS/IT) and healthcare informatics. He is the editor-in-chief of
International Journal of Healthcare Information Systems & Informatics (IJHISI). He has served as
acting director for the master’s of health administration program at the Faculty of Medicine,
University of British Columbia; as chair of the Information Systems and Manufacturing
Department of Wayne State University’s School of Business Administration; as consultant to
the Ontario Council of Graduate Studies; as well as a research fellow and advisor to various
professional research institutes and nonprofit and for-profit organizations. His professional
background spans a broad spectrum of disciplinary expertise and research interests, with a
demonstrated ability to serve in both academia and industry. He is the lead investigator in re-
defining the frontiers of interdisciplinary and translational business and health IT knowledge
development and expansion, including active involvement in collaborative research and multi-
disciplinary joint-grant submissions. He has achieved recognized scholarship in teaching and
learning with students’ nominations for teaching excellence awards, and he networks widely
with key decision and policy makers as well as academic scholars and practitioners at local,
provincial/state, national, and international levels, including private, public, and nongovern-
mental organizations and universities.
Dr. Tan has been asked to provide keynote speeches at doctoral seminars and conferences
and has been invited to conduct research seminars and/or make appearances at numerous ma-
jor universities around the world. His work is widely cited, and he has more than 100 academic
publications, including a four-volume encyclopedia and numerous research monographs and
teaching textbooks. He has taken leadership roles in team-based research, curriculum and pro-
gram development and accreditation, peer-reviewed journal publications and book reviews,
online education and programming, planning and organization of symposiums and confer-
ences, development of book series, special issue journals, and federal grant proposals. His past
20-year academic experience includes full-time employment in academia, private and nonprofit
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sector organizations, as well as consulting and engaging in executive program development ac-
tivities catering to executives and foreign delegation. His overall career focus is on reshaping the
landscape of IS/IT applications and promotion in e-healthcare informatics through cross-
disciplinary thinking/project partnering with diverse practitioners, clinicians, researchers, and a
variety of user communities.
Co-editor Fay Cobb Payton, PhD, is an associate professor of IS/IT at North Carolina State
University (NCSU), where she serves as the IS area coordinator. She is the vice chair of the AIS
SIG-Health International group and is an active member of the Institute of Electrical and
Electronics Engineers (IEEE) medical technology policy group. She is currently serving as a
member of the NCSU Advisory Board for the Women in Science and Engineering Program.
She has worked on consulting and/or research projects with Ernst & Young/CAP Gemini
Health Care IT Practice, IBM, Blue Cross Blue Shield of Ohio and North Carolina, Duke
Medical Center, the North Carolina Medical Society, Quintiles Transnational, and Time-
Warner. Her research interests include healthcare informatics (AIDS/HIV among African
American and sub-Saharan African populations; health disparities), data management (data an-
alytics and quality), and social exclusion (including the digital divide/equity and STEM
[Science, Technology, Engineering, and Mathematics] pathways). She has published in many
peer-reviewed publications, including Journal of the AIS; The Information Society; Journal of
Organizational Computing and EC; IEEE Transactions; Communications of the ACM; Health
Care Management Review; Computer Personnel, Information and Management; Decision Sciences
Journal on Innovative Education; Computers and Society; and International Journal of Technology
Management.
Dr. Payton served on the editorial board of ITProfessional—an IEEE computer society
journal—for four years and is the co-editor of the Health Care section for the National Science
Foundation (NSF)-sponsored African Journal of Information Systems. She is also the co-editor of
a Journal of the AIS special issue—“Healthcare: People and Processes.” She is part of a research
team that received an NSF ADVANCE grant. She has actively served in an advisory role for
The PhD Project and the project’s IS Doctoral Student Association.
Editorial assistant Joshia Tan is a sophomore (and on the Dean’s List) at the Olin Business
School, Washington University, in St. Louis, Missouri. Even at an early age, Mr. Tan displayed
an affection for and interest in a vast range of pursuits, so it comes as no surprise that, years
later, he is involved in an incredible variety of activities. He serves as a college council represen-
tative, writes and distributes for Eleven Music Magazine, and works at the WashU Law School.
A National Merit Scholar and Washington University in St. Louis Book Award recipient, Mr.
Tan has also received numerous other awards, including graduating cum laude, the AP Scholar
with Distinction award, Cranbrook Prize Papers, Michigan Math Prize Competition Finalist,
and Brook Film Festival’s 3rd place award as lead actor and co-director of The Broken Silence. In
addition, one of Mr. Tan’s most recognized film productions, Tao Te Cranbrook, has been pre-
sented at a number of classes and seminars in the Business Department, School of Business
Administration, Wayne State University, Michigan. He has also brought his activities to new
levels by sharing them with others; for example, he volunteered for two years as a snowboarding
xx ABOUT THE EDITORS
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counselor for Bloomfield Hills Ski & Snowboard club in Michigan. He also played violin with
various schools’ orchestras and served as assembly pianist for one his schools.
The literary world plays a large role in Mr. Tan’s life, as he has co-authored “The Oliver
Home Case” (with J. Tan/G. Demiris) and “CyberAngel: The Robin Hood Case” (with J. Tan),
both appearing in J. Tan (Ed.) E-Health Care Information Systems: An Introduction for Students
& Professionals (San Francisco: Jossey-Bass, 2005): 52–55 and 290–294, respectively. In 2008,
Mr. Tan self-published The Apprentice Bistro: A Feast for Amateur Writers, an adaptation of his
2007 Davidson Fellows entry—for which he received an honorable mention. More recently, he
has completed another major work, Concord in Calamity: Taming the Awakening Armageddon.
Mr. Tan is also an avid traveler with numerous countries under his belt; he keeps a steadfast
hold on his life dream of seeing the world—and changing it for the better. True to this vision,
he has studied various languages, including English, French, and two different dialects of
Chinese. Moreover, to better appreciate the Chinese language and culture, he spent an entire se-
mester fulfilling the challenge of his dream by accepting an invitation to work as an intern in
Shanghai, China. Furthermore, he incorporates this dream into his hobbies, such as drawing
from international influences for his dabbles in the musical and culinary arts. Ultimately, it is
this vision that continues to drive him; it is this dream that he works toward; and it is this
dream that may, years later, very well become reality.
ABOUT THE EDITORS xxi
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56918_FMxx_Final_Tan 4/6/10 1:31 PM Page xxii

Contributors
Amal Al-Madouj
Clinical Research Assistant, Epidemiology Research Unit
Biostatistics, Epidemiology, and Scientific Computing
King Faisal Specialist Hospital and Research Centre
Riyadh, Kingdom of Saudi Arabia
Amal Al-Madouj is a clinical research assistant at the Biostatistics, Epidemiology, and
Scientific Computing Department, King Faisal Specialist Hospital and Research Centre,
Riyadh, Kingdom of Saudi Arabia (KSA). She graduated from the Health Sciences College and
has been awarded an associate degree in the field of health record administration.
In 2001, she joined the Epidemiology Research Unit (ERU) at King Faisal Hospital and
Research Centre, Riyadh, KSA. She has been involved in various projects as co-principal inves-
tigator and co-investigator.
Nuri Basoglu, PhD
Associate Professor
Department of Management Information Systems
Bogazici University
Istanbul, Turkey
Dr. Nuri Basoglu is an associate professor in the Department of Management Information
Systems, Bogazici University, Istanbul, Turkey. His research interests are sociotechnical aspects
of information systems, customer-focused product development, information technology
adaptation and wireless service design, intelligent adaptive human computer interfaces, and in-
formation systems strategies. He has published articles in journals such as Technology
Forecasting and Social Change, Journal of High Technology Management and Technology in
Society, and International Journal of Services Sciences.
Dr. Basoglu received his BS in industrial engineering from Bogazici University in Turkey,
and his MS and PhD in business administration from Istanbul University.
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Bryan Bennett
President and Founder
Insight Data Group LLC
Riverwood, Illinois
Bryan Bennett is the founder and chief executive officer of Insight Data Group (IDG) and is
an internationally renowned data-driven business strategy professional with more than 15 years
of data and database marketing experience serving clients in the banking, credit card, invest-
ment, telecommunications, pharmaceutical, and insurance industries. His work has led to the
identification of new customer insights and business opportunities, resulting in improved oper-
ations and efficiencies.
Mr. Bennett is also a proven thought leader with articles and whitepapers requested by and
published in several national and international journals and magazines. In addition to a
whitepaper published in the Journal of Financial Transformation, he is a frequent contributor to
national publications and is the primary contributor to IDG’s Biz Insights newsletter. He has
been invited to speak at several conferences and has developed and delivered training sessions
for several organizations. Mr. Bennett teaches the graduate-level course “Audience Insight” for
West Virginia University’s (online) Integrated Marketing Communications Program. He is a
member of the Chief Marketing Officer Council, Reuters Insight Community of Experts,
Gerson Lehrman Group Consulting Council, and the IT Senior Management Forum. Mr.
Bennett has an MBA in marketing, finance, management policy, and management information
systems from the Kellogg Graduate School of Management at Northwestern University and a
BS in accounting from Butler University. He is also a certified public accountant.
Jon Blue, PhD
Assistant Professor
Department of Accounting and Management Information Systems
University of Delaware
Newark, Delaware
Dr. Jon Blue is an assistant professor in the Department of Accounting and Management
Information Systems at the University of Delaware. He received a PhD in business with a con-
centration in information systems from Virginia Commonwealth University. His primary re-
search interests are healthcare informatics, decision support systems, information technology
adoption and implementation, and information systems project management. He is on the edi-
torial board of the International Journal of Healthcare Delivery Reform Initiatives.
Prior to his academic career, Dr. Blue worked for more than 20 years in large companies—
specifically IBM, Hewlett-Packard, and 3Com. In these companies, he worked in and managed
domestic, as well as worldwide, organizations in various fields, including software and Internet
development and testing, technical consulting, operations, sales, marketing, and engineering.
His last corporate position was as the worldwide senior director of e-business professional ser-
vices. In this position, he led a worldwide solutions management e-business professional services
(consulting) organization and was responsible for the entire division’s profit and loss.
xxiv CONTRIBUTORS
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Tugrul U. Daim, PhD
Associate Professor
Department of Engineering and Technology Management
Portland State University
Portland, Oregon
Dr. Tugrul U. Daim is an associate professor of engineering and technology management at
Portland State University. He is published in many journals, including Technology in Society,
Technology Forecasting and Social Change, International Journal of Innovation and Technology
Management, Technology Analysis and Strategic Management, International Journal of Healthcare
Information Systems & Informatics, and Technovation.
Dr. Daim received his BS in mechanical engineering from Bogazici University in Turkey, MS
in mechanical engineering from Lehigh University in Pennsylvania, another MS in engineering
management from Portland State University, and a PhD in systems science–engineering man-
agement from Portland State University.
Jayfus T. Doswell, PhD
Founder, President, and CEO
Juxtopia, LLC
Distinguished Professor of Biotechnology
School of Math, Science, and Technology
Elizabeth City State University
Elizabeth City, North Carolina
Dr. Jayfus T. Doswell is the founder, president, and chief executive officer of Juxtopia LLC, a
biomedical and information technology company with a mission to improve human perform-
ance. Dr. Doswell is also the chairperson of The Juxtopia Group Inc., a nonprofit 501c3 organ-
ization with a mission to improve human learning performance with science and technology
research that adapts to individual learning needs. Additionally, Dr. Doswell is a distinguished
professor of biotechnology at Elizabeth City State University (ECSU), located in North
Carolina, where he is responsible for instructing the next generation of leaders fund-raising, en-
trepreneurship, and outreach. Dr. Doswell sits on several not-for-profit boards and is an active
member of the American Public Health Association (APHA) Health Informatics and
Information Technology (HIIT) special interest group, American Telemedicine Association
(ATA), Association of Computing Machinery (ACM), Institute of Electrical and Electronics
Engineering (IEEE), and the National Society of Black Engineers (NSBE). Prior to starting
Juxtopia in 2001, Dr. Doswell led several commercial software engineering teams, ranging from
Lockheed Martin and SAIC to BearingPoint.
Dr. Doswell and Juxtopia currently lead research and product development combining
artificial intelligence, telemedicine/tele-health, bioinformatics, computational biology, and
biosensors.
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Kelley M. Duncanson, PhD
Assistant Professor of Management and Accounting
School of Business
College of The Bahamas
Nassau, Bahamas
Dr. Kelley M. Duncanson is an assistant professor of management and accounting in the
School of Business at the College of The Bahamas. Her primary research interests include deci-
sion support systems, simulated learning, student budgeting and personal finance, organiza-
tional citizenship behavior, and student learning techniques. She consults with businesses
regarding management and accounting systems issues. She has published in the Business
Research Yearbook and Global Business Perspectives and has presented papers at the International
Academy of Business and Economics and INFORMS conferences. She received her PhD in
management from Jackson State University, Jackson, Mississippi.
Naser Elkum, PhD
Professor and Research Methodologist
Biostatistics
King Faisal Specialist Hospital and Research Centre
Riyadh, Kingdom of Saudi Arabia
Dr. Naser Elkum is a professor and research methodologist of biostatistics at King Faisal
Specialist Hospital and Research Centre. In 1997, he earned his PhD in statistics from Queen’s
University, Canada. Subsequently, he worked as a manager of the biostatistics and data manage-
ment department at Pharma Medica Research Inc. (PMRI), Mississauga, Canada. Currently, he
is scientist and head of biostatistics unit at King Faisal Specialist Hospital and Research Centre,
Riyadh, KSA.
Dr. Elkum has more than 15 years of health science work experience in internationally rec-
ognized institutions, including National Cancer Institute of Canada Clinical Trials Group,
Queen’s University, Canada; Health Canada; Laboratory Center of Disease Control, Ottawa,
Canada; Pharma Medica Research Inc., Mississauga, Canada; and King Faisal Specialist
Hospital and Research Centre, Riyadh, KSA. He provides statistical leadership in studies in
various areas of population health research, clinical research, and health services and outcomes
research.
SherRhonda Gibbs, PhD candidate
Department of Management and Marketing
Jackson State University
Jackson, Mississippi
SherRhonda Gibbs is a PhD candidate in management at Jackson State University; her pro-
gram status is ABD (all but dissertation). She received her BS degree in computer science from
Grambling State University in Louisiana. She also holds a Master’s of Business Administration
degree from Winona State University in Minnesota. Her research concentration is in technology
entrepreneurship, entrepreneurial opportunity recognition, careers, information technology,
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and small business. Ms. Gibbs has made numerous academic presentations on diverse topics
both nationally and internationally. She has published in, among others, the International
Journal of Globalization and Small Business and E-Business Review. As a Cal State–San
Bernardino ITTN fellowship recipient, she has been certified in technology entrepreneurship,
transfer, and commercialization. Last year, she received the AOM Careers Division, Best
Doctoral Student Paper Award. Ms. Gibbs has also received entrepreneurial leadership awards
and service recognition for her work with entrepreneurship students at Jackson State.
William Greer, PhD
Senior Clinical Planner
Health Statistics
Sidra Medical and Research Center
Weill Cornell Medical College
Doha, Qatar
Dr. William Greer is currently a senior clinical planner in health statistics at Sidra Medical
and Research Center in Qatar. Originally a physicist, he obtained his PhD in bioengineering in
1978 from Strathclyde University in Scotland, where he developed an integrated mathematical
model of the neural and chemical control of breathing in humans. His postdoctoral research
was divided between an epidemiological study of musculoskeletal injuries in Mt. Isa Mines,
Australia, and the application of control systems techniques to the analysis of totally closed
breathing circuits at Manchester University, England. In 1980, he joined the National Institute
for Medical Research in London, where he initially commissioned its new mainframe computer
system prior to spending several years collaborating with biologists in computational and math-
ematical aspects of developmental biology and neurobiology, including the development of the
first computerized mapping system for biological electron microscopy. While at the National
Institute, he also developed one of the first bioinformatics software packages (MGS), which was
later adopted by a number of U.K. research institutions and universities. In 1986, he moved to
the King Faisal Specialist Hospital and Research Centre in Riyadh, Kingdom of Saudi Arabia,
where he carried out biocomputing, epidemiological, biostatistical, and bioinformatics research
for the next 10 years.
In 1995, Dr. Greer relocated to Edinburgh as an independent research consultant in biosta-
tistics and pharmacogenomics. During this period, he became responsible for the data manage-
ment and analysis of one of the largest collections of normative bone mineral density
measurements in women, at the Bone Densitometry Unit in the Nuffield Hospital, Oxford. In
1998, he returned to King Faisal Specialist Hospital and Research Centre to develop a new
Scientific Computing Research Unit, focusing on clinical image analysis, biological simulation,
geographical information systems (GIS), and bioinformatics. In 2005, he assumed a faculty po-
sition in public health at the Weill Cornell Medical School in Qatar, where—in addition to de-
veloping research on diabetes in Qatar—he was responsible for teaching biostatistics,
epidemiology, and evidence-based medicine. His current research interests include diagnostic
aspects of postmenopausal osteoporosis, epidemiological applications of GIS, biological and
physiological modeling, and the computational analysis of promoter regions of DNA.
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Henry J. Groot, MS
Director
Information Resources
Holy Cross Health System Corporation
South Bend, Indiana
Henry J. Groot is the director of information resources at the corporate offices of Holy
Cross Health System Corporation. His accomplishments include positioning the decision
support function to support the decision makers in multiple business units and clinical settings
and to support their information needs by increasing use, understanding, and application of
information for analysis and reporting. The deployment of decision support has spanned across
disciplines such as finance, corporate development, utilization and quality assurance, and oper-
ations. Mr. Groot received his MS in management information systems from Purdue
University, West Lafayette, Indiana. His work has been published in Healthcare Informatics and
Topics in Healthcare Information Management.
Sandhya Keeroo
C-DAC School of Advanced Computing
University of Mauritius
Quatre Bornes, Mauritius
Sandhya Keeroo is an information technology (IT) graduate and is presently working on
an MBA at the University of Mauritius. Her research on healthcare IT, a multidisciplinary
field of paramount necessity, presents unrivaled challenges to enhance ostensibly unyielding
problems across the medical field. She is honored to bring forward a handy and an informa-
tive resource that would catalyze further research as well as contribute to the win–win para-
digm shift pertinent to wellness and treating illness. She is thrilled to claim that this chapter
will help identify elusive broken links that still exist and eradicate problems of heterogeneity
in clinical knowledge.
William Klepack, MD
Primary Care Physician
Dryden Family Medicine
Medical Director
Tompkins County Health Department
Dryden, New York
Dr. William Klepack is board certified in family practice and received his MD from
Johns Hopkins University Medical School in Baltimore, Maryland, after obtaining his un-
dergraduate degree in physics and science from the Massachusetts Institute of Technology.
His three years of family practice residency training were at the University of Rochester,
Family Medicine Program. Following residency he practiced in Nome, Alaska, with the U.S.
Public Health Service for two years. Returning to the “lower 48” he joined a group practice
in Bath, New York, where he stayed for eight years before moving to Tompkins County,
New York, in July 1989.
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Dr. Klepack is medical director of the Tompkins County Health Department. His particular
interests include patient education, public health, preventive care, electronic health records, dis-
ease management, and orthopedic medicine.
Rajiv Kohli, PhD
Associate Professor
Management Information Systems
College of William & Mary
Williamsburg, Virginia
Dr. Rajiv Kohli is an associate professor of management information systems (MIS) at the
College of William & Mary. He received his PhD from the University of Maryland, Baltimore
County. Dr. Kohli serves as an associate editor for MIS Quarterly and is a member of editorial
boards of several international journals.
For more than 15 years, Dr. Kohli has worked or consulted with IBM Global Services, SAS
Corporation, United Parcel Service, AM General, MCI Telecommunications, Westinghouse
Electronics, Wipro Corporation, and Godrej Industries (India), in addition to several health-
care organizations. Prior to joining full-time academia in 2001, he was a project leader in deci-
sion support services at Trinity Health. Dr. Kohli has held positions at the City University of
Hong Kong, China; University of Canterbury, New Zealand; Sloan School of Management,
Massachusetts Institute of Technology, Cambridge, Massachusetts; and the University of
Cambridge, United Kingdom.
Academic studies have ranked Dr. Kohli among the top 20 MIS researchers worldwide. Dr.
Kohli’s research is published in MIS Quarterly, Management Science, Information Systems
Research, Journal of Management Information Systems, and Communications of the ACM, among
other journals. He is a co-author of IT Payoff: Measuring Business Value of Information
Technology Investment, published by Financial Times Prentice-Hall. Dr. Kohli has been a recipi-
ent of several grants in information systems research.
Victor W. A. Mbarika, PhD
Director
ICITD
Editor-in-Chief
The African Journal of Information Systems (AJIS)
Southern University and A&M College
Baton Rouge, Louisiana
Dr. Victor W. A. Mbarika has been in the forefront of academic research into information
communications and technologies (ICT) implementation in Africa. Dr. Mbarika is serving at
Southern University and A&M College at Baton Rouge, Louisiana, and has received several
National Science Foundation and state grants.
Professor Mbarika has more than 90 published works, including three books; five book chap-
ters; 31 peer-reviewed journal papers in premier outlets such as IEEE Transactions, CACM, JAIS,
ISJ, The Information Society, and Journal of the American Society for Information Sciences; and more
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than 45 papers at premier conferences such as IFIP, ICIS, DSI, AMCIS, and HICSS. He has
chaired several mini-tracks/workshops at DSI and AMCIS, where he introduced the first mini-
track on ICT in developing countries. His publication outlets clearly reflect the impact he is having
on the information systems, computer science, information science, and engineering communities.
Philip F. Musa, BSEE, MSEE, MBA, PhD, PE
Associate Professor
Department of Management and Information Systems
The University of Alabama at Birmingham
Birmingham, Alabama
Dr. Philip F. Musa is an associate professor of management and information systems in the
School of Business at the University of Alabama at Birmingham. He teaches various courses such as
project management, supply chain management, quality management, strategic information sys-
tems, electrical engineering, and operations management. He holds a BSEE, an MSEE, an MBA,
and a PhD, all from Texas Tech University. He has published research in various prestigious jour-
nals, including Communications of the ACM, Information Systems Journal, Communications of AIS,
European Journal of Information Systems, Journal of Global Information Technology Management,
Journal of Global Information Management, and Journal of Information Systems Education.
Dr. Musa has served on special assignments related to PhD programs to other universities
around the world. In addition to serving on the editorial boards of several academic and practi-
tioner journals, Dr. Musa has presented at and published in dozens of proceedings of national
and international information systems conferences such as America’s Conference on Information
Systems, the International Federation for Information Processing, Information Resource
Management Association, Global Information Technology Management, and Decision Sciences
Institute, among others. He has also served as chair or on program committees of many of the
professional conferences and dissertation committees. Dr. Musa is an academic professional
member of APICS, senior member of the Institute of Electrical and Electronics Engineers
(IEEE), member of the Association of Information Systems (AIS), and a lifetime member of Phi
Kappa Phi. He is a licensed professional engineer (PE) with backgrounds in electrical engineer-
ing and the semiconductor industry. He is also a certified supply chain professional (CSCP).
Liam O’Neill, MS, PhD
Associate Professor
Department of Health Management and Policy
School of Public Health
University of North Texas, Fort Worth
Fort Worth, Texas
Dr. Liam O’Neill is an associate professor in the School of Public Health at the University of
North Texas Health Science Center in Fort Worth, Texas. He earned an MS in operations research
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from the University of North Carolina and a PhD in operations management from
Pennsylvania State University. Prior to his present position, he was on the faculty at Cornell
University and the University of Iowa.
Dr. O’Neill’s primary research interests are in healthcare operations and information sys-
tems, including hospital efficiency analysis, hospital marketing, technology diffusion, and
managerial benchmarking using data envelopment analysis. He has published more than 20
articles and book chapters in scholarly journals, such as Health Care Management Science,
Management Science, Medical Care Research and Review, Neurology, Anesthesia and Analgesia,
Naval Research Logistics, and Socio-Economic Planning Sciences. In addition, his research has re-
ceived awards from the Production and Management Society and the Western Decision
Sciences Institute. He is on the editorial board of Health Care Management Science and
International Journal of Healthcare Information Systems and Informatics and is past-president of
the Health Care Applications Section of Institute for Operations Research and Management
Science (INFORMS).
Anantachai Panjamapirom, MS, MBA, PhD Candidate
School of Health Professions
University of Alabama at Birmingham
Birmingham, Alabama
Anantachai Panjamapirom is from Bangkok, Thailand. He is currently a doctoral student in
administration health services in the School of Health Professions at the University of Alabama
at Birmingham (UAB). He earned an MS in information and communication sciences from
Ball State University, Muncie, Indiana, and an MBA from UAB. He holds a B.Eng. in civil en-
gineering from Mahidol University, Bangkok, Thailand. While he worked as a web designer in
the Division of Continuing Medical Education (CME), School of Medicine at UAB for three
years, he was involved in conceptualizing, designing, producing, and maintaining more than 20
educational Web sites for different grant-funded research studies. The majority of these studies
employ Web-based interventions as a strategic tool to conduct research on the decision-making
patterns and behavioral predictors of healthcare providers.
Mr. Panjamapirom has collaborated with multiple research organizations such as the
Alabama Quality Assurance Foundation (AQAF), the UAB Center for Education and Research
on Therapeutics of Musculoskeletal Disorders (CERTs), the UAB Center for Outcomes and
Effectiveness Research and Education (COERE), and the UAB Center for Emergency Care and
Disaster Preparedness. He is a member of various professional organizations such as American
Medical Informatics Association (AMIA), Academy of Management (AOM), American Public
Health Association (APHA), and Association of University Programs in Health Administration
(AUPHA). He has presented at the annual conferences of AOM, APHA, and Academy Health.
He is also a member of Beta Gamma Sigma.
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Nupur Prakash, PhD
Professor and Dean
School of Information Technology
Guru Gobind Singh Indraprastha University
Delhi, India
Dr. Nupur Prakash is a professor and the dean at the School of Information Technology, Guru
Gobind Singh Indraprastha University (GGSIPU), Delhi, India. She holds a PhD in engineer-
ing and technology and has worked as a scientist at the Central Scientific Instruments
Organisation (CSIO), Chandigarh, India, on microprocessor-based cross-correlation flow meters.
She has also worked at Punjab Engineering College, Chandigarh, India, and was the head of the
computer science and engineering department.
Dean Prakash has been the principal of Indira Gandhi Institute of Technology at GGSIPU,
Delhi. Her research interests include wireless communications, mobile computing, network se-
curity, and cryptography. She has authored and/or presented 40 research papers in various na-
tional and international journals and conferences.
Homer Schmitz, PhD
Professor and Interim Dean
School of Public Health
St. Louis University
St. Louis, Missouri
For more than 40 years Dr. Schmitz has accumulated extensive executive experience in
managing the operations, information systems, planning, and finances of various sectors of
the healthcare market, including a 450-member multi-specialty physician practice, a man-
aged care organization with more than 250,000 enrollees, an EMS organization with more
than 100 vehicles, and a 500-bed acute care teaching hospital. He is a nationally recognized
author and lecturer in healthcare management. During his career, he has authored or
co-authored five books and more than 80 articles in peer-reviewed technical and profes-
sional journals.
Dean Schmitz has lectured at more than 90 national and international meetings and semi-
nars. Numerous national and international healthcare consulting assignments have been carried
out, including domestic engagements with the Center for Health Services Research of the
University of Southern California, the Lutheran Hospital Society of Southern California, and
Arthur D. Little. International engagements have been completed in Syria, the United Arab
Emirates, Qatar, and South Africa. Professional memberships held included those in the
American Hospital Association, the Healthcare Financial Management Association, and the
Medical Group Management Association. In addition, he is a life member of the Healthcare
Information Management Systems Society (where he has held national committee appoint-
ments) and holds Fellow status. Dr. Schmitz is also on the editorial boards of two healthcare
journals. His research interests include information systems, ambulatory services management,
and health services financing.
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Sanjay Prakash Sood, MTech
C-DAC School of Advanced Computing
University of Mauritius
Quatre Bornes, Mauritius
Sanjay Prakash Sood, MTech, specializes in healthcare technologies. He has pioneered
telemedicine projects in India, Benin, and Mauritius. He has been a telemedicine consultant to
the World Health Organization and a consultant on healthcare technologies for a World Bank
Project in Punjab, India. He is also associated with the United Nations (UN Office for Outer
Space Affairs, Vienna) for telemedicine. He has been the principal resource person (medical in-
formatics) for a premier Indian government organization (C-DAC: Centre for Development of
Advanced Computing) and was the co-investigator/project manager for the National
Telemedicine Project (Development of Telemedicine Technology) in India. He has authored
more than 50 publications, including five chapters on cutting-edge applications of information
technology in health care. Mr. Sood has been a member of the executive council of the
International Society for Telemedicine and eHealth. He is a recipient of international scholar-
ships and travel grants. He is the director and founder of C-DAC Operations in Mauritius and
is currently researching (PhD) diffusion and adoption of e-health technologies in hospitals. He
may be contacted via www.spsood.com.
Jing Kai Zhang, PhD
Dr. J. K. Zhang was awarded his PhD degree by the University of Surrey, and his research
funding came from the School of Biomedical Engineering, University of Surrey, and from the
Henry Lester Trust, United Kingdom. His research interest is in data mining, distributed sys-
tem architecture, healthcare management information systems, and system interoperability. He
has published in several journals, including Journal of Computer Science and Science Publications,
and he has presented at The International MultiConference of Engineers and Computer
Scientists; the International Conference on IEEE Biomedical and Pharmaceutical Engineering,
Singapore; and in the International Conference on IEEE E-he@lth in Common Europe,
Krakow, Poland.
Kai Zheng, PhD
Assistant Professor
Health Management and Policy
School of Public Health
Assistant Professor, Information
School of Information
University of Michigan
Ann Arbor, Michigan
Dr. Kai Zheng is an assistant professor of health management and policy in the School of
Public Health and an assistant professor of information in the School of Information at the
University of Michigan. He is also affiliated with the Medical School Center for Computational
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Medicine and Biology and the Michigan Institute for Clinical and Health Research. Dr. Zheng’s
research and teaching are in the area of information systems, particularly focusing on health
informatics, which studies the use of information, communication, and decision technologies
in healthcare delivery and management. He holds a PhD in information systems and health
informatics from Carnegie Mellon University, where his dissertation, entitled “Design,
Implementation, User Acceptance, and Evaluation of a Clinical Decision Support System for
Evidence-Based Medicine Practice,” received the 2007 William W. Cooper Doctoral Dissertation
Award in Management or Management Sciences.
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Foreword
When I joined the health information world many years ago disc drives storing 5 to 10
megabytes of information and costing upward of $200,000 were the standard; central process-
ing units with memories of 512K to 1024K and costing many thousands of dollars were the
rule; elaborate climate-controlled environments costing tens of thousands of dollars were
mandatory; elaborately trained operators were required to be present at all times that the tech-
nology was being used; and an online, real-time order entry system was rare and very expen-
sive. At that time there were less than a dozen such systems in the United States that were
actually working as true real-time order entry and data collection systems. Their computing
power was probably less than what we carry around on our belts today. We talked about how
healthcare organizations had more data than they knew what to do with but that very few had
more information than they could use.
The distinction between data and information is subtle but important. The technology has
changed enormously with regard to price and performance but the problem has not changed.
We still wrestle with the question of how we can better provide the information that a decision-
maker needs in a timely, accurate, and cost-effective manner. In addition to the enormous
changes in technology, the explosive increase in information availability seriously complicates
the problems of information management. In today’s world of the Internet and Web services,
there is the additional problem of discriminating between reliable and accurate information
and unreliable information while at the same time protecting the privacy and confidentiality of
healthcare consumers who are seeking help in understanding their specific situation.
Against this backdrop of complicating factors and profound change Joseph Tan with Fay
Cobb Payton and colleagues deliver a richly informative and well-organized text that addresses
many of the issues facing health information users seeking answers in this more complex and
rapidly changing world. They examine the dynamics of merging healthcare organizations with
health information systems. They scrutinize the tools and methodologies that are available to
the information seeker from traditional sources to the Internet and related technologies. They
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investigate new social groupings for health information dissemination such as community net-
working and building virtual communities. All of this is accomplished while also providing an
excellent coverage and insight into current management and technology issues related to build-
ing effective information systems in healthcare organizations. The task of building and manag-
ing these enormously complex systems in an environment that is changing so rapidly is
daunting. Joseph Tan with Fay Cobb Payton and colleagues have done an excellent job of de-
scribing not only the technology and information needs of this dynamic time but also have
done an extraordinary job of investigating those influential forces or critical success factors that
have an impact on current and future-oriented health information management systems and
their use to support a growing network of multi-provider healthcare delivery services in an age
of globalization, continuing knowledge explosion, and technological innovation diffusion.
I would be remiss if I did not acknowledge the many insightful contributions that Joseph
Tan has made to the field of health information systems over the years. These contributions
have been pragmatic as well as scholarly and have impacted enormously the way health infor-
mation systems are viewed and used. This book will only add to that legacy.
—Homer H. Schmitz, PhD
Interim Dean and Professor
School of Public Health
Saint Louis University
Saint Louis, Missouri
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Preface
Adaptive Health Management Information Systems, Third Edition, is a gift especially designed for
the professional readers and instructors who want their students to keep pace with rapid changes
in the evolving field and knowledge domains of healthcare management information systems
(HMIS) and health informatics (HI). This new edition is not simply an update of the second
edition—it is, in fact, a completely reorganized, expanded, and thoroughly revised manuscript
containing new and logically ordered contributions partitioned into five major themes connect-
ing the 14-chapter series. It is supplemented with Research, Technology, and Policy Briefs, plus five
major cases. Simply stated, significant updates and complete revisions to every part of the previ-
ous edition have been meticulously generated throughout the text—so much so that readers
who may be familiar with the previous edition would not have recognized this work as a deriva-
tive of the other. It is analogous to producing a new hybrid vehicle but doing away with most of
the parts empowering the old model design that is purely gasoline-based.
As we moved across and beyond the 21st century, the active cross-pollination of ideas and
fresh knowledge from multiple disciplines—including advances in information science and
pervasive technology, management theories and information systems practices, the marriage of
the health sciences with ubiquitous computing technologies, and the ever-increasing volumes
of healthcare informatics and telematics publications—are beginning to influence the growth
and knowledge explosion of the HMIS field. To this end, this newly minted HMIS text con-
tains streamlined discussions of more established, state-of-the-art as well as hot emerging topics
ordered under each of the five major themes discussed later, spiced with motivating scenarios;
real-world examples; mini-cases; stimulating chapter questions; illustrative graphics, tables, and
exhibits; and notes and supplementary and additional readings.
One advantage, as evidenced both on the book cover and throughout the different parts of
the book, is the wide spectrum of topics covered in a variety of forms by the different con-
tributing authors as shown in the Table of Contents. In this new edition, the five-part clusters
used in previous editions have been completely reconstituted along the following themes:
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Part I, which encompasses Chapters 1 through 3, lays the foundation for HMIS conceptualiza-
tion. Part II, covering Chapters 4 through 7, concentrates on HMIS technology and applica-
tions, whereas Part III, including Chapters 8 through 11, shifts focus to HMIS planning and
management. Part IV, comprising Chapters 12 through 14, addresses HMIS standards, gover-
nance, policy, globalization, and future. Finally, five major cases highlighting HMIS practices
and implementation lessons are presented in Part V. Each of these major themes progressively
flows into one another to unveil different aspects of the hidden HMIS gem.
More particularly, Part I offers the readers an overview of HMIS foundational concepts and
attempts to showcase the significance of having an education in the discipline. Chapter 1 starts
off with the historical development of the HMIS field, traces a roadmap to guide readers in
navigating through the different parts and chapters of the text, details the basic HMIS compo-
nents and functions, and reflects upon HMIS cultures. Chapter 2 focuses on key roles and re-
sponsibilities of senior executives in healthcare services organizations vis-à-vis taking the HMIS
leadership through a process comprising vision, strategy, and intelligent execution. To succeed,
these executives must show characteristics of being trustworthy, inspirational, and ready to mo-
tivate others, as well as learning to be effective communicators. An accompanying Research
Brief offers insight into how HMIS devices as simple as a PDA can be used to cut down on wait
time in an emergency department. Chapter 3 redirects the attention of the readers to online
health information seeking behaviors among Internet versus non-Internet users and touches on
access and digital equity considerations. An interesting question raised here is: can the Internet
and associated technologies be used to provide emotional support and empowerment to online
health information seekers? Technology Brief I, which presents a refresher course on the funda-
mentals of Internet and associated technologies for healthcare services organizations, comple-
ments the chapter reading. Altogether, the significance of HMIS influence can be seen
throughout history (Chapter 1); on individuals, groups, and organizations (Chapter 2); as well
as on society at large (Chapter 3). The key message conveyed in Part I is that of the increasing
significance of HMIS proliferating through every aspect of both our personal and organiza-
tional life and addresses, in large part, the “whys” of educating health informatics, manage-
ment, and professional students in the HMIS discipline.
Part II challenges the readers to examine the HMIS technology and applications theme.
Isolated legacy systems such as hospital information systems; financial, budgeting, and payroll
systems; nurse scheduling systems; admission-discharge-transfer systems; purchasing and inven-
tory control systems; facility planning systems; and basic clinical workflow systems used for
decades in healthcare facilities will soon give way to emerging enterprisewide systems—namely,
supply chain management (SCM), customer relationship management (CRM), and enterprise
resource planning (ERP). Chapter 4, therefore, begins a discussion on these three systems, SCM,
CRM, and ERP—enterprisewide systems believed to be emerging as the next-generation HMIS
administrative applications that will significantly affect the future quality of healthcare services
delivery. Technology Brief II features hardware, software, and computer-user interface design and
supplements the chapter reading. Chapter 5 continues this same line of thought by highlighting
network-based HMIS technology and applications, specifically, community health information
networks (CHIN) and regional health information organizations (RHIO). Technology Brief III
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summarizes health organization merger arrangements vis-à-vis the telecommunications and net-
work infrastructures that are appropriate for these arrangements and is offered as supplementary
reading. The central message here is the wide-ranging applications of HMIS technologies for
bringing community organizations together as partners for healthcare services delivery.
Representing a natural expansion of concepts discussed in HMIS administrative applications
and technologies (Chapter 4) as well as CHIN and RHIO (Chapter 5) is the concept of
patient-centric management systems and integrated HMIS systems discussed in Chapters 6 and
7, respectively. Among the most popular HMIS applications and technologies employed in to-
day’s healthcare services organizations are electronic health records (EHR), computerized
physician order entry (CPOE), and clinical decision support systems (CDSS), which are the
subjects of Chapter 6. As noted in the chapter title, these applications represent a movement
toward patient-centric management systems because the technology is ultimately designed to
elevate patient care by providing the caregivers with relevant, current, accurate, reliable, avail-
able, and accessible health information. Therefore, the significance of these systems for bench-
marking both administrative and clinical performance across healthcare services organizations
cannot be overly emphasized. Technology Brief IV, focusing on database, data-mining, and data-
warehousing concepts for healthcare services organizations, has been appended to this chapter
to augment the readers’ understanding not only of the internal structure, content, and func-
tionalities of these systems, but also to provide insights into the enabling and empowering na-
ture of these systems for the end-users. Finally, the benefits and challenges of these
patient-centric management systems are also discussed in the context of electronic health
records, which is the HMIS cornerstone of both the U.S. and Canadian healthcare services de-
livery systems.
Finally, Chapter 7, which focuses on the topic of HMIS integration, concludes the Part II dis-
cussion of HMIS technology and applications. Apparently, maintaining legacy systems in health-
care services organizations can be both costly and increasingly cumbersome due to the lack of
interoperability among disparate applications. Indeed, these isolated systems will eventually re-
sult in unsatisfactory delays to patient care and will continue to take a toll on both clinicians’ and
employees’ time and productivity. The application of Web services as a way to transform health-
care organizational HMIS into seamless integrated systems is certainly a major step that promises
to benefit the healthcare services organizations in the longer term, not just temporarily.
Therefore, the technology discussed in Chapter 7 is extremely innovative. Not only would this
technology help ready readers to move away from islands of legacy systems in light of the rapid
advances in HMIS technology and applications, but the message conveyed could also help the
readers adopt new HMIS thinking as well as assist them to take the next steps toward achieving a
higher and wider HMIS perspective. Altogether, the knowledge acquired in Part II offers the
readers a wide-ranging survey of the “whats” of HMIS technology and applications.
This brings us to Part III, which focuses on HMIS planning and management. Chapter 8
concentrates on HMIS strategic planning and information requirements because these are two
of the early, but critical, steps in the administration of HMIS planning and management for
healthcare services organizations. This chapter therefore lays the groundwork for the “hows” of
realizing HMIS initiatives in practice (Part III), not just the “whys” (Part I) and “whats” (Part
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II). Beyond instructing students, practitioners, and administrators on how to align HMIS goals
and objectives with corporate goals and objectives and how to go about deciding on the best al-
ternative means of developing the system that would fit well with organizational information
requirements and culture (Chapter 8), the next steps will have to include a thorough familiarity
with HMIS analysis and development methodologies (Chapter 9); followed by practical advice
on HMIS design, implementation, and evaluation through a focus on data stewardship
(Chapter 10); and the proper managing of pre-implementation preparation, implementation
processes, and post-implementation upkeep, as well as ongoing IT service management
(Chapter 11). Part III, therefore, bridges HMIS technology and applications (Part II) on the
one hand and HMIS standards, governance, policy, and international perspectives (Part IV) on
the other. This then takes us to Part IV.
Part IV acquaints the readers with HMIS standards, governance, policy, globalization, and
future. It begins with Chapter 12, featuring a comprehensive review of HMIS standards—a
topic of increasing significance for HMIS students, practitioners, and researchers. Major stan-
dards relating to data coding (vocabulary), data schema (structure and content), data exchange
(messaging), and Web standards are formulated by groups of enthusiastic standards developers
through standards development organizations to evolve a common language for sharing health
information electronically among care providers. This chapter also links the readers back to the
earlier parts of the text regarding HMIS foundational conceptualization and the use of data for
managerial decision making and online health data searches (Part I). Again, the concepts of
standards link the readers back also to the significance of sharing information among commu-
nity health networks and the challenge of overcoming interoperability among disparate systems
by integrating HMIS technology and applications via Web services (Part II). A Policy Brief on
the Health Insurance Portability and Accountability Act (HIPAA), privacy, and security issues
complements the reading for Chapter 12.
Beyond HMIS standards, Chapter 13 attempts to widen the readers’ perspectives on HMIS
by moving into the topic of HMIS globalization and e-health. Apparently, the application of
e-health conceptualization demonstrates to whom the concepts of information and communi-
cation technologies (ICT) in health care, as well as HMIS in healthcare services organizations,
relate to most in everyday life: humankind. Accordingly, HMIS used in the context of Chapters
1 through 12 of this text are now expanded to an e-health perspective used specifically in the
globalization context of Chapter 13. In this sense, both e-health and HMIS may be conceived
as umbrella terms encompassing all ICT and related e-technologies applied in a global health-
care services context. Hence, there is a true parallelism in terms of the need for ICT governance,
policies, and sharing of ICT innovations among developed, developing, and underdeveloped
countries for both HMIS and e-health. In light of this, the term HMIS has been inserted
throughout Part IV, where appropriate, to sound the underlying message of the similar chal-
lenges facing designers and administrators of healthcare systems—whether it is to be deployed
as an isolated system for healthcare providers (health informatics), an integrated system for
healthcare services organizations (HMIS), or an Internet-based system for entire populations
(e-health).
xl PREFACE
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Up to this point, the readers should not be surprised by the inclusion of a chapter on inno-
vation diffusion, Chapter 14, constitutes the final chapter of this adaptive HMIS text and
brings closure to Part IV—or to the entire text. It does this by highlighting the barriers to
HMIS implementation and innovation diffusion and by providing key theoretical concepts for
HMIS innovation management. Evidently, the benefits of HMIS should extend beyond just in-
dividuals, even beyond healthcare provider groups and healthcare services organizations. HMIS
must be adaptive to change, to innovations, and to everyone’s business. Before HMIS can dif-
fuse so as to raise the quality of healthcare services, not only in the United States and Canada,
but also all over the world, HMIS developers must learn to integrate, adapt, and innovate the
technology. As with the management of any innovation, HMIS innovation diffusion manage-
ment is definitely not going to be an easy, static process. Instead, it is a very dynamic and adap-
tive one, depending on how the healthcare services delivery system changes vis-à-vis the
organizational changes affected by movements in the larger political, technological, social, and
cultural environments in which any HMIS innovation is to be deployed. Put together, Part IV
has to do with addressing the “whos” of HMIS effects.
Finally, the five major case studies in Part V cluster largely around the notion of HMIS im-
plementations in diverse organizational environments, whether these be in the past (Cases 1
and 4), the present (Cases 2 and 3), or in the future (Case 5). These cases combine the elements
of the HMIS conceptualization (Part I); the HMIS technology and applications (Part II); the
HMIS planning and management (Part III); and the HMIS standards, governance, policy, and
future (Part IV).
—Joseph Tan with Fay Cobb Payton
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Foundation Concepts
of Health Management
Information Systems
I
PART
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Health Management
Information Systems:
A Managerial Perspective
Joseph Tan
3
1
CHAPTER
CHAPTER OUTLINE
Scenario: Key Trends Contributing to the Merging of Enterprise and Health Information
Exchange Models
I. Introduction
II. Evolution of HMIS
III. HMIS Components and Basic Functions
● HMIS Components
● HMIS Basic Functions
IV. HMIS Cultures
V. Conclusion
Notes
Chapter Questions
Mini-Case: MinuteClinic
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S c e n a r i o : Key Trends Contributing to the Merging of Enterprise
and Health Information Exchange Models1
Informatics Corporation of America (ICA), with its website (www.icainformatics.com) offering
insightful materials for the interested readers, is a health information technology (HIT) organi-
zation whose mission is to provide clinicians and healthcare providers with more or less seam-
less access to information extracted from various uncoordinated systems for patient diagnosis
and evaluation. Recently, ICA sent out a press release to various stakeholders in the healthcare
informatics (HI) community outlining five key trends shaping the development of health infor-
mation exchanges (HIE) among large healthcare organizations:
1. The growing impetus for healthcare provider connectivity.
2. An increasing focus on the need to manage chronic diseases.
3. Increased patient expectation of personal involvement in the care process.
4. Market pressures for improved hospital–physician alignment.
5. Advances in technology facilitating system interoperability.
With an increasing number of baby boomers and the elderly constituting the U.S. population,
it is envisaged that these trends will become more prevalent for U.S. healthcare services organi-
zations in the near future.
“These trends highlight the benefits which community-based healthcare models can offer all
constituents—physicians, patients, and healthcare providers across the continuum of care,” says
Gary M. Zegiestowsky, chief executive officer (CEO) of ICA. “The gap between traditional en-
terprises and HIE is closing, with growing connectivity for physicians and ultimately the entire
healthcare community in certain cities or regions. We believe this is signaling a paradigm shift
that has both near- and long-term implications for healthcare and HIT.”
“In order to keep pace with these trends,” Zegiestowsky continues, “physicians in every com-
munity first need intuitive, proven technology solutions aligned with clinical workflow to speed
the adoption of electronic health records. Moving toward patient-centric care will be possible
when all providers across the broad spectrum of care are able to access and utilize a unified pa-
tient record in combination with tools that enable better care.”
ICA’s response to this growing trend is the use of an exchange platform created for both en-
terprise and HIT systems, such as the A3Align Solution™. For 10 years, practicing physicians
and informatics professionals from Vanderbilt Medical Center have developed this technology,
which has eventually been installed at Bassett Healthcare’s enterprise comprising four hospitals
and 27 clinics in Cooperstown, New York. A3Align Solution will also be implemented by both
the Montana and Northwest Healthcare for HIE. In addition, Vanderbilt distributed this same
technology across its 40 facilities in the Mid-South eHealth Alliance, a successful HIE in west-
ern Tennessee.
With these major trends encouraging HIE among healthcare services organizations, what do
you believe are the benefits of having all of your health information made freely accessible and
interchangeable among all of your caregivers? What would be your worst fear?
4 HEALTH MANAGEMENT INFORMATION SYSTEMS
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I. Introduction
As we enter this world, how did we become aware and conscious of who we are, and of things
that surround us? How did we learn about the myriad ideas, sights, sounds, and smells and the
many events that we see, hear, feel, and witness in the surrounding space in which we live and
breathe for each day of our lives? Aren’t “data” and “information” the essential constructing
blocks in our lives? Isn’t “knowledge” the central intellectual core that links everything else to
form meanings, interpretations, and actions? Aren’t “information systems” innate in each and
every one of us as human beings who find it so very natural to process incoming streams of
“stimuli” continuously, seamlessly, and automatically—irrespective of how cognitively complex
these stimuli may at first appear to be? Seemingly, all of us have already been introduced some-
what to the subject of health management information systems (HMIS) even from the first day
of birth as we “woke up” from our “deep sleep” inside our mother’s wombs, most likely, within
the confines of a healthcare or maternal health-related facility.
The field of HMIS is inherently complex. Take the myriad terminologies employed in this
text as an example. There are subtle differences even with major terminologies used to describe
the field. For instance, health management information systems (HMIS), which is the term used
liberally throughout the first edition of this text, has, in and of itself, a managerial slant, and
whereas healthcare information technology (HCIT or health IT–HIT) has a technology slant,
health information systems (HIS) or healthcare information systems (HCIS) may be interpreted as
the umbrella term with a systems or information systems connotation. Informatics is another
commonly used term among European researchers, and health informatics or clinical informatics
generally refers to the application of data methods in medicine, healthcare services, and clinical
practices. For this reason, some authors, as will become apparent in the latter part of the text,
use the terms health informatics (HI) and medical informatics (MI) as well as e-health (electronic
health). Thus, in this edition of the HMIS text, for the sake of simplicity and to further reduce
complexities for less sophisticated readers, we allow the usage of these several and diverse termi-
nologies to be more or less interchangeable among the works accumulated by the different con-
tributing authors and accompanying editors. Also, to ease the disruption in the readings and
simplify the editing process, we have generally dropped the “s” that is typically appended to
many of these acronyms to create the plural sense and simply use these acronyms in more or less
the plural sense unless it is specifically preceded with an article such as “a” or “the” when at-
taching a verb to the specific acronyms or using it as a descriptive adjective, as in “the HMIS”
field.
More importantly, the HMIS conceptualization we have drawn in this text comes from an
eclectic well of traditionally established as well as newer disciplines. Academic researchers, edu-
cators, and practitioners from diverse disciplines—including, but not limited to, electrical and
computing engineering, industrial engineering, clinical and management engineering, nursing
and allied health, health informatics, health management, organizational behavior, computer
science, and cognitive science—have all contributed, in one form or another, to the develop-
ment and accumulation of HMIS knowledge domains.
I . INTRODUCTION 5
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Indeed, as early as the 1960s, cognitive scientists have modeled the human cognition as an
information processing system. Here, the human brain is perceived to act just like the computer,
and experiments conducted on the human stimuli-response system inform us of the familiar
story of how different external stimuli (information) can exert different patterns of resulting or
induced behaviors among the human observers. In other words, the information systems
within humans are exemplified by the cognitive activities recurring within the human brain.
In the HMIS analogy, the information processors are likened to the eyes and minds of the
health organization.
In this newly revised edition, the term adaptive HMIS has been used specifically to empha-
size the need for a flexible approach to health information administration and management.
HMIS students must learn how to apply information science, information systems, and health
informatics concepts from an adaptive but integrated health management perspective. More
generally, this text aims to provide the students with a state-of-the-art managerial perspective of
health information technological systems in the coming years so that they are well prepared to
face the many challenges of acquiring and applying new forms of HCIT for healthcare services
management purposes in this century and beyond. In this first chapter, we briefly cover the HMIS
evolution, its underlying architecture, and its basic functions. We then close the chapter with a
brief survey of the role HMIS technology plays in driving today’s healthcare and healthcare-
related businesses.
II. Evolution of HMIS
In its broadest sense, HMIS encompasses diverse concepts, methods, and applications from
many related fields. Its genesis may be traced to multiple roots, including general systems think-
ing, information economics, management science, information systems development method-
ologies, software engineering, computer science and communication theory, medical
computing, health organization behavior, health management, policy, and health services re-
search. From a practical viewpoint, the evolution of HMIS over the past several decades has
been largely driven by strategic, tactical, and operational applications of various information
technology (IT) and advanced systems concepts for healthcare services delivery within an indi-
vidual, group, and, more appropriately, an organizational perspective. The regional or even na-
tional health coalitions are also on the horizon, enabled by the establishment of electronic
health information exchange infrastructures.
In a world where growing competition for healthcare services delivery is defined by rapidly
changing technology and maturing organizational arrangements, it is critical to understand
how evolving HMIS technologies operate and how HMIS interact within all key aspects of an
organization. In other words, it is important to know how HMIS are developed or procured;
how they are managed and maintained; how their functions are executed to support daily oper-
ations and more advanced activities, such as continuous quality improvement programs and
medical research; and finally, how to evaluate their performance and cost-effectiveness. More
importantly, with globalization and the emergence of large-scale computing systems such as
electronic health records (EHR) and innovative business-driven applications such as enterprise
6 HEALTH MANAGEMENT INFORMATION SYSTEMS
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resource planning (ERP), customer relationship management (CRM), supply chain management
(SCM) systems, and patient-centric applications such as personal health records (PHR), the re-
sulting landscape for future-oriented HMIS is bound to change quickly.
New advances in HMIS are vital to our society because these technologies guide our every-
day lives; without them, life would be rather difficult. Imagine, for example, while visiting with
your doctor today, you find him or her searching busily through a mountain of incoherent, un-
organized, and piecemeal data about you for all of the different visits that you may have made
to the different clinics that may now be part of a merged health maintenance organization
(HMO), or, what if your doctor has to spend most of his or her time making clarification
phone calls to laboratories and pharmacies to gather information rather than focusing on diag-
nosing and treating your illnesses? Imagine also that these data were recorded using various
data-coding schemes by different clinicians with different recording media (such as paper
records, tapes, and film images) and stored in multiple locations. How different would it be for
your doctor to manage you and your information if these data had been “digitally” captured in
standardized formats on nano-chips and could now be easily recombined, reorganized, and
made securely accessible and available to him or her quickly even before meeting with you?
Indeed, past technologies such as file folders, paper-and-pencil entries, tape recordings, and
X-ray films are both physically limited and very restrictive in terms of keeping secure, accessi-
ble, portable, and available records about you and capturing progressive changes to your health
and wellness status each time you visit with one of your care providers, who may be practicing
in different hospitals and clinics associated with your HMO. These traditional recording meth-
ods are limited because the captured data and information can only be kept largely in a “physi-
cal” form and not easily accessible, transportable, or available “virtually” or “digitally” to other
expert clinicians or even to you, who may decide to travel to another country seeking a second
opinion, or who may have been placed in emergencies outside the state of your residence. New
forms and modes of HMIS technology such as wearable devices and embedded chips promise
to give you the ability to access such recorded information that has been accumulated over the
years both conveniently and securely at any time, anywhere. In the foreseeable future, you will
also be able to control and access your own personal health records stored online and con-
tributed by all of your care providers. As amazing as new technologies can be, it is important to
first understand the type(s) and basic functions of HMIS technologies that currently exist and
how these technologies will likely evolve due to increased globalization, continuous healthcare
reforms, the corporatization of medicine, and other major trends such as the formation of new
alliances and consolidations among healthcare provider organizations.
Apparently, the emergence of satellite-based, wireless, user-friendly portables; the proliferation
of cellular networks; new computing privacy and security technologies; and new implementation
of various powerful network-based systems such as sensor networks and Internet-based data
warehouses are now in the order of multimillion-dollar projects to serve large populations with
massive capabilities of automated collection, manipulation, and analysis of multidimensional
data sets. These emerging trends are now pressuring senior healthcare executives and managers to
become seriously interested in understanding and endorsing cost-beneficial, integrative, and in-
novative HMIS solutions.
II . EVOLUTION OF HMIS 7
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III. HMIS Components and Basic Functions
Publicly, as health consumers become more aware, more informed, and better trained in access-
ing electronic and social media and as they become more intelligent in evaluating alternative
healthcare services (such as using Leapfrog’s hospital ratings), engaging in online forums for
health information sharing, and participating in physician/hospital referrals among patients
and/or virtual marketing using social network sites, consumers are exerting greater pressures for
a revolution in HMIS technological applications. With the expansion of the aging baby boomer
generation and the accelerating growth in U.S. healthcare expenditures, we can confidently ex-
pect the continuing growth of HMIS applications during the coming decades to have a signifi-
cant impact on primary healthcare, pharmaceutical, rehabilitative, palliative, and home
healthcare services. Therefore, management should not and cannot afford to leave the job of de-
signing, developing, and implementing network-based, integrated HMIS in the hands of IT ex-
perts or commercial vendors alone. Instead, they must now take a personal interest in paving
the way for new generations of HMIS technology—technology that satisfies both organiza-
tional requirements and patient needs. As such, the importance of using an adaptive managerial
perspective in HMIS design and development within an organizational context for the coming
decades cannot be overly emphasized. Let us now turn to an overview of the basic HMIS com-
ponents and functions.
HMIS Components
An understanding of the adaptive but integrated HMIS begins with differentiating among its
five major components and their interrelationships:
1. Data/information/knowledge component.
2. Hardware/software/network component.
3. Process/task/system component.
4. Integration/interoperability component.
5. User/administration/management component.
The data/information/knowledge component forms the central core, the content, of all HMIS.
It encompasses the specification of, organization on, and interrelationship among data, infor-
mation, and knowledge elements required of integrated HMIS.
Raw data form the basic building blocks for generating useful information that is to be
stored in any HMIS; processed data are transformed into information that serves as useful out-
put for HMIS end-users to make informed and intelligent decisions. Some pieces of data about
your child may be that of his or her demographics or the medication that he or she is allergic to
(e.g., penicillin). Another example would be his or her childhood vaccination records. Here, the
data would be immunization dates and type. Putting all these data together to form a view of a
child’s immunization schedule derives information. Determining whether the child is due for a
vaccine requires knowledge, specifically, the captured experience and knowledge of the attend-
ing physician, which could further be stored and recorded into existing HMIS and passed on to
another care provider for future care delivery.
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The combination of effective data, information, and knowledge resource management in-
volves designing the critical databases and instituting various intelligent data-mining algo-
rithms, rule engines, and online analytical processing (OLAP) tools to manage the increasingly
complex and information-intensive care decision situations physicians are facing in this day and
age. In other words, organized information and captured experience will, in turn, yield the es-
sential knowledge and business intelligence for guiding healthcare services for the individual
care provider, a group of care providers managing related health problems, or an entire health
provider organization trying to deliver healthcare services. Figure 1.1 shows the conceptual flow
of the data/information/knowledge paradigm within the HMIS organizational and healthcare
provider decision-making context.
Ultimately, the HMIS used to support key decision-making functions of healthcare
providers and administrators within the organization must be reformed to achieve greater inte-
gration of data, information, and knowledge across organizational stakeholders. ICA’s newly
proposed A3Align Solution, discussed in the chapter-opening scenario, is an example of how
innovative HMIS applications can better integrate enterprise databases (such as EHR) and
other uncoordinated data systems [such as computerized physician order entry (CPOE) and
clinical decision support systems (CDSS)] and to support integrated healthcare delivery at a re-
gional level. In an integrated and well-designed HMIS, the goal is to distribute these information-
related elements efficiently, effectively, and appropriately throughout the organization for enriching
learning among organizational users and for enhancing the delivery of healthcare services among
care providers.
The next critical component within “information systems,” aside from the “information”
core, is the “technology” layer. Here, the hardware/software/network component features
prominently as it entails the choice deployment of various information and computing-re-
lated technologies to support HMIS applications and use. Briefly, this component involves
configuring various hardware, software, user interface, and communication-enabling infra-
structures, associated devices, and applications in such a way as to best achieve efficient and
effective information services integration throughout while connecting individuals, groups,
and organizations.
III . HMIS COMPONENTS AND BASIC FUNCTIONS 9
Data Information
Feedback Loop
Knowledge
Decision
Action
FIGURE 1.1 A Data/Information/Knowledge Decision System.
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ICA’s A3Align Solution, for example, is an exchange platform created for integrating data
and information from both enterprise and HIT systems. It would be important to ensure that
all connected devices can access the HMIS applications seamlessly; better yet, these devises can
access an adapted version of an application customized to a device platform. In this sense, for
any healthcare organization, the technology layer must be supportive of the people (internal
users), aiding the performance of tasks to be accomplished by these users and helping them to
thrive in the resulting technology-driven environment. Furthermore, new and emerging
HMIS technologies and methods play an increasingly significant role in enhancing healthcare
organizational delivery of patient care–related services. This brings us to the third basic HMIS
component.
The process/task/system component exemplifies the routine and internalized driving engine
for HMIS. Here, our focus should be on the cohesion to be achieved within established “local”
processes, tasks, and applications. In other words, existing administrative-based HMIS, such as
financial information systems, human resources information systems, facility utilization and
scheduling systems, materials management systems, facilities management systems, and office
automation systems, as well as clinical-based HMIS applications such as EHR, CPOE, and
CDSS, must be designed to collect relevant data and accumulate useful information for organi-
zational task-processing and decision-making activities. It is possible, too, that over time orga-
nizational structural and procedural changes and/or regulatory changes may require certain
different routine processes that have been instituted previously to be changed or completely
deleted, yielding room to new processes, tasks, and applications. Therefore, a systems perspec-
tive is critical in order to achieve optimal functionality among the different task processes and
applications.
Surely, the integration/interoperability component is a key determinant of HMIS success
from an enterprise view. Often, the key to positioning today’s healthcare services organizations
for future success is the interoperability of systems used in managing existing and ongoing
healthcare information services vis-à-vis its competitive marketplace environment. The “inter-
operability” for much of the computerized information processing within the organizational
framework must be upheld both internally and externally to achieve efficient, effective, and ex-
cellent delivery of healthcare services. This requires not only an elaborate understanding of
evolving technological innovations and changing needs in organizational task processes, but
also knowledge of the market structure and changing characteristics of the healthcare services
industry and how the different current systems should be designed to fit well with every other
HMIS application to achieve an integrated, enterprisewide HMIS.
In fact, as early as 1980, Lincoln and Korpman recognized the difficulties with computer ap-
plications in healthcare services delivery.2 In their classic paper, “Computers, Healthcare, and
Medical Information Science,” they argued that the goals for medical information science, al-
though easy to state, are difficult to achieve for several reasons. First, adapting well-tested informa-
tion processing procedures and methods from other fields into medicine is difficult because of the
uncertainty and sophistication surrounding the medical context; the wide spectrum of medical
data; and the vagueness, disparity, and variation of organizational healthcare objectives. Second,
this difficulty is further exacerbated by the apparent dissonance between the often-embedded
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ambiguity in medical data structure and the rigidity of computer logic structure. Specifically, in
medicine, the materials cover the entire range of patient care data and the methods used span a
wide range of disciplines, including the management, behavioral, and fundamental sciences, not
just information processing and communications.
This brings us to the final but most critical HMIS component, the users. The user/
administration/management component brings together and intelligently coordinates all of the
other HMIS components. Based on a shared technological infrastructure, for example, various
users are, in turn, empowered to perform designated tasks and activities that will support the
overall business goals of the organization—that is, to serve their clients both inside and outside
the organization in the most efficient, productive, and effective manner. The function of this
critical user component, when blended appropriately with all the other HMIS components, is
to engender a holistic conceptualization that absorbs the many insights and interactions inher-
ent in any organizational HMIS endeavor.
Altogether, an adaptive, managerial HMIS perspective encompasses a combined interaction
of data-related elements, appropriate technologies and methods, designated task processes, and
intended users to gather, store, manipulate, and supply the needed information to support key
organizational decision-making activities. The HMIS is an integral part of the organizational
system, a mechanism that is central to integrating the enterprise and its various components.
Every unit of that enterprise, which presumably is interrelated, must necessarily complete its
purpose by working in unity. Like a jigsaw puzzle comprising a mass of irregularly shaped pieces
that form a picture when fitted together, an adaptive, integrated HMIS emerges when the dif-
ferent components of the enterprise fit together. Still, the HMIS must fit in with the existing
culture and organization work environment. An adaptive, integrated HMIS approach therefore
exemplifies a holistic conceptualization of the fit among various enterprise components within
the context of an adaptive, integrated management perspective. The relationships among these
major enterprise components are illustrated in Table 1.1, which may be further used to outline
the different parts of this text.
Part I, comprising Chapters 1 through 3, emphasizes HMIS foundational concepts. Chapter
1 provides an overview of HMIS from the health managerial perspective. Chapter 2 highlights
the roles and responsibilities of chief executive and chief information officers in healthcare ser-
vices organizations followed by Research Brief I, discussing how a personal digital assistant
(PDA) can enhance data collection efficiency for wait-time reductions in emergency depart-
ments. Chapter 3 discusses online health information–seeking behavior among Internet users,
accompanied by Technology Brief I, which focuses on the fundamentals of Internet and associ-
ated technologies for healthcare services organizations.
Part II, comprising Chapters 4 through 7, surveys the technology and application layers of
HMIS. Chapter 4 focuses on HMIS enterprise software, the new generation of HMIS adminis-
trative applications, accompanied by Technology Brief II, a refresher overview of basic hardware,
software, and interface design concepts. Chapter 5 concentrates on community health informa-
tion networks (CHIN) to interconnect healthcare provider organizations and build virtual
communities. Technology Brief III, focusing on HMIS telecommunications and networks, fol-
lows this chapter. Chapter 6 familiarizes readers with three key patient-centric management
III . HMIS COMPONENTS AND BASIC FUNCTIONS 11
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12 HEALTH MANAGEMENT INFORMATION SYSTEMS
Table 1.1 HMIS Text: Content and Organization
Part I Chapter 1. HMIS: A Managerial Perspective
Foundation Concepts Joseph Tan
of HMIS
Chapter 2. HMIS Executives: Roles and Responsibilities of Chief
Executive Officers and Chief Information Officers in Healthcare
Services Organizations
Joseph Tan
Research Brief I: Personal Digital Assistants Enhance Data
Collection Efficiency during a Study of Waiting Times in an
Emergency Department
N. Elkum, W. Greer, and A. Al-Madouj
Chapter 3. Online Health Information Seeking: Access and Digital
Equity Considerations
Fay Cobb Payton and Joseph Tan
Technology Brief I: Fundamentals of Internet and Associated
Technologies for Healthcare Services Organizations
Joshia Tan
Part II Chapter 4. HMIS Enterprise Software: The New Generation of HMIS
HMIS Technology and Administrative Applications
Applications Joshia Tan with Joseph Tan
Technology Brief II: Basic Hardware, Software, and Interface Concepts
for Healthcare Services Organizations
Joshia Tan and Joseph Tan
Chapter 5. CHIN: Building Virtual Communities and Networking
Health Provider Organizations
Jayfus T. Doswell, SherRhonda R. Gibbs, and Kelley M. Duncanson
Technology Brief III: Telecommunications and Network Concepts for
Healthcare Services Organizations
Joseph Tan
Chapter 6. Trending toward Patient-Centric Management Systems
Joseph Tan with Joshia Tan
Technology Brief IV: Database, Data-Mining, and Data-Warehousing
Concepts for Healthcare Services Organizations
Joshia Tan and Joseph Tan
Chapter 7. HMIS Integration: Achieving Systems Interoperability
with Web Services
J. K. Zhang and Joseph Tan
Part III Chapter 8. HMSISP/IR: Health Management Strategic IS Planning/
HMIS Planning and Information Requirements
Management Jon Blue and Joseph Tan
Chapter 9. HMIS Development: Systems Analysis and Development
Methodologies
Joseph Tan
Chapter 10. Data Stewardship: Foundation for HMIS Design,
Implementation, and Evaluation
Bryan Bennett
(continues)
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systems, namely, EHR, CPOE, and CDSS. Technology Brief IV, focusing on the fundamentals
of HMIS database, data warehousing, and data-mining concepts, accompanies this chapter.
Lastly, Chapter 7, which centers on the idea of achieving HMIS integration with systems-
interoperable Web services, provides closure to Part II.
Part III, which encompasses Chapters 8 through 11, concentrates on HMIS planning, de-
sign, and management issues. Chapter 8 covers HMIS strategic planning and methods to elicit
organizational information requirements. Chapter 9 presents HMIS analysis and development
methodologies, whereas Chapter 10 offers practical advice on HMIS design, implementation,
and evaluation from a data stewardship perspective. Chapter 11 then closes Part III by reinforc-
ing the concepts of HMIS implementation from the perspective of IT project management as
well as IT service management concepts.
Part IV, which covers Chapters 12 through 14, acquaints the readers with HMIS standards,
policy, governance, and the future. Chapter 12 presents HMIS standards and is augmented
with Policy Brief I, focusing on the Health Information Portability and Accountability Act
III . HMIS COMPONENTS AND BASIC FUNCTIONS 13
Table 1.1 (Continued)
Chapter 11. Managing HMIS Projects: HMIS Implementation and IT
Services Management
Joseph Tan
Part IV Chapter 12. HMIS Standards: Standards Adoption in Healthcare IT
HMIS Sanjay P. Sood, Sandhya Keeroo, Victor W. A. Mbarika, Nupur Prakash, and
Standards, Policy, Joseph Tan
Governance, and Future
Policy Brief I: HIPAA, Privacy, and Security Issues for Healthcare
Services Organizations
Joseph Tan and Fay Cob Payton
Chapter 13. HMIS Governance, Policy, and International Perspectives:
HMIS Globalization through E-Health
Anantachai Panjamapirom and Philip F. Musa
Chapter 14. HMIS Innovation: HMIS Innovation Diffusion in
Healthcare Services Organizations
Tugrul U. Daim, Nuri Basoglu, and Joseph Tan
Part V Case 1. Emergency Medical Transportation Resource Deployment
HMIS Practices and Cases Homer H. Schmitz
Case 2. The Clinical Reminder System (CRS)
Kai Zheng
Case 3. Integrating Electronic Medical Records and Disease
Management at Dryden Family Medicine
Liam O’Neill and William Klepack
Case 4. Delivering Enterprisewide Decision Support through
E-Business Applications
Rajiv Kohli and Henry J. Groot
Case 5. Mapping the Road to the Fountain of Youth
Joshia Tan
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(HIPAA), privacy, and security issues that govern HMIS design, deployment, and use; Chapter
13 opens up the scope of earlier discussions by transitioning into HMIS governance, policy,
and international perspectives based on emerging trends of globalization and the e-healthcare
paradigm; and Chapter 14 jumps forward with a look at the future of HMIS by dwelling on in-
novation diffusion.
This ushers us into the final part of the text, Part V, which is devoted completely to selective
cases intended to pull together parts and pieces of HMIS concepts, methods, and applications
as presented throughout the different parts of this text. Briefly, five selective contributions of
HMIS applications cases are covered in Part V. Case 1, which focuses on strategic planning for
HMIS in the context of an emergency medical transportation (EMT) setting, opens the case
discussions for examining the applications of HMIS solutions to real-world problems. Case 2,
“The Clinical Reminder System,” offers insights into the development, utilization, and accept-
ance of a patient-oriented system to aid clinical workflow activities and routine decision mak-
ing. Interestingly, Case 3, “Integrating Electronic Medical Records and Disease Management at
Dryden Family Medicine,” zooms in on HMIS implementation within a small physician group
practice, while Case 4, “Delivering Enterprisewide Decision Support through E-Business
Applications,” shows how different generations of decision support evolved for a large-scale
healthcare services delivery system. Case 5, “Mapping the Road to the Fountain of Youth,” is an
accumulation of the concepts covered in the cases in Part V and brings a closure to the entire
text. With this overview, it is important to get back to the fundamental conceptualization of an
HMIS and what are its basic functions.
HMIS Basic Functions
It is critical that beginning HMIS students achieve a good grasp of the basic functions of an in-
formation system. Historically, all information systems, including HMIS, are built upon the
conceptualization of three fundamental but iterative information-processing phases: data input,
data management, and data output. The data input phase includes data acquisition and data
verification. The data management or processing phase includes data storage, data classifica-
tion, data update, and data computation. Finally, the data output phase includes data retrieval
and data presentation. Altogether, these eight elements and three phases define a typical infor-
mation system as represented schematically in Figure 1.2.
Data acquisition involves both the generation and the collection of accurate, timely, and rel-
evant data. Data are the raw materials needing verification, organization, and transformation
before they can be useful information. The process of data generation in HMIS is normally
achieved through the input of standard coded formats (e.g., the use of bar codes), thereby al-
lowing rapid mechanical reading and capturing of data. The process of data collection differs
from that of data generation in that data can be entered directly at the source (e.g., the use of a
point-of-care bar code scanner), thereby enhancing data timeliness, validity, and integrity. Data
verification involves the authentication and validation of gathered data. It is generally known
that the quality of collected data depends largely on the authority, validity, and reliability of the
data sources. The garbage in garbage out (GIGO) principle is an important factor to consider
in this process; that is, data containing inaccuracies and inconsistencies should be detected as
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early as possible in the system to allow immediate correction and minimize the eventual costs of
system output errors.
The preserving and archiving of data may be regarded as part of the data storage function.
Memory (i.e., a physical storage system) and indexing (i.e., the selection of key words to deter-
mine major subject areas) are primary means of amassing data. When accumulated data are no
longer actively used in the system, a method to archive the data for a certain period is usually
advisable and may sometimes be mandatory, as when it is required by legislation. A closely re-
lated element to data storage is data classification (or data organization). It is a critical function
for increasing the efficiency of the system when the need arises to conduct a data search.
Moreover, imposing a taxonomy on the data that have been collected and stored provides
greater understanding of how the data can be reused. Most data classification schemes are based
on the use of certain key parameters. For example, data referring to a patient population may be
classified and sorted according to various diagnostic classification schemes, such as the widely
accepted ICD-9-CM, a clinical modification of the original ICD-10 system developed by the
National Center for Health Statistics (NCHS). More recently, the ICD-10-PCS (the
International Classification of Diseases, 10th Procedure Coding System) has replaced volume 3
of ICD-9-CM.3,4 While ICD-10-PCS is yet to be implemented, awaiting propagation from the
World Health Organization (WHO), such an organized patient data system is useful for con-
ducting a case-mix analysis because it comprises a set of diagnostic codes of thousands of pa-
tient classifications. Each code has seven alphanumeric characters, including section, body
system, root operation, body part, approach, device, and qualifier. Indeed, the particular taxon-
omy employed will have a powerful influence on the way the data can be subsequently used.
III . HMIS COMPONENTS AND BASIC FUNCTIONS 15
Data
Management
Data
Input
Data
Output
Data
Storage
Data
Classification
Data
Computation
Data
Retrieval
Data
Update
Data
Presentation
Data
Acquisition
Data
Verification
FIGURE 1.2 Basic Functions of a Health Management Information System.
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This is because a high degree of semantics is implied in any particular data classification. Crowe
and Avison noted that if the wrong classification is chosen, a great deal of potentially useful in-
formation could be lost.5 This, however, is not a problem that can be easily resolved due to the
lack of standardization among competing taxonomies. System integration and data interoper-
ability have, therefore, been an enduring challenge for HMIS researchers and practitioners.
New and changing information is accounted for through the element of data update. The
dynamic nature of such data modification calls for constant monitoring. For HMIS to main-
tain current data, mechanisms must be put in place for updating changes in the face of any on-
going manual or automated transactions. The concept of processing a transaction (i.e.,
whenever an event alters the current state of the system) is critical for ensuring data timeliness.
Such updates can be either online (real-time) or batch processed sequentially. Due to legal and
ethical considerations, archiving and tracking each data update can be a critical requirement in
designing and implementing HMIS. Data computation involves various forms of data manipu-
lation and data transformation, such as the use of mathematical models, statistical and proba-
bilistic approaches, linear and nonlinear transformation, and other data analytic processes.
Computational tasks allow for further data analysis, synthesis, and evaluation so that data can
be used for strategic decision-making purposes other than tactical and/or operational use.
Data retrieval is concerned with the processes of data transfer and data distribution. The data
transfer process is constrained by the time it takes to transmit the required data from the source
to the appropriate end-user. A key problem in data transmission is the existence of noise (i.e.,
distortion) that could be both internal and external to HMIS. The data distribution process en-
sures that data will be accessible when and where needed. There must also be ways to ensure
that unauthorized users are denied access to sensitive data in the system. This is normally
achieved through the institution of data security and access control mechanisms, such as the use
of firewalls, passwords, user authentication, and other forms of user identification. One signifi-
cant criterion to be considered in the data retrieval function is the economics of producing the
needed information. Many early systems (particularly stand-alone hospital information sys-
tems) were far too costly to operate, and the costs were simply not justified relative to the value
of information that was finally produced. This situation has largely changed with advancing
HMIS techniques and technologies available at decreasing costs.
Finally, data presentation has to do with how users interpret the information produced by
the system. In situations where only operational or even tactical managerial decision making is
expected, summary tables and statistical reports may suffice. However, certain managerial deci-
sion making involves strategic thinking and active collaboration. The use of presentation graph-
ics for higher-level managerial decision analysis is particularly encouraged because these appear
to provide a better intuitive feel of data trend. Tan and Benbasat6 and Tan7 have presented a
theory to explain and predict the human processing of graphical information, which is valuable
to guide HMIS designers in the matching of presentation graphics to tasks.
To illustrate these various HMIS data phases, we can use the case of a computerized patient
health records system for inpatients, which is usually supported with bedside terminals. In this
system, data acquisition comprises the generation and gathering of daily notes on symptoms,
treatments, diagnoses, progress notes, discharge summaries, registration of orders for laboratory
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tests, operations, anesthesia, and other sources of information such as patient demographics
and physicians’ findings. The data may also come from other interconnected HMIS through
live or batched data feeds. The data to be coded and automated are usually formatted into spe-
cific and normalized elements, fields, and records.
Figure 1.3 illustrates an abstract of a patient health record that could be implemented as a
Web-based system for monitoring patient medical conditions and treatments in a healthcare
services organization. As for data verification, the system relies on the ease with which the
coded data may be mechanically processed and properly decoded. In many cases, standard
forms and standard terms are used in recording patient data to ensure data integrity and consis-
tency. Most computerized patient record systems have built-in capabilities to reject invalid data
inputs through the use of range checks (e.g., specifying a patient’s age to fall within a verifiable
III . HMIS COMPONENTS AND BASIC FUNCTIONS 17
1. Patient Medical
Insurance Number:
2. Patient Name:
5. Sex:
— Male
— Female
12. Discharge Status:
15. Principal Procedure:
a. Date: / /

16. Additional Procedures
a.
b.
c.

17. History/Physical:

18. Laboratory:

19. Radiology:
PROCEDURES
PHYSICIANS DIAGNOSIS
Alive:
— With Approval
— Against Notice
Death:
— Autopsy
— No Autopsy
Transfer to:
— Other Institution
— Home
13. Type of Death:
— Anesthesia
— In Operating Room
— Postoperative
— Other
14. General Remarks:
11. Location
of Patient:
6. Birthdate: / /
7. Tel. No.:
8. Next of Kin:
9. Address:
10. Admission Source:
— Admitting
— Emergency
— Outpatient
20. Principal Specialist:
Second Specialist:
Family Physician:
21. Principal Diagnosis:
22. Additional Diagnoses:
a.
b.
c.
3. Date of Admission: / /
4. Date of Discharge: / /
Mo/Day/Yr:
FIGURE 1.3 A Sample Abstract for a Computerized Patient Medical Record System.
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range of classification) and other means (e.g., using batched totals). After data input, the data
are kept securely (data storage) in a database, a central data repository. This is to ensure that the
data are accessible to the healthcare services providers on any subsequent visits by the same pa-
tient. A unique patient identifier and a master patient index (MPI) are used to identify the ex-
act locations of all related records of a specific patient. This type of data organization also allows
for easy processing and regular updating by care provider organizations.
Updating and maintenance of the data (data update) to ensure timeliness and integrity can
be carried out either on a daily basis (i.e., routinely) or interactively (real-time). For example,
some hospitals collate their daily census through batch processing around midnight. Additional
data-processing functions include data analysis and synthesis to transform and combine various
elements of the input data into useful and meaningful information (data computation). The
data retrieval function ensures that the appropriate end-users (e.g., physicians, nurses, quality
improvement managers, and medical researchers) have access to accurate, timely, and relevant
information from the system. The distribution of information to end-users typically occurs
through Web-based services, where appropriate users can be authenticated whenever they want
to abstract certain views of the stored data or perform queries. Ultimately, data presentation in
the context of the preceding example is concerned with generating reports that are easy to read
and interpret for use in informed patient care or related decision making.
IV. HMIS Cultures
Why do HMIS cultures matter? A health information system exists as part of a larger system to
support one or more of a combination of administrative, financial, clinical, research, or mana-
gerial activities occurring within a health organization. Yet, it is the culture of the health services
organization that largely determines the appropriate product mix, roll out, and use of HMIS
solutions within the organization. More likely than not, existing and traditional HMIS applica-
tions often tend to be disintegrated so that critical information embedded in the different parts
of the organization is not going to be transparent among employees of the organization.
In terms of HMIS cultures, based on what we now know about successful and effective
IS/IT (information systems/information technology) leadership, a healthcare services organiza-
tion may intentionally or unintentionally adopt and nurture one of four types of cultures: an
information-functional culture, an information-sharing culture, an information-inquiring cul-
ture, and an information-discovery culture.8 Understanding the different characteristics of each
of these cultures is important to guide managers, administrators, and systems analysts in gener-
ating appropriate HMIS solutions for the organization.
An information-functional culture essentially takes the traditional view that information is
power and that giving up information means giving up the power of controlling others. It also
follows that as most organizations are structured functionally, information-functional culture
therefore limits the flow of information within a functional area such as human resources, ac-
counting and finance, sales and marketing, and IT. For example, nurses in an emergency de-
partment of a healthcare services organization adopting an information-functional culture will
attempt to safeguard their own use of patient-gathered information as well as limit the sharing
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of patient records as a way of exerting power over nurses in other departments. Thus, whenever
nurses from the acute care units or other departments need to schedule a care routine of a dis-
charged patient from the emergency department, they would have to involve the emergency de-
partment nurses.
In contrast, an information-sharing culture promotes trust among employees of different
departments within the same organization. While needing to be sensitive as to the privacy,
confidentiality, and security of particular information under his or her safeguard, it is impor-
tant that nurses, physicians, and others be able to share certain types of information with fel-
low employees for the benefit of the entire organization. For example, the chief medical officer
(CMO) of a hospital who wants to see that his or her direct reports work collaboratively to
benefit the efficient and effective running of the entire hospital must not only encourage shar-
ing of information among individual physicians, but he or she should also focus on making in-
formation—especially on procedural problems and patient care process failures—transparent
among the individual physicians in the hospital.
An information-inquiring culture essentially makes transparent the core values, beliefs, and
purpose of the organization and ensures that critical information about the due processes, pro-
cedures, and functioning of the organization is easily accessible for all employees throughout
the organization. Employees are also encouraged and trained to actively monitor such informa-
tion and to align their daily actions and behaviors with the trends and new leadership directions
of the organization. For instance, all nurses and doctors of a healthcare provider organization
could be asked to greet and politely interact with incoming and discharged patients to promote
its reputation as an organization focused on patient care and customer satisfaction. All employ-
ees are also clear about how conflicts should and can be resolved quickly and the due procedures
for attending to patient complaints.
Finally, an information-discovery culture entails that the organization is able to share in-
sights freely and encourages its employees to collaborate in offering new products and/or ser-
vices that meet the needs of existing and new clients. Employees throughout the organization
are also provided with a comprehensive view of how the organization functions and how it will
support them in their attempt to deal with crises and radical changes and/or finding ways to
achieve competitive advantages against its competitors. For healthcare organizations, it is diffi-
cult to imagine the adoption of an information-discovery culture, especially among the physi-
cians, because of these organizations’ strong traditional roots in which physicians are
accustomed to make their decisions independently about the patients under their care, even
though they are affiliated with the organizations in which they practice.
Understanding HMIS applications begins with having an appreciation of how health organ-
izations function and how IT is used in these organizations. The complexity of healthcare or-
ganizations and the intricacy of its myriad processes often is the root cause of IT failures in
health care. Many health executives thought that slapping a complex HMIS on top of the prob-
lems encountered in a healthcare organization would resolve its woes when, in many cases, it
not only worsens it, but adds unnecessary expenses when the root causes of these problems are
not well understood. It is far more important to map out the processes, simplify the complexity,
consolidate the needs, and identify the core IT requirements. From here, management has to
IV. HMIS CULTURES 19
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nurture, cultivate, and respect the working of the HMIS culture and implement appropriate
HMIS solutions accordingly.
V. Conclusion
This chapter started out with a real-world scenario describing the challenge of HMIS integra-
tion within a healthcare organization. It briefly highlighted the roots and evolution of HMIS
discipline. The basic components and functions of a health management information system
were further contemplated. It is clear that in order to understand HMIS, students should ap-
preciate the functioning of a healthcare organization, such as the HMIS cultures, before HMIS
solutions can be efficiently and effectively deployed in the organization and used to their full
capacity.
In the next chapter, we highlight the roles of the chief information officer/chief executive
officer for healthcare services organizations. Understanding these roles is critical for managing
and designing future HMIS. Following this, we close Part I of this text with a chapter on how
users are individually seeking health information on the Internet, selecting the best healthcare
providers, and learning to become better-informed consumers. It is hoped that instructors will
find these three foundational chapters in Part I helpful in encouraging students to become ex-
cited about the world of HMIS. The scenario at the beginning of each chapter and the mini-
cases, Research Briefs, Technology Briefs, Policy Briefs, additional readings, and discussion questions
that are offered at the end of the chapters are ways to motivate the students’ learning—as well as
to help them seek answers to many more new questions about HMIS—as new knowledge
and technological breakthroughs in HMIS-related fields continue to emerge in a rapidly
changing world.
Notes
1. http://www.digitalhcp.com/2008/05/27/dc-rhio-sets-ambitious-plans.html, accessed May 27,
2008.
2. T. L. Lincoln and R. A. Korpman, “Computers, Healthcare, and Medical Information
Science,” Science 210, no. 4467 (1980): 257–263.
3. ICD-9 is a U.S. Public Health Service official adaptation of a system for the classification of
diseases and operations. The original system was developed and updated periodically by the
World Health Organization for indexing hospital records. See T. C. Timmreck, Dictionary
of Health Services Management (Owings Mills, MD: National Health Publishing, 1987):
306.
4. ICD-10-PCS is purported to be a replacement code set for ICD-9-CM. See http://www
.inhcc.com/Standardization/coding _systems.htm, accessed June 1, 2008.
5. T. Crowe and D. E. Avison, Management Information from Data Bases (New York: Macmillan
Press, 1980).
6. J. K. H. Tan and I. Benbasat, “Processing Graphical Information: A Decomposition
Taxonomy to Match Data Extraction Tasks and Graphical Representation,” Information
Systems Research 1, no. 4 (1990): 416–439.
7. J. K. H. Tan, “Graphics-Based Health Decision Support Systems: Conjugating Theoretical
Perspectives to Guide the Design of Graphics and Redundant Codes in HDSS Interfaces.”
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In J. K. H. Tan with S. Sheps, Health Decision Support Systems (Gaithersburg, MD: Aspen
Publishers, 1998): 153–173.
8. Booz Allen Hamilton, Information Sharing (New York: HarperCollins, 2006). See also www
.boozallen.com.
Chapter Questions
1–1. How does HMIS affect or influence the different departments within a healthcare ser-
vices organization?
1–2. Why is it difficult to integrate IT and medicine? Discuss the need for an integrated man-
agement perspective of HMIS.
1–3. List the five major components of integrated HMIS. Discuss which component deserves
the most attention in today’s HIT environment and why. Provide specific examples of
each component in the context of your work.
1–4. If you were a CIO, which of the four types of IT cultures would you pursue, and why?
1–5. List and illustrate the basic functions of an HMIS. How may these basic functions be ex-
tended to accommodate complex health information processing tasks such as medical di-
agnosis and teleconsultation?
M i n i – C a s e : MinuteClinic
MinuteClinic, owned by pharmacy giant CVS, is a retail healthcare provider with more than
500 locations established throughout the country. The centers are designed to treat patients
with minor injuries or sicknesses, and more than 1.8 million patient visits have been docu-
mented since the company’s inception in 2000. By creating a healthcare delivery model that re-
sponds to consumer demand, MinuteClinic makes access to high-quality medical treatment
easier for more Americans.
As more patients used MinuteClinic resources, one issue the company faced was how to pass
medical information to primary care physicians. As Cris Ross, chief information officer of
MinuteClinic, explains, “There are a number of things we do very well with physicians, except
connect electronically. We’ve been looking for a business-to-business exchange.”
As a solution to this problem, MinuteClinic recently turned to ePrescribing connectivity
network SureScripts to facilitate this exchange. It is the first time the SureScripts network has
been used for anything other than pharmacy orders and related transactions.
“The idea is that we already have pharmacies connected,” acting SureScripts CEO Rick
Ratliff told Digital Healthcare & Productivity by telephone. “We have an ability to identify a
physician uniquely on the network.”
As part of this connection, MinuteClinic will convert records from its proprietary electronic
medical records system into Continuity of Care Record (CCR) standard format. Ratliff adds
that this record “can be moved around almost like a piece of mail” from provider to provider,
and into personal health records (PHR).
Now with every visit, MinuteClinic practitioners stress the importance of maintaining a
medical home for each patient by making information accessible to primary care providers. If a
patient doesn’t have a primary care provider, MinuteClinic provides a list of physicians in the
CHAPTER QUESTIONS 21
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area who are accepting new patients. Practitioners are then able to use a multipurpose software-
based approach at the conclusion of each visit that generates educational material, an invoice,
and a prescription (when clinically appropriate) for the patient, as well as a diagnostic record
that is automatically sent to the patient’s primary care provider’s office (with the patient’s con-
sent) to facilitate continuity of care.
Mini-Case Questions
1. How might embracing the CCR standard benefit and/or damage MinuteClinic’s overall
profitability?
2. Why does MinuteClinic choose to promote the patient/primary care provider relationship?
3. What patient issues might MinuteClinic face in implementing an electronic record that can
be easily transferred from clinic to physician?
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Health Management Information
System Executives:
Roles and Responsibilities
of Chief Executive Officers
and Chief Information Officers
in Healthcare Services Organizations
Joseph Tan
23
2
CHAPTER
CHAPTER OUTLINE
Scenario: Managing Waiting Time in Emergency Rooms
I. Introduction
II. Vision
III. Strategy
IV. Execution
V. Senior Executives in Healthcare Services Organizations
● A Trustworthy Leader
● An Inspirational Manager and Motivator of Others
● An Effective Communicator
VI. Specific CIO Role and Responsibilities
VII. Conclusion
56918_CH02_Final_Tan 4/6/10 11:35 AM Page 23

S c e n a r i o : Managing Waiting Time in Emergency Rooms1
For the most part, patients entering the emergency room (ER) will not know what treatment
they need or the specific department they should be admitted into; often, they are largely de-
pendent on the ER to quickly and effectively diagnose their illness so as to get them transferred
into the right department for optimal care and treatment. Some patients, for example, should
be transferred to the intensive care unit (ICU), others should proceed to the operating room
(OR), and some others to the recovery room (RR) waiting to be enrolled into possible long-
term rehabilitation programs.
In November 2006, Beatrice Vance of Chicago, Illinois, was experiencing chest pains and
quickly found her way to a local hospital ER. Hours later, she apparently died of a heart attack.
The coroner’s report concluded that the length of her wait time in the ER was partly responsi-
ble for her death because she died of congestive heart failure—the inability of the heart to
pump the required amount of blood to her body due to a weakened muscle. At 10:15 P.M., she
was already checked into the ER but was told to wait her turn for a doctor. At 12:25 A.M., she
collapsed and died.
As Carol Haraden from the Institute for Healthcare Improvement noted, “The dangers are
that the person’s condition may escalate . . . (during) . . . waiting time in the ER.” With wait
time in the ER averaging 3 hours and 47 minutes nationally in the United States, it is clear that
something should have been done. When an inquiry into a case such as that of Beatrice Vance is
made, senior executives of the healthcare organization, including the chief executive officer
(CEO) and others such as the chief information officer (CIO), may be held partly responsible.
Thus, it is critical nowadays for healthcare organizations to shorten ER waiting times and be
fully prepared to deal with differing needs of patients being admitted.
Indeed, the number of U.S. emergency departments has fallen by about 425, or about 12 per-
cent from 1993 through 2006, while 26 percent more (or 114 million patients) have sought ER
care during the same period. Hospitals across the nation are being pressured to find new ways of
coding and assessing patients to keep the ER services efficient and effective by attending to
24 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M E X E C U T I V E S
Notes
Additional Readings
Chapter Questions
Mini-Case: Predicting Future HMIS Trends by Chief Information Officers
Research Brief I: Personal Digital Assistants Enhance Data Collection Efficiency during
a Study of Waiting Times in an Emergency Department
N. Elkum, W. Greer, and A. Al-Madouj
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admitted patients within 30 minutes. At the very least, the hospital should provide accurate and
timely services to their patients who come to the ER for care. An ER triage system, for instance,
is essential for the prompt recognition of urgent cases.
Imagine yourself to be one of these patients who would like to see changes to the ER waiting
times. Do you feel this might be an opportunity where it would be beneficial for appropriate IT
solutions and effective leadership in healthcare services organizations to come into play? What
could, or would, you do to fix the situation, if you were given a leadership role by the Chicago
hospital where Beatrice Vance was admitted?
I. Introduction
For years, practicing physicians in urban areas, especially those catering primarily to under-
served communities, have struggled with patients who frequently miss scheduled appoint-
ments. With the national no-show rate in 2000 averaging 5.5 percent, many physician offices
have now adopted a double-patient booking schedule in order to remain productive and finan-
cially viable. In other words, two patients are scheduled every 15 to 20 minutes at the physi-
cian’s office, resulting in patients having to wait their turn even if they arrive on time. This then
puts a lot of stress on the system as office staff struggles to balance between patient flow and
flaring tempers, greatly increasing the potential for staff frustration and patient dissatisfaction.
To further aggravate the situation, physicians also have the habit of placing patients on a
wait list that may be months away. Typically, these physicians would advise their patients to go
to the ER if it is something for which the patients cannot wait. With ER services, no appoint-
ments are maintained, so situations can be even more demanding because federal law dictates
that no patient can be denied needed treatments when showing up at an ER. As with challenges
encountered in many critical business operations, where scheduling, queuing, and waiting time
create problems, one way of resolving the ER challenge in the U.S. healthcare system is the
adoption and implementation of appropriate health management information systems
(HMIS). This opens up discussion of the critical roles played by the chief executive officer
(CEO) and the chief information officer (CIO) in healthcare services organizations. These ex-
ecutives are responsible for providing an appropriate vision for future HMIS directions. They
are responsible for aligning IT departmental goals and strategies with corporate goals and
strategies, and they are also responsible for strategizing appropriately, executing intelligently,
and evaluating wisely on the system’s performance of healthcare services delivery with the appli-
cation of effective and efficient business processes and information technologies throughout the
corporation.
II. Vision
The role of the CEO or CIO to oversee the use of HMIS in any healthcare services organization
requires that the individual has at least been trained and has experienced and mastered a certain
set of strategic, tactical, and operational IT competencies. Just as with any business organization,
I I . V I S I O N 25
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every healthcare services organization drastically needs such an individual to be visionary in
providing future directions with respect to the organizational HMIS infrastructure, product
life cycle management, and innovations. Aside from being visionary, the CEO or CIO is ex-
pected to be goal-directed in resolving HMIS performance in different parts of the organiza-
tion on the one hand and to be emphatic in dealing with HMIS staff and daily customer
complaints on the other.
Imagine that with the shortage of administrative and clinical staff members hired to man ER
services, you, as the appointed CEO or CIO, have been asked to execute and implement a
triage system and other critical clinical database and reminder systems for the ER to monitor
the flow of patient traffic and ER scheduling information. What will be your role and responsi-
bilities? How would you go about aligning the IT goals and strategies to be pursued for the ER
with the greater organizational mission, goals, objectives, and strategies?
Essentially, senior executives who are directing organizational information systems or tech-
nology development efforts are expected to think quickly and strategically, solve problems intel-
ligently in many areas of IT specializations, and advocate influentially on the use of available
and advancing technologies to close the gap between departmental HMIS strategies and “the
business” strategies. In a healthcare services organizational context, the mission, goals, and ob-
jectives of the health organization determine how HMIS should be incorporated throughout an
organization. Oftentimes, not only is senior management expected to be responsible for imme-
diate challenges facing the organization due to a breakdown of computing services, but more
importantly, top management is often looked upon to take the lead in championing existing
and new HMIS services. Among the most important roles, then, is having a vision—a vision
that involves the creation of scenarios and possibilities to drive needed directions for future or-
ganizational HMIS growth and investments. For the CEO, the end result of this visioning
process may be an enterprisewide business plan; for the CIO, it is more likely to be an IT plan
aligned with this corporate business plan.
Backtracking to our ER example, for instance, one vision of the CEO/CIO may be the de-
ployment of IT systems to ensure that all future incoming patients who are being transported
via the hospital ambulance service are assessed even while en route to the hospital through the
use of tele-medical devices, thereby shortening the assessment wait time for other incoming pa-
tients. Furthermore, installation of courseware for self-help and patient education can further
help to reduce wait time. A targeted wait time for incoming patients can also be effectively cut
down by ensuring that any available treatment records of new and previously admitted patients
be abstracted electronically and in real time to all attending ER physicians and nurses; the en-
tire ER patient record systems could also be wirelessly connected to all local area hospitals, and
patients who banked their personal health records (PHR) with any secured health information
agencies can then download their records conveniently and/or allow the reading and updating
of their records by the attending ER physicians and nurses.
In practice, however, crafting such a “vision” is a long-drawn-out process whereby a set of
shared and related notions in the form of a vetted “proposal” or “business plan” supported by
top management in the organization is generated. Presumably, there is an assumed need to sell
both the professional staff and other employees within the organization on the vision in one
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fashion or another. This means that a large majority of the organizational members should be-
come aware of it, must be willing to support it, and must be able to participate in it in some
fashion to bring about the realization of that vision. Surveys of management, professional staff,
and other employees are some of the ways to promote an understanding and keen awareness of
such a corporate view.
Strategic IT planning sessions could also be held on a continuous basis. These sessions need to
be attended and supported by the key stakeholders across the organization, with the possibility of
instituting changes as new ideas are introduced. Top management of the organization must also
approve the finalized proposal, because future directions of the organization should extend the
major thoughts captured by that proposal. It is also important to generate a business plan clarify-
ing the strategies, policies, and procedures connected to unfolding the vision—one that is shared
and supported by the majority of the organizational stakeholders. Essentially, this articulation
should bring together all the pieces of HMIS components related to the organization: data, peo-
ple, hardware and software, network requirements, and functional tasks to be supported.
While the CEO/CIO may not yet find complete answers to many of the questions raised by
such a visioning process, having a well-consolidated plan is better than having none at all. After
all, if you don’t really know and can’t articulate where you are heading, any road will lead you
to it. This simply means that the next best thing to do may just be to do nothing because there
will be no significant difference if you take (or don’t take) actions without first having a strong
conviction about the purpose for doing so.
Key questions to be answered by the CEO/CIO in such a business plan include:
1. What is the core mission of the IT department vis-à-vis that of the organization?
2. What are the major IT department goals to be accomplished in the longer term?
3. What are the specific objectives relating to each of these major, longer-term goals?
To turn the vision into reality, however, top management will need to take a practical approach
to understanding and detailing the “strategies” in the context of unfolding the business plan.
III. Strategy
Whereas vision is concerned primarily with future directions and mission with a sense of pur-
pose, “strategy” is concerned with how we go about achieving that vision and/or mission. For
all intents and purposes, there are several levels of strategies, which should not be confused with
those at the tactical and/or operational levels that pertain to shorter-term or more immediate
goals and objectives, respectively. Among major groups of strategies with which top manage-
ment should become fully acquainted are corporate strategies, competitive strategies, and func-
tional strategies, as depicted in Figure 2.1.
Developed through a detailed scanning of the corporate environment at its highest level, in
which the threats and opportunities of the external environment are assessed with respect to in-
ternal corporate strengths (core competencies) and weaknesses (inadequacy of corporate re-
I I I . S T R AT E G Y 27
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sources), corporate strategies may be further categorized into four major groups: growth, diver-
sification, turnaround, and defensive strategies.
Growth strategies, in the form of product and market development, mergers, acquisitions,
and/or internal ventures, are aggressively followed when the healthcare organization’s internal
resources and competencies serve identified market opportunities readily. With a growing pop-
ulation of baby boomers, seniors and elderly persons facing the challenges of increased physical
limitations and mobility, and increased chronic ailments, it may signal a time of growth for
tele-home healthcare services. Moreover, with increased fuel and public transportation costs, an
aggressive entry into the mobile healthcare market opportunities such as the promotion of tele-
home care products and services may also be justified. Several national pharmaceutical chains in
the United States and Canada (such as London Drugs) are already pursuing this strategy.
Examples of such products and services include wearable medical devices; in-home, medical
tele-consultation; and in-home, real-time monitoring care services via secured electronic net-
worked devices.
Diversification strategies represent an approach to risk management. These strategies are often
adopted when the existing healthcare organizational business portfolio is threatened; for exam-
ple, delays in the reading of digitized images taken for ER patients may be a problem if other
competitive healthcare services organizations are able to provide one-stop comprehensive ER
services due to the availability and round-the-clock accessibility of in-house radiological serv-
ices. One diversification strategy in this instance may be for the CEO/CIO to increase out-
sourcing of digital imaging services through the value chain by adding tele-radiological services
to assess ER patient conditions quickly.
28 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M E X E C U T I V E S
Corporate
Strategies
Growth
Strategies
Diversification
Strategies
Turnaround
Strategies
Defensive
Strategies
Competitive
Strategies
Taxonomies of
Organizational Strategies
Cost
Leadership
Differentiation
Strategies
Innovation
Strategies
Functional
Strategies
Marketing
Strategies
Financial
Strategies
Operation
Strategies
Human Talent
Management
FIGURE 2.1 Taxonomies of Strategies.
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Turnaround strategies essentially take advantage of situations to retrofit the organizational
strengths and internal capabilities to market opportunities that may still be available and waiting
to be served. Typical approaches pursued in turnaround situations may be those of outsourcing,
organizational restructuring, business process reengineering, budgetary cost-cutting measures,
assets reallocation and reduction, or even service downsizing. One example here may be the in-
troduction of expert-based courseware in integrative medicine to combat the strong growing
market forces in the complementary and alternative medicine services for educating ER pa-
tients in follow-up and self-care services to reduce the need for time-consuming patient educa-
tion by the attending ER physicians and nurses.
Finally, defensive strategies come into play when the stage of the industry and/or product life
cycle is experiencing a steady decline due to its ongoing maturity. Here, several approaches that
are typically used include divesting and liquidating to reduce the losses sustained by unproduc-
tive and increasingly inactive engagements as well as exiting the oversubscribed industry niches
and/or practices. As an example, traditional paper-based patient records and paper-based pre-
scribing are difficult to maintain but still used by many physicians across U.S. healthcare sys-
tems. These practices will eventually decline in popularity as competitive clinics move to
electronic patient records and e-prescription services—and gain a larger percentage of the mar-
ket share of patients. Part of the role and responsibilities of the CEO/CIO is then to employ
defensive strategies to move the organization to a 21st-century healthcare services organization
by replacing these paper-based medical records and drug prescribing systems with server-
networked electronic health records (EHR) and/or e-prescription systems.
Based on Porter’s classical work on competitive advantage strategies, for a healthcare services
organization to stay competitive, commonly employed strategies include cost leadership, differ-
entiation, and innovation strategies. In cost leadership, cost advantage is gained through
economies of scale and cost-effectiveness as well as other cost-cutting measures. Differentiation
highlights the uniqueness of certain aspects of the business activities maintained by the organi-
zation in a competitive marketplace. Lastly, innovation strategy for an organization is to be con-
stantly at the leading edge of its product offering and service development. We illustrate the
applications of these various strategies in terms of how a specific health maintenance organiza-
tion such as Blue Care Network (BCN) can stay competitive in the marketplace so as to provide
its clients with greater benefits as well as continuing to attract new subscribing members.
BCN, an affiliate of Blue Cross Blue Shield (BCBS), for example, is relatively successful in
attracting new clients in the Detroit metropolitan area. Their clientele include neighboring
state universities and other major corporate employers such as the University of Michigan,
Michigan State University, Wayne State University, General Motors, Ford One, and Chrysler
Corporation. Their competitors operating in the same regional area are less competitive because
of somewhat higher co-payment options for active and nonmedical retirees; less benefit cover-
age; greater limitations for servicing active subscribers; and/or less comprehensive and competi-
tive benefits for emergency, diagnostic, and preventive services.
With regard to differentiation strategy, what distinguishes BCN from its competitors here is
the sheer growth in the number of its subscribing physicians, all of whom practice in the sur-
rounding area and will thus be able to accept new patient-subscribers. Not surprisingly, their
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less competitive counterparts may have a relatively limited list of available general practitioners
and specialists. Other factors distinguishing BCN from its competitors may involve BCBS and
its affiliates’ voluminous purchasing power, rapid third-party service reimbursement schemes,
and effective supply chain management. Many third-party healthcare provider organizations
would gladly work with BCN subscribers due to easy third-party reimbursement payment
schemes. For instance, Dynamics, a Michigan company specializing in neck-and-back pain
therapies for accident victims, will readily accept subscribers of BCBS of Michigan, BCN of
Michigan, and Community Blue PPO (another affiliate of BCBS of Michigan), but may have
difficulty accepting patient-subscribers of less known health maintenance organizations
(HMOs) because of challenging third-party service provider reimbursement schemes. Finally,
new-product developments and wellness programs such as smoking cessation, nutrition, and
other health preventive measures are being actively propagated and introduced to BCN sub-
scribers in order to stay competitive in the HMO marketplace.
Functional strategies, another set of strategies typically employed at the more operational
level of managing the healthcare services organization, are nonetheless still critical for success in
the longer-term and intermediate-term time frame. These strategies include marketing strategy,
financial strategy, operation strategy, and human talent management.
Marketing strategy has to do with how the products and services are being propagated and
promoted in the marketplace. BCN, for example, may decide to join forces with other compet-
ing HMOs to provide educational seminars and presentations to major corporate employees
who represent the bulk of potential new HMO subscribers on a yearly basis. Financial strategy
has to do with the intelligent use of financial information to make key decisions on resource al-
location and financing of new programs within the organization. In an attempt to understand
how chief executives use HMIS for strategy implementation in hospitals, David Naranjo-Gil
and Frank Hartmann surveyed 218 public hospital CEOs in Spain and noted that executives
with a “predominant administrative” background tend to be more effective in “establishing
cost-reduction strategies, through their larger inclination to emphasize financial information in
combination with a diagnostic use of the MIS” whereas executives with a “predominant clini-
cal” background will “focus more on nonfinancial information for decision making and prefer
an interactive style” of using HMIS, which tend toward use of flexibility strategies.2 The latter,
it appears, has to do more with operation strategy where quality improvement and greater effi-
ciencies become the key focus for achieving greater patient satisfaction in healthcare services or-
ganizations. Thus, both financial and operation strategies are important for senior executives
of BCN to implement appropriately and intelligently to achieve immediate, intermediate, and
longer-term goals in the face of competitive challenges in the healthcare marketplace. Above
all, human talent management is critical to determine the success of any organization because
it is the people who work for the organization who portray the organization—they are the
ones who put a face to how the organization really is perceived by its customers, third parties,
and external relations.
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IV. Execution
The McKinsey 7-S framework was developed by McKinsey & Company to guide the evalua-
tion and implementation of organizational strategies. The underlying premise is that all seven
elements of this model—strategy, structure, systems, style, staff, shared values, and skills—
should be moving in the same direction in order to achieve a “strategic fit” for the organization.
In other words, the strategy of the organization “fits” with every other variable within the 7-S
organization framework3 of strategy, structure, systems, style, staff, shared values, and skills as
illustrated in Figure 2.2.
Strategy is the set of activities or actions targeted at achieving a competitive edge in the mar-
ketplace through organizational process improvements, intelligent capital management applica-
tion, and systemic resources allocation. Structure is the reporting hierarchy of the organization
as determined by the placement of personnel within the organization and the accompanying di-
vision and/or integration of organizational tasks, roles, and responsibilities to be accomplished
on a daily and longer-term basis. Systems are the task and informational processes and workflow
that together determine how the organization conducts its daily affairs. Examples include infor-
I V. E X E C U T I O N 31
Strategic
Fit
Strategy
Structure
Systems
Style
Staff
Shared
Values
Skills
FIGURE 2.2 McKinsey’s 7-S Strategic Fit Framework.
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mation systems, healthcare delivery systems, performance evaluation systems, quality control
systems, and capital budgeting systems. Style refers to the way management behaves within the
organization, not just what is being communicated—the tangible evidence of how the organiza-
tion spends time, pays attention, and performs collectively. Staff refers to the human resources—
the people hired by the organization to perform its daily functions—although it is important to
think of this not in terms of individuals, but of corporate demographics. Shared values portray
the common goals, objectives, and beliefs of most members of the organization and may be in-
dicative of both the organizational identity and corporate destiny. Finally, skills may be con-
ceived as the total competencies of the organization due not simply to individual expertise in
isolation, but more appropriately, to the interactive coordination among the hired employees.
In essence, it is a derivative of the other six organizational elements noted in the 7-S framework.
Ginter, Swayne, and Duncan4 used the case of Allegheny General Hospital (AGH) as
sourced from David Burda’s article5 in Modern Healthcare to illustrate the McKinsey 7-S frame-
work as applied in a healthcare organizational setting. Today, as a top-performing, tertiary-care
hospital and academic medical center serving Pittsburgh and the surrounding five-state area
with 724 beds,6 AGH competes in an extremely sophisticated healthcare marketplace against
the background of other highly performing, tertiary-care competitors. These competitors in-
clude the 729-bed St. Francis Medical Center, the 583-bed Presbyterian-University Hospital,
the 500-bed Mercy Hospital of Pittsburgh, and the 452-bed Western Pennsylvania Hospital.
Without a proper strategic fit, AGH would not have been able to excel in one of the country’s
most challenging and competitive tertiary-care marketplaces.
Strategically speaking, AGH has, over a critical period of time, been able to establish itself as
a significant regional level-1 resource trauma center in Pennsylvania for tertiary-care services,
with added recognition in pediatric trauma. Services offered by AGH include specialized pa-
tient care, resident physician teaching, and research administered collaboratively by more than
850 physicians and 4,000 employees. Located in the North Side section of Pittsburgh, AGH
admits more than 29,000 patients and registers no less than 450,000 outpatient visits annually.
In term of its structure, AGH is strongly linked both professionally and academically. Not
only is it affiliated with the Medical College of Pennsylvania, which has significantly strength-
ened its resident physician teaching mission, but it has significantly augmented its research mis-
sion through the ASRI (Allegheny Singer Research Institute). ASRI has an annual research
budget of more than $30 million and conducts research in many clinical areas, including cardi-
ology, cardiothoracic surgery, diagnostic radiology, gastroenterology, nephrology, neurology,
neurosurgery, obstetrics/gynecology, oncology, ophthalmology, orthopedic surgery, pediatrics,
psychiatry, pulmonary medicine, and transplant surgery.
Management style at AGH is known to be both aggressive and direct. AGH management is ex-
ternally oriented and is prepared at all times to take the challenge of meeting the tertiary-care
needs of the region. More recently, the hospital has focused on providing comprehensive care to
those with behavioral disorders in their central nervous systems through the Allegheny
Neuropsychiatric Institute (ANI). By emphasizing service quality, operational efficiencies, and in-
dividual productivity with a strong internal orientation, AGH management is highly committed
to the excellence of the hospital’s overall performance and to becoming the region’s top hospital.
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AGH also employs a variety of systems to guide future directions for the hospital progress
and for new services and technology. For example, a system of objectives and strategies is main-
tained for implementing organizational policies and procedures, an advanced system is used for
matching referring physicians to specialists, and plans are available for medical staff develop-
ment and clinical services development.
Shared values of AGH’s medical staff and employees reach above and beyond the highest
level of community involvement, advanced technology deployment, and service excellence. The
aim is to promote employees’ commitment through supporting development and training pro-
grams as well as gain-sharing programs.
Staffing at AGH, as noted previously, comprises more than 850 physicians and 4,000 em-
ployees. These include more than 565 medical staff members, more than 1,350 registered and
practicing nurses, and other personnel. AGH’s residency program for junior and senior Medical
College of Pennsylvania students is well managed, with a reputation that attracts fully qualified
practicing specialists who love to teach and practice high-quality medicine. The hospital runs a
medical staff development plan that emphasizes the training of the medical staff to meet the
medical needs of the community.
Finally, skills and competencies at AGH are the sum derivatives of all the other elements
within the 7-S strategic framework. AGH not only employs highly qualified experts, specialists,
and staff members, but also promotes a learning environment throughout the organization to
ease the flow of key clinical and nonclinical procedures, processes, and services. Both the public
and its referring physicians are well aware of AGH’s high-performing and accreditation stand-
ing and professional marketing strategies.
At this point, we move on to discuss the differing roles and responsibilities of the various
senior executive positions within a healthcare services organizational context. For HMIS to
make a significant contribution and impact on the organizational performance, understanding
the role and responsibilities of the CIO is most critical, which is where our discussion is con-
centrated. In an organization where a CIO has not been appointed, the CEO or another desig-
nated senior officer is expected to step in and take on the CIO role and responsibilities.
V. Senior Executives in Healthcare
Services Organizations
Among the highest-ranking officers appointed in a healthcare services organization is the presi-
dent and chief executive officer (CEO). This individual is largely responsible for articulating the
organizational vision and mission, specifying the core competencies of the organization, and de-
lineating its strategic plan and directions typically with the aid of an appointed high-level board
of governors. It is also often the case that this individual is elected as the chairman of the board.
The CEO is also expected to appoint and oversee the meetings involving all other senior ex-
ecutives of the organization. These senior executives may include a chief financial officer
(CFO); a chief operations officer (COO); a chief marketing officer (CMO); and other IT-
related strategic appointments such as a chief information officer (CIO), a chief technology offi-
V. S E N I O R E X E C U T I V E S I N H E A LT H C A R E S E R V I C E S O R G A N I Z AT I O N S 33
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34 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M E X E C U T I V E S
Table 2.1 Executive Roles and Responsibilities for Healthcare Services Organizations
Executive Designation Executive Role and Responsibilities for Health Services Organizations
Chief executive officer Articulates corporate vision, mission, and strategy; chairs senior
(CEO) executive meetings and conducts performance evaluation of top
management personnel; oversees corporate growth and
development; and ensures the realization of strategic business goals
and objectives over time.
Chief financial officer Oversees the financing function, budgeting, and funding of the health
(CFO) services organization’s operating programs and services, including
advising the CEO and other senior executives on strategic capital
investment decisions, capital expansion projects, market competition,
and organizational revenue-generation strategies.
Chief operations officer Oversees the daily healthcare services delivery operations, business
(COO) processes, policies, and procedures of the health services organization’s
care delivery, including advising the CEO and other senior executives on
strategic business process reengineering; human resources development
and productivity improvement projects; operational and clinical
efficiency and effectiveness enhancement projects; scheduling, facility,
and inventory management; logistics; and changes in daily
organizational production functions.
Chief marketing officer Oversees the marketing and promotion operations, business processes,
(CMO) policies, and procedures of marketing and promoting the health services
organization’s care delivery, including advising the CEO and other senior
executives on strategic marketing opportunities, purchasing and external
relations projects, customer relation and satisfaction ratings, and
changes in daily organizational marketing functions.
Chief medical officer Oversees the decisions and operations of physicians and other clinical
(CMO) personnel providing services within the context of a health services
organization.
Chief information officer Oversees all HMIS applications and technology procurement,
(CIO) acceptance, and adoption practices throughout the healthcare
services organization; responsible for the alignment of corporate and
HMIS strategic goals and objectives, including use of IT to improve
administrative efficiencies and clinical productivity and effectiveness.
Chief technology officer Oversees the throughput, accuracy, speed, availability, and reliability
(CTO) of an organization’s HMIS; improving the efficiency of IT systems; and
the appropriate implementation of hardware, software, communication,
and network technology solutions.
Chief security officer Oversees the security and backup of HMIS applications and developing
(CSO) strategies, including safeguarding HMIS technology applications against
attacks from hackers and viruses.
Chief privacy officer Oversees the ethical and legal dimensions of organization information
(CPO) use and releases; sets policies, standards, and procedures for privacy and
confidentiality of health information release in compliance with HIPAA
rules and standards.
Chief knowledge officer Oversees the gathering, maintenance, and dissemination of the
(CKO) health organization’s knowledge; designs the organizational
programs and systems to ease the reuse of knowledge among
organizational employees, with the aim of creating a knowledge-
enabled organization.
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cer (CTO), a chief security officer (CSO), a chief privacy officer (CPO), and a chief knowledge
officer (CKO). For small businesses and start-ups, the CEO may be the only person who takes
on the roles and responsibilities of all these different executive functions. In healthcare organi-
zations, a chief medical officer (CMO) is also appointed. Table 2.1 provides brief definitions of
the different roles and responsibilities of these various executive officers.
In this discussion, our focus is on the overall roles and responsibilities of the CIO for a
health services organization because these functional duties are representative of the key duties
to be performed by a single individual or a combination of senior officers who are asked to take
charge of the procurement, development, use, and servicing of health management information
systems within the organization. As we know, when a company does not have a CIO or any
other senior officer appointed to be in charge of HMIS, it would be included as part of the role
and responsibilities of the CEO. In this instance, the CEO in the healthcare services organiza-
tion would be responsible for aligning the HMIS mission and goals with the enterprisewide
mission and goals.
Before spelling out the specific roles and responsibilities for the CIO with respect to
HMIS strategic planning and service management, it is critical to note that most senior ex-
ecutives share some important functions and should have a number of key traits in order to
successfully carry out their share of duties. These important characteristics include being
(1) a trustworthy leader, (2) an inspirational manager and motivator of others, and (3) an
effective communicator.
A Trustworthy Leader
Regardless of the senior executive appointments, trustworthiness is an essential trait of effective
leadership. Because “trust” is the essence of leadership effectiveness, extraordinary leaders must
have the ability to exude trust from their direct reports and corresponding followers. As leaders,
senior executives should be able to command the highest respect from their subordinates. In
other words, for this trustworthiness to be sustained, it cannot simply be one-sided. The devel-
opment of a mutual trust and respect over time between the superior and his or her direct re-
ports is key to building a lasting and successful working relationship. This is true for a CEO,
CKO, CTO, CSO, or any other executive officer (such as a CIO asked to take charge of
HMIS).
Closely related to trustworthiness and respect is the concept that leaders should not upset
their followers with any unannounced surprises—which requires that they stick to their princi-
ples, keeping precisely to what they have articulated or promised, with a clear and open attitude
about how and why certain things are or are not being executed. Effective leadership can then
result naturally in having the highest trust and respect from others. For a CIO, this means being
consistent in everything that he or she does, showing good judgment on equality and equity is-
sues, and providing equal opportunities for the advancement of subordinates.
At times, some employees may become frustrated because there is more work to be com-
pleted than there are people assigned to the task—due, perhaps, to budgetary constraints, regu-
latory changes, and/or economic downturns. This frustration may result in employees having
difficulty understanding where they should focus their time. It is the job of an effective CIO,
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then, to prioritize tasks for the employees: framing major issues, simplifying complex assign-
ments, and spelling out what is the most to the least important. By eliminating the unnecessary
distractions to employees and focusing on what should be the central issue, the employees will
be less frustrated with their work. Not only will they become more satisfied, but they will also
be more creative and productive in achieving the key goals set for them by the CIO.
An Inspirational Manager and Motivator of Others
As a manager, the CIO wants to ascertain that all HMIS projects are delivered on time and
within budget. This requires the CIO to provide in-depth inspiration and self-motivation as
well as to be a motivator of others. Motivation is the art of inspiring others, giving them a sense
of confidence and/or the desire to accomplish certain goals. Because it is an “art” form, motiva-
tion requires that the CIO have special skills and elevated expertise before he or she can effec-
tively manage and inspire others.
How, then, is the CIO able to effectively motivate others? Among the first critical steps is ef-
fective communication, which is discussed more fully later. Here, rather than making general-
izations, effective managers should be as specific as possible when detailing the goals and
objectives for their employees. A follow-up point is that when goals are set, the employees must
be sold on the feasibility of achieving those goals, and how best to reach them. Once the em-
ployees are clear about what is expected of them and realize how the goals may be achieved,
they can then be inspired to do so.
Another characteristic of an effective manager and motivator of others is that not only is the
CIO able to position specific individuals who are capable of accomplishing the different tasks
in the appropriate spaces throughout the organization, but when all tasks are fully accounted
for as a whole, the CIO can expect his or her subordinates to have reached key goals of the or-
ganization at an even higher level. In addition, it is the job of the CIO to support his or her
subordinates to become skilled and ever ready to complete the most challenging tasks at hand.
Above all, instituting a collaborative spirit with a strong sense of team belonging and task infor-
mation sharing among subordinates is critical to success when faced with executing any com-
plex HMIS-related project goals.
Another very important step in motivating others is measurement; that is, for subordinates
to remain motivated, not only must they have a clear grasp of their assignments, but they must
also be clearly informed on how they are performing at any given time. Providing constructive
feedback as opposed to micro-managing and unnecessary criticisms is therefore the key to suc-
cessful goal attainment among employees. Conversely, employees often need to be encouraged
and recognized for their achievements, which would give them a sense of being valued while
they seek to improve further. Without individualized recognition, the employees are not moti-
vated to do their best—to work past their potentials and to reach out for the top or to perform
to the best of their abilities.
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An Effective Communicator
Effective communication is essential for forming all kinds of work relationships. It is especially
important for building strong social networks among key stakeholders, whether it is to be exe-
cuted through e-mail, one-on-one meetings, bulletin boards, Weblogs (or blogs), or other more
formal means of communication. Communication is, in fact, the core of effective management.
Without it, chaos and dissatisfaction can emerge and evolve over time.
Clearly, one-sided communication is ineffective, which means that it is essential for a CIO to
learn to “listen.” What is the difference between just “speaking” and “speaking and listening” to
others? To ensure that subordinates understand what is being communicated, it is critical for
the CIO to remain open and “listen” to his or her subordinates. Listening requires patience. It
is having eye contact with others; spending time to acknowledge what others have articulated
with appropriate gestures; and being able to provide feedback, whenever necessary, by rephras-
ing what others may have articulated to achieve clarity of thoughts. This will then begin to
build a good rapport between the conversing parties. Listening also allows the CIO to relate the
concerns of the subordinates to those key points he or she wishes to communicate to them.
As well, effective communicators are media-sensitive. Understanding the media used in the
communication is important because different types of information may be received under each
setting. For example, certain means of communication, such as television and radio broadcast-
ing or even a newspaper press release, may be appropriate for specific or more formal messages
to be conveyed, whereas other means such as e-mail and telephone communications are useful
for informal, humorous, and/or lighthearted exchanges.
Moreover, having specific knowledge about your audience or those to whom you will be
communicating is critical in effective communications because every audience is different with
different needs to be satisfied. Among senior-level colleagues, for example, the CIO must advo-
cate and articulate the HMIS vision and strategy through developing and maintaining cohesive
executive relationships. He or she has to communicate the same message, but in a very different
way, to his or her direct reports internally and/or to the customers and third parties externally.
VI. Specific CIO Role and Responsibilities
Broadly speaking, the CIO role is to provide strategic HMIS vision and leadership for integrat-
ing IT initiatives in a healthcare services organization. As most healthcare services organizations
are increasingly dependent on IT to improve on service quality, enhance efficiencies, and pro-
ductivity, as well as to reduce human errors, a CIO is expected to work intelligently in a grow-
ing political environment.
Today, the CIO job has become increasingly stressful, more business oriented, and less
hands-on. For example, he or she directs the planning and implementation of enterprisewide
HMIS in order to improve health information exchanges within the organization and enhance
overall cost-effectiveness, operational efficiencies, and healthcare services delivery quality. This
individual is clearly responsible for all aspects of the organization’s HMIS functions and appli-
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cations. In addition, most CIO responsibilities now have expanded beyond the traditional role
to include concerns about enhancing “customer satisfaction” and being “customer-centric.”7
The formal education and on-the-job training for a CIO can differ significantly, but having
a university degree in a related field such as industrial engineering, computer science, and/or
business administration is a very good start. A CIO must be able to execute strategic as well as
tactical HMIS planning effectively. He or she must have knowledge and experience in manag-
ing and directing increasingly sophisticated HMIS operations, and possess acumen in routine
business operations, periodic performance evaluation activities, and strategy and human re-
source management. The CIO is expected to demonstrate the ability to apply HMIS concepts
in real-world business problem-solving situations. He or she is also largely responsible for
negotiating, outsourcing, and/or managing vendor contracts on HMIS products, services, and
other related projects (such as ensuring the compliance of the health organizational information
systems with HIPAA rules and standards).
Overall, the key role of a CIO is the need to develop and preserve tight integration between
HMIS decisions and corporate business goals. The CIO must have superior understanding of
both the organization’s and HMIS departmental goals and objectives so as to align these goals
and objectives seamlessly. This single set of responsibility calls upon every CIO’s political, nego-
tiation, and project management skills.
In response to an increasingly hyper-competitive HMIS marketplace, the CIO of a health-
care services organization today has to learn to focus on external relations such as customer sat-
isfaction concerns, HMIS security issues, technology acceptance and evaluation ratings,
budgeting, staffing, outsourcing, hosting, and return on investment (ROI) analysis. With ad-
vancing technology and a more computer-literate U.S. population, the role of a CIO will con-
tinue to evolve over the next several years; most likely, the future CIO will be expected to act as
a change agent and as a business change leader. The traditional HMIS functions will move from
internal-focused tactical operations to more global-oriented strategic functions. For example, if
an HMO decides to branch out to a different country such as Mexico, then the HMIS depart-
ment must necessarily support the Mexican operations. Indeed, globalization and advancing
technology are “flattening” the competition among multi-provider organizations in the health-
care services industry and are breaking down traditional barriers to business, which will impact
significantly on the evolving role of the CIO.
Ultimately, CIOs must combine strong technological and business skills with leadership,
persuasion, and communication skills to be successful at their jobs. Over the years, chief infor-
mation officers have helped many different companies to succeed as well as fail. Lac Van Tran,
former CIO at Children’s Hospital Boston, has now relocated to join Houston-based
Methodist Health Care System. His new role and responsibilities as senior vice president and
CIO at Methodist Health Care System will be to boost e-health development, solicit and estab-
lish business partnerships, and promote standardization and common practices.8 Danny Shaw,
the first chief knowledge officer at Children’s Hospital Boston, for example, has helped inte-
grate information from diverse sources and systems to enable analysis of both the hospital’s ad-
ministrative and clinical operations.9 Beginning with a series of small HMIS integration efforts,
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Shaw quickly demonstrated value, which eventually led to increased operational efficiencies,
clinical effectiveness, and improved quality of the hospital’s care delivery systems. Building on
past successes, Shaw was able to create a knowledge-enabled organization out of Children’s
Hospital Boston. The CEO/CIO of Green Valley Hospital, discussed in one of the cases pre-
sented in the previous edition of this text, failed the hospital miserably by relying on personal
friendships to decide vendor outsourcing of the hospital’s HMIS services. Thus, if a healthcare
services organization does not have a good strategy or a good CIO, it can be devastating for the
organization. Even successful businesses can fall behind if there is lack of leadership to guide IT
development for the organizations.
VII. Conclusion
Management students should pay particular attention to the role and responsibilities of senior
healthcare executives if they want to follow in their footsteps. This is why such a topic has been
placed near the beginning of this text. Senior health executives must not only have a strong vi-
sion and an awareness of different types of strategies, they must also be able and ready to exe-
cute such strategies to ensure that any obstacles encountered while achieving the ultimate
organizational vision and mission can be wisely eradicated. This is one difficult challenge for
many budding executives to overcome.
Moreover, real-world practices are not easily replicated and cannot be learned by merely
reading published theories or cases in textbooks. Successful practices have to be learned on the
job, hands-on, and must be orchestrated in a variety of social settings. Hence, the use of the
word inspiration in this chapter does a great justice to the idea. It is vital that senior managers
are “inspirational” and “on fire,” doing what the employees are not able to “articulate” clearly
for themselves; these executive leaders must be the “mouthpiece” of the organization in crafting
the organization’s future visions, strategic directions, and strategic thinking. They must meet
and talk with everyone who is a part of the organization, both at the top and on the front line.
It is the inspiration from senior executives that will ultimately make a difference in transform-
ing the organization. For the CIO, this inspiration has to be transcribed into words, articulated,
and produced as an active HMIS plan, in alignment with the overall corporate plan. The cor-
porate plan must then be rolled out into actions, thereby subsequently realizing the key goals
and objectives that have been envisioned.
An effective leader and manager must also possess several specific characteristics, each of
which significantly affects the performance of subordinates. The abilities to communicate effec-
tively, to motivate others, and to lead followers are all essential for being a good leader. By earn-
ing the trust and respect of their employees, these senior executives help and allow their
subordinates to work to the best of their abilities. This not only generates personal success for
the employees but, ultimately, for the organization. Another essential point is the importance of
continuing to “sharpen the saw” when it comes to effective management skills.10 We have to be
willing to learn from our own mistakes and understand that learning is a part of the total
process of becoming an effective manager. It is not possible to always get things right the first
V I I . C O N C L U S I O N 39
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time; thus, good managers learn from their own mistakes, turning those mistakes to their ad-
vantage at the earliest points of opportunity.
Finally, one of the most important steps that an effective CEO/CIO should take is seeking
feedback from his or her direct reports. Using such feedback to turn the CEO/CIO’s noted
weaknesses into additional strengths makes the CEO/CIO that much more effective. In other
words, being an effective leader is a continuous process. By possessing and continuing to
sharpen those effective management skills, the CEO/CIO can positively affect the morale of the
organization’s employees. It also naturally enlarges the CEO/CIO’s circle of influence, and the
less senior managers can then be inspired to follow through with the outstanding model exem-
plified by the senior management team. Effective management inspires everyone from your
employees (who will manage successfully in the future) to other managers (who will immedi-
ately manage more effectively). By effectively managing people, the CEO/CIO is ensuring the
success of his or her subordinates, which will ultimately translate into the organization’s suc-
cess.
In summary, senior executives play critical roles in organizational success. The overall per-
formance standard of a healthcare services organization, in particular depends not only on the
quality and work productivity of its employees, but also on the training, quality, and active par-
ticipation of the administrative and professional staff in supporting the services of the organiza-
tion. It also depends on the extent to which IT support has empowered and enabled these
various individuals to perform as productively as possible. The sharing of a technology vision
among top management team members, professional staff members, and employees within the
organization is also critical in determining the success of the HMIS leadership. The culture of a
healthcare services organization can transform because of changes in HMIS implementation, as
well as the extent to which employees are accepting the HMIS innovation and working collab-
oratively with each other, and with the organization’s customers. In healthcare services organi-
zations, these customers are those patients who are helping the organizations generate
much-needed revenues. Under the supervision of a proactive, productive, and politically astute
CEO/CIO, the health organizational HMIS support and services can grow and expand effec-
tively and quickly, leading to a transformed organization and the envy of all its competitors.
Notes
1. MSNBC. (2006). “Tired of Waiting for the Doctor? You’re Not Alone.” Retrieved March
18, 2008, from http://www.msnbc.msn.com/id/15487676/.
2. David Naranjo-Gil and Frank Hartmann, “How CEOs Use Management Information
Systems for Strategy Implementation in Hospitals,” Health Policy 81 (2007): 29–41.
3. Robert H. Waterman, Jr., “The Seven Elements of Strategic Fit,” Journal of Business Strategy
2, no. 3 (Winter 1982): 69–73.
4. Peter M. Ginter, Linda M. Swayne, and W. Jack Duncan, Strategic Management of Health
Care Organizations, 2nd ed. (Malden, MA: Blackwell Publishers, 1998).
5. David Burda, “Allegheny: A Tertiary Titan with All the Right Moves,” Modern Healthcare,
February 12, 1990: 50–58.
6. http://www.wpahs.org/agh/about/index.html, accessed June 28, 2008.
40 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M E X E C U T I V E S
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7. Cindy Waxer, “The 2008 State of the CIO: The Imperative to Be Customer-Centric IT
Leaders.” Retrieved June 28, 2008, from www.cio.com.
8. Retrieved June 28, 2008, from www.cio.com.
9. Ibid.
10. Stephen R. Covey, The 7 Habits of Highly Effective People. (New York: Free Press, 1989).
Additional Readings
Sam Geist, “Are You a Boss or a Leader?” Super Vision 67 (January 2006).
Paul Glen, “Developing the Managerial Mind,” Computer World 40 (January 9, 2006).
Stephen R. Robbins, The Truth About Managing People . . . And Nothing But the Truth. (Upper
Saddle River, NJ: Prentice Hall, 2003).
Jack Welch and Suzy Welch, “The Leadership Mindset,” BusinessWeek, January 30, 2006.
Chapter Questions
2–1. Imagine you came into a company without an organizational IT strategy. Describe in de-
tail how you would develop an IT strategy. Some questions to consider are:
a. Who would be involved in the strategy meeting?
b. How would you involve participants in developing a strategy? What questions would
you ask?
c. How would you get participants to adopt your shared vision?
2–2. In your own words, what are the role and responsibilities of a CIO? What would be the
difference between the role and responsibilities of a CEO versus a CIO in a healthcare
services organization if both of these executives were appointed? Who would the CEO
pick to be the most appropriate senior executive responsible for HMIS in the absence of
a CIO? Why?
2–3. What are the three most important traits of a CIO? On a scale from 1 to 10, rank your-
self in each of these categories. For each trait, give an example of a time that you did and
did not demonstrate this trait effectively. How might you improve your score in each
category?
2–4. How does an executive such as a CIO become an effective leader? What will be the great-
est challenges in a healthcare services organizational context?
M i n i – C a s e : Predicting Future HMIS Trends by Chief
Information Officers
Quammen Group, an Orlando, Florida–based consulting firm, co-sponsored the Health Data
Management 2008 CIO Survey and found CIO and HMIS executives to be optimistic on many
aspects of future HMIS growth, including real-time claims adjudication and clinical decision
support.
When asked, “How do you expect your organization’s total IT budget to change in your
next fiscal year?”, 37 percent rated it to grow between 5 and 10 percent, 23 percent felt it would
grow less than 5 percent, 20 percent expected it to exceed 11 percent or more, 13 percent did
not expect a change, and only 4 percent claimed there would be a decline—leaving 2 percent
for all other rating categories. More generally, the survey found that most healthcare services or-
M I N I – C A S E Q U E S T I O N S 41
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Personal Digital Assistants Enhance
Data Collection Efficiency during a
Study of Waiting Times in an
Emergency Department
N. Elkum, W. Greer, and A. Al-Madouj
42
ABSTRACT
Objectives
To explore the suitability of the personal digital assistant (PDA) as the primary vehicle
for data collection within the context of a clinical research study and to quantify the im-
provement in performance compared with a conventional paper-based approach.
Methods
This investigation was an adjunct to a study of waiting times in the emergency depart-
ment (ED) of a large, tertiary-care hospital. Medical charts were randomly selected for
those patients who had been recently triaged in the ED. In addition to patient identifica-
tion and demography, five principal variables were collected: day of arrival, registration
time, triage level, room assignment time, and MD time (time physician spent with the
patient). A database application was developed for the PDA. When the PDA was subse-
quently connected to a desktop computer, the data were automatically synchronized with
the PC-based Access database. The data for each patient were captured in two different
ways: using the PDA and using the traditional paper-based approach. For each method,
the data-collection time was recorded for each patient.
I
RESEARCH BRIEF
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Introduction
Data collection is the spine of most medical research studies. The ideal data-collection method-
ology should be inexpensive, easy to use, and applicable to widely varying types of studies.
Paper forms have traditionally been used to record these types of data. However, these forms
can lead to a number of different errors, such as ineligible scripts, undefined codes, and illegal
or inappropriate dates. It can also make it difficult to obtain complete answers to questions
within the time allocated for the patient interview or chart review. Furthermore, data collected
in this way are often subsequently entered into a computer database, which can introduce addi-
tional sources of error. Problems associated with the paper-based method can be minimized by
improving the quality of the training given to data-entry personnel and by performing double
data entry, but this incurs a larger cost to the research project.
Electronic methods of data capture have been available for many years. Mark sense technol-
ogy, for example, uses “marks” (usually shaded boxes) at predefined locations on specially pre-
pared sheets of paper to store information.1 This approach is very successful when the data can
be easily categorized into a small number of categories (such as multiple-choice examination
questions) but becomes unwieldy for continuous data or when a large number of categories are
involved. A more recent electronic alternative is to use optical character recognition (OCR)
technology to “read” data directly from paper-based questionnaires and automatically trans-
form the contents into electronic form.2
Although OCR software can achieve excellent results when the data have been typed using
predefined fonts, the fidelity of the recognition process leaves much to be desired when hand-
written text is involved and would not normally be considered for clinical research studies. In
any case, any electronic scanning approach requires the raw data to be stored on loose (and los-
able) sheets of paper; it therefore offers no advantage with respect to missing pages, data storage
space, or confidentiality issues. The extra cost of the technology can also be prohibitive.
I N T R O D U C T I O N 43
Results
Using the traditional paper-based approach, the average time per patient for data capture
was 226 seconds, whereas using the PDA, average time was significantly reduced to only
78 seconds.
Conclusions
The PDA is a superior alternative to traditional methods for data collection in simple
clinical research studies. PDAs are more convenient and diminish overall data-collection
time by 60 to 70 percent, thereby significantly reducing the cost of clinical research.
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One relatively recent electronic alternative is the personal digital assistant. Personal digital
assistants (PDAs) are already being used throughout clinical medicine to deliver information at
the point of care in such diverse areas as anesthesia,3 surgery,4 pediatrics,5 general practice,6 ob-
stetrics,7 evidence-based medicine,8 and public health.9 They are also being used to collect pa-
tient information and improve clinical records for administrative functions such as electronic
prescribing,10 coding and tracking,11 and medical education.12 This research brief explores the
suitability of the PDA for the collection of clinical research data.
King Faisal Specialist Hospital and Research Centre (KFSHRC) maintains many disease reg-
istries, such as the National Cancer Registry13 and the Congenital Heart Defects Registry,14
which routinely require detailed patient interviews and structured data abstraction from med-
ical charts. There are also a large number of scientists and clinicians who regularly conduct re-
search projects involving the collection of large amounts of data.
The cost of recording, entering, and cleaning these data consumes a significant part of the
budget of every research project. A systematic approach to data capture, which would reduce
this cost and improve the accuracy of the collected data, would therefore be welcomed by our
research community.
To this end, we conducted a study to investigate the advantages and disadvantages of using a
PDA during a typical clinical research study. This was developed as an adjunct to a pilot study
of the distribution of waiting times experienced by patients at our emergency department (ED).
This is a key entry point to the healthcare system at our institution, and having patients wait for
excessive periods of time prior to treatment may negatively color their perception of the care
provided by KFSHRC. The specific objective of this study was to compare the data-collec-
tion efficiency of the PDA-based method with the more traditional approach comprising stan-
dard paper forms and subsequent computer data entry. To our knowledge, this was the first
research study at this hospital to be conducted using a PDA-based data-entry system.
Methods
Medical charts were randomly selected for those patients who had been recently triaged in the
ED during the period of the study. In addition to patient identification and demography, five
principal variables were collected: day of arrival, registration time, triage level, room assignment
time, and MD time. The triage nurse and the evaluating physician(s) recorded the various times
required by the study in the charts.
A trained research assistant captured the data for each patient in two different ways: (1) en-
tering data directly into a PDA database and (2) manually recording data on case report forms
and subsequently typing these data into a PC-based Microsoft Access database. These methods
were applied “one-after-the-other,” so that each patient’s data were recorded twice. To avoid ob-
server bias, the order of the methods was randomly changed between patients. For a given pa-
tient the same research assistant was responsible for applying both methods. For each method,
the time spent in collecting data for every chart was also recorded. A Palm Pilot (Compaq Inc.,
Houston, Texas) was selected as the PDA for this study. The PDA database application was de-
veloped using the Data-on-the-Run database system (Biomobility Inc.). This permits databases
44 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M E X E C U T I V E S
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to be developed directly on the PDA and is designed to integrate seamlessly with Microsoft
Access on the PC; when the PDA was connected to a PC, the databases were automatically syn-
chronized. We further replicated the database on an SQL server so that multiple users via the
hospital’s intranet could access it.
The difference in the time taken for data capture between the two methods was assessed us-
ing the paired t-test within the SPSS statistics package (SPPS Inc.). This study was approved by
the Research Advisory Council (Institutional Review Board) of our hospital.
Results
During the period of the study, charts were randomly selected from the medical records for
those patients who were triaged in our emergency department. Using the traditional method,
the average time for data capture was 226 seconds, whereas using the PDA approach, the aver-
age time was significantly reduced to only 78 seconds (p < 0.0001); this difference is illustrated in Figure RB1.1. Discussion The application of PDAs within clinical research studies can lead to substantial cost savings by directly reducing the duration of the data-capture period. Based on our results (and depending on the specific study design) a PDA-based approach can reduce the duration of the data-capture phase by as much as 60 to 70 percent in comparison with paper-based alternatives. Using a PDA may also improve the quality of the data because it eliminates the need for a paper intermediary between the recording of the data from the patient’s interview or medical chart and the final entry of these data into a database. Further gains in usability and efficiency (Table RB1.1) can also be found through the easy data-storage and downloading capabilities in D I S C U S S I O N 45 260 210 160 110 60 10 Manual Methods 9 5 % C I W a iti n g T im e s (S e co n d s) PDA FIGURE RB1.1 Comparison of Mean Waiting Times (with Their 95% CIs) between the Two Different Methods Used in the Study. 56918_CH02_Final_Tan 4/6/10 11:35 AM Page 45 combination with fast data processing; these enable the researcher to more easily perform analy- ses while the study is in progress. Furthermore, the ability of the PDA to create electronic doc- uments eliminates printing, binding, and shipping costs and provides a reduction in storage space at research locations. The choice of a database system is crucial to the effectiveness of the PDA in the clinical re- search context. Using the data-on-the-run package, we were guaranteed a user-friendly, net- worked environment, which provided frequent data backups and which could make use of the SQL databases on our Windows servers. Increasing responsibilities and other demands on researchers’ time necessitate more and more reliance on technology. The personal data assistant provides an effective answer to the problem of efficiently capturing, storing, and retrieving large volumes of medical research infor- mation within reduced timescales. PDAs offer a superior alternative to traditional methods for data collection in clinical research studies. Notes 1. IBM Reference Manual, “Reproducing Punches,” pp. 513, 514, October 1959. 2. H. F. Schantz, The History of OCR, Optical Character Recognition (Manchester Center, VT: Recognition Technologies Users Association, 1982). 3. Q. Fu, Z. Xue, and G. Klein, “Using Mobile Information Technology to Build a Database for Anesthesia Quality Control and to Provide Clinical Guidelines,” Studies in Health Technology and Informatics 95 (2003): 629–634. 4. T. V. McCaffrey, “Using Hand-Held Computing Devices in the Practice of Otolaryngology- Head and Neck Surgery,” Current Opinion in Otolaryngology & Head and Neck Surgery 11 (2003): 156–159. 5. C. G. Weigle, B. P. Markovitz, and S. Pon, “The Internet, the Electronic Medical Record, the Pediatric Intensive Care Unit, and Everything,” Critical Care Medicine 29, no. 8 (2001): N166–N176. 46 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M E X E C U T I V E S Table RB1.1 Comparison of Data Collection Methodologies Mark Optical Paper Sense Character PDA Forms Forms Recognition Forms No manual data-entry cost – + + + Multicenter trials: No shipping/faxing – – – + Tracks response times – – – + Easily handles complex skip patterns – – – + Prevents incorrect responses – – – + Images, videos easily incorporated – – – + Speed of completion – – – + No computer skills required + + + – Automatic desktop synchronization – – – + 56918_CH02_Final_Tan 4/6/10 11:35 AM Page 46 6. M. Greiver, “Evidence-Based Medicine in the Palm of your Hand,” CMAJ: Canadian Medical Association Journal 164, no. 2 (2001): 250. 7. S. Joy and G. Benrubi, “Personal Digital Assistant Use in Florida Obstetrics and Gynecology Residency Programs,” The Southern Medicine Journal 97, no. 5 (2004): 430–433. 8. G. M. Leung, J. M. Johnston, and K. Y. Tin, “Randomised Controlled Trial of Clinical Decision Support Tools to Improve Learning of Evidence Based Medicine in Medical Students,” British Medical Journal 327, no. 7423 (2003): 1090. 9. I. Abubakar, C. J. Williams, and M. McEvoy, “Development and Evaluation of a Hand Held Computer Based On-Call Pack for Health Protection Out of Hours Duty: A Pilot Study,” BMC Public Health 5, no. 1 (2005): 35. 10. B. C. Grasso, R. Genest, K. Yung, and C. Arnold, “Reducing Errors in Discharge Medication Lists by Using Personal Digital Assistants,” Psychiatric Services 53, no. 10 (2002): 1325–1326. 11. J. Luo, “Portable Computing in Psychiatry,” Canadian Journal of Psychiatry 49, no. 1 (2004): 24–30. 12. S. Fischer, S. E. Lapinsky, J. Weshler, et al., “Surgical Procedure Logging with Use of a Hand-Held Computer,” Canadian Journal of Surgery 45, no. 5 (2002): 345–350. 13. Registry NC, Cancer Incidence Report Saudi Arabia 2001 (Riyadh, Saudia Arabia: Ministry of Health, 2005). 14. King Faisal Specialist Hospital and Research Centre, Congenital Heart Defects Registry: Annual Report (Riyadh, Saudi Arabia: Ministry of Health, 2005). N O T E S 47 56918_CH02_Final_Tan 4/6/10 11:35 AM Page 47 56918_CH02_Final_Tan 4/6/10 11:35 AM Page 48 Online Health Information Seeking: Access and Digital Equity Considerations Fay Cobb Payton and Joseph Tan 49 3 CHAPTER Editor’s Note: Readers of this health management information systems text should be aware of the growing force that the Internet has exerted on the masses, in particular, how it affects health consumers in term of their health information searches. Apparently, the Internet is beginning to change the way medicine is going to be practiced as more and more computer-literate health consumers, armed with the latest research information on their particular illnesses, shop around for the best doctors. This chapter prepares the readers to predict the next major HMIS evolu- tion. Legacy systems used in healthcare services organizations for isolated routine information processing will soon become obsolete given the rapid advances in HMIS applications and tech- nologies (Part II), Similarly, how we perform HMIS planning and management (Part III) will have to change to accommodate new policy, governance, and regulatory changes as well as glob- alization (Part IV). While bringing a close to Part I, the knowledge acquired in Chapter 3 is in- tended to stimulate us to explore more fully the other parts of the text. 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 49 S c e n a r i o : A New RHIO in DC 1 With $11,000,000 of seed funding from the District of Columbia’s government, the District of Columbia Primary Care Association (DCPCA) has launched a new regional health information organization (RHIO) in the nation’s capital to improve healthcare services delivery for the city’s poor and underserved population. RHIO aims to reform health management information systems (HMIS) in the coming decade by deploying integrated electronic medical records (EMR) solutions among six community-based health centers in the District to better serve DC’s poor and uninsured populations. It is envi- sioned that the EMR will link these centers to major DC hospitals such as the Washington Health Center and Georgetown University Hospital. Although there is a high degree of diffi- culty for cash-strapped health centers to adopt this type of technology, the six organizations that decided to jump on board felt that the need for an integrated EMR justified the added stress of additional staff and resources. Sharon Baskerville, DCPCA’s CEO, notes that the proposed RHIO differs from past iso- lated and stove-piped systems oriented toward low-income populations because with “siloed care, problems go unidentified. Our way of addressing the problem is different from any ap- proach . . . (in that) . . . the safety net group is leading the pack. We’re going to try to take les- sons from . . . (past failed RHIO efforts) . . . and focus our energy on things like governance and a long-term business plan for sustainability. . . . I do hope that this becomes a model, not 50 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G CHAPTER OUTLINE Scenario: A New RHIO in DC I. Introduction II. Emotional Support and Empowerment of Health Information Seekers III. Profiling Health Information Seekers IV. Accessing Health Information beyond the Internet V. Alternative Means of Accessing Health Information VI. Future Directions Notes Chapter Questions Technology Brief I: Fundamentals of Internet and Associated Technologies for Healthcare Services Organizations Joshia Tan 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 50 just for communities but for payers and the government. It needs to be clear that there must be incentives and large-scale programs that enable these kinds of providers to be involved.” Apparently, the newly proposed DC RHIO will network the district’s community health centers. Its EMR vendor, eClinicalWorks, will customize the system to the needs and special re- quirements of these centers. Baskerville noted that the mental health module for eClinicalWorks did not provide sufficient capacity to account for the large volume of patients. As a result, the company crafted an expanded version of the software. The current plan is to have EMR solutions installed at all six centers with at least three functional in 2008. The en- hanced version of eClinicalWorks will first be piloted with the local hospitals. DCPCA is hope- ful that robust and continuing support from diverse sources will help them avoid many of the same technological and economic threats that have overwhelmed past RHIO efforts. Could the RHIO initiative be expanded to help other healthcare consumers, aside from fo- cusing on the underserved and underinsured? What is the significance of improving health in- formation accessibility, availability, and connectivity? How can initiatives such as RHIO be linked to Internet use among consumers searching for health information? I. Introduction Undoubtedly, the Internet has become a significant and powerful mechanism in the dissemi- nation of health information. Over the years, researchers as well as healthcare educators have employed Web-based courseware to advise select populations on every conceivable subject in the medical field, including identifying symptoms of common illnesses, advising on key reha- bilitative procedures to promote self-care, and sharing practical strategies about preventive medical or health promotional activities (such as healthy lifestyle alternatives and wellness maintenance). Online health information seeking should be of concern for health administrators for myr- iad reasons. The management and dissemination of health information via the Internet engages the faster diffusion of medical findings, improves consumer empowerment, reduces social isola- tion often associated with stigmatizing medical conditions, improves patient–physician interac- tions, and provides efficiencies in the health insurance and registration processes, just to name a few.2 Consequently, these outcomes affect the demand for medical services, resource utilization, and, ultimately, costs. Not surprisingly, online extraction of relevant health information by both experts and laypersons have proliferated due to advances in Web-based interface technology; improved computing literacy; and greater availability, affordability, and accessibility of the Internet and other information and communications technologies (ICT). It is further anticipated that the growing community of Internet users will continue to expand globally in the coming years, es- pecially for rapidly developing countries and emerging markets such as Brazil, Tanzania, Russia, India, and China. More users can now easily access the Internet via smart phones as well as other cellular and wireless devices while these hand-held technologies are increasingly dissemi- nating health information to health consumers. For example, in South Africa, the Cell-Life project connects HIV/AIDS patients with the public health system to monitor treatment plans, I . I N T R O D U C T I O N 51 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 51 drug therapy and interactions, and dietary compliance. According to the 2007 African Global Innovation Report, “In five years, the service has grown from one site with 200 patients to 11 sites with more than 15,000 patients . . . with improved health, there is greater opportunity for improved wealth and quality of life.”3(p. 29) Among the myriad prospective advantages that arise from use of the Internet and other ICT are cost reductions, minimal time and spatial barriers, increased access, rapid diffusion of med- ical research, improved patient empowerment, reduced social status cues, and improved provi- sions for peer group support. Participants who are normally reserved during face-to-face interactions now have a medium in which they can freely express their thoughts and desires without fear of public speaking or physically encountering socially challenging moments. Those who are unable or unavailable to participate physically on site may now do so virtually. Nonetheless, the Internet is not void of particular weaknesses, including fragmentation of health information, continual digital and health inequities among underrepresented popula- tions, lack of data quality in health information, iron-clad security, and inappropriate access to third parties.4 Oftentimes, it is up to individual Internet users to distinguish whether the infor- mation they receive is trustworthy or not. It is also difficult for laypersons to determine the au- thentication of the experts claiming to post certain information. Health information seekers, according to the Pew Internet and American Life Project release, are “Internet users who search online for information on health topics” whether they take on the role of consumers, caregivers, or e-patients.5 Given its ubiquitous nature, the Internet continues to be a key source of health information among health seekers. Specifically, the Pew Internet data in- dicate that 8 of 10 Internet users, or roughly 113 million adults, have sought health information online. The question is, What type of health information do these Internet users want or need? In 2006, 66 percent of all health seekers searched for information on a specific disease or medical problem for themselves, family members, or friends. Based on this metric, the Pew study commit- tee concluded that health searches have reached parity with common uses of the Net, such as elec- tronic bill paying, blogging, or directory lookups for addresses and telephone numbers. II. Emotional Support and Empowerment of Health Information Seekers As Internet use continues to help inform a variety of decisions challenging experts and layper- sons, breakthroughs in the application of such Internet use are mounting. One of the most im- portant breakthroughs thus far is the emotional support and empowerment of health information seekers. The Internet and other ICT have granted all such seekers a convenient and easy means of access to available health information and social networks. For instance, patients who are faced with debilitating diseases and chronic ailments are experiencing a new dimension of social networking and support via the Internet. The Internet has facilitated the use of ICT to educate, guide, and sustain patients with a variety of illnesses. Specifically, for those affected by Alzheimer’s disease,6 smoking addiction,7 and AIDS,8 researchers have found that the use of the Internet can further reduce social isolation and increase 52 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 52 emotional support. In fact, each of these recently published U.S.-based studies implemented home- care health information networks to meet the needs of patients. The varying needs meant that pa- tients were able to participate in different levels of services: decision support, nurse moderation, e-mail, and discussion boards. These services were found to have empowered participants with in- formation beneficial to the understanding of new developments in the treatment of their diseases, and, more importantly, researchers were able to determine which computer-supported services were most utilized by patients based on their individual medical and emotional concerns. In the case of Alzheimer’s, Payton and Brennan9 reported that over an 18-month period 30 per- cent of the caregivers accessed the system more than 100 times while one individual accessed ComputerLink 868 times. Users accessed the ComputerLink functions 3,926 times based on total frequency of use of each system function. Users accessed the bulletin board and read messages 2,095 times (which appears to be the most used service), and this substantial figure was attributed to the social interaction among users as they formed electronic support groups and communities to cope with the challenges associated with caregiving. The question-and-answer utility represented 24 percent of the total frequency of use and clearly points to the critical role of the nurse-moderator, who received private, direct inquiries from caregivers. The decision-making module was the second least accessed (218 times, or 5 percent of the total frequency) system function. The electronic ency- clopedia depicted the least used ComputerLink function, with least number of accesses shown for both the self and disease-related services. The authors concluded that these findings were a function of caregivers seeking to communicate with those in similar circumstances or socialization to over- come isolation rather than decision-making assistance concerning care delivery. With regard to cancer patients, for example, the Internet has proven to be a valuable communication source for patients and their families. Several researchers have argued that computer-mediated communities supporting cancer patients foster emotional support and em- powerment,10 in addition to providing a vehicle by which patients and family members can ac- quire familiarity with the disease and its stages.11 As the number of worldwide cancer deaths escalates to 7.6 million people, based on World Health Organization (WHO) data,12 the role played by computer-mediated communities is seen to be even more critical. One such online community is CarePages, accessible via www.carepages.com. CarePages is a blossoming social networking site for patients with various ailments. Patients of sponsoring hospitals, as well as their families, can create an account, which provides them with a personal page. On this page are various features, including a blog and comment page. Both the patient and his or her family members can write updates in the blog for friends and caring strangers alike to follow. Visitors create their own accounts and can leave personal comments on the pa- tient’s page, whether they are reactions to the blog or simple messages of support. This way, pa- tients can seek emotional support through friends, strangers, or even other patients. A simple tour of the website reaffirms the notion that many patients find this an excellent coping mech- anism—and a place to discover hope and understanding. Again, for breast cancer patients who may have distinct needs for care and coping, several re- searchers have also found that these patients actively engage in online and interpersonal interac- tions via support groups and seek information regarding treatment plans and medical progress.13,14 Interestingly, differences in race, ethnicity, education level, and cultural backgrounds II . E M O T I O N A L S U P P O R T A N D E M P O W E R M E N T O F H E A LT H S E E K E R S 53 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 53 are found to be significant; any one factor, or a combination of them, can alter the prospective psychological benefits of using the Internet, or any other means of communication, for interac- tions among women with breast cancer. III. Profiling Health Information Seekers While Internet use has increased among all demographic groups, access has been found to be great- est among those with higher education and incomes. Moreover, this access is least significant among African Americans and Latinos, who both continue to trail whites and Asian Americans.15 This phenomenon contributes to the digital divide, or exclusion, and stands to affect education and health quality, equity, accessibility, affordability, and availability.16–19 According to the National Telecommunications and Information Association,20 Internet use and online activities have signifi- cantly increased between 2001 and 2003. While the primary use of the Internet is e-mail, users 54 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G 10 20 30 40 50 60 70 80 90 1000 18.7 35.7 41.6 66.5 76.5 27.8 6.8 6.4 52.1 21.7 38.1 87.8 16.0 30.1 34.1 66.0 73.2 17.4 8.6 4.0 44.1 18.9 36.5 86.9 Search for a Job Search for Information about Gov't Services or Agencies Search for Information on Health Services or Practices Get News, Weather, or Sports Information Search for Product or Service Information Bank Online Trade Stocks, Bonds, or Mutual Funds Take a Course Online Purchase Products or Services Listening to the Radio or Viewing TV or Movies Playing Games E-Mail or Instant Messaging Percent of Internet Users (Age 15 and over) Sept 2001 Oct 2003 COMMUNICATIONS ENTERTAINMENT TRANSACTIONS INFORMATION FIGURE 3.1 Online Activities, 2001 and 2003 (Percent of Online Activities for Internet Users Age 15 and Over). Source: National Telecommunication and Information Administration (2004). 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 54 tend to engage in myriad online activities. These activities can be clustered into four major areas of interest: communications, entertainment, transactions, and information, as shown in Figure 3.1. Figure 3.1 indicates that overall, the percentage of users seeking health information grew from 34.1 percent to roughly 41.6 percent between September 2001 and October 2003. This trend is consistent with the increased use of the Internet for seeking other forms of information, including extraction of general products and services information, online searches for informa- tion on government services and agencies, and Web mining for job-related information. As stated earlier, the 2006 Pew Internet and American Life Project survey indicated that 8 out of 10 Internet users seek health information online. This statistic is surprisingly high even for America as a developed country. Of those participants surveyed by Pew, 82 percent of the users were women and 75 percent were men. Table 3.1 offers a detailed profiling of the health information seekers as informed by the 2006 Pew survey. Seventy-eight percent of the surveyed sample were between ages 50 and 64, while 71 percent had a high school education or less. Again, these statistics portray a relatively high level of computing literacy among the baby boomers and seniors, most of whom may have significantly fewer opportunities to become edu- cated during these times as compared with children of this generation. Using the Pew Internet and American Life data from 2006, several key observations can be noted about Internet use for health information seeking (Table 3.2): ● Of the 537 survey participants in the study, 79 percent of Internet users investigated at least 1 of 16 health topics. III . P R O F I L I N G H E A LT H I N F O R M AT I O N S E E K E R S 55 Table 3.1 Health Seekers from Pew Internet and American Life Project Percent Who Have Looked for Health Demographic Group Information Online Online women 82% Online men 77 Internet users ages 18–29 79 Internet users ages 30–49 84 Internet users ages 50–64 78 Internet users ages 65+ 68 Internet users with a high school diploma or less 71 Internet users with some college education 80 Internet users with a college degree 89 Internet users with 2–3 years of online experience 62 Internet users with 6+ years of online experience 86 Internet users with a dial-up connection at home 75 Internet users with a broadband connection at home 86 Source: Pew Internet and American Life Project, August 2006 survey (n = 1,990). Margin of error for the entire sample of Internet users is ±3 percent. Margins of error for comparison of subgroups are higher. 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 55 T ab le 3 .2 H ea lt h T o p ic s Se ar ch es f ro m t h e 2 0 0 6 P ew I n te rn et a n d A m er ic an L if e P ro je ct In a ll, 8 0 p er ce n t o f In te rn et u se rs h av e lo o ke d o n lin e fo r at le as t 1 o f 1 7 h ea lt h t o p ic s. C er ta in s u b gr o u p s re p o rt ed s ig n if ic an tl y h ig h er in te re st in s o m e to p ic s an d a re m ar ke d in b o ld t yp e. F o r ex am p le , w h en c o m p ar ed w it h o n lin e m en , o n lin e w o m en r ep o rt ed s ig n if ic an tl y m o re in te re st in in fo rm at io n a b o u t sp ec if ic d is ea se s, c er ta in t re at m en ts , d ie t, a n d m en ta l h ea lt h . A ll H ig h In te rn et O n lin e O n lin e A ge s A ge s A ge s A ge s Sc h o o l So m e C o lle ge U se rs W o m en M en 1 8 –2 9 3 0 –4 9 5 0 –6 4 6 5 + o r Le ss C o lle ge G ra d u at es (n = (n = (n = (n = (n = (n = (n = (n = (n = (n = H ea lt h T o p ic 1, 9 9 0 ) 1, 1 1 6 ) 8 7 4 ) 3 3 3 ) 7 5 1 ) 5 7 9 ) 2 7 7 ) 6 1 4 ) 5 1 0 ) 8 5 3 ) Sp ec if ic d is ea se o r m ed ic al p ro b le m 6 4 % 6 9 % 5 8 % 6 1 % 6 7 % 6 4 % 5 4 % 5 2 % 6 5 % 7 4 % C er ta in m ed ic al t re at m en t 5 1 5 4 4 7 4 5 5 6 5 1 4 0 4 1 5 1 6 2 D ie t, n u tr it io n , vi ta m in s 4 9 5 3 4 5 4 5 5 5 1 9 2 9 4 0 5 2 5 6 E xe rc is e o r fi tn es s 4 4 4 6 4 1 5 5 4 7 3 5 2 4 3 5 4 7 5 1 P re sc ri p ti o n o r o ve r- th e- co u n te r d ru gs 3 7 3 9 3 5 2 9 4 2 4 0 3 0 2 9 3 8 4 5 A p ar ti cu la r d o ct o r o r h o sp it al 2 9 3 1 2 7 2 7 3 3 2 6 1 8 2 1 2 5 4 0 H ea lt h in su ra n ce 2 8 2 7 2 9 2 3 3 4 2 7 1 2 2 0 2 8 3 7 A lt er n at iv e tr ea tm en ts o r m ed ic in es 2 7 2 9 2 5 2 5 2 9 2 9 1 4 2 2 2 9 3 1 D ep re ss io n , a n xi et y, s tr es s, o r m en ta l h ea lt h is su es 2 2 2 6 1 7 2 5 2 4 2 0 7 2 1 2 4 2 2 E n vi ro n m en ta l h ea lt h h az ar d s 2 2 2 1 2 2 2 5 2 3 2 2 1 0 1 6 2 3 2 6 E xp er im en ta l t re at m en ts o r m ed ic in es 1 8 1 8 1 9 1 8 1 9 1 8 1 4 1 5 2 1 2 0 Im m u n iz at io n s o r va cc in at io n s 1 6 1 5 1 7 1 8 1 8 1 2 7 1 3 1 5 1 9 D en ta l h ea lt h in fo rm at io n 1 5 1 4 1 5 1 7 1 6 1 2 6 1 3 1 4 1 6 M ed ic ar e o r M ed ic ai d 1 3 1 3 1 3 1 0 1 1 1 5 2 2 1 2 1 4 1 3 Se xu al h ea lt h in fo rm at io n 1 1 1 1 1 2 2 1 1 0 7 2 1 0 1 5 1 0 H o w t o q u it s m o ki n g 9 1 0 8 1 3 8 9 3 1 1 1 0 7 P ro b le m s w it h d ru gs o r al co h o l 8 9 8 1 4 6 7 2 8 1 0 7 So ur ce : P ew I n te rn et a n d A m er ic an L if e P ro je ct , A u gu st 2 0 0 6 s u rv ey ( n = 1 ,9 9 0 ). M ar gi n o f er ro r fo r th e en ti re s am p le o f In te rn et u se rs is ± 3 p er ce n t. M ar gi n s o f er ro r fo r co m p ar is o n o f su b gr o u p s ar e h ig h er . Si gn if ic an t d if fe re n ce s b et w ee n d em o gr ap h ic gr o u p s ar e in b o ld ty p e. 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 56 ● In comparison to 60 percent of the men surveyed, 71 percent of the women participants probed for a specific disease or medical problem. ● Women sought more information related to depression/stress/mental illness and smoking cessation than did men. ● Internet searches on a specific disease or medical condition were significant and compara- ble among those with some college education and those who have completed college. Table 3.2 highlights additional significant differences among demographic groups based on the reported data from the 2006 Pew Internet and American Life Project. IV. Accessing Health Information beyond the Internet While the Internet has proven to be a means of health information dissemination and a com- monly used tool among health seekers, there are populations that are best reached via other communication modalities or that choose not to engage in online use. In a survey of 3,553 Americans, the 2003 Pew Internet and American Life Project21 identified the profile of Internet users and nonusers. While issues associated with digital divide, divide inequity, and social exclusion22,23 have been used to rationalize the resistance among non-Internet users for going online, interesting facts exist to demonstrate the need for targeted strategies. In a survey of 3,553 participants, women are more likely to be nonusers than men by a margin of 8 percent. With regard to race and ethnicity, African Americans comprise 11 percent of the overall U.S. population. Yet 14 percent of non-Internet users surveyed are African American, while the figures for Hispanics re- mained constant at about 10 percent. The largest group of nonusers (32 percent) ranged in age from 30 to 49. Interestingly, Internet users did not show a gradual increasing pattern relative to income level, even though this is not true with the pattern shown by nonusers. That is, those with lower incomes were more likely to be nonusers (41 percent); this figure declines to 6 percent at an income level greater than $75,000 per year. V. Alternative Means of Accessing Health Information Interestingly enough, alternative means of communication and health information dissemina- tion can capture the diversity of social, economic, ethnic, racial, gender, and educational back- grounds of the healthcare populations in a specific region or community. For instance, the Metamorphosis Project24 has targeted the Los Angeles Hispanic community to engage in and promote early childhood development from prenatal stages to age 5.25 In a survey of 327 Hispanics alongside a series of planned focus group interviews, the re- searchers determined the top 10 ways the targeted Los Angeles Hispanic community seeks V. A LT E R N AT I V E M E A N S O F A C C E S S I N G H E A LT H I N F O R M AT I O N 57 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 57 health information. From these data, they also determined the most cited referral sources. The statistics of their findings break down as follows: (1) more than one-third of the Hispanics in the study received their health and medical care information via television, (2) discussions with family/friends via the telephone are pivotal, (3) a smaller sample of about 22 percent consulted with healthcare providers, and (4) radio and print media (newspapers, magazines) should not be ignored. More importantly, Latino men play a pivotal role as influencers in women’s lives and should not be ignored. Accordingly, the researchers concluded: “increased education while maintaining control by the men may influence increased support of early detection and medical care of Latina women.”26 Still others have investigated the relationship between race and use of health information re- sources. In a random-digit dialed survey of 509 women (341 white, 135 African American, and 33 of other races), Nicholson, Grayson, and Powe27 investigated the independent effect of race on women’s use of health information resources. Print, news, broadcast media, Internet, health organizations, and organized health events were among the sources of information in their study. Women with higher education levels tended to use print health or news media, broadcast media, health policy organizations, and organized events 2.0 to 2.4 times more than less edu- cated women (high school education or less); these findings, however, were not statistically sig- nificant. Interestingly, more than 40 percent of white women used the Internet compared to 20 percent of African American women. Whites, however, used health policy and other organiza- tions three times more than African Americans. VI. Future Directions The literature demonstrates that implementation of multiple access points to health informa- tion is critical. Health administrators must recognize and act upon the unbounded nature of health information seeking among consumers. This action on behalf of the consumers creates greater equity in health dissemination, democratizes the healthcare process, and empowers users. Despite the proliferation of the Internet, administrators should implement multiple com- munication modalities (i.e., mobile phones, television, print, and radio should not be elimi- nated), which then provides the opportunity to reach diverse socioeconomic, cultural, and global populations. The profile of the health information seeker/participant in medical studies, particularly longitudinal investigations, has an essential role in the interpretation of health out- comes: reducing health disparities and health dissemination. One communication mode or ap- proach will and does not attract diverse populations to medical studies and clinical trials. Digital equity is pivotal to this notion, along with awareness of culturally competent ap- proaches to healthcare delivery. Social networking among online healthcare support groups is on the rise. While Google Health and Microsoft HealthVault are working to assist patients to electronically share their own medical information, social networking ventures, such as Trusera (invitation only), DailyStrength, PatientsLikeMe, and Caring.com, enable storytelling and blogging among their users. Determinants of success rest with a triad of theory, research, and practice.28 58 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 58 Notes 1. Maureen D. C. McKinney, “RHIO Sets Ambitious Plans.” Accessed May 27, 2008, from http://www.digitalhcp.com/2008/05/27/dc-rhio-sets-ambitious-plans.html. 2. M. Mureo and R. E. Rice, The Internet and Health Care: Theory, Research and Practice (Mahwah, NJ: Lawrence Erlbaum Associates, 2006). 3. Africa: A Global Innovation Report 2007 (Armonk, NY: IBM, 2007). 4. Ibid. 5. Pew Internet and American Life Project. Online Health Search 2006, p. 1 (2006). Accessed June 10, 2007, from http://www.pewinternet.org/pdfs/PIP_Online_Health_2006 . 6. F. C. Payton and P. F. Brennan, “How a Community Health Information Network Is Really Used,” Communication of the ACM 42, no. 12 (1999): 85–89. 7. K. Bosworth and D. H. Gustafson, “CHESS: Providing Decision Support for Reducing Health Risk Behavior and Improving Access to Health Services,” Interfaces 21, 3: 93–104, (May-June 1991). 8. P. F. Brennan, “Use of a Home-Care Computer Network by Persons with AIDS,” International Journal of Technology Assessment in Health Care 10, no. 2 (1994): 258–272. 9. Payton and Brennan (1999). 10. J. W. Turner, J. A. Grube, and J. Meyers, “Developing an Optimal Match within Online Communities: An Exploration of CMC Support Communities and Traditional Support,” Journal of Communication 51 (2001): 231–251. 11. S. Ziebland, A. Chapple, C. Dumelow, J. Evans, S. Prinjha, and L. Rozmovitis, “How the Internet Affects Patients’ Experience of Cancer: A Qualitative Study,” Briti (2004). 12. World Health Organization. (2006). Accessed July 2, 2007, from http://www.who.int/media centre/news/releases/2006/pr06/en/. 13. J. Fogel, S. M. Albert, F. Schnabel, B. A. Ditokk, and A. I. Neugut, “Racial/Ethnic Differences and Potential Psychological Benefits in Use of the Internet by Women with Breast Cancer,” Psycho-Oncology 12 (2003): 107–117. 14. G. A. Barnett and J. M. Hwang, “The Use of the Internet for Health Information and Social Support: A Content Analysis of Online Breast Cancer Discussion Groups.” In M. Mureo and R. E. Rice (Eds.), The Internet and Health Care: Theory, Research and Practice (Mahwah, NJ: Lawrence Erlbaum, 2006). 15. National Science Board. Science and Engineering Indicators (Arlington, VA: National Science Foundation, 2006). 16. C. Zarcadoolas, A. Pleasant, and D. S. Greer, Advancing Health Literacy: A Framework for Understanding and Action (San Francisco: Jossey-Bass, 2006). 17. F. C. Payton, “Rethinking the Digital Divide,” Communication of the ACM 46, no. 6 (2003): 89–91. 18. L. Kvasny and F. C. Payton, “Minorities and Information Technology: Critical Issues and Trends in Digital Divide Research.” In M. Khosrow-Pour (Ed.), Encyclopedia of Information Science and Technology, 2nd ed. (Hershey, PA: IGI Global Publisher, 2007). 19. Payton (2007). 20. National Telecommunications and Information Administration, “A Nation Online: Entering the Broadband Age” (2004). Accessed June 22, 2007, from http://www.ntia .gov/reports/anol/NationOnlineBroadband04 . 21. Pew Internet and American Life Project. “The Ever-Shifting Internet Population: A New Look at Internet Access and the Digital Divide” (2003). Accessed June 10, 2007, from http://www.pewinternet.org/pdfs/PIP_Shifting_Net_Pop_Report . 22. F. C. Payton, “Digital Divide: Other Considerations?” (2008). In W. Darity (Ed.), International Encyclopedia of the Social Sciences, 2nd ed., 9 vols. (Detroit: Macmillan Reference USA, 2008). N O T E S 59 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 59 23. Kvasny and Payton (2007). 24. See www.metamorph.org. 25. P. H. Cheong, H. A. Wilkin, and S. Ball-Rokeach, “Diagnosing the Communication Infrastructure in Order to Reach Target Audiences.” In P. Whitten and D. Cook (Eds.), Understanding Health Communication Technologies (San Francisco: Jossey-Bass, 2004). 26. D. O. Erwin, V. A. Johnson, M. Trevino, K. Duke, L. Feliciano, and L. Jandorf, “A Comparison of African American and Latina Social Networks as Indicators for Culturally Tailoring a Breast and Cervical Cancer Education Intervention,” Cancer Supplement 109, no. 2 (2006): 375. 27. W. K. Nicholson, H. A. Grason, and N. R. Powe, “The Relationship of Race to Women’s Use of Health Information Resources,” American Journal of Obstetrics and Gynecology 188, no. 2 (2003): 580–585. 28. G. A. Barnett, “Communication and Organizational Culture.” In G. M. Goldhaber and G. A. Barnett (Eds.), Handbook of Organizational Communication (Norwood, NJ: Ablex, 1988): 101–130. Chapter Questions 3–1. What are the anticipated shifts in service utilization due to consumer health information seeking? 3–2. How are these shifts likely to differ among the population being targeted by DCPCA? 3–3. Describe the emerging trends in consumer health information seeking. 3–4. In the 1990s, community health information networks flourished. By the early 2000s, these technology-enabled models were termed health information networks. How do these networks compare with RHINs relative to service provided, consumer influence, and health administration? 3–5. What are the (non)technological barriers DCPCA must address in its implementation of its RHIN? 3–6. How can Web 2.0 (social networking) influence consumer health dissemination? Describe the anticipated advantages and disadvantages. 3–7. Given the trends in the Pew Health data, how can the trends shift among consumers seeking health information? 60 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 60 Fundamentals of Internet and Associated Technologies for Healthcare Services Organizations Joshia Tan 61 I TECHNOLOGY BRIEF Introduction Generally speaking, the Internet may be thought of as a complex web of networks.1 Briefly, Internet services include electronic mailing (e-mail); newsgroups; file transfer protocols (FTPs); and other information transfer and exchange services, including, notably, the access of the World Wide Web (WWW) through browser software (e.g., Mozilla Firefox, Safari, and Microsoft Internet Explorer). Currently, within the context of healthcare services organiza- tions, this technology architecture has become a vital interactive research and communication tool—one that aids both medical professionals and health consumers in search of health-related information and knowledge. The massive, indispensable Internet we know today had humble beginnings as a military project, the ARPANET.2 Funded by the U.S. Department of Defense (DOD) through the Advanced Research Projects Agency (ARPA), its initial goal was to be a bombproof means of communication. This, however, inevitably propagated the idea of dynamic message routing (i.e., automatically rerouting the initiated communication through alternative pathways in the network, should a certain part of the communication network be attacked or destroyed). Severely underestimated by technology companies, the earliest users of the Internet were re- stricted to university scholars and military personnel. Today, however, the Internet boasts more than a billion users, as well as several regulating bodies, including the Internet Engineering Task Force (IETF),3 Internet Architecture Board (IAB),4 and Internet Engineering Steering Group (IESG).5 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 61 So what exactly is the Internet? In the United States, the physical backbone of the Internet was constructed by NSFNET6 (a hub infrastructure sponsored by the National Science Foundation). It consisted of several supercomputer installations servicing as major “hubs,” col- laborated by a few key universities and commercial undertakings. Today, it is a universal net- work of smaller computer networks that send and receive information from each other, open to everyone. Certain standards, or protocols, managed by the IETF, define various rules and the format of data that must be adhered to while passing from one network to another. Fundamentally, intranets and extranets are extensions of the Internet concept because they all use the same hardware and software to build, manage, and view websites. Unlike the Internet, however, these virtual private networks (VPNs) are protected by security software known as “firewalls” to keep unauthorized users from gaining access. In essence, an intranet is a private computer network built for the purpose of providing Internet-based services only to in- side organizational members. Similar to the intranet concept, an extranet offers network access privileges to certain external parties, giving them access to selected areas inside the VPN, thereby creating a secure customer or vendor network. World Wide Web When the World Wide Web (WWW) appeared, the Internet started down a different road al- together. With the hypertext transfer protocol (HTTP), which supports the transmission of data on the universal hypertext system that is the WWW, individuals could now place hyper- links in WWW files through the use of universal resource locators (URLs)—locators that may be employed to obtain resources anywhere in the networks of the Internet. A user would use a browser, or Web client, to send a request for certain information; the process through which the request is sent is specified by the HTTP. A program constructed to reply to HTTP requests, or a Web server, would then offer the requested information. The aforementioned hyperlinks are used in this manner: the user clicks a certain hyperlink, sending a request, and receives a second document. Soon, hypertext markup language (HTML) was developed. In this language, browsers receive the HTML text and translate it into a Web page for users. HTML allows for much more than simple text to appear on Web pages, including sound and even video files. It could also include links in a page that would permit a user to rapidly switch from one document to another—even if the document has been stored in separate computers. Web 2.0 and 3.0 Web 2.0,7 the next revolution in the Web, is not a simple technological update, as the name might suggest. It is, instead, a new approach to using the Internet. With more than a billion users; the continuous mass proliferation of never-off, high-speed broadband connections; and the rising popularity of mobile Internet-access devices, the Internet has been building itself up for a change. Web 2.0 will transform how business is done, changing the Internet from simply being user-friendly to user-driven. With such radical changes, and Web 3.08 on 62 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 62 the horizon, the Internet is constantly gravitating toward being open to everyone across the globe. As for Web 3.0, different writers have used the term in dissimilar manners. The primary idea is that of an evolving and expanded Web, in which artificial intelligent technologies, semantic, and three-dimensional (3D) orientation can transform Web usage. This has numerous advan- tages for the user: 1. It serves as a virtual database, in the form of linkable Web pages, in which content access may be shared by multiple nonbrowser applications. This is due to the Web’s increasing propagation as a medium for storing and sharing information that can be queried with standard query language. 2. The application of powerful Web-mining strategies, based on previous patterns of Web usage, represents the integration of Web with artificial intelligence technologies; this re- sults in the prediction of new and interesting search paths for the users. 3. An evolution into the semantic Web extends the usefulness of WWW by giving struc- tured meanings to information. It also permits the automation of data and software in a format to be read, shared, and used by intelligent software agents. 4. The concept of service-oriented architecture (SOA) offers an interchangeable bundle of services to create competitive advantage; this is produced by reengineering the existing business and IT processes of its Web services, especially for organizations connected through a value chain. 4. The evolution of the WWW into a series of shared 3D spaces means that a new vision of the Web could allow many dimensions of services and resources to be innovatively integrated. Applications of Internet-Related Technologies in the Healthcare Services Industry There are many published examples of Internet use, within the context of healthcare services organizations, providing relevant health information and services. A simple strategy is offering access to online insurance service data to users such as patients, physicians, hospitals, and oth- ers. Offering electronic claims for insurance benefits is a simple cost-cutting measure for the HMO and its network of hospitals, physicians, and corporate clients. The network-based ser- vices improve access, convenience, and usability for members. It also cuts agency and other la- bor costs while providing insight into healthcare trends and medical practices. For example, Blue Cross Blue Shield (BCBS) of Massachusetts employs WWW server and onsite multimedia kiosks, equipped with modem connections to the insurance carriers’ cus- tomer service operations, to enhance access to online insurance services. Apart from real-time access to information about particular BCBS services, the Internet services also provide users with healthcare and medical updates. Furthermore, the website provides a front end for medical information available at other points on the Internet, such as OncoNet,9 a repository for data on treatments for cancer patients. It is also possible to access the Internet via kiosks; this allows I N T E R N E T-R E L AT E D T E C H N O L O G I E S I N H E A LT H C A R E S E R V I C E S 63 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 63 users to extract, query, and print physician and hospital database information as well as to pe- ruse drug and treatment alternative information as part of BCBS services. In addition, these kiosks provide telephone links to customer service representatives and member services. Corporate customers have claimed that being able to provide services and information to users directly over the Internet and via kiosks can significantly reduce the cost of in-house insurance support and education. Intranet and extranet architectures have also been profusely applied across a growing number of hospitals for in-house and external health data and information sharing and distribution. Aetna/US Healthcare10 of Hartford, Connecticut, for example, allows members to change their primary care providers online via an extranet service. The EZenroll application handles the crit- ical process of adding, dropping, or changing health plans. Members gain access to the system with a user name and password supplied by their employer, who also approves the transactions online through their intranet–extranet architectures. Implementation of electronic health records via this same technology has been shown to be generally reliable and secure. Web-based transactions also provide the potential to reduce some of the inherent inefficiencies of paper forms and faxes and to circumvent the postal mailing system. Group Health Northwest (GHNW),11 another HMO, has been among the first to tap the potential of intranet and Web technology in aiding cost-effective sharing of information in a user-friendly fashion. For example, it has Web-enabled the organization’s patient accounts data to give users at outlying physicians’ offices the ability to query the data. Using a client server architecture, where clients can access data from a database, GHNW’s intranet and Web applications not only provide a better solution than previously used legacy systems, but also improve the quality of patient care. Previously, much of the information had been dissemi- nated in paper form. Geisinger Health Care System12 of Danville, Pennsylvania, the largest U.S. rural HMO, is seen as applying Internet-related technologies to reinvent health care. Its system concept includes replacing isolated legacy systems with a universal workstation concept, resulting in a patient- accessible intranet supported by an Ethernet backbone. Through this, Geisinger is able to offer innovative services such as Tel-a-Nurse, where nurses, who have access to relevant information and expert knowledge through the intranet, answer medical questions that users call in with. Geisinger’s physicians can also use digital cameras to take pictures of patient injuries, making these pictures accessible via the intranet. Geisinger’s intranet is also being used to support pa- tient education. The radiology department, for example, which performs diagnostic procedures such as X-rays, mammograms, and magnetic resonance images, has a kiosk in its waiting room. Through this kiosk, patients can access the radiology home page and retrieve a list of the vari- ous departmental procedures. The Detroit Medical Center (DMC) Virology Lab,13 a world leader in identifying and treat- ing different strain of the HIV-1 virus, has used DNA sequencing to prescribe medication for patients. In recent years, with the implementation of a semantic Web solution to replace legacy systems, the new software tools have helped doctors gather information of the sample workflow in the HIV virology laboratory system. Moreover, by tracking any changes that may have affected 64 O N L I N E H E A LT H I N F O R M AT I O N S E E K I N G 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 64 the HIV strains, these tools further enhance patient care by also allowing the doctors a better overview of patient history. Finally, Google has been developing a 3D satellite-based application, Google Earth, to help capture data and images that are not possible with basic guidance systems. A possible future ap- plication would be for an emergency call center to track the status, type of services needed, and urgency of the situation for a patient by simply zooming in on a 3D image of the patient re- questing assistance. Indeed, with the continuous development of groundbreaking technology, the healthcare services industry will soon be significantly more effective, efficient, and user-friendly. Notes 1. A. T. Stull, On the Internet: A Student’s Guide (Upper Saddle River, NJ: Prentice-Hall, 1997). 2. Michael Hauben, “History of ARPANET: Behind the Net—The Untold History of the ARPANET, or—The ‘Open’ History of the ARPANET/Internet,” accessed June 23, 2008, from http://www.livinginternet.com/i/ii_arpanet.htm. 3. Internet Engineering Task Force (IETF), http://www.ietf.org/, accessed June 23, 2008. 4. Internet Architecture Board (IAB), http://www.iab.org/, accessed June 23, 2008. 5. Internet Engineering Steering Group (IESG), http://www.ietf.org/iesg.html, accessed June 23, 2008. 6. B. Chinoy and Hans-Werner Braun, “NSFNET: The National Science Foundation Network,” accessed July 1, 2008, from http://moat.nlanr.net/Papers/nsfnet-t1-technology.ps. 7. Tim O’Reilly, “What Is Web 2.0? Design Patterns and Business Models for the Next Generation of Software,” accessed July 3, 2008, from http://www.oreillynet.com/pub/a/ oreilly/tim/news/2005/09/30/what-is-web-20.html. 8. Cade Metz, “Web 3.0,” PC Magazine, accessed July 3, 2008, from http://www.pcmag.com/ article2/0,1759,2102852,00.asp. 9. B. Blobel, “OncoNet: A Secure Infrastructure to Improve Cancer Patients’ Care,” European Journal of Medical Research 5, no. 8 (August 2000): 360–368. 10. Aetna/US Healthcare of Hartford, www.aetna.com/news/1997/pr_19971112.htm, accessed July 3, 2008. 11. Group Health Northwest (GHNW), www.ghc.org, accessed July 3, 2008. 12. Geisinger Health Care System, www.geisinger.org, accessed July 3, 2008. 13. Detroit Medical Center (DMC) Virology Lab, http://www.dmc.org/univlab, accessed July 3, 2008. N O T E S 65 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 65 56918_CH03_Final_Tan 4/6/10 11:38 AM Page 66 Health Management Information System Technology and Applications II PART 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 67 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 68 Health Management Information System Enterprise Software: The New Generation of HMIS Administrative Applications Joshia Tan with Joseph Tan 69 4 CHAPTER Editor’s Note: Isolated legacy systems—such as hospital financial and payroll systems, nurse scheduling systems, admission-discharge-transfer systems, purchasing and inventory control systems, facility planning systems, and the like—used for decades in healthcare facilities will soon give way to emerging business-oriented systems, namely, supply chain management, cus- tomer relationship management, and enterprise resource planning. These systems are believed to be emerging as the next-generation enterprisewide HMIS administrative applications that will significantly affect the future quality of healthcare services delivery. Chapter 4, therefore, begins our discussion of HMIS applications and technologies. Chapters 5, 6, and 7 will then continue this line of thought by highlighting applications such as community health informa- tion networks (CHIN), regional health information organizations (RHIO), electronic health records (EHR), computerized physician order entry (CPOE), clinical decision support systems (CDSS), and integrated HMIS via Web services technology. Put together, Chapters 4 through 7 offer readers a wide-ranging survey of HMIS applications and technologies. The knowledge ac- quired in Chapter 4 therefore prepares students to face new and emerging challenges in the evolving HMIS field. 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 69 S c e n a r i o : Customer Relations Management with Blue Cross Blue Shield of Minnesota1 In 2001, Blue Cross Blue Shield (BCBS) of Minnesota sought to persuade executives at the consumer goods giant General Mills to join its regional health plan. These executives decided they would switch health plans on one condition: BCBS of Minnesota needed to install a Web- based customer service system that would allow subscribers to manage their health profiles and benefits online. BCBS of Minnesota consented, and the task of building a customer relation- ship management (CRM) system that would live up to General Mills’s assurances fell upon John Ounjian, then senior vice president and CIO of BCBS of Minnesota. From the very beginning, Ounjian clearly understood the requirements imposed by General Mills: to give subscribers the ability to select health plans tailored to their individual needs and budgets, to calculate their own contributions to their coverage, to research information on pre- scription drugs and other treatments, to locate nearby participating physicians, and to check the status of their claims at any time of the year. Before such a system could be implemented, however, Ounjian needed to create a brand-new infrastructure that linked website and call cen- ter operations with timely, accurate information. In addition, he needed to transfer gigabytes of data from back-end databases to the Web so that it could be accessible and meaningful to con- sumers. It was a very challenging assignment with limited time and budget. In the end, Ounjian pulled it off. But how did he do it? The difference, Ounjian liked to think, was in the planning. From the outset, Ounjian had a data management strategy. He likened constructing an online customer self-service system without this type of strategy to 70 HMIS E N T E R P R I S E S O F T WA R E CHAPTER OUTLINE Scenario: Customer Relations Management with Blue Cross Blue Shield of Minnesota I. Introduction II. Supply Chain Management III. Customer Relationship Management IV. Enterprise Resource Planning V. Conclusion Notes Chapter Questions Technology Brief II: Basic Hardware, Software, and Interface Concepts for Healthcare Services Organizations Joshia Tan and Joseph Tan 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 70 building a bridge without support. “If you don’t have a data management strategy, then you’re only building half the bridge,” he reasoned. Thus, he and his staff began the project by at- tempting to develop a new infrastructure to record, over the Internet, automated interactions that had previously taken place over the phone. They then proceeded to pursue a strategy that would overcome many of the problems that could arise from converting raw data from back- end systems to consumer-accessible information on the Web. Had Ounjian been restricted to moving data back and forth, customers would end up looking at information that was essen- tially outdated, inaccurate, or not synchronized with other company information channels. Once its website was ready for beta testing, Ounjian and his staff invited a focus group of customers to evaluate it. The customers were initially unimpressed, mainly because they found the site to be lacking a consumer-friendly interface. Specifically, BCBS-hired engineers discov- ered that they needed to redesign the layout of pull-down menus that guided viewers around the site. The interface was eventually improved with added features; as a result, customers were able to access information in a more efficient and relaxed manner. As of 2003, 61 employers (including Northwest Airlines, 3M, and Target) have used the system—more than 450,000 individual employees in total. This number has also been pro- jected to grow as more companies and individuals adopt this consumer-driven approach. Ounjian used a car metaphor to describe the flexibility of his new system: “We have the chassis on which to build our investments from year to year. If my transmission needs to move from a three-speed to a five-speed, I don’t have to redesign the whole car.” Now, imagine you are the next CEO of General Mills and would like to build a strong infor- mation systems department to do in-house systems development with the criteria of these sys- tems being customer-friendly. What do you think would be some examples of such systems? Would Ounjian be a person you may want to consider hiring to be in charge of the IS depart- ment of General Mills? If so, why? Otherwise, why not? I. Introduction In Part I, we learned that health management information systems (HMIS) combine people, data, processes, and health information technologies to collect, process, store, and provide needed results—all in support of a healthcare services organization’s different departmental functions and task activities. This is the foundational knowledge to prepare us on how to go about managing HMIS within healthcare services organizations as complex adaptive systems so that these organizations can thrive in an intensely competitive and increasingly demanding marketplace. Part II of this text covers HMIS technology and applications. At this point, we need to spec- ify the type of HMIS applications, in today’s healthcare services organizations, in which strate- gic and operational initiatives may be championed to yield competitive advantages. Our focus here is on HMIS administrative applications at the enterprise level. At this level, the overall per- formance of the organization depends on effective communications among its members; the building of an interoperable, interconnected HMIS architecture; and, finally, the implementa- I . I N T R O D U C T I O N 71 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 71 tion of effectively integrated enterprise software to connect the existing legacy administrative systems that support the organization’s routine functions and activities. As we move steadily toward globalization; e-commerce; knowledge asset management; col- laborative partnerships; total quality management; and greater expectations for the security, pri- vacy, and confidentiality of patient data, HMIS must evolve into an integral part of any healthcare services delivery system. To sustain an intense competitive edge and promote strate- gic initiatives, several high-profile enterprise software systems have emerged in the HMIS land- scape. Key among these include: ● Supply chain management (SCM). ● Customer relationship management (CRM). ● Enterprise resource planning (ERP). These enterprise software systems play numerous important roles, including supporting and en- hancing (among key stakeholders inside and outside of the networked enterprise) communica- tion, coordination, collaboration, information exchange, and resource management sharing. The successful implementation of these systems also ensures that every internal enterprise unit is somehow interrelated and interoperable and, furthermore, able to link with external support infrastructure systems. Just as a jigsaw puzzle, comprised of a mass of irregularly shaped pieces, forms a total picture when fitted together, these strategic HMIS initiatives combine effectively to help integrate the enterprising functions and task activities among the various constituencies. They will also link to external entities to provide seamless high-quality healthcare services deliv- ery, as is expected by today’s healthcare consumers. These enterprise software systems primarily target large-scale health maintenance organiza- tions (HMOs) and integrated healthcare services delivery systems to satisfy the need for economies of scale; the increasing volume of daily purchasing, claims, and information ex- change transactions; the trend toward increased growth, acquisitions, and merger arrangements; and globalization. Therefore, discussion of these systems takes center stage in this text, rather than the disparate legacy administrative systems such as hospital financial systems, material purchasing systems, nursing scheduling systems, facilities management systems, and many other systems that are typically covered in most published standardized and more traditionally oriented HMIS texts.2-4 We believe that the major HMIS enterprise applications presented here will soon become the next-generation administrative applications for most, if not all, healthcare services organizations. II. Supply Chain Management Owing to escalating costs, advances in medical devices, innovations in health technology, new discoveries in prescription drugs, and increasing demand for quality services in the U.S. health- care marketplace, large-scale HMO and multi-provider healthcare organizations must now be- gin to evaluate their supply chain management (SCM). The design of an effective SCM system essentially involves an understanding of how to man- age the information flow throughout a supply chain (SC) so that the total SC effectiveness is 72 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 72 maximized.5-7 In other words, the primary goals of SCM are (1) to optimize service quality in terms of an organization’s internal information flow processes, while reducing costs and deliv- ery time, and (2) to achieve increased efficiencies with regard to information flows and ex- changes between the organization and its external parties, including all its vendors and suppliers. Take the case of the materials purchasing and handling department of a health maintenance organization that oversees, on a daily basis, the purchasing and inventory of supplies from a multitude of suppliers for several HMO-affiliated hospitals. First, it is almost always a challenge to predict, at any one time, the composition of patients in the different affiliated hospitals and, ultimately, their supply consumption of medical equipment or devices, prescriptions, ambu- lances, and office supplies, such as computer hardware and software. Second, different vendors and suppliers may behave very differently with differing systems, policies, and procedures for fulfilling orders. These vendors and suppliers can change from time to time, and depending on their efficiencies, some orders may be misfiled, shipped to the wrong places, or even lost in the process—any of which would lead to unsatisfactory backlogs and further logistical delays. Poor inventory management and inadequate quality control on the part of any of the suppliers, as well as on the part of the materials purchasing and handling department of the HMO, will also significantly affect subsequent costing and budgeting, as well as delivery time or recalls of these supplies. Many of these events will, in turn, affect the availability and eventual pricing of cer- tain products and, ultimately, the customers’ perceived product and service quality. The deployments of e-commerce enterprisewide software, such as electronic data inter- change (EDI) or Web services, are examples of SCM solutions. Having the materials purchas- ing and handling department set up and send electronic orders to all the vendors and suppliers in a preauthorized standardized format not only reduces errors in manual paperwork, lessens in- consistencies among disparate legacy systems, minimizes mail order delays, lowers costs, and in- creases the overall efficiency achieved in order procedures, but it also reduces the need to spend time chasing unfilled orders or canceling orders. Moreover, information flow among manufac- turing, purchasing, and acquiring parties on quality control can easily be an added component in the system. SCM also ensures readily available access to electronic order information, such as order tracking, at any time and anywhere the e-commerce application is operable. It even grants the materials purchasing and handling department the ability to confirm approximate delivery time and availability of products—such as the type, number, and functionalities of wheelchairs at or- der placement. Moreover, staffing in the materials purchasing and handling department may also be reduced. Electronic healthcare requisition, or e-procurement, therefore, saves tremen- dous logistics costs, with the added possibility of instituting a just-in-time (JIT) inventory. JIT is a strategy used by many businesses to improve the return on investment (ROI) by reducing in-process inventory and its associated costs. Demand printing, such as the publication of re- quired health information brochures, is an example of JIT because only the number of ordered brochures is printed for delivery as orders are received. It is expected that the HMO’s process efficiencies, service quality, and performance effectiveness will dramatically improve if JIT in- ventory can also be implemented as part of the SCM strategy. II . S U P P LY C H A I N M A N A G E M E N T 73 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 73 Over the years, the healthcare industry has lagged in terms of innovative HMIS implementa- tions and IT applications compared with banking, manufacturing, and many other service in- dustries. As the next-generation HMIS enterprise software strategy, SCM provides the healthcare industry with an opportunity to systematize materials purchasing and handling processes. In fact, there is the possibility that globalization will soon transform SCM for health- care supply purchasing into global sourcing. With an increasing global population, healthcare services organizations—although long rec- ognized to have thrived as one of the most established industries—are also now predicted to be- come the world’s fastest growing industry sector. Because the supply chain is being identified as a means of equating supply and demand in terms of the high daily volumes of information that are exchanged between suppliers and customers, the management of healthcare services organi- zations should not analyze a single department, or even a single enterprise. Instead, these organ- izations should collaborate and, perhaps, integrate purchases by applying SCM philosophy for networks of healthcare services organizations and partnering HMOs. Not only will this lower the cost of SCM investments, it will also increase SCM efficiencies and promote cost-effectiveness in the building of supplier–customer relationships. As a result, both the primary and support activities levels will see greater competitive advantages among the partners with shared infra- structure. To this extent, it could be demonstrated that outsourcing may be the next growth- strategic initiative for many HMO and healthcare services organizations, so that the current borders in the relationship between suppliers and customers are expanded. Evidently, the tradi- tional approach of “make or buy” is rapidly approaching extinction, yielding to transforma- tional outsourcing as an SCM strategy in redesigning traditional links. This would allow healthcare services organizations to focus on their core businesses and core competencies, which are, essentially, patient care. To further illustrate the SCM concepts for healthcare services organizations, we present two relevant cases drawn from different vendor-published websites. The first is Marion Area Health System (MAHS) of north-central Ohio’s Caduceus Material Management Information System (Caduceus MMIS)8; the second is a press release of Andersen’s pharmaceutical, biomedical, and health services (PBH) supply chain practice on its attempt to project, in the IT industry, the valuation of future, achievable, e-commerce benefits.9 MAHS, whose affiliates include the Marion Area Health Center, Smith Clinic, and Marion Ancillary Services, recently licensed the Caduceus MMIS for implementation throughout its system. The Caduceus MMIS involves more than 70 physicians, whose specialties range from minor illnesses to full-blown surgery. Because of its sheer size, a new technological approach to managing its inventory and records was needed. Rick Brunswick, the director of materials management at MAHS, believes the system will fill this need by “automat[ing] a wide range of supply-related processes and eliminat[ing] a series of manual tasks.” Such processes and tasks include the ability of electronically managing purchasing contracts, invoices, and finan- cial records. Using wireless technology and automatic updating, Caduceus MMIS seeks to cut costs by managing inventory and finances in a comprehensive manner. This extinguishes any superflu- ous or redundant practices and diminishes the risks associated with human error and safety haz- 74 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 74 ards. MAHS physicians and clinicians will then have more time to personally care for patients without having to worry about locating and correcting misplaced or mislabeled supplies. As the system is developed with a scalable and receptive architecture, existing systems can be incorporated into Caduceus MMIS. Not only will this reduce the funding needed to replace existing systems, but it will also save implementation time. Ed Lane, the president and CEO of Caduceus Systems, has faith that “the Caduceus MMIS will equip MAHS with the capabilities to realize significant efficiency improvements, cost sav- ings, accurate charge generation, and improve communication with their suppliers and trading partners while positioning MAHS with a strategic software platform for managing their inter- nal supply chain operations.” A study by Andersen’s PBH supply chain practice found that the future value of e-commerce is predicted to fall between 2 and 10 percent of total benefits for members of the healthcare in- dustry supply chain. Providers would receive 1 or 2 percent of the benefit, while suppliers would obtain the remainder. These values were calculated from interviews and activity-based costing methods, involving both tangible and intangible future values of e-commerce. These in- cluded improvements in procuring products, managing orders, invoice processing, integrating systems, managing contracts, and operational efficiency. However, the largest benefit has been purported to be from controlling redundancy, such as overpayment and rework. Furthermore, as administrative issues can now be handled with less effort through e-commerce, and real-time information is easily accessible and available, salespeo- ple now have more time to focus on completing sales transactions and garnering new clients. “This study quantifies the future state of the healthcare industry through the use of e-commerce,” said Ramona Lacy, partner with Andersen’s PBH supply chain practice. “It will be a roadmap for all parties involved in the supply chain.” III. Customer Relationship Management Customer relationship management (CRM) is another major HMIS enterprise software system that is emerging in the healthcare IT marketplace. As noted in the beginning scenario of this chapter, the responsibility eventually rests on BCBS of Minnesota’s CIO, John Ounjian, to im- plement Web-based CRM software so that executives at General Mills are convinced to join BCBS of Minnesota’s health plan. Such software would permit subscribers to manage and per- sonalize their healthcare services benefits online. In brief, the system will enable them to cus- tomize their plans to their individual needs and budgets, locate participating and select highly recommended physicians and specialists, decide on their own coverage contributions, check on the status of their submitted claims, and uncover the research information on prescription drugs and/or other recommended treatments at their own convenience. How, then, would having CRM software distinguish BCBS of Minnesota from its competi- tors? Although CRM applies to organizations of every market, John Ounjian claimed that healthcare organizations such as BCBS are ready for such a system and would find it to be ex- tremely beneficial in retaining its customers. Evidently, in order to maximize revenue genera- tion and maintain customer loyalty, BCBS of Minnesota, as a leading-edge HMO, must be III . C U S T O M E R R E L AT I O N S H I P M A N A G E M E N T 75 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 75 ready to implement such a solution and use it to carefully manage all of the customers’ associa- tions with the organization—this is exactly what customer relationship management is all about, and what BCBS of Minnesota’s competitors have yet to discover. With CRM, BCBS of Minnesota customers can now communicate with the HMO through numerous means and at different times. An archetypal CRM scheme would record each inter- action a customer has had with the HMO and allow all the different departments of BCBS of Minnesota to access this record. In so doing, the HMO can garner valuable perspectives on both the effectiveness of its current systems and the preferences of any individual customer. Furthermore, with this knowledge, BCBS of Minnesota can save considerable cost by eliminat- ing corporatewide inefficiencies. Customer satisfaction will also be improved, because the treat- ment of each individual client can be further personalized, given that BCBS of Minnesota can access the record of interactions the customer has had with it, and then offer, accordingly, only the services and information that the customer seeks. Targeted mailing of information will also reduce waste. With reduced inefficiencies leading to reduced costs, and increasing customer loyalty leading to augmenting sales, BCBS of Minnesota can then, as a result of implementing powerful and unique CRM software, maximize its revenue generation. Still, in order to design the most appropriate CRM software, the HMO or healthcare serv- ices organization must have an in-depth recognition of its customers’ specific needs. Accordingly, Shams and Farishta10 argue that the application of CRM philosophy is based on understanding the communications architecture of the healthcare services organization. The communications architecture should include a center core communications piece, augmented by branding and strategic communications. In terms of core communications, the patient’s profile, which includes a synopsis of his or her physical demographics and other treatment-spe- cific information (such as gender, age, allergies, and so forth) would be used to further trigger event-specific communications. In terms of branding communications, the messages will be used to distinguish the type and quality of products, programs, and services that the health or- ganization in question is able to offer from its competitors in the regional, or even global, healthcare marketplace. Finally, strategic communications refer to the enhancement of existing programs and services, as well as to the development of new programs and creative services that would progress and fulfill the organizational long-term goals.11,12 Ultimately, the CRM being designed should first capture and generate customer profile data. With the core communications architecture in place, it should then allow an authorized em- ployee or affiliate of the healthcare organization to offer, at the patient’s convenience, appropri- ate information on treatments in a relatively shorter span of time. With the additional branding and strategic communications layers implemented, CRM would further allow the healthcare organization to reach its target audience for specific programs, such as immunizations, by con- tacting only those patients whose profiles suited the need. The CRM would also be able to communicate to the selected customers specifically why these services or programs are unique and competitively desirable, compare these services and programs to other apparently similar programs and services available in the healthcare regional marketplace, and offer special and personalized packages to the customers. Not only would such a system save the healthcare or- ganization significant funds from general advertising and marketing costs, but it would also, in- 76 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 76 IV. E N T E R P R I S E R E S O U R C E P L A N N I N G 77 dubitably, recover the cost of its implementation over the long run. Moreover, it will increase patient retention by offering customers a personalized relationship with tailored suggestions that other health organizations are not yet able to offer. IV. Enterprise Resource Planning Enterprise resource planning (ERP) is the final, major, enterprisewide software system to be highlighted in this chapter. As with many businesses, legacy systems in healthcare services or- ganizations require employees to post different departmental financial, purchasing, and other service-oriented data in separate systems. These systems may not be consistent with each other, thereby encouraging the proliferation of islands of HMIS. Posting is the essence of manual op- erations. In an integrated environment, all that is needed is a “view.” For instance, a patient’s claims and claims reimbursement filing forms are just different views of the same data set in dif- ferent order. In this regard, Duncan et al.13 observe that the integration of intraorganizational processes can significantly affect strategic management. Linked inventory control, if it exists, can be up- dated every time a drug, special diet, medical device, or other item is ordered; the cost of the item can then be added electronically to the patient’s claims and claims reimbursement filing forms, thereby improving efficiency and reducing costs. Extending this linkage externally, the process of reordering items from designated suppliers, so that sufficient safety stock is main- tained, can also be automated. With SCM, suppliers can be linked to customers in real time for electronic order processing, third-party payors can be linked to health providers for billing and claims reimbursement procedures, government regulators can be linked to providers for docu- mentation, and researchers can be linked to all of the various stakeholders for the purpose of conducting studies. In essence, the ERP philosophy is an attempt to integrate all departmental and functional processes throughout the enterprise into a single, integrated HMIS, enabling enterprisewide in- formation management and decision making on all organizational operations. If the entire or- ganization is not sold on the philosophy of change accompanied by the use of ERP applications, for example, unintended and highly disruptive consequences may result. Existing ERP packages include SAP, R/3, Baan, PeopleSoft, and Oracle.14 In the same context as the assembly of isolated legacy systems into an integrated system with real-time access of different views (allowing decisions to be made intelligently across the enter- prise) is the idea of reducing, or possibly eliminating, all paper-based forms for which health- care services organizations are especially vulnerable. If all transactions between customers and providers can be captured online and directly via CRM, then all the troubles of any manual follow-up that may be needed could be avoided. With CRM and SCM in place, ERP can pro- vide management quick access to enterprisewide resource planning summaries, such as the gen- eration of enterprisewide purchasing aggregate reports, shipping status reports, and revenue-generation reports from all related services, programs, and investments. Yamanouchi Pharmaceutical Co. Ltd. and Fujisawa Pharmaceutical Co. Ltd. merged in April 2005 to form Astellas Pharma Inc., ranking among the top 20 global pharmaceutical 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 77 companies. Astellas Pharma US Inc., headquartered in Deerfield, Illinois, represents the U.S. Astellas operation.15 Previously, Yamanouchi Pharmaceuticals, with sales at $3.9 billion, was also the third-largest pharmaceutical company in Japan. It has made information systems the key component in improving the timeliness and quality of answers to customers’ tough questions. Product support personnel at Yamanouchi can immediately answer half the questions that come in from the doctors or pharmacists. To find answers to more difficult questions, they have access to Yamanouchi’s Web-based PRoduct INformation CEnter Supporting System (PRINCESS).16 With the help of JRI Consulting, Astellas Pharma was able to further integrate both Yamanouchi’s and Fujisawa’s systems to quickly achieve stable operations within a short period of time. The Astellas ERP system is based on SAP R/3 products with business processes in accounting, production, sales and distribution, purchasing, and personnel from both compa- nies integrated.17 Still, ERP is not a panacea. Take, for instance, a typical healthcare services organization to- day, where management, employees, or customers need specific answers to important product order or service information. There are also the related questions about suppliers, shipping sta- tus, and sales status, causing the front offices of these healthcare services organizations to typi- cally scramble behind the scenes for answers. The inconsistency across disparate databases and business operations in legacy systems often make it difficult for conflicting data sets to be rec- onciled. These cannot be used to provide straight answers, either, to many of the questions per- taining to the provided services. Moreover, it will always be complicated to provide straight answers for such questions as, “How long does it take to perform a knee replacement operation today?” or “How much does it cost the HMO to schedule a knee replacement operation to- day?” The HMO can generate the answers only after that knee replacement operation is completed—its expenses depend on, among other things, who performs the surgery, how is it performed, when is it performed, the patient’s insurance subscription and the extent of its cov- erage, the length of the patient’s postoperation stay in the hospital, and any complications aris- ing from the operation(s). Administrators of healthcare services organizations can only provide a smile as service until their employees and subordinates have had sufficient time to deal with addressing many of these questions. Operational practices within healthcare services organiza- tions and subcomponents are diverse and sometimes unique. Software development has to be done on a project-by-project basis, because the service processes are often nonstandardized. Developing ERP software, or even customizing and implementing some off-the-shelf packages, is, therefore, a very lengthy, risky, and difficult venture. In this sense, the information architec- ture that can be achieved through the integration of core business processes and requirements will sometimes be limited, complex, and expensive. The goal for ERP, then, is to achieve single data-entry points throughout the organization so that the goal of enterprise data modeling can be realized wherever possible. Today, this is becoming a more attainable goal with the adoption of data and process standardization, ad- vances in business process reengineering, and the willingness of healthcare professionals and employees to streamline processes and operations. When standardization goes beyond the ba- sic data levels to a service process level, invoices and paper-based orders can be eliminated, and payments or services can be made without the need for a paper trail. Often, the major is- 78 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 78 sues are not technical, but process reconceptualization and educational issues. Overcoming these issues is key to making intra- and interorganizational systems work together. Simply put, ERP software can be used to facilitate data integration by amalgamating existing busi- ness processes in an organization. ERP implementation for an integrated delivery system (IDS) essentially connects the different pieces of existing HMIS applications in the system to fit into the ERP centerpiece software. Figure 4.1 shows how the ERP replaces the existing islands of HMIS for an IDS with a re- sulting centerpiece ERP application, which allows sharing of core administrative data. It is im- portant to note that not all services and functions currently performed in healthcare services organizations can be easily integrated. The service process model for healthcare services proposed in the previous edition of this text is the beginning of an ERP conceptualization for healthcare services organizations. It is an attempt to reconceptualize and streamline all services and processes transpiring within these or- ganizations into an integrated model. We briefly summarize the approach here; those who are enthusiastically interested can seek out further details by consulting the previous edition of this text, as referenced.18 IV. E N T E R P R I S E R E S O U R C E P L A N N I N G 79 Government Universities Health Professional Associations Medical Supply Companies Mental Health Institutions Acute Care Hospitals Educational Institutions Long-Term Care Facilities Medical and Specialty Clinics Drug Companies Insurance Companies Charity Organizations Research Facilities Census Data Laboratories Physicians’ Offices Core Administrative Data as ERP Centerpiece FIGURE 4.1 The Enterprise Resource Planning (ERP) Conceptualization. 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 79 All organizations, including healthcare services organizations, provide services. The service process is therefore a common link among organizations, subsets of organizations, and various people who work for these organizations. All service processes have three common basic ele- ments: a customer, a service that is provided, and a provider. Information pertaining to these elements may be maintained as servicing records in master tables. Service processes are simple and very consistent; in general, most organizational services can be classified into three levels, each having a few major types. Uniformity in service processes is essential because it shortens the customization and implementation time for an integrated ERP application. Service transactions occur at three levels within a unit: (1) external services, (2) internal serv- ices, and (3) procured services. External services are services provided by the unit or persons to ex- ternal units or persons. Internal services are services provided within the unit by one person or unit to another person or unit. Procured services are services procured by units or persons from external units or persons. Within each of these three levels, service processes of (or for) units or individuals can be classified as consultative, procedural, material (consumable), facility (use of hard or soft assets), monetary, or information (maintenance). In healthcare services organiza- tions, consultative services involve logical interactions between customers and providers; these in- clude services provided by doctors, management consultants, and clinical specialists. Procedural services involve physical interactions between customers and providers. This type of service may also involve the use of equipment, such as a hard or soft instrument. Material services transfer the ownership of hardware or software from providers to customers. These services result in debits or credits to the material accounts of providers and customers. Facility services involve the blocking and releasing of assets used. In this case, the service providers typically limit the use of their hard- ware or software to the customers. Examples are use of hospital beds (hard assets) or Internet services (soft assets). Monetary services are either independent or reciprocal of other service types. For example, money is transferred from customers to providers by various negotiable instru- ments, resulting in debits and credits to monetary accounts of customers and providers, respec- tively. Information services merely involve updating the service master tables after transactions. The customer, provider, and service master tables are results of such service transactions, and the structure of these service master tables depends on the type of the service provided. IDS can easily customize the layout of data on these services into service master tables, de- pending on their needs and information requirements. Services of all types within each level are processed with multiple steps. At least four of these steps are common to most service processes: request for service, acknowledgment of request, service delivery, and confirmation of service de- livery. Figure 4.2 shows how these steps can be sequenced and analyzed along a value-added chain, resulting in a service outcome. Services can sometimes, alternatively, be processed with a single step, or multiple steps can be merged into a single step. It is also possible for these steps to take place all at the same time. First, a service process is initiated through a request for service. Numerous forms have been used in the manual process for making requests (e.g., drug prescrip- tions and test orders). Apart from other attributes, these service request forms commonly iden- tify the customer, the service to be provided, and the provider—that is, the basic elements of the service process. The manual forms necessitated a docket number (header) and a detailed type of reference system, which are not necessary in our standardized model. Abolishing this 80 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 80 concept of header and details requires a change of the old mind-set for many health profession- als. This also means abolishing the names used for identifying all the different request forms. In the integrated, computerized model, each record consists only of one customer, one deliverable item of service, and one provider. In general, requests are generated one at a time. However, it is possible for group requests to be made for several services ganged together. Moreover, requests may also be prescheduled with a start time, end time, and follow-up periods. Requests for a particular service may also be auto- matically generated for a predefined condition by activating it through a triggered built-in logic when a change in certain fields is registered. For example, a purchase request for an item can be generated automatically when the reorder level is reached. This type of request is unnecessary in an integrated environment, because the provider who is sharing the data will supply the item with an automated built-in request. In this case, what should have been a reorder level would now become a supply level. Also note that requests and services flow in opposite directions be- tween the various request levels and that external and procured services are usually accompanied by reciprocal monetary transactions. Following the service request, the acknowledgment screen of the service provider is updated with the new request. The service provider then acknowledges the request by some preliminary action. For example, in the case of a laboratory test request arising within a hospital, the phle- botomist will have to collect the required blood sample. In the case of a machinery breakdown, the request is made to the service engineer to carry out a preliminary inspection of the equip- ment. Table 4.1 shows the “acknowledgment actions” of the different requests, as noted on the system by the provider. The system also notes the user identity of the person acknowledging the request and the date and time of acknowledgment. After the acknowledgment is registered, the person actually responsible for delivering the service is notified through an automatic update of IV. E N T E R P R I S E R E S O U R C E P L A N N I N G 81 Request for Service Acknowledgment of the Request Delivery of Service Confirmation of Delivery Value Direction of flow Service initiated by customer to provider Service request acknowledged by provider to customer Service delivered by provider to customer Service delivery confirmed by customer to provider Service outcome: customer is (is not) satisfied 1 Request for Service 2 Acknowledgment of the Request 3 Delivery of Service 4 Confirmation of Delivery 5 Value FIGURE 4.2 The Service Model Value Chain. 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 81 this person’s pending actions list. Services are then delivered and the records of “delivery ac- tions” are updated electronically by the providers or, subsequently, by individuals acting on their behalf, as shown in Table 4.2. Again, the identity of the person updating the records and the date and time are noted by the system. The last step is confirmation of the service provided, that is, an acceptance or approval of the service by the customer. As noted, all services have outcomes; for example, a service may be completed to satisfaction or below satisfaction. The consultative and procedural services may have outcome values for various parameters, as recorded by their providers. An outcome may also be the identity of another service request. Moreover, a service may be canceled or rolled back at any stage. Hence, if the service is accepted, the system merely updates the ac- knowledgment; otherwise, a feedback occurs, and the “chain” of service activities is repeated accordingly. Following the service delivery, the transaction data are archived into a service data archival table or the service database. It is possible that services may be grouped and ordered together by a group name, and a hi- erarchy pattern of multiple levels of groups thus enables rapid ordering of related services. 82 HMIS E N T E R P R I S E S O F T WA R E Table 4.1 Services Processes and Acknowledgment Actions Taxonomy Types of Service Processes Acknowledgment Actions Consultative Confirmation that the provider and the customer are both ready Procedural Pre-procedure preparation carried out by the system Material (consumable) Transportation of material Facility (use of hard or soft asset) Reservation/allotment of facility Monetary System checks to ensure that the service is deliverable and instruments are acceptable Information System checks to ensure that all information required for master updating is available Table 4.2 Services Processes and Delivery Actions Taxonomy Types of Service Processes Acknowledgment Actions Consultative Recording the outcome parameters Procedural Recording the procedure outcomes Material (consumable) Transfer of ownership of material to the customer; stock records update Facility (use of hard or soft asset) Physical occupation of the facility Monetary Transfer of money to the customer; financial records update Information Master update 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 82 V. Conclusion Only the primary features underlying the service process model have been presented so far to give the reader a sense of the benefits of what process standardization can provide. In other words, standardization can incur benefits at levels beyond data codes, data schema, and data ex- change formats; in fact, significant efficiencies can be recovered from standardizing the service processes. Standardization of all these levels, if pursued appropriately and vigorously, holds great potential for reduced costs, diminished complexity, greater security control, and better data management—a systems philosophy that prepares the organization to move into an SCM, CRM, and ERP environment. Adoption of HMIS standards is discussed in Chapter 12. In closing, here are some pointers toward achieving HMIS integration in an IDS context. The first significant change, as was noted throughout many of the illustrations covered in the chapter, is increasing awareness of the organization to reconceptualize its business and services processes as well as the need to adopt a new corporate culture of data sharing. This culture needs to be sup- ported across all organizational units and departments. In this light, SCM, CRM, and ERP play key roles in supporting meaningful sharing, integration, and exchange of data; such software sys- tems allow enterprisewide views of the organization, thereby ensuring efficient and effective in- terorganizational cooperations and intraorganizational collaborations. For such interorganization and intraorganizational linkages to succeed, Sprague and McNurlin19 note that all linked pro- grams and processes should be expandable to other links in the future, whether these are at com- munity, regional, state, national, or international levels. This can only be possible if an enterprise view, process standardization, and a data-sharing culture are upheld and if stakeholders and users are educated about the significance of the standardization process (the subject of Chapter 12). In an IDS context, the more technologically advanced partners will typically have to pull the others along, whether it is through education or some other means. Standardization also requires the cooperating organizations to be involved in the ongoing development of standards. Government agencies, regulators, and third parties are often also involved. Standards task forces can be formed to operate as electronic intermediaries, facilitating the flow of information. In hammering out a consensus among the stakeholders involved in a standardization process, a change in one of the cooperating systems often must be coordinated with all others. Finally, as illustrated by the Yamanouchi-Fujisawa case, applications of the HMIS enterprise software will, sooner or later, allow individual organizations to go beyond their limitations as such software systems require the participation of other organizations before total efficiencies and effectiveness can be achieved. As long as organizational employees and staff are ready to share views, and management is open to high-performance changes, new enterprise software can be instituted to add value to the organization’s growth and development. Along this line, we close this chapter by summarizing a press release on the combination of ERP and SCM so- lutions for pharmaceutical distribution channels across Europe. Frost & Sullivan20—a global innovative growth strategies consulting company—proposes, in one of its press releases through its London office, the use of ERP and SCM solutions to ease the flow of pharmaceutical distribution channels across Europe. The company argues that ERP and SCM solutions will ease integration of processes across various functional areas and stream- V. C O N C L U S I O N 83 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 83 line related functions of key stakeholders in the pharmaceutical distribution channel, resulting in rapid and secure delivery of pharmaceutical products. Rahul Philip Mampallil, a Frost & Sullivan research analyst, claims that “with these IT solutions, manufacturers and other partici- pants in the distribution channel can track the flow of drugs from pharmacy shelves and replenish accordingly to avoid stock outs. . . . Moreover, companies can monitor the movement of stocks and detect the illegal intrusion of batches into the distribution channel.” The challenge, he be- lieves, lies in correcting the current lack of understanding about specific business requirements that organizations have when implementing particular add-on ERP modules, and when these modules do not support those requirements. Andersen21 projected that these solutions will gen- erate revenues of $1.835 billion by 2013, given the high market potential, in the European pharamaceutical sector, for these technologies to diffuse. The application of IT solutions such as SCM, CRM, and ERP will translate into new efficiencies, new boundaries, and new possibilities. Notes 1. http://www.cio.com/article/31903/Blue_Cross_and_Blue_Shield_of_Minnesota_s_Success _With_CRM/4, accessed June 29, 2008. 2. J. Tan (Ed.), Health Management Information Systems: Methods and Practical Applications, 2nd ed. (Gaithersburg, MD: Aspen Publishers, 2001). 3. C. J. Austin and S. B. Boxerman, Information Systems for Health Services Administration, 5th ed. (Chicago: AUPHA/Health Administration Press, 1998). 4. K. LaTour and S. Eichenwald Maki (Eds.), Health Information Management: Concepts, Principles, and Practice, 2nd ed. (Chicago: AHIMA, 2006). 5. H. L. Lee, V. Padmanabhan, and S. Whang, “Information Distortion in a Supply Chain: The Bullwhip Effect,” Management Science 43, no. 4 (1997): 546–558. 6. J. W. Forrester, “Industrial Dynamics: A Major Breakthrough for Decision Makers,” Harvard Business Review 38 (July–August 1958): 37–66. 7. C. Bechtel and J. Jayaram, “Supply Chain Management: A Strategic Perspective,” International Journal of Logistics Management 8, no. 1 (1997): 15–34. 8. http://www.caduceussystems.com/news-marion-selects-caduceus-systems.html, accessed May 27, 2008. 9. M. Pastore, The ClickZ Network. Accessed June 27, 2001, http://www.clickz.com/show Page.html?page=792781. 10. K. Shams and M. Farishta, “Knowledge Management.” In K. LaTour and S. Eichenwald Maki (Eds.), Health Information Management: Concepts, Principles, and Practice, 2nd ed. (Chicago: AHIMA, 2006). 11. N. Paddison, “Benefits of Event-Driven CRM in Healthcare, Part 1,” DM Review, January 26, 2001. 12. N. Paddison, “Benefits of Event-Driven CRM in Healthcare, Part 2,” DM Review, February 2, 2001. 13. W. J. Duncan et al., Strategic Management of Health Care Organizations (Oxford, UK: Blackwell Business Publications, 1996). 14. G. Koch and K. Loney, Oracle: The Complete Reference (NY: McGraw-Hill, 1996). 15. http://www.astellas.us/press_room/docs/launch_release033105 . 16. B. Gates, Business at The Speed of Thoughts (NY: Time Warner, 1999). 17. http://www.jri.co.jp/english/press/press_html/2005/050624.html, accessed July 2, 2008. 18. Tan (2001). 84 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 84 19. B. C. McNurlin and R. H. Sprague, Jr., Information Systems Management in Practice, 2nd ed. (Englewood Cliffs, NJ: Prentice-Hall, 1989). 20. http://www.frost.com. 21. http://www.itconsulting.com/press-releases/european-pharma-streamline-112006/, accessed July 3, 2008. Chapter Questions 4–1. What are some of the major HMIS enterprise software systems? Discuss the need for a data-sharing culture in implementing the various HMIS enterprise software systems. 4–2. Why would it be (or not be) beneficial to combine SCM and CRM into a single system for healthcare services organizations? What about combining SCM with ERP, or other combinations of HMIS enterprise software systems for healthcare services organizations? 4–3. How should one go about standardizing service nomenclature, such as the process service names and outcomes, in order to achieve a level of ease with implementing enter- prisewide software? Why must people be sold on the software and be ready to change be- fore moving ahead with a large-scale implementation such as ERP? 4–4. What do you see as the trend of healthcare services organizations with the applications of HMIS enterprise software? C H A P T E R Q U E S T I O N S 85 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 85 Basic Hardware, Software, and Interface Concepts for Healthcare Services Organizations Joshia Tan and Joseph Tan t II TECHNOLOGY BRIEF 86 Introduction Health management information systems (HMIS) are the result of blending healthcare busi- ness operations and processes with informational, technological, and human resources. To un- derstand the role and capabilities of technology architecture in the healthcare environment, it is necessary to have a working knowledge of the various hardware, software, and interface con- cepts. It is assumed that most readers already have a basic understanding of many of these tech- nological concepts in this age of information and knowledge explosion. Hardware Hardware includes all physical devices (machines, storage, and input/output devices) that con- stitute a computer system. A computer system is a subsystem of an organization’s HMIS and is an assembly of physical devices connected to at least one processing mechanism, the central processing unit (CPU). Central Processing Unit Often referred to as the “brain” or “heart” of the computer, the CPU is the primary core of a computer system. The CPU consists of three associated elements: the control unit (CU), the arithmetic/logic unit (ALU), and the registers. 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 86 The CU accesses program instructions, decodes and interprets these instructions, and then issues to other parts of the computer system the necessary orders to carry out the functions. The CU coordinates the flow of data in and out of the ALU, registers, primary storage, secondary storage, and various input and output devices. The ALU receives instructions from the CU and then performs the necessary mathematical calculations and logical comparisons. The registers are used in the CU or the ALU. Registers are high-speed temporary storage areas used to hold small units of program instructions and data temporarily, immediately before, during, and after execution by the CPU. The CPU is designed so that data can be placed into or removed from a register faster than from a location in the main storage area. The CPU has the ability to process raw data into information and execute directions and instructions in a program. The execution of an instruction is known as a machine cycle. The machine cycles, which determine the speed of modern computer processing, are measured in nano- (one-billionth) and pico- (one-trillionth) seconds. Bus lines, which are the physical wires connecting the various computer system com- ponents, transfer data from the CPU to other system components. The number of bits that a bus line can transfer at any one moment is the bus line width, which should be matched with CPU word length. Word length is the number of bits a CPU can process at any one time. Multiprogramming involves executing more than one program at a time. The memory is di- vided into segments or partitions, each of which holds a program. Virtual storage is an exten- sion of multiprogramming, in which, instead of storing a complete program in memory, the computer stores in memory only a small part of the program at a time while the rest is stored on disk. Thus, the entire program is not needed because the computer is executing only a few in- structions at a time. The CPU is therefore less likely to be waiting for programs to be trans- ferred from disk to memory. This reduces idle CPU time and increases the number of jobs that can be completed within a given time span. Primary and Secondary Storage Primary storage, or main memory, is closely associated with the CPU. Primary storage holds program instructions and data immediately before or after the registers and provides the CPU with a working storage area for program instructions and data. All programs and data must be transferred to primary storage by way of an input device or secondary storage before programs can be executed or data can be processed. Types of primary storage include random-access memory (RAM), read-only memory (ROM), programmable ROM (PROM), and erasable PROM (EPROM). RAM is used for short-term storage of data and/or program instructions. It is the memory in which a program is stored when it is presently active in the computer. RAM is volatile because it requires a continuous application of power to retain data and programs: if the power is turned off, everything in RAM is lost unless it is first saved or stored. Two types of RAM chips are dy- namic RAM (DRAM) and static RAM (SRAM). The main difference between them lies in how often each needs to be refreshed or recharged per second. DRAM needs to be refreshed thou- sands of times per second, whereas SRAM needs to be refreshed less often. ROM is used for the permanent storage of program instruction, such as standard instructions. ROM can only be H A R D WA R E 87 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 87 read, not changed or erased, and is nonvolatile. The information it stores is not lost when the power to the computer is interrupted. PROM is a memory device in which the memory chips can be programmed only once and are used to store instructions entered by the purchaser. Once a program is written into PROM, it is permanent. EPROM is a device whose memory chips can be erased and reprogrammed with new instructions.1 Secondary (external) storage supplements main memory by holding data and instruction in machine-readable format outside the computer. It offers the advantages of nonvolatility, greater economy, and greater capacity than primary storage. Common forms of secondary storage are floppy disks, magnetic tape and disks, optical disks, optical or laser cards, and smart cards. Small areas or spots of magnetized particles are used to represent bits on magnetic tapes or disks. Two types of access to the information stored on the magnetic media are available. Direct access allows the computer to go directly to any desired piece of data, regardless of its location on the magnetic medium, such as a floppy disk (which is a flexible disk inside a plastic sleeve). Sequential access, on the other hand, can only read and write data in sequence, one data item after another (e.g., a cassette tape).2 Operating like a compact disc (CD) player, an optical disk device uses laser beams to store and retrieve data. One advantage of optical disk storage is its ability to withstand wear, finger- prints, and dust. Two of the most common optical disc storage systems are compact disc–read only memory (CD-ROM) and digital versatile discs (DVDs). Data are stored on these discs by burning small crevices into their coatings. This allows another laser device to read the disc by measuring the difference in the reflected light caused by the crevices on the disc. Each crevice represents the binary digit 0, and the smooth surface area represents the binary digit 1. Storage capacity in DVDs can be several times that of a typical CD-ROM. Typically, each side of a compact disc is capable of storing 800 or more megabytes of infor- mation, which may include text, sound, and pictures. A DVD has the ability to hold a massive amount of information (e.g., an encyclopedia or even a series of movies). Write once, read many (WORM) format allows users to record data only once on a customized basis and then access it whenever needed. WORM discs are nonerasable and are often used to store original versions of valuable documents or data (e.g., archives). Finally, optical or laser cards and smart cards are the emerging, secured secondary storage medium for many commercial applications. Resembling plastic credit cards, the only difference between these cards has to do with their storage (and processing) capacity. Smart cards have the added capability of “intelligent” processing. As the use of these cards proliferates in commercial and healthcare applications, the cost of manufacturing and supporting their applications will soon become very attractive. Input/Output Devices A number of devices can be used to input or enter data into a system. For larger computer sys- tems, key-to-tape and key-to-disk devices have been used, which allow data to be keyed directly onto a secondary storage device. Personal computers are often used for initial entry, editing, or correction of data before the data are downloaded to a larger system for processing. 88 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 88 Keyboards are inexpensive and easy-to-use devices that enter alphanumeric data. Some key- boards allow special character data input at the same time. Online data-entry and data-input devices are connected directly to the computer system by phone lines or cables. The mouse, a pointing device, is another example of an input device. Light pens and track balls, both of which evolved from the mouse concept, are becoming popular for use with portable and hand- held devices. Voice recognition systems are used to capture and respond to human speech. Scanning devices, such as direct magnetic ink character recognition (MICR) systems, allow data printed in a special magnetic ink to be read by both humans and computers; the bottom part of a check is an example. Optical scanners and data readers are used to read characters directly from a page without using special ink. Optical character recognition (OCR) equipment can read alphabetic, numeric, and special characters (i.e., bar codes). Image-processing systems use scanners to input an image into memory. Scanned images can then be manipulated by using graphic software and reprinted as de- sired. Other input devices include handwriting recognition devices, data tables, and touch screens. There are many forms of computer output media, including ink-jet and laser printers, video display terminals (VDTs), plotters that draw graphics on paper, computer output microfilm (COM) devices, and voice output devices. As we move into the future, the miniaturization trend of hardware will reduce the size of pe- ripheral equipment, CPUs, storage, and other computer components. With an increasing re- duction in hardware size and increased hardware processing capabilities, costs of computer hardware will continue to drop.3 This will generate faster, greater volume, and more accurate information for the user.4,5 Software Over the decades, software and user interface technologies have gained a larger share of total system costs.6 Advances in hardware have dramatically reduced costs; however, prices in soft- ware and user interface have increased. Currently, software encompasses 75 percent or more of the costs of an organization’s computer system.7 Increasingly complex software systems require more time, memory, and money to develop and, in turn, increase the demand for the product and the salaries of developers. Systems management software and applications software are two classes of software used routinely. Systems Management Software Systems management software refers to machine executable programs designed to supervise and support the overall functioning of the computer system, independent of any specific applica- tion area. Systems software manages computer resources, such as the CPU, printers, terminals, communication links, and peripheral equipment. Three main categories include operating sys- tems (OS), language translation programs (LTP), and utility programs (UP). OS, written for specific computers and usually stored on disk and transferred to memory when a computer is “booted” (i.e., turned on), run the computer hardware and interface with S O F T WA R E 89 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 89 applications software. Examples include Mac OS V10.5 (Leopard), Windows Vista, and Windows Server 2008. LTP convert statements from high-level programming languages into machine code. The high-level program code is referred to as the source code and the machine language code as the object code. To perform such a conversion, a compiler is used. An inter- preter executes each machine language statement, discards it, and then continues to translate the next statement. UP perform specialized functions directly related to the actual computer operation. They are considered part of systems software and are used to prepare documents, merge and sort files, keep track of computer jobs being run, manage printers and disk drives, recover lost programs, and lock confidential files. A mainframe is a large computer that has access to large amounts of data and is capable of processing these data very quickly. Mainframes have now been replaced with supercomputers. Online and real-time processing involves the running of a program whenever data are collected and entered into the computer system. Online processing is possible because terminals and other devices are directly connected to the main computer; as a result, data files are kept as cur- rent as possible. Batch processing is done at the end of the day, mostly to back up transactions and other data types. Applications Software Applications software, designed to handle the processing for particular tasks, refers to programs written to solve specific domain problems and cannot be used without the system software. A company can develop applications software in house (make), use existing off-the-shelf software (buy), or outsource part of their data processing (contract). Microsoft Office 2008, Adobe Flash, and Macromedia Dreamweaver are some of the more popular applications software systems. A programming language is a set of symbols and rules used to write program code. There have been at least five identifiable “generations” of programming languages. First-generation, or machine, language is the most basic level of computer operation. It uses binary coding and ad- dresses to execute instructions and is difficult to write because of its binary representation of in- formation as 1s and 0s corresponding to “on” and “off” electrical states of the computer. Second-generation, or assembly, language is a low-level symbolic language, unique to a specific computer. It replaces binary digits with understandable symbols to ease programming. Third- generation, or procedure-oriented, language uses structured English-like statements in the cod- ing of program instructions. Each instruction is equivalent to multiple machine-level instructions. Examples include Cobol, Fortran, Pascal, C, C++, Visual Basic, and Java. Fourth-generation language (4GL), or very high-level language, is nonprocedural and more English-like than any previous generation language. Its distinctive features include high-level queries for direct database access; interactive dialogs; simple-to-learn, helpful error messages; and use of defaults and relational database management systems. However, these application generators, as 4GLs are sometimes called, are often less efficient in terms of computer running time than earlier-generation languages. Examples include database query languages such as SQL, data analysis such as SAS, and report generators such as Oracle Reports.8 Fifth-generation languages, or artificial intelligence, include expert systems and natural language interfaces. Research in this domain has also advanced the knowledge of user–computer interface. 90 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 90 User–Computer Interface When the concept of interface emerges, it was commonly understood as “the hardware and software through which a human and computer could communicate.”9 Over time, the concept has broadened to include “the cognitive and emotional aspects of the user’s experience as well.”10 From a user’s perspective, an interface is a discrete and tangible thing that can map, draw, design, implement, and attach items to an existing bundle of functions. Interfacing allows users to interact with the computer to perform various interactive functions. Two main types of user–computer interfaces are action and presentation language.11 In ac- tion language, the user instructs the computer to take a series of actions; it is the way in which the user’s intentions are translated into syntax that the machine understands. A simple example is the use of a touch screen or an icon. Presentation language is the way in which the computer communicates with the user, for example, by the use of color and graphics.12 Four main designs for user–computer interface are graphical, iconic, direct manipulation, and group interfaces. A graphical interface is associated with presentation languages, whereas an iconic interface relates to action language. Graphical interfacing allows tables and numbers to be converted and represented spatially. Common examples include lines, bar graphs, and scatter plots. These in- terface architectures enable visual representations of trends, taxonomies, statistical summaries, forecasting patterns, and performance reports—generally giving the user an increased under- standing of data patterns and trends.13 Iconic interfaces use pictures or images to represent com- mands and objects that can be invoked by users.14 They allow for improved performance and learning and help eliminate unnecessary errors. Icons allow for easy recognition and categoriza- tion and are usually faster to absorb than words. A key disadvantage of iconic interfaces is that it is often difficult to convey the desired meaning to the user without sometimes invoking other undesirable properties and connotations. Three different classes of icons are representational icons (or metaphor graphics), abstract icons, and arbitrary icons. Representational icons or metaphor graphics15 are prototypical images of a specific class of physical objects. These types of icons correspond to real-world objects, thereby enabling the user to recognize the icons and make some inferences based on them. Examples of representational icons are file folds, trashcans, and document images. Abstract icons convey a specific concept us- ing a visual image. Examples of abstract icons are warning labels on household products. Arbitrary icons have a meaning assigned to them; however, they are often difficult to interpret. For these types of icons to be meaningful and useful, there needs to be some standard definition. Another design of user–computer interface is direct manipulation, which involves communica- tion between a system and a user through the physical manipulation of object representations us- ing a device, such as a mouse. The general characteristics of direct manipulation interfaces are a continuous representation of the object of interest; physical actions instead of complex syntax; and rapid incremental reversible operations, whose impact on the object of interest is immediately vis- ible.16 In general, direct manipulation incorporates the concept of an analogy between the system and a problem domain. Through direct manipulation, the users feel as if they are working on the actual problem of interest rather than interacting with an abstract, computer-based model. Finally, the complexity of the user interface increases as HMIS become more complex and there is a need for communication and collaboration between several individuals. Malone S O F T WA R E 91 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 91 defines a “group” interface as an organization interface (i.e., the parts of a computer system that connect human users to each other and to the computing capabilities provided by systems).17 A group interface provides a flexible interface that allows different individuals to communicate with one another efficiently and effectively. To tie in the discussion of hardware, software, and interface concepts with healthcare services organizations, we proceed with a real-world scenario where the applications of these concepts can improve organizational efficiency. How Hardware/Software and Interface Design Affect the Healthcare Services Industry During the 1980s, Harvard Pilgrim sought to expand its business presence through purchasing a number of healthcare services organizations. After 13 years of acquisitions, Harvard Pilgrim had accumulated more than 55 separate core HMIS applications that were not integrated with each other, including four claims-processing systems that failed to track claims or set accurate insurance premiums. The situation became critical in 1999, when the health maintenance or- ganization (HMO) reported an astonishing $54 million net loss and an operations loss of $94 million. A new management team was hired, and Louis Gutierrez, the new CIO, blamed part of this mess on the lack of Harvard Pilgrim’s systems integration. Immediately, Gutierrez looked for ways to improve IT operations. He decided to outsource both claims processing and the technology functions, which included data center operations, network infrastructure, and programming. In October 1999, the HMO signed a $700 million, 10-year contract with Perot Systems as an answer to the company’s massive IT problem. Unfortunately, the next year showed additional losses of between $60 and $70 million, and Harvard Pilgrim was forced into temporary receivership by the courts, effectively putting the organization into state control to keep it from going bankrupt. Searching for solutions, Gutierrez and Perot Systems decided to tackle the claims-processing mess first. They narrowed the problem to four outdated hardware and software systems that were unable to handle the heavy load of daily transactions. The team eventually kept only a sin- gle HMIS, upgraded it, and added a more durable hardware platform. They brought in Cap Gemini consultants to help install Oracle financials, human resources, and payroll systems, in an effort to consolidate all operational data from claims systems, pharmacies, and other third- party service providers. Since implementing these new systems, Harvard Pilgrim’s situation has stabilized, and the fi- nancial outlook gradually improved. During the turnaround, Harvard Pilgrim spent $75 to $80 million on HMIS investments alone. Surprisingly, Gutierrez credits much of the success to overall cost cutting rather than implementing new HMIS solutions. “Many of the key levers were decidedly nonsystems fixes,” he claimed. “A lot of the progress was in tighter management and better business processes. I learned a lot from that. We were very smart about what we did to clean up on the IT side, but it’s just not the case that one can point to massive new systems as the solution here.” 92 HMIS E N T E R P R I S E S O F T WA R E 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 92 Notes 1. K. C. Laudon and J. P. Laudon, Business Information Systems: A Problem-Solving Approach (Hinsdale, IL: Dryden Press, 1991). 2. J. O’Brien, Introduction to Information Systems in Business Management, 6th ed. (Homewood, IL: Richard D. Irwin, 1991). 3. T. K. Zinn, “HIS Technology Trends,” Computers in Healthcare (February 1991): 46–50. 4. C. Dunbar, “It Comes Down to Managing Minutes,” Computers in Healthcare (March 1992): 6. 5. S. L. Mandell, Dr. Mandell’s Ultimate Personal Computer Desk Reference (Toledo, OH: Rawhide Press, 1993). 6. P. J. Hills, Information Management Systems: Implications for the Human-Computer Interface (Toronto: Ellis Horwood, 1990). 7. J. Burn and E. Caldwell, Management of Information Systems Technology (Orchard, Oxfordshire, UK: Alfred Waller, 1990). 8. J. K. H. Tan, “An Introduction to Health Decision Support Systems: Definition, Evolution and Framework.” In J. K. H. Tan with S. Sheps (Eds.), Health Decision Support Systems, (Gaithersburg, MD: Aspen Publishers, 1998): 25–32. 9. I. Benbasat et al., The User-Computer Interface in Systems Design (British Columbia: Faculty of Commerce and Business Administration, University of British Columbia, 1993). 10. B. Laurel (Ed.), The Art of Human-Computer Interface (Reading, MA: Addison-Wesley Publishing Co., 1992). 11. Benbasat et al. (1993). 12. J. K. H. Tan, “Graphics: Theories and Experiments,” Computer Graphics Forum 11, no. 4 (1992): 261. 13. J. K. H. Tan and I. Benbasat, “Processing of Graphical Information: A Decomposition Taxonomy To Match Data Extraction Tasks and Graphical Representations,” Information Systems Research 1, no. 4 (December 1990): 416–439. 14. D. Gittens, “Icon-Based Human-Computer Interaction,” International Journal of Man- Machine Studies 24 (1989): 519–543. 15. W. Cole, Metaphor Graphics and Visual Analogy for Medical Data, Section on Medical Information Science (San Francisco: University of California at San Francisco, 1988). 16. Benbasat et al. (1993). 17. T. Malone, “Designing Organizational Interfaces,” Proceedings of CHI’85 (1985): 66–71. 18. W. Raghupathi and J. K. H. Tan, “Strategic Uses of Information Technology in Health Care: A State-of-the-Art Survey,” Topics in Health Information Management 20, no. 1 (1990): 1–15. 19. S. Patton, “Turnaround Strategies: Harvard Pilgrim Health Care Finds a Remedy.” Accessed July 7, 2008, from http://www.cio.com/article/31506. N O T E S 93 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 93 56918_CH04_Final_Tan 4/6/10 11:42 AM Page 94 Community Health Information Networks: Building Virtual Communities and Networking Health Provider Organizations Jayfus T. Doswell, SherRhonda R. Gibbs, and Kelley M. Duncanson 95 5 CHAPTER Editor’s Note: Building virtual community networks involves the use of a combination of the Internet and associated technologies (Technology Brief I); hardware, software, and computer- user interface design (Technology Brief II); as well as telecommunications and network technolo- gies (Technology Brief III). Its primary concern is the integration of community organizations as partners for healthcare services delivery. This represents an expansion of concepts discussed in HMIS administrative applications and technologies (Chapter 4), patient-centric management sys- tems (Chapter 6), and/or Web services applied for healthcare services delivery (Chapter 7). Community organizations will always play a significant role in the development and applica- tion of HMIS foundational concepts (Part I); technologies and applications (Part II); planning and management (Part III); and policy, governance, and globalization (Part IV). The knowledge acquired in Chapter 5 will, therefore, be useful and important to aid in the understanding of many other parts of this text. 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 95 S c e n a r i o : Designing an Intelligent Community Health Information Network1 Imagine that you have been asked to oversee the design of a new community health infor- mation network (CHIN) that would electronically link information from various “smart spaces” in a community ranging from homes, parks, fitness centers, and restaurants to avail- able health provider networks and other community services such as police, fire, and ambu- latory care. Depending on age, prior health condition, genetic profile, and current prescribed medica- tions, intelligent and noninvasive sensors may be employed remotely to monitor your health in a home environment, where personalized medicine is being propagated. While asleep, your bed may be equipped with sensors to monitor vital physiology to determine current health status against optimal health. When you wake up and brush your teeth, the toothpaste may be equipped with nano-particles to automatically eliminate tartar, and the toothbrush may include nano-electronics to collect information about critical plaque areas. Data collected from the toothbrush may wirelessly communicate incidences of periodontal disease, which has direct correlation to heart disease. At the same time, a mirror may use intelligent software agents to vi- sually recognize skin and eye abnormalities and determine severe incidences of stress, natural 96 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S CHAPTER OUTLINE Scenario: Designing an Intelligent Community Health Information Network I. Introduction II. Previous Community Health Information Networks III. From CHIN to RHINO IV. Prospects for RHINO V. HL7 Standard Health Data Exchange ● Community Management Systems VI. Mayo Clinic Case Study VII. Conclusion Notes Chapter Questions Technology Brief III: Telecommunications and Network Concepts for Healthcare Services Organizations Joseph Tan 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 96 aging, or the consequences of poor nutrition. When you urinate, sensors in the toilet may automatically analyze nutritional deficiencies and incidences of disease progression and update your health profile, all in real-time. Your genetic profile may automatically be registered when you go to the hair salon or barber shop when equipment, used to cut the hair, has embedded sensors to collect hair samples and process them using on-board “lab-on-the-chip” before send- ing data to the centralized CHIN repository. All information collected and processed using artificial intelligent algorithms may be filtered and then transmitted to the CHIN grid, where a collection of community-volunteer computer processors interpret the information and consequently reduce community healthcare costs. From a public health perspective, human healthcare data may be continually collected in parks, fitness centers, supermarkets, homes, and schools to monitor the overall health of various com- munities around the nation and the world to prevent illness, injury, and disease at an affordable cost to the community. Imagine no more—the future of intelligent CHIN is here! I . I n t r o d u c t i o n A community health information network (CHIN) is a combination of telecommunication and networking capabilities that links healthcare stakeholders throughout a community. It is what Ernst and Young Health Care practices describe as “interorganizational systems using in- formation technologies and telecommunications to store, transmit, and transform clinical and financial information.”2 This information can be shared among patients, providers, employers, pharmacies, and related healthcare entities within a targeted geographical area.3 The rapid advancements of e-commerce and managed care placed new demands on the healthcare industry in the 1990s to establish information infrastructures that facilitate timely, accurate, secure, and interoperable patient information across the continuum of care.4 Integrated healthcare delivery systems and managed care organizations responded by develop- ing health information networks within their organizations to support required internal infor- mation.5 Hospital information systems have evolved from mainframe legacy systems to complex, integrated, PC-based administrative, clinical, and financial decision support systems. In the late 1990s, the paradigm of dot-com start-ups has led to several online medical records solutions for healthcare providers unable or not wishing to support electronic medical records (EMR) internally. With the exception of Internet-based EMR, clinical and financial informa- tion was trapped within each organization’s system and could not be shared through the con- tinuum of care or with business partners.6 Data in EMR often could not be shared beyond the provider, and electronic data sharing was not possible between competitors even for the purpose of continuity of care. By 2002, the government recognized the inability of healthcare service organizations to effectively communi- cate healthcare information across disparate networks and consequently endorsed the National Health Information Infrastructure (NHII). The fundamental objective of the NHII is to bring timely health information to, and aid communications among, those making health decisions I . I N T R O D U C T I O N 97 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 97 for themselves, their families, their patients, and their communities. Individuals, healthcare providers, and public health professionals are key NHII stakeholders and users, and the applica- tions that meet their respective needs are distinct dimensions of the infrastructure. As a result of problems in data standards, patient restrictions in healthcare information ac- cess, and poor interoperability among healthcare systems, the concept of CHIN emerged. Specifically, the CHIN concept grew out of grassroots community efforts to streamline infor- mation among myriad partners with the end goal of better integration of care, increased cost savings, and efficient data interoperability.7 Many definitions are offered to describe CHIN. Common elements from these definitions include: ● Interorganizational information systems for data and information exchange among par- ticipants in the local healthcare delivery system. Members include physicians, clinics, hos- pitals, payors, managed care companies, community health centers, public health, laboratories, diagnostic/testing companies, pharmacies, and educational entities (includ- ing universities). ● Improved efficiency and effectiveness of healthcare services delivery. ● Independent operation of member organizations, often initiated by grassroots or community- based not-for-profit organizations. ● Resources and educational tools for the community and disease management and case management modules. I I . P r e v i o u s C o m m u n i t y H e a l t h I n f o r m a t i o n N e t w o r k s Various types of CHIN have emerged in the past, ranging from home healthcare delivery and voluntary care to enterprise- and telephone-based networks. For example, telephone-based net- works (funded by organizations such as ComputerLink) have emerged as a type of CHIN offer- ing a relatively inexpensive alternative to those involving a full-function centralized computer network. In early CHIN implementations, telephones provide community links through a low- cost, widely used alternative to care delivery. Used to address public health needs, telephone technology can help deliver medical, prevention, and patient self-care services through confer- ence calling, patient education, support groups, voice-mailing, referral information, announce- ments, and services. Even with the promise of improved healthcare delivery, very few CHIN implementations survived. Notable survivors include the Wisconsin Health Information Network (WHIN; www.whin.net) in Milwaukee and the London and Regional Global Network (LARG*net). The WHIN is an open system design intranet used to track, access, and distribute voluntar- ily provided patient and medical information.8 WHIN offers services such as eligibility verifica- tion, electronic claim submission, benefits review, and prescription-refill authorization. These services focus on the health transactions needed by healthcare professionals to tend to their pa- tients. It also delivers access to application, human, financial, and time resources to support the CHIN initiative. WHIN operates independently of its member organizations as a for-profit 98 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 98 organization that, in part, derives revenue from electronically processing healthcare transac- tions. WHIN is made up of three independent components working together to make the flow of information possible:9 ● WHIN connect software to give users access to the network. ● WHIN processor interface software to connect provider and health information. ● WHIN switch to route request for information and corresponding responses between users and providers, besides managing the network security. Some CHIN have focused on the efficient care for uninsured community residents.10 Others like the Vermont Health Information network11 provides a Web interface to assist consumers in finding quality medical and healthcare information on the Internet. Because of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), new iterations of CHIN have emerged with a better chance at success because of environmental factors such as increased data and transaction standardization. These factors simplify data exchange and promote Internet uti- lization for platform-independent applications and tools that will be more widely available to the community. I I I . F r o m C H I N t o R H I N O Community health information networks have evolved into what researchers and practitioners now call regional health information networks (RHIN) or regional health information organi- zations (RHIO), hereafter referred to as RHINO. As evolutions of CHIN concepts, RHINO are quickly becoming the organizational structure of choice for many healthcare organizations and networks. As discussed, the funding support for previous CHIN implementations was lim- ited due to reliance on cumbersome pre-Internet technology, lack of standardization of data, and insufficient funding sources. With the advent of advanced health data exchange methods from Health Level 7 (HL7); the adoption of NHII standards; and the work performed at the American Public Health Association health informatics/information technology special interest groups (SPIG), Healthcare Information and Management Systems (HIMSS), and the American Telemedicine Association, on-demand and client-governed healthcare delivery may now be achieved. More recently, Thielst defined RHINO as “a network of stakeholders within a defined re- gion who are committed to improving the quality, safety access and efficiency of healthcare through the use of HIT (health information technology).”12,13 RHINO involve a complex amalgamation of communitywide collaborations and the creation of sustainable organizational structures. They are designed to move healthcare information efficiently and inexpensively. RHINO usually proceed through a series of life cycle stages consisting of start-up (recognition of need, stakeholder consensus building, creation of organizational structure, governance, and acquisition of financial support and resources), transition (implementation under way, person- nel expansion, beta and pilot testing, and Web presence), and production (live data processing, adding new partners, and administrative routine). RHINO are typically not-for-profit organi- zations, although some are now adopting for-profit status. To successfully implement a I I I . F R O M C H I N T O R H I N O 99 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 99 RHINO, stakeholders must bring together competitors to share a common vision and goals. Key barriers14 to RHINO implementation include: ● Cost of development (46 percent). ● Lack of organizational leadership (2 percent). ● Lack of clinical nomenclature (19 percent). ● Concerns about data security (10 percent). ● Unknown (2 percent). At the same time, successful RHINO focus on the delivery of relevant information to clinicians at the point and time of care and clinical decision support (to help process vast amounts of data and benchmarking to save time and eliminate redundancies).15 HIPAA is also touted as being an enabler of RHINO through its requirements for privacy and security regulations that permit electronic health record (EHR) diffusion. There are three types of RHINO structures: federation, co-op and hybrids. According to Thielst16 1. Federation. RHINO structure includes multiple independently strong enterprises in the same region, which are self-sufficient but that agree to share access to information main- tained on a peer-to-peer basis. This is facilitated through a system of indexing (e.g., re- gional or statewide master patient index). 2. Co-op. RHINO structure also consists of multiple but smaller enterprises that agree to share resources and create a central utility. Within this structure, technology and admin- istrative overhead are shared. 3. Hybrid. As the name implies, hybrid structures contain both federation and co-op net- works. The model allows aggregation within and across healthcare organizations in large regional areas, statewide regions, or multistate regions. I V. P r o s p e c t s f o r R H I N O Ultimately, the primary goal for the CHIN evolution and the RHINO movement is the subse- quent establishment of a national health information network (NHIN). NHIN, which will be supported by new U.S. federal governmental initiatives, will comprise a network of RHINO. While progress toward this goal is still in the infancy stage, forums are taking place with discus- sions concerning connecting provider EHR and consumers’ personal health records (PHR) as well as state, regional, and nongeographic health information exchanges and specific network functions such as clinical laboratory records, disease registries, and beyond. To achieve the steps toward establishing a NHIN, practitioners must first address broader challenges faced in the healthcare competitive marketplace. These challenges relate to major is- sues such as: ● Competition. ● Internal policies. ● Consumer privacy. 100 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 100 ● Uncertainties regarding liabilities. ● Difficulty reaching multi-enterprise agreement on information sharing. ● Economic factors. ● Incentives. ● Interoperability. ● Security testing, authentication, and auditability. In a recent article, Feris17 notes that RHINO are struggling to survive, despite the intentions of U.S. Department of Health and Human Services (HHS) policy makers for RHINO to serve as the building blocks for a national system. A total of 145 RHINO were known to exist na- tionwide during their first inception. However, a recent Harvard University study showed that currently only 20 of these are functioning at a modest scale with just 15 of them tending to a broad set of patients. Nearly 25 percent of RHINO existing in mid-2006 have now gone defunct, suggesting an increased difficulty for achieving a nationwide electronic clinical data exchange. Key barriers to RHINO implementations are financial sustainability and partnering to in- crease membership. This seems to suggest that problems may exist in terms of championing by governmental and healthcare leaders. RHINO cannot succeed without the joint funding and sharing of resources from governmental, public, and private sector organizations. Consequently, healthcare leaders from the aforementioned networked organizations must lend their full sup- port to RHINO. In recognizing this need, Frisse18 also argues that sustained leadership, a re- view of best practices in other regions, and an assessment of regional needs and capabilities are all key to the long-term success of RHINO alliances. Frisse’s work concludes that over the long term, a truly interoperable health information infrastructure depends on the extent to which the alliances demonstrate value to consumers and practitioners. V. H L 7 S t a n d a r d H e a l t h D a t a E x c h a n g e The new CHIN will have to rely on standard health data exchange in order to achieve the health system data interoperability goal of the National Health Information Infrastructure. HL7 is a collaboration in health data standardization that would help to realize this goal. HL7—an international community of healthcare subject matter experts and information scientists who collaborate to create standards for the exchange, management, and integration of electronic healthcare information—promotes the use of health data standards within and among healthcare services organizations to increase the effectiveness and efficiency of healthcare services delivery. It focuses on developing coherent, extendible standards that permit structured, encoded healthcare information of the type required to support patient care to be exchanged between computer applications while preserving meaning. The stated goals of HL7 collaboration are to: ● Develop coherent, extendable standards that permit structured, encoded healthcare infor- mation of the type required to support patient care, to be exchanged between computer applications while preserving meaning. V. H L 7 S T A N D A R D H E A L T H D A T A E X C H A N G E 101 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 101 ● Develop a formal methodology to support the creation of HL7 standards from the HL7 Reference Information Model. ● Educate the healthcare industry, policy makers, and the general public concerning the benefits of healthcare information standardization generally and HL7 standards specifically. ● Promote the use of HL7 standards worldwide through the creation of HL7 International Affiliate organizations, which will, in turn, participate in developing and in implement- ing HL7 standards locally as required. ● Stimulate, encourage, and facilitate domain experts from healthcare industry stakeholder organizations to participate in the HL7 healthcare information standards developmental process in their area of expertise. ● Collaborate with other standards development organizations and national and interna- tional sanctioning bodies such as the American National Standards Institute (ANSI), International Organization for Standardization (ISO), and others in both the healthcare and information infrastructure domains to promote the use of supportive and compatible standards. ● Collaborate with healthcare IT users to ensure that HL7 standards meet real-world re- quirements and that appropriate standards development efforts are initiated by HL7 to meet emergent requirements. HL7 Version 3 is an HL7 messaging standard that has been developed. Version 3 uses a Reference Information Model (RIM) as a common source for the information content of speci- fications. As part of Version 3, the HL7 Vocabulary Technical Committee developed methods that allow HL7 specifications to draw upon codes and vocabularies from a variety of sources. The V3 vocabulary work ensures that the systems implementing HL7 specifications have an unambiguous understanding of the code sources and code value domains that are being used by those who adopt HL7 standards. The HL7 Version 3 development methodology is a continuously evolving process that seeks to develop specifications that facilitate interoperability among healthcare systems. The HL7 RIM, vocabulary specifications, and model-driven process of analysis and design combine to make HL7 Version 3 one methodology for development of consensus-based standards for healthcare information system interoperability. Community Management Systems New CHIN need to implement community management systems that operate from a central information hub. This “hub” connects to practice management systems, personal medical records, and novel health data collection devices around a community. For practice management systems delivered from private healthcare organizations and hospi- tals, electronic billing and patient scheduling are being developed to reduce time for data entry and increase the accuracy of billing/coding, patient scheduling, and reporting to healthcare in- surance companies through registered clearinghouses. Practice management systems do not 102 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 102 work alone but are accompanied by electronic records that are increasingly complementing and, in some cases, replacing physical charts. Earlier versions of electronic medical records are lim- ited mostly to gathering patient data only in a single-provider clinical environment—the data therefore, would, not be easily shared with other providers. Owing to reported medical errors arising from restricted sharing of critical healthcare in- formation, policies are now being addressed on the need to apply HL7 to facilitate the ex- change of EMR across healthcare providers and managed through practice management systems. This observed trend in data sharing, as discussed, provides the benefits of improv- ing the quality of care services to patients, who are potentially consumers in a community. As well, the new HL7 standardized data system will provide a trajectory record of patient historic data and prescriptions to yield better accuracy in portraying a person’s health state at any time. Unfortunately, there still is a lack of health decision support systems that will be referenced on the recorded data to help healthcare providers improve their quality of decision making with respect to optimizing care for the patient. In this sense, new CHIN are being developed with artificial intelligent (AI) algorithms embedded. The application of such intelligent CHIN will not only enhance the analysis of patients’ health profiles, but also provide continuous monitoring of their lifestyle changes (e.g., nutrition and exercise). Moreover, for the purpose of public health reporting, these intelligent CHIN will permit the use of predictive models to further determine health risk and the onset of adverse health impact to both the individuals and the community. A good example of a community health exchange system would be that of HealthBridge. HealthBridge, a not-for-profit health information exchange center, primarily serves Cincinnati, Ohio, and the surrounding area. The organization is noted as being one of the nation’s largest, most advanced, and most financially successful community health information exchanges. HealthBridge provides connectivity for more than 4,400 physicians; 29 hospitals; 17 local health departments; and dozens of physician offices and clinics, nursing homes, independent labs, and radiology centers, as well as connectivity for others in the healthcare community. Through the clinical messaging system, HealthBridge is able to deliver more than 2.4 million laboratory, radiology, transcription, and Admission-Discharge-Transfer (ADT) results to physi- cians every month. Currently, HealthBridge represents nearly 95 percent of the hospital sector activity in the Cincinnati region.19 HealthBridge’s exchange system is driven by software developed by the Axolotl Corporation. According to CEO Ray Scott, this is how the system works: (1) Each hospital pushes out re- ports from its own systems to a local Axolotl server. (2) In turn, periodically the local server pushes aggregated data to a central HealthBridge server. (3) From there, reports are collated from the various hospitals and sorted by patients against a community index that the software maintains. (4) Then, organized around the physician of record, these “messages” are distributed to physicians electronically, via fax, or through the regular mail. Many physicians receive the messages electronically but print out the results they need for their own charts. This, in turn, benefits the hospitals since they no longer must mail and track reports being generated by V. H L 7 S T A N D A R D H E A L T H D A T A E X C H A N G E 103 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 103 multiple departments. Furthermore, by organizing data around physicians, HealthBridge side- steps sticky privacy issues.20 HealthBridge has overcome major milestones with regard to its clinical messaging feature. At the beginning, physicians were constrained by the company’s “pull” technology. Eventually, the messaging system gained the capacity to “push” information out to the hospitals. And for the first time, they could justify HealthBridge through a more definitive return on investment formula. Now with the ability to use a common tool to distribute lab results, radiology re- ports, transcribed documents, and admission-discharge-transfer summaries, hospitals could identify savings. V I . M a y o C l i n i c C A S E S t u d y At this point, it should be noted that the possibilities for enhancing an interoperable CHIN are limited only to our imagination as described in the opening scenario of this chapter. We close the chapter with a case study on the Mayo Clinic. In this case study, the organizational struc- ture described closely resembles that of a hybrid RHIO—or a RHINO—functioning in two ways: utility versus neutral/convener/facilitator. Whereas the utility works using a centralized database and serves as a patient information exchange, clearinghouse, and location, the role of the neutral/convener/facilitator is to partner competitive enterprises and bridge multiple RHINO through an open-standards approach. Indeed, the latter of these two roles is more dif- ficult to implement, although it may be ideal for laying the foundation to establishing a National Health Information Network. In recent years, an increasing number of healthcare organizations began efforts to create more efficient, integrative communication and information systems infrastructure and architec- ture. For instance, to increase its effectiveness and to affect surrounding communities with its capabilities, the Mayo Clinic has pursued an aggressive strategy of complementation using a number of communication configurations, including both hub-and-wheel and group commu- nity support systems. The Mayo Clinic, which is most renowned for its outpatient clinic, is a diverse and complex organization. Today, the Mayo Clinic network spans far beyond its outpatient facilities to in- clude multiple hospitals, research facilities, a medical university, affiliated partner clinics and hospitals in surrounding states, and independently run hospitals and clinics in places such as Arizona and Florida. Affiliated hospitals and clinics are located in smaller communities in southern Minnesota, northern Iowa and western Wisconsin. All facilities within the network are able to provide better patient and community care because they benefit from the vast re- sources, knowledge, and technological capabilities of the Mayo Clinic. Through shared re- sources (e.g., clinicians, researchers, and information systems), smaller hospitals and clinics are able to offer specialized radiological services or cancer treatments to patients. While many of the affiliate and independently run hospitals maintain their own centralized EMR, patient medical history is shared through a centralized EMR database maintained by 104 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 104 Mayo. At the same time, affiliate hospitals and clinics can access Mayo’s centralized EMR to monitor the health care of their patients at other Mayo facilities. Mayo’s visionary leadership and its integrated IT systems group enabled this strategy of collaboration. The IT group used the Tandem platform and GE Carecast software to develop Mayo’s centralized, comprehensive EMR system that now contains data from all providers within Mayo’s network. Through this system, Mayo is able to maintain an EMR system that provides unprecedented access to patient history and medical information. EMR for patients seen at affiliates within the Mayo network can be retrieved by author- ized network providers by way of a master patient index (MPI) linked to the centralized EMR system. Mayo employs electronic data interchange (EDI) using HL7 messaging to fa- cilitate data sharing among affiliates whose EMR systems may operate on diverse platforms such as the IBM mainframe, Sun OS, AIX, AS/400, or Linux. Even within Mayo’s main campus facilities, researchers and clinicians enjoy cross-platform access to shared departmen- tal resources, directories, and server-based applications. This is due in part to Mayo’s unique RHINO implementation. Mayo’s information infrastructure allows for the integration of disparate platforms and sys- tems, giving network providers maximum flexibility in resource selection. Mayo’s research computing facility,21 for example, utilizes Red Hat Linux high-powered computing systems to perform large computations for research. In contrast, Mayo’s on-campus hospitals may opt to maintain EMR on the IBM platform, while specialty areas such as radiology may use the Sun OS. Despite the diversity in systems, through HL7 EDI, patient medical data are continually sent to the integrated, centralized EMR system via the MPI and standard system interfaces. This eliminates the need for cross-training on multiple systems and enables better decision making on the part of the care providers. Health care becomes more efficient by providers hav- ing access to their own system as well as the centralized EMR. Theoretically, a patient’s com- plete medical history could be available to any Mayo network care provider. The RHINO implemented by Mayo is particularly important for healthcare organizations that (like the Mayo Clinic) are frequented by patients from other cities, states, and countries. Figure 5.1 il- lustrates Mayo’s health information network and depicts the various components of its com- munications systems infrastructure. Mayo offers a fully integrated intranet that allows providers access to shared information and Web-based applications. Patients and potential patients also have access to research and information disseminated by Mayo care providers through the Mayo Clinic consumer infor- mation website.22 Soon, Mayo Clinic patients will be able to make Web-based calls into a sep- arate customer-centric website, where patient portals allow customers to view their bills and information online while speaking with their physicians. Mayo is also taking the lead by tap- ping into multimedia technologies that offer simulation-based education to medical students and residents.23 Although integration and collaboration dominate current planning efforts at Mayo, research performed in specialized fields such as genetics may exist external to the infra- structure described. V I . M A Y O C L I N I C C A S E S T U D Y 105 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 105 V I I . C o n c l u s i o n While the Mayo model is reflective of current healthcare trends, like many healthcare institu- tions, change is painstakingly slow, whereby new technology and innovative methods for deliv- ering patient information are provided only after its effectiveness and efficiency have been proven. Current efforts toward cost minimization and improved patient care are starting to af- fect this brontosaurus-like movement. However, technological challenges and policy-related is- sues may continue to stall RHINO implementations so long as information infrastructures are 106 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S Mayo Hospitals Shared Applications Web Servers Etc. EDI Interface EDI Interface Data Data Data Affiliate Hospitals and Clinics Data Centralized EMR Centralized EMR Patient Portal Master Patient Index Genetics Pharmacy Laboratories and Imaging Patients Mayo Governance Data DataData FIGURE 5.1 Mayo Clinic Health Information Network. 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 106 governed by well-intentioned committees concerned with the effects of network innovations on established policies and procedures. In cases where technology adoption and network collabora- tion decisions are dictated by a single decision maker or specially appointed teams, more inno- vative and expedited choices can be made. Whether the larger community accepts the resulting RHINO and adopted technologies has yet to be further evaluated. Other issues that may arise with a RHINO setup like the Mayo Clinic’s include problems with data shadowing and the need for creating interfaces to communicate among disparate platforms and software. These problems are, in part, controlled by implementing HL7, which enables messaging and data interchange among systems. Also, the continuing need for CHIN data storage, backup, and replication on all platforms must be accommodated with a failsafe for system outages and during times of inclement weather. Timing is another cause for concern be- cause patient test results may be delayed or dated depending on the accuracy and speed of the RHINO EDI. Reciprocal access is another potential problem that has to be addressed. While Mayo’s centralized EMR is available to affiliates, the same access to affiliates’ EMR may not be available to Mayo’s main campus providers. At the same time, Mayo allows network providers limited access to patient EMR while technical issues, security protocols, and agreements are re- solved. The governing bodies of organizations within the network must decide the scope and level to which access (and reciprocal information sharing) is given to other network providers that will allow the best patient care possible. RHINO or CHIN like the Mayo Clinic were set up to improve the quality of health care, support provider decision making, and facilitate cost reductions.24 They allow physicians to make better judgments concerning patient care, which saves lives, time, and money. To truly benefit from a CHIN, hospitals must closely align their centralized systems with key business processes and strategies. The systems will then generate strategic output, whose uses allow CHIN providers to enjoy an advantage over competitors. As is the case with the United Kingdom na- tional healthcare model, most hospital systems are moving toward CHIN/RHINO, where all af- filiated healthcare facilities can feed to and read from a centralized “spine” that houses all patient data. Eventually, it is expected that more use of wireless technologies will factor into CHIN/RHINO when issues such as learning curves and compatibility can be overcome. N o t e s 1. F. Payton and P. Brennan, “How a Community Health Information Network Is Really Used,” Communications of the ACM 42 (1999): 85–89. 2. Ibid. 3. F. Payton, P. Brennan, and M. Ginzberg (1995). “Needs Determination for a Community Approach to Health Care Delivery,” Special Issues Series on Management of Technology in Health Care, International Journal of Technology Management 1, no. 1 (1995): 157–173. 4. P. Soper, “White Paper: Realizing the Potential of Community Health Information Networks for Improved Quality and Efficiency through the Continuum of Care: A Case Study of the HRSA Community Access Program and the Nebraska Panhandle Partnership for Health and Human Services,” WHP023A, December 2001. 5. C. J. Austin and S. B. Boxerman, Information Systems for Health Services Administration (Chicago: Health Administration Press, 1997): 359–381. N O T E S 107 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 107 6. Soper (2001). 7. Ibid. 8. Payton and Brennan (1999). 9. J. Tan, Health Management Information Systems: Methods and Practical Applications, 2nd ed. (Gaithersburg, MD: Aspen Publishers, 2001). 10. Soper (2001). 11. http://library.uvm.edu/dana/vthealth/. 12. C. B. Thielst, “Regional Health Information Networks and the Emerging Organizational Structures,” Journal of Healthcare Management, 52 (2007): 146–150. 13. C. B. Thielst and L. E. Jones, Guide to Establishing a Regional Health Information Organization (Chicago: Healthcare and Information Management Systems, 2007): 1. 14. www.himss.org/content/files/vantagepoint/vantagepoint_200604b.htm, Vantage Point, 2006. 15. Thielst (2007). 16. Ibid. 17. N. Feris, “RHINOs Fail to Thrive, New Study Finds,” Government Health IT, December 11, 2007, www.govhealthit.com/online/news/350142-1.html, accessed December 12, 2007. 18. M. E. Frisse, “State and Community-Based Efforts to Foster Interoperability,” Health Affairs 25 (2005): 1190–1196. 19. http://www.healthbridge.org/index.php?option=com_content&task=view&id=5&Itemid =6, accessed October 29, 2008. 20. http://www.healthbridge.org/downloads/HealthLeaders-2005-07 , article published May 2005. 21. http://mayoresearch.mayo.edu/mayo/research/rcf/crick.cfm, accessed October 1, 2007. 22. www.mayoclinic.com. 23. http://www.mayo.edu/simulationcenter, accessed October 9, 2007. 24. R. Wullianallur and J. K. H. Tan, “Strategic IT Applications in Health Care,” Communications of the ACM 45 (2002): 56. C h a p t e r Q u e s t i o n s 5–1. In the future, with advanced EMR and CHIN, public health experts will be able to mon- itor health levels of the masses of populations and certain at-risk groups. Comment and discuss the implication of this statement. 5–2. How is data sharing different between previous CHIN, RHINO, and something like the Mayo Clinic? 5–3. Interoperability is facilitated through the use of HL7 for standardization among health- care systems. This protocol was not previously available among other systems. Additionally, wireless technologies and better visualization systems are advances in health IT. Sensors are also used for better data collecting. What do you see as the trend of RHINO or the potential of an NHIN? 5–4. Advances in technology and multidisciplinary thinking have driven the evolution be- tween previous and current CHIN. Healthcare informatics takes stored data about a population of people’s health and analyzes the data to retrieve current reality and trends occurring within certain groups. Physicians realized that better and more accurate care could be provided through electronic data interchange of patient information between providers. This sparked the creation of electronic medical records and the concept of a centralized IT system. Provide a rationale for the noted evolution. 108 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 108 Telecommunications and Network Concepts for Healthcare Services Organizations1 Joseph Tan 109 III TECHNOLOGY BRIEF I n t r o d u c t i o n Telecommunications has been conceptualized since the mid-1800s, when the telegraph, tele- phone, and teletypewriter all emerged. Since the 1960s, it has become one of the world’s fastest growing areas of technology as its applications allow individuals, as well as businesses, to access information near-instantaneously from anywhere in the world. Metcalfe’s law, N(N – 1), where N refers to the number of nodes on the network, expresses the value of a network to a business; apparently, as N grows, the number of connections tends to grow exponentially. In Technology Brief I, we covered the fundamental concepts of network technologies such as the Internet, intranets, and extranets. Here, we expand the discussion to look at how network and telecommunications technologies relate to the transformation of healthcare services organ- izations. To date, many of these organizations have all been reconstituted under one of two arrangements: consolidation or complementation.2 Each of these two different arrangements eventually suggest the relevant administrative and appropriate technological requirements that can help them achieve their intended goals of functioning as a merged organization. C o n s o l i d a t i o n v e r s u s C o m p l e m e n t a t i o n Consolidation, sometimes purported as a “market-sheltering activity,” occurs when two or more comparable healthcare services organizations combine to augment or preserve market power. The 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 109 merger leads to reduced price competition and aggregated economies, as well as operational effi- ciencies, which, in turn, will result in a quasi-monopoly or local market dominance.3–5 A health maintenance organization (HMO), where the player with the most money rules, is a good example. By instituting uniformity across specialties in local and regional hospitals, the now-defunct Columbia/HCA had consolidated to gain a dominant market position.6,7 This, in turn, helped the HMO to gain leverage on local pools of physicians who wished to gain practice privileges on mul- tiple sites, as well as to benefit from operational efficiencies in managing their overlapping services.8 The development and implementation of a common managerial system (CMS) is a key ad- ministrative necessity for consolidation. Instituted through a formal managerial process, CMS provides a shared platform for guiding policies and procedures, standard business practices, and performance evaluation.9,10 For instance, Columbia/HCA’s CMS streamlines overlapping activ- ities offered by the original separate units in the same neighborhood and concentrates all the previously nonoverlapping activities of various geographically dispersed units into a single oper- ation. Not only were administrative overheads drastically reduced, but allocation and sharing of resources were also economized. From a corporate perspective, the Columbia/HCA network, during its rise to popularity, was able to achieve greater economic benefits while simultaneously developing superior enterprise resource planning, allocation, and management. Complementation occurs when two or more healthcare organizations with contributing production/service expertise selectively merge. Such a union capitalizes on transactional economies, expands both the scope and area of services for an individual-partner organization, and reduces costs via symbiotic interdependence.11 Such a partnership is analogous to supplier– retailer value chain integration, as illustrated by the merger of Vencor and Hillhaven, which re- sulted in the nation’s second-largest nursing home chain. As Osterland notes, “Vencor treats chronically ill patients, particularly those with respiratory problems, through a network of 36 hospitals, while Hillhaven provides nursing home care and rehabilitation service. . . . Therefore, if Hillhaven patients get sick, they can be placed in Vencor hospitals. If Vencor patients im- prove, they can be referred to less intensive Hillhaven facilities.”12(p.20) The Vencor–Hillhaven case also contrasts the main rationale of consolidation versus comple- mentation. That is, consolidation typically occurs with healthcare organizations competing in different locations of the same market, whereas complementation increases the scope or area of cooperational services in a region by unifying partner organizations with complementary pro- duction or service expertise. Therefore, the implementation of cooperative data interchange sys- tems to oversee the supplier–retailer value chain, such as the Vencor–Hillhaven’s cross-referral system, is a key administrative necessity for complementation. With regard to computing archi- tecture, contemporary client–server-based IT can bridge disparate systems and manage the dis- tribution of transaction-oriented functionality.13 K e y H e a l t h c a r e C o m m u n i c a t i o n C o n f i g u r a t i o n a n d S y s t e m A r c h i t e c t u r e Several categories of health communication configuration and system architecture can be used to support consolidation and/or complementation: (1) the hub-and-wheel (H&W) communication 110 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 110 configuration, (2) open systems and intranets, (3) groupware and group communication sup- port systems (GCSS), (4) executive information systems (EIS), and (5) others. Given that Technology Brief I already covered open systems and intranet architecture, we will briefly touch on these topics while focusing primarily on H&W, GCSS, EIS, and other configurations. Hub-and-Wheel Hub-and-wheel topology comprises (1) the hub, which enables centralized system control or monitoring among inter-unit exchanges, and (2) the wheel, which includes systems that sup- port and respond to local requirements and functional linkages between and among units.14 Unlike peer-to-peer (P2P) networks, where central file servers are not used and all networked computers are automatically opened for accessing any publicly stored files, H&W employs client–server computing. Client–server computing supports the hub configuration through its architecture, in which a specific application is partitioned among multiple processors (clients) that combine the process in a single, unified task (server).15 Essentially, a hub network system sustains a many-to-many system linkage by using a local area network (LAN), metropolitan area network (MAN), or wide area network (WAN) to connect the geographically dispersed clients and servers. Conversely, end-user computing supports the wheel configuration by featur- ing applications administered by local unit, often involving LAN-based connections.16 The H&W topology typically exhibits a two-tier network configuration. For one layer, a client–server-based distributed network, which serves as a control and coordination channel, is commonly installed between headquarters and the remote units. This “hub” configuration, with an implemented CMS that employs resource sharing and elimination of redundancies to consolidate all activities into a single operating framework, supports the expansion of healthcare services organizations via consolidation. The other layer, supported by a number of LAN-based installations, is of the “wheel” configuration. Here, the inter-unit linkages are typically achieved via a private access-protected WAN. Alternatively, links between far-flung local area networks, among other links, can be achieved by a proprietary organizationwide network using a satellite- based WAN, as opposed to the H&W configuration. Healthcare services organizations expanding via complementation will therefore also find H&W a necessity and a preferred configuration because it supports the linkages between het- erogeneous systems, which are common to partnering specialty healthcare services organiza- tions. In summary, H&W does not only empower headquarters as the core resource coordinator/controller by providing the units access to the LAN-based bulletin board systems or the corporate databases, it also allows the remote units to be more efficient and responsive to local situations.17 Open Systems and Intranets Open systems, as characterized by the Internet, electronic data interchange (EDI), and ex- tranets, provide a supportive computing architecture to an HMO expanding via consolidation or complementation. They offer two-way access for external agencies, provide for the exchange of standard-formatted transactions, and support electronic ordering and invoicing through EDI. As these Web-based open-system networks gradually become the mainstream of emerging C O M M U N I C A T I O N C O N F I G U R A T I O N A N D S Y S T E M A R C H I T E C T U R E 111 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 111 technologies, they heighten the ability of healthcare services organizations to share information both within and across organizational units. Moreover, intranets provide unmediated reticular linkages for exchanging information be- tween corporate headquarters and their units. The architecture also promotes additional com- munication support for the expansion of healthcare services organizations, specifically for operations transforming via complementation. This mode of expansion demands a more effi- cient informal channel for coordination and collaboration of integral activities, which, in turn, require input from both formal and informal sources. This is especially true when intersecting activities require inter-unit relational linkages or involve quasi-autonomous units, such as those between two specialized hospitals. Technologically, intranets also complement the previously introduced H&W communication configuration by increasing the effectiveness of local re- sponses, especially in sharing know-how information on research and development (R&D). It is also an important supportive communication system for healthcare services organizations ex- panding via consolidation, because it can facilitate the development of a common operating framework for the consolidated functions or services. To illustrate, Koala, a corporate intranet of Columbia/HCA, provides a common intracommunication network for delivering patient care among the local units while consolidating various services.18 Finally, intranets provide support for intelligence, the tool for capturing and sharing corpo- rate knowledge. This knowledge-sharing capability makes it easier for a healthcare services or- ganization to market new services better than its competitors, thereby meeting or exceeding the expectation of its customers. Traveling health executives can also use the corporate intranet as a means of keeping in touch with headquarters and staying abreast of late-breaking company in- formation. Essentially, intranets support free access to internal online databases, corporate grapevine communications, and information interchanges among dispersed units.19 Healthcare organizations have used intranets to distribute information, computing applications, and every- day communications (such as online medical newsletters), and even as virtual meeting places for work groups. In summary, the intranet architecture is essential for complementation, but supportive for consolidation, because it allows for efficient and effective supply chain manage- ment and collaboration across networked partnering organizations. Group Communications Support Systems Group communications support systems provide a platform for group cooperation and collabo- ration. The architecture will affect the way people work and, eventually, the reporting and power structure of the organization. GCSS support real-time communication among distant locations via a public or proprietary WAN and provide a common and shared interface with representational capability. In other words, GCSS can use information control to facilitate cooperative work and group collabora- tion, support communication processes among group members, and reduce group communica- tion barriers such as distance, cultural, and linguistic differences.20 GCSS can also generate collective wisdom, knowledge, and better interpersonal communications; these can then be ap- plied to increase productivity, reduce costs, and improve services or product quality. GCSS, ul- timately, offer the opportunity for interaction among remote units and are, specifically, capable 112 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 112 of collecting and exchanging different inputs or decision predicates from widespread sources. From this perspective, GCSS establish the communication basis for supporting both the rela- tional linkages among subsidiaries and the interactions between quasi-autonomous corporate units. It is expected that GCSS use will improve decision-making quality, enhance user satis- faction, and increase the efficiency of group meetings. Common examples include the use of videoconferencing, electronic messaging systems, electronic boardrooms, and local group networks. GCSS will, therefore, offer a communications solution for complementation, because health- care services organizations expanding via this mode require the establishment of cooperation- oriented processes to support the intersecting activities between their quasi-autonomous corporate units. Executive Information Systems Executive information systems enable headquarters to monitor the operational performance of remote units. The architecture provides senior managers with critical aggregate information to facilitate coordination on key strategic decisions. EIS collect, filter, and extract a broad range of current and historical information from mul- tiple applications and multiple data sources, both internal and external to an organization. EIS functions are deemed essential for healthcare services organizations expanding via consolida- tion, because the concept involves the extension of organizational communications systems to widespread healthcare units or networks. The technology benefits those healthcare services or- ganizations, specifically, that demand process consistency and coordination. Finally, the EIS architecture is complementary to the H&W configuration. EIS can assist top management in extracting, filtering, compressing, and tracking critical data from dispersed corporate units, while providing online access, trend analysis, exception reporting, and drill- down capabilities.21,22 Drill-down is an exceptional capability of EIS; it allows top management at headquarters to access or track a remote unit’s detailed operational status and performance indicators by conducting a reverse exploration of a critical data point. By monitoring the indi- cators preset by top executives, EIS can also quickly and automatically identify the unit that has not met corporate performance benchmarks. Top healthcare executives receive needed informa- tion from many sources, which may come in the form of memos, periodicals, letters, telephone calls, meetings, social activities, or reports produced either manually or electronically. With the growth in the use of electronic devices such as personal digital assistants (PDAs), executives nowadays rely on paper-based sources and electronic means equally to meet their information needs. Therefore, for EIS to become truly useful and practical in this day and age, these systems must be linked to data from multiple sources and permit the exchange of data with diverse elec- tronic devices, such as PDAs, at any time. Other Configuration Several other network configurations may be used to support information flow and e-commerce exchanges when healthcare services organizations merge. In this sense, the use of hybrid and wireless topology are two potential network configurations. C O M M U N I C A T I O N C O N F I G U R A T I O N A N D S Y S T E M A R C H I T E C T U R E 113 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 113 Combining the bus and H&W configurations, hybrid typology can be used to satisfy the ad- ministrative requirements of an HMO expanding via either consolidation or complementation. The bus (or backbone) typology dictates that all connected devices be linked to a central cable and is the easiest or least expensive network typology to install. When combining the bus with the H&W typology, the enhanced hybrid network will be flexible in supporting the data-sharing, intersect-transaction processing, and information exchange needs of both centralized headquar- ters and its dispersed but affiliated units. Similarly, wireless typology can also be used to support either a consolidated or comple- mented HMO expansion. With wireless networks, devices are connected by a receiver/transmitter to a special network interface card that transmits signals between a computer and a server, all within an acceptable transmission range. Wireless typology can be used in a LAN-based, MAN- based, or WAN-based network. A MAN-based network provides connectivity of data commu- nication services for healthcare services organizations within a geographic area or region larger than a LAN-based network but smaller than the area covered by a WAN-based network. This is usually within the confines of a metropolitan region, whereas LAN connections span mostly roundabout a localized area, such as nearby buildings within a university and WAN could cover as far as the four corners of a nation like the United States. At this point, we move to a case on wireless applications for healthcare services delivery. A C a s e o f Wi r e l e s s N e t w o r k i n g i n t h e I n g a l l s H e a l t h S y s t e m Ingalls Memorial Hospital, a renowned community medical center located south of Chicago, is taking a technology lead among its competitors. As a 564-bed private facility operating within the Ingalls Health System, it is consistently ranked among the top 50 hospitals by US News and World Report. According to a February 2008 press release, Ingalls recently engaged ARINC to design and implement a wireless network system for positioning its physicians, nurses, and other clinical staff to gain rapid access to medical data. The newly planned system is designed to support a virtual private network (VPN) of the newest Wi-Fi standard—802.11N—for fast, secure wireless transmissions. Such a move could simultaneously reduce paperwork and increase the dependability of medical records, resulting in improved clinical efficiencies and effectiveness. In addition to installing private network ac- cess points throughout the hospital’s campus and other Ingalls facilities in nearby areas, AR- INC also plans to offer complimentary Wi-Fi access in its public areas. “We are moving forward as the technology permits to ensure patient safety and enhance the quality of care Ingalls provides,” stated Vince Pryor, the CFO for Ingalls.23 “One of Ingalls’s core values is to seek innovative approaches to delivering high-quality patient care for the com- munities we serve, by leveraging technology in our healthcare environment.” One immediate application of the ARINC-installed network will be to track the distribution of medicine to patients. It is envisaged that bar codes and scanners will provide an electronic means of collecting data about the types, times, and dosages of medications administered, re- sulting in the elimination of potential human errors. 114 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 114 Moreover, the new Ingalls system will be designed to enable the introduction of voice over Internet protocol (VoIP) technology—a technology that will provide a means of relatively inex- pensive, quick, and clear communications across the hospital’s campuses. Other future updates of the system anticipated include such ancillary support systems that will allow physicians ac- cess to medical information from the patient’s bedside, automated physician-submitted med- ication orders, and electronic file documentation. Such flexibility is further expected to maximize Ingalls’s preparedness for future health IT strategies and applications that may de- velop, ensuring that it remains among the top-ranked hospitals in America. N o t e s 1. The content of Technology Brief III presented here is based largely on the published work of Wen et al. on the same topic, appearing in J. K. H. Tan, Health Management Information Systems: Methods and Practical Applications, 2nd ed. (Gaithersburg, MD: Aspen Publishers, 2001). 2. R. C. Coile, “Health Care Outlook 1997–2005: Transitions, Transactions, and Transformations,” Journal of Lending & Credit Risk Management 79, no. 8 (April 1997): 18–22. 3. H. Leibenstein, “X-inefficiencies Xists—Reply to an Xorcist,” American Economic Review 68 (1978): 203–211. 4. W. G. Shepherd, On the Core Concepts of Industrial Economies, in Mainstreams in Industrial Organization, J. W. DeJong and W. G. Shepherd, Eds. (Boston: Kluwer Publications, 1986). 5. J. Hopping, “The Layered Look,” Health Systems Review 30, no. 3 (May/June 1997): 24–25. 6. J. Morrissey, “Columbia Wraps up Mass. Venture,” Modern Healthcare (May 6, 1996): 26. 7. S. Lutz, “Columbia Completes Deals in N.C., Texas,” Modern Healthcare (May 6, 1996): 26. 8. “University Hospital Blurs Richmond, Va., Battle Lines,” Modern Healthcare (April 22, 1996): 40–41. 9. B. R. Robinson and W. Peterson, Strategic Acquisitions: A Guide to Growing and Enhancing the Value of Your Business (Burr Ridge, IL: Irwin, 1995). 10. P. McKiernan and Y. Merali, “Integrating Information Systems after a Merger,” Long Range Planning 28, no. 4 (August 1995): 54–62. 11. O. E. Williamson, The Economic Institutions of Capitalism: Firms, Markets, Relational Contracting (New York: Free Press, 1985). 12. A. Osterland, “Acquire, then Digest: Vencor—Specialty Hospital Chain Acquires Nursing Home Operator Hillhaven,” Financial World 164, no. 14 (June 20, 1995): 20. 13. J. Smith, “There’s More Than One Road to Client-Server,” Computing Canada 18, no. 16 (August 4, 1992): 40. 14. J. H. M. Tarn, Exploring the Impact of Geographic Dispersion on Information System Requirements (Richmond, VA: Virginia Commonwealth University, 1998). Dissertation. 15. B. H. Boar, Implementing Client/Server Computing (New York: McGraw-Hill, 1993). 16. E. A. Regan and B. N. O’Connor, End-User Information Systems: Perspectives for Managers and Information Systems Professionals (New York: Macmillan, 1994). 17. J. Diamond, “Modem Sharing and Collaborative Computing,” Network World 12, no. 19 (May 8, 1995): 35. 18. “Intranet Lexicon,” Business Communications Review 26, no. 6 (1996): 8. 19. L. Fried, “Advanced Information Technology Use: A Survey of Multinational Corporations,” Information Systems Management 10, no. 2 (Spring 1993): 7–14. 20. A. Pinsonneault and K. Kraemer, “The Effects of Electronic Meetings on Group Processes and Outcomes: An Assessment of the Empirical Research,” European Journal of Operational Research 46, no. 2 (May 25, 1990): 143–161. N O T E S 115 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 115 21. H. J. Waston, R. K. Rainer, and C. E. Koh, “Executive Information Systems: A Framework for Development and a Survey of Current Practices,” MIS Quarterly (March 1991): 13–30. 22. P. Palvia, A. Kumar, N. Kumar, and R. Hendon, “Information Requirements of a Global EIS,” Decision Support Systems 16, no. 2 (February 1996): 169–179. 23. Annapolis, MD: Brand Management & Communications, February 21, 2008, http://www .arinc.com/news/2008/02-21b-08.html, accessed July 11, 2008. 116 C O M M U N I T Y H E A L T H I N F O R M A T I O N N E T W O R K S 56918_CH05_Final_Tan 4/6/10 11:46 AM Page 116 Trending toward Patient-Centric Management Systems Joseph Tan with Joshia Tan 117 6 CHAPTER Editor’s Note: Among the most popular HMIS applications and technologies employed in to- day’s healthcare services organizations are electronic health records (EHR), computerized physician order entry (CPOE), and clinical decision support systems (CDSS), which are the topics of this chapter. As noted in the chapter title, these applications may be seen as a move- ment toward patient-centric management systems because they are ultimately designed to ele- vate patient care by providing the caregivers with relevant, current, accurate, reliable, and complete information. Therefore, the significance of these systems for benchmarking both ad- ministrative and clinical performance across healthcare services organizations cannot be over- emphasized. Technology Brief IV, focusing on database, data-mining, and data-warehousing concepts for healthcare services organizations, has been appended to this chapter to augment the readers’ understanding not only of the internal structure, content, and functionalities of these systems, but also to provide insights as to the enabling and empowering nature of these systems for the end-users. Finally, the benefits and challenges of these systems are discussed in the context of electronic health records, which is the cornerstone of the U.S. and Canadian healthcare services delivery systems. 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 117 Scenario: Google Health, a Portal for Personal Health Records and Health Decision Support1 Google Health, an Internet portal where patients can collate their personal data previously en- trusted to various care providers, pharmacies, insurers, and even laboratories in a single reposi- tory upon consenting, is a site that planned to compete with existing vendors supporting the storage and tracking of personal health records (PHR). In contrast to competitors such as Dr. Koop, HealthCentral, and Revolution Health (which require their subscribers to key in their own personal health information), Google’s PHR sys- tem aims to permit subscribers to upload their previously captured records from care providers such as Cleveland Clinic, PatientSite, Longs, MEDCO, Beth Israel Deaconess Medical Center (BIDMC), Minute Clinic/CVS, Quest Laboratories, RxAmerica, and Walgreens. With the pa- tient’s agreement, their records can be conveniently uploaded directly into Google Health— they do not have to gather any of these data manually or risk entering their private personal health information erroneously. Once their records have been uploaded, health decision sup- port and knowledge services such as drug monographs, drug-to-drug interaction advice, reference 118 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S CHAPTER OUTLINE Scenario: Google Health, a Portal for Personal Health Records and Health Decision Support I. Introduction II. Definitions of EHR, CPOE, and CDSS III. Historical Evolution of EHR, CPOE, and CDSS IV. Electronic Health Records V. Computerized Physician Order Entry VI. Clinical Decision Support Systems VII. Benefits and Challenges of EHR, CPOE, and CDSS ● Benefits ● Challenges VII. Conclusion Notes Chapter Questions Technology Brief IV: Database, Data-Mining, and Data-Warehousing Concepts for Healthcare Services Organizations Joshia Tan and Joseph Tan 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 118 materials on diseases, and other health information will become available and accessible to the subscribers. Another prominent feature of Google Health is that subscribers can link with ap- plications of other third parties who have partnered with Google Health, share their health in- formation with these third parties if they so wish, and receive even more specialized health decision support and knowledge services. Google Health pays particular attention to security and privacy issues. The privacy policy, for example, clearly restricts the transmission or release of the subscriber’s information to third parties without the subscriber’s consent. Just as with the Microsoft HealthVault policy, sub- scribers will have complete control over the content of their records and will have the option to delete or destroy their stored information at any time. In terms of security standards, Google Health uses digital certificates, IP address restrictions, and encryption technology to manage in- formation exchange between Google Health and its partners, as well as temporarily storing or “caching” of retrieved health data on desktop computers and workstations. To enhance interop- erability, data standards adopted by Google Health and its decision support partner, Safe-Med, include CCR/G (Continuity of Care Record/Google), SNOMED CT, LOINC, NDC, RxNorm, and ICD-9. Over time, Google Health aims to empower subscribers by providing them with connectivity and interoperability with as many well-recognized third-party care- givers as possible. The message that BIDMC dispatched to patients and clinicians is as follows: “Over the past year, BIDMC has worked with Google Health to integrate PatientSite and Google’s new patient portal. It is an Opt-In service and the patient controls every aspect of the Google Health site. . . . Patients who use PatientSite will now be able to upload their records about di- agnoses, medications, and allergies from PatientSite to Google Health, and then also use Google’s specialized medical knowledge features—online reference materials about medical conditions, information about drug safety, questions to ask your doctor, and more . . . patients with a Google Gmail e-mail address will have a new link in PatientSite called Google Health that will enable them to optionally use these Google features. . . . At no time will BIDMC share your data with Google without your consent. . . .” At this time, BIDMC expects to em- power 5,000 patients with existing Google Gmail accounts by connecting them to the Google Health link. Imagine trusting all your personal health records with a carrier such as Google Health. Remember that giant commercial partners such as Microsoft and Google are new to the e-healthcare marketplace but are entering into the business of safekeeping one’s personal health records (PHR) because of its potential for profitability. Such an approach can indeed cause quite a bit of apprehension for some health consumers. As these organizations lack a history of involvement with healthcare services businesses prior to their offering of PHR systems, what if the information could be sold to, or mined by, people from organizations that are unknown to the patients? What is the chance or potential for security breaches and privacy compromises with the patient health information captured in Google Health? Take a minute to reflect on these possibilities and debate the various probable scenarios. T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 119 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 119 I. Introduction The past few decades have seen continuing cost acceleration, advancing technologies, and growing competition challenging the healthcare marketplace. To adapt, healthcare services or- ganizations have become increasingly more eager to change from relying on traditional paper- based health data and information processing systems to newer forms of electronic health recording practices so as to ensure greater efficiencies in health data management and effective- ness in clinical decision making. While patients have voiced major concerns over the security, privacy, and confidentiality of their health records being captured electronically, their ultimate objective remains unchanged: to receive high-quality healthcare, with easily accessible and avail- able records for preauthorized care providers and referral specialists, especially in emergencies. Accordingly, the need for electronic data gathering, tracking, and coordinating systems that can provide caregivers with timely, reliable, and secured access to a patient’s files—such as his or her complete medical history, laboratory test results, and radiological images—cannot be overly emphasized. An ideal network of health data-entry, storage, and reporting systems should achieve interoperability among themselves, as well as with all of the legacy systems. Such is the concept of electronic health records (EHR), a system that will allow doctors and nurses to ac- cess conveniently accurate health records, reduce the need for unnecessary duplication of pa- tient data, and give clarifications to clinicians performing follow-up care, to whom a patient’s previous treatment or medical information is often needed. Without knowing a patient’s his- tory, practitioners—especially in the case of an emergency—will have to blindly perform treat- ments on such a patient in hope of saving his or her life. It is apparent that the quality and speed of care can be enhanced, in many cases, if only the appropriate and relevant patient infor- mation were available, accessible, and verifiable. Three major patient-centric management systems have evolved in the healthcare services in- dustry that will continue to affect patient care and the performance of care providers in the coming years: electronic health records (EHR), computerized physician order entry (CPOE), and clinical decision support systems (CDSS). Among these, the EHR system is the most inclu- sive and important for direct patient care because it typically also encompasses the other two patient-centric management systems. Therefore, our discussion of CPOE and CDSS will be embedded partly in the larger EHR context for delivering error-free and quality patient care. Tan2 addresses the concerns of those who would like to have a more detailed understanding of these different systems, their historical developments, applications, and cases, especially for EHR and CDSS implementations. Meanwhile, a brief review and empirical evidence on the ac- ceptance of CPOE among physicians may be found in Liang, Xue, and Wu.3 Here we begin our limited review by first defining and reviewing the historical evolution of these three patient-centric management systems. 120 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 120 II. Definitions of EHR, CPOE, and CDSS Electronic health records (EHR)4 comprise, essentially, the health information of an individual pa- tient that exists as part of a complete history; such records are, furthermore, designed to provide clinicians with a comprehensive picture of the patient’s health status at any time. Today, the EHR term has largely replaced older terms such as “computerized patient records” and “elec- tronic medical records.” Specifically, the U.S. Department of Veterans Affairs defined computer- based patient records (CPR) as records that are stored in decentralized hospital computer software, whereas electronic medical records (EMR) may be conceived as an enterprisewide sys- tem where patient medical histories are captured in a single repository. The EHR term has taken on an even wider connotation in that these systems are also meant to automate and streamline the clinician’s workflow, besides having the ability to independently generate a complete record of clinical patient encounters, sourcing data from various care episodes over the lifetime of a pa- tient. In other words, these patient-centric, electronic database management systems capture, us- ing all available patient–provider encounters in a longitudinal fashion, both the historic and current records of a patient’s health information. Altogether, the system may contain various pa- tient demographics and patient history information, such as progress notes, medical diagnoses, prescriptions, vital signs, immunization records, laboratory test data, and radiology reports. Closely related to, and often functioning as part of, EHR, a computerized physician order en- try (CPOE)5 system is basically an automated order-entry system that captures the instructions of physicians with regard to the care of their patients. Physicians enter orders in the EHR using CPOE, which has been shown to increase patient safety and improve the quality of care. The system also provides clinical guidelines for physicians and prints summaries of visits for pa- tients, among other services. CPOE orders are disseminated, via computer networks, through- out various parts of a healthcare services facility, such as pharmacy, laboratory, or radiology, as well as to other care providers, including nurses, therapists, and other consulting medical pro- fessional staff, who will then follow up on the orders. Finally, computer-based decision support systems (CDSS)6 are medical information processing systems that are designed to aid clinicians in making complex and/or less-than-complex clinical- based decisions. CDSS provide data banks, alerts and reminders, algorithms, analytic or patho- physiologic models, clinical decision theoretical models, statistical pattern recognition methods, symbolic reasoning, and/or expert knowledge bases to enhance the diagnostic, therapeutic, and prognostic-thinking and cognitive-reasoning strategies of expert and amateur clinicians alike. Healthcare managers, administrators, and executives hoping to perform well in complex healthcare services organizations must become thoroughly familiar with all of these patient-centric management systems. These are the three major systems that drive the majority of diagnostic, therapeutic, and prognostic decisions made for patients attending the different care facilities of a health maintenance organization. These systems have evolved over the years and have drawn significant influence from the early developments and history of computer-based patient records and hospital information systems. We turn now to look briefly at the historical develop- ments of these systems. III . H I S T O R I C A L E V O L U T I O N O F EHR, CPOE, A N D CDSS 121 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 121 III. Historical Evolution of EHR, CPOE, and CDSS Computer-based patient records, according to the 1997 National Academy of Sciences Institute of Medicine (IOM) report,7 are systems specifically designed to aid clinical users in assessing patient information. Such information typically includes complete and accurate patient history, alerts and reminders, clinical decision support models, guides and links to medical knowledge bases, and other references and informational resources (such as a referencing drug database). The evolution of computer-based patient data systems such as EHR, CPOE, and CDSS is best understood in terms of the historic evolution of hospital information systems (HIS), artificial intelligence (AI) in medicine, health decision aids, and electronic patient records. The genesis of HIS dates back to the early 1950s, when only mainframes were available and when even the processing of a batch of patient-related information required considerable time, knowledge, and expertise. From the 1960s to the 1970s, a new era of HIS emerged when “pio- neering” American and European hospitals joined forces to eventually develop a successful pa- tient information management system prototype, named the Technicon system. It is this prototype that laid the foundation for many of today’s working hospital patient information systems throughout North America and Europe. The major lesson learned was the need to fo- cus on users’ information needs and the need to change the attitudes of the users, particularly those of physicians, nurses, and other clinicians. During the early and mid-1970s, computerization was pinpointed as the source of the evi- dent gains in productivity and increased efficiency, prompting the diffusion of large-scale data- processing applications in medicine and health record systems. With the emergence of minicomputers and microcomputers during the 1980s, physicians and clinical practitioners soon began to realize the speed and astounding harnessing power of computers. During this time, interest in the application of AI in medicine expanded and soon contributed to the devel- opment of CDSS. In 1999, the IOM reported a disturbing statistic—each year, in the United States, medical errors were responsible for up to 98,000 unnecessary hospital patient deaths. An urgent call was immediately made for healthcare services organizations to reduce this exorbitant level of med- ical errors.8 Several institutions took up the challenge; Palo Alto Medical Foundation (PAMF), for example, became one of the earliest adopters of EHR, replacing paper charts with electronic records, thereby allowing physicians and clinical staff direct and very convenient access to pa- tient information. The adoption not only eliminated the hectic scramble to locate paper records, but also led to a reduction in medical errors. Similarly, in 2004, three suburban Chicago hospitals reported a 20 percent drop in medication errors and the complete elimina- tion of transcription errors with their EHR implementations. Against this background, Arsala et al.9 believe that we have undergone four generations in the evolution of computer-based pa- tient records in overcoming the medical error challenge and will soon move into fifth-generation EHR by 2010. During the first generation of computer-based patient records (CPR), hospitals relied heav- ily on the clinical data repository (CDR); in fact, the adoption of a single, comprehensive repository for clinical information during the 1960s to 1970s was said to have eliminated 122 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 122 about 15 percent of preventable medical errors in hospital-based patient care. From the 1970s to 1980s, the next generation of CPR development was noted to have the added capability of documenting clinical activities, as well as the ability to tailor the IT report for the use and needs of specific caregivers. This resulting improvement was estimated to have garnered up to another 25 percent reduction in medical errors. Moreover, CDSS implementation during this period was thought to have further reduced error rates with their automated intelli- gence. The combination of these augmented capabilities thus amounted to a 40 percent level of reduction in preventable errors. Third-generation CPR/EHR development, during the 1980s to 1990s, involved the combi- nation of an improved CDSS with the use of a controlled medical vocabulary to standardize medical concepts and the availability of a CPOE system, thus allowing a more effective man- agement of the physician ordering process. It was envisaged that this increased level of automa- tion helped to realize up to a 70 percent preventable error reduction as compared with the systems capabilities of the previous generations. During this generation, it became progressively critical for workflow capabilities to emerge as tools for supporting the optimal delivery of patient care. The fourth-generation EHR, which are expected to reduce preventable errors by up to a 90 percent level, have now been realized. These systems are considered to have an improved CDSS function capable of providing a detailed portrait of each patient and automated support for care management protocols. These systems are claimed to be flexible so that clinician users can tailor them for individual patients; they are also capable of knowledge management so that continual improvement in care delivery can be provided; they are supposedly geared with formal work- flow capability so that the consistencies of medical practices can be balanced as needed for opti- mal care outcomes. The next-generation EHR are projected to have complex CDSS functionalities, to have a networked CPOE, and to be supportive of natural language interfaces. In this sense, EHR soft- ware will enable automation of the care processes with preprogrammed alerts and reminders. With CPOE interfacing capability, the future EHR software will not only aid caregivers in ob- taining complete, real-time updates of patient information at all times, but also offer caregivers the ability to disseminate their orders efficiently and effectively. These fifth-generation systems are, therefore, expected to aid clinicians intelligently, especially in the caring of patients who may demand real-time monitoring, and even those with multiple, concurrent medical condi- tions. Finally, with mobile and sensor networks on the rise, these systems should also support interfaces to wireless health data networks, enhance mobile healthcare services, and provide se- cured linkages to sensor-based tracking and health monitoring devices. IV. Electronic Health Records For decades, healthcare services organizations have invested millions of dollars in the research and development of a system that can computerize patient records, thereby satisfying the infor- mation needs of care providers who deliver high-quality patient care. Despite the noted progress, even until today, some healthcare facilities are still relying on traditional paper-based IV. E L E C T R O N I C H E A LT H R E C O R D S 123 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 123 recordkeeping systems. This may be due, in whole or in part, to the high cost of implementing computerized patient records; the expressed concerns of patients over privacy, confidentiality, and security issues with computerized records; and the lack of government and private funding to support computerized healthcare databases administration, research, and development. As previously noted, many terms have been used interchangeably to describe how patient records are captured electronically, and these terms have often resulted in some confusion— and a lack of strategic vision alignment and conceptual integration among healthcare adminis- trators and health IT managers. Specifically, computer-based patient records (CPR) may be regarded as records that are stored in decentralized hospital computer software systems, whereas electronic medical records (EMR) refer generally to an enterprisewide system captur- ing patient medical histories in a single repository. The EHR term has a wider connotation, encompassing automation and streamlining of the clinician’s workflow besides being capable of independently generating, by sourcing data from various care episodes throughout a pa- tient’s life, a complete record of clinical patient encounters. In addition, EHR will support other care-related activities, including, but not limited to, clinical decision support, care deliv- ery quality management, and clinical reporting.10 According to Dickinson,11 the EHR should serve diverse purposes such as assisting direct patient care, improving routine reporting on the care processes, aiding the processing of claims reimbursement, credentialing care providers, providing an audit trail for care processes, ensuring quality, preventing medical errors, satisfy- ing public health needs, enhancing education, supporting research, and satisfying the legal needs of healthcare services organizations. Ultimately, these incredibly powerful systems are intended to improve physician practices as well as increase health organizational competitive- ness and profitability. An integrated EHR will link all electronic patient records and critical patient care systems so that patient data can be shared and disseminated among authorized clinician users. In general, such an integrated system comprises six primary modules or components working in unison, most of which have already been alluded to in earlier discussions. Specifically, these compo- nents include (1) a CDR, which offers a comprehensive source for storing and retrieving rele- vant, reliable, and accurate clinical information; (2) a CDSS, which provides rule-based alerts such as warning messages against potential harmful drug interactions when patients are inad- vertently placed on two or more potentially interactive medications; (3) a clinical documenta- tion module, which can inform the caring clinician of specific activities taken by other clinicians in managing a particular patient; (4) a CPOE, which will electronically capture the attending physician’s instructions so as to help eliminate errors caused by illegible handwritten orders; (5) a controlled medical vocabulary (CMV) module for ensuring that information sourced from various clinical repositories can be easily compared, making it easier to generate proper clinical rules for achieving quality patient care; and (6) a workflow controller module, which manages clinical care processes so that these processes may be sequenced appropriately, executed properly, and executed without omissions.12 124 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 124 Other systems that can be integrated with the EHR, but that are discussed later, include lab- oratory information systems (LIS), pharmacy information systems (PIS), and radiological infor- mation systems (RIS). By implementing an integrated EHR, a healthcare services organization is therefore expected to gain data management speed and accuracy, enhance patient safety and clinical workflow effi- ciencies, reduce medical errors, and control administrative and medical cost. Not surprisingly, EHR technology is quickly replacing paper-based systems as well as legacy EMR in many healthcare services organizations today.13 V. Computerized Physician Order Entry A CPOE system, as noted in earlier discussions, is often implemented as a component of the EHR. This accompanying system must be able to communicate orders to other connected sys- tems within the EHR. These include ancillary support systems such as laboratory information systems (LIS), where laboratory results are captured; pharmacy information systems (PIS), where medication information is captured; radiology information systems (RIS), picture archiving and communications systems (PACS), where radiological reports and images are captured; and electronic document/content management (ED/CM) systems, where form doc- uments are captured, streamlined, and managed. Medical records scanning is often a solution when such data are entered manually into forms and need to be archived, stored, and/or shared electronically. When combined with various other workflow tools, CPOE can also be useful in providing information about patient scheduling, wait times, referral networks, physician work patterns, and disease management. Similarly, the CPOE system may be enabled via PIS for presenting clinical drug choices to the ordering provider. The key success factor for implementing CPOE is overcoming user resistance, particularly the resistance from physicians who may be accus- tomed to giving verbal or written orders. Accordingly, acceptance of CPOE by physicians can induce numerous benefits, including decreased delays in order completion and reduced errors from handwritten or transcribed or- ders. It will also allow order entry at point-of-care or off-site, provide error checking for dupli- cate or incorrect medication doses or tests, and simplify inventory and posting of charges. A successfully implemented CPOE system can therefore improve the quality of healthcare services delivery and significantly cut healthcare costs. VI. Clinical Decision Support Systems At this point, we turn our attention to the last patient-centric managment systems in the group, the clinical decision support systems. In this age of healthcare reform, health administrators and clinicians, with their increasingly complex decision-making activities, are in need of advanced methodological and technological support tools to enhance their effectiveness. CDSS are computer-based information-processing VI. C L I N I C A L D E C I S I O N S U P P O R T S Y S T E M S 125 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 125 and decision support tools that are intended to serve as aids in the rationalization of the clinical decision-making process and/or justifying final choices the clinicians have advocated for their patients. Indeed, these systems are not meant to replace the clinical decision makers. Specifically, if clinicians are armed with CDSS containing computerized models, alerts, re- minders, and critical sets of data—all of which will contribute in one way or another to analyz- ing the probability of the onset of certain acute or chronic illnesses for a particular patient—it is anticipated that these clinicians, assisted by the CDSS, will exercise better diagnostic, therapeu- tic, and/or prognostic judgments. In order words, they would not simply jump to conclusions about the complex data set based on the shortsightedness of their self-evaluations, their limited cognitive reasoning power, or even their intuitive feelings. Use of CDSS interrelate and span almost every conceivable area of healthcare administrative and clinical decision-making activities. Key components to the building of CDSS include data- base management subsystem, model management subsystem, knowledge bases, inference engine, intelligent graphical interfaces, and any other modules that may enhance the function- alities of the CDSS. In this sense, clinicians can use CDSS to query general and specific ques- tions about the conditions of their patients based on data that have been collected, stored, organized, manipulated, and retrieved appropriately from its database management subsystem. The model base management component in the CDSS permits clinicians to infer and/or fore- cast resulting outcomes, based on various mathematical computations and analytic model fit- tings of collected data about the patient’s conditions. The knowledge base component of the CDSS typically contains rule-based knowledge, case reasoning, neural networks, artificial intel- ligence, and/or other expert diagnostic consults for the clinicians. The inference engine compo- nent then integrates these different components to arrive at the computed alternatives and/or choice outcomes for the decision makers. It is the intelligent graphical interface that will finally translate and interpret resulting choices in either graphical forms or images to support the deci- sion makers’ varying perspectives. Today, CDSS have evolved to support many administrative and medical specialties—examples include nursing decision support systems, pharmacy decision support systems, health executive decision support systems, and specialty medical expert systems. The major cases provided in Part V at the end of this text provide a further examination of EMR and DSS functions. For the next part of this chapter, we review the key benefits and challenges of EHR. As previously stated, with CPOE and CDSS being typical parts of EHR system installments nowadays, read- ers can safely assume that the discussion on EHR benefits and challenges apply similarly to the other two patient-centric management systems. VII. Benefits and Challenges of EHR, CPOE, and CDSS Healthcare is an industry that is, apparently, very data intensive; the complexity of healthcare data cannot—and must not—be overlooked. Imagine what impact human-induced medical er- 126 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 126 rors can wreak on the quality of life and safety of patients and what benefits systems such as EHR, CPOE, and CDSS can have in reversing the adverse effects of these errors. Paul Tang, the chief medical information officer for the Palo Alto Medical Foundation (PAMF) and chair of the IOM’s Committee on Data Standards for Patient Safety,14 notes that electronic health records such as PAMF’s system can cut healthcare costs, enhance the quality of healthcare services delivery, and significantly lower the risk for medical errors. He believes that providing physicians with convenient and direct access to the information they need for making patient care decisions will automatically raise the bar for ensuring patient safety to a higher level, or “new standard of care.” Aside from the benefits of using EHR and other patient-centric computerized management systems, there are still many challenges in implementing these systems. These benefits and chal- lenges are discussed next. Benefits One of several key benefits of using EHR, CPOE, and CDSS is that they allow direct sourcing and capturing of patient data, which, in turn, can be used flexibly for myraid purposes. Some of the more important purposes, aside from direct patient care, include continuing patient care, follow-up treatment protocols, medical education for nurses and resident physicians, and re- search. Many resident physicians, for example, are learning from interacting with these systems on job sites and taking orders when caring for particular patients by automatically extracting captured instructions left for them by mentoring physicians. More importantly, the combined usage of these systems will eventually lead to a noticeable reduction in medical errors, prevent- ing potential patient deaths and possible legal repercussions for clinical malpractices such mis- takes may cause. These systems, therefore, will also assist with legal compliance, cut costs, and improve patient safety by performing such tasks as providing an audit trail for treatment proto- cols or alerting physicians of potentially adverse drug reactions. Indeed, the acceptance and regular use of these systems promises to yield the primary bene- fits of cost cutting. This will be accomplished through lowering costs related to personnel, pa- per storage, processing, and treatment delays; enhancing safety of patient care; reducing medical errors; and controlling quality to eliminate poor or inadequate care. And because pa- tient data and images can be conveniently accessed with the click of a computer mouse via one or more of these systems, physicians and other healthcare providers no longer have to search for misfiled paper charts or wait for another healthcare facility to send duplicate copies of patient records and/or images. Moreover, these systems can even source data from the patient bedside, if necessary, and furthermore provide a common platform for coordinating patient care across multiple care providers. This permits caregivers a common understanding of a patient’s health condition, thereby preventing unnecessary treatments and/or omissions of critical treatments. Use of these systems will also provide doctors and nurses with decision support capabilities. For example, laboratory and X-ray results can be sent electronically, immediately after completion, to a physician for prioritized interpretation, diagnostic analysis, and decision making regarding treat- ment alternatives. The EHR installed at PAMF, for example, enables caregivers to document inter- actions with patients, improve on physician–patient relationships, ease the charge-capturing VII. B E N E F I T S A N D C H A L L E N G E S O F EHR, CPOE, A N D CDSS 127 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 127 process, eliminate repetitive tests, allow hospital personnel to view patient medical history and in- surance information, assist in making referrals, and speed up prescription orders through electronic requests to pharmacies. PAMF’s EHR also incorporated a computerized physician order entry (CPOE) system, which provides resident physicians and nurses with clinical guidelines and patients with printed summaries of visits and other services.15 The EHR system is also cost-effective, scala- ble, and flexible in the sense that new security features, improved CDSS capabilities, and other an- cillary support systems can be added at any time to enhance future healthcare services delivery. Finally, the benefits of using an integrated EHR system must be contrasted with the many challenges that also come with its implementation, which is the topic of discussion. Challenges Several major challenges, with respect to the acceptance and adoption of EHR in healthcare services organizations, have been noted in the extant literature.16–20 These include confusion about the concept; the cost of implementing EHR or customizing EHR to a particular health- care services organization; the lack of standardization; and other challenging issues such as the reliability, privacy, confidentiality, and security of patient data housed by the system. There is also a lack of motivation in creating interoperability among the connected systems of compet- ing care provider organizations. This is due to uncertainties about the direct benefits the care providers of one healthcare facility can reap by coordinating patient care and sharing patient data versus the benefits another facility can sow. First, EHR software can be complex—the technology is known by various names, each indi- cating a specific vision that differs from the others. For example, as previously indicated, the vi- sion of the computer-based patient record (CPR) was popular for a while, albeit more than a decade ago. Eventually, the idea of enterprisewide electronic medical records (EMR) replaced the limited CPR concept. Subsequently, a migration to the EHR philosophy seems to have gained worldwide acceptance as the preferred, generic term of use in describing the vision of how the electronic records of a patient should contain information, such that it would allow the trajectory of patient care in the patient’s lifetime to be traced. Yet some authors continue to use terms such as CPR, EPR (electronic patient records), and EMR interchangeably, which has, in- evitably, added to the confusion.21 EHR will be one of the most costly project expenditures that a healthcare services organiza- tion will undertake, with regard to the investments of time and money and the resultant chal- lenge of returns on investments (ROI). This is because the significance of the returns to be realized from an EHR implementation remains a concern for many healthcare executives. Not only will the initial outlay be significant and extremely challenging, but equally difficult tasks lie in trying to customize the system, linking it with existing legacy systems, and garnering ac- ceptance from the user community. Understanding the needs and wants of healthcare profes- sional users is unlike building an automobile; therefore, drilling into the requirements and specifications for EHR means that either technical people will have to speak a layperson’s lan- guage, or healthcare professional users must change the way medicine is practiced. Patient ex- aminations and procedures have to be differently structured by the care providers before data can be entered into the EHR, which is completely different from what these professionals prac- 128 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 128 ticed when using a paper-based medical record system. In addition, some familiarity with the “EHR” procedures is needed; otherwise, the clinical users will soon become frustrated with us- ing the system, as it certainly does not align easily with what physicians and/or nurses believe to be the typical way of practicing medicine. While the vision of EHR is theoretically possible, it is difficult to realize in practice. EHR would portray a lifetime record of every health encounter between the patient and all of his or her caregivers, regardless of which clinic or hospital the episode was recorded in, and regardless of who the healthcare provider was—a dentist, family physician, physiotherapist, cancer spe- cialist, or nurse. Interestingly, there are good reasons as to why sharing patient data by creating interoperability among systems belonging to competing clinics or hospitals is not practical, even if direct benefits can be obtained with interoperable patient information systems that cut across organizational boundaries. The responsibility of housing patient data in EHR is one that each clinic or hospital would prefer to bear independently. Major gains from implementing EHR are therefore confined within the boundaries of a single enterprise. In this manner, pa- tient safety, care efficiencies, and clinical decision effectiveness can be clearly demonstrated, and the motivation to share patient data among competing HMO can, as a result, be diminished. Moreover, EHR require practitioners to perform more computer entries and less handwriting, which is often counterintuitive to practitioners in terms of being productive—a computer order entry may, for example, take twice as long as writing or dictating an order, and practitioners who are not familiar with how the EHR-embedded CPOE functions may experience anxiety, thereby finding difficulty in reviewing his or her instructions stored in the system in front of a co-worker or patient. Worse still, some practitioners are not in the habit of sharing their analy- sis of patient data with other practitioners or would prefer to privately review their own notes before opening them for distribution. Such practitioners would not want to see their detailed progress notes automatically stored in a system that other practitioners can freely access. The lack of standardization has been a major barrier to linking different EHR systems and related components. These standards can range from how patient information is stored or the terminology used to store the information to the procedures for exchanging information among the different systems. Major areas where the lack of standards prevent interoperability and data sharing include information content (e.g., uniformity or comparability); input procedures (e.g., direct sourcing); representational format (e.g., data coding); clinical practice (e.g., treatment protocols); decision support (e.g., reminders and alerts); performance metrics (e.g., quality as- surance); and security, confidentiality, and privacy (e.g., compliance with the Health Insurance Portability and Accountability Act of 1996, or HIPAA). Indeed, one of the most formidable challenges for EHR technology adoption involves HIPAA’s privacy and security ruling. HIPAA rules prohibit the disclosure of patient health in- formation, except where it is specifically permitted with the patient’s consent. HIPAA viola- tions can result in civil sanctions (entailing a limited fine, which varies for individuals and organizations) or criminal liability (entailing fines of $50,000 to $250,000, or 1 to 10 years of imprisonment).22 In any case, training authorized personnel, instituting appropriate organiza- tional policies, and having effective audit processes are all critical factors for properly securing the EHR information and accomplishing a successful EHR implementation. VIII. C O N C L U S I O N 129 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 129 VIII. Conclusion Despite rapid and continuing growth in the healthcare services industry, the application of health management information systems (HMIS) in enhancing organizational efficiency and effectiveness has been slow. Technologies, such as EHR, need to be appreciated (and accepted) by both healthcare administrators and practitioners before EHR can significantly affect the performance of healthcare organizations. As previously discussed, considerable benefits can be gained from the electronic processing of a patient’s records, because they will then be made ac- cessible and available to the treating physician and other caregivers. New EHR features will also enable physicians to monitor their patients’ responses to treatment interventions quickly and will improve their ability to manage patients with chronic illnesses. Perhaps it is time for EHR technology to replace many of the fragmentary data repositories used in legacy systems throughout the healthcare services industry. This move will eradicate unnecessary redundancies, unwanted anomalies, and unacceptable errors in patient records, all of which can only con- tribute to poor quality in healthcare services. Upham23 argues that substantial administrative and clinical benefits can be achieved, should a universal EHR system be finally realized. His list of benefits include (1) easy dissemination of critical patient information to other care providers for follow-up assessments; (2) rapid accessi- bility of patient records universally; (3) fewer documentation errors, less paperwork, and less fil- ing of paperwork; (4) more efficient navigation through patient records; (5) no misfiled or lost charts; (6) standardization of care procedures among providers; (7) ease of clinical data manage- ment; (8) shared coding; (9) greater awareness of medical errors, possible drug interactions, and inherent patient allergies; and (10) ease of performing quality, risk, utilization, and ROI analy- ses due to the improved accessibility and availability of clinical data. Of course, as noted, these benefits must still be weighed against the challenges of implementing EHR. At present, much of a patient’s health information acquired from a specific healthcare facil- ity stays within the facility; it is not routinely shared with other clinics or healthcare providers. This has been a significant problem, especially for patients who happen to require emergency treatment. To eliminate this predicament, future patient records should use EHR technology to provide connectivity, reliability, flexibility, efficiency, security, mobility, availability, and accessi- bility. Ideally, the EHR should be receptive to continuous updates. Newer functions—such as statistical reporting for varying purposes, wireless links to other databases and systems, and the incorporation of advanced decision support and graphical imaging tools for shortcutting the clinical decision processes—will further enhance the quality of patient care. Other features and connecting devices—such as Web-based personal health records (PHR), radio-frequency identification (RFID), virtual medical patient records (VPR), and smart cards—will combine with EHR to empower patients and providers. The ultimate aim is to ensure the highest quality of patient care provided always and everywhere. A Web-based PHR system will, for example, empower patients with access to their own records and help them take a more active role in managing their own health. They will be able to check these records, ensuring that they are receiving appropriate care in a safe and effective manner. A Web-based PHR will organize the patient’s private health information, allow them to restrict cer- 130 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 130 tain caregivers to particular views, and allow them to efficiently communicate with their caregivers about test results and follow-up plans. Older patients may be able to add remote patient- monitoring tools so their caregivers are kept abreast of possible warning symptoms, thereby man- aging their chronic states of health, from anywhere in the world, in a more effective manner. RFID24 is an unusual form of health IT; based on the VeriChip system, an RFID microchip can be implanted under the skin, granting instant access to a patient’s records. Developed by Applied Digital Solutions Inc. of Delray Beach, Florida, this VeriChip system works by trans- mitting a unique code to a scanner, permitting caregivers to confirm a patient’s identity and ex- tract detailed patient information from a connected database. The implant will only provide the identification so that the system will remain limited to hospitals, doctors, and patients who have access to the scanner. VPR,25 another approach to the access of patient medical records (in which data from all the different sources are merely linked electronically as and when needed), allow integration of pa- tient information from all sources, including data from the many ancillary health information systems used in enhancing patient care. VPR are electronically created, edited, and stored in electronic digitized media, just as traditional patient records were done with the medium of ink on paper. A smart card is an integrated circuit card that can retain a patient’s vital medical informa- tion. The information can then be easily retrieved, after entering the necessary security informa- tion, by swiping the card through a reader. The technology is also compatible with mobile healthcare computing, so that products, medical treatments, or alternative medical therapies can be purchased wherever a card reader is available. More research and development is needed to ensure that future EHR systems meet the needs of patients, providers, administrators, researchers, and policy makers. Pressing issues relating to reliability, privacy, confidentiality, and security also need to be resolved. The need to protect pa- tient privacy must be balanced by the need for efficient access to data from multiple sites. It is therefore necessary to find the solutions that will reduce the barriers in implementing and de- veloping EHR. If all of the challenges and concerns are resolved, future EHR will quickly pro- pel the healthcare services industry to new heights and possibilities. Notes 1. Google Health, accessed Monday, May 19, 2008, from http://geekdoctor.blogspot.com/2008/ 05/launch-of-google-health.html. 2. J. Tan, E-Health Care Information Systems-An Introduction for Students and Professionals (San Francisco, CA: Jossey-Bass, 2005). 3. H. Liang, Y. Xue, and X. Wu. “User Acceptance of Computerized Physician Order Entry: An Empirical Investigation.” International Journal of Healthcare Information Systems & Informatics 1, no. 2 (2006): 39–50. 4. Wikipedia, http://en.wikipedia.org/wiki/Electronic_health_record. 5. Wikipedia, http://en.wikipedia.org/wiki/CPOE. 6. J. Tan, with S. Sheps, Health Decision Support Systems (Gaithersburg, MD: Aspen Publishers, 1998). N O T E S 131 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 131 7. Institute of Medicine, The Computer-Based Patient Record: An Essential Technology for Health Care (1997), from http://www.nap.edu/openbook.php?isbn=0309055326. 8. M. Arsala, N. Rosenblatt, S. Singer, and L. Slouffman, “EHR History and Technology” (2005), accessed June 1, 2008, from http://www7.kellogg.northwestern.edu/techconcepts/ Winter2005Projects/healthcaresoftware/techhome.htm. 9. Arsala et al. (2005). 10. HIMSS EHRVA, “Definitional Model and Application Process” (2006), Accessed June 15, 2007, from http://www.himssehrva.org/docs/EHRVA_application . 11. G. Dickinson, “HL7 EHR System Functional Model and Standard” (2003), accessed June 15, 2007, from http://www.himss.org/Content/Files/EHR_Functional_Model_Ballot . 12. Arsala et al. (2005). 13. CTEC, “Glossary of Telemedicine and eHealth” (2006), accessed June 15, 2007, from http://www.cteconline.org/terms.html. 14. Palo Alto Medical Foundation, “EHRs Revolutionize Care for Patients, Physicians” (2006), accessed June 15, 2007, from http://www.pamf.org/news/2006/0706ehrs.html. 15. Ibid. 16. A. Melczer, “Background on Electronic Health Records” (2005), accessed June 15, 2007, from http://www.providersedge.com/ehdocs/ehr_articles. 17. “Electronic Health Record,” accessed June 15, 2007, from http://findarticles.com/p/articles/ mi_hb4365/is_200602/ai_n18950965. 18. M. Amatayakul, “Electronic Health Records.” In K. M. LaTour and S. Eichenwald-Maki (Eds.), Health Information Management: Concepts, Principles, and Practice, 2nd ed. (Chicago: AHIMA, 2006): 211–237. 19. P. Waegemann, “Healthcare Informatics Online (EHRs vs. CPRs vs. EMRs)” (2003), ac- cessed June 15, 2007, from http://www.providersedge.com/ehdocs/ehr_articles/EHR_vs_ CPR_vs_EMR . 20. P. Waegemann (2004). “EHR vs CCR: What Is the Difference between the Electronic Health Record and the Continuity of Care Record?” (2004), accessed June 15, 2007, from http://www.providersedge.com/ehdocs/ehr_articles/EHR_vs_CCR-What_is_the_difference_ between_the_EHR_and_the_CCR . 21. Waegemann (2003; 2004). 22. Wikipedia, Computer physician order entry. 23. R. Upham, “The Electronic Health Record: Will It Become a Reality?” (2004), accessed June 15, 2007, from http://www.hipaadvisory.com/action/ehealth/EHR-reality.htm. 24. P. Fuhrer and D. Guinard, “Building a Smart Hospital Using RFID Technologies (2006), accessed June 15, 2007, from http://diuf.unifr.ch/people/fuhrer/publications/external/ RFIDECEH . 25. F. Malamateniou (2007). “A Workflow-Based Approach to Virtual Patient Record Security” (2007), accessed June 15, 2007, from http://ieeexplore.ieee.org/xpl/freeabs_all.jsp?arnumber =735778. Chapter Questions 6–1. What is the rationale for classifying EHR, CPOE, and CDSS as patient-centric manage- ment systems? 6–2. Why might it be important to link EHR to CPOE and/or CDSS? What about linking EHR to LIS, PIS, RIS, and any other clinical-based IS? What about linking it to a physi- cian PDA? 6–3. Why is user resistance—particularly from physicians and nurses—often considered the greatest obstacle to successfully implementing patient-centric management systems? 132 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 132 Database, Data-Mining, and Data-Warehousing Concepts for Healthcare Services Organizations Joshia Tan and Joseph Tan 133 IV TECHNOLOGY BRIEF Introduction A healthcare services organization is essentially a collection of interacting subsystems, one of which is its health management information system (HMIS). A key part of HMIS is the data- base, which is the focus of this technology brief. Healthcare Data and Data Sources According to Kroenke, a database is a “model of a model,” a self-describing repository of inte- grated records.1 In other words, a health database contains healthcare data such as patient de- mographics (socioeconomic data), patient billing and accounts information (financial data), patient Social Security number (a master index or other personal identification data), and pa- tient treatment data and progress notes (clinical data) to support the delivery of healthcare services. Three categories of healthcare data are required, almost universally, by healthcare services organizations for supporting their planning and decision-making activities: health status statis- tics, health resource statistics, and environmental statistics.2 Health status statistics include pop- ulation, vital, and morbidity statistics. Population statistics are invaluable in planning and delivering community healthcare services, identifying high-risk groups, locating local and re- gional services demands, flagging potential problems, and evaluating the effectiveness of existing 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 133 programs. Examples include the size, composition, and growth of the population. Vital statistics like mortality–morbidity rates provide important indicators about the prevalence of specific dis- eases, or the incidence of ill health in the population. These data facilitate the identification of high-risk groups, who can then be reached through special programs. Health resource statistics are concerned with the availability of healthcare personnel, facilities, and services. These data are useful for manpower planning and other resource allocation decisions. Environmental statistics, or public health statistics, provide critical data for the prevention of public health problems. Data and data sources must first be recognized as the fundamental basis for generating meaningful information, because they are the primary drivers of a healthcare enterprise’s opera- tion, control, and management. Therefore, the quality of the data being collected is very impor- tant. If the data cannot be understood or are inaccurate, it will be a significant impediment to generating the needed information for setting healthcare organizational policies and decisions. Healthcare Databases Healthcare databases have been in existence for as long as there have been data storage devices. Even so, the volumes of patient files lining the shelves of a physician’s clinic may be considered a physical “database” of patient records. It must, however, be clarified that the database term applies typically in a computer data-processing context. Databases are essentially collections of data, organized in software, that can be easily ac- cessed, managed, and updated just like an electronic file system. Therefore, instead of paper fil- ing, the data are organized in fields, records, and files in a database. A file is a collection of records, and a record is a complete set of fields. Fields contain individual data elements; for in- stance, a patient record can be organized into fields of information relating to individual pa- tients. Database management systems (DBMS) are software employed to manipulate (enter, reorganize, and retrieve) data into or from a database. Depending on how the data are organized, users will extract information from databases by us- ing a query language as part of the DBMS. SQL, which can be formulated in the form of a ques- tion, is an example. If a physician is looking for a prescribed medication given to a patient on a certain day, he or she can use SQL to retrieve the information by inputting the patient name or the prescription date. In fact, with the appropriate question framed in SQL, information on all of the patients given a certain medication on the same day may also be extracted. The DBMS architecture can affect how quickly and/or flexibly one can extract the information from the database. There are different data models by which DBMS organize information, the most common ones being rela- tional, network, flat, and hierarchical, all of which are discussed later in the section on data models. At this point, we highlight a commonly used graphical tool for database design, the E-R model. E-R Model The entity–relationship (E-R) models are among the most popular means of depicting the data architecture of healthcare services organizations and other data-intensive organizations. E-R models3 concentrate on highlighting the data structure underlying the information processes, 134 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 134 whereas E-R diagrams may be used to model these processes or flows. More specifically, E-R models can be used to show entities and relationships among them for any simple or complex network of entities within a system. Key elements of the E-R model include entities, relationships, and attributes. An entity is a “thing” that can be identified in a workplace—common examples include patients and physi- cians. An entity of a given type may be grouped into entity classes: the “volunteer” entity class is the collection of all volunteers. Each entity class can have many entity instances; for example, John and Peter may be instances of the “patient” entity. In the E-R model, a relationship, or an associa- tion between entities, can be one-to-one (1:1), one-to-many (1:N), and many-to-many (N:M) re- lationship. For example, the statement, “Dr. Nolan ‘treats’ John,” portrays a 1:1 relationship between a single-entity instance of one type to a single-entity instance of another type. If Dr. Nolan also “treats” Peter, then the relationship becomes a 1:N (one physician, many patients) rela- tionship. Also, if John and Peter are referred by Dr. Nolan to Professor Chen and both these refer- rals are also Professor Chen’s patients, then it is a N:M (many physicians, many patients) relationship. The determination of these relationships depends largely on the user’s and designer’s perspectives. Attributes, meanwhile, are the properties of an entity class and are descriptions of the entity’s characteristics. In the E-R models, entities are conceptualized as having various attributes. One such attribute, or a certain combination of them, serves as the entity’s unique identifier, or “key,” allowing it to be distinguished from the other entity instances. For example, John’s personal health number, name, age, and gender are attributes of the patient instance, John. The unique identifier, which is the personal health number, can be used to differentiate among the patient in- stances. E-R diagrams—by focusing on “things” about which data must be recorded (entities), the re- lationships among the entities, and their attributes—provide a high-level architectural view of any health database. Moreover, these diagrams can also assist in identifying various ways of divid- ing the database into subject databases so that they can be used in distributed systems. If changes are made, E-R diagrams can therefore offer great assistance in redesigning the data architecture and will be helpful tools for logical modeling of HMIS problem solutions. An example of an E-R diagram for a community health promotion project (CHHP) is given in Figure TB4.1. E-R M O D E L 135 Health Promotion Supervisor Health Promotion Program Participant One-to-One Relationship One-to-Many Relationship Many-to-One Relationship Many-to-Many Relationship Events FIGURE TB4.1 An Example of an Entity–Relationship Diagram for the Multicommunity Health Promotion Project. 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 135 Data Models Data models are ways of conceptualizing how information is organized and how it can subse- quently be extracted from a database. Among the different record-based logical models, the hi- erarchical, network, and relational models are most widely used. For the database designer, the use of these models depends chiefly on the user’s perspective and interpretation of their organi- zational structure and processes. Hierarchical models are those in which the structures are organ- ized in a top-down, inverted tree-like structure. Health data are stored as nodes in a tree structure, with each node having one “parent” node and perhaps multiple “child” nodes, which may or may not contain health data. For instance, health data about a CHPP, run by staff from a community hospital, may follow the hierarchical model shown in Figure TB4.2. At the top of the tree hierarchy is the root segment of an element of the tree that corresponds to the main record type, which, in this case, is the CHPP. Below the root element is a subordi- nate level of health data elements, possibly the walking or restaurant program, each directly linked to the root. Health data elements at each subsequent (subordinate) level are linked to only one element above, but they may be linked to more than one element below; this is demonstrated in our example by the various events of Programs 1 through N. Accordingly, E1 and E2 may refer to the Walkathon event and the Walk-for-Life event of the Walking Program (Program 1). The hierarchical organizational structure is best suited to situations in which the logical relationship between data can be properly represented with the one-to-many ap- proach—that is, where subordinate levels of health data can sufficiently define all relevant at- tributes of the superior data element. In our case, the CHPP has several programs, which, in turn, are filled with numerous events. In a hierarchical health database, data are accessed logi- cally (navigated) by going through the appropriate levels of data elements to reach the desired data element. There is usually only one access path to any particular data element. Network data models are logical extensions of the hierarchical models. Instead of having vari- ous levels define one-to-many relationships, the network structure represents a network of “many-to-many” relationships, as shown in Figure TB4.3. 136 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S Program N E1 E2 E3 Community Health Promotion Project (CHPP) E1 E2 E1 E1: Event 1 E2: Event 2 E3: Event 3 E2 Program 2 (Restaurant) Program 1 (Walking) FIGURE TB4.2 An Example of the Hierarchical Model. 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 136 Here, the CHPP and the University Health Outreach (UHO) project, for example, may re- quire work from two or more programs: walking, restaurant, smoking cessation, and so on. Although all three of the programs mentioned here are involved in the CHPP project, only the latter two are part of the UHO project. Lines joining the responsible programs with the respec- tive projects indicate these relationships. In a network health database, there is often more than one navigational path through which a particular health data element can be accessed. Unfortunately, health databases structured according to either the hierarchical or the net- work data model suffer from the same deficiency. Once these relationships are established be- tween data elements, it is difficult to modify them (modification/update anomalies), either by adding new relationships (addition anomalies) or by removing old ones (deletion anomalies). For these reasons, the relational structure has gained popularity among database designers and users over the past several years. Relational data models are those in which all health data ele- ments are placed in two-dimensional tables that are the logical equivalent of files. The purpose of the relational structure is to describe health data by using a standard tabular format. As long as the tables share at least one common health data element, any health data elements in these tables can be linked, and the desired data elements subsequently generated in a usable fashion. The health data in the relational model, in most cases, can be linked according to the actual re- lationship of the various health data elements (i.e., one-to-one, one-to-many or many-to-one, and many-to-many). In the relational tables, each row, called a “tuple,” normally represents a record or collection of related facts. The attributes are represented by the table columns, with each attribute only capable of taking on certain values. The allowable values for these attributes or columns constitute the domain. The domain for a particular attribute indicates what values can be placed in each of the columns in the relationship role. The concept is analogous to a se- ries of vectors. Figure TB4.4 provides an example of how a relational health database may be organized and accessed for the evaluation of the CHPP case. A health program evaluator may, for instance, wish to determine the performance of a particular program’s leader (say, of the walking pro- gram) under the previously mentioned CHPP and the number of events for that program that have been held by this supervisor to date. The evaluator would make an inquiry to the health database via, say, SQL or another query facility linked to the DBMS. DBMS are software for accessing and processing databases and applications. The query facility provides end-users with a structured tool for searching and making changes to the database. In this case, the query D ATA M O D E L S 137 Community Health Promotion Project (CHPP) Program 1 (Walking) Program 2 (Restaurant) Program 3 (Smoking Cessation) Program N University Health Outreach (UHO) FIGURE TB4.3 An Example of the Network Model. 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 137 would start with the project description and search the Project Table (Data Table 1) to find the appropriate program number, then use the number to search the Program Table (Data Table 2) for the project leader’s employee identification number. This identification number, in turn, would be used to search the Supervisor Table (Data Table 3) for the name and other attributes of this supervisor. From here, the evaluator can tell, as a response to the query, if there were 50, or however many, events held to date by this supervisor. Normalization Normalization is a process for standardizing relations. A relation is defined as a table where all of its cells are single valued with no repeating groups and all entries in any column (attribute) are of the same kind. Data Tables 1, 2, and 3 in Figure TB4.4 are all relations. Essentially, normalization con- verts problematic relations or tables into desirable and well-structured ones. Thus, highly normal- ized relations are designed to avoid addition, deletion, and anomalies in updates. This means that the structure of normalized relations is designed to support data integrity, consistency, comparabil- ity, and reliability, apart from achieving physical and logical data independence; that is, data can be manipulated freely in the database without the need to revise linked application programs. Although a discussion of the various normal forms is beyond the scope of this technology brief, Figure TB4.4 summarizes five important normal forms (NF) and the famous domain/key 138 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S Project # 155 : 443 Description CHPP : UHO Program # 1 : 20 Project Table (Data Table 1) Program # 1 : 20 Description Walking : Eating Supervisor ID 331 : 411 Program Table (Data Table 2) Supervisor ID Last Name First Name Events Held to Date Supervisor Table (Data Table 3) 331 : Home : John : 50 : FIGURE TB4.4 An Example of the Relational Model. 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 138 normal form (DK/NF). Fagin4 argues that a DK/NF relation has no modification anomalies and that, conversely, any relation having no modification anomalies is a DK/NF relation. In other words, the highest normal form that a relation needs to achieve is DK/NF, which, with very few exceptions, is a desirable standard data schema for database designs. Despite promises for the standardization of relations and automation of database design, many end-users continue to find concepts of normalization difficult to grasp. Readers who are interested in further details on data normalization should consult Silberschatz et al.5 or any other recently published text on database management. Data Mining For decades, different companies have used data mining, or “data dipping,” to uncover hidden knowledge or patterns from massive data. To understand data mining, the reader should first understand data warehousing, which essentially refers to the amassment of enterprise-related data for strategic decision support analysis and knowledge discovery. Hospital CEOs now realize that the only way to survive and grow in a managed care market is to gain significant expertise in managing information, knowledge, and documentation. Thus, many workers in the medical field are searching for quick and affordable ways to tap into avail- able information banks of detailed patient records. The data-warehousing concept is crucial, be- cause the healthcare industry is moving from a revenue-based business model to one focused on cost-outcomes information management. Many hospitals need data-warehousing architecture to handle the tedious process of analyzing and comparing massive patient treatment outcome information. Johnson Medical Center in Johnson City, Tennessee, needed a data warehouse for studying the historical records of patient treatments and spotting trends or anomalies. Its aim was to help create report cards about physicians, thereby measuring the cost of each doctor’s services at the hospital; this was measured by the types of treatments used, total time spent with patients, and other factors. Also, the data gathered could be used to analyze cost of each treat- ment vis-à-vis the amount of money paid for by insurers. This architecture, then, permits com- parison of information among the various departments to show the profitability of each individual operation. More recently, HIC, the Australian federal agency that processes all medical claims, began using data-mining software to discover subtle patterns, useful for making strategic business de- cisions, by sifting through seemingly unrelated data. Given the breadth of its transactions, HIC is a classic example of an organization that could benefit from the data-warehousing technology architecture. The staff traditionally relied on paper reports to ensure that medical services were appropriately prescribed and billed. However, with HIC conducting more than 300 million transactions and paying out $8 billion annually to physicians and hospitals, the ability to mon- itor everything was almost impossible. By using various data-mining tools, HIC’s staff can now track areas never before possible. For instance, the different ordering habits of physicians in similar clinical situations can be analyzed so that best practices for various treatments can be es- tablished. Often, the key challenge is to know what information to tap into and to ensure that the information tapped will be reliable and valid. D ATA M I N I N G 139 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 139 There are different data-mining techniques, such as artificial neural networks (ANN), deci- sion tree analysis, genetic algorithms, and rule induction. ANN is a nonlinear predictive model that learns through training and resembles biological neural networks in structure. ANN are ex- pensive due to their need for extensive training, although they are compatible with all data types. Decision trees are tree-shaped structures that entail an analytic drill-down process when examining a given decision task’s best alternatives. Genetic (evolutionary) algorithms are essen- tially iterative procedures for evolving new populations of structures; this is done through re- production, cross-over, mutation, and natural selection methods in order to effect the best solutions (chromosomes) to specific domain problems. Finally, rule induction is the extraction of useful if–then rules from statistically significant data, accommodating all forms of numeric as well as nonnumeric (symbolic) data. Conclusion Frontiers of the medical field are advancing at an escalating pace; parallel to this, the amount of patient information required by healthcare services organizations, in order to achieve high-quality care, has also soared. At the same time, stringent budgetary measures have put enormous pressure on the healthcare industry to tighten cost-control mechanisms and form new alliances. These changes have, in turn, dramatically increased the need for an integrated HMIS approach that can produce the relevant information; with numerous desirable characteristics, the appropriate infor- mation would reduce the need for duplicated services in the healthcare system. This technology brief has introduced the basic concepts of healthcare data, databases, DBMS, and various other as- pects related to databases, such as health data-mining and data-warehousing methods. Data mining is an influential business intelligence technology with great potential for rapid growth. Data-mining tools predict the future patterns and behaviors of employees and clients alike; help guide managers to arrive at rational and sensible decisions; and can be applied to an- swer complex questions that, without extensive research, may not be easily addressed within a short and rapid time period. As an example, a telxon, which is a 900-MHz wireless hand-held terminal equipped with a barcode scanner, is sometimes used to locate specific items. In some organizations, when these products are scanned, the inventory database will be automatically updated; using preprogrammed electronic orders automatically sent to the suppliers, items in need of reordering would also be replenished. In essence, data mining automates the process of finding predictive information in large databases. Similarly, data mining is a powerful technol- ogy that will help many healthcare services organizations focus on the most important informa- tion in their databases. Data-mining programs can be installed, with relative ease, on existing software and other hardware platforms, and result in instant added value to the healthcare ser- vices organization’s information resources. Nearly every healthcare facility has massive quanti- ties of data on patients and the many different services each patient has received over the years, but a good number of these facilities lack the tools to fully utilize the information they have toiled so hard to acquire. We end this discussion with an illustration. A pharmaceutical company can analyze its recent sales force activity and their results—and use these results to improve the targeting of high-value physicians—while simultaneously determining 140 T R E N D I N G T O WA R D PAT I E N T-C E N T R I C M A N A G E M E N T S Y S T E M S 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 140 which marketing activities will have the greatest impact in the next few months. The data need to include competitor market activity, as well as information about the local healthcare systems. The results can be distributed to the sales force via a wide area network (WAN), enabling the representatives, as the key attributes in the decision process, to review the recommendations. The ongoing, dynamic analysis of data warehousing allows best practices from across the organ- ization to be applied in specific sales situations. Notes 1. D. M. Kroenke, Database Processing: Fundamentals, Design, and Implementation, 6th ed. (Upper Saddle River, NJ: Prentice Hall, 1998). 2. G. Thompson and I. Handelman, Health Data and Information Management (London: Butterworth Publishers, 1978). 3. P. Chen, “The Entity-Relationship Model: Toward a Unified Model of Data.” ACM Transactions on Database Systems 1, no. 1 (March 1976): 9–36. 4. R. Fagin, “A Normal Form for Relational Databases That Is Based on Domains and Keys,” ACM Transactions on Database Systems (September 1981): 387–415. 5. A. Silberschatz et al., Database System Concepts, 3rd ed. (New York: McGraw-Hill, 1997). 6. Kurt Thearling, “An Introduction to Data Mining” (2008a), accessed February 11, 2008, from www.thearling.com. 7. Kurt Thearling, “Data Mining and Customer Relationships” (2008b), accessed April 6, 2008, from http://www.thearling.com/index.htm#wps. N O T E S 141 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 141 56918_CH06_Final_Tan 4/6/10 11:50 AM Page 142 Health Management Information System Integration: Achieving Systems Interoperability with Web Services J. K. Zhang and Joseph Tan* 143 7 CHAPTER Editor’s Note: Chapter 7, which focuses on the topic of HMIS integration, concludes the Part II discussion on HMIS technology and applications. Apparently, maintaining legacy systems in healthcare services organizations can be both costly and increasingly cumbersome due to the lack of interoperability among disparate applications. Indeed, these isolated systems will eventually result in unsatisfactory delays to patient care and will continue to take a toll on both clinicians’ and employees’ time and productivity. The application of Web services as a way to transform healthcare organizational HMIS into seamless integrated systems is certainly a major step that promises to benefit the healthcare services organizations in the longer term, not just temporarily. Therefore, the technology discussed in Chapter 7 is an innovative one. Not only would this technology help prepare the readers to move away from islands of legacy systems in light of the rapid advances in HMIS technology and applications, but the message conveyed could also help open the readers to adopt new HMIS thinking through careful analysis, planning, design, and management (Part III) as well as help them take the next steps to move into higher and wider perspectives regarding HMIS (Part IV). Altogether, the knowl- edge acquired in Chapter 7 will assist the readers in relating to the other parts of the text much more comprehensively. *The authors would like also to acknowledge specifically the contribution of Ms. Ai Li Mao, a data analyst at Airinmar Ltd, UK, for her valuable assistance in improving the content of several parts of this manuscript. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 143 144 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N S c e n a r i o : The SAPHIRE Project1 Interoperability is concerned primarily with the challenge of linking software and systems being developed and implemented with diverse platforms and languages when required information has to be shared conveniently and securely among multiple providers and users. For example, it is typical for medical and clinical users to derive information embedded in heterogeneous and independent health management information systems (HMIS), most of which are often sup- ported traditionally with the use of specialized clinical hardware and applications. In other words, people with varying levels of expertise and needs typically use different parts of a large- scale HMIS supported by different vendors, who will also adopt different standards, technolog- ical architecture, and information formats. Once these interoperability problems are tamed, it is believed that large-scale HMIS can be more easily implemented and maintained with the bene- fits of reusing previously captured data, adopting well-tested programming codes, and diffusing proven and related applications. In the United States, Europe, and elsewhere, growing demands for health care due to an aging population and the slowing down in mortality rate among older adults over the last few decades have led to further growth and development of wearable medical devices, sensor-based monitor- ing technology, and mobile health care. Advanced IT, network, and Web technologies must now be combined to offer support to healthcare professionals in delivering healthcare services at a dis- tance. With these advancing HMIS capabilities, it is anticipated that the quality of health care CHAPTER OUTLINE Scenario: The SAPHIRE Project I. Introduction II. Current HMIS Interoperability Issue III. Web Services: The Interoperability Solution IV. WSIHIS Case ● Background of WSIHIS ● WSIHIS Interoperability ● Web Service–Based Solution for WSIHIS Interoperability ● System Assessment on WSIHIS Interoperability V. Conclusion Notes Chapter Questions 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 144 will be further enhanced, thereby letting people live longer than they are used to. Owing to the increasing percentage of elderly people in Europe, the SAPHIRE Project was launched. The aging population trend basically means that a growing number of people will need to become more aware of the basic and clinical research on disease pathophysiology and treat- ment. Coupled with increased demands on healthcare services delivery systems, this rapid growth has made the future practice of medicine even more complex. Essentially, using an in- teroperable and integrated platform to connect between the hospital information systems and the wireless medical devices, SAPHIRE aims to build an intelligent healthcare monitoring and health decision support system (HDSS) to address the challenge of growing workload intensity in medicine. Clinical decision support systems (CDSS) are used to provide clinicians or patients with clinical knowledge and patient-related information, intelligently filtered and processed to en- hance patient care. The healthcare community response to the complex challenge of modern medical practices is through developing clinical practice guidelines to simplify and improve healthcare services delivery. Although there are many clinical standards and practice guidelines, it is easier for healthcare professionals to access and apply these guidelines if computerized HDSS (automating these clinical guidelines to support the health professionals) are readily available. When developing computerized HDSS, one of the major challenges is to retrieve patient-specific information from the many disparate data sources. There are a large number of legacy clinical systems that have been independently created and administered; they do not, therefore, physically or logically provide support for interoperating and sharing information. In addition, most of the healthcare systems in Europe are built with various computer technolo- gies (e.g., different system platforms supported by diverse vendors and using various database management systems). Moreover, most HMIS applications supplied by local and national ser- vice providers are introduced alongside existing departmental applications such as laboratory information systems and mental healthcare record systems. In the SAPHIRE platform, the solution to tackling the interoperability problem is to expose the data coming from sensors as well as the data stored in medical information systems as se- mantically enriched Web services. Data from both of these sources and their functionalities could then be combined into different Web services through standard-based ontologies. With the support of Web services, different platforms would be enabled to exchange information and share the functions. Apparently, the interoperability problem is significant and central for the development of an effective intelligent healthcare monitoring tool. The key challenges have to do with the fact that the data coming from the wireless medical sensors are either (1) in proprietary format, or (2) when it conforms to a standard, the interoperability challenge remains or could not be com- pletely solved because there are numerous standards being adopted. For electrocardiogram data, the available standards include SCP-ECP, U.S. Food and Drug Administration FDA/HL7 Annotated ECG, I-Med, and ecgML. If these data are to be combined with those stored in elec- tronic healthcare records (EHR), the problem would become more complicated due to the fact that hospital information systems are mostly isolated; even when these systems do conform to an interface standard, there still will be the challenge of different standards (or different versions S C E N A R I O : T H E S A P H I R E P R O J E C T 145 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 145 of the same standards). Specific examples include HL7v2.x, HL7v3 CDA, CEN ENV 13606, EHRExtract, and openEHR archetypes. Therefore, the existence of these differing standards does not achieve the aimed interoperability. Besides, interoperability of data coming from dif- ferent wireless medical sensors is critical to infer information by integrating data coming from various sensors. By examining the guideline models that are used in SAPHIRE, an understanding of the in- teraction with the clinical workflow running in the hospital is a necessity. For example, “aspirin should be prescribed to the patient” could be decided on one of the guideline models. For this type of interactions, medical Web services are used to store such medication and procedure or- ders to the available hospital information system. These kinds of orders are usually imple- mented as asynchronous Web services to increase the performance. As the result of a European commission–funded project, IST-1-002103 Artemis, the SAPHIRE project is being developed. IST-1-002103 Artemis developed a semantic Web service-based P2P infrastructure for the interoperability of medical information systems. With the support of Artemis project, the Healthcare Institutes are able to exchange EHR in an inter- operable manner through semantically enriched Web services and semantic mediation. These results are well used by the SAPHIRE project for the integration of the patient data collected through wireless medical sensor devices with hospital information systems. This infrastructure comprises the interoperability base for the intelligent healthcare monitoring system. Imagine a world where everyone speaks the same language—the international language. How easy would it be for people to exchange ideas—and understand each other? Trading among world partners would occur in a snap, and there would be reduced costs for everything, including paperwork, whether manual or computerized. That, in essence, is interoperability. Why is interoperability an important milestone for HMIS integration in a healthcare services organization? What would be the rationale for some people to be against such an idea? I. Introduction Characteristically, healthcare information is highly complex, heterogeneous, dynamic, and time-oriented. These features, together with the need to satisfy increasingly stringent regulatory and medico-legal requirements, make healthcare management information systems (HMIS) a costly investment. HMIS cost has been projected to comprise 25 to 39 percent of total health- care costs.2 The traditional healthcare services organizations are expected to be transformed in the com- ing years, extending from their traditional hospital base to include the home, and from focusing on the treatment of acute and chronic diseases to general patient well-being and improvement of the quality of life. This translates to massive amounts of information to be communicated and shared. With advances in information technologies and greater HMIS complexity, many healthcare institutions have developed systems3 to manage and process these large amounts of medical information. While the accuracy and performance of health information processing have significantly improved, in order to support massive information exchange and medical knowledge sharing, healthcare providers have to integrate their systems’ functions and data. 146 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 146 This desire raised some concerns, such as data security, data transmission and network limita- tion, and system interoperability.4 In this chapter, our focus is on system interoperability, a major barrier for HMIS integration. In the United Kingdom, for example, most legacy systems are isolated in that data cannot be shared among them. Hence, if a patient needs to change his original general practitioner (GP), the patient’s information cannot be immediately moved to the new GP’s system until his origi- nal GP transfers the information. Technically, these systems were developed using different lan- guages such as Java, Visual Basic, and C++; different system platforms such as the Microsoft Windows operating systems (OS), Linux OS, and Macintosh OS; and different database man- agement systems (DBMS) such as Microsoft SQL server, Oracle, and Microsoft Access.5–7 The use of a distributed middleware technology, or Web service, is one solution. Traditionally, the middleware is a convenient means of dealing with the interoperability problem. Distributed object middleware provides the abstraction of an object that is re- mote; yet, its methods can be invoked, just like those of an object in the same address space as the caller. Distributed objects make all the software engineering benefits of object- oriented techniques—encapsulation, inheritance, and polymorphism—available to the dis- tributed application developer. Developers have used distributed middleware technologies like CORBA (Common Object Request Broker Architecture)/DCOM (Distributed Component Object Model)—both of which incorporate software such as I-HER,8 BHS,9 and Hospital Information System10—to tackle the issue of system and language interoper- ability. Yet, CORBA/DCOM solutions, which are largely applied in complex systems con- text based on Internet environment, are unsuitable because of shortcomings in the firewall crossing and wireless environment.11–13 In contrast, Web service, as a new distributed mid- dleware technology, can overcome these CORBA/DCOM shortages. It will also successfully address the system-language interoperability issue. However, this new technology has not been formally applied to HMIS domains. Unlike most commercial systems, HMIS involves many more users and entails more historical data and legacy systems. Therefore, the influ- ence of interoperability issues in HMIS is much more apparent. Moreover, Web service technology and Microsoft .NET (a platform for developing Web services applications) are still relatively young. Guah and Currie14 state that “Web service architectures are the key to unlocking the full business potential of any Internet-based strategy” and argue for its application into HMIS. Another HMIS researcher notes that “Microsoft .NET platform is a very promising solution but it was not fully available. . . .”15 Others observe that flexible Web-based services in e-health care are a result of the recent Microsoft .NET developments and that these solutions are proba- bly more flexible, more dynamic, and easier to implement than CORBA-based systems. Our focus here, therefore, is to address the interoperability issue with the Web service technology in the healthcare arena. A small-scale but real-world Web service–based integrated healthcare informa- tion system (WSIHIS) designed for the osseointegration project at Queen Mary’s Hospital is presented at the end of the chapter to demonstrate and assess such an HMIS integration solu- tion. Although this case study is based specifically in the United Kingdom, its application is similarly significant for healthcare services organizations in the United States, given the abun- I . I N T R O D U C T I O N 147 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 147 dantly complex and heterogeneous information systems employed in the U.S. multi-provider healthcare delivery systems. II. Current HMIS Interoperability Issue The intention of nationalizing and even globalizing healthcare systems through IT has become a very common talking point. Since the end of 2003, the British government started to develop a computerized healthcare system on a national scale, namely, the National Program for IT (NpfIT). NpfIT aims to integrate most of the healthcare systems and services based in England and Wales. However, this project was severely delayed for years because of various issues, such as data transmission, network limitation, data security, and the disincentives for medical staff to cooperate with each other. Today, the issue of system interoperability appears to have become increasingly critical be- cause there are a considerable number of hospitals in England and Wales that run on different healthcare IT servicing models. Many of these hospitals have also built up their own HMIS and DBMS. This situation is disconcerting because it may easily result in one individual patient having multiple medical records in different hospitals or even in different departments within a single hospital. In addition, most hospital legacy systems have been developed using different computer languages, compiled on different platforms, executed on different hardware—thereby supporting different data structures, types, and formats. The diversity of these systems was not the result of a well-planned development effort nationwide, but it has simply evolved, as au- tonomous and heterogeneous systems proliferated due to changing institutional needs. Eventually, these islands of HMIS function independently and do not share their data and process. Meanwhile, computer technologies have advanced and the needs for systems that will be able to share information across organizational units have changed. If systems are designed inadequately and with poor interoperability planning for future connectivity—as with the in- creasing demands from healthcare employees, caregivers, and patients living in today’s health- care services organization environment—a small mistake in early HMIS design and developmental efforts could easily stop these systems from working properly the next time around. Interoperability, a critical HMIS issue,16,17 may thus be defined as “the capability with which two or more programs can share and process information irrespective of their imple- mentation language and platform.”18 Connecting for Health, as a single IT provider for the National Health Services (NHS), identified the interoperability challenge as the need to interconnect heterogeneous HMIS to share information easily, seamlessly, and securely whenever and wherever information sharing is needed. As noted, most clinical applications are determined by a huge variety of heterogeneous and independent workplaces, and most of them are also equipped with specialized clinical hardware.19 Moreover, people with vary- ing levels of expertise and needs typically use different parts of a large-scale telemedicine sys- tem. These systems may also be from different vendors, who adopt different standards and information formats, as in the case of NpfIT.20 Once the interoperability problem is re- 148 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 148 solved, it is believed that the development and maintenance of large-scale telemedicine sys- tems (or any other large-scale HMIS) can be streamlined with data reuse, code reuse, and application reuse. Several major HMIS interoperability challenges have been noted to date: 1. Database (DB) system interoperability. Patient records are often located in different data- bases21; however, data stored in different database platforms using Microsoft SQL server, Oracle, and Microsoft Access cannot be exchanged among the different systems nor be used by applications based on different DBMS. 2. Language interoperability. Different HMIS have been designed and developed by different IT providers, as is the case with patient record systems under the NHS system,22 where developers make use of different programming languages such as Java, Visual Basic, C++, and C# to build their HMIS. This inevitably makes reusing and sharing of applications nearly impossible because of the programming language incompatibility. 3. System platform interoperability. This equates to operating system (OS) interoperabil- ity, although over the past few years the Internet browser has, in and of itself, emerged as a platform.23 As different HMIS applications emerged based on different development platforms (e.g., Microsoft Windows OS, Linux systems, IE Web browser, and Avant Web browser), most of these HMIS applications will only work on certain system platforms. For example, if the HMIS were built based on a Windows system platforms, it would restrict the software to run also on another platform such as Linux. 4. Semantic interoperability. Many interoperability problems arise because of semantic dif- ferences. Semantic interoperability assumes that the components of the distributed ap- plication will have different interpretations of the data. For example, the same term may have different meaning contents in different countries, or different terms could have the same meanings. Such situations are common in medical information systems, and hu- man intelligence is often required to resolve such semantic interoperability issues. HMIS integration is necessary when two previously independent organizations (such as NHS trusts) merged—each of which not only has its own IT architecture but also promotes different ways of recording, sharing, and accessing information. Somehow, these merged organ- izations have to unify core applications, such as patient administration systems, so that the staff can continue to use both the newly installed system and the legacy system. More recently, the NHS has proposed the NpfIT, which is aimed at integrating HMIS under the NHS in England and Wales.24 Unfortunately, a large number of legacy clinical systems, which do not provide the support for interoperating and sharing information either logically and/or physically, have been independently created or administered in the NHS. In addition, most of the healthcare systems in England and Wales are built with different system platforms and DBMS, and most HMIS applications supplied by local and national service providers are I I . C U R R E N T H M I S I N T E R O P E R A B I L I T Y I S S U E 149 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 149 introduced alongside existing departmental applications like laboratory information systems (LIS) and mental healthcare record systems. As a result, the interoperability issue was a major challenge for the NpfIT when it was proposed in 2002.25,26 Put together, the NpfIT interoperability issue is largely a result of several factors: 1. Interoperable business processes. There are thousands of hospitals under the NHS adopt- ing different business processes with different health systems, which makes NpfIT more complex to interoperate. 2. Changing interoperability requirements among NpfIT systems. For example, Electronic Transmission Prescription, one of the systems delivered by NpfIT, was envisaged origi- nally as a separate system, but the program is now required to be integrated with an- other software system, NHS Care Records Service.27 3. Diverse patient record systems in use across the NHS. The challenge of integrating records is augmented largely by diverse NHS patient record systems contracted to isolated soft- ware vendors. 4. Need to interoperate with systems on doctors’ desktops. NHS Care Records Service, as one of NpfIT’s services, will need to interoperate with doctors’ desktop systems. The chal- lenge for NpfIT is not really building systems from scratch, but having to deal with many existing hospital and GP systems to be connected to the “spine,” which is a newly developed NHS database system.28 5. Two separate Scottish and English NHS systems. Because Scotland and England are using two different NHS systems,29,30 both of these places are also developing two different HMIS with different IT providers, potentially leading to future interoperability between systems. 6. Localized systems. Under the NHS system, most existing IT systems in trusts are localized and do not typically support information sharing across buildings and departments. Consequently, within a single organization, several records are often created for the same patient. In primary care, individual practices also have their own IT applications and databases, so patient records are not easily transferred to other practices or care providers. III. Web Services: The Interoperability Solution Integrating with seamless interoperability among applications and data from different systems is a very challenging task. As noted, the achievement of a good interoperability strategy is sig- nificantly constrained by many restrictions in traditional CORBA or DCOM implementa- tions.31,32 Fortunately, Web services have emerged as the next-generation HMIS integration technology.33 Based on open standards, Web services permit any piece of software to communi- cate with any other in a standardized XML messaging system, resolving the constraints with DCOM/CORBA. As a modular, self-describing type of software service, Web services are self-contained appli- cations that can be published, located, and dynamically invoked across the Web. The Web ser- vices technology is built on the foundation of open standards and common infrastructure, comprising three areas: communication protocols, service descriptions, and service discovery, of which each is specified by an open standard.34 In general, Web services consist of two major 150 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 150 technologies—XML (eXtensible Markup Language) and SOAP (Simple Object Access Protocol)—and two assistant technologies—WSDL (Web Services Description Language) and UDDI (Universal Description, Discovery, and Integration). The specifications of services can be described using WSDL. WSDL is a general framework (based on XML) for describing network services as collections of communication endpoints ca- pable of exchanging messages. It describes where a service is located, what operations are sup- ported, and the format of the messages to be exchanged based on how the service is invoked. WSDL does not mandate a specific communication protocol used. The Web service vision foresees a proliferation of services, which in turn requires the avail- ability of public directories that can be used for the registration and finding of services. UDDI provides a mechanism for service providers to advertise their services in a standard form and for service consumers to query services of interest, thereby paving the way for interoperability be- tween services. A UDDI entry consists of white pages (e.g., address, contact information), yel- low pages (e.g., industrial characterization based on standard ontologies), and green pages (e.g., references to specifications of services). Focusing on the core technology of Web Services, SOAP is a platform-independent protocol that uses XML to make remote procedure calls over HTTP. SOAP message is written in an easy-to-understand and platform-independent XML. HTTP was chosen to transmit SOAP be- cause HTTP is a standard protocol for sending information across the Internet. The use of XML and HTTP enables different operating systems to send and receive SOAP messages. As well, Web services allow client and server implementations to construct their distinct but equiv- alent representations of any data structures. Web services that use SOAP support a wider variety I I I . W E B S E R V I C E S : T H E I N T E R O P E R A B I L I T Y S O L U T I O N 151 UDDI Registry Points to Descriptions Register Services in UDDI Points to Services SOAP/HTTP Communication with XML Messages Discover Services Describe Services WSDL Applications (Service Consumers) Service Providers FIGURE 7.1 A Detailed Architecture of Web Service. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 151 of data types, including most basic data types as well as Dataset, DateTime, XMLNode, and several others. SOAP also permits the transmission of arrays of all these types. Figure 7.1 indicates how Web services works. First, Web service providers make use of WSDL to describe their Web services. Following this step, Web service providers register and publish their services in UDDI. In this way, applications or service consumers are then able to find or locate the services that interest them via UDDI, which directs these service consumers to relevant services according to the description of Web services. With regard to the last step just discussed, applications or service consumers are able to invoke relevant Web services using SOAP transmitted via HTTP on the Internet. When Web services are encoded in XML, SOAP then provides a way to facilitate communi- cations between applications developed with different programming languages and/or running on different operating systems. In fact, Web services provide a distributed computing technol- ogy environment for integrating HMIS applications on the Internet using open standards and XML encoding. The use of standard XML protocols makes Web services platform-independent, language-independent, and vendor-independent. In light of this, Web services will provide an ideal solution for use in HMIS application integration. Figure 7.2 depicts how applications work with Web services. With respect to Figure 7.2, applications or service consumers send requests and responses to and from Web services via SOAP. When any piece of software system invokes a Web service method, the request and all relevant information are packed in a SOAP message and sent to the 152 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N Response Results Packed in SOAP Messages Call/Invoke Applications/Consumers Web Services’ Methods Services Providers FIGURE 7.2 Interaction between Applications/Consumers and Web Services. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 152 appropriate destination. When the Web service receives the SOAP message, it triggers an auto- matic processing of the contents (called the SOAP envelope), which specifies the method that the client wishes to execute and the arguments the client is passing to that method. After the Web service receives this request and parses it, the proper method is called with the specified arguments (if there are any), and the response is then sent back to the client in another SOAP mes- sage. Conversely, the client parses the returned response to retrieve the result of the method call. As illustrated in the second half of this chapter, an integrated HMIS Web service (or WSIHIS) can be developed and its performance assessed using different OS platforms, programming lan- guages, and DBMS. The result of assessment showed that Web services enabled WSIHIS to work on cross-system platforms, make use of functions and applications developed by different programming languages, and exchange the data across database systems. It can therefore be ar- gued that the Web service–based solution could help existing and future HMIS to reduce sig- nificant effort in overcoming the interoperability challenge today and in the future. IV. WSIHIS Case Evidently, system interoperability has become critical for NpfIT or any large-scale HMIS to share information. To this end, HMIS developers have used CORBA/DCOM, a traditional distributed middleware technology approach, which is unfortunately relatively complex to han- dle without specialized expertise. Given that any large-scale systems are challenging to develop and maintain, it is all the more critical that these systems should be technically easy for longer- term development and maintenance requirements. Web services were touted here to address the interoperability issues. Compared with CORBA/DCOM, Web services could reduce development and deployment time, lessen system implementation costs, reduce the maintenance complexity, and lower HMIS project failure risk. These features make Web services suitable for large-scale projects such as NpfIT. Simply put, Web service, as a new distributed middleware technology, promises to address the HMIS interoperability challenge. Yet, the technology has not been formally applied to HMIS, unlike known successful applications in e-business. To illustrate Web services conceptualization, a small-scale but real-world Web service–based integrated healthcare information system (WSIHIS) designed for the osseointegration project at Queen Mary’s Hospital, was designed and developed based on the Web service technology, using flowcharts and object-oriented system development methodology. In this section, we present a case description of the necessary knowledge and technologies for implementing WSIHIS. Background of WSIHIS Many people around the world become amputees due to warfare, traffic accidents, and the pro- gression of diseases such as diabetes. Traditionally, these amputees would have to be treated with conventional socket techniques. With the development of new medical technologies, however, new treatment techniques for amputees, based on the osseointegration technique discovered by Professor Branenmark in the 1990s, have emerged. I V. W S I H I S C A S E 153 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 153 Basically, Professor Branenmark’s osseointegration technique makes use of a titanium im- plant as the attachment site for the artificial limb. The first osseointegration surgery performed was a dental implant.35 Professor Branenmark further applied the osseointegration technique in orthopedics. In 1997, he decided on Queen Mary’s Hospital as the site for the clinical trial out- side of Sweden. Because osseointegration is an entirely new technique, patients have to be selected carefully. A scheme called OPRA (Osseointegration Programme for Rehabilitation Amputee) was devel- oped in Sweden that consists of patients’ selection and recruitment, surgical plan after surgeon retirement, and rehabilitation. The whole procedure of osseointegration—from the operation to the rehabilitation of patients—can last several years. Overall, this process would involve doc- tors, patients, surgeons, prosthetic clinicians, and rehabilitation clinicians. All relevant informa- tion must be recorded and documented for progress review. Patients’ files are also required if the infection is developed at a later stage. An integrated HMIS would be needed to manage and process the massive health data to be exchanged and processed accordingly at each stage, be- cause the patient, the hospital, the rehabilitation center, and the prosthesis are not normally in same location. The data exchange between the systems would be very important. Consequently, WSIHIS is proposed to computerize all documents and data and offer a secure and stable envi- ronment for the communications between doctors and patients across the Internet. WSIHIS Interoperability On the basis of the need to integrate and share information about the patients among care- givers, it is not difficult to surmise that WSIHIS would also face most, if not all, of the interop- erability challenges affecting any other HMIS. Principally, WSIHIS interoperability issues could be purported as follows: ● System interoperability. Based on the background description, WSIHIS would be required to link with various medically relevant caregivers such as the GP, surgeon, prosthetic clini- cian, and rehabilitation clinician, who might be using different systems on their desktops to access WSIHIS for different purposes. To accommodate the needs of these caregivers, WSIHIS would require the capability to interoperate among different systems such as Microsoft Windows Systems, Linux, and other operating systems. Additionally, some parts of patient records may have to be extracted from legacy systems used by some med- ical staff (such as the GP) or be derived from data previously captured in existing legacy systems. As with the data-sharing purpose, WSIHIS would need to interoperate with dif- ferent DBMS such as Microsoft SQL server, Oracle, and Microsoft Access. ● Language interoperability. WSIHIS will have to integrate with functions of existing and fu- ture healthcare systems. Generally speaking, different systems are developed using different technologies, particularly the use of different programming languages. For example, the NHS houses many different patient record systems in use across units that were developed by independent software providers. To enable WSIHIS to be compliant with the function- alities of different systems, WSIHIS would have to interoperate with applications devel- oped in different programming languages such as Java, Visual Basic, C++, and C#. 154 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 154 Web Service–Based Solution for WSIHIS Interoperability As a solution to resolve the interoperability challenges noted earlier, WSIHIS was developed with the support of Web service. Currently, there are two major application platforms— Microsoft .NET and Java 2 Enterprise Edition (J2EE)—that can be applied to create Web services. Microsoft .NET is selected as the major platform for developing the proposed system be- cause it would be more suitable than J2EE in terms of certain features from the NHS perspec- tive, including overall maturity, interoperability, scalability, and cost.36,37 Besides, several HMIS developers have expressed interests in Microsoft .NET for health IT development even before Microsoft .NET packages were marketed. Consequently, Microsoft .NET has been selected as the platform for building the proposed system. Figure 7.3 illustrates the general conceptualiza- tion of a Web service–based solution of WSIHIS. User Interfaces WSIHIS provides front-end users with convenient and easy-to-use interfaces. Medical content provided through these interfaces is generated dynamically based on a specific patient’s medical profile. To get access to these interfaces, patients or relevant medical staff members are required to log in by entering the user name, password, and identity code. Data Repository The WSIHIS data repository holds medical data and knowledge. The WSIHIS data repository has been developed to store all of the data related to patients’ medical profiles and information about the progress and status of treatment. In addition, all data in the WSIHIS data repository come from various DBMS. I V. W S I H I S C A S E 155 Data Repository UDDI Registry Points to Descriptions Register Services in UDDI Points to Services SOAP/HTTP Communication with XML Messages Discover Services Describe Services WSDL Applications (Service Consumers) Service Providers WSIHIS Core System Data Repository (Medical Data, Patient Profiles, Knowledge Base) User Interfaces FIGURE 7.3 General Concept of a Web Service–Based Solution for the Interoperability Issue of WSIHIS. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 155 WSIHIS Core System A Web service–based middleware, the WSIHIS core system, encapsulates business logic in a shared middle tier. As such, all of the different client applications will access the same middle tier, avoiding the redundancy of duplicating business rules for each one. Additionally, the WSIHIS core system can render data from different DBMS readable and understandable to client applications. Within WSIHIS, Web service plays the role of middleware that hides all these differences in system platforms, programming languages, and DBMS to both users and developers. Accordingly, from the users’ perspective, they would be oblivious to the differences in their sys- tem platforms because these were able similarly to get access to WSIHIS. From the developers’ perspective, they can invoke or reuse WSIHIS applications in their systems with the support of Web services. On the one hand, Figure 7.3 illustrates a general conceptualization of Web service–based so- lution for WSIHIS interoperability. On the other hand, Figure 7.4 explains how Web service and Microsoft .NET technology are applied in WSIHIS. WSIHIS is built upon the Microsoft .NET platform, and Web service plays the role of middleware. Web services can be ex- posed from and consumed by any platform that can format and parse an XML message due to the use of XML for the formatting of requests and responses. This allows XML-based Web ser- vices to bring together disparate pieces of functionality—whether exiting or new, internal or ex- ternal to an organization—into a coherent whole. Web service core technologies include XML and SOAP. Once Web services receive requests from applications, Web services would retrieve data from different DBMS such as SQL server, Microsoft Access, and/or Oracle into data sets based on the requirements of applications. All data sets would be written in XML messages; in additions, SOAP would act as an XML enve- 156 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N C# Web Services SQL Web Service-Based Middleware Microsoft .NET Platform Various Operating Systems Visual Basic Web Services Java Web Services XML Messages SOAP C++ Web Services Access Oracle ...... C# Net-Based WSIHIS Applications Various Web Browsers FIGURE 7.4 The Way of Web Service Working in WSIHIS with the Support of Microsoft .NET Technologies. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 156 lope to wrap those XML-based data sets into SOAP messages. Then, these SOAP messages would be transmitted back to applications via HTTP. SOAP in Web service–based middleware provides a way to communicate between applications developed with different programming languages and running on different operating systems. Additionally, the Microsoft .NET platform is another important part of the WSIHIS interop- erability solution. First, it is language-neutral and best thought of as an open programming platform into which a variety of languages can be plugged. Second, how this is achieved is through translating all different programming languages into a common language called Intermediary Language (IL). Here, the source code is first translated into Microsoft Intermediate Language (MSIL). This IL code is language-neutral and is analogous to Java byte- code. The IL code then needs to be interpreted and translated into a native executable. The .NET framework includes the Common Language Runtime (CLR), analogous to the Java Runtime Environment (JRE), which achieves this goal. The CLR is Microsoft’s intermediary between .NET developers’ source code and the underlying hardware, and all .NET code ulti- mately runs within the CLR. Finally, Microsoft has indicated that the Microsoft .NET plat- form would also enable the system to run under different system platforms and Web browser platforms. System Assessment on WSIHIS Interoperability All results of this assessment have shown that WSIHIS could interoperate with data from dif- ferent DBMS and different Web service–based applications developed in different program- ming languages. This section discusses how a Web service–based solution achieves the interoperability among HMIS applications. The Web services exchange information in XML, a universal format for structured docu- ments. To support XML document processing, a variety of specifications and standards have emerged, such as eXtensible Stylesheet Language (XSL), Document Object Model (DOM), Simple API for XML (SAX), and Resource Description Framework (RDF). Due to wide indus- trial support, the XML-formatted documents are much more searchable, integratable, reusable, and manageable. In fact, converting proprietary documents to XML is the most economical way to add intelligence to documents and to make them immediately consumable over the Internet. Figure 7.5 illustrates how easily an XML-formatted proprietary document is extracted from Hospital A’s HMIS, transferred over the Internet, and consumed by different HMIS based in Hospitals B, C, and D. In Figure 7.5, a Web service acts as a middleware among hospitals. If Hospitals B, C, and D need to get the data based in Hospital A, they would send their requests to the Web service over the Internet. All requests sent to the Web service would be wrapped in SOAP envelopes. These requests contain criteria and parameters for retrieving the data. Once the Web service gets the request, it would extract the data from the HMIS in Hospital A according to the cri- teria and parameters specified in the request. When the Web service obtains the required data, it would convert the data to an XML-based document. The XML-based document would then be wrapped in the SOAP envelope and sent to the other hospitals over the Internet. An I V. W S I H I S C A S E 157 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 157 XML-based document is in a standard-based format that can be readily parsed and consumed by other HMIS. Applications in some legacy systems have been functioning reliably with the help of many years of maintenance efforts. These applications could still be useful for a certain period of time. As a result, it is important to enable these legacy systems to participate in new systems as part of the clinical data and data-related activities to be performed. However, seamless system interoperability of legacy HMIS is a challenging task because these legacy systems were largely developed when there were no open standards. HMIS developers implemented these legacy sys- tems through their proprietary technologies that are typically not interoperable with each other. In this sense, a Web service–based solution is critical to sharing information among the systems by providing a distributed computing environment for interoperating the healthcare-related services on the Internet using open standards and XML encoding. The use of standard XML protocols makes Web services platform-independent and language-independent. Built on the foundation of open standards, Web services eliminate the major interoperability issues. Based on the result of the system interoperability assessment, Figure 7.6 illustrates how the Web service– based solution addresses the WSIHIS interoperability between HMIS and legacy systems. The Web service–based solution does offer a fundamentally different way to deliver business functions. It uses open standards to expose functions internally and externally to other systems. According to Figure 7.6, the Web service–based solution for system interoperability between WSIHIS and legacy systems consists of the following steps: 158 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N Web Database Data Data Send Import Import Import Hospital A Hospital B Web Service Export XML Documents Request Response XML Documents SQL Hospital C Access Hospital D Oracle FIGURE 7.5 Web Service–Based Data Exchange between HMIS. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 158 ● Core functions of WSIHIS are based on different Web services, such as the appointment service, the patient ID validating service, the patient record search service, and the patient record update service. These Web Services could be developed in different programming languages. For example, for the purpose of system assessment, some of the Web services in WSIHIS were developed in C#, Visual Basic, C++, and Java. ● Before exposing these Web services externally to other systems, WSDL is used to describe these services, specifying its location and publishing its operations (methods). WSDL I V. W S I H I S C A S E 159 WSIHIS Web Services Appointment WS in C# Describe WS Publish WS Use WS Register WS Find WS WS – Web Service Network Network WSDL Patient Record Search WS in VB Patient Record Entry WS in Java UDDI Registry Patient Record Update WS in C++ ...WS in other languages Legacy HMIS Systems FIGURE 7.6 Web Service–Based System Interoperability between HMIS. 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 159 provides a standard way to describe the Web service interfaces in enough detail to allow other systems to build a client application talking to the described Web service. ● Web service would then be registered with UDDI. UDDI offers Web service users a uni- fied and systematic way to find service providers through a centralized registry of service. The registry of service is an automated online “phone directory” through which the registered Web services advertise their business services. UDDI registry access is accom- plished using a standard SOAP API for both querying and updating. ● Once these Web services are published and registered, legacy systems could start to use these services over the network. ● Legacy systems could find services via UDDI, which directs service consumers to relevant services according to the description of Web services. ● With respect to the previous step, applications or service consumers are able to invoke rel- evant Web services using SOAP transmitted via HTTP on the Internet. Figure 7.6 shows how Web services enable legacy systems to participate in WSIHIS. Web ser- vices could also be applied in legacy HMIS systems. With minimal programming, a Web service, as an interface, can be layered on top of a legacy HMIS system to allow it to be accessed by other systems (e.g., WSIHIS) over the network. The Web service–based solution could provide HMIS with an open architecture, allowing both existing legacy HMIS and new systems to be rapidly and seamlessly integrated. It also allows developers to reuse the system’s applications and yields loosely coupled open-system architecture. The legacy systems can continue to oper- ate as stand-alone systems until the new HMIS become stable. V. Conclusion According to the standard system development life cycle (SDLC), a WSIHIS model has been designed and implemented based on a Microsoft .NET platform by using the C# programming language. To prove if Web services is an appropriate solution for the interoperability challenge, an assessment has been done concentrating on the system interoperability from several aspects. The major purpose of assessment attempts to ensure if WSIHIS could be run on different sys- tem platforms such as Linux system platforms, Windows system platforms, or other OS plat- forms integrated with some applications developed in different computer programming languages and different DBMS. The result drawn from the assessment satisfied the interoper- ability challenges, and there are reasons to believe a Web service–based solution implemented on the Microsoft .NET platform with use of the C# programming language would be suitable to overcome the system interoperability challenges for current HMIS. Web service supports increased interoperability but also represent a significant increase in run-time cost for Web service solutions. Conversion to text format and parsing of XML docu- ments is inherently more costly than the alternative mechanisms used to convert data to a com- mon data representation for the network. The additional communications and processing costs are frequently perceived as a potential barrier to the use of Web services technologies. Hence, fu- ture research should try to find out a solution to overcome these shortcomings of Web services. 160 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 160 Notes 1. SAPHIRE: Intelligent Healthcare Monitoring Based on Semantic Interoperability Platform, http://www.ehealthnews.eu/content/view/282/27/. 2. S. Chu and B. Cesnik, “A Three-Tier Clinical Information Systems Design Model,” International Journal of Medical Informatics 57, no. 2–3 (2000): 91–107. 3. L. G. Kun, “Telehealth and the Global Health Network in the 21st Century, From Homecare to Public Health Informatics,” Computer Methods and Programs in Biomedicine 64, no. 3 (2001). 4. Department of Health and National Health Services, Connecting for Health—A Public- Private Collaborative (London: National Health Services, 2003). 5. G. K. Matsopoulos, V. Kouloulias, and P. Asvestas, “MITIS: A WWW-Based Medical System for Managing and Processing Gynecological–Obstetrical–Radiological Data,” Computer Methods and Programs in Biomedicine 76, no. 1 (2004): 53–71. 6. M. Tsiknakis, D. G. Katehakis, and S. C. Orphanoudakis, “An Open, Component-Based Information Infrastructure for Integrated Health Information Networks,” International Journal of Medical Informatics 68, no. 1–3 (2002): 3–26. 7. B. Varge and P. Ray, “Interoperability of Hospital Information Systems: A Case Study.” In Enterprise Networking and Computing in Healthcare Industry, 5th International Workshop, 2003. 8. Matsopoulos et al. (2004). 9. Tsiknakis et al. (2002). 10. Varge and Ray (2003). 11. H. M. Deitel, P. J. Deitel, J. Listfield, and T. R. Nieto, C# How to Program—Introducing .Net and Web Service (London: Prentice-Hall, 2002). 12. T. M. Chester, “Cross-Platform Integration with XML and SOAP,” IT Professional 2005. 9, no. 4 (2005): 67–70. 13. G. A. Duthie, Microsoft ASP.Net Programming With Microsoft Visual C# .Net Step by Step (Washington, DC: Microsoft Press, 2003). 14. M. W. C. Guah and W. L. Currie, “Logicality of ASP in Healthcare: The NHS Case Study.” In Proceedings of the 37th Annual Hawaii International Electrical and Electronics Engineers Conference, 2004. 15. Matsopoulos et al. (2004). 16. S. Jablonski, R. Lay, and C. Meiler, “Data Logistics as Means of Integration in Healthcare Applications,” ACM Symposium on Applied Computing 1 (2005): 236–241. 17. N. Maglaveras and I. Chouvarda, “The Citizen Health System (CHS): A Modular Medical Contact Center Providing Quality Telemedicine Services.” IEEE Transactions on Information Technology in Biomedicine 9, no. 3 (2005). 18. G. Pronab and R. Pradeep, “Software Interoperability of Telemedicine Systems: A CSCW Perspective,” IEEE 2000. 19. Ibid. 20. NpfIT, Making IT Happen—Information about the National Programme for IT (London, U.K.: Department of Health, 2005). 21. A. E. James and Y. H. Wilcox, “A Telematic System for Oncology Based Electronic Health Patient Records,” Information Technology in Biomedicine 5, no. 1 (2001): 16–17. 22. M. Cross, “In Sickness or In Health?” IEEE Review 50, no. 10 (2004). 23. B. Albahari, P. Drayton, and B. Merrill, C# Essential—A Comparitive Overview of C# (Sebastopol, CA: O’Reilly, 2001). 24. National Health Services, “History of Connecting for Health,” accessed December 2005 from http://www.connectingforhealth.nhs.uk/aboutus/history. N O T E S 161 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 161 25. J. K. Zhang, W. Xu, and D. Ewins, “System Interoperability Study for Healthcare Information System with Web Services.” In Asia Pacific Association for Medical Informatics (APAMI) 2006—Towards Global Interoperability for Electronic Health Records (Taipei, Taiwan: APAMI, 2006). 26. J. K. Zhang and W. Xu, “The Study of Web Service on the System Interoperability Concern in E-Healthcare System.” In Proceedings of World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education 2006. (Chesapeake, VA: AACE, 2006). 27. National Health Services, “Electronic Transmission of Prescriptions (ETP) Programme,” November 2005, accessed December 2005 from http://www.connectingforhealth.nhs.uk/ newsroom/news-stories/news280205/. 28. Department of Health and National Program for IT, Choose and Book Service Implementation Guide (London: National Health Services, 2005). 29. A. G. Mathews and R. Butler, “A Vision for the Use of Proactive Mobile Computing Tools to Empower People with Chronic Conditions.” In Proceedings of the 18th IEEE Symposium on Computer-Based Medical Systems (CBMS’05) (IEEE, 2005). 30. Department of Health and National Health Services, NHS Connecting for Health Fact Sheet (London: National Health Services, 2005). 31. A. Banerjee and A. Corera, C# Web Services—Building Web Services With .NET Remoting and ASP.NET (WROX, 2002). 32. A. Gokhale, B. Kumar, and A. Sahuguet, “Reinventing the Wheel? CORBA vs. Web Services.” In The Eleventh International World Wide Web Conference (Honolulu, HI, 2002). 33. A. Umar, “The Emerging Role of the Web for Enterprise Applications and ASPs.” In Proceedings of the IEEE (IEEE, 2004). 34. F. Curbera, M. Duftler, and R. Khalaf, Unraveling the Web Services Web—An Introduction to SOAP, WSDL, and UDDI (IEEE Internet Computing, 2002). 35. J. Sullivan, M. Uden, and K. P. Robinson, “Rehabilitation of the Trans-Femoral Amputee with an Osseointegrated Prosthesis: The United Kingdom Experience,” Prosthetics and Orthotics International, 2003. 36. R. Sessions, Java 2 Enterprise Edition versus The .Net Platform—Two Visions for eBusiness (Texas: ObjectWatch, Inc., 2001). 37. C. Vawter and E. Roman, J2EE vs. Microsoft .NET—A Comparison of Building XML-Based Web Services (The Middleware Company, 2001). 38. J. K. Zhang and W. Xu, “Web Service-Based Healthcare Information System (WSHIS): A Case Study for System Interoperability Concern in Healthcare Field.” In International Conference on Biomedical &Pharmaceutical Engineering 2006 (Singapore: IEEE, 2006). Chapter Questions 7–1. What are the major issues with existing HIMIS? Discuss why system interoperability is becoming a major concern for HMIS. 7–2. Discuss main components or protocols of Web services. Discuss how Web services could be fitted into or applied to HMIS. 7–3. Research potential advantages and disadvantages of Web services to HMIS. Discuss if there are any other effects or beneficial uses of Web services to HMIS besides as a solu- tion for the HMIS interoperability issue. 7–4. Discuss how feasible the Web services solution is for HMIS. 7–5. What are the challenges with the Web services solution? How could these challenges be overcome for future HMIS implementations? 162 H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M I N T E G R A T I O N 56918_CH07_Final_Tan 4/6/10 11:53 AM Page 162 Health Management Information System Planning and Management PART III 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 163 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 164 Health Management Strategic Information System Planning/ Information Requirements Jon Blue and Joseph Tan 165 8 CHAPTER Editor’s Note: HMIS strategic planning and information requirements are two of the early, but very critical, steps in the administration of HMIS for healthcare services organizations. This chapter lays the groundwork for the “hows” of all of HMIS initiatives (Part III), not just the “whys” (Part I), “whats” (Part II), and “whos” (Part IV). Beyond preparing students, practition- ers, and administrators for aligning HMIS goals and objectives with corporate goals and objec- tives, and for deciding the best alternative means of developing that system which would fit well with organizational information requirements and culture as highlighted in this chapter, the next steps have to include HMIS analysis and development methodologies (Chapter 9), followed by practical advice on HMIS design, implementation, and evaluation through data stewardship (Chapter 10) and managing of pre-implementation, implementation, and post-implementation processes as well as IT service management (Chapter 11). Part III, therefore, bridges HMIS ap- plications and technologies (Part II) on the one hand and HMIS standards, governance, policy, and international perspective (Part IV) on the other. Moreover, the cases in Part V cluster largely around HMIS planning and implementation in diverse organizational settings. Knowledge of this chapter thus provides readers with a solid base for initiating the HMIS plan- ning and management process. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 165 166 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S S c e n a r i o : Open Health Tools1 Open Health Tools (OHT), a collaborative health information technology (HIT) open-source site, continues to develop ways for healthcare services organizations to curtail electronic medical records (EMR) development costs and reduce time-to-market releases. Recently, the OHT has added code from the United Kingdom’s National Health Service (NHS) and incorporated an academic outreach project to motivate students to embrace its programming tools. With sup- port from major healthcare services organizations in the United States, Canada, the United Kingdom, and Australia; vendor giants, including IBM and Oracle; and health standards or- ganizations HL7 and the International Health Terminology Standards Development Organization, OHT hopes that healthcare services organizations will use its open-source tech- nology as the backbone for HMIS infrastructure. Specifically, Open Health Tools is developing a free software platform that allows EHR data to be exchanged among various commercial products. In essence, OHT tools are the translator that permits various legacy databases to communicate with one another. This in- volves processes such as message and document interchanges, static model designers, simula- tors, adaptors, data transformers, and device access. The underlying frame is available under an open-source license so organizations can design and build applications without any pay- ment required for the software. CHAPTER OUTLINE Scenario: Open Health Tools I. Introduction II. The Essence of Management III. The PODC Model IV. HMSISP V. Information Requirements ● Information Sources ● Business Systems Planning ● Critical Success Factors ● In-Depth Interviews VI. Conclusion Notes Chapter Questions Chapter Appendix: Glossary of Terms 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 166 OHT hopes to duplicate the success of the Eclipse, a popular nonprofit, open-source com- munity whose projects are focused on developing an open platform for building, deploying, and managing software across its life cycle. Skip McGaughy, one of Eclipse’s founders and OHT’s executive director, envisions OHT to mimic a “satellite” of Eclipse. “We’re going to be using Eclipse technology,” McGaughy claims, “but our governance is un- der the direction and control of the health and computer industry. We use the same develop- ment and intellectual property process, the same paradigms, and many of the same people. The Eclipse code has been downloaded and used by millions of programmers, so it’s thoroughly tested and debugged. Programs using the Eclipse framework, through the use of plug-ins, are compatible.” As high-quality medical decisions are based on the reliability of health data, the need for re- liable and accurate coding in healthcare services is essential. With increasing complexity of HMIS, it is argued that OHT’s dynamic, open-source software tools have a unique advantage over other competitive commercial products. McGaughy further clarifies, “It’s componentized, it’s modular, and it’s done in the open, so everyone understands what the requirements are, and there’s a dialogue about the requirements.” McGaughy also maintains a perspective of HIT as a means to achieving the goal of improving health. “At the end of the day, what’s really important is reducing costs, but also saving lives and improving care. And what is unique is the number of really good software developers who are joining this effort. So instead of just moving little bits on the screen, they can now save lives.” How do you feel about saving lives as a result of the willingness of the human spirits to join forces, to share, and to collaborate on HMIS software development—isn’t this a noble cause? Yes, but it all begins with planning and strategizing, which are precisely the focus of this chapter. I. Introduction Information technology (IT) in health care changes rapidly and dictates the importance of in- formation systems (IS) strategy planning. Subsequent to the planning, it is important that healthcare management be evaluated on meeting the specifics of the plan using predetermined criteria. Doing so will assist a healthcare services organization in meeting its goals. With the proliferation of managed healthcare organizations that affect nearly every healthcare organiza- tion, one would think that the task of strategic planning would be different. However, while the internal and external inputs and the requirements that are necessary to develop a healthcare or- ganization strategic plan may differ, the process is exactly the same. Healthcare senior management, when developing the overall strategy, provide the overall vi- sion and mission for the organization. These executives expect that those individuals who com- prise the health management information systems (HMIS) team not only share in the vision, but also develop achievable, measurable goals that are consistent with the strategy. The HMIS team also supports the objectives and carries out tactics in support of the mission. For example, a pharmacy department in a hospital may be responsible for reducing the number of prescrip- tion fulfillment errors by 8 percent in 18 months. The HMIS team may assist the pharmacy by I . I N T R O D U C T I O N 167 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 167 suggesting the implementation of a mandatory technology of electronic prescribing (e-prescribing) and fulfillment that must be performed electronically. Among the benefits that will assist the pharmacy in reducing errors that occur due to doctors’ or nurse practitioners’ poor penman- ship, other benefits will result. Additionally, senior management may have goals for which the HMIS team is primarily re- sponsible. If management’s goal is to have the ability for all departments of the hospital to com- municate electronically in four years, the HMIS team may be responsible for initiating, developing and/or securing, and rolling out the infrastructure and technologies needed to meet this goal. Such an implementation would include the telephony, systems, networking, software, hardware, and training. In a supporting role, or as the primary responsible department in fulfilling the goals that cas- cade from the vision and mission, it is important that a health management strategic informa- tion system plan (HMSISP) be developed. With IS technology rapidly changing and the important role that IS services plays in nearly every healthcare department, the HMSISP will provide the systems structure and detail needed to assist a healthcare services organization to fulfill its overall vision and mission. In this chapter, the roles of health management and how performance is normally evaluated in healthcare services organizations are reviewed. Also visited here are several techniques that can be used to acquire healthcare individuals’ information needs that become a very important ingredient when developing an HMSISP. The HMSISP must tie directly into the health organi- zation’s mission and vision. II. The Essence of Management Management is a science as much as it is an art.2 However, on a continuum of art and pure sci- ence, management leans toward “art” because managers must deal with people and their behav- ior and guide employees’ activities. There is much discussion on how to maximize individual performance in different domains.3,4 Continued external pressures on health organizations and on their HMIS teams dictate that an HMSISP is necessary in order to avoid being reactive. For instance, U.S. politicians are pressuring healthcare services organizations by demanding legislation that mandates elec- tronic health records (EHR). EHR would allow the records of patients to be standardized so their information is sharable across organizations. The movement toward the use of EHR has developed much further in countries other than the United States, where only 5 to 15 per- cent of practices use EHR.5,6 EHR use by Israeli physicians is close to 100 percent; this level of use leads the world.7 In the United Kingdom, as early as 1995, 80 percent of primary care physicians worked in facilities that were computerized, with more than 60 percent of these practitioners using EHR. Also in 1985, Danish general practitioner EHR use was 70 percent; use in Sweden was 60 percent and was 40 percent in the Netherlands.8 There is very little support on EHR use adversely affecting physician and patient satisfaction.9,10 Recent studies have also found EHR use to be perceived by patients and physicians as enhancing the overall quality of care.11–13 168 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 168 Another force pressuring HMIS teams in healthcare services organizations to innovate and reform is with the phase-in of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The mandated processes and procedures are in place to ensure that patients’ informa- tion is secure and is only disclosed on a need-to-know basis. Noncompliance could result in the levy of fines by the Office of Civil Rights (OCR) of up to $25,000 a year for each violation. OCR is an office in the Department of Health and Human Services (HHS). Even with this threat of fines, the HIPAA Compliance Survey of 2006 indicates that full compliance only min- imally improved over the previous three years.14 Fortunately for many healthcare services organ- izations, there have not been any fines levied for the last several years, even though there have been more than 4,100 complaints. Nonetheless, if OCR begins to levy fines, a healthcare ser- vice organization needs to be ready. An HMSISP, with underlying objectives that detail activi- ties to move an organization to full HIPAA compliance, will greatly assist in attenuating the risk of fines. To react most effectively and efficiently to events such as possible HIPAA violations, healthcare services organizations must strategically plan their HMIS to ensure that they can sur- vive in the healthcare industry. Considering that organization behavior is key to how management is applied, Longest15 de- fines management as a process that has both interpersonal and technical aspects. Management specifies the goals for the healthcare services organization—and using technology, as well as hu- man and physical resources or capital, accomplishes the objectives of the goals. Therefore, when used in a healthcare services organization context, the age-old process of health management is the art of planning, organizing, directing, and controlling (PODC). These activities are applied to both tangible and intangible resources such as people, facilities, equipment, information, and technology, such that the objectives that are resultant from the strategy, as prescribed, are met. The processes for combining and allocating these resources would be part of the intangible cap- ital. Looking at this in context with healthcare services organizations, the entire process of man- aging resources and capital in a health organization needs to be done in the most efficient and effective way to provide the best services. III. The PODC Model The planning, organizing, directing, and controlling (PODC) model, as shown in Figure 8.1, has iterated often over the years. However, Henri Fayol16 was the primary contributor. Fayol was one of the first to say that management is a science. He presented a specific body of knowl- edge and managerial activities: planning, organizing, directing, and controlling. PODC is presented as an operationalized and rationally designed tool to assist in meeting organizational goals. We can still see Fayol’s categorizations in today’s publications such as Hellriegel, Jackson, and Slocum;17 Lewis, Goodman, and Fandt;18 Kinicki and Williams;19 Rue and Byars;20 Schermerhorn.21 Several of these publications include areas of discussion other than PODC. Nonetheless, the Fayol functions are present and offer a solid base for these authors to build on. As the PODC model is viewed, it is important to understand that in today’s healthcare ser- vices organizations, there is not a hierarchical connection among the different functional levels I I I . T H E P O D C M O D E L 169 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 169 or activities. The functions continuously interplay with one another. Nor do these functions oc- cur in any specific order; instead, they are practiced at all levels as are necessary throughout var- ious times. High-level strategic planning is initiated at the apex of healthcare services organizations. As stated, this often begins with the executive team formulating the vision and mission (at a mini- mum). The vision and organizational mission are broken down into goals, objectives, and tac- tics that are manageable, understandable, and measurable. Some senior management teams may go as far as formulating values, goals, and objectives. The executive team in these healthcare services organizations typically include, at minimum, the chief executive officer (CEO), chief financial officer (CFO), chief operating officer (COO), and chief medical officer (CMO). A chief information officer (CIO) is often also appointed and is becoming more commonplace in healthcare services organizations; it is possible, however, that at the executive level, the role of the CIO may be assigned to the COO or the CFO. Strategy sessions are normally held at least annually, and it is during these meetings that the executive team sets the direction for the organization for years forward—normally at least three years. The mission statement sets the strategic focus of the business. As shown in Table 8.1, the mission and vision of healthcare services organizations vary, as well as the level of detail presented. Senior executives of healthcare services organizations are consistently involved with building external relations, so they must ensure that the strategies they formulate are consistent with what is going on around them. This not only includes the community or segment of the popu- lation that their organizations serve, but also the laws and regulatory policies for which their or- ganizations must comply. For instance, with a for-profit healthcare services organization, the 170 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S Environmental Assessment Strategy Formulation Policy Development Organizational Design Implementation Performance Evaluation Controlling Directing Organizing Planning FIGURE 8.1 The Planning, Organizing, Directing, and Controlling (PODC) Model. Source: Reprinted from Henri Fayol (1949). 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 170 ultimate goal may simply be profit; thus, without a strategy for achieving cost-effective compli- ance with current legislations and regulatory requirements within a reasonable span of time, continuing the present operations of the organization may result in the increase of expenses, thereby leading to a loss. Even though the executive team’s main focus in strategic planning is to set the vision and mission, it may also be necessary for these managers to go beyond these initial steps and actually make specific decisions for the overall organization. Making these decisions prior to the plan rollout not only relieves other organization members of making some tough choices, but also I I I . T H E P O D C M O D E L 171 Table 8.1 Example Vision and Mission Statements Organization Vision Mission Penang Adventist Hospital* A patient-centered teaching and Penang Adventist Hospital is learning tertiary healthcare committed to demonstrating the facility with international love and healing ministry of Christ quality standards bringing by providing comprehensive, to the community acclaimed competent, and excellent health selected centers of excellence. care for all. Blue Cross and Blue Shield To improve the lives of To improve the lives of of Louisiana** Louisianians by providing Louisianians by improving the health guidance and affordable quality, universality, affordability, access to quality care. and differentiation of the health guidance and health care they receive, and by improving the quality, universality, affordability, and differentiation of the services we ourselves provide directly on behalf of our membership. BCBSLA will, by every measure, enhance its role and its competitive standing, both in the state of Louisiana and beyond. Brookhaven Memorial Deliver leading-edge healthcare Deliver accessible, high-quality Hospital Medical Center*** solutions through a focused health services in a focused, caring and compassionate team in environment, while providing technologically advanced health advocacy for the facilities. Achieving the capacity community and people we serve. to invest in the future enables us to create recognized Centers of Excellence, provide a learning culture, and become the employees’ and patients’ provider of choice. *Penang Adventist Hospital (2007). Vision, Mission & Values. Retrieved December 20, 2007, from http://www.pah.com.my/about_us/mission_and_values/index.asp ** Blue Cross Blue Shield of Louisiana (2007). Mission, Vision and Values. Retrieved December 20, 2007, from http://www.bcbsla.com/web/reddotcm/html/20_95.asp *** Brookhaven Memorial Hospital Medical Center (2007). Mission, Vision and Core Values. Retrieved December 20, 2007, from http://www.brookhavenhospital.org/aboutus/missionvisionstatements.html 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 171 provides leadership and dictates a clear organizational direction. The decisions could affect such things as the number of employees in the organization, the service level of the emergency room, or a sick leave policy. This increased level of direction does not occur often; executives primarily operate at a strategic level and do not dictate departmental strategies, objectives, and tactics. The executive role is to offer the vision, mission, values, and some goals. The majority of the di- visional goals, objectives, and tactics are left for middle management and lower-level employees to develop that fit into the overall vision and mission. These goals, objectives, and tactics are subsequently reviewed and approved by the health organization’s senior management team. The “big picture” is what executives should be focusing on primarily—they need to make sure that what is planned to occur will result in the organization meeting the mission and realizing the vision. An example of vision, mission, goals, objectives, and tactics of a hospital is shown in Exhibit 8.1. 172 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S Exhibit 8.1 Strategic Planning Focus AREA A: The vision and mission are typically determined by the executive team. Vision, Mission The vision and mission statements, when articulated, clarify who the healthcare organization is. They will describe the organization. Vision Statement To be viewed internationally as a hospital that is based on comprehensive research activities and clinical excellence. Mission Statement To be considered by all our patients, and their families, as delivering excellent care and the utmost concern for their overall well-being. AREA B: Senior Managers are typically evaluated on meeting goals. Goals Goals will allow a level of focus on how the vision and mission will be achieved. Goals are usually provided in an outline or bulleted form. Each goal is specific and measurable and if all goals are met then the organization is successful and the vision and mission has been achieved. Both short-term goals (within 12 months) and long-term goals (3 to 5 years) should be presented. Organization Goals ● Patient and family satisfaction will improve in 1 year. ● Within the next 6 months, 50% of our palliative care patients will have reported pain less than 5 (1–10 scale). ● Medical errors of commission and omission* will be reduced by 8 and 5 percent, respectively, in 18 months. ● Physicians will express satisfaction with the emergency care program after 2 years. ● Revenue will meet direct expenses within 3 years. For each goal there is a series of objectives that need to be achieved in order to reach the goal. [*Errors of commission would be errors such as prescribing a medication that has adverse side effects with another medication that the patient is taking. Errors of omission would be such errors as the failure to prescribe a medication to a patient that he or she would more than likely benefit from.] (continues) 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 172 The middle managers are given the responsibility of communicating the strategy, mission, and goals. Some health organizations may develop tactics from the bottom up (meaning that individual employees suggest the tactics). Alternatively, tactics can be developed and mandated from the top. More likely, there could be a mix of the two methods. The difference depends on the organization and the objective. Mandates that have legal implications may need to come from, and be imposed by, the top level of the healthcare services organization. For instance, all 50 states require both laboratories and physicians to report to health departments the names of persons newly diagnosed with Centers for Disease Control–defined AIDS.22 Executives may dictate this law’s compliance by directing the human resources department to develop a rollout plan, delivering the plan, and developing employee noncompliance sanctions. I I I . T H E P O D C M O D E L 173 Exhibit 8.1 (Continued) AREA C: Middle managers are typically evaluated on meeting objectives. Objectives The objectives delivered focus on how each individual goal will be achieved. For example, for the goal: “Medical errors of commission and omission will be reduced by 8 and 5 percent, respectively, in 18 months” four objectives might be: ● A mandatory electronic prescription system (EPS) will be introduced within 1 year that must be used by all clinicians when prescribing medications to patients. ● A wireless secure link between clinicians’ personal digital assistants and the EPS will be available within 14 months. ● A bar-scanning mechanism that includes the patient, all hospital personnel who treat the patient, and the prescribed/administered service will be implemented within 1 year. ● The status of achieving this goal will be presented to the chief medical director monthly and to the chief executive officer quarterly. AREA D: First-level managers and individual contributors are typically evaluated on meeting tactics. Tactics Tactics are described that will meet the objectives. There are usually several tactics that are needed to achieve each objective. For each tactic include times and identify accountable individual(s). Goal, Objectives, and Tactics Goal: Medical errors of commission and omission will be reduced within 1 year by 8 and 5 percent, respectively, in 18 months. Objective 1: A mandatory electronic prescription system (EPS) will be introduced within 1 year that must be used by all clinicians when prescribing medications to patients. Tactic 1.1: Choose HMIS EPS project manager (PM) (1 month; owner: HMIS first-level manager). Tactic 1.2: Engage consultant to assist in decisions and development needs (1.5 months; owner: HMIS team). Tactic 1.3: Determine vendor (2 months; owner: HMIS EPS PM). Tactic 1.4: Develop implementation and roll out plan (4 months; owner: HMIS EPS PM). 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 173 When providing strategic plans, healthcare executives, their management teams, and (possi- bly) hired organizational change consultants must ensure that the organization in its current form is capable of carrying out the vision. Additionally, the necessary resources must be avail- able. For the plan to be realized, the current organizational structure may need to be scrutinized to determine if its current form facilities the team in meeting the objectives. If not, it is neces- sary for the executives to restructure the organization so that the mission can be realized. The restructuring effort may be as small as shifting employees among departments or as major as moving to an entirely different organizational structure. The healthcare services organizational structure determines the hierarchy within an organization: it determines who reports to whom. Types of organizational structures include division structure, functional structure, and ma- trix structure. The divisional structure can take on three different forms: service, market, and ge- ographic. In a service structure, employees are grouped by service in divisions that encompass such services as emergency, surgery, and dermatology. A market structure would divide services based on the market served such as pediatrics, adult health, and geriatrics. The last of the divi- sional structures is geographic. In this structure, employees are grouped based on specific geo- graphic locations. This type of structure may occur in large healthcare services organizations that operate in many, or disperse, locations. In a functional structure, employees are grouped based on the functions of specific jobs within the organization. For instance, there may be a de- partment of nursing (nursing function) and a customer service department (customer service function), each of which may be led by a director. A matrix organization groups employees by both division and function. This structure can combine the best of both separate structures. For instance, a nurse who works in the emergency room may report to both the emergency room manager and the manager of nursing. Overall, the roles that managers are currently playing, and the roles that are necessary to best meet the strategy, must be reviewed. One way for this to happen is that senior management may di- rect an internal review of employee competencies. These are then matched with the required skills needed to accomplish the mission, and a gap analysis is conducted. Determining the fit and place- ment of individuals can be complex. Moreover, doing so is not a healthcare organization’s core competency. Therefore, consultants are often enlisted to assist the healthcare organization.23–25 If it is determined that the current managers will not facilitate meeting the strategy, then a change in leadership may be necessary—or, at minimum, the executive management must en- sure that the current leaders have, or are able to acquire, the required skills. What could occur, which would be counterproductive to achieving the organization goals, would be to force-fit the strategy into an organization that is not ready to carry out the activities that are needed to fulfill the executives’ vision. Senior healthcare managers need to be forthright and determine if the current team—both health management and employees—is capable and able to do what it takes to achieve the mission. Based on this assessment, management has to decide if there is a need to redeploy the current personnel. In addition to assessing the organizational structure and employees, managers must provide the necessary resources to accomplish the vision, mission, goals, objectives, and tactics. The work systems and relationships must also be in place or estab- lished. Not having the resources, the work systems, or the relationships could jeopardize the re- alization of the vision. 174 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 174 Even if the executives paint a clear picture of where they would like to see the organization in the future, without employees’ assistance in getting there, the vision will not be realized. Therefore, guidance from top and middle management is necessary. The managers must pro- vide not only the day-to-day supervision, but they must work closely with their teams to deter- mine the objectives and tactics needed to meet their specific team goals. Not only must a manager direct team members to do his or her part in implementing the strategy, the team leader must make sure that teamwork is optimized. Having the individual fulfill his or her part in meeting the objectives in order to realize the vision and the team working together to meet the organization’s goals is paramount. As a part of control, to ensure that the goals are being met, measurable performance evaluations are necessary to assess how managers, individuals, and teams are meeting the overall objectives. What is most important is that the expectations of meeting the mission are cascaded throughout the organization in the form of performance ob- jectives that are met prior to evaluation. Senior managers’ performance objectives are more in line with meeting the healthcare ser- vices organization goals, as shown in Area B of Exhibit 8.1. Middle managers are evaluated on how well their teams meet the organizational objectives, as shown in Area C of Exhibit 8.1. Individual contributors (nonmanagement) and frontline managers in the organization should be evaluated on how well they accomplish the tactics that contribute to meeting the objectives as shown in Area D of Exhibit 8.1. The process of ongoing feedback among different levels of the organization occurs cyclically, and continuous feedback is exchanged among levels throughout the evaluation period. As is shown in Figure 8.2, the higher levels use environmental factors as input, among many other I I I . T H E P O D C M O D E L 175 Strategic- Level Planning and Control Environmental Factors Organizational Resources Tactical- Level Planning and Control Operational- Level Activities Feedback Loop (Goal Setting) Feedback Loop (Goal Seeking) FIGURE 8.2 Levels of Feedback Loops for Organizational Thinking. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 175 items. Organizational resources are infused into the operational levels of the organization. In addition, there is a feedback loop between the different levels of the organization. The feedback loop between the senior level and the middle levels of the organization is goal setting, and the interaction between middle management and the individual contributor level is goal seeking. IV. HMSISP In today’s turbulent society, with globalization and an increased level of government interven- tion, developing an HMSISP has become quite necessary to remaining competitive. The process of developing an HMIS plan includes determining the computer-based applications that are needed to assist an organization in meeting business objectives.26,27 Developing an HMSISP will facilitate an organization in identifying how they can use information systems to positively differentiate themselves from the competition. Such planning, followed by system ac- quisition and implementation, will hopefully create a competitive advantage. The increased rate of change of environmental factors, the difficulty in predicting these changes, the scarcity of resources, and the degree of competition have been said to moderate the impact of strategic information systems planning.28–31 Business executives indicate that they be- lieve strategic information systems planning is challenging.32 But even though developing an HMSISP may be difficult, healthcare professionals believe that doing so is necessary to remain- ing competitive. While the overall higher-level strategic plan guides the entire health organization, the HMSISP must exist to assist the organization in fulfilling its objectives. There may be specific informa- tion systems objectives; however, most often, the HMSISP assists the realization of nonsystems objectives. Dunbar and Schmidt33 have suggested that at least 35 percent of a healthcare service organization’s strategic plan should tie in to the HMSISP. A healthcare services organization’s HMSISP that directs the implementation of an e-prescrib- ing system is shown in Exhibit 8.2. Such a PDA e-prescribing focus would not only be helpful to the organization, but patients could benefit from it as well because of its appeal relative to another competing organization that would rely on manual prescription orders. In addition, healthcare services organizations that have implemented e-prescribing at varying levels can cut down on medication errors arising from illegible prescription scripts. In other words, this ful- fills the HMIS objective of a hospital’s pharmacy to decrease the error rate of prescription re- fills, as well as to shorten the time between the ordering and delivery of the medication. A PDA can also be used by providing doctors with a source of drug reference in aiding decisions on which drug and dosage should be prescribed for particular patients. As the cost of technology continues to decrease rapidly,34 the impact that HMIS has on assisting in accomplishing the or- ganization’s strategic goals will also increase. Figure 8.3, a diagram modeled from Tan,35 is a partial presentation of a top-down hierar- chical stages planning model. The model shown clarifies the planning activities and the or- der of the activities. Additionally, clarity is obtained on alternative techniques, methodologies, and the applicable strategies. This model is consistent with, and extends, the framework offered by Bowman, Davis, and Wetherbe.36 Tan suggests that this model can be 176 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 176 used as a general framework that guides HMIS strategic planning, design, and development. An organization’s ability to support the processes and business functions encountered in healthcare services delivery is determined by the information and technology architecture that is in place. He continues by suggesting that the organization’s processes and business functions should determine the information that is needed to support an organization’s business strategies.37 I V. H M S I S P 177 Exhibit 8.2 PDA E-Prescribing Focus It would be great if a clinician could: ● Print a copy of all patients for whom you prescribed a recently recalled drug. ● Easily look up drug interactions for a drug you are considering prescribing. ● Be able to create a script electronically that automatically determines the recommended dosage for a 30-lb., 3-year-old boy. ● Quickly determine the available dosages for a drug you want to prescribe to your hypertensive patient. Such is possible today using a handheld prescribing device, such as a personal digital assistant (PDA) that is no larger than a prescription pad. The handheld device comes on immediately, has a secure wireless connection to your computer, and can tell you your daily appointments. You can use your PDA to select a specific patient and immediately see her demographics and insurance plan. Drugs on the device are alphabetized and side effects are presented for each medication. The patient’s health insurance information, as it pertains to the drug, is also displayed. Allergies and drug interactions for your patient are automatically determined from the patient’s currently prescribed medications. To prescribe a medication, you choose the medication from a drop-down menu, select the correct dosage from another drop-down menu, digitally sign the medication, and then electronically send the script to the patient’s pharmacy (or, optionally, securely send to your printer). At this point, the patient’s EHR is automatically updated via a secure wireless connection. Organization Strategic Planning HMIS Strategic Planning Strategic Alignment Strategic Grid Strategic Fit and Integration Business Systems Planning (BSP) Critical Success Factors (CSF) In-Depth Interviews Information Requirements (IR) FIGURE 8.3 Partial Framework for HMIS Strategic Planning: A Top-Down Stages Planning Model. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 177 It has been shown that alignment and fit of HMIS strategies to organizational strategies alone are not enough to ensure success. For success, in addition to plan alignment, many as- pects (e.g., technology, structures, processes, skills) must be considered.38 As important as these aspects are, the “people” element of implementing the HMIS must also be considered. Managers need to establish ways to minimize organizational resistance and business disruptions to ensure the best coexistence of the strategies.39 If a clinic plans to implement a computerized physician order entry (CPOE) system, unless physicians are involved from the beginning, such a system is destined to fail. All HMIS users must be involved in the planning, the determina- tion of needs, and the implementation—they must be a part of the solution. While alignment among organizational strategies, HMIS strategies, and the delineations of HMIS goals is important, equally important is the determination of information requirements (IR). As can be seen in Figure 8.3, this is the next activity in HMIS strategic planning. V. Information Requirements Traditionally, information has been seen as a resource that needs to be managed by healthcare services organization executives—just like labor and capital. However, HMIS managers need to ensure that technology and information resources are used to meet the organization’s IT needs. First, HMIS teams must investigate and prioritize the organization’s information needs. It is quite difficult to determine the information needs of different individuals and departments in healthcare services organizations. Prior to determining the appropriate HMIS that need to be implemented, it is necessary to identify the type of decisions that are made. With today’s prolifer- ation of managed care organizations, many decisions have already been determined. This is be- cause, depending on the insurance company or organization (e.g., Blue Cross Blue Shield, Kaiser Permanente, Medicare), there may be limited choices available to the decision maker. Because managed care organizations have become more the norm than the exception, it is even more diffi- cult for HMIS teams to identify the subset of choices that are applicable to different patients. These decisions can be broadly divided into strategic and day-to-day operational decisions. Executives make far more strategic decisions than others in the organization. Some healthcare em- ployees primarily, if not totally, make operational decisions. The type of decision that needs to be made, whether strategic or operational, determines the information needs—and the needs differ. Strategic decisions are those that affect the healthcare organization in the long term. The de- cisions are often unstructured and use less quantitative inputs than operational decisions.40,41 These “soft” decisions are often difficult to make, and therefore, much of the information that is needed is not precise. Making strategic decisions often relies on a leader’s experience. Decisions such as organizational restructuring and fund-raising directions are at the strategic end, whereas decisions such as daily budgeting, hiring, and training of personnel would be at the more operational end. While the ultimate decision is difficult, an HMIS could assist a decision maker in solving this unstructured problem, as well as semistructured, unprogrammed, and nonrepetitive problems.42 Because strategic decisions are often “one-time decisions,” the infor- mation needs are difficult to determine a priori. For instance, a healthcare executive may need to make a decision on the location of building a new outpatient clinic that will have the least 178 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 178 social impact. For instance, one of the officers who reports to the leader may have provided the following list of locations to choose from: East Los Angeles, South Central Los Angeles, Compton, and North Hollywood. This decision is an unstructured strategic task because evalu- ating social impact is an unstructured problem. It is strategic in that it relates to a new clinic and could affect the entire organization. Operational decisions happen more frequently, and the information that is needed for these short-term decisions is easier to predict than strategic decisions. As stated, those in lower levels of the organization often make the decisions. The type of department, as well as the type of healthcare services organization, often determines the type of decisions that need to be made. For example, an HMIS may be used to decide the etiology of a patient’s pain in his leg. A sim- ple binary decision can be developed that allows a physician to enter data, and the information systems (IS) could output possible causes, in probability order. Information Sources Many ways have been introduced that assist in gathering information needs in organizations. Methods such as in-depth interviews, brainstorming sessions, participant observation, docu- ment analysis, business systems planning, determining health service organization critical suc- cess factors, and ends–means analysis are a few among many.43–45 Even though the techniques are abundant, it is still quite difficult to anticipate all of the information needs of a healthcare services organization. From a human behavioral point, many people cannot articulate the infor- mation they really need; at a minimum, it is difficult to predict all needs. This is specifically dif- ficult as one elicits information needs from healthcare organization executives. As stated earlier, this is because the information needs of those at the higher end of the organizational apex are more closely tied to strategic, unique decisions. Each of the different methods of gathering healthcare services organization information needs views IR differently. Often, HMIS teams use myriad ways in order to gather the most and the best data in different departments and at different levels. Business systems planning, critical success factor generation, and in-depth interviews are three of the ways that healthcare services teams use often to solicit IR. Business Systems Planning Initial work on business systems planning (BSP) began in the early 1970s by IBM and was intro- duced to support strategic information systems planning.46 BSP was developed for use internally within IBM, but later it was offered as a planning method to customers. BSP focuses on data and processes. It is generic in its application, meaning that products, as well as HMIS services organiza- tions, can benefit from its use. Healthcare services organizations use BSP when they want a new way to view the organization and determine the information needs in order to build HMIS. The process is very comprehensive; therefore, it is often time-consuming and expensive. While there are other models used on occasion for planning (e.g., business process reengi- neering or enterprisewide architecture strategy [EWAS] methodology), all have been a rendition of BSP. The BSP defines the information architecture for an organization. The basic building blocks of the BSP are data classes and health services processes. The data classes are the categories V. I N F O R M A T I O N R E Q U I R E M E N T S 179 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 179 of the necessary data to support the organization. Healthcare services processes are logically re- lated activities and decisions that are required to manage the resources of the organization. The steps to develop a BSP that are normally taken by HMIS management include the following: 1. The study is authorized. 2. The team is assembled. 3. The data classes and healthcare services processes are defined. 4. The information architecture is defined (from the data classes and healthcare services processes). 5. The as-is system (technically based system or not) is compared with the information ar- chitecture, and the needed HMIS are identified to fill the gap. 6. Healthcare services executives are interviewed to verify the architecture and to deter- mine any problems. 7. Priorities are established on the major HMIS contained in the architecture. 8. The final BSP report is prepared and presented to the healthcare services management. An example of the steps for developing a BSP for an e-prescribing system at a hospital is illus- trated in Table 8.2. 180 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S Table 8.2 BSP Example for an E-Prescribing System Step Activity/E-Prescribing Example 1 The study is authorized. Senior management gives the directive to implement an e-prescribing system to replace the hospital’s manual system. 2 The team is assembled. The first-level HMIS manager assigns the project manager, consultant, and an HMIS employee to the team. 3 The data classes and health service Table 8.3 shows a subset of the data classes/processes processes are defined. matrix for the e-prescribing system. 4 The information architecture is The flow of information and connections are defined. determined, given the data classes/health service processes matrix from step 3. 5 The as-is system is compared with The current nonautomated system is compared with the information architecture, and the information architecture from step 4, and the the needed HMIS are identified to HMIS needed are chosen. fill the gaps. 6 Health service executives are Interviews are conducted with senior management interviewed to verify the architecture to ensure that the architecture developed in step 4 is and to determine any problems. correct and appropriate. 7 Priorities are established on the The HMIS from the architecture are prioritized, with major HMIS contained in the the capabilities of each HMIS documented. architecture. 8 The final BSP report is prepared The e-prescribing HMIS BSP is completed and and presented to the health presented to the health organization executives for services management. approval. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 180 T ab le 8 .3 D at a C la ss es /H ea lt h S er vi ce P ro ce ss es E -P re sc ri b in g Sy st em M at ri x D at a C la ss es P at ie n t E n tr y P re sc ri b in g B ar P at ie n t P re sc ri p ti o n T ec h n o lo gy E ve n t P at ie n t P h ys ic ia n A ss is ta n t C o d e D ia gn o si s Lo ca ti o n D o cu m en t R es o u rc es C o m p o n en t- Le ve l P ro ce ss es C re at e a n ew p at ie n t m ed ic at io n r ec o rd R * C R * C C C R * C U p d at e an e xi st in g p at ie n t’ s m ed ic at io n r ec o rd R R U D R R U D R U D R U D R R U D Q u er y th e e- p re sc ri b in g sy st em f o r ex is ti n g p at ie n t R R R R R R R R in fo rm at io n M an ag e th e co m p o n en t le ve l e -p re sc ri b in g sy st em C R U D D ep ar tm en t- Le ve l P ro ce ss es P ro vi d e d ep ar tm en tw id e p ro gr am m an ag em en t fo r e- p re sc ri b in g sy st em C R U D Le ge n d : C : cr ea te , R : re fe re n ce , U : u p d at e, D : d el et e * So m e d at a en ti ti es a re c re at ed b y p ro ce ss es t h at a re o u t o f th e sc o p e o f th is a n al ys is . 181 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 181 In addition to the value that BSP adds to the health services, business process reengineering of the 1990s is based on the BSP concept. In addition, BSP identified the need to separate data and applications that use these data and supported the systems development database approach. Critical Success Factors Daniel47 of McKinsey & Company was the first to introduce the term success factors. He sug- gests that companies need to identify and focus on the critical information needs that relate to corporate success factors in order to achieve control and management effectiveness. This focus on information needs is necessary because organizations are in times of continuous change and growth. Rockart48 introduced the term critical success factor (CSF), which identifies “for any business the limited number of areas in which results, if they are satisfactory, will ensure suc- cessful competitive performance for the organization.” These areas are those that need to have continual and careful monitoring so that performance criteria are met and the existing areas of the organization are improved. Bullen and Rockart49 identify three main uses for conducting CSF planning: (1) deter- mine an individual manager’s information needs, (2) aid an organization in general corpo- rate planning, and (3) aid an organization in its IS/IT planning. They present five prime CSF sources: the industry, competitive strategy and positioning, the environment, manage- rial position, and temporal factors. These authors suggest that the factors can further be classified by internal versus external (or monitoring versus building). The monitoring fac- tors involve the review of existing situations such as performance management. Building factors are those that the organization needs to plan for or change for in the future. Johnson and Friesen50 show how CSFs can be used in a versatile manner and how the approach can be applied to solve a wide range of quality, operational, and planning problems across many industries, including health care. As depicted in Figure 8.4, Tan51 applied the Bullen- Rockart model to health care. 182 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S Cost Quality of Service Industry Factors Service Mix Geography/Location Specialty Market Factors External CSF Sources Internal CSF Sources Organizational Success Population Growth Political and Socio- economic Factors Activities of Key Actors (Payors, Providers, and Patients) Service Integration Resource Allocation Budgeting Environmental Factors Managerial Factors Labor Disputes Electrical Breakdown Temporal Factors FIGURE 8.4 Bullen-Rockart’s (1981) Five Prime Sources of Critical Success Factors Applied to Health Care. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 182 In-Depth Interviews Conducting in-depth interviews52 can be quite productive in assessing healthcare services or- ganization information needs. Unfortunately, while interviewing may appear to be simple, it is actually quite difficult; in order to ascertain the actual information needs of individuals, there are specific skills that an interviewer must use to be effective. There are five basis steps: 1. Select the interviewees. 2. Design the interview questions. 3. Prepare for the interview. 4. Conduct the interview. 5. Conduct a post-interview follow-up. Interviewees are selected based on the type of information that is needed. Obtaining differ- ent perspectives from individuals at various levels of the healthcare services organization pro- vides a more comprehensive picture of the health organization’s information needs. This could include healthcare service middle managers and individual contributors, as well as executives in the organization. In addition, it is important to engage in discussions with individuals in differ- ent departments in the organization. The design of interview questions varies. The HMIS team can perform interviews in a struc- tured, unstructured, or semistructured format—each needing different types and numbers of “start” questions. Structured interviews would be very specific and would focus on a specific problem area. The questions are scripted prior to the interview, and the recipe is closely followed. Using such a structure can possibly confine the application of the information needs. However, if a specific area is being studied, and the goal is to obtain only data about that specific area, this would be the most appropriate process to follow. At the opposite end of the continuum are unstructured interviews. There is much less prepa- ration in developing the questions prior to the interview. The interviewer acts more as a facilita- tor, allowing the participant to take the lead and only guiding the interview. Broad, roughly defined information is obtained from unstructured interviews. Using this type of process allows the interviewee to talk freely, with fewer boundaries than structured interviews. This method would be more appropriate when the HMIS teams want to understand needs in general. Using this method burdens the HMIS team in determining and prioritizing the many information needs that are uncovered. The semistructured interview method falls between the other two processes. There is some question preparation prior to interviews; however, the interviewer is likely to follow up partici- pant answers with additional probing questions to acquire additional detail. Semistructured in- terviews allow for a free-flowing, comfortable conversation with some direction in order to obtain the goal desired. An excerpt from a semistructured interview is shown in Exhibit 8.3. The interviewer must prepare a general interview plan with a list of questions, anticipated answers, and follow-up questions. Having this plan keeps the interview on track and allows for an effective and efficient meeting. The interviewer needs to set priorities of what areas the V. I N F O R M A T I O N R E Q U I R E M E N T S 183 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 183 184 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S Exhibit 8.3 Semistructured Interview Focus The following is an example of a portion of a semistructured interview of a physician about PDA use/nonuse: Interviewer: OK, great. What is your familiarity with the use of PDAs in the healthcare environment? What do you know? Interviewee: I have one, so probably most of what I know is my own experience. I bought a PDA I believe in 1998, so that gives me about 7, 8 years’ experience. Originally, I just used it for keeping track of phone numbers, as a date book, and for memos. But I also have a program on it, which I’ve had for several years, probably at least 6 years, called Epocrates. I found it to be very helpful because it has a listing of medications and it’s helped me ’cause it’s updated, so I always feel like it’s up-to-date, whereas a textbook wouldn’t be; it gets out of date quickly. So, I found that to be helpful, too. And I do use that probably every day or a few times a day. Interviewer: So, any time you need to look up a medication or something, you use your PDA? You usually go there first? Interviewee: Now, we have other sources, too. We have the books here in the offices. That’s more exhaustive. I do prefer that, but I’m much more likely to refer to the Epocrates in the PDA first. And we have drug references online. The Physician’s Resource through the university medical center that’s called Up-To-Date. And that is a medical database and it has information, different medical cases. And it also has a section on medications. So, I can type in a medication and get information on that as well. Interviewer: Have you heard of other usages of the PDA for other applications of health care? Interviewee: I know it’s used for—and I have not used it so much for—equations, but I think in the hospital where they do calculations for drugs, they have to do special calculations for people with impaired kidney or liver functioning for certain drugs. Or if there’s cancer or chemotherapy or things like that that involve a lot of calculations. Even for kids based on weight. I don’t see kids here; they’re all young adults or adults. So, I know there are other uses for it that way. There’s like a body mass index they can get a calculation from. I just have a formula. I probably would get that if I could pick that up easily. There’s a limit, I guess, as far as memory, too, so. There are a lot of other programs out there that I’ve heard about, but none of them seem like things that I need. Interviewer: You say you brought a PDA in ’98. Have you had the same PDA or have you upgraded or done anything different to it, or are you using the same one? Interviewee: I think is the third one that I’ve had. Interviewer: Same model or have you changed models? Interviewee: Well, it’s the model of where it’s changed to. It’s their standard model, so it’s upgraded each time. So, I’ve sort of gone with like a standard or middle-of-the-road kind of model, not necessarily the absolute newest, because those are usually premium priced. So, middle-of-the-road model that I can get for about $200 or $250, something like that, or less. Interviewer: So, you’re using a PDA. Now, you talked a lot about within your profession. Personally, I think you said a little bit about names and addresses. So, do you use it in that aspect pretty much in— Interviewee: I use it as my address book, basically, and phone book. So, I found that to be very helpful. Every time I get a new number, I try to enter it. So, my wife sometimes will ask me, do you have the number for so-and-so. And I can even be driving somewhere and I can pull it out and have it. You know each relative. My relatives, her relatives. I always have it. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 184 information needs of the participant are mandatory, in the event that time becomes short dur- ing the interview. These priorities will ensure that the most important information needs are captured. Not only is a plan needed prior to the interview, the schedule, the reason for the in- terview, and the areas of discussion need to be detailed for the participant beforehand. When the interview is conducted, the interviewer must appear to be professional and unbi- ased. To get different views from an interview, more than one interviewer may conduct the in- terview. This would attenuate the bias that could result from just one interviewer and increase the reliability of the results. Also, as much information as possible should be recorded. Actually, many interviews today are digitally recorded, transcribed, and loaded into a computer system for storage, management, and manipulation. However, some organizations have policies against recording and therefore the rules need to be reviewed prior to the interview. Of course, the in- terviewee needs to agree to the recording. Reviewing a recording after the interview allows the team to listen to the interview more than once in order to extract information needs and to de- lineate between facts and opinions. Prior to concluding the meeting, the interviewers must make sure that all issues and terms are understood. If there are any questions, it is best to get answers before ending the session. The participant should also be given time to ask questions before concluding the session. Finally, in addition to ending on time, the interviewee should be thanked. After the interview, the interviewers should prepare interview notes by summarizing key points. The consolidation of these notes becomes the interview report. After review of the re- port, the team can assess the gaps and determine possible additional questions that can be used in subsequent interviews. VI. Conclusion The work of today’s senior HMIS managers is quite complex. Not only must they be viable members of the executive team that plans, organizes, develops, and controls the whole health- care services organization, they are given the added responsibility of ensuring that the health management information systems are available to assist in meeting the overall health organiza- tion’s vision and mission. Potentially, taking advantage of HMIS technology can be used to counter competition in the healthcare field. With the decrease in the cost of IT overall, HMIS management is called on V I . C O N C L U S I O N 185 Exhibit 8.3 (Continued) Interviewer: So, you keep it with you all the time. Interviewee: That’s another thing I’ve found that I think it’s most helpful if it’s kept with one all the time. I know other folks say they have PDA, but it’s in a drawer, they don’t use it. They don’t hot-sink it. So, when I got it, I try to make a point of having it with me all the time. I got a little Velcro strap to keep it from slipping out of my pocket. I just wrap that around. So, if I bend over from [inaudible], it doesn’t slide. Source: Modified from J. T. Blue, Dissertation, Virginia Commonwealth University, 2006. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 185 more and more to assist in meeting the corporate and department objectives. Why shouldn’t HMIS be an integral part of the mission? While history has HMIS as an enabler that supports and assists in realizing a health organization’s vision, in order to remain competitive there need to be more HMIS top-level strategies. 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(Cincinnati, OH: South-Western, 2001). 186 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 186 19. A. Kinicki and B. K. Williams, Management: A Practical Introduction, 2nd ed. (Boston: McGraw Hill/Irwin, 2006). 20. L. W. Rue and L. L. Byars, Management: Skills and Applications, 11th ed. (Boston: McGraw- Hill/Irwin, 2005). 21. J. R. Schermerhorn Jr., Core Concepts of Management (Hoboken, NJ: John Wiley & Sons, 2004). 22. A. Forbes, “Naming Names—Mandatory Name-Based HIV Reporting: Impact and Alternatives,” AIDS Policy and Law 1 (1996): 1–4. 23. E. O. Olson and G. H. Eoyand, Facilitating Organisation Change—Lessons from Complexity Science (San Francisco: Jossey-Bass/Pfeiffer, 2001). 24. R. S. Kaplan and D. P. Norton, The Strategy-Focused Organization, Strategy and Leadership (Boston, MA: Harvard Business School Press, 2001). 25. L. Willcocks and G. Smith, “IT-Enabled Business Process Reengineering: Organizational and Human Resource Dimensions,” Journal of Strategic Information Systems 4 (1995): 279–301. 26. B. H. Reich and I. Benbasat, “Factors That Influence the Social Dimension of Alignment Between Business and Information Technology Objectives,” MIS Quarterly 24 (2000): 81–111. 27. A. L. Lederer and V. Sethi, “The Implementation of Strategic Information Systems Planning Methodologies,” MIS Quarterly 12 (1988) 445–461. 28. H. E. Newkirk and A. L. Lederer, “Incremental and Comprehensive Strategic Information Systems Planning in an Uncertain Environment,” IEEE Transactions on Engineering Management 53 (2006). 29. T. S. Teo and W. R. King, “Integration between Business Planning and Information Systems Planning: An Evolutionary-Contingency Perspective,” Journal of Management Information Systems 14 (1997): 185–214. 30. R. Sabherwal and W. R. King, “Decision Processes for Developing Strategic Application for Information Systems: A Contingency Approach,” Decision Science 23 (1992): 917–943. 31. D. Miller and P. H. Friesen, “Strategy-Making and Environment: The Third Link,” Strategic Management Journal 4 (1983): 221–235. 32. J. C. Brancheau, B. D. Janz, and J. C. Wetherbe, “Key Issues in Information Systems Management: 1994–1995 SIM Delphi Results,” MIS Quarterly 20 (1996): 225–242. 33. C. Dunbar and W. A. Schmidt, “Information Systems Must Represent 35 Percent of Total Strategic Plan,” Computers in Healthcare 12 (1991): 22–24. 34. S. E. Kern and D. Jaron, “Healthcare Technology, Economics, and Policy: An Evolving Balance,” IEEE Engineering in Medicine and Biology Magazine 22 (2003): 16–19. 35. J. K. H. Tan, Health Management Information Systems: Methods and Practical Applications, 2nd ed. (Gaithersburg, MD: Aspen Publishers, 2001). 36. B. Bowman, G. Davis, and J. C. Wetherbe, “Three Stage Model of MIS Planning,” Information and Management 6 (1983): 11–25. 37. Tan (2001). 38. J. C. Henderson and J. B. Thomas, “Aligning Business and Information Technology Domains: Strategic Planning in Hospitals,” Hospital and Health Service Administration 37 (1992): 71–87. 39. K.-K. Hong and Y.-G. Kim, “The Critical Success Factors for ERP Implementation: An Organizational Fit Perspective,” Information and Management 40 (2002): 25–40. 40. S. Jarupathirun and F. M. Zahedi, “Dialectic Decision Support Systems: System Design and Empirical Evaluation,” Decision Support Systems 42 (2007): 1553–1570. 41. H. Mintzberg, D. Raisinghani, and A. Theoret, “The Structure of ‘Unstructured’ Decision Processes,” Administrative Science Quarterly 21 (1976): 246–275. N O T E S 187 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 187 42. R. Bonczek, C. Holsapple, and A. Whinston, Foundations of Decision Support Systems (New York: Academic Press, 1981). 43. M. McDiarmid, S. Kendall, and M. Binns, “Evidence-Based Administrative Decision Making and the Ontario Hospital CEO: Information Needs, Seeking Behaviour, and Access to Sources,” Journal of the Canadian Health Libraries Association 28 (2007): 63–72. 44. K. Holtzblatt and H. R. Beyer, “Requirements Gathering: The Human Factor,” Communications of the ACM 38 (1995): 31–32. 45. R. L. Daft and R. H. Lengel, “Organizational Information Requirements, Media Richness and Structural Design,” Management Science 32 (1986): 554–571. 46. J. A. Zachman, “Business Systems Planning and Business Information Control Study: A Comparison,” IBM Systems Journal 21 (1982): 31–53. 47. D. R. Daniel, “Management Information Crisis,” Harvard Business Review 111 (1961). 48. J. F. Rockart, “Chief Executives Define Their Own Data Needs,” Harvard Business Review 57 (1979): 81–93. 49. C. V. Bullen and J. F. Rockart, ed. J. F. Rockart, A Primer on Critical Success Factors. Unpublished Sloan WP No. 1220-81. (Cambridge, MA: Center for Information Systems Research, Massachusetts Institute of Technology Sloan School of Management, 1981), p. 64. 50. J. A. Johnson and M. Friesen, The Success Paradigm: Creating Organizational Effectiveness through Quality and Strategy (New York: Quorum Books, 1995). 51. Tan (2001). 52. J. T. Blue, Rebuilding Theories of Technology Acceptance: A Qualitive Case Study of Physician’s Acceptance of Technology. Unpublished Dissertation, Virginia Commonwealth University, 2006. Chapter Questions 8–1. Describe the different organizational structures. Given your answer, how would the in- put be different if 98 percent of the patients are participants in a managed healthcare program? 8–2. Develop a matrix, and list the advantages and disadvantages of using each of the organi- zation structures as presented in the chapter. 8–3. When would it be appropriate for executives in a healthcare organization to dictate tac- tics to an organization? 8–4. Using the objective “A bar-scanning mechanism that includes the patient, all hospital personnel that treat the patient, and the prescribed/administered service will be imple- mented within 1 year,” develop four tactics for this objective as demonstrated in the strategic planning focus in Exhibit 8.1. 8–5. As presented in the chapter, the executives in a healthcare organization strategically plan and produce the vision and mission. What are some of the inputs that the senior man- agement team would consider when developing the strategic plan? 8–6. Discuss how the different organizational structures, as presented in the chapter, would be applied in different types of healthcare organizations (private hospital, public hospital, clinic, urgent care facility, private doctor’s office, etc.). Which structure do you think is most productive in the different healthcare organizations that you determine, and why? 8–7. What methods have you seen used in gathering information needs in organizations? How was the method used, and was it successful? 8–8. If you are the information systems manager at a community clinic and the clinic is plan- ning to implement an EHR system (from a complete paper-based file system): a. List five semistructured interview questions that you would ask a physician. 188 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 188 b. List five semistructured interview questions that you would ask a registered nurse. c. List five semistructured interview questions that you would ask a registration clerk. Chapter Appendix: Glossary of Terms accountability The result of holding an individual responsible for delivering a set of goals, objectives, and/or tactics. business process re-engineering Analyzes and redesigns the workflow between and within business enterprises (emphasized by Michael Hammer and James Champy1). business system planning (BSP) Used by health service organizations to facilitate viewing the organization differently and determining the organization information needs in order to build health management information systems. critical success factor (CSF) “For any business the limited number of areas in which results, if they are satisfactory, will ensure successful competitive performance for the organization” (Rockart2). data classes Used in business system planning; the categories of the necessary data to support the organization for the application in question. Health service processes are logically related activities and decisions that are required to manage the resources of the organization. e-prescribing Using electronic systems to assist and enhance the communication of a pre- scription, helping the administration, choice, or supply of a medicine through supporting clinicians’ decisions with a thorough audit trail for the entire medicine’s use process. EHR system An electronic system that stores patient health information and data, provides for electronic order entry of processes, allows for the electronic view/review of information, and provides decision support. electronic health record (EHR) An electronic version of a patient’s health record. enterprisewide architecture strategy (EWAS) Developed by John A. Zachman; a sophisti- cated framework that integrates the technical components within the larger enterprise architecture. gap analysis A technique in which the difference between the desired performance levels and the extrapolated results of the current performance levels is measured and examined. This measurement shows what resources are required and what needs to be done to achieve the mission of a healthcare organization’s strategy. goal Adds focus to a healthcare organization’s vision and mission. If the goal(s) is attained, the mission has been accomplished. Health Insurance Portability and Accountability Act of 1996 (HIPAA) U.S. law that pro- vides standards for the interchange of patients’ health, financial, and administration data— C H A P T E R A P P E N D I X : G L O S S A R Y O F T E R M S 189 1Hammer, M., & Champy, J. (1993). Reengineering the Corporation: A Manifesto for Business. New York: Harper Business. 2Rockart, J. F. (1979). Chief executives define their own data needs. Harvard Business Review, 57(2), 81–93. 3U.S. Department of Health & Human Services HIPAA (2007). Office for Civil Rights—HIPAA. Retrieved December 20, 2007, from http://www.hhs.gov/ocr/hipaa/ 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 189 including privacy and security. The Act began to roll out in phases, with full compliance ex- pected by 2004. Additionally, the law protects employees’ health insurance when they lose or change jobs (U.S. Department of Health & Human Services3). health management information systems (HMIS) A technologically based systems designed to operate in a healthcare environment. health management strategic information systems plan (HMSISP) A plan developed by the healthcare organization information systems team that lays out the requirements of systems for a healthcare organization that will assist in fulfilling an organization’s strategy. health service processes Used in business system planning; logically related activities and de- cisions that are required to manage the resources of the organization. managed healthcare A system where non-medical administrators, like insurance companies, control and limit such things as medical procedures, medications, and the frequency of service. mission statement A concise description of a healthcare organization’s fundamental purpose. A mission statement answers the question, “Why do we exist?” objective Provides focus on how a specific goal with be achieved. planning, organizing, directing, and controlling (PODC) model An operationalized and ra- tionally designed tool to assist in meeting organizational goals (Fayol4). strategy According to Henry Mintzberg5: ● A “how”; a means of getting from here to there. ● A pattern in actions over time. ● Position; that is, it reflects decisions to offer particular products or services in particular markets. ● Perspective; that is, vision and direction. tactic A specific, measurable task that contributes to attaining a particular objective. vision statement Often referred to as a picture of the healthcare organization in the future. It should be the organization’s inspiration and the framework for all strategic planning. 190 H M S I S P L A N N I N G / I N F O R M A T I O N R E Q U I R E M E N T S 4Fayol, H. (1949). General and Industrial Administration. London: Pitman. 5Mintzberg, H. (1994). The Rise and Fall of Strategic Planning. New York: Simon & Schuster. 56918_CH08_Final_Tan 4/6/10 11:56 AM Page 190 System Development: Health Management Information System Analysis and Developmental Methodologies Joseph Tan 191 9 CHAPTER CHAPTER OUTLINE Scenario: Richmond Township I. Introduction II. HMIS Analysis and Development Methodologies III. SDLC-Based Methodologies IV. Structured Methodologies V. Prototyping VI. Contemporary Models ● Computer-Assisted Software Engineering (CASE) Tools ● Multiview ● Open-Source Software VII. Conclusion Notes Chapter Questions 56918_CH09_Final_Tan 4/6/10 12:03 PM Page 191 S c e n a r i o : Richmond Township The municipal government of Richmond Township, through the Richmond Economic Council, voted to fund a number of neighborhood sites to develop community health programs for sur- rounding residents. Each site was equipped first with a Macintosh computer and a small office run by a full-time program coordinator. The council requires that the site coordinators report to the community supervisor and the medical health officer (MHO) of the region for which the community was funded. Residents of these communities interact with their program coordina- tors as volunteers and as participants in community health awareness programs. The council also funds a team of evaluators, who are affiliated with certain university research groups, to provide technical assistance to the various community sites and to conduct independent reviews of the various community health demonstration programs. Imagine yourself to be appointed as the site coordinator for one of these communities. Apart from setting up various community health programs and managing the daily chores of tracking levels of community participation in various programs, you must now try also to mobilize com- munity support and delegate responsibilities to task forces for the different programs. Through the collaborative efforts of the community supervisor, the MHO, and, most importantly, the task forces (whose memberships mainly comprise volunteers drawn from various stakeholder groups in your community), you are able to initiate a number of healthy lifestyle programs. You are expected to report the latest developments on each of these programs during scheduled meetings and to perform your daily office routine efficiently and effectively. Realizing the power of automation in achieving greater efficiency and effectiveness, you de- cide to get help from the evaluation team by asking for the design and implementation of Macintosh-based software that would track, on a real-time basis, the various pieces of informa- tion from each of the three programs currently being suggested: (1) the walking program, (2) the restaurant program, and (3) the worksite program. Because these are new programs and you are still uncertain about the response of the community at large to these planned activities, you find it difficult to give an accurate description of the process. To make matters worse, you would like to design the system yourself, even though you have only taken one introductory health man- agement information systems (HMIS) course during your training as a health administrator. You therefore realize that you would need a great deal of technical assistance from the analyst, but it is your strong belief that if you do not champion the system design and software develop- ment efforts, you may not be using the resulting system after all. In this case, you may have to rely heavily on your current manual filing system, which is proving to be inadequate in helping you carry out your various responsibilities. In your first interaction with the analyst from the evaluation team, who is assigned to assist you with the technical details involved in designing and developing the community health in- formation systems (CHIS) to satisfy the need for moving these programs forward, both of you arrive at a rich picture following a general analysis of the situation for which the CHIS is to be used. This rich picture is shown in Figure 9.1. You and the analyst then proceed to design the main menu and the organization of several possible screen layouts. Figure 9.2 shows the structure 192 S Y S T E M D E V E L O P M E N T 56918_CH09_Final_Tan 4/6/10 12:03 PM Page 192 of the main menu with its interface to the various subsystem menus for your community site, which is designated as Site A by the evaluation team. While helping you think about how you could specify your information requirements and how these requirements might be translated into a well-structured data model, your analyst comes up with a rough entity-relationship (E-R) model. This E-R model is depicted in Figure 9.3. You then proceed with the analyst to design the user interface for the “main and new S C E N A R I O : R I C H M O N D T O W N S H I P 193 HP Programs Public Health Officers and Administrators Stakeholders (Key Actors) Government Community Residents Observations Surveys Interviews Walking Restaurant Worksite HMIS Technology Cost Capabilities Volunteer Task Forces Training Productivity Satisfaction HP Program Supervisors Evaluation Leadership Effectiveness Storage Tapes Hard Copies Documents Collection Dissemination There is too much work and too few volunteers! Why don’t we use state-of-the-art technology? How can technology help us in our jobs? What are my duties and responsibilities? What is my budget? How can I cope with increasing demands and ensure success of the program? FIGURE 9.1 A Rich Picture of a Multicommunity Health Promotion Project. Community Site “A” Main Menu Restaurant Menu Walking Menu Worksite Menu Exit Miscellaneous Menu FIGURE 9.2 Main Menu Subsystem for Multicommunity Health Promotion Project Community Site A. 56918_CH09_Final_Tan 4/6/10 12:03 PM Page 193 event” screen as well as the “new participant” screen for your community. The resulting screen displays are shown in Figures 9.4 and 9.5. In designing these interfaces, you feel that the earlier step of trying to list the information you wanted has helped you and your analyst greatly in determining what data elements should be appearing in the respective data entry screens (views). The process has also helped clarify the data elements to be captured in the CHIS. You now realize that it is possible to generate reports 194 S Y S T E M D E V E L O P M E N T Health Promotion Supervisor Health Promotion Program Participant One-to-One Relationship One-to-Many Relationship Many-to-One Relationship Many-to-Many Relationship Events FIGURE 9.3 An Example of an Entity-Relationship Diagram for the Multicommunity Health Promotion Project. NEW EVENT Date Name of Supervisor: Event Name: Event Place: Event Date (MM/DD/YR): Event Time: Number of Volunteers: Attendance: Event Type: 6 / 7 / 94 OK Detail Cancel Richard Richard’s Cafe Restaurant MAIN SCREEN FIGURE 9.4 The Main and New Event Screens for Community Site A. Source: Courtesy of Microsoft Corporation, Redmond, Washington. 56918_CH09_Final_Tan 4/6/10 12:03 PM Page 194 by combining and statistically manipulating the different data elements that are entered into the CHIS. Think about the kind of aggregate information you may want from the data that will be captured in the CHIS to help you structure your reports on the latest developments of the different programs. At this point, you are informed by members of one of the task forces that two of the partici- pating volunteers would be able to spare some additional time to help you with questions, work with other residents, and update information on CHIS whenever necessary if only you are able and willing to train them. Essentially, this would mean that the CHIS must be developed to be used by these volunteers, who may have even less knowledge of computerized systems than you do. Your analyst also informs you that you have the choice of customizing an off-the-shelf ap- plication to fit your needs or pursuing self-developed CHIS. Contemplate how you would go about making an informed choice about this and what additional information you might want in order to manage the process of this CHIS analysis and project development. Remember also that you only have a very limited budget and time line to complete the CHIS project. S C E N A R I O : R I C H M O N D T O W N S H I P 195 English French NEW PARTICIPANT Language Date Title: Given Name: Surname: Blood Pressure Blood Cholesterol Height Weight Address: City: Province: Postal Code: Telephone: Date of Birth (DD/MM/YR): S.I.N.: Occupation: Smoker Nonsmoker Ex-smoker stopped Smoking Physiologic Measure Male Female Gender Risk Questionnaire 5 / 19 / 94 High blood pressure Diabetes Elevated blood cholesterol Exercise >20 min. at least 3 times/week
Family history of heart disease
History of heart disease
Healthy diet
Martial Status
Single
Married
Separated
Widowed
Divorced
Other
OKCancel
FIGURE 9.5 The New Participant Screen for Community Site A. Source: Courtesy of
Microsoft Corporation, Redmond, Washington.
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I. Introduction
In this chapter, we discuss a variety of approaches used to deal with the challenges of initiating
and coordinating HMIS analysis and developmental efforts. Each of the different classes of
methodologies to be covered may be based on a philosophical view, which can range from a
complete focus on the humanistic side to the technical aspects of HMIS analysis and develop-
ment. For example, many traditional methodologies emphasized systems analysis (SA), whereas
others focused on systems design (SD) phases within the larger systems development life cycle
(SDLC). The SDLC represents essentially an iterative process in project managing an informa-
tion system project development from its beginning to end: it first encompasses the analysis
phase in which existing system(s) is (are) studied so as to uncover gaps that have to be filled; fol-
lowed typically by designing new and/or needed components to address the identified chal-
lenges; eventually resulting in the “physical” programming, the training of staff, and the
implementation of a newly developed system. In turn, the new system apparently also raises the
need for regular maintenance and ad hoc attention for additional refinements or changes as
needed over the years. This will then put us back into the analysis phase, when the existing in-
formation system no longer meets the needs of the organization it serves.
Briefly, then, SA involves activities related to reviewing current information architecture and
the organizational environment, whereas SD encompasses activities related to specifying new
information architecture and systems requirements. Most traditional systems development
methodologies (SDM) will employ a combination of SA and SD phases in a sequential manner,
that is, SD to follow SA process. More recently, contemporary models, including computer-
aided software engineering (CASE) tools and Multiview, attempt to take a contingency ap-
proach, thereby providing a framework for managing SA and SD phases, contingent on
changes in the organizational environment.
Beyond SA and SD phases is systems implementation. Systems implementation involves the
selection and inauguration of new system architecture and applications, which is the subject of
an entire chapter of its own. A key phenomena in the evolution of SDM, however, is open-
source software (OSS), which focuses on the adoption of working “prototypes” that contain
shareable codes to be used freely or modified freely as a result of end-user computing (EUC) or
development process. We will therefore also discuss the OSS approach and conclude the chap-
ter with some thoughts and recommendations on EUC.
II. HMIS Analysis and Development Methodologies
Early computer applications were typically designed without adequate analysis and planning.
As HMIS evolved, the need for a “systematic” approach became increasingly necessary.
Consequently, numerous approaches to managing the SDLC have emerged.
Systems development methodologies (SDM) are systematic approaches to HMIS planning,
analysis, and design.1 A methodology is a collection of procedures, techniques, tools, and docu-
mentation aids to help HMIS developers in their efforts to implement a new information archi-
196 S Y S T E M D E V E L O P M E N T
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tecture and system. It therefore provides a framework (consisting of phases and subphases) that
guides the developers in their choice of appropriate techniques at each stage of a project. A
technique is a way of performing a particular activity in the system development process.
Widely used techniques include rich pictures, E-R modeling, normalization, data flow dia-
grams (DFDs), decision trees, decision tables, structured English, action diagrams, and the en-
tity life cycle, several of which have already been discussed and illustrated throughout this text.
We focus the discussion here on two major techniques often applied with surprising effective
results in HMIS analysis to assist communications between the analyst and the layperson, who
will eventually become the end-user of the system: rich picture and DFD.
A rich picture2 as shown in Figure 9.1 at the beginning of this chapter, for example, is simply
a convenient tool for documenting themes or issues for an ill-defined problem situation, specif-
ically for soft and fuzzy issues to be discussed among different laypeople when doing an HMIS
analysis. This innovative diagramming tool does not subscribe to any standards (or a particular
convention). It uses the language and terminology of the environment and shows how those
who developed the picture perceive various pieces of a problem situation as relating to each
other. The aim here is to record the problem situation as a whole, that is, in a holistic fashion
without limiting it to the agenda or biases of key actors and decision makers. Figure 9.1 illus-
trates the various parties who share the information pool and some of the tasks and concerns
encountered in the community health promotion project (CHPP) discussed in the chapter-
opening scenario. Based on the information provided in this picture and a further investigation
of other available health services programs in Richmond Township, the first step in the HMIS
analysis process is to ask the various CHPP stakeholders to provide a sense of where and how
the different proposed health promotion programs and services can be situated and fitted ap-
propriately into the larger picture of the present healthcare services delivery system of
Richmond Township. In other words, the CHPP rich picture provides a starting point for
discussions on how various HMIS components and systems thinking can be combined to
lead to resolving CHPP challenges and generating an acceptable HMIS to support the CHPP
program.
As for the DFD, it is a network representation of a system, which itself may exhibit varying
degrees of automation. Essentially, DFDs are top-down hierarchical diagrams, which can pro-
vide successive levels of details and are particularly useful in documenting data flows and
processes in a system. Like other information flow diagrams such as node diagrams, block dia-
grams, data flow graphs, or even bubble charts, DFDs provide a standardized approach to sys-
tems documentation and aid in the development of future system designs. DFDs are useful for
documenting the logical design of an information system by graphically showing how data flow
to, from, and within an HMIS, as well as the various processes that transform the data into
meaningful and useful information. The main purpose of DFDs is to break down a system into
manageable levels of detail that can be visualized—first at a very general (context) level and
then gradually in greater detail, in a process termed leveling. For example, a walk-in clinic serv-
ing the medical needs of the community could review its overall services by sequencing the
steps a patient takes to access any or all of its services. The staff’s corresponding actions and
flow of information can then be listed and categorized to clarify the center’s operations. Thus, a
I I . H M I S A N A L Y S I S A N D D E V E L O P M E N T M E T H O D O L O G I E S 197
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large complex information process is first depicted as a context diagram. Each subprocess can
also be subdivided into successive levels of “detailed” DFDs, with corresponding subsystem de-
tails. This ability to expand and contract levels of details as needed, depending on the particular
requirements at that moment, is what makes a DFD such a valuable and flexible information
flow documentation technique.
In formalizing a DFD, the basic schema of inputs, processes, and outputs becomes essential.
To operationalize this relation for HMIS solutions, two different aspects—variables and
processes—can be utilized. Variables here refer to the input and output data. A variable must be
defined specifically before any formal analysis of the system can take place. Examples include
patients who are admitted daily and drugs that are prescribed weekly. In contrast, the processes
are defined by algorithmic relations or other computations and are the mechanisms for making
changes to the variables over time. In essence, a DFD is a network representation of a system,
which itself may exhibit varying degrees of automation. As shown in Figure 9.6, DFDs are con-
structed by using four basic symbols: arrows, rounded boxes, open boxes (rectangles with three
sides), and rectangular boxes.
Arrows represent the movement of data (with directions) between processes, data sources
(sinks), and data stores (files). Arrows are therefore used to denote data flows. Each data flow ar-
row should be labeled to indicate the type of data involved, for example, “admission notifica-
tion (phone)” and “chart package,” as shown in Figure 9.7.
In DFDs, rounded boxes represent the operational transformation of input data to output
data. Labeling of these processes typically involves verb clauses such as “Prepare patient chart
package” and “Review and implement physician’s orders for work requests,” as shown in the ex-
ample. Open boxes are used to represent data stores, that is, repositories of data used in the sys-
tem. Examples of data stores are files, databases, microfiches, and binders of paper reports. In
Figure 9.7, “patient charts” represent data stores.
Data sources or external entities, represented by rectangles, are the entities that lie outside
the system. Patients, laboratories, wards, customers, banks, and even employees may be re-
garded as external entities. These data sources (or sinks) help define the boundary of the system.
In our case, the emergency room, the pharmacy, and the dietetics department are examples of
data sources.
198 S Y S T E M D E V E L O P M E N T
Data Stores
“Process” that Transforms
the Data Flows
Data Source or
External Entity
Data Flows
or
or
FIGURE 9.6 Conventional Data Flow Diagram Symbols.
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To illustrate the use of DFDs, we examine an actual application in the health service field.
Figure 9.7 illustrates the flows of data involved in a surgical department at a university hospital.
As noted, DFDs are used to provide both overall and detailed views of an HMIS. What takes
place within a process box in one DFD can be “exploded” in greater detail by another DFD.
For instance, the process “Review and implement physician’s orders for work requests” in
Figure 9.7 is expanded in the DFD shown in Figure 9.8. In other words, these two figures are
“leveled” in terms of context and details. Figure 9.8 breaks down a process (from Figure 9.7)
into its subprocesses.
In summary, an accurate picture of various subsystem interactions involved in a typical sur-
gical procedure at a local hospital is given by these two figures, yet each has its own special func-
tions. The context DFD facilitates higher-level decision-making activities like strategic
planning, whereas the more detailed DFD is more suitable for aiding operational and tactical
decision making.
Additionally, each technique employed within an SDM may involve using one or more
tools. Examples of tools include database management systems (DBMS), query facility, data
dictionaries, fourth-generation languages (4GL), methodology workbenches, project manage-
ment tools, and expert systems. The phases and subphases of an SDM also help the developers
plan, manage, control, and evaluate their HMIS projects. As an example to illustrate SDM con-
cepts, imagine running a general business election meeting. To do this, you can follow an
I I . H M I S A N A L Y S I S A N D D E V E L O P M E N T M E T H O D O L O G I E S 199
Control
Center
Physician
Emergency
Room
Other
Hospitals
Housekeeping
Dietetics
Control
Center
Pharmacy
Prepare
Patient
Chart Package
Chart
Package
Physician’s
Orders
Admission
Notification
(Phone)
Patient
Transport
Request
Patient and
Documentation
Cleaned Rooms Info
Rooms to Be Cleaned Info
Check
Mark
Day Room and
Outpatient
Department
Review and
Implement
Physician’s
Orders for
Work Request
Inform Control
Center and
Pharmacy of
ADTs–Check
off ADT Notifi-
cation Slip
Patient
Chart
ADT Info
Slip
ADT Info
ADT Info
ADT Info
ADT = Admission Discharge Transfer
FIGURE 9.7 Surgical Interdepartmental Data Flows at a University Hospital.
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agenda (methodology) to guide the progress of the meeting. One technique used in making de-
cisions during the meeting may be “voting,” which might entail the use of a certain “tool,” such
as the use of a ballot card for each member to ensure equitable representation based on the prin-
ciple of “one member, one vote.”
Making use of a methodology lessens the risk of wasting resources during the course of sys-
tems analysis and development. Holloway3 notes that use of an SDM increases the productivity
200 S Y S T E M D E V E L O P M E N T
Dietetics
Department
Physician
Health
Records Health Records Info
Request for Health Records (Phone)
Chart
Package
Physician’s
Orders
Dietary Changes
Diet Changes
Medication Details
Lab Results
Respiratory Results
Operating Room
Chart Package
Physiotherapy
Assessment
Health Records
Information
Radiology Results
D
ie
t
O
rd
e
rs
H
e
a
lth
R
e
co
rd
s
O
rd
e
rs
P
h
a
rm
a
cy
O
rd
e
rs
P
h
ys
io
O
rd
e
rs
L
a
b
O
rd
e
rs
Radiology Orders
Respiratory Orders
O
p
e
ra
tin
g
R
o
o
m
O
rd
e
rs
Prepare
Patient
Chart Package
Inform
Dietetics of
Any Diet
Changes
Process
Phamacy
Orders
1.
Process
Lab
Orders
2.
Process
Radiology
Orders
3.
Process
Respiratory
Orders
4.
Make up
Operating
Room Chart
Package
Process
Physio
Orders
Obtain
Information
from Health
Records
Review
Physician’s
Orders for
Work Requests
Patient
Chart
FIGURE 9.8 The Process of “Review and Implement Physician’s Orders for Work
Request” in Detail.
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of the development staff by providing a standard framework (to avoid reinventing the wheel for
each HMIS project), the right tools (to assist successful completion of each stage of development
task), effective review procedures (to identify errors and inconsistencies early), and a productivity
aid (to reduce the amount of development documentation). A good SDM not only allows
healthcare management to review the progress of an HMIS project, but also permits the devel-
oper to accurately identify the user needs. Effective SDM make HMIS project planning easier by
allowing both designers and users to plan, correct, and re-plan the project as it progresses.
More generally, the benefits of employing well-tested SDM include user satisfaction, the
meeting of management needs, timely development, the avoidance of systems implementation
deficiencies, and the appropriate provision of maintenance and support activities. The method-
ologies described in this chapter can be evaluated on these criteria or standards.
III. SDLC-Based Methodologies
During the late 1970s, the Waterfall model was proposed as a formal approach to systems de-
velopment. It was a first-generation SDM, embodying the systems development life cycle
(SDLC) concept, a highly regarded concept among healthcare services systems analysts as a way
to provide much more control over SA and SD processes than was previously possible. This
model consists of six hierarchical steps.
1. Feasibility study.
2. Systems investigation.
3. Systems analysis (SA).
4. Systems design (SD).
5. Systems implementation (SI).
6. Systems maintenance, evaluation, and review.
Essentially, the SDLC dictates that whenever a systems review indicates that the current system
is no longer adequate, a new feasibility study is then initiated for the new system, as shown in
Figure 9.9.
The Waterfall model was a landmark achievement and included all the attributes expected of
a methodology—a philosophy (systemic approach that leads to reduced costs and gains in pro-
ductivity), a series of steps (from the feasibility study to system maintenance), a series of tech-
niques (e.g., ways to evaluate the costs and benefits solutions), and a series of tools. Although
this conventional methodology was a definite improvement, it was frequently criticized; for ex-
ample, it failed to meet the needs and expectations of end-users because they were not involved
in the systems analysis and development process. Incomplete systems and large application
backlogs resulted from the lack of emphasis on front-end planning. Ignoring the SA process
gave rise to inflexible and overly ambitious SD. Revisions were also not easily accommodated
during the SD process. This traditional methodology involved a heavy maintenance workload
and was laden with problems of documentation.
The next-generation SDM integrated basic techniques and tools to create more complete speci-
fications for the systems designer. Table 9.1 summarizes three of these methodologies: accurately
I I I . S D L C – B A S E D M E T H O D O L O G I E S 201
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defined systems (ADS), business information analysis and integration technique (BIAIT),
and business systems planning (BSP). Many of these early methodologies, which are classi-
fied as SDLC-based methodologies, focus on the planning involved in developing HMIS
that will meet the objectives of the health organization. They are outlined only briefly in
this discussion.
ADS comprise an integrated systems representation of systems inputs, outputs, processes,
procedures, and files.4 The analysis package also includes cross-referencing structures, which
202 S Y S T E M D E V E L O P M E N T
1. Feasibility
Study
2. Systems
Investigation
3. Systems
Analysis
4. Systems
Design
5. Systems
Implementation
6a. Systems
Maintenance
6b. Systems
Review
FIGURE 9.9 The Waterfall Model.
Table 9.1 Traditional Methodologies Based on SDLC (Second-Generation
Development Models)
Methods Major Concepts
Accurately defined systems (ADS) Represents system inputs, outputs, processes, procedures,
and files; also includes cross-referencing structures to
ensure consistencies.
Business information analysis and Creates a grid based on seven close-ended binary
integration technique (BIAIT) questions to aid analysts in systems planning and future
analysis.
Business systems planning (BSP) Similar to SDLC model except that it has a two-level design
stage theme and a new emphasis on strategic planning.
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ensure consistency across the sets of documents produced. Some aspects of ADS may now be
automated to assist in the development process.
BIAIT addresses top management requirements by using a set of seven close-ended binary
questions to generate a model that aids the analyst in determining an organization’s informa-
tion requirements.5 The resulting profile is a grid (matrix) of possible responses classifying exist-
ing “order-supplier” relations and identifying the data owners and users. This matrix is then
used for effective systems planning and future analysis.
A BSP addresses the requirements of top management by aligning systems planning with the
organization’s strategic plan. Three principles are observed in BSP: the need for an organiza-
tionwide perspective, top-down analysis but bottom-up design and implementation, and the
need for independence of the business plan from computer applications (i.e., changes in the
business plan may take place without effecting changes in the application systems).
Except for greater emphasis on strategic planning in the analysis stage and the subdivision of
the design stage into general and detailed design phases, the phases in these second-generation
SDM are fundamentally similar to the Waterfall model. The lack of attention to data structur-
ing in SDLC-based methodologies has slowed progress in software design and given rise to the
need for greater structural detailing in SDM. This brings a whole new perspective to systems
development and gives rise to structured programming techniques and structured methodolo-
gies, the third-generation SDM.
IV. Structured Methodologies
The structured methodologies represent a new level of SA and SD approaches that address mul-
tiple structural issues.6 Among the structured SDM that have earned wide acceptance and pop-
ularity are systems analysis and design technique (SADT), structured analysis and structured
designs (SA/SD), and structured systems analysis and design methodology (SSADM). Table 9.2
summarizes these models.
SADT was proprietary, but a public version has since been released.7,8 In addition to depict-
ing data flows between functions, SADT diagrams portray the control under which each func-
tion operates and the mechanisms responsible for the function implementation. This is
I V. S T R U C T U R E D M E T H O D O L O G I E S 203
Table 9.2 Structured Methodologies (Third-Generation Systems Development Models)
Methods Major Concepts
System analysis and design technique Both data and process oriented; provides analytical detail
(SADT) at all levels and is easy for nontechnical personnel to use.
Structured analysis/structured design Supports analysis and design stages; uses transformational
(SA/SD) and transactional analysis; generates hierarchical structure
charts for defining the various functions.
Structured system analysis and design Supports both analysis and design stages; used by the
methodology (SSADM) British government.
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analogous to information structural diagrams (ISD), an example of which is shown in Figure
9.10. Here, a block represents an object with attributes, and a line with arrows shows the rela-
tionship between objects and the inheritance properties. The ISD therefore outlines how the
objects within a class are related to each other. In Figure 9.10, ISD is used to show patient–
physician interactions in a hospital setting. Even more comprehensive than ISD, the SADT di-
agramming technique is supported by function descriptions and a complete data dictionary
package. A data dictionary is a catalog of data types that includes their names, structure, and us-
age. A function that reports on cross-references between the components of a data or business
model is provided. SADT therefore combines basic elements of traditional approaches with
structured methods. Olle et al.9 describe SADT as both a data-oriented and a process-oriented
methodology, while Colter10 claims that it provides analytical detail at both high and low levels
and is reasonably usable for nontechnical personnel. However, SADT has been criticized as fo-
cusing primarily on the SA stage; other competing structured methodologies such as SA/SD
and SSADM have since been developed to provide more comprehensive support for the differ-
ent SDLC stages.
204 S Y S T E M D E V E L O P M E N T
Hospital
number
name
area
Physician
number
name
address
phone
works for a
is in care of
serves calls for a
places a
is placed by a
test items
contains
is given to a
hires a
Test Order
order number
order date
delivery address
Test Items
test number
description
Patient
patient number
name
address
balance
condition
FIGURE 9.10 Example of an Information Structure Diagram.
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Unlike SADT, the SA/SD methodology clearly supports both the SA and SD stages.11 Two
techniques often used to transition from SA to SD include transformational analysis and trans-
actional analysis. Essentially, these are design strategies for deriving modular structures from
different parts of the DFD. It is claimed that continuous applications of these strategies will ul-
timately result in the generation of hierarchical structure charts12 for defining the various func-
tions to be performed by the separate modules. SA/SD is also closely related to certain other
structured methodologies, such as structured analysis, design, and implementation of informa-
tion systems (STRADIS); structured analysis and system specification (SASS); and Yourdon
and Constantine’s.13 Olle et al.14 summarize the various perspectives of these methodologies as
process oriented, data oriented, or behavior oriented.
SSADM is a powerful methodology sponsored by the British government and has been suc-
cessfully promoted as a standard in all central government computer projects in Great Britain
since 1983.15 SSADM extends soft system methodology (SSM), which used rich pictures. Like
SA/SD, SSADM strongly supports the SA and SD stages of the SDLC model. As noted in Tan,
the major stages in SSADM include analysis of the current system, specification of the required
system, user selection of service levels, detailed data design, detailed procedure design, and
physical design control.16
Despite their popularity, both SDLC-based and structured methodologies require the user
to know precisely what information will be required in the system weeks, months, or even
years in advance. Yet users often find it difficult to specify what they want; even if they can,
their wants often may not match their real needs. This is evidenced by the number of revi-
sions that systems go through after implementation before users get to tell all the information
they really need. Prototyping, a fourth-generation SDM, which is discussed next, deals with
this problem.
V. Prototyping
Over the past few decades, much controversy has been generated around prototyping. This
debate concerns how prototyping may best be applied to achieve the productivity gains in
software development claimed by vendors. Table 9.3 summarizes two opposing views of
prototyping emerging from this debate: the evolutionary approach versus the revolutionary
approach.17
V. P R O T O T Y P I N G 205
Table 9.3 Prototyping (Fourth-Generation System Development Models)
Methods Major Concepts
Revolutionary approach Applies programming tools and techniques in a new and revolutionary
way; argues against traditional methodological mind-sets.
Evolutionary approach Merges prototyping techniques and produces an evolution of traditional
and structured programming.
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Advocates of the “evolutionary” approach want to see prototype techniques incorporated
into the “proven” SDLC and structured methodologies, which in essence will produce a merging
of traditional (structured) and new (4GL) programming approaches. They argue that prototyp-
ing using 4GL does not encourage a structured approach, which may result in considerable dif-
ficulties in interfacing newly developed applications with existing SDLC-based applications.
They also argue that prototyping using 4GL provides only marginal benefits because this new
approach primarily affects the coding phase of the application development. Thus, it appears
reasonable to incorporate prototyping using 4GL into classical SDLC and structured models in
order to achieve fine-tuning of the development process in the same way that structured
methodologies were incorporated to fine-tune earlier SDLC-based approaches. McNurlin and
Sprague18 believe that many developers will likely prefer this “safer” approach when adopting
new methods of 4GL programming.
In contrast, advocates of “revolutionary” prototyping argue that the only way productiv-
ity gains in software development can be realized is by applying them in new and innovative
ways. Here, the rationale is that the traditional methodological mind-set (e.g., the emphasis
on precise specifications of application systems before they are built, the abstraction of a
static set of user requirements, and the concern about code details and exactness) prevents
the effective use and application of prototyping tools and techniques. Rather, these tools
and techniques are meant for people who can adapt to an environment supportive of a cre-
ative trial-and-error process—for example, nontraditional programmers who will use 4GL
to support interactive editing and updating until the “right” system is developed. The
framework of the applications is of major concern, and details should be ignored until later.
Earlier methodologies address the problem of analyzing and designing a system “right”;
however, there is also the problem of designing the “right system.” The revolutionary ap-
proach addresses this problem.
VI. Contemporary Models
The proliferation of HMIS development methodologies over the years has caused some con-
fusion as to which methodology is best. Many argue that no single approach is superior, but
each methodology has its strengths and weaknesses. Tools and techniques that are appropri-
ate for one set of circumstances may not be appropriate for others. Choosing an appropriate
methodology will therefore depend on the context, the organization, the users, and the ana-
lysts who are developing the HMIS. The best compromise is therefore to choose an ap-
proach in which the choice of techniques and tools can be made within a loose
methodological framework. This gave rise to contemporary models emphasizing a flexible
systems approach.
Contemporary models synthesize many earlier approaches and include the automation of
techniques and tools. The CASE method, which automates different parts of software or systems
development, is one such option. Multiview is another. Both of these approaches support flexi-
bility in SA and SD processes. Finally, a more recent development in SDM has been open-source
206 S Y S T E M D E V E L O P M E N T
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software (OSS), which appears to provide a promising approach to rapid and inexpensive
HMIS design and development for healthcare services organizations.
Computer-Assisted Software Engineering (CASE) Tools
CASE tools can assist with any or all aspects of the SA and SD processes. The CASE tool cus-
tomer usually wants a tool that will help organize, structure, and simplify the development
process. The goal is to develop better software more quickly. It has been shown that close to 80
percent of the problems in a given application system stem from SA and SD stages.19 Hence,
automating the SA and SD functions, rather than only those of physical development, should
make development effort more efficient and productive.
The CASE concept includes tools for building systems, platforms for integrating tools,
methods for developing applications, and techniques for managing the SA and SD processes.
CASE encourages an environment for interactive development and automation of core and
repetitive HMIS developmental tasks. It has been called “a philosophy of application develop-
ment which embraces a systems approach,”20 in which better connections between end-users
(health professionals) and HMIS developers are supported. Traditional approaches focus on
technical aspects of applications and the best way to solve a given problem; the CASE approach
looks at the broader health organizational context and searches to identify the right problems to
solve, as well as how to solve those problems.
In the past, CASE tools have provided some functions to automate different aspects of sys-
tems development, but not all of them, because one truly integrated tool set covers the entire
SDLC process. In this sense, an individual CASE tool automates one small, specific part of the
development process. There are several categories of tools. For example, diagramming tools pic-
torially depict systems specifications. Screen and report painters create systems specifications
and may be used for basic prototyping. Dictionaries are information management tools that fa-
cilitate storing, reporting, and querying of technical and project management information.
Specification tools detect incomplete, syntactically incorrect, and inconsistent system specifica-
tions. Code generators can generate executable codes from the pictorial system specifications.
Finally, documentation generators can produce technical and user documentation that is nec-
essary in using structured approaches. As summarized in Table 9.4, Brathwaite describes three
types of CASE tools, including SDM tools, systems development support (SDS) tools, and
programmer/project productivity (PP) tools.21
V I . C O N T E M P O R A R Y M O D E L S 207
Table 9.4 Three Types of CASE Tools
Tools Concepts
System development Combine to minimize effort and maximize coordination; enforce
methodology tools methodology rules and provide expertise to users.
System development Support systems development tools and techniques at any stage in the
support tools life cycle; do not necessarily enforce a methodology.
Programmer/project Provide support for software programmers and designers at the back
productivity tools end of the development life cycle.
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SDM tools combine to minimize effort and maximize coordination. These tools give sup-
port for an SDM at any (or all) of the stages of the SDLC process. They can include any of the
tools appropriate to the methodology being used, while enforcing methodological rules and
providing expertise to the users. SDS tools provide support for SA and SD techniques used at
any stages of the SDLC process, but they do not necessarily enforce a methodology. PP tools
provide support for programmers/designers of software mostly at the back end of the develop-
ment life cycle. Examples include project management and documentation tools. Project man-
agement is discussed later.
Alternatively, CASE tools may also be classified according to a different taxonomy: CASE
toolkits, workbenches, frameworks, and methodology companions. CASE toolkits are integrated
tools that automate only one part of the SDLC process. CASE workbenches provide integrated
tools to automate the entire SDLC. CASE tools that are integrated and linked with non-CASE
systems developmental tools are known as CASE frameworks. IBM’s application development/
cycle (AD/Cycle) is one proprietary example of an open platform or CASE framework within
which any CASE tool can participate. AD/Cycle can support HMIS application developers
with everything CASE has to offer to date and has the ability to adapt and incorporate future
technologies. CASE methodology companions sustain a specific methodology by automating the
entire SDLC process.
It can be difficult to decide which of the many CASE tools available is most appropriate
for a given situation or environment. Brathwaite22 proposes using a series of simple questions
such as:
● What are the future direction and functionality of the tools?
● Does the tool’s manufacturer have a philosophy of “open architecture”?
● Does the tool interface with other CASE tools being considered?
● Does the tool provide a detailed means of prototyping?
● Does the CASE design provide analysis support for design documentation?
● Does the tool enhance project management?
Although CASE has been in existence for many years, it is still poorly interfaced with users
(humans). For many years, technical aspects of SDM predominated over human aspects. Only
recently has there been a shift to a more humanistic perspective. This shift has resulted in the
emergence of new systems development methodologies, which are even more contemporary,
such as Multiview.
Multiview, which is discussed next, brings together what appear to be the most flexible (as
the name suggests) of alternative methodologies to create synergy in a merged methodology.
Multiview
Multiview is a comprehensive methodology and is described in considerable detail by Wood-
Harper et al.23 The authors saw it as a blending of the previous methodological approaches but
especially emphasized the influence of SSM and effective technical and human implementation
of computer-based systems (ETHICS),24 both of which strive to incorporate the human aspects
of systems development. Indeed, Multiview is based on the systems paradigm and emphasizes
208 S Y S T E M D E V E L O P M E N T
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the relationship between the organization and its environment. In this aspect, the ultimate ob-
jective of Multiview is to amalgamate the human and technical subsystems for the enhance-
ment of HMIS development as a whole.
Multiview is a nonprescriptive methodology that strives to be flexible. As a result, it contin-
ues to evolve as an SDM. Action research, in which knowledge gained from real applications in
the field is incorporated, continually refines the Multiview methodology. The methodology was
originally designed to aid development of IS/IT for small-business and small-scale HMIS proj-
ects, but it is no longer limited to this scope.25
The methodology contains five major steps:
1. Analysis of human activity.
2. Analysis of information (information modeling).
3. Analysis and design of sociotechnical aspects.
4. Design of human–computer interface.
5. Design of technical aspects.
Figure 9.11 illustrates the Multiview framework and the relationships among the five stages,
whereas Table 9.5 summarizes activities entailed within each of the five components of the
Multiview framework.
V I . C O N T E M P O R A R Y M O D E L S 209
Informational
Requirements
Organizational
Context
Technological
Context
User/Environmental
Context
Technical
Requirements
Human/Organizational
Requirements
Computer Task
Requirements
HMIS
1. Analysis of
Human Activity
2. Analysis of
Information
3. Analysis and Design of
Sociotechnical Aspects
4. Design of Human–
Computer Interface
5. Design of
Technical Aspects
FIGURE 9.11 A Layered Multiview Framework for HMIS Design and Development.
56918_CH09_Final_Tan 4/6/10 12:03 PM Page 209

Stage 1: Analysis of Human Activity
The objective of stage 1 is to identify the purpose and problem related to HMIS within the con-
text of the organization. This stage attempts to answer the question of how the HMIS is supposed
to further the aims of the organization. Rich pictures are frequently used to accomplish this stage
for connecting the analysts to the users’ view of the problem situation. Its ultimate objective is to
identify problems and avenues to relieve these problems via HMIS design and development.
The first stage of Multiview provides the information necessary to conceptualize the human
activities within the health service organization and helps to understand what HMIS can do for
the organization. It also provides the inputs for the subsequent stages.
Stage 2: Analysis of Information
The objective of stage 2 is to analyze the information on data flow and data relationships col-
lected in stage 1. This stage attempts to answer the question of what information processing
functions the HMIS is to perform. There are two primary steps: (1) the development of a func-
tional model and (2) the development of an entity model. The functional model begins by
identifying the main functions of the system. This model is then progressively broken down
into subsystems until they can no longer be subdivided (usually four to five levels). This may be
accomplished by using a DFD.
The development of an entity model serves a slightly different function. The entity model
defines all entities within the system. An entity is anything that is relevant to records keeping;
for example, in a bed allocation system, care providers, patients, and hospital beds are entities
perceived to be useful for generating information about the system. It is also important to de-
scribe the relationship between entities and any other relevant attributes for designing an effec-
tive HMIS database.
Stage 3: Analysis and Design of Sociotechnical Aspects
The objective of stage 3 is to produce a design that incorporates the needs of individual users, as
identified in the preceding stages, while balancing them with the technical objectives of the system.
210 S Y S T E M D E V E L O P M E N T
Table 9.5 The Stages of the Multiview Framework
Stage Major Concept
1. Analysis of human activity Identifies problems within organization and suggests HMIS
solutions to solve problems.
2. Analysis of information Uses information modeling techniques to analyze the problems of
stage 1.
3. Analysis and design of Balances the social objectives with the technical objectives, and
sociotechnical aspects ranks and chooses among these alternatives.
4. Design of human– Gathers user input to create the technical design of the HMIS.
computer interface
5. Design of technical aspects Formulates the technical specifications of the HMIS.
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The sociotechnical analysis follows a logical sequence of events that begins with the identifica-
tion of separate objectives for both the social and technical aspects and then goes on to develop
alternatives that blend the objectives. Alternatives are ranked according to their ability to meet
both sets of objectives, and a final selection is made of the best sociotechnical option. Unlike
other stages, this stage addresses the question of how the HMIS can be incorporated into the
working lives of the people in the organization.
Stage 4: Design of Human–Computer Interface
The objective of stage 4 is to define the technical aspects of the system, including, for example,
whether it will be command driven, have a main menu and submenus, or use a point-and-click
(mouse) interface. The users are major contributors to these decisions, but this stage relies heav-
ily on the systems analyst to guide the process and detail the final technical requirements.
Equally important is the ability to incorporate the multiplicity of hardware and software already
in existence within the overall HMIS design. Users should express their concerns to the analyst,
who must in turn find the most appropriate human–computer interface to address these con-
cerns. This stage attempts to answer the question of how individuals (i.e., users) can best relate
to the HMIS in terms of operating and using the system.
Stage 5: Design of Technical Components
The objective of stage 5 is to formulate the technical requirements of the system. At this point
in the development, the human needs should already be integrated into the HMIS design.
Therefore, this stage is only technical because the analyst concentrates on detailing the full spec-
ifications of the HMIS design for efficient operations. This stage attempts to answer the ques-
tion of what technical specifications are required for the HMIS to satisfy the needs identified in
the four preceding stages.
Altogether, the Multiview methodology is characterized by several underlying assumptions.
First, it provides a framework for resolving a problem. Multiview is not intended as a develop-
ment prescription; rather, it offers guidelines within which to assemble a set of tools and tech-
niques for developing an HMIS. More importantly, it is situation dependent, and the people
who employ Multiview must be knowledgeable about the methodology as well as the problem
situation, the users, and the organization. The practical approach produces knowledge for sub-
sequent applications within similar contexts (i.e., action research). Finally, it strives to integrate
the human and technical subsystems, whereas past practices tended to focus on just one domain
while ignoring the other.
Open-Source Software
The lack of standards and the absence of systems interoperability have continued to challenge
the successful deployment and adoption of new HMIS practices and emerging systems develop-
ment models in healthcare services organizations. Many applications have also failed to keep
pace with the changing and growing needs of new forms of consolidated or complemented
healthcare services organizations. Lately, considerable attention among healthcare practitioners
and researchers has been given to open-source software (OSS).
V I . C O N T E M P O R A R Y M O D E L S 211
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With OSS, any programmers can adopt, modify, use, and reconstruct the rich libraries of
source codes available from well-tested products (such as Massachusetts General’s COSTAR
and the Veterans Administration’s VISTA software) without incurring licensing fees, provided
the newly developed and modified software is also made available for others wanting to adopt
these derivative products just the same way as the original source codes were made freely avail-
able to them. With OSS, HMIS designers therefore have great opportunities to innovate and
help proliferate a range of key products that would resolve many of the major challenges facing
the healthcare system constraints by growing demands but limited IT resources. The
Regenstrief Institute, for example, has also contributed in the same manner by channeling all of
their future HMIS development efforts to the OSS model. Apparently, the OSS trend is here to
stay, encouraged by the rapidity to which many useful HMIS products can be generated
through a collaborative exchange among governmental agencies, university researchers, and
nonprofit and public institutions.
Key advantages of OSS adoption include, but are not limited to, promoting interoperability,
reducing overall HMIS costs, supporting efficiencies of software development processes, de-
creasing backlogs with complex HMIS product design and development, and increasing the
diffusion of OSS products. Additionally, these OSS products will also become more reliable
and secure, enabling standards and scalability as well as minimizing vendor lock-in.26 Specific
reasons for these advantages are that source codes can be examined and tested for security flaws
and/or bugs before it is applied; software developers’ time can be put to better use for attacking
new and interesting challenges, rather than focusing on previously solved problems; and main-
tenance of these source codes can now be openly contracted, even if the original software devel-
opers are no longer available because the bulk of the codes and software components used in
OSS products already exist.
Conversely, some other researchers have noted that it is the vendors who have mostly fueled
OSS adoption in hospitals and that it is the lack of in-house development and/or the “perceived
lack of security, quality, and accountability of OSS products” that are slowing down OSS adop-
tion.27(p. 16) Moreover, OSS applications are seen to also be more general-purpose oriented than
domain specific. Altogether, the contemporary models appear to emphasize integrating both the
technical and human aspects of systems development and trending toward end-user computing
(EUC), which is highlighted as we move to conclude this chapter.
VII. Conclusion
The need to balance the human and technical aspects in the evolution of SDM was fueled by
the predominance of the technical components and the subsequent user dissatisfaction. The
shift to a more humanistic perspective and the infiltration of the microcomputer at the worksite
have led to the emergence of EUC.28 EUC is not personal computing; personal computing is a
subcategory of EUC. An end-user is anyone who uses information generated by a computer.
Hence, EUC is any direct use of the computer by an individual whose primary interest is some-
thing other than just that use. Stated simply, EUC is the capability of users to have direct con-
trol of their own computing needs.
212 S Y S T E M D E V E L O P M E N T
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When EUC began, most projects were simple applications. Today, EUC spans the whole organ-
ization and has a significant effect on HMIS functioning of the entire healthcare services organiza-
tion. The literature on EUC agrees on two primary guidelines for the successful inclusion of
EUC within the organizational HMIS planning process:
1. HMIS policies and procedures for the use of system quality control. To maximize the benefits
of EUC, an organization should have strategies for promoting, managing, and control-
ling the evolution of EUC.29
2. HMIS support services. The development of end-user applications or OSS products does
not obviate the need for guidance and assistance with difficult and challenging prob-
lems, especially those of a technical nature.
In this light, HMIS service management and the development of an HMIS support center
in a healthcare services organization is almost a given in order to achieve successful HMIS
implementations.
For today’s health services organizations, it is crucial to incorporate an SDM as a key instru-
ment in the effective and efficient development of HMIS. These systems development method-
ologies have evolved from rigid, step-by-step formulas for success to contemporary models,
such as CASE, Multiview, and OSS model. In the end, the problem of choosing among alterna-
tive SDM approaches is one of recognizing the broader environmental, organizational, and
technological contexts in which the need for health information systems design and develop-
ment is embedded.
Notes
1. J. Rowley, The Basics of Systems Analysis and Design for Information Managers (London: Clive
Bingley, 1990).
2. D. Avison and G. Fitzgerald, Information Systems Development—Methodology, Techniques
and Tools (Boston: Blackwell Scientific Publications, 1988).
3. S. Holloway, Methodology Handbook for Information Managers (Aldershot, U.K.: Gower
Technical, 1989).
4. J. Cougar et al., Eds., Advanced System Development/Feasibility Techniques (New York: John
Wiley & Sons, 1982).
5. D. Burnstine, BIAIT: An Emerging Management Discipline (New York: BIAIT International,
1980). Read this reference for a detailed discussion of the seven questions used in the BIAIT
method.
6. M. Colter, “A Comparative Examination of Systems Analysis Techniques,” MIS Quarterly 8,
no. 1 (1984): 51–66.
7. D. Ross and K. Schoman, “Structured Analysis for Requirements Definition,” IEEE
Transactions on Software Engineering SE-3, no. 1 (1977): 6–15.
8. D. Ross, “Structured Analysis (SA): A Language for Communicating Ideas,” IEEE
Transactions on Software Engineering SE-3, no. 1 (1977): 16–34.
9. T. Olle et al., Information Systems Methodologies: A Framework for Understanding (Reading,
MA: Addison-Wesley, 1988).
10. Colter (1984).
11. T. DeMarco, Structured Analysis and System Specification (Englewood Cliffs, NJ: Prentice
Hall, 1979).
N O T E S 213
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12. C. Floyd, Information Systems Design Methodologies: Improving the Practice (Amsterdam:
North-Holland, 1986).
13. E. Yourdon and L. Constantine, Structured Design (Englewood Cliffs, NJ: Prentice Hall,
1979).
14. T. W. Olle et al., Eds., Information System Design Methodologies: A Comparative Review
(Amsterdam: North-Holland, 1982).
15. E. Downs et al., Structured Systems Analysis and Design Method: Application and Context
(Englewood Cliffs, NJ: Prentice Hall, 1988).
16. J. K. H. Tan, “Health Care Information Systems: An Organized Delivery System
Perspective.” In L. F. Wolper, Ed., Health Care Administration: Planning, Implementing, and
Managing Organized Delivery Systems, 3rd ed. (Gaithersburg, MD: Aspen Publishers, 1995).
17. J. K. H. Tan and J. Hanna, “Integrating Health Care: Knitting Patient Care with
Technology through Networking,” Health Care Management Review 19, no. 2 (1994):
72–80.
18. B. McNurlin and R. Sprague, Information Systems Management in Practice, 2nd ed.
(Englewood Cliffs, NJ: Prentice Hall, 1989).
19. L. Towner, CASE Concepts and Implementation (New York: McGraw-Hill, 1989): 2. This is a
technical book that is part of an IBM series.
20. S. Montgomery, AD/Cycle: IBM’s Framework for Application Development and CASE (New
York: IBM, 1991): 9.
21. K. Brathwaite, Applications Development Using CASE Tools (New York: Academic Press,
1990): 108.
22. Ibid.
23. A. Wood-Harper et al., Information Systems Definition: The Multiview Approach (Oxford,
U.K.: Blackwell Scientific Publications, 1985).
24. E. Mumford and M. Weir, Computer Systems in Work Design: The ETHICS Method (London:
Associated Business Press, 1979).
25. D. Avison and A. Wood-Harper, “Information Systems Development Research: An
Exploration of Ideas in Practice,” Computer Journal 34, no. 2 (1991): 98–112.
26. W. Raghupathi and W. Gao, “An Eclipse-Based Development Approach to Health
Information Technology,” International Journal of Electronic Healthcare, forthcoming.
27. G. Munoz-Carnejo, C. B. Seaman, and A. G. Koru, “An Empirical Investigation into the
Adoption of Open Source Software in Hospitals,” International Journal of Healthcare
Information Systems & Informatics 3, no. 3 (July–Sept 2008): 16–37.
28. R. Panko, End User Computing: Management, Applications and Technology (New York: John
Wiley & Sons, 1988).
29. G. B. Davis and M. H. Olson, Management Information Systems: Conceptual Foundations,
Structure and Development, 2nd ed. (New York: McGraw-Hill, 1985).
Chapter Questions
9–1. Define the following, and describe a health-related example that incorporates these
terms:
a. Methodology.
b. Technique.
c. Tool.
d. Phases and subphases.
9–2. Discuss the SDLC, and explain why this concept is critical for understanding HMIS
development.
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9–3. Provide a list of the second-, third-, and fourth-generation methodologies as well as the
flexible and integrated methodologies (i.e., contemporary models) discussed in the chap-
ter, and devise taxonomies to contrast and compare the main features, advantages, and
disadvantages of these alternative system development methodologies.
9–4. Why use CASE tools? Discuss how CASE supports various aspects of systems develop-
ment and the challenges with CASE applications.
9–5. List at least three tools or techniques that can be used within the Multiview framework to
aid in the development of an information system. Identify at what stage each tool/technique
is most appropriate, which inputs are required, and the intended outputs.
9–6. Define open-source software (OSS), and distinguish the advantages of an OSS approach
from other methods of software development. Describe an example of an OSS “success”
story in the healthcare services industry.
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Data Stewardship:
Foundation for Health Management
Information System Design,
Implementation, and Evaluation
Bryan Bennett
217
10
CHAPTER
Editor’s Note: In this chapter, the author takes on the perspective of data quality and data stew-
ardship and relates and integrates these two major concepts to bear on the significance of de-
signing, implementing, and evaluating the right health management information systems
(HMIS) for the right people at the right time. The organization of the chapter is straightfor-
ward. After the opening scenario, the introduction (Section I) touches on the need for high-
quality data in HMIS design, implementation, and evaluation. Next, the concepts of the
change continuums, namely, technology, people, and processes, are introduced (Section II). The
author perceives these three major HMIS components as the bases for transforming healthcare
services organizations and driving high-quality versus poor-quality HMIS design, implementa-
tion, and evaluation. Without a focus on data quality and an understanding of how these vari-
ous HMIS components need to be aligned, many challenges with HMIS design,
implementation, and evaluation remain unresolved. Section III then discusses how the four ma-
jor aspects of data stewardship—data quality, data management, data security, and business in-
telligence—can affect HMIS design, implementation, and evaluation. Section IV outlines the
HMIS implementation and post-implementation process, followed by a discussion that moves
back to the case scenario and applies it to achieve a broader understanding of the HMIS design,
implementation, and evaluation topic.
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S c e n a r i o : The Metropolitan Medical Group
Four internal medicine physicians formed the Metropolitan Medical Group as a general medi-
cine medical practice. The practice has grown from a single office to five offices in the local area
and now includes a gynecological practice, outsourced laboratory services, X-ray and mammog-
raphy screening, and nutrition counseling. See Figure 10.1 for a diagram depicting the current
network infrastructure of Metropolitan Medical Group.
The practice also owns several of the buildings in which it has offices and rents unused office
space to other noncompetitive medical practices. Each office has a separate network, with the
billing function as the only function networked among the offices.
Dr. Mark Jones, one of the practice founders, has been attending several seminars and read-
ing articles about the benefits of an integrated health management information system (HMIS)
that could network all five offices and the administrative function. Functions that could be in-
cluded in this integrated HMIS include a patient database, patient billing, provider billing, re-
ferral database, and treatment codes database.
218 DATA STEWARDSHIP
CHAPTER OUTLINE
Scenario: The Metropolitan Medical Group
I. Introduction
II. The Change Continuums
● Technology
● Processes
● People
III. Data Stewardship
● Data Quality Implications
● Data Management Implications
● Data Security Implications
● Business Intelligence Implications
IV. Implementation Process
● Step 1: Assessing the Available Resources
● Step 2: Assessing Data and Data Inventory
● Step 3: Profiling Data and Determining the Valid Values for Each Attribute
● Step 4: Reviewing Processes
● Step 5: Reviewing Personnel Responsibilities
● Post-Implementation Review
Notes
Chapter Questions
Mini-Case: The Metropolitan Medical Group (MMG)
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I . I n t r o d u c t i o n
When HMIS initiatives are based largely on inaccurate or poor-quality data, it is similar to
building a house on sand: the foundation will keep shifting until the house finally collapses.
Unlike many other industrial manufacturing and/or production services sectors, where the
ultimate products may just be satisfying growing demands for material goods or the accumula-
tion of capital assets by humankind, the importance of accurate, reliable, and timely data is
even more critical in healthcare services management because these services are much more con-
cerned with resulting outcomes that will significantly affect the health and well-being of hu-
mankind compared with all other production or service processes.
Accordingly, high-quality data may be considered as the number-one priority when design-
ing, implementing, and evaluating HMIS. There are many hidden risks associated with poor
data quality that could cost the healthcare services organization a sizable amount of money
and/or lost opportunities, including but not limited to the following:
● Poor customer service and strained physician–patient relations as patients requiring spe-
cial care are not being easily identified and/or served adequately by staff manning the
front offices.
● Revenue losses from utilizing incorrect billing codes or billing the incorrect health insur-
ance provider for the service and/or treatment performed by the respective caregiver.
I . INTRODUCTION 219
Office 1
Referral
Database
Treatment Codes
Database
Services
Database
Central Billing and
Administration
Server
Patient
Database and
Records
Office 3 Office 2
Office 5 Office 4
FIGURE 10.1 Current Network Diagram. (All offices have individual databases like
Office 1.)
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● Patchy partnership or referral information, which could eventually lead to misunder-
standing of the value of a relationship with partners and physician referrals made and
received.
● Lost opportunities from new and/or ongoing services and treatments that should have
been added or eliminated.
● Higher capital expenditures as equipment purchases are made before the revenue stream
is in place to support a reasonable return on investment.
Applying these various risks characterizations to the chapter-opening scenario, the following
episodes could be an outgrowth:
Mrs. Smith is a middle-aged woman who has been a patient of Dr.
Jones for the past 12 years. Two years ago, she developed an illness
that requires her to see the doctor every two months for follow-up
tests and monitoring. Mrs. Smith is normally a nice person, but she
hates waiting in drafty waiting rooms for a long time. When the
doctor is running late, she gets very cranky and takes it out on the
front desk staff. When she does see the doctor, she is not very coop-
erative, has her tests done, and leaves.
Additionally, the front desk clerk forgot to verify her insurance
provider information and missed the fact that she has recently
changed jobs and her corresponding insuring care providers. Dr.
Jones also recognized that he requested the same tests for Mrs.
Smith that were also requested for two other patients that morn-
ing and had referred her to the same specialist he referred some-
one else to yesterday. He began to wonder if Metropolitan
Medical Group should add these laboratory services and/or a new
specialty to their group practice.
Unbeknownst to Dr. Jones is the fact that one of the tests has
been requested several times a day by him and his practice partners,
while the other is requested only three times a month. Moreover, the
referral he made for Mrs. Smith was to a physician that a doctor at
one of their other facilities has had repeated complaints about (re-
garding that physician’s recurring tardiness).
I I . T h e C h a n g e C o n t i n u u m s
Besides the requirement for quality data, management of healthcare services organizations must
factor in several other considerations prior to making a decision to design, implement, and/or
evaluate HMIS.
In practice, many of these factors stem typically from one of three basic continuums: tech-
nology, processes, and people. We now illustrate where the applications of each of these contin-
uums are key to transforming the healthcare services organizations in achieving successful
HMIS design, implementation, and evaluation.
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Technology
In healthcare services organizations, patient data are the basis for many health administrative
and clinical decisions. The patient data warehouse that is built with the accumulated data it
contained should therefore be completely synchronized with the data in the services/treatment
database and the patient billing, health organization billing, referral, and finance databases. Not
only will this help the healthcare services organization better align corporate goals and objec-
tives with HMIS goals and objectives, but management of the healthcare services organization
will then have a greater appreciation of the impact an individual patient can and will have on
the entire operation.
Nonetheless, accurate billing is a challenge faced by many healthcare services organizations.
In spite of their attempts to maintain accurate patient and healthcare organization billing
records, the human factor can easily negate all of the technology and precautions that have been
implemented throughout the years. With the massive amount of data generated and collected
from each patient interaction on a day-to-day basis for populating their electronic medical
records and new changes to business processes and procedures over time, it is imperative that an
organization design, implement, and evaluate HMIS policies and procedures to keep the differ-
ent systems properly updated.
Moreover, there may also be redundant processes that could be eliminated to improve the ef-
ficiency of technology use and data processing. This brings us to the next level of consideration,
processes.
Processes
Without an accurate and repeatable entry and update process, the organization risks updat-
ing the wrong record, incorrectly updating the correct record, or not updating any record
at all.
A system has to be structured and defined to ensure that the flow of data is well organ-
ized and properly tracked so as to take into account all of the necessary follow-up actions in
order for a cycle of transaction updates to fully be completed. Thus, understanding the flow
of information across the different units of the healthcare services organization from the
point a patient enters the system to the point a patient is being served and/or discharged is
paramount. Any of these actions, or inactions, put the organization at risk both financially
and legally.
People
People are always a factor in any HMIS design, implementation, or evaluation attempt. Past
studies and experience have, for example, indicated that more than 75 percent of the bad-quality
data is likely caused by employee data-entry errors. This is a major obstacle that can only be
overcome through improved human resources training, reengineering of business processes,
and/or instituting technological checks and balances that will automatically reject or accept en-
tries, or entry types, based on predefined criteria.
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I I I . D a t a S t e w a r d s h i p
Having high-quality data is not just about the accuracy of each patient record. It also involves
controlling access to the data, managing data updates, and validating the data. Taken together,
this process is commonly referred to as data stewardship, which goes beyond just the physical
managing of the data. It is a process with the goal of delivering the right information, to the
right person, at the right time. By doing so, it will enable the healthcare services organization to
make the right decision.
Data stewardship has four major components, each of which must be addressed within the
context of HMIS design, implementation, and evaluation.
● Quality. This component is concerned with providing current, accurate, and consistent
information whenever and wherever the data are accessed.
● Management. This is the physical aspect of handling or managing data from the point the
data are collected to the point the data are used and archived. This component not only
includes the hardware and software technology, but also the processes, as well as both the
people and the machine involved in managing the data.
● Security. This component has to do with controlling access to the data to ensure that not
only are data available and retrievable to those who are supposed to access the data but
the release of data is also securely guarded from those who are not supposed to have access
to the data.
● Business Intelligence. This component has to do with utilizing the data to yield better,
more complete, and more usable information. This is what some have called “putting the
information back into information technology.”
We now take a closer look at each of these components and highlight their potential impacts on
HMIS design, implementation, and evaluation for healthcare services organizations.
Data Quality Implications
The implications for data quality on HMIS design, implementation, and evaluation are multi-
faceted. For the data to be accurate and consistent, rules for standardizing data, transforming it,
or mapping it to existing data are essential. This is often complicated by healthcare services or-
ganizations having and maintaining legacy systems that also have accommodating processes and
designs, which allow for errors or poor-quality data to be entered.
Indeed, many of these problems often begin at the initial data-entry stage. For example, pa-
tient information can be entered by a wide variety of individuals, including physicians, nurses,
and other clinicians such as laboratory assistants and pharmacists. As a result, without the adop-
tion of shared standards throughout the healthcare services industry or within the different
units of the healthcare services organization itself, a patient’s name can even be entered multiple
ways, multiple times—for instance, Robert Stevens, Robert Stephens, Rob Stephens, and Bob
Stevens may all be referring to the same person.
Having processes in place that allow for selecting the specific patient from a list of current
patients will help minimize future data-quality issues. Use of a master patient index (MPI) also
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helps differentiate and uniquely identify a particular patient from among all the other patients
whose data are also stored in the same database. In the current age of information technology
explosion, it appears safe to assume that most, if not all, healthcare services organizations
would already have some kind of standard adoption practices and a proper data verification
process in place.
Data quality can also be affected by the HMIS design and structure. This is most prevalent
when several systems or databases are permitted to be in use simultaneously. One system may
use a single address field for street address and unit number, while another may use multiple
fields for this same data. Additionally, one system may use standardized state abbreviations
from a drop-down menu, while another may allow free-flowing entry of two or three characters
for the state. Along this line of reasoning, the adoption of consistent and shared coding stan-
dards across all organizational units is one approach to reducing and eventually eliminating the
possible proliferation of data redundancies and data update anomalies throughout the different
databases and systems.
Data Management Implications
In the context of HMIS design, implementation, and evaluation, there are generally two types
of data that need to be managed: the master data and transactional data.
The master data are the most commonly used data across the organization, such as patient
data, provider data, and billing code data, among others. These are generally static data that are
extracted from the transactional data derived from various sources. These data are cleansed, de-
duced, standardized, matched, transformed, and loaded into the master data warehouse.
The transactional data are the actual invoices and receipts and are stored in a separate data
warehouse after similar standards are applied. These data are mainly created for analytical and
tactical purposes, whereas the master data are used for providing the “single version of the
truth” about the patients, providers, suppliers, and other relevant third parties.
Between these two data warehouses, a complete 360-degree enriched view of the patient or
provider is often possible and delivered.
Data Security Implications
Data security is probably the most important aspect of HMIS design, implementation, and
evaluation. No matter how complete the data may be, or how high their quality, if at the end of
the day, an employee of the healthcare services organization can walk out the door with the data
undetected, or if the wrong employee has access to the confidential and personal data of certain
patients and uses these data improperly, everything the organization has done to protect the pri-
vacy and preserve the integrity of the data will be opened for federal investigations under the
Health Insurance Portability and Accountability Act (HIPAA).
The primary concerns with data security, therefore, have to be releasing private and personal
health information and permitting authorized individuals to access only the data they need for
their normal business activities. Protecting against viruses, spyware, and intrusion attacks is also
becoming more of an issue lately.
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In terms of data security, another issue most organizations fail to truly and completely pre-
pare for is disaster recovery so as to ensure business continuity. Such a disaster need not come
from a terrorist attack—it can be as simple as the computer room being flooded after a harsh
storm. How can a practice open the office the next day? What happened to the patient records?
These are very real situations that need to be envisioned and procedures for recovery properly
documented before they occur. Backing up the system on a weekly basis and taking the tapes
home is not an acceptable solution. What happens to all the patient and provider billing trans-
actions that occurred since the system was backed up? Some sort of incremental daily backup
mechanism should be in place.
Fortunately, several organizations are now offering secure online backup services. These ser-
vices have several advantages, including:
● The backups can be programmed to occur automatically.
● The data are maintained in a secure off-site location.
● Downtime is shortened in the case where the data are needed, because there is no need for
time to be wasted in traveling to the off-site storage location to retrieve the backup tapes.
To ascertain that proper data security and business continuity protocols are in place, a yearly
security assessment of the HMIS privacy and security procedures and policies by a qualified
organization is highly recommended.
Business Intelligence Implications
An effective data stewardship function in the context of HMIS design, implementation, and
evaluation eventually leads to better business intelligence (BI) for the healthcare services organ-
ization. It will enable an organization to better monitor and track the state of the business by
providing the user with actionable information, which can lead to better and more intelligent
decisions.
Dr. Jones, in our chapter-opening scenario, would know how many of each test his practice
performs with the application of a good BI tool. In many cases, the information is just a click
away, making it very timely because it is typically accessed in real time or near real time.
Still, there has been some confusion about what BI is and what it can or cannot do, espe-
cially among healthcare management students. Some of the myths are addressed here:
● “It only involves technology!” BI involves changes in technology, processes, and people. No
amount of technology will fix human input errors without some corresponding checks
and balances. No amount of technology will fix an organization’s multiple definitions of
key elements such as treatment codes. These inconsistencies can and do cause many or-
ganizations to spend more time reconciling one report to another versus acting effectively
on the information.
● “I need a PhD to be able to use it!” With advancing technologies in this day and age, many
end-users are finding complex software easy to manipulate and use. Indeed, many off-the-
shelf BI tools currently available include functionality such as natural query language,
which allows the user to query the data in the form of almost English-like regular sentences
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versus a structured query statement. Some of the tools also include an iconic drag-and-drop
interface, which allows a user to just drag the elements needed for the query to a workspace.
● “It’s for customer data only!” BI is for creating information from any kind of data. Whether
the information is about customers, vendors, pharmaceuticals companies, financial
and/or legal compliance, or customer service, BI will help the entire enterprise because it
presents the single version of the truth about the entire operation.
● “It’s all about dashboards and pretty pictures!” The dashboard visually displays important
information on a single screen. It can quickly convey to the user actionable information
to monitor the state of the business, which is useful in consolidating relevant data from
several sources and presenting it visually for immediate absorption. They are great in
monitoring and communicating information, which helps in the organizational strategic
and high-level decision-making process.
● “It’s too costly!” Even though the software may be a bit costly, especially if the wrong-sized
solution is purchased for the situation, it is important to match the right tool to the size
of the organization, number of data elements, and business needs. The most important
investment should be up-front in determining the organization’s needs, data profiling,
and process mapping, as well as determining the initial state of business intelligence re-
quired. This process is unlikely to be as costly as the cost of missed opportunities, over-
purchased assets, or mismatched future treatment demand.
● “I can wait until later!” BI can be a competitive advantage for a healthcare services organiza-
tion if its concept and uses can be better understood. In other words, BI helps management
and employees alike to better understand their own organization and how it is currently be-
ing positioned to compete in the larger marketplace vis-à-vis their competitors. Surely, if BI
is properly utilized, it can help identify opportunities, such as cost savings, efficiencies, or
process changes that will improve the positioning of the healthcare services organization.
I V. I m p l e m e n t a t i o n P r o c e s s
At this point, we move the discussion to HMIS implementation, which involves five essential
steps: (1) assessing the available resources, (2) assessing data and data inventory, (3) profiling
data and determining the valid values for each attribute, (4) reviewing processes, and (5) re-
viewing personnel responsibilities.
Step 1: Assessing the Available Resources
The first step in HMIS implementation is to determine if the organization is prepared and has
the necessary internal resources and skill sets required to perform the work for a project of the
magnitude envisaged. If it is found that internal personnel resources are lacking, augment the
staff with some external personnel for the project. Referrals from trusted friends and colleagues
would be the safest route for identifying external consultants to hire.
In addition to the proper staffing levels and skills, other factors to be considered include the
technology that is needed—hardware and software—as well as additional staff training that
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may be needed once the HMIS are implemented. As previously discussed under the change
continuums, technology is only a part of the change process. The right people must be in place
to perform the right tasks.
Regardless of how the project is to be staffed, it is essential to set clear and attainable goals at
the outset. The key stakeholders should agree upon the desired outcomes, such as when the
product is expected to be completed. They also have to be very specific. For example, stake-
holders cannot just say “this is not what I wanted”; instead, they have to indicate which aspect
of the product is not acceptable, such as “the screen shots are not easy to read because of the
color used” or the “information regarding patient name should be longer to accommodate
someone having a 10-character surname.” To keep the project on track, a project plan with
identifiable milestones is recommended. The project should then be managed to the plan such
that at any given time, the status can quickly be assessed.
Step 2: Assessing Data and Data Inventory
Like any asset, the data need to be inventoried as the next step. The organization needs to de-
termine what data it has, what the sources of these data are (e.g., internal departments versus
external suppliers or vendors), who handles the data in the healthcare services organization, and
what the final state of these data will be after any manipulation.
A data inventory should be accompanied by a data assessment to determine where the weak-
nesses in the healthcare services organization are that could affect achieving the full potential
from the data.
Step 3: Profiling Data and Determining the Valid Values for
Each Attribute
One of the more difficult tasks to perform is profiling the data and correcting any inaccuracies.
The purpose is to eliminate duplicate records, standardize addresses, verify use of valid billing
codes, and more.
In this step, fields that must only contain numeric characters are identified and the data in
those fields verified, such as billing rates. Fields that are of a fixed length are also identified and
verified, such as state, billing code, or zip code. This step is difficult because there is only so much
that technology can do for you. Many times, it requires direct human intervention to make spe-
cific decisions on whether certain records should be combined, remain separate, or altered.
Step 4: Reviewing Processes
Each process that takes place in the healthcare services facility should be documented. This
serves not only as a good starting point for the healthcare services organization’s current state,
but also helps identify weaknesses that could affect the HMIS design, implementation, and
evaluation. Some of the processes that should be diagrammed include:
● Patient receiving and processing.
● Cash receipts.
● Cash disbursements, including accounts payable and payroll.
226 DATA STEWARDSHIP
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● Provider billing.
● Medical and office supplies inventory management.
Figure 10.2 provides a flowchart depicting an example of an accounts payable process for the
Metropolitan Medical Group as discussed in the chapter-opening scenario. Typically, flowcharts
IV. IMPLEMENTATION PROCESS 227
Invoice
Matched
Scheduled
for Payment
Invoice
Received by
Facilities
Checks
Created
(Tuesdays)
Entered into
System and Sent
to Accounting
Reviewed and
Approved by
Asst. Controller
Countersigned
by
CEO and COO
Reviewed
by CFO
Sent to
Vendor
Existing
Purchase
Requisition?
Over
$2,500?
Invoice Sent to
Responsible
Party
Returned to
Accounting
No
Yes
Expense
Report Created
and Approved
FIGURE 10.2 Metropolitan Medical Group Accounts Payable Process.
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are constructed so that the general direction is from left to right and top to bottom; otherwise,
a snakelike layout makes the flow of the process difficult to follow. The criteria for the decisions
indicated by the diamond-shaped symbol need to be shown in all instances, even by referring to
supporting documents, where the detailed criteria are spelled out. For instance, “Over $2,500”
could have been replaced by “Approval” decisions, which may have to be judged acceptable or
unacceptable for each instance as set out in a separate but detailed reference document.
Step 5: Reviewing Personnel Responsibilities
The last step is reviewing personnel responsibilities. With documented processes, the organiza-
tion can identify who is receiving, manipulating, or entering data into the system. These touch-
points are usually where most of the errors occur. Some areas to examine closely include
personnel who are critically involved in multiple processes. For a small practice, that may be
unavoidable; however, in larger practices, a clear separation of duties with oversight is possible.
Additionally, a person’s workflow may be constantly interrupted by his or her responsibili-
ties. This is a concern because of the loss of concentration that is involved, which can lead to in-
put errors. Once these risk areas are identified, changes in the tasks and/or staffing levels can be
made. Figure 10.3 provides a diagram of the new network configuration, detailing the different
228 DATA STEWARDSHIP
Referral
Database
Master Data
Warehouse
Patient
Records
Services
Database
Treatment
Codes
Billing
Database
Transactional Data
Warehouse
Office 3 Office 5
Office 4
Office 1 Office 2
FIGURE 10.3 New Network Diagram.
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databases providing sources of data that are linked to the two major data warehouses (master
data warehouse and transaction data warehouse) that could now be shared and accessible in an
integrated HMIS environment among the five offices. Such a network could then replace the
earlier network configuration shown in Figure 10.1.
Post-Implementation Review
Unfortunately, the work is not over even when the project is completed. Many of the same im-
plementation processes that were just completed must be performed on a regular basis to main-
tain the quality of the data and integrity of the system. Otherwise, the HMIS will be back to its
pre-implementation stage before too long.
These reviews should take place as post-implementation reviews a couple of times a year,
more intensely during the time period immediately following implementation. Some of these
reviews may also have to be performed after significant changes in billing codes, when new
physicians or services are added to the practice, or when new administrative staff are hired. The
only way to make sure the entire office is operating to its fullest is to make sure everyone is per-
forming their tasks as they should.
N o t e s
1. B. Bennett, “Data Centricity Leads to Customer Centricity,” DM News, June 26, 2006.
2. B. Bennett, “Six Myths about Business Intelligence,” Biz Insights, Fourth Quarter 2006.
3. “Seven Steps to Flawless Business Intelligence,” Cognos White Paper, September 2005.
4. R. Gonzales, “Dashboards Can Help You Align Operations with Business Goals,” BI Report,
September 2006.
5. W. Laurent, “The Case for Data Stewardship,” DM Review, February 2005.
C h a p t e r Q u e s t i o n s
10–1. Identify critical success factors for the system integration of the two practices discussed in
the MMG mini-case that follows.
10–2. What are some of the project management implications for the integration of the
practices?
10–3. List some the master data and transactional data elements that should be captured and
managed. What is the difference between these types of data elements?
10–4. How would you secure access to the data and what personnel implications do you fore-
see? How do you ensure that the proper records are updated in a timely manner?
10–5. The combined practice wants to implement wireless notepads for the physicians and staff
to make changes directly to a patient’s records. What data integrity and security issues do
you foresee?
10–6. What key performance indicators should the management of the practice monitor?
10–7. How can the information system be utilized to bring the receivables and payables bal-
ances and aging into sync?
10–8. What is the importance of having end-user involvement in the implementation of the
combined HMIS? How do you go about getting them engaged in the process?
10–9. After the system integration, how will you maintain data integrity throughout the
system?
CHAPTER QUESTIONS 229
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M i n i – C a s e : The Metropolitan Medical Group (MMG)
The Metropolitan Medical Group (MMG) merged with the Oak Grove Medical Group
(OGMG). The Oak Grove Medical Group has four offices and owns the medical office build-
ing where their imaging and radiology lab and physical therapy and diagnostic laboratory cen-
ters are located.
Although the size of staffs in both practices is about the same, OGMG has a very different fi-
nancial structure. Not only are their receivables a lot higher, but the aging of their receivables is
much older. This has caused them to miss payments to their vendors, resulting in a higher ac-
counts payable balance. Further analysis revealed that some of the doctors from remote offices
have referred patients for laboratory tests and to specialists outside the practice when these same
tests or specialists are available internally at other offices.
The room that houses the network servers is not climate controlled, secure, or backed up
off-site.
230 DATA STEWARDSHIP
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Managing Health Management
Information System Projects:
System Implementation and Information
Technology Services Management
Joseph Tan
231
11
CHAPTER
CHAPTER OUTLINE
Scenario: Louisiana Rural Health Information Exchange
I. Introduction
II. Critical Success Factors for Systems Implementation
● User Characteristics
● Systems Design Characteristics
● Organizational Characteristics
III. Strategic Planning and Management Issues
● Staffing Issues
● Organizational Project Management
● Reengineering Considerations
● End-User Involvement
● Vendor Involvement
● Additional Considerations
IV. Systems Implementation
● Pre-Implementation Preparation
● Proposal Evaluation and Selection
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S c e n a r i o : Louisiana Rural Health Information Exchange1
Louisiana Rural Health Information Exchange (LARHIX) is a pilot project championed by
Louisiana Senate President Don Hines and Representative Francis Thompson as a means of
servicing the state’s rural residents with better healthcare delivery, the need for which was made
even more evident following Hurricane Katrina. The initiative aims at demonstrating the possi-
bility of, and potential benefits of, exchanging patient information electronically between Delhi
Hospital, a small hospital in rural Delhi, Louisiana, and a major health sciences center such as
the Louisiana State University (LSU) Health Sciences Center in Shreveport. According to
Michael Carroll, Delhi Hospital’s CEO and administrator, success of the LARHIX project will
permit patients in underserved rural areas, especially those suffering from chronic ailments and
mental diseases, to be treated regularly by physicians situated in a major health sciences center.
“We treated hundreds of people . . . (at LSU) . . . that didn’t have any medical records at all af-
ter the hurricane,” McCarroll noted. “We were starting from scratch and at that point, we real-
ized that we needed portable, transferrable medical records in order to avoid this kind of
situation in the future.”
Interestingly, the project started with a physician at the LSU Health Sciences Center in
Shreveport showing how he could remotely instruct a Delhi clinician to perform a simulated,
but complete, evaluation of a surrogate patient—checking and collecting vital statistics on the pa-
tient. Flat-screen 50-inch monitors, advanced cameras, and other equipment were used in each
examination room located at the two sites to transmit a live telecast of the remote physician–
patient interactive session.
In addition to EHR solutions, LARHIX utilizes Fusion, a clinical portal from Carefx
(Scottsdale, Arizona) to aggregate patient information from the various sources. Brenna Guice,
Delhi Hospital’s information systems (IS) head, notes that real-time Delhi patient care to be
delivered by LSU physicians will begin only when laboratory IS, pharmacy IS, and radiology IS
are all implemented and integrated into the health information exchange (HIE) system. Other
vendors participating in the project included Chicago-based Initiate Systems, which offered the
software for the HIE’s enterprise master person index (MPI) numbers, and EHR vendor
232 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
● Physical Implementation
● Post-Implementation Upkeep
V. IT Services Management Concepts
VI. Conclusion
Notes
Chapter Questions
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Dairyland Healthcare Solutions—even though the requirements for LARHIX are independent
of any HIE and EHR vendor products, so long as these software solutions are interoperable
with those of other hospitals.
While Delhi was among the first of seven facilities to be piloted in the LARHIX initiative,
the longer-term vision is actually an extended project inclusive of all 44 members of the
Louisiana Rural Hospital Coalition following an approved five-year proposed funding.
According to a representative in charge of rolling out the five-year project: “Not all facilities will
need a brand new system, and some may only need an upgrade. The ultimate goal is, at the end
of that five-year period, to have everyone on a state-of-the-art system that can communicate
with the hospital in Shreveport.”
Imagine you have lost everything following Katrina, except for your identity papers, the pre-
scriptions you were taking just before Katrina, and a disk drive containing some of your per-
sonal health records, which you happened to have downloaded from your personal computer
with other important information prior to Katrina. How do you perceive something like the
LARHIX project could be of any help to you as you go about reconstructing your life and your
personal health information? Why might it be important to keep good records of your personal
health information, and what kind of a system would you trust your family physician to imple-
ment for the safekeeping of your personal health records?
I. Introduction
Systems implementation (SI) in healthcare services organizations entails a process whose success
is dependent on the fulfillment of a number of key activities. These may include strategic plan-
ning, a thorough preliminary systems analysis, broad and detailed systems design specifications,
user training and education, and hardware–software vendor selection. Health information sys-
tems analysts and professionals are among the best people overseeing such projects due to the
project management skills that are needed to ensure a well-managed project that is completed
on time and within budget.
In practice, certain critical factors can influence the success of health management informa-
tion systems (HMIS) implementation. For example, two broad areas have played key roles: (1) the
application of well-tested guidelines and standard protocols and (2) the enforcement of ethical
and legal concerns. Our focus here is on the HMIS implementation process; some of these fac-
tors and challenges are addressed in the chapter on standards, which is also accompanied by a
policy brief included in Part IV of this text. Figure 11.1 shows that once HMIS planning is
fine-tuned to address success factors for HMIS implementation on the one hand, and organiza-
tional planning and management considerations on the other, the actual steps including specific
activities for HMIS implementation can be specified, directed, monitored, and controlled by
project planning and management directives.
This chapter highlights the steps necessary to achieve HMIS implementation success within
a healthcare services organizational setting. It draws from previous parts of the book, in particu-
lar Chapters 8 through 10, to show how HMIS implementation is no more than an outgrowth
I . I N T R O D U C T I O N 233
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of strategic planning, systems development, and data stewardship. Even so, with the growing
complexity of HMIS applications and the increased investments placed on HMIS projects, all
(or most) healthcare services organizations today require that success be a prime criterion in any
HMIS implementation effort. We begin with a look at the critical success factors (CSFs) under-
scoring HMIS implementation.
II. Critical Success Factors for
Systems Implementation
Many critical factors have been found to affect the success of HMIS implementation in health-
care services organizations. Top management should focus undue attention on these CSFs be-
fore any major HMIS implementation exercise is undertaken. Generally, management should
position the organization for HMIS technology adoption. More particularly, management must
pay special attention to those factors that are likely barriers or constraints to the implementa-
tion process. Minor issues that do not warrant top management consideration can be delegated
to middle managers, who can oversee these issues or control them with inputs from top man-
agement on an ad hoc basis during the actual implementation. However, there may be times
when minor issues are truly major issues in disguise, and if so, these should then be flagged for
top management intervention.
In general, the CSFs for HMIS implementation fall into one of three broad categories: user
characteristics, systems design characteristics, and organizational characteristics. Figure 11.2
shows specific examples of factors from each of the three categories that contribute to successful
or unsuccessful HMIS implementation.
234 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
1. Implementation
Success Factors
2. Planning/Organization
Considerations
3. Guidelines and Standards
4. Legal and Ethical Issues
5. Implementation Steps
6. Implementation Activities
FIGURE 11.1 The Implementation Process.
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User Characteristics
Among the factors believed to influence HMIS success, user characteristics (i.e., the “people
problem”) are by far the most extensively studied.2,3 Examples include individual differences
such as learning style, cognitive behavior, user attitudes, and user expectations of what the
HMIS can do for them.
HMIS implementation often carries with it great expectations. It is not unusual, for in-
stance, to find that many end-users who have little or no direct involvement with system devel-
opment become disappointed with the final results of HMIS implementation because the
end-product does not match their expectations. Indeed, the argument that HMIS applications
are a “mirage” is familiar.4 Clearly, the HMIS solutions are not a panacea, in and of themselves,
but the HMIS, if developed properly, will certainly help managers make better choices as well
as speed up processes that were previously handled manually. Adopting an attitude that HMIS
applications are the ends and not the means sets up impossible goals and expectations that can
only result in unfulfilled expectations. Consequently, this is another reason to involve personnel
from across all organizational units in HMIS planning and implementation right from the be-
ginning. In so doing, we can generate positive attitudes and feelings among end-users, with re-
alistic expectations that can only enhance successful HMIS implementation. Further, the
adoption of a comprehensive user education program can serve to increase the likelihood of
meeting operational objectives sought in initial HMIS planning.
Among various personal reactions to HMIS, resistance is the most destructive behavior re-
lated to HMIS implementation. Dickson and Simmons noted five factors relating to resist-
ance.5 First, the greater operating efficiency of HMIS often implies a change in departmental or
divisional boundaries and a high potential to eliminate duplicating functions. This can create a
sense of fear of job loss among operational and clerical workers. Second, HMIS can affect the
informal organizational structure as much as the formal one by creating behavioral disturbances
such as doing away with informal interactions. Third, whether individuals will react favorably
to HMIS implementation depends on their overall personalities (e.g., younger, inexperienced
I I . C R I T I C A L S U C C E S S F A C T O R S F O R S Y S T E M S I M P L E M E N T A T I O N 235
Organization Structure
Hierarchy of Authority
Organization Culture
Top Management
Support
Commitment
Involvement
Hardware and Software
Performance
Learning
Decision-Making Support
Ease of Use
Graphical User Interface
Cognitive Style
Personality
Demographics
Situational Variables
Attitudes
Expectations
User
Characteristics
Systems Design
Characteristics
Organizational
Characteristics
Implementation Success
FIGURE 11.2 Characteristics of Implementation Success Factors.
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workers are less likely to resist than older, more experienced ones) and cultural background
(e.g., the replacement of interpersonal contacts with human–computer interface). Fourth, the
presence of peer pressure and previous experiences with HMIS implementation can also influ-
ence the organizational climate for success. Finally, the management techniques used to imple-
ment HMIS (e.g., the use of project planning and scheduling methodologies) directly affect
user perception of the system.
The recognition of potential dysfunctional user behaviors is a first step toward successful
HMIS implementation. User orientation, training, education, and participation are ways to
minimize the behavioral problems that may follow the introduction of HMIS in healthcare
services organizations.
Systems Design Characteristics
Aside from user characteristics, systems design characteristics also play an important role in de-
termining the eventual HMIS acceptability. Examples here include hardware–software per-
formance, the characteristics of information and decision-making support provided to the user,
and systems interface characteristics, such as the availability or incorporation of easy-to-use and
easy-to-learn features into the HMIS.
The essential ingredients of any computer-based HMIS are the hardware, software,
firmware, and middleware. Common sense dictates that configuration of wares be applicable
to the organizational performance and strategies. For an organization’s information needs to
be satisfied from a systems design perspective, they need to be articulated and documented
during the early planning stages and acted upon using tailored implementation techniques.
Further, the reliability of hardware, software, and middleware is critical to HMIS perform-
ance. It is important to acknowledge, for example, that most information needs demand a cer-
tain amount of flexibility, notwithstanding the needs for completeness, accuracy, validity,
reliability, frequency, and currency (timeliness) of information to be supplied to the user.6
Flexibility necessitates an ability to cope with growth and variability in an ever-changing
healthcare services environment.
Systems interface is a subject that could fill an entire chapter of its own and has been briefly
discussed earlier in one of the Technology Briefs. To relate this topic to HMIS implementation,
examples are provided. First, HMIS should be designed in the way end-users such as nurses
organize themselves. For example, many nurses organize their thoughts about patients by us-
ing patient room numbers as a constant frame of reference.7 Inevitably, when a dietetics sys-
tem in a hospital uses the alphabet as an organizing scheme, the systems interface becomes
inadequate to support the nurses in performing their routines. This has happened in real life,
where a group of nurses and clerks who were exposed to the system complained about the time
it took to enter diet orders and changes into the HMIS. They became less efficient and in-
creasingly anxious, frustrated, and dissatisfied with the system. The result was to abandon the
system unless software would be redesigned to follow through with the patient room number
organizing scheme.
Second, HMIS interface design should incorporate favorable factors, such as the proper use
of graphics and color.8 One patient registration system used bright primary colors that were
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“hard on the eyes” and thus distracting during prolonged use. The system also produced graph-
ics that were difficult to read and interpret. The system was almost abandoned until it was dis-
covered that both the graphics and colors were changeable.
Third, the design of HMIS should consider the users’ previous knowledge. For instance, in a
long-term care facility, nurses who, for years, had used large desktop screens to register new pa-
tient information have found the smaller screen-size bedside monitoring and tracking system
extremely cumbersome for entering this information. In that case, the incorporation of a coded
identification bracelet placed around the wrists of the patients along with an automated remote
scanning device resolved the problem. Nurses quickly embraced the new bedside tracking sys-
tem in place of the old desktop system.
These cases illustrate the significance of human–computer interface in HMIS implementa-
tion success.
Organizational Characteristics
Organizational characteristics can also influence HMIS implementation success. Examples of
variables include organizational structure and power, organizational culture, and other manage-
rial factors, such as top management support, commitment, and involvement.
One of the key areas affecting implementation success is the influence of top management.
Exercising sound project control, resolving issues in a timely manner, allocating resources accu-
rately, and avoiding short-lived changes in critical areas are all serious management considera-
tions.9 The strategic alignment of corporate HMIS planning and the application of proper
project planning and scheduling can together serve to prevent costly delays in HMIS imple-
mentation. Such an alignment also ensures that the organization is not forced into a reactive as
opposed to a proactive role.10 Here, a proactive strategy anticipates industry trends and instills
innovative processes for competitive advantages and operational efficiencies, whereas a reactive
strategy takes into account current industry trends and chooses to adopt a known process devel-
oped elsewhere.
Key strategies to achieve successful HMIS implementation include a realistic situational as-
sessment, accurate identification of necessary resources, and development of an action plan.11 It
is therefore critical to encourage top management involvement in many areas, and there should
be a CIO or another knowledgeable senior member of the management team taking charge of
HMIS implementation.
HMIS implementation in healthcare services organizations is no different than in busi-
ness organizations. The degree of commitment and involvement of all end-users and espe-
cially the support, commitment, and involvement of top management affect long-term
success. All users need to invest their energy in HMIS planning and implementation in or-
der to create a system that is going to be accepted and adopted. Top managers in particular
must provide support and act as role models to their subordinates. Potential heavy users,
such as middle managers, physicians, nurses, and support staff, also need to be committed
and involved in the HMIS implementation process in order to improve the likelihood of its
long-term success.12,13 In short, HMIS success requires inputs that come directly from all
users, not just systems professionals.
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III. Strategic Planning and Management Issues
Our analysis of CSFs for HMIS implementation reveals a number of critical considerations in-
volved in HMIS planning and management. Often, careful attention to these details in the
early planning stages can facilitate the creation of strategies that will enhance HMIS success.
Figure 11.3 shows the various types of planning and management issues that will influence
the process and the strategy chosen to optimize HMIS implementation for healthcare services
organizations. The key issues to be addressed are staffing issues, organizational project manage-
ment, reengineering considerations, end-user involvement, and vendor involvement, as well as
other additional considerations.
Staffing Issues
HMIS staffing issues can be addressed by first simply asking the question: “Do we have the ad-
equate human resources and HMIS expertise to carry out a successful implementation project?”
The answer to this question was articulated in previous discussions, which essentially advocate
the use of an internal audit of the current HMIS staffing situation.
For new organizations, HMIS development is relatively straightforward; that is, all individu-
als with the needed skills are simply to be recruited externally. However, once beyond that, it is
a more complicated process. It becomes necessary to identify potential knowledge gaps in
HMIS staff that need to be filled. The following are more specific questions that need to be
answered.
● Are the current staff members already working at capacity?
● What level of knowledge and skills does the current staff have, and how does this affect
recruitment and training?
● How many new staff members will be needed, and when will they be needed?
The answers to these questions enable the planning of staffing strategies to be layered into an
HMIS implementation plan. It is critical that these considerations be addressed so that arrange-
ments can be made well in advance to hire the necessary staff or to plan for the needed training.
238 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
Project Management
Experience
User Knowledge End-User
Involvement
Vendor Roles
Reengineering
Considerations
User Training
Requirements
HMIS Staff
HMIS Implementation
Strategy
FIGURE 11.3 Planning and Management Issues.
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For instance, carrying through with an implementation schedule requires data on the availabil-
ity of staff members with HMIS expertise for certain periods. Conversely, the training of staff
members and the scheduling of recruitment depends on the overall implementation schedule.
Clearly, a lack of needed expertise among existing personnel can slow the process of HMIS im-
plementation, often leading to increased pressure and frustration among the existing staff mem-
bers and possibly resulting in missed opportunities associated with on-time and “seamless”
project completion. A projection of future staffing needs is also warranted if the project has a
long-term focus.
Although the staffing issues can be resolved at the systems implementation stage, manage-
ment of healthcare services organizations must establish clear reward policies to encourage the
retention of experienced staff members. Gray documented that the demand for new systems
personnel of all types grows at a rate of 15 percent per year, whereas the turnover of information
systems personnel averages about 20 percent per year.14 Reducing this high turnover rate can
immediately improve productivity and reduce operation costs.
To reward good technical HMIS personnel, health organizations can use a dual career path or
a professional stage model.15–18 In the former, a pathway of promotions in the technical level is
created to parallel the managerial path in rank and salary. For example, a technical staff member
would be promoted from programmer to systems analyst, then to systems specialist, and finally
to senior analyst and technical specialist. In the latter, the path for promotions can be from ap-
prentice to colleague to mentor to project sponsor.19 Both models provide significant incentives
for the return of experienced staff members past the initial stage of HMIS implementation,
thereby sowing the seed for long-term success.
After examining various staffing issues at the system level, an important issue at the indi-
vidual level—user knowledge—must be briefly examined. HMIS implementation in health
organizations requires an assessment of in-house systems and expert knowledge. This assess-
ment should take into account future user needs. Together with staffing needs assessments,
management can ascertain the educational requirements of the organization. By doing so,
the organization also avoids heavily diverting its resources to educating and training users
during and after the online implementation. Thus, educational planning—including gen-
eral training for managers, technical training for HMIS professionals, and specific end-user
training to satisfy the needs of various user groups—helps ensure a smooth and timely
HMIS implementation.20
Numerous difficulties, both expected and unexpected, associated with the initial three
months of online operations can be prevented through proper orientation and HMIS staffing
and training. In certain cases, this responsibility can even be off-loaded to software vendors.
This approach may be particularly desirable for “turnkey” systems prepackaged and serviced by
a single vendor. However, the costs in the long run can be significant.
Alternatively, if the organizational structure is capable of supporting this role with an inter-
nal training department and knowledgeable personnel, it may be more cost-effective to provide
the staff education in-house. If in-house training is to be conducted, the training personnel
should be able to distinguish between two levels of training—holistic training and technical
training. Holistic (or ideological) training here refers to training modules focused on the systems,
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and not the operational, perspective. Systems goals and benefits, systems constraints and limita-
tions, organizational effects, and functional implications are sample topics for this level of train-
ing. In short, holistic training intends to bring the entire system into view and to analyze its
relationship with its surrounding elements (the macro view). This kind of training should be di-
rected primarily to managerial staff, who need to view HMIS in its entirety, and secondarily to
operational staff, who are more concerned with the day-to-day operations (the micro view).
Technical (or operational) training is aimed at familiarizing the appropriate personnel with
the operational aspects of HMIS that pertain to their tasks. This level of training may encapsu-
late such topics as completing forms, report abstracting, data-coding standards, data validation,
standard data input or update procedures, and introduction of routine tasks. This kind of train-
ing is directed primarily to technical or operational staff, who are concerned with daily use of
HMIS, and secondarily to managerial staff, who also need to know the procedures of their
subordinates.
In any event, it should be recognized that the use of a team approach in-house does have the
added benefit of increasing user acceptance and reducing resistance in the long run. Regardless
of how a healthcare services organization is planning to conduct the needed staff training, the
quality of the training should be stressed, because well-managed training for HMIS operations
has the potential to reduce anxiety and potential user resistance and to promote an organiza-
tional climate toward HMIS implementation success.
Organizational Project Management
The style of project management is extremely dependent on the organizational culture and on
the depth of experienced personnel who are available to manage such a process. In many in-
stances, experienced project managers with both technical and application knowledge are diffi-
cult to find. Consequently, outside consultants are often used. However, time is needed to
educate these consultants on specific situational and historical characteristics, both internally
and externally, that can at times be significant enough to make outside consultation counter-
productive. As within the healthcare services organization, there is often a trade-off. Although
team or committee management of the implementation process provides the benefits of inter-
nal knowledge, user acceptance, and overall effectiveness of implementation,21 the need for a
fresh look from an external, unbiased perspective should not be overlooked.
Although it is difficult to make specific recommendations with respect to HMIS implemen-
tation, certain techniques are useful in project management. Here, a brief examination is given
to some of the commonly used techniques for project scheduling and program coding. To en-
sure that the system implementation is completed by a certain date, a detailed and realistic
schedule needs to be prepared and followed at the initial and subsequent planning stages. At the
same time, the schedule should be flexible enough to accommodate some unexpected delays.
Moreover, a detailed timetable for implementation is often essential to inspire management
confidence in the installation plan. Here, two techniques to assist project scheduling are dis-
cussed—the critical path method (CPM) and Gantt charts.
When using the CPM, the duration of all the tasks involved and the sequence (indicated by
arrows) of all tasks need to be compiled in a network representation, as shown in Figure 11.4.
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In the figure, the numbers in circles represent different stages of implementation, the letters
represent different tasks involved, and the numbers beside the letters represent the number of
days needed to complete the task.
After translating the implementation schedule into a network representation, the critical
path of the network can then be determined. The critical path is the sequence of activities that
will take the longest period to complete. The time needed to complete all the activities on this
critical path is the minimum period required to complete the entire project. Figure 11.5 lists all
the possible paths (activities in sequence) and the time needed to complete each. In this exam-
ple, the path through activities A-B-F-J-K is the longest, requiring 15 days for completion. This
is therefore the critical path of the project. In other words, the project cannot be completed in
less than 15 days unless certain tasks are started early or shortened.
Another way of representing the details in Figures 11.4 and 11.5 is to use Gantt charts,
which represent project tasks with bar charts. They are often easier to construct and under-
stand than CPM but may capture and generate less information. Figure 11.6 shows a Gantt
chart for the same project described. It is worth mentioning that the exact start and end dates of
certain noncritical tasks can be moved without causing delay to the overall schedule. For instance,
I I I . S T R A T E G I C P L A N N I N G A N D M A N A G E M E N T I S S U E S 241
4
7 3
5
2 6
8
9 10
K2 J2 G2 G5
D2
A3
B4 E1 I1
F4
H4 L3
Activity Path
Critical Activity Path
1
FIGURE 11.4 A System Implementation Schedule in a Network Representation for
the Critical Path Determination.
Note: Letter–numbered pairs represent the name of the path and the amount of time (in
days) it takes to travel it. For example, “A3” indicates that path A takes 3 days.
A
A
A
A
B
B
C
D
E
F
G
H
I
J
J
L
K
K
K
11
15
14
12
Days Required Path
FIGURE 11.5 Possible Paths through the Critical Path Network in Figure 11.4.
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if every other task in Figure 11.5 commences and finishes on time, task L can be postponed for
a day without delaying the final completion date.
Program coding, or simply programming, refers to the process of writing instructions that the
computer system can execute directly. This is usually a very labor-intensive task, and as a result,
coordination among programmers needs to be emphasized. Here, two useful coordination tech-
niques—data dictionaries and walkthroughs—are introduced.
Data dictionaries, containing definitions and proper uses of entities that are in alphabetical
order, can be computerized or manually compiled. Data dictionaries should also have the iden-
tities of database programs used; the names of all the data fields found in the database, along
with the names of the programmers that use them; and descriptions of the data and the person-
nel responsible for the data. Just like regular dictionaries, data dictionaries are useful in program
coding coordination, because they allow the names of data elements to be cross-referenced, help
programmers locate blocks of codes that are reusable in new applications rapidly, and ensure
that all codes are consistent with the overall application.
Another very useful tool in program coding is conducting a walkthrough (or review). A walk-
through can take place at various stages of program design and development. It is essentially
peer evaluation and testing of a programmer’s work, with the primary objective of soliciting
constructive feedback. In other words, walkthroughs act as control points in programming,
making sure that what is programmed is in line with specific goals and objectives and other op-
erational constraints. It is not in any way directed personally at the programmer.
242 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
A
B
C
D
E
F
G
H
I
J
K
L
0 5
Days
10 15
FIGURE 11.6 A Gannt Chart Representation of the System Implementation Schedule
in Figure 11.4.
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Reengineering Considerations
Often when new HMIS applications are implemented, work flows and processes may also
change drastically because of the inherent differences of daily operations with the computerization.
Even without the changes as a result of computerization, users may still find changes to daily
operations as their tasks at work gradually change from time to time. Whereas adequate train-
ing initially helps better prepare end-users for some of these changes, end-user involvement in
the reengineering process can greatly enhance satisfaction with computerization. This again re-
lates to the importance of the “people aspect” in HMIS.
To gain maximum benefit from HMIS implementation, all operations must be redesigned
periodically to accommodate environmental changes and maximize operational benefits, while
still maintaining the necessary controls in the process. If the delivery systems are not reengi-
neered to meet new organizational needs, the increase in efficiency brought about by the HMIS
implementation may be offset by the unmet demands in the environment.
Often, it is inefficient simply to automate old systems processes, because computerization
lends itself to a new workflow, thus demanding extra personnel and resources. A good example
of this is the attempt to automate patient charts to mimic paper-based systems currently in
place. This document is primarily a legal document on paper, but once captured in HMIS, it
can become a much more versatile tool. Very often, healthcare services organizations are reluc-
tant to rely totally on HMIS and therefore opt to keep the paper copy for backup. Therefore,
health professionals are required to continue filling out these forms manually, which essentially
is a duplication of effort, thus creating an unnecessary workload.
To decide how HMIS operations (or parts thereof ) are to be reengineered, it is useful to so-
licit inputs from the staff already acquainted with existing procedures. Team or committee fo-
rums on system-supported group decision settings are excellent means to decide what should or
should not be modified. This leads us to the topic of end-user involvement.
End-User Involvement
In healthcare services organizations, HMIS planning and development are recognized to be
slow compared with the rapid pace of change in the business world. However, lessons learned in
the business sector have been found especially useful; one such lesson is the empowerment of
end-users through their involvement in systems planning and design.
HMIS planning and development require active (not passive) end-user involvement
throughout the entire process in order for implementation to be truly successful. It has been
recognized that unless HMIS staff, physicians, and nurses are involved in systems planning
and ongoing evaluation, HMIS success will be short-lived.22 In fact, in the healthcare
services system, which consists of a much broader group of individuals representing many
technical and professional groups, it seems wise to extend this to users of all the different
modules or areas of HMIS. For this to materialize, adequate time and resources need to
be allotted, and critical committees and internal and external liaisons have to be established
such that all aspects of HMIS can be optimized while generating organizationwide user
acceptance.
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Specific considerations with respect to acceptance of end-users include the effect of the
change on the need satisfaction of the affected personnel, the position of those affected, and the
leadership style of those managing the change. Furthermore, direct involvement of application
program vendors, which is the next topic of discussion, is often of critical importance.
Vendor Involvement
The traditional view that vendors specialize only in sales of equipment or computer software is
fast giving way to the realities of the vendors of today. Although the primary function of com-
puter systems vendors is and will continue to be the actual equipment sale, there is rapidly in-
creasing emphasis on the sale of “services” beyond the realm of equipment maintenance. In
other words, vendors can be—and in fact very often are—involved in some degree of systems
development and implementation, including HMIS implementation. IBM is a prime example
of such a vendor.
The options with respect to the roles of vendors vary between two extremes. Here the term
vendor usually refers only to software vendors because they dictate much of the implementa-
tion. However, the hardware vendor is also important when considering outsourcing HMIS
services. On the one hand, there can be complete turnkey implementation by the software ven-
dor (turnkey systems are prepackaged, ready-to-go application programs that are often products
supplied by a single vendor). On the other hand, there is the option of exercising complete in-
house organizational control. Between these extremes lies the most used option, a blend of ven-
dor and organizational responsibilities, with each performing in areas of specialty to tailor the
process to the needs of the HMIS implementation.
Depending on the strengths of the organization and the vendor, areas of responsibility that
can be shared include analyst support, project management, user training, hardware and facili-
ties planning, software modification, interface development, conversion assistance, procedure
development, and implementation audits. The means through which vendors can be involved
vary from one organization to another. In some cases, a single vendor acts as the sole handling
agent for all technical problems and even some user training; in others, several vendors may
have to cooperate to deal with systems problems.
Nevertheless, there are generally six steps through which a healthcare services organization
can solicit and apply useful inputs from vendors.
1. Initial conceptualization.
2. Strategic planning.
3. Feasibility study.
4. Request for proposals.
5. Proposal evaluation and selection.
6. Physical implementation.
These, as well as post-implementation upkeep issues, are outlined later in the chapter.
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Additional Considerations
A few other considerations that are not often described in the literature can help ensure smooth
HMIS implementation. The first of these is related to the concept of quality. Several method-
ologies can be adapted to address quality in the healthcare services delivery industry. The methodol-
ogy continuum consists of quality control, quality assurance, continuous quality improvement,
total quality management, Six Sigma, and reengineering. Depending on the organization’s
information status, implementation may be facilitated by the inclusion of any one of these
principles.
Another consideration that needs to be taken into account pertains to the manner in which
healthcare services organizations have been changing the way they measure performance. Many
organizations are progressing from an efficiency and throughput approach to an effectiveness
and outcome measurement approach. Experiencing the economic pressure perceived by many
businesses, healthcare services organizations are also increasingly being pressured to link the uti-
lization of various healthcare resources to their level of outcome and demand and, in many
cases, to justify the utilization with the outcome produced.
Although almost all organizations are run differently with respect to performance measure-
ments, management styles can directly affect HMIS implementation. For example, the struc-
ture of management within organizations—such as departmental organization, program
management, matrix design, hierarchical design, and circular design—can influence HMIS im-
plementation. In keeping with the changing priorities in the healthcare services delivery system,
there has been a demonstrated need for more highly integrated and interoperable HMIS.23
Thus, it is critical to keep these considerations in mind when making decisions regarding any
HMIS implementation project.
It is also crucial to keep in mind that leadership roles exhibited by the CEO and the CIO
can affect the success of HMIS implementation. Information technology, therefore, needs to be
integrated from the cultural perspective of an organization. For this to occur, both the CEO
and CIO must leverage HMIS in achieving the goals and objectives of the organization and
communicate this effectively within the organization.
In particular, Austin has called attention to several areas that should be addressed when
monitoring and evaluating HMIS implementation: productivity, user utility, value chain, com-
petitive performance, business alignment, investment targeting, and management vision.24
Although it is recognized that these criteria suit profit-oriented organizations, several seem
equally applicable to nonprofit healthcare services organizations.
IV. Systems Implementation
Regardless of the strategies utilized in HMIS implementation, there are several steps most
healthcare services organizations should take in order to optimize internal and external
processes in a manner that ensures an efficient and effective outcome. In general, these steps fall
into two broad stages: pre-implementation preparation and post-implementation upkeep, each
of which is now discussed in greater detail.
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Pre-Implementation Preparation
The stage of pre-implementation preparation begins with the initial HMIS conceptualization
and ends with the initial online operation of the system. The major steps included are initial
conceptualization, strategic planning, feasibility study, request for proposal, proposal evaluation
and selection, and physical implementation.
Initial conceptualization can take place in a variety of ways. For instance, the CEO of a long-
term care facility may be impressed by another healthcare services organization’s HMIS in the
same community or regional area; the board of directors of a health facility may have discussed
HMIS in their 10-year plan; staff members of a health maintenance organization (HMO) may
complain about their aging islands of technological applications. In short, the initial conceptu-
alization represents a genuine wish to consolidate and improve the information flows, data stor-
age, and information exchange capabilities in a healthcare services organization.
As stated previously, incorporating organizational strategic planning into HMIS strategic
plans is a desirable milestone in any HMIS implementation. HMIS development must be
based on a strategic information plan that is aligned with the organization’s mission, vision,
goals, and objectives. Adopting a strategic approach helps focus measurable goals and objectives
for IS/IT implementation that best suit internal and external information needs. Only in this
way can the necessary factors and considerations (such as outcome measurement, future tech-
nological change, networking, and process reengineering) be included.
Once strategic information planning is completed, a feasibility study can be carried out. In
general, this study aims to determine the extent to which the implementation and the HMIS
upkeeps are feasible. It includes results from various meetings with the board, middle manage-
ment, and even staff members who are likely to be affected (user involvement) to solicit their
input. It also incorporates financial (how much is available) and physical (whether the facility is
too crowded for extra equipment) feasibility research. Moreover, the feasibility study can also
make recommendations on the schedule of implementation, its speed, and other issues of con-
cern. In many healthcare services organizations, the reports for the feasibility study need to be
approved or endorsed by the board of trustees. In these cases, the feasibility study report also
acts as project proposals subject to extensive inquiries. The study reports should always be pro-
duced professionally and should be subjected to peer review.
Following the feasibility study, the detailed goals and objectives for the HMIS project can be
outlined on the basis of an internal and external needs assessment. Needs assessment makes it
possible to formulate a request for proposal (RFP) for the various hardware and/or software ven-
dors to submit bids. The RFP can include details on the organization, its information needs,
and the specifics of the organization’s goals and objectives that the system is expected to fulfill.
When vendor replies are received, it is then possible to correlate proposals on the basis of such
internal objectives as budget and infrastructure compatibility issues in terms of existing hard-
ware and software. This leads to the next stage of proposal evaluation and selection, which is
followed by physical implementation. Separate discussion sections are dedicated to each of
these important steps.
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Proposal Evaluation and Selection
As soon as all the proposals have been submitted, it is time to evaluate them to make a selection.
In the proposal evaluation and selection process, two methods commonly used are benchmark
tests and the vendor rating system. In a benchmark test, the healthcare services organization
provides the vendors with a set of mock data. This set of data then acts as inputs in a prototype
of the proposed system. The prototype system then simulates the performance of the real system
using this list of computations. The actual performance of the prototypes is then compared
with the prespecified standards for evaluation.
Benchmark testing attempts to create an environment that is as close to the real clinical set-
ting as possible. As the prototypes are being tested, it is not uncommon to find that the real,
constructed system may, in fact, perform at a lower level due to the heavy load of information
to be processed in real life. Nevertheless, benchmark testing gives the organization a “concrete”
feel for what the system would look like and how it would function (to some extent) in the clin-
ical setting. In comparison, the vendor rating system is simply one in which the vendors are
quantitatively scored as to how well their proposed systems perform against a list of weighted
criteria. Commonly used criteria include user friendliness, data management, graphical and re-
porting capabilities, forecasting and statistical analysis capabilities, modeling, hardware and op-
erating system considerations, vendor support, and cost factors.
The importance of the “people” aspect to the success of HMIS implementation cannot
be overemphasized. As a direct consequence, user friendliness should be a prime concern
when evaluating system proposals from vendors. User friendliness can be manifested in a va-
riety of ways. The consistency of language command, the use of natural language and touch
screens, automatic grammar checker and spelling correction, and the availability of the
“Help” and “Undo” commands are examples of user-friendly hardware and software fea-
tures. Moreover, menus and prompts, novice and expert modes, spreadsheet display of data
and results, as well as what-you-see-is-what-you-get features also contribute to the user
friendliness of the system.
Designed as advanced “data-processing” facilities, HMIS should have adequate data
management tools to handle the massive volumes of data to be processed in the day-to-day
operation of a healthcare services organization. Such features as a common database man-
ager, data security measures (log-in password, etc.), simultaneous access (without significant
trade-off in performance), data selection, data dictionaries, and data validation should be
supported and included. The primary HMIS function is to produce timely and accurate in-
formation for making intelligent healthcare decisions. Accordingly, HMIS should have the
capability to generate standard and custom reports; to generate basic graphical plots and
three-dimensional charts; to allow multicolor support and the integration of graphical
and text files; and to allow compatibility and interoperability with existing graphics devices,
the legacy systems, the Internet, new organizational IS/IT applications, or other electronic
devices.
An important theme emphasized throughout this latest edition of our HMIS text is systems
integration and interoperability. The selection of HMIS should take this matter into considera-
I V. S Y S T E M S I M P L E M E N T A T I O N 247
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tion. In practice, this can be viewed in terms of hardware and operating system considerations.
Compatibility with various operating systems (icon-based versus command-based), microcom-
puter support, compatibility with workstation requirements, and printer and plotter support, as
well as server and network compatibility, should also be considered when selecting HMIS. Even
so, the interoperability most likely is a matter of software or middleware capabilities. As noted
in previous chapters, Web services and open-source systems provide interoperable solutions to
many islands of HMIS and legacy systems.
Finally, vendor involvement can positively influence HMIS implementation. In selecting
HMIS, the amount of vendor support can definitely be a valid selection criterion. Vendor
support can be provided in a variety of ways: consultation, training, active research and devel-
opment, maintenance of local branch offices, technical support personnel, and continuing en-
hancements. Also, the financial stability and credibility of the vendor should be confirmed
before reaching a final decision.
Probably the most important factor for all health organizations is the cost. In evaluating
HMIS proposals, it would be very helpful to bear in mind how the costs are calculated and
which items are or are not included. A modular pricing approach combined with some form
of “packaged offer” is one of the more common approaches. In this case, the management
should pay particular attention to the initial license fees, license renewal fees, maintenance
248 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
VENDOR RATING
Vendor:
Total Score:
Additional Comments:
Evaluated By: Signed: Date:
Criteria Criteria
User Friendliness
Language Command
Help Command
Undo Function
Others:
Reports and Graphs
Report Format
Basic Graphs
Graph Previews
Others:
Weight Score Weighted
Score
Proposed System:
Modeling
Mathematical Functions
User-Defined Functions
Procedural Logic
Others:
Vendor Support
Consultation
Training
Technical Support
Others:
Forecasts and Statistics
Linear Regression
Multiple Regression
Curve Fitting
Others:
Weight Score Weighted
Score
Hardware and Operating
System
Hardware Compatibility
Operating System
Compatibility
Workstation Compatibility
Others:
Cost Factors
Total Budget
Leveraged Payment
Maintenance Cost
Others:
Data Management
Common Database Manager
Security
Simultaneous Access
Others:
FIGURE 11.7 Sample Evaluation Sheet for HMIS Proposal.
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arrangements, documentation, and resource utilization, as well as to hidden conversion
costs. Certainly, the cost of training and staffing has to be estimated by the management
itself.
Figure 11.7 presents a sample evaluation sheet used in a vendor rating system. Note that al-
though these criteria are generally applicable to all healthcare services organizations, specific cri-
teria are more important to each organization by virtue of its unique environment. These
should be specified separately and weighted accordingly.
Physical Implementation
Once the vendors are chosen, a contract is signed, thereby beginning the physical implemen-
tation stage—the stage when the most “action” takes place. This stage actually consists of
several steps, including recruitment of personnel, training of staff, acquisition of equipment,
I V. S Y S T E M S I M P L E M E N T A T I O N 249
Evaluate Organization
Strategic Plan
Evaluate
Information Plan
Request for
Proposal
Vendor
Reply Analysis
Vendor Selection
Proposed System “A” Proposed System “ Z ”
Acquisition of
Hardware/Software
Personnel Training
System Testing
and Documentation
System Online
FIGURE 11.8 Common Steps of Initial Implementation of an HMIS.
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installation of equipment, uploading of initial data, system testing, documentation, and on-
line implementation.
All these steps are performed in a logical progression (some carried out simultaneously), de-
pending on the needs of the organization and how these are reflected in decisions based on the
described factors and considerations. The keys to a smooth implementation process are effective
planning and project management. Some variations may be necessary, depending on the differ-
ences in each organization, but some common steps (including some earlier steps) in initial
HMIS implementation are shown in Figure 11.8.
Among these steps, the recruitment of HMIS personnel and training of existing staff mem-
bers have already been discussed. The modes of acquisition and installation of the equipment
are highly dependent on the characteristics of each health organization, as well as on the con-
tract between the vendor and the management. In addition, whether the equipment is acquired
over some period or at the same time ultimately depends on the payment scheme agreed upon
by the vendors and the management.
The uploading of initial data and systems testing are sometimes conducted simultaneously.
The initial sets of data are used to test whether the system is functioning at the desired level. If
there are any significant discrepancies between the predesignated level of performance and the
actual level, the system may have to be modified. Accordingly, there should be ample time allot-
ted to these two steps.
Very often, documentation can proceed simultaneously with systems testing because the
structural layout of the system is already fixed. Any additional modifications along the way can
then be documented as updates or memos. Ideally, there should be at least one copy of the mas-
ter documentation with details on how to operate the system at the technical level and on how
to manage the system at the tactical and strategic levels. The distributing copies as well as the
master copy should be updated periodically, incorporating the ad hoc updates or memos.
Online implementation involves four common approaches:
1. Parallel approach.
2. Phased approach.
3. Pilot approach.
4. Cutover approach.
In the parallel approach, systems activities are duplicated; the old system and the new system
are both operated simultaneously for a time so that their results can be compared. In the phased
approach, different functional parts of the new system become operative one after another. This
approach is relatively safe and less expensive than the parallel approach because the systems are
not duplicated. The pilot approach requires the installation of the new system in sites that are
representative of the complete system (e.g., in a small geographical area). This means that cer-
tain locations or departments are to serve as “alpha” pilot test sites first, followed by other
“beta” pilot sites or departments until all sites operate under the new system. The cutover ap-
proach is also called the “cold turkey” or “burned bridges” approach. Essentially, this approach
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requires the organization to “flip the switch” to the new system all at once. If the results are not
satisfactory, the system can be revised and activated again.
Figure 11.9 gives a diagrammatic representation of the four common approaches to online
implementation. As to which approach is most suitable, it depends directly on the specific
environment of each health service organization. For instance, the general level of HMIS
knowledge in the staff, the availability of resources for systems implementation, and the
amount of data handled per day will and should all affect the choice of online implementa-
tion approach.
Post-Implementation Upkeep
Although full, online HMIS implementation is a prominent milestone, it is definitely not the
end of the story. Once the HMIS become operational, ongoing maintenance kicks in—good
maintenance is essential to achieve implementation success in the long run.
I V. S Y S T E M S I M P L E M E N T A T I O N 251
Period of Parallel Operation
Phase I
Phase II
Phase III
Phase IV
“Alpha” Pilot Site/Department
“Beta” Pilot Site/Department
Switchover Date
Time
Parallel
Approach
Phased
Approach
Pilot
Approach
Cutover
Approach
Old System
New System
New System
New System
New System
Old System
Old System
Old System
FIGURE 11.9 Common Approaches to Online Implementation.
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In general, ongoing upkeep is required because of problems within the system and changes in
the environment. Problems within the system may be errors that have not been discovered by
previous tests or may develop primarily because of an unexpectedly heavy workload. Changes in
the environment include those in related systems, such as in inventory order systems, and those
in the organization of human resources. In many cases, simply because of the length of time it
takes to develop HMIS, there are some deviations between the initial planning and final produc-
tion; these deviations also contribute to the need for close post-implementation monitoring.
Regardless of why the system needs to be maintained and modified, the maintenance cycle
depicted in Figure 11.10 captures the major steps involved.
Problems are usually discovered in either unexpected events or periodic systems evalua-
tions. Post-audits (or post-evaluations) are intended to evaluate the operational characteris-
tics of the system, thereby acting as control points throughout the operation of the system.
Once the problem is defined, a maintenance project can be initiated. Very often, because
of creativity and the uncertainty involved, this type of project is relatively unstructured,
characterized by numerous attempts to search for the ultimate “ideal” solution. Here, the
concepts of IT services management, which are highlighted in the next section, are very use-
ful. After a feasible solution is found, it is then implemented and tested. If the problem
is still not completely solved, it may need to be redefined. Attempts to search for an accept-
able solution are then resumed. If the problem is solved, the project can be completed by
making notations on maintenance logs and by producing the appropriate documentation
for circulation.
252 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
Periodic
Evaluation
Record of
Maintenance Log
Implementation
of Solution
Research
for Solution
Problem(s)
Defined
Problem(s)
Redefined
Unexpected
Events
Maintenance
Project Initiation
FIGURE 11.10 A Sample Maintenance Cycle for HMIS.
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It is also worth noting that documentation does not just take place at the end of the mainte-
nance cycle. Rather, it occurs throughout the entire cycle in the form of documentation of
problems, written requests for change, and memos on possible sources of problems and solu-
tions. The documentation at the end of the cycle therefore emphasizes the incorporation of all
these forms and memos into a mini-report that can be used for future reference or for incorpo-
ration into the system manual.
Figure 11.11 recaptures the main steps of the overall schema of HMIS implementation.
Throughout the entire implementation process (both pre-implementation preparation and
post-implementation upkeep), active involvement of both the users and the managers cannot
be overemphasized, for reasons described earlier.
V. I T S E R V I C E S M A N A G E M E N T C O N C E P T S 253
Strategic Planning
Feasibility Study
Request for Proposal
Documentation
Going Online
Ongoing
Maintenance Cycle
Proposal Evaluation
and Selection
Systems Testing
Contract Signing
Uploading of Initial
or Additional Data
Recruitment of Personnel
Installation of Equipment
Training of Staff
Acquisition of Equipment
FIGURE 11.11 The Overall Schema of an HMIS Implementation.
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V. IT Services Management Concepts
After examining the various steps of HMIS implementation, we now turn to an emerging field
relating to the upkeep of HMIS products after these have been implemented: IT services man-
agement concepts.
At present, a growing number of governmental bodies in the United Kingdom and non-
profit organizations around the world have been formed to assist in the establishment of best
practices in IT services management based on core principles of ITIL® standards and guide-
lines. ITIL, a registered community trademark of the Office of Government Commerce
(OGC) that stands for IT Infrastructure Library, is essentially a set of publications that to-
gether offers a framework of “best practices” management guidance for all aspects of IT services.
Major categories include guidance for planning to implement service management, the business
perspective, IT infrastructure management, application management, service delivery, service
support, and security management.
In this text, concepts of HMIS strategic planning and implementation have been covered pri-
marily from a general organizational and management perspective, but not specifically along
the IT service management perspective, which emphasizes a continuous service quality improve-
ment process. Nonetheless, key processes underpinning IT services planning, implementation,
and management are akin to those of HMIS planning, implementation, and review—begin-
ning with a vision; assessing the external marketplace and scouting the environments to surmise
the best and most appropriate strategies that should be considered to improve expected out-
comes; providing strong leadership support and directions to subordinates whenever possible
and practical to do so; striking a balance among the different roles played by human resources,
technology, and culture within the boundaries of an organization; setting goals; deciding on
measurable targets; conducting process improvement cycles; and achieving goals based on spe-
cific predetermined measures and metrics.
The business perspective essentially conveys the message of the need for aligning IT goals and
objectives with the broader corporate goals and objectives. To achieve a well-knitted alignment,
the processes emphasized by ITIL include: (1) building long-term business relationships and rec-
ognizing the value chain as part of the business partnership management; (2) enhancing supplier
relationships, including supply chain management; (3) reviewing, planning, and developing IT
applications as these applications relate to the business goals and objectives; and (4) providing li-
aison, education, and communication on IT services so as to influence, gain support, and
achieve changes through IT services for greater business competitive advantage. Many of these
concepts have also been covered throughout parts of this new edition of the text.
In the domain of IT infrastructure management, IT managers are challenged to managing ap-
propriately the people, products, processes, and partners (4 Ps) associated with IT services
throughout the different HMIS life cycle stages. The key steps include, but are not limited to,
feasibility analysis, systems requirements, design specifications, software development, testing,
implementation, operation, review, and retirement. All aspects of infrastructure management
and administration, design and planning, technical support, and operational deployment are
covered. The IT infrastructure manager coordinates among the different players to ensure that
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all necessary support processes are in place to aid service efficiencies and the effective use of IT
services throughout daily operations, during periods of change management, and when in crisis
management situations. Various aspects of these concepts relating to HMIS planning and man-
agement have been discussed and illustrated in earlier sections of this and the previous few
chapters.
In the domain of application management, it is important to relate service management con-
cepts to application development and management in that all deployed applications should be
designed for services. In this sense, all applications have to be more flexible, scalable, interoper-
ationable, available, reliable, maintainable, manageable, usable, and in compliance with design
specifications and organizational requirements. Service management is concerned with the ac-
tivities relating to the release, delivery, support, and optimization of the application. Again, a
critical theme emphasized throughout this text has been the interoperability of HMIS applica-
tions and the management of systems that do not support interoperability.
In the domain of service delivery, various forward-looking delivery aspects of IT servicing are
covered, including availability management, capacity management, financial management for
IT services, IT service continuity management, and service-level management. Availability en-
sures that IT services are reliable, available, secure, serviceable, and able to be maintained. It is
the key to quality servicing in IT service management. Capacity management ensures that em-
ployee requests for capacity to meet business needs and goals are given priority consideration at
all times. Financial management sees IT servicing run as a business within the larger corporate
business operation. In other words, employees and technicians are both cost-conscious about
IT services and will minimize future expenditures by trying to take care of problems in the best
way possible to the extent that these problems can be eliminated once and for all. IT service
continuity management entails setting in place a recovery plan for crisis situations management
and ensuring that a certain level of servicing be made available within an agreed-upon work
schedule to minimize any unnecessary work disruption. Finally, service-level management
(SLM) refers to the satisfactory delivery of services on a daily operational level based on the
service-level agreement (SLA) acceptable to the organization.
In the domain of service support, daily maintenance and support services are covered, includ-
ing (1) incident management, where incident reports are filed with the support personnel man-
ning the computer help line or help desk; (2) problem management, where a proactive
approach is taken to reduce the adverse impacts from the same problem or persistent incidents;
(3) change management, where a more centralized approach is taken at a higher level to control
persistent problems; (4) release management, in which new releases are being considered due to
major changes so as to reduce work discontinuity and improve business processes; and (5) con-
figuration management, where IT assets such as the centralized or enterprisewide databases are
being managed for the successful running of the enterprise.
In the domain of security management, the IT services management must institute a security
policy to ensure all personnel are aware of the significance of protecting IT assets and informa-
tion resources and conduct risk analyses from time to time throughout the life cycle of the IT
servicing, including planning and implementation, operation, evaluation, and auditing.
Topics on regulatory policies related to the release and protection of health information and
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HMIS resources have also been covered separately in the Policy Brief accompanying Chapter 12
of this text.
VI. Conclusion
In summary, successful HMIS implementation and the continual evolution of HMIS as the in-
formation backbone of healthcare services organizations are the ultimate objectives of the
healthcare services delivery field. Among the various steps along the path from initial conceptu-
alization to physical implementation to operation, the stage wherein HMIS acceptance resides
in the spotlight of organizationwide attention seems to be the post-implementation stage. This
is when the employees of the organization are truly milking HMIS to perform key task activities
and achieving the goals of the corporation. But it is also here that IT services management con-
cepts play a most critical role to determine if HMIS will be of value to assist the healthcare ser-
vices organization attain the goals of high-quality healthcare services delivery.
This chapter has discussed various concerns to be addressed in HMIS implementation and
some general steps involved. It is, however, not expected that managers of all healthcare services
organizations follow the same steps and address the same concerns in an identical fashion. Rather,
it is hoped that the chapter has provided the “essentials” for healthcare managers and planners
as well as health administration students interested in HMIS implementation or expansion to
oversee new projects in HMIS such as an integration of new systems with legacy systems. With
the lessons learned, the students will then be able to adapt this global knowledge to schemes
suitable to the special environment of each healthcare services organization.
Notes
1. Maureen McKinney, “Louisiana Rural Health Information Exchange Counts First Success,”
May 20, 2008, http://www.digitalhcp.com/2008/05/20/larhix-pilot.html.
2. J. E. Toole and M. E. Caine, “Laying a Foundation for the Future Information Systems,”
Topics in Health Care Financing 14, no. 2 (1988): 17–27.
3. R. W. Zmud, “Individual Differences and MIS Success: A Review of the Empirical
Literature,” Management Science 25, no. 10 (1979): 966–979.
4. J. Dearden, “MIS Is a Mirage,” Harvard Business Review 50, no. 1 (1972): 90–99.
5. G. Dickson and J. Simmons, “The Behavioral Side of MIS: Five Factors Relating to
Resistance,” Business Horizons 13, no. 4 (1970): 59–71.
6. K. Kropf, San Bernadino County Medical Center Implementation of a Hospital Information
System (New York: New York University, 1990): 7–8.
7. M. Staggers, “Human Factors: The Missing Element in Computer Technology,” Computers
in Nursing 9, no. 2 (1991): 47–49.
8. J. K. H. Tan, “Graphics-Based Health Decision Support Systems: Conjugating Theoretical
Perspectives to Guide the Design of Graphics and Redundant Codes in HDSS Interfaces.”
In Health Decision Support Systems, J. K. H. Tan with S. Sheps, Eds. (Gaithersburg, MD:
Aspen Publishers, 1998).
9. R. Lemon and J. Crudele, “System Integration: Tying It All Together,” Healthcare Financial
Management 41, no. 6 (1987): 46–54.
256 M A N A G I N G H E A L T H M A N A G E M E N T I N F O R M A T I O N S Y S T E M P R O J E C T S
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10. H. Austin, “Assessing the Performance of Information Technology,” Computers in Health
Care 9, no. 11 (1988): 56–58.
11. Ibid.
12. R. J. Feldman, “System Evaluation and Implementation Strategies.” In Information Systems
for Ambulatory Care, T. A. Matson and M. D. McDougall, Eds. (Chicago: American
Hospital Publishing, 1990): 67–78.
13. H. W. Ryan, “User-Driven Systems Development: Defining a New Role for IS,” Information
Systems Management (Summer 1993): 66–68.
14. S. Gray, “DP Salary Survey,” Datamation 28, no. 11 (1982): 114–128.
15. J. Couger and R. Zawacki, “What Motivates DP Professionals,” Datamation 24, no. 9
(1978): 116–123.
16. K. Bartol and D. Martin, “Managing Information Systems Personnel: A Review of the
Literature and Managerial Implications,” MIS Quarterly, Special Issue (1982): 49–70.
17. J. Couger and M. A. Colter, Motivation of the Maintenance Programmer (Colorado Springs,
CO: CYSCS, 1983).
18. J. Baroudi, “The Impact of Role Variables on Information Systems Personnel Work
Attitudes and Intentions,” MIS Quarterly 9, no. 4 (1985): 341–356.
19. K. C. Laudon and J. P. Laudon, Management Information Systems: A Contemporary Perspective
(New York: Macmillan Publishing, 1988): 698.
20. C. J. Austin and S. B. Boxerman, Information Systems for Health Service Administration, 5th
ed. (Ann Arbor, MI: AUPHA Press/Health Administration Press, 1998).
21. Feldman (1990).
22. Ryan (1993).
23. Lemon and Crudele (1987).
24. Austin (1988).
25. D. M. Robinson, “Patient Access to Health Records: New Legal Developments and
Implementations,” Healthcare Communication and Computing Canada (4th Quarter 1992):
54–60.
26. D. M. Robinson, “Health Information Confidentiality: Balancing Extremes,” Healthcare
Communication and Computing Canada (3rd Quarter 1991): 8–9.
Chapter Questions
11–1. What are some of the critical success factors in HMIS implementation?
11–2. Why is careful planning so important to HMIS implementation?
11–3. With respect to HMIS staffing, what are some of the major concerns for HMIS planners?
11–4. Describe some useful tools in HMIS implementation project management.
11–5. Why is end-user involvement important in HMIS implementation? How can end-users
be more involved in the process?
11–6. What are the key concepts underlying IT services management? Why are these various
concepts important, and how do these relate to the HMIS post-implementation stage?
C H A P T E R Q U E S T I O N S 257
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Health Management
Information System
Standards, Policy,
Governance,
and Future
PART
IV
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Health Management Information
System Standards:
Standards Adoption in Healthcare
Information Technologies
Sanjay P. Sood, Sandhya Keeroo, Victor W. A. Mbarika,
Nupur Prakash, and Joseph Tan
261
12
CHAPTER
Editor’s Note: Part IV (Chapters 12, 13, and 14) acquaints readers with HMIS standards,
governance, policy, and future. Part IV begins with Chapter 12 on HMIS standards—a topic
of increasing significance for HMIS students, practitioners, and researchers. Major standards
relating to data-coding standards (vocabulary), data-schema standards (structure and con-
tent), data-exchange standards (messaging), and Web standards that work toward a common
language for sharing health information electronically among care providers are covered. This
chapter also links to earlier parts of the text relating to HMIS foundational concepts about
use of data for managerial decision making and for online health data searches (Part I);
HMIS technology and applications on databases, community health networks, and data inte-
gration via Web services (Part II); and HMIS planning, data stewardship, and systems man-
agement (Part III).
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Scenario: HHS to Form Standards, Operability Group to Spur
Health IT Adoption1
Mike Leavitt, who served as U.S. Department of Health and Human Services (HHS) Secretary
during President George W. Bush’s second term, championed the creation and development of a
national collaboration in terms of standards adoption in order to aid rapid health information
exchange and the diffusion of health information technologies (IT) among U.S. healthcare facil-
ities. Such a vision was to lead the way for achieving interoperable medical information systems
and to further motivate patients and healthcare providers such as nurses, doctors, hospitals, in-
surance companies, and employers to agree on standards for electronic health records (EHR).
An EHR is essentially a digital database of a patient’s medical history and clinical informa-
tion. Such patient data could include patient demographics, vital signs, immunizations, diag-
nosed medical conditions, lab test results, and ordered prescriptions. “The use of electronic
health records and other information technology will transform our health care system by re-
ducing medical errors, minimizing paperwork hassles, lowering costs and improving quality of
care,” Leavitt claimed.
262 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M S TA N D A R D S
CHAPTER OUTLINE
Scenario: HHS to Form Standards, Operability Group to Spur Health IT Adoption
I. Introduction
II. HMIS Standards
III. HIPAA to Spur Data Standards Adoption
IV. HL7: Health Level Seven
● The Vocabulary Problem
● HL7 Development
● HL7 Adoption
V. DICOM: Digital Imaging and Communication in Medicine
● Purpose of DICOM
● Adoption of DICOM Standards
VI. Web Standards
VII. Conclusion
Notes
Chapter Questions
Policy Brief I: HIPAA, Privacy, and Security Issues for Healthcare
Services Organizations
Joseph Tan and Fay Cobb Payton
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“Once the market has structure, patients, providers, medical professionals, and vendors will
innovate, create efficiencies, and improve care,” Leavitt touted. “The national strategy for
achieving interoperability of digital health information is for federal agencies—[which] pay for
more than one-third of all health care in the country—to work with private-sector healthcare
providers and employers in developing and adopting an architecture, standards, and certifica-
tion process.”
To this end, HHS has elected to consult with the American Health Information
Community (AHIC) on various key issues and questions such as how to protect the privacy and
security of patient health information; what health IT capabilities are needed to yield the most
immediate results and benefits to healthcare consumers, including matters relating to drug
safety, laboratory testing, and dissemination of such test results; and bioterrorism surveillance,
as well as thoughts about instituting a standard-setting and harmonization process so that pa-
tient health records may be shared digitally among interoperable systems, while preserving the
confidentiality and security of such transactions. Recommendations made by AHIC will also
include a separate product certification process.
Taking the leadership role, not only will HHS fund creative proposals for data standardi-
zation processes, for a means to work toward nationwide Internet-based health information
exchange architecture, and for the planning and development of policies relating to patient
privacy and security, but HHS will also ensure that both Medicaid and Medicare programs
adopt standards and data-sharing processes for Internet-based applications. It is envisaged
that the initial public–private collaboration championed by HHS will eventually turn into a
private-sector health information community initiative to set additional needed standards,
certify new health IT, and provide long-term governance to transform the U.S. healthcare
system.
Imagine having traveled to a foreign country and fallen ill while abroad. How could you en-
sure that your personal health records could be accessible to you? Do you think this informa-
tion is at all useful to the foreign doctor trying to treat you? What if you do not have access to
your personal health records but know that your family doctor is willing to share your data with
the foreign doctor—what needs to be in place for the foreign doctor to have online access to
your personal health records? Also, would the coding of these records be meaningful to the for-
eign doctors?
I. Introduction
The origins of healthcare management information systems may be traced back to hospital
database systems. The first articles on information management in medicine appeared in the
1950s; the number of publications in this domain rapidly increased between the 1960s and
1970s as medical informatics (MI) became identified as an emerging field and a new specialty.2
Before that time, other terminologies and acronyms were also used, and some are being used
even to this day—examples include medical computer science; medical information science; com-
puters in medicine; and other more specialized terms, such as nursing informatics, dental infor-
matics, and bioinformatics.3
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Medical informatics, as the buzzing interdisciplinary–multidisciplinary topic of the 1960s,
is today honored for being recognized as a maturing scientific discipline that has evolved in its
own right over the past century. While there still is no consensus on a universally accepted def-
inition for such a field as medical informatics, crossing all boundaries, the discipline is dynam-
ically evolving with its very own language of communication. Accordingly, different authors
have taken on diverse perspectives to suggest an overwhelming number of definitions for MI
as it evolves; attempts have also been made to differentiate among the various subfields within
the broader MI field. Still, MI confronts considerable idiosyncrasies to find a common ground
to claim its so-called identity. Yet, the continuous diffusion of this field into other healthcare
and IT-related disciplines such as health informatics, healthcare technology management, and
bioinformatics has spawned a movement for multiple subspecialties and subfields to emerge,
each of which may have some overlapping concepts, theories, methods, and applications
drawn differently from well-established reference disciplines within the broader IT and sys-
tems movements, influenced by the booming evolution of computing and information man-
agement technologies.
Turning now to the field of health management information systems (HMIS), information
systems (IS) in healthcare, or healthcare information technology (HIT), the evolutionary roots
and history of the various HMIS-related fields appear to parallel those of the history and evolu-
tion of MI concepts, except for the differing emphasis of the two emerging disciplines. For ex-
ample, the long-standing challenge of MI in etching an identity to establishing itself is well
known among health informaticians based on the many attempts to define its scope of cover-
age—just as the paralleled efforts of many healthcare administration and information systems
academics, health records specialists and practitioners, and healthcare IT pioneers and re-
searchers in establishing an identity and defining the boundaries of the HMIS field over the last
several decades are known as well. Currently, these two broad disciplines are still facing the need
to overcome the ostensibly intransigent problems of increasingly unmanageable health records
and the explosion of biomedical knowledge and clinical information about patients, coupled
with the need to merge myriad uncontrolled movements of administrative, financial, and clini-
cal test reports generated from physician referrals and patients changing health insurers or seek-
ing alternate opinions from different care providers. Apparently, while the field of MI is more
concerned with clinical-based data accumulation and diagnostic, therapeutic, and prognostic
decision making, the field of HMIS emphasizes the integration of administrative, financial, and
clinical data sets. Herein lies the key difference between the two broad disciplines.
Yet, despite the many similarities and/or differences among all health IT–related disciplines,
especially the broader MI and HMIS disciplines, the need to improve the accuracy, reliability,
consistency, and sharing of medical process and knowledge; the need to automate clinical
guidelines and streamline administrative workflow; the need to enhance administrative and
managerial directives, as well as physician decision making and research; and the need to permit
electronic data interchange among care providers and to achieve higher-quality health care have
all given rise to the need for adopting standards. Among the key benefits of standards adoption
would be empowering the medical sector to share patient information, encouraging the merg-
ing of medical discoveries and MI developments, and optimizing the applications of the new
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medical technologies. Hence, interface solutions in the form of standards are critical to bringing
together the contributions of multiple caregivers; to combining the contributions from diverse
health IT–related research; and to satisfying the unique needs of the health and medical field,
especially in areas where data integrity and reliability, relevancy, responsiveness of knowledge,
and security are of utmost importance.
II. HMIS Standards
Today, we are already seeing major standards being applied across many hospital-based infor-
mation systems developed as a result of growing MI expertise and HMIS know-how such as
electronic health records (EHR), clinical decision support systems (CDSS), computerized
physician order entry (CPOE), radiological information systems (RIS), laboratory information
systems (LIS), and pharmacy information systems (PIS). Without these HMIS standards, the
medical field would have been at a standstill in terms of rapid IT adoption and diffusion, which
explains why, in the past decades, nurses and physicians were particularly resistant to new tech-
nologies and why it took years for many routine hospital activities such as nurse scheduling,
prescription orders, and physician workflow to be computerized.
The intensive information-generating and health-providing “industry” epitomized by hospi-
tals and health maintenance organizations (HMOs) has been notoriously slow in exploiting and
making optimum use of the new technologies and computing practices, thereby still lagging be-
hind in this competitive century of today. Several reasons underpin the slow automation of
medical records. For instance, the widespread use of narrative text and lack of standard vocabu-
lary, shared medical terminology, and relevant taxonomic code schemes in the field have wors-
ened the situation. Imagine a diabetic patient who would unknowingly be ordered multiple and
seemingly different, but redundant, test procedures while moving from one doctor to another
when, in effect, the same intended treatment is needed just because of the different terminolo-
gies used in the patient’s prescriptions. Additionally, the lack of political spirit and fragmented
markets, with scarce income streams to support new systems development and with sluggish
adoption of technically feasible medical standards, further fuel the problem. This also accounts
for the often cumbersome, slow, expensive, and sometimes unreliable technology adoption by
healthcare organizations.
But the laudable effort on the part of concerned standards development organizations
(SDOs) in quest of bridging the gap between the medical field and IT cannot be ignored. Well-
established and influential SDOs, like HL7, the Institute of Electrical and Electronics Engineers
(IEEE), the American National Standards Institute (ANSI), and many others such as the World
Wide Web Consortium (W3C)—all of whose efforts have significant implications for the med-
ical information systems and healthcare informatics community—are engaged in developing
and promoting the adoption and diffusion of pertinent gold standards to ease the exchange of
complex medical information, among other types and forms of information. Although these
burgeoning standards exist in niche areas, significant effort still needs to be made so that na-
tions and government agencies around the world are willing to trust and adopt a good number
of the more established standards and embrace new ones such as Logical Observation Identifiers
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Names and Codes (LOINC), Systematized Nomenclature of Medicine (SNOMED), Medical
Information Bus (MIB), American Society for Testing and Materials (ASTM), Healthcare
Informatics Standards Board (HISB), and Comité Européen de Normalisation (European
Committee for Standardisation; CEN).
Indeed, many of these standards, if adopted and shared by government and healthcare
services organizations around the world, would automatically lead to higher-quality healthcare
services for both individuals and the population at large. Not only would the appropriate and
proper sharing of health information and medical knowledge improve healthcare service effi-
ciencies, but it would make healthcare services more cost-effective as well as more readily avail-
able when people of one country travel to another country. Consequently, the potential benefits
and implications of key standards adoption for international data interchange standards would
soon become apparent. The following is part of an ever-expanding list of direct beneficiaries of
HMIS standards adoption:
● Individuals.
● Independent healthcare providers.
● HMIS suppliers, consultant companies, and developers.
● University-affiliated teaching hospitals and major healthcare centers and research bodies.
● Major corporations such as those in the medical devices and pharmaceutical industrial
sectors.
● Healthcare maintenance organizations, nongovernment organizations, nonprofit health-
care organizations, and third-party payors.
● Governments and/or funding agencies.
In the next few sections, we highlight some of the more established and widely accepted
standards, such as international data-coding standards, HL7, DICOM, and Web standards.
III. HIPAA to Spur Data Standards Adoption
The migration from traditional paper-based health data processing to electronic data collection,
storage, and dissemination of pertinent health information points to the need for standardizing
procedures and guidelines in protecting against authorized access of patients’ private and per-
sonal information. In this sense, the Health Insurance Portability and Accountability Act
(HIPAA) was enacted on August 21, 1996, by the U.S. Congress to accelerate the development
of data standards to improve the privacy, confidentiality, integrity, and security aspects of per-
sonal health information and to simplify the movement of individual patients’ protected health
information (PHI) between healthcare professionals and other covered entities that require the
information, such as insurance companies.4
Because HIPAA is separately discussed in the accompanying Policy Brief, our focus here is
primarily on the resulting influence of HIPAA on data standards adoption—in particular, data-
coding standards or terminology–vocabulary standards. Many health professionals have realized
that the lack of comprehensive data standards is key to inhibiting the sharing of medical infor-
mation electronically. For example, an influential 1993 report by the U.S. General Accounting
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Office5 highlighted the need for data standards and grouped these needs into three broad cate-
gories: vocabulary standards, structure and content standards, and messaging standards. These
taxonomies correspond neatly to our categories of data-coding, data-schema, and data-exchange
standards.
Data-coding standards (vocabulary) aim at defining common medical terms and specifying
how medical data are to be coded within the records. For example, the ICD-9-CM is a standard
numeric coding system adopted by many U.S. health provider organizations to ensure that similar
diagnoses and procedures are similarly coded.6 Using standard codes (i.e., the same abbreviation to
represent similar conditions and treatments) allows not only achievement of data reliability, in-
tegrity, comparability, and consistency, but also helps with the easy retrieval of needed data. The
following standards are among the key terminology–vocabulary standards that any HMIS students
should be familiar with when it comes to classifying and separating healthcare data sets:
ICD: International Classification of Disease
● MS-DRG: Medicare Severity Diagnosis-Related Groups
● CPT: Current Procedural Terminology
● LOINC: Logical Observation Identifiers Names and Codes
● SNOMED: Systematized Nomenclature of Medicine Reference Terminology
● CCC: Clinical Care Classification
● ICPC: International Classification of Primary Care
ICD, developed under the auspices of the World Health Organization (WHO), refers to an in-
ternationally recognized standard classification of diseases in the form of standardized diagnos-
tic codes with ICD-10-CM (ICD 10th Revision, Clinical Modification, June 2003)
representing a progression of ICD-9-CM coding standards’ capability to cover an expanded vo-
cabulary and new requirements generated by the 1996 HIPAA. MS-DRG, which is based on
Medicare Severity DRG derived from ICD-9-CM, is a classification system primarily used by
healthcare services organizations such as the Centers for Medicare and Medicaid Services
(CMS) for inpatient prospective payment services and billing. In addition, MS-DRG coding
can be used for utilization review such as aiding in the planning of hospital inpatient discharge
services by providing the hospital wards with critical information pertaining to the most preva-
lent groupings of inpatient services and/or average length of stays. CPT, published by the
American Medical Association (AMA), provides standard procedure codes for professional re-
imbursement and billing. The CPT code book, maintained by the CPT Editorial Panel, is
structured according to specialty, body system, or service provided. LOINC is a classification
system used for identifying laboratory results and clinical observations. Therefore, two major
sections of LOINC are Lab LOINC and Clinical LOINC. SNOMED, developed and main-
tained by the College of American Pathologists (CAP), is a coding scheme meant to integrate
the data accumulated from multi-provider care processes by mapping with ICD, LOINC, and
various other data classification standards. CCC, previously known as Home Health Care
Classification (HHCC), offers a taxonomic framework for documenting holistically hospital-
based patient care process along two interrelated dimensions: (1) CCC of Nursing Diagnoses
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and Outcomes and (2) CCC of Nursing Interventions and Actions. ICPC-2, developed by the
International Classification Committee of the World Organization of National Colleges,
Academies, and Academic Association of General Practitioners/Family Physicians (WONCA),
is a coding taxonomy that maps to ICD-10 for primary care services. A severity of illness check-
list and functional status assessment charts are included in ICPC-2.
Not surprisingly, new versions of codes have continued to evolve, including ABC codes and
numerous others (e.g., CRM or Galen Common Reference Model, LOINC, UMLS, NDC,
and NANDA).7,8 Table 12.1 summarizes a sampling of the more popular codes.
Data-exchange standards (messaging) use a standardized interconnecting system protocol to
predictably transmit electronic data, that is, standardizing the order and sequence of data dur-
ing transmission between two points across a network or subnetwork. Open-systems intercon-
nection (OSI) is an open architecture having seven layers, each demanding a different level of
functionality for data exchange to materialize among different systems. These OSI levels in-
clude physical, data link, network, transport, session, presentation, and application as described
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Table 12.1 A Summary of Coding Systems Representing Healthcare Concepts
Standard Description
Read codes Detailed set of codes used to explain patient care and treatment information.
LOINC Standard codes and classifications for identifying laboratory and clinical terms.
ICD-10 codes New diagnostic codes developed by the World Health Organization (WHO),
not yet used in North America.
IFC International Classification on Functioning, Disability, and Health; a taxonomy
to describe bodily functions and structure, domains of activity and
participation, and environmental factors interacting with these components.
CPT4 codes Procedure codes developed by the American Medical Association for professional
billing and reimbursement for outpatient and ambulatory care.
HCPCS Healthcare Common Procedure Coding System; provides codes used for
reporting physician services for Medicare patients.
APC Ambulatory Payment Classification system; refers to outpatient reimbursement
based on groupings of CPT/HCPCS–coded procedures.
CDT-2005 Code on Dental Terminology; a dental procedural and nomenclature standard.
NANDA North American Nursing Diagnosis Association code; set of nursing diagnoses.
National Library A cross-referenced collection of codes and related information sources.
of Medicine (NLM)
Unified Medical
Language System
(UMLS)
APA DSM-IV Diagnostic codes organized by the American Psychiatric Association (APA).
ECRI Codes used to identify medical equipment.
Others Diagnosis-related group (DRG) databases, SNOMED, IUPAC Codes, Arden
Syntax, etc.
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in Table 12.2. Other standards for system networking include IBM’s SNA (system network ar-
chitecture), DEC’s DNA (DEC network architecture), TCP/IP (transmission control protocol/
Internet protocol), and MUMPS. Table 12.2, extracted from Bourke,9 provides brief summaries
of these layers and accompanying functions and a comparison of various standards that can be
used in the respective layers.
Data-schema standards (structure and content) involve defining essential data elements in
the database, such as a minimum data set (MDS), and specifying the structure, domains, rules,
and relationships among these data elements to be maintained within the records to facilitate
data retrieval. In the manual system, the data entry was serial and not random at the functional
level. Computerization allows the data representation to become functionally complex. Here,
the data comes with different type, categorization, and transaction identities assigned at each
functional level. This led to the development of widely used data schema, such as hierarchical,
network, and relational data models, which were detailed in one of the Technology Briefs earlier
in this text. Complex data object models have also evolved, which allow users to view data at a
high conceptual level.
Coupled with HIPAA, all of these data standards will serve to minimize potential misuse of
patient information and limit access to medical records by so-called covered entities, including
physicians, clearinghouses, healthcare providers, hospital administrators, clinical researchers,
and other employees. Because of the potential for serious harm through discrimination, loss of
insurance, unemployability, or stigmatization, HIPAA regulations provide federal protection
for this health information.10 With respect to security and confidentiality of electronic health
I I I . H I PA A T O S P U R D ATA S TA N D A R D S A D O P T I O N 269
Table 12.2 Layers of Open-Systems Interconnection (OSI) and Other Standard Protocols
OSI Layers Description IBM DEC TCP/IP
Physical Immediate network characteristics Twinax Twisted Twisted pair
(AS 400) pair/MMJ coaxial
Data link Node-to-node transfer of data via Bisync DDCMP Arcnet Starian
access to immediate subnet SDLC Asynch
Network Routing across subnets to deliver SNA DNA/LAT TCP/IP and
data packets others
Transport Data integrity, packaging data for SNA DNA/LAT TCP/IP and
transmission others;
NetBios
Session Dialogue management between two SNA DNA TCP/IP and
end systems others;
NetBios
Presentation Data encoding SNA DNA NetBios
Application User interface, e-mail, remote database Various Various Windows
access, file transfer, document IBM DEC SMTP (TCP)
exchange, transaction standards standards FTP; others
Source: Adapted with permission from M. K. Bourke, Strategy and Architecture of Health Care Information Systems,
© 1994, Springer-Verlag.
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information, HIPAA legislation makes adequate as well as excessive provisions to cover certain
exigencies in cases where legislation was not passed. For example, the HIPAA further enhances
the healthcare information and communications technology (HICT) agenda. In HIPAA’s
Administrative Simplification provisions, the National Committee on Vital and Health
Statistics (NCVHS) was named to advise the Secretary of the Department of Health and
Human Services (HHS) on those dimensions that related to confidentiality and security, identi-
fiers, and standards for computer-based patient records.11 Furthermore, HIPAA revised and re-
formulated the NCVHS from a venerable committee into the nation’s health information
policy advisory committee.
IV. HL7: Health Level Seven
Health Level Seven (HL7), as accredited by ANSI, is a system development organization whose
aim is to promote interoperability for the interchange of healthcare data. “Level Seven” refers to
the highest level of the International Organization for Standardization (ISO) communications
model for open-systems interconnection (OSI)—the application level.12 HL7 was built on ex-
isting production protocols, predominantly those of ASTM Standard 1238. It operates as a
nonprofit volunteer-, vendor-, and provider-supported organization to encourage information
scientists and various experts in the healthcare field to endeavor toward the development of
standards for the management, processing, integration, and exchange of electronic healthcare
information.
The Vocabulary Problem
The chief aim of HL7 is to address the vocabulary problem, which has paralyzed HMIS develop-
ers, implementers, and users of computer-based applications in medicine. The vocabulary prob-
lem is best characterized by the failure among communities of healthcare information end-users
to find a common denominator for representing healthcare knowledge and discoveries. Despite
many years of countless efforts invested by medical terminology developers and informatics spe-
cialists, the vocabulary problem remained until the emergence of HL7. HL7 provided a com-
mon interface among the various healthcare user communities in terms of the nomenclature of
health-related knowledge—its growing popularity hinges on its promise to realize the semantic
interoperability of the HL7 Message Development Framework (MDF), which aims at easing
the exchange and use of clinical information among disparate systems as well as enhancing clin-
ical research and promoting population health management.
HL7 is responsible for driving the development of specifications for messaging standards
that will enable disparate healthcare applications to exchange key sets of clinical and adminis-
trative data. It is not specifically a programming language meant for handling HMIS software
development. Current core clinical standards available through HL7 include order entry, sched-
uling, medical records management, imaging, patient administration, observation (laboratory
results, radiographic reports, examination findings, and so on), and patient financial mes-
sages.13 Being a message standard protocol, HL7 handles clinical information communication
such as diagnostic results, scheduling information, clinical trials data, and master file records.
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HL7 serves the purpose of data sharing among disparate vendors or sources of electronic data
interchange within the healthcare organizational environment. HL7 acts as a means to reduce,
if not eliminate, the level of interface programming and program maintenance. It, therefore,
ensures timely data exchange with minimal deficit of clinical knowledge.
HL7 Development
In 1987, the first version (HL7 version 1.0) was published and was responsible for the scope
and format of the HL7 standard. The following year, version 2.0, which serviced a number
of data-interchange demonstration projects, appeared. In 1990, HL7 version 2.1 was
broadly adopted on a global scale, followed by the development of HL7 version 2.2 in 1994.
In 1996, ANSI adopted HL7 as the first healthcare data interchange American National
Standard. In 1997, with HL7 progressively expanding its scope through the provision of
standards for further data exchange related to patient administration (such as admission,
discharge, and transfer), billing, order entry, clinical observation data, medical information
management, and messages supporting communication for problem-oriented records, HL7
version 2.3 appeared.
In 1999, a complete revision of HL7, which was based on the common Reference
Information Model (RIM), was undertaken and appeared as HL7 version 3. All the data con-
tent for HL7 messages would now originate from the HL7 RIM, serving as a coherent and
mutual information model. More recently, Health Level 7 has also been developing standards
for the representation of clinical documents such as discharge summaries and progress
notes.14 Bakken et al.15 discussed the development of two sets of principles to provide guid-
ance to terminology stakeholders: (1) principles for HL7-compliant terminologies and (2) prin-
ciples for HL7-sanctioned terminology integration efforts. To help healthcare services
organizations achieve HL7 compliance, the key activities undertaken by HL7 organizations
today include the completion of a survey of terminology developers, the development of a
process for HL7 registration of terminologies, and the maintenance of vocabulary domain
specification tables.
A summary description of HL7 strategies includes the following:
1. HL7 will maintain the meaning and/or semantics of nomenclature of health-related
knowledge and will promote the development of relevant and compatible standards that
would support the efficient transfer and sharing of healthcare knowledge and informa-
tion between computers.
2. It will evolve a formal methodology to support the creation of HL7 standards from the
HL7 RIM.
3. It will disseminate information on the benefits of healthcare information standardiza-
tion to academic institutions, healthcare management organizations, healthcare services
providers, policy makers, and the public at large.
4. It will encourage the adoption and diffusion of HL7 standards worldwide through the
efforts of HL7 international affiliate organizations, which will be formed to participate
in developing and localizing HL7 standards.
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5. It will bring together domain experts from academic institutions, healthcare services
provider organizations, and healthcare management organizations to collaborate and de-
velop standards for HL7 inclusion in various specialty areas.
6. HL7 will join with other SDOs and national and international sanctioning bodies such
as ANSI and ISO to promote the mutual exchange and use of compatible and other
healthcare information standards.
7. HL7 will ensure that current propagated standards fulfill the diverse requirements of the
present era and will initiate effort to meet the emergent requirements.
8. HL7 will institute membership policies to ensure that all requirements are met uni-
formly and equitably with quality and consistency.
HL7 Adoption
The relentless efforts put forward by HL7 have paid off in that countries such as Argentina,
Australia, Canada, China, the Czech Republic, Finland, Germany, India, Japan, Korea, Lithuania,
The Netherlands, New Zealand, the Republic of South Africa, Switzerland, Taiwan, Turkey, and
the United Kingdom have now become part of HL7 initiatives. Presently, HL7 is also being used
by about 2,000 leading hospitals in countries like Japan, Germany, Sweden, and Holland. In the
United States alone, HL7 standards have been influential—more than 150 U.S. healthcare institu-
tions, U.S. Centers for Disease Control and Prevention (CDC), large referral laboratories and emi-
nent universities have adopted these standards. Moreover, countries like New Zealand and Australia
have already adopted HL7 as their national standards. Today, HL7 is known to be the most widely
implemented healthcare data-messaging standard and boasts more than 500 organizational mem-
bers along with more than 2,000 individual members, including top healthcare executives, health
information system vendors, and pharmaceutical representatives and computer manufacturers.
V. DICOM: Digital Imaging and
Communication in Medicine
Originally, the joint committee of the American College of Radiology and the National Electronic
Manufacturers Association (ACR/NEMA) oversaw the development of Digital Imaging and
Communication in Medicine (DICOM) standards. DICOM, which has emerged to fulfill the
need for transferring digital images of various formats as well as related information between de-
vices (irrespective of the device manufacturer), is a nonproprietary data interchange protocol.16
The comprehensive specification of DICOM includes the detailed engineering information
used as a blueprint for information structures and procedures. These engineering details will en-
hance the network connectivity among the community of vendors’ products, thereby enabling
exchange of various formats of medical information within and outside the healthcare services
organizations through the far-fetched abilities of telemedicine and other technologies.
The DICOM standards documentation comprises the following modules:17
● PS 3.1: Introduction and Overview
● PS 3.2: Conformance
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● PS 3.3: Information Object Definitions
● PS 3.4: Service Class Specifications
● PS 3.5: Data Structure and Encoding
● PS 3.6: Data Dictionary
● PS 3.7: Message Exchange
● PS 3.8: Network Communication Support for Message Exchange
● PS 3.9: Retired
● PS 3.10: Media Storage and File Format for Data Interchange
● PS 3.11: Media Storage Application Profiles
● PS 3.12: Media Formats and Physical Media for Data Interchange
● PS 3.13: Retired
● PS 3.14: Grayscale Standard Display Function
● PS 3.15: Security Profiles
● PS 3.16: Content Mapping Resource
The DICOM Standards Committee comprises several working groups; the description and ob-
jectives of each group are beyond the scope of this chapter, but readers can get more details about
WG 1 through WG 21, and WG 22 through WG 26 from Klein18 and the DICOM Standards
Committee website.19 There are five general application areas covered by the DICOM standards:20
● Network image management.
● Network image interpretation management.
● Network print management.
● Imaging procedure management.
● Off-line storage media management.
In 1985, DICOM version 1.0 was developed by ACR/NEMA. It has since undergone two
consecutive revisions. Consequently, a revised version 2.0 emerged in 1988, which included
version 1.0 but with additional information on new commands to uniquely identify any infor-
mation object from the hierarchy scheme and to add data elements for precise description of an
image. Today, DICOM version 3.0 is recognized as the improved and most recent version.
Purpose of DICOM
The DICOM message standard, in collaboration with other standard groups, vies for the com-
patibility with other MI and HMIS standards. The aim is to enhance the form and flow of dig-
ital information between medical imaging systems across the different healthcare services
delivery environments globally. With its growing success, DICOM intends to bring together all
the medical societies, universities, governmental and nongovernmental agencies, and nonprofit
as well as for-profit organizations to join or participate in the DICOM Standards Committee.
Awareness and knowledge of the DICOM standards will create ample room for its adoption
and diffusion as well as its further extension.
The DICOM standards are used, or will soon be used, by virtually every medical profession
that utilizes images within the healthcare industry, such as cardiology, dentistry, endoscopy,
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mammography, ophthalmology, orthopedics, pathology, pediatrics, radiation therapy, radiology,
and surgery. The DICOM standards are even used in veterinary medical imaging applications.
There is an escalating interest regarding the efficient management of digitizing medical images for
easy transfer between electronic devices. These standards are structured to support the formatting
and exchanging of complex medical imaging applications in all the major medical disciplines noted
earlier. Tele-radiology has emerged as the bridge to close the gap between the general physicians and
the referral specialists, including radiologists, cardiologists, orthodontists, ophthalmologists, pathol-
ogists, radiation therapists, pediatricians, surgeons, and other medical specialists who are used to
reading radiological images to support the continuing care of their patients. Today, these encoding
and communications protocols have largely moved into electronic storage, exchange, pre-fetching,
real-time retrieval, and return of diagnostic and therapeutic images and image- and non-image-re-
lated information in emergencies and other high-stress medical environments.
The DICOM standards aim to bridge the gap through interoperability while enhancing the
workflow efficiency between medical imaging equipment and other medical image–intensive de-
partments on a global scale. By so doing, DICOM standards will enhance communication
among image acquisition, waveform, picture archiving, and information system components.
During the 1990s, laudable effort was done to achieve filmless radiology. The strides of DICOM
standards were recognized in achieving this goal. The flexible nature of DICOM standards en-
ables users to create an image management system. Designing a system around DICOM can pre-
vent a department from being ‘‘trapped’’ by a single vendor and limited to a proprietary family
of products; still, naive implementation of DICOM standards does not guarantee this flexibil-
ity.21
The DICOM standards allow proper organization of “information objects” by aggregating
images having similar attributes. It further provides free-text and coded-data entry as well as
fields for structured encoding. This increases the direct benefits of information retrieval
through precise encoding. With the compatibility provided by DICOM standards, it is antici-
pated that use of image management systems would soon become a “plug-and-play” channel
suitable for handling by any non–technically oriented physician. The DICOM standards also
minimize duplicate data entry at the modality console due to the work lists received by the imag-
ing modality. Additional facilities like query, storage, retrieval, print, and other functionalities are
also supported by the DICOM standards. These cooperative standards promote network con-
nectivity through interoperability of multi-vendor devices by specifying levels of conformance.
DICOM standards maintain nomenclature of a multipart document to support the evolving
standards by the addition of new features. DICOM standards will accommodate explicit hierar-
chy of information objects ranging from images, graphics, texts, reports, waveforms, and print-
ings. Service classes are used to uniquely identify information objects from the hierarchy as part
of the DICOM standards. A lexicon having the nomenclature in groups defines the hierarchy
of information objects, while each data element defining the individual object consists of a data
tag, a data-length specification, and the data value.
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Adoption of DICOM Standards
One of the reasons DICOM standards have been popularly accepted and adopted across a wide
variety of clinical imaging contexts is that these standards specify a conformance statement that
improves the communication of software specifications for imaging equipment.22 Being a part
of cooperative standards, DICOM connects every major diagnostic medical imaging vendor for
cooperating individual testing. The participation of the vendor’s professional societies around
the world will also support and further result in the enhancement of these standards.
With such a long listing of well-tested benefits provided by DICOM, concerned organiza-
tions such as imaging vendors, physician users, SDOs, and those of general interest would not
need to hesitate in embracing DICOM standards. In an effort to improve healthcare imaging,
these standards have long been used and adopted by highly reputed academic institutions such
as Harvard Medical School and other major medical establishments. The radiology department
at Massachusetts General Hospital (MGH), for example, adopted DICOM standards years
ahead of others for all of its tele-radiological programs.
VI. Web Standards
In 1994, Tim Berners-Lee founded the World Wide Web Consortium (W3C)—a consortium
formed to ensure compatibility and agreement among industry members in the adoption of
new Web standards. W3C’s mission is “To lead the World Wide Web to its full potential by de-
veloping protocols and guidelines that ensure long-term growth for the Web.”23
The World Wide Web (WWW) differs from the Internet in that it essentially is a set of soft-
ware protocols that resides on the network or the Internet and that allows easy access of infor-
mation for the end-user. W3C establishes the agreed-upon Web standards. Web standards
basically encompass many formal standards and other technical specifications that define and
describe various aspects of the WWW. Among the more popular conceptualization of Web
standards is that these standards are linked to the trend of endorsing a set of established best
practices for building websites and a philosophy of Web design and development that includes
those methods.
Many interdependent standards and specifications exist, which can directly or indirectly af-
fect the development and administration of websites and Web services. Some of these standards
govern aspects of the Internet—and not just the WWW. More particularly, strong advocates of
“Web standards” tend to focus on the higher-level standards that most directly affect the acces-
sibility and usability of websites. Examples include standards to ensure compatibility and inter-
operability between a server computer and its client computers, standards that entail
integrating the variety of different hardware–software configurations that accumulate the Web-
based data on a routine basis, or standards that must support easy access and sharing of Web-based
patient information virtually among multiple end-users. For example, prior to the creation of
the W3C, incompatible versions of HTML were offered by different vendors with emphasis
chiefly on increasing market share over the needs of interoperability, thereby increasing the po-
tential for data inconsistency among Web pages.
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Web standards, when translated, can be separated generally into two different categories,
namely, a “table-free site,” and a site “using valid code.” However, Web standards themselves in-
volve broader aspects. A website built to comply with Web standards should adhere to com-
monly accepted standards such as Hypertext Markup Language (HTML), XHTML and
Modularization, Extensible Markup Language (XML), Cascading Style Sheets (CSS),
Document Object Model (DOM), and others (e.g., MathML) while utilizing valid code prac-
tices, accessible code, semantically correct code, and user-friendly URLs (universal resource lo-
cators). In the broader sense, Web standards, therefore, comprise the following generally
accepted specifications:
● Hypertext Markup Language (HTML). HTML 4.0 is widely used on the Web for adding
structure to text documents; Web browsers interpret these documents, representing the
structure in media-specific ways to the user.
● XHTML and Modularization. XHTML 1.0 is a reformulation of HTML as an XML ap-
plication; XHTML 1.1 is an upgrade.
● Extensible Markup Language (XML). XML 1.0 is a markup language that allows you to
define your own elements.
● CSS: Cascading Style Sheets. CSS is a mechanism for changing the appearance of HTML
or XML elements by assigning styles to element types, self-defined classes of elements, or
individual instances.
● Document Object Model Level 1 (DOM 1), DOM allows the full power and interactivity
of a scripting language such as ECMA Script, the standardized version of JavaScript, to be
exerted on a Web page.
● MathML: Document Markup for Mathematics. MathML is an XML enabling application
for sharing mathematical documentation through standardized notations adoption for
conveying both the structure and content of Web-based mathematical information.
Complying with Web standards can give Web pages greater visibility in Web search engines
such as Yahoo! and Google. The structural information present in standards-compliant docu-
ments makes it easy for search engines to access and evaluate the information in those documents.
Websites get indexed more accurately due to the use of Web standards, making it easier for server-
side as well as client-side software to understand the structure and content of the document.
Web standards are adopted so that old browsers will still understand the basic structure of a
document. Writing Web pages in accordance with the standards shortens site development time
and makes pages easier to maintain. Debugging and troubleshooting become easier as the code
follows a standard of Web page development. This all ties in with the W3C mission statement
to help ensure positive long-term growth for the Web.
VII. Conclusion
Both MI and HMIS disciplines are undergoing a state of rapid metamorphosis and promising
new initiatives that will have significant effects on the practice of medicine. Together with fields
like medicine, health sciences, systems sciences, information technology, education, and com-
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puter and electrical engineering, these disciplines have fueled myriad gold standards. Despite
the overwhelming array of benefits presented by the gold standards of these disciplines, their
adoption has either been too sluggish or not universal. Why? Systems developers generally indi-
cate that, while they would like to make use of standards, they cannot find one that meets their
needs. What are those needs? The answers to this question are less clear. The simple answer is, “It
doesn’t have exactly what I want.” In the quest of decreasing the health disparities and despite
the hopeful aims of these standards, the knowledge gap has limited the acceptance of some. A
major challenge is, apparently, adopting those standards that will become gold standards.
During the past century, the medical field has experienced thrilling changes like new drugs,
new devices, and new techniques. These mega-changes are being constantly adopted, but the real
metamorphosis will be seen when the concepts of MI and HMIS help build real-world solutions
for the administrative, clinical, and relevant systems that would enhance seamless interoperabil-
ity and multilateral communication between the business units of the enterprise, whereby a co-
hesive information model can be maintained to promote the strategic goals of the enterprise. If
we want to enjoy the benefits of information management technologies, we must embrace and
even streamline many of these standards for the welfare of the planet. Heterogeneity of clinical
knowledge and the continuing diversity that preclude effectiveness have plagued users, develop-
ers, and implementers of computer-based applications in medicine. International standards in
healthcare information systems have provided the pivotal backbone to integrating clinical knowl-
edge discovery. Standards such as ICD-9, HL7, and DICOM have been so overwhelmingly ac-
cepted that when strengthened by an enforceable law like HIPAA, these standards promise to
satisfy the demanding capabilities of the electronic and digital needs in medicine.
Notes
1. M. Mosquera, GCN Staff, http://www.gcn.com/online/vol1_no1/35995-1.html?topic=e_gov#,
accessed July 30, 2008.
2. M. F. Collen, “Origins of Medical Informatics,” Western Journal of Medicine 145 (1986):
778–785.
3. http://www.ii.metu.edu.tr/~ion535/demo/lecture_notes/week1/week1-3.html#1-2, accessed
April 8, 2006.
4. W. D. Pace, E. W. Staton, and S. Holcomb, “Practice-Based Research Network Studies in
the Age of HIPAA,” Annals of Family Medicine 3, suppl 1 (2005): S38–S45. DOI: 10.1370/
afm.301.
5. “Standards for Automated Medical Records,” General Accounting Office report GAO/
IMTEC-93–17, April 30, 1993.
6. The ICD-9-CM is a standardized system of codes describing diagnoses developed and main-
tained by the World Health Organization (WHO).
7. Physicians’ Current Procedural Terminology (CPT) is a coding system established in 1966
by the American Medical Association to provide a uniform language to accurately describe
medical, surgical, and diagnostic services. Each procedure or service is identified with a five-
digit code.
8. Detailed descriptions of ICD-10 codes and many other coding schemes can be found
in various websites or from links to the Duke University Medical Center site (www
.mcis.duke.edu).
N O T E S 277
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9. M. K. Bourke, Strategy and Architecture of Health Care Information Systems (New York:
Springer-Verlag, 1994).
10. J. K. O’Herrin, N. Fost, and K. A. Kudsk, “Health Insurance Portability Accountability Act
(HIPAA) Regulations Effect on Medical Record Research,” Annals of Surgery 239 (2004):
772–778.
11. E. S. Berner, D. E. Detmer, and D. Simborg, “Will the Wave Finally Break? A Brief View of
the Adoption of Electronic Medical Records in the United States,” Journal of the American
Medical Information Association 12 (2005): 3–7, DOI 10.1197/jamia.M1664.
12. http://www.hl7.org/about/, accessed March 18, 2007.
13. Ibid.
14. R. H. Dolin et al., “The HL7 Clinical Document Architecture,” Journal of the American
Medical Information Association 8 (2001): 552–569.
15. S. Bakken, K. E. Campbell, J. J. Cimino, S. M. Huff, and W. Hammond, “Toward
Vocabulary Domain Specifications for Health Level 7-Coded Data Elements,” Journal of the
American Medical Information Association 7, no. 4 (2000): 333–342.
16. A. T. Ramos, “Information Object Definition–Based Unified Modeling Language
Representation of DICOM Structured Reporting. A Case Study of Transcoding DICOM to
XML,” Journal of the American Medical Information Association 9 (2002): 63–71.
17. “Digital Imaging and Communications in Medicine (DICOM), Part 1: Introduction and
Overview,” PS 3.1-2004, http://medical.nema.org/dicom/2004/04_01PU.PDF, accessed
December 5, 2006.
18. G. O. Klein, “Review Paper: Standardization of Health Informatics—Results and
Challenges,” Yearbook of Medical Informatics (2002): 103–114.
19. Dicom Standards Committee, http://www.nema.org/prod/med/upload/DICOM%20
STANDARDS%20COMMITTEE-3 , accessed December 2, 2006.
20. W. D. Bidgood, S. C. Hori, F. W. Prior, and D. E. V. Syckle, “Understanding and Using
DICOM, the Data Interchange Standard for Biomedical Imaging,” Journal of the American
Medical Information Association 4 (1997): 199–212.
21. Ibid.
22. Ibid.
23. W3C, http://www.w3.org/consortium, accessed December, 2008.
Chapter Questions
12–1. Define the following terms:
a. Medicine.
b. Medical informatics.
c. Standards.
d. HIPAA.
[Hint: All these terms come from the list of Medical Subject Headings (MeSH) main-
tained by the U.S. National Library of Medicine. It is updated annually and keeps record
of the nomenclature of the world’s medical literature index; see http://www.nlm.nih
.gov/cgi/mesh/2007/MB_cgi.]
12–2. What are data standards? Discuss the usefulness of these standards to implementing
HMIS. [Think, for example, what the purpose of a unique patient identifier (PID)
would be and who should be authorized to access and share this information to whom.]
12–3. How should one go about adopting a major HMIS standard, for example, HL7 or
DICOM?
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12–4. The Complete Reference observes:
The economic justification for [standardized] codes vanished years ago.
Computers are now fast enough and cheap enough to accommodate the hu-
mans, and work in human languages with words that humans understand. It is
high time that they did so. Yet, without really thinking through the justifications,
developers and designers continue to use codes willy-nilly, as if it were still
1969. . . . There is an immediate additional benefit: key entry errors drop to
zero because the users get immediate feedback, in English, of the business infor-
mation they are entering. Digits aren’t transposed, codes aren’t remembered, and
in financial applications, money rarely is lost in suspense accounts due to entry
errors, with very significant savings.
As a student of health information systems, can you justify the continuing use of stan-
dardized codes for referencing medical data?
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HIPAA, Privacy, and Security Issues
for Healthcare Services Organizations
Joseph Tan and Fay Cobb Payton
280
Introduction
Health management information systems (HMIS) relate to the accumulation of paper-based
and electronic data applicable to health administrative and clinical decision making that will as-
sist an organization to achieve its predetermined goals and specific objectives. It is, therefore, in
the best interest of every member of a healthcare organization to be responsible for the critical
task of securing and protecting the quality, management, privacy, and confidentiality of health
information kept within the HMIS of the healthcare organization.
The Fourth Amendment to the U.S. Constitution essentially guarantees every American res-
ident his or her basic rights to privacy and freedom. Everyone employed by a healthcare services
organization, but especially those who are asked to handle sensitive personal health informa-
tion, such as patient health records, has the responsibility of protecting the privacy, confiden-
tiality, and security of these records or any other means of identification. Congress has,
furthermore, enacted laws to help prevent private information from being inappropriately re-
leased or handled and to ensure that the personal information of Americans is kept confiden-
tial. With the growing use of electronic information exchanges, and the resultant spike in
identity theft and other electronically based misdeeds, it is no wonder that the public is becom-
ing increasingly apprehensive about providing personal data. In this policy brief, our focus is on
the Health Insurance Portability and Accountability Act (HIPAA), the Privacy Rule, confiden-
tiality, and security issues related to health information handling and information resources
management.
I
POLICY BRIEF
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HIPAA
Specifically tailored for the healthcare services industry, the HIPAA rulings, along with other se-
curity measures, have been instituted to protect the freedom, security, privacy, and confidential-
ity of individuals. Such measures arise amid the patients’ increased sharing of personal
health-related information with authorized agencies and care providers. In the United States,
therefore, every citizen has the basic right to the protection and safeguarding of his or her health
information and for those managing and handling these data to take an ethical responsibility to
uphold the laws within our ever-changing, innovative technological environment.
In 1996, Congress passed Public Law 104-191, otherwise known as HIPAA.1 HIPAA
required the U.S. Department of Health and Human Services (HHS) to establish, with far-
reaching implications and consequences, new guidelines, key principles, and national standards
for handling electronic healthcare transactions. Everyone working within the U.S. healthcare
system must strictly adhere to these principles, guidelines, and standards. Covered entities in-
clude, but are not limited to, individual caregivers such as doctors, nurses, and pharmacists;
healthcare facilities such as hospitals, clinics, and nursing homes; and groups and organizations
such as private physician organizations (PPOs), private health insurance companies, and health
maintenance organizations (HMOs). Even government programs, such as Medicaid and
Medicare, must follow the HIPAA-imposed guidelines. HIPAA, therefore, covers the majority,
or even the entirety, of the U.S. healthcare system, including private, public, and government
healthcare facilities, as well as practicing health professionals.
What information, precisely, is HIPAA protecting? This federal mandate covers the pro-
tection of any information in an individual’s personal records, including diagnosis and treat-
ment reports, progress notes, recommendations, and even conversations with personal
caregivers. It also safeguards the information that is processed into computer systems used by
care providers for billing, medication, clinical evaluation reports, radiological images and re-
ports, laboratory test results, and any information collected by individuals or organizations that
has a health semantic.2 Therefore, HIPAA essentially protects all personal health information,
stored in any medium, located in any U.S.-based organization, regardless of whether this infor-
mation was obtained directly from an individual or through third parties. Owing to the vast
amount of information being collected daily on patients by their healthcare insurers, these or-
ganizations must be particularly conscious of HIPAA’s requirements for the protection of this
collected information. HIPAA law simply states that all persons who have access to health in-
formation must comply with the regulations, including the protection of anything, whether
written or spoken, that deals with a particular patient’s current medical condition and his or
her past or ongoing treatments.
Privacy and Confidentiality
HMIS pose a threat to all health information stored electronically if the healthcare organiza-
tion, as the custodian, does not act responsibly in securing the information gathered from its
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trusting patients. One critical success factor toward maintaining health information security,
privacy, and confidentiality, therefore, is simply to educate those who use and handle HMIS on
a daily basis about how to protect a patient’s health information. The HIPAA not only estab-
lishes national standards and guidelines to protect access to, and use of, a patient’s health infor-
mation, but also gives the patient specific rights. Under HIPAA, each individual patient has the
right to obtain a copy of his or her own medical records and the right to review the content of
these records. If, at any time, a patient feels that there are errors found on these records or that
the individual rights under HIPAA have been violated, he or she has the right to have correc-
tions and/or notes appended to these records, as well as the right to file a complaint with the
healthcare provider organization, and, at an even higher level, with the U.S. government.
HIPAA regulations also state how healthcare providers and insurance companies are to com-
ply with the law.3 HIPAA grants patients the right to receive notice when their health informa-
tion is being used or shared. Specifically, patient consent is always a basic requirement for
health information releases, except when such uses are only for certain marketing purposes, in
which case aggregated information is largely derived from statistical summaries of patient
health records. Moreover, if a patient’s information has been used, the patient has the right to
receive a report on when and why this information was used. Reports stating why someone’s
records have been shared are important because these provide the documentation on who,
when, and why someone, or an organization, has attempted to access a certain patient’s medical
history. In essence, HIPAA protects any private information regarding the health status of the
patients, and the care they have received from U.S. health organizations. Also, for a higher level
of protection, the patient may also exercise the right to request communications from some-
where other than his or her home, as long as it is within reason.
Healthcare services organizations that want to take further steps to protect personal private
health and medical information will also find that HIPAA offers guidelines on education—
specifically, with operations that involve health information within the HIPAA legal frame-
work. Basically, HIPAA requires organizations to respect and safeguard the privacy and
confidentiality of collected personal health-related information. This is accomplished by de-
manding that organizations educate the direct handlers and users4 of such information about
the process an information release request must follow—for example, to whom or which organ-
ization, or for what purposes (such as personal safekeeping, marketing, specialist referrals,
and/or research) the information can or cannot be shared and/or other steps that organizations
can take to keep an individual’s health information private.
In fact, after Congress passed HIPAA in 1996, the HHS introduced the “Privacy Rule” to
further refine and clarify HIPAA’s articulated view of privacy. In July 2001, and again in
August 2002, HHS released a series of guidelines to clarify questions pertaining to the original
Privacy Rule, describe policies and key elements of the final modified Privacy Rule’s require-
ments, and provide further modifications that would lead to the Final Rule.5 Within the
HIPAA privacy framework, HHS also incorporated appropriate safeguards for personal health
information. Certain aspects of the modified rule acknowledge marketing capabilities and the
privacy of an individual’s health information. Other areas deal with clarifying consent and
notice, uses of disclosure, and authorization specifications. The modifications define issues with
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incidental use, parents and minors, and research. Designed to give patients more control over
their own health information, the Privacy Rule sets boundaries on health records and limits on
how these records can be used and viewed. It also determines who can view the records and
when; for example, a person’s health information may not be disclosed to a third party unless
consent has previously been given, and if so, the information should be released within 30 days
upon request.
Generally speaking, the Privacy Rule comprises five key principles: (1) consumer control, (2) the
setting of boundaries, (3) accountability, (4) public responsibility, and (5) security. Consumer
control, which was highlighted earlier, provides individuals with the right to control the release
of their information. For example, patients now have to sign a specific authorization before a
covered entity can release their health information to a life insurer, bank, marketing company,
or any other entity for any use not pertaining to healthcare services. Herein lies the crux of the
boundaries concept; that is, healthcare information should be used for healthcare purposes, such
as treatment and payment options, unless there is an exceptional reason for not doing so.
Accountability, the next principle, infers that all covered entities must be held responsible for
their actions; for example, each healthcare organization is accountable for guaranteeing its pa-
tients the secure storage of their health information, so that it is not released without the pa-
tient’s specific written consent. Public responsibility implies that there are certain exceptions
when dealing with the support of national priorities. These exceptions may include emergency
circumstances, identification of a deceased person or cause of death, catering to public health
needs, or activities related to national defense and security. Anything that will affect the public
and national security must be handled promptly, with a certain amount of exception to the
Privacy Rule.
To comply with HIPAA standards regarding privacy,6 affected individuals and organizations
can enact several changes. The use of privacy screens such as standard blur, double axis, and
blackout on computers is one example. Recognizing information privacy and protecting it
when an employee of the healthcare organization is entering identifiable health information
into a computer is important. What these privacy screens do, essentially, is to block the screen
so it cannot be viewed by anyone outside a 25° angle from the screen. In this sense, nobody, ex-
cept the person entering the information, will be able to discern what is being entered. Another
means of privacy control is the use of encryption, which is also an excellent choice for security
and access control. Encryption takes the text and scrambles the letters into many different com-
binations, so that without the “key” to decipher the encrypted text, the information remains
locked. A popular form of encryption is 256-bit encryption, which amounts to precisely 2256
possible combinations. This would render it physically impossible to figure out the encrypted
message, simply due to the gargantuan number of possible combinations.
Finally, the emergence, in recent years, of wireless Internet services and mobile wearable de-
vices has introduced a new dimension to safeguarding and protecting individuals’ private
healthcare information. In August 2007, the standards for electronic transactions, which cover
the rules and regulations for sending and receiving an individual’s private health and medical
records, were released.7 Previous legacy HMIS render interoperability among systems a chal-
lenging issue, but the lack of such data-sharing capabilities also provided an easier and better
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privacy control environment. The implementation of Web services, as well as other advancing
data interchange technologies today, will raise further concerns over the privacy and security of
personal health data, because they are being shared among automated intelligence and applica-
tions. HIPAA addresses what strategies are appropriate for staying in compliance with the fed-
eral law. To insure HIPAA compliance, HHS issued seven regulatory steps that healthcare
services organizations must follow:
1. Encryption of private health data will prevent intruders from locating transmissions across
cyber space and makes recoding the transmission more difficult.
2. Authentication will help the organization identify who is, or is not, allowed to access spe-
cific documents and records.
3. Access control will minimize the inappropriate retrieval of critical information stored in
HMIS.
4. Integrity control will protect the validity and reliability of HMIS-accessible data.
5. Alarms will provide warnings and alerts about attempted or intended intrusions into
stored private data.
6. Audit controls will allow for meaningful tracing of inappropriate acts of information ac-
cess and retrieval.
7. Event reporting will ensure that any breach of HIPAA standards and regulations is swiftly
reported, and resulting damages controlled within a short span of time.
Security
Security is essential to every aspect of life. For healthcare services, patients must feel safe when
providing their caregivers and/or healthcare services organizations with sensitive and personal
information. This is essential to the construction of a trusting relationship between the patients
and their caregivers.
The security law, which is the final component of HIPAA, was put into place in February
2003. Security deals with the protection of identifiable health information against both in-
advertent disclosure and deliberate misuse. Two types of security breaches result in the im-
position of penalties. One is the failure of a covered entity to comply with HIPAA
standards. Here, the penalty can be up to $100 per violation and up to $25,000 per year.
The other type, where the imposed penalties are steeper, is for any intentional misuse of
someone’s health information—whether it was done for commercial advantage, personal
gain, or malicious harm. These penalties can range from a fine of $50,000 and 1 year in
prison to $250,000 and 10 years in prison.
The final security law established standards and regulations for healthcare providers on the
required procedures toward ensuring administrative safeguards. For ensuring the security of in-
formation, for example, the access points to the information are crucial. Passwords and log-ins
are often used as the first line of defense in HMIS. Physical, as well as technical, safeguards
must also be in place. These safeguards protect the healthcare services organizations from
security violations and the maintenance of an individual’s private health and medical records.
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The final security law also specifies the type of security policies and procedures that the organi-
zation must follow. If a person feels that a complaint about the security of his or her identifiable
health information should be filed, he or she can first approach the care provider or the insurer.
If that is not responded to in a satisfactory manner, request for enforcement must then be sub-
mitted in writing within 180 days of the occurrence. This complaint should then be sent to the
Office for Civil Rights (OCR) within the Department of Health and Human Services.
Security, confidentiality, and privacy of clinical, financial, and management health data
(whether computerized or not) are, therefore, major concerns for healthcare services organiza-
tions. As such, the development and enforcement of stringent HMIS policies and procedures
must strike a balance between restrictive user access and data sharing. The management and re-
tention of patient records and the security of health networks are particularly important.
Nowadays, owing to the massive storage capacity of computers relative to physical storage, it
may be easier for healthcare services organizations to electronically store and share massive
amounts of health information across organizational units, but it is also easier for thieves and
computer hackers to steal large amounts of information in incredibly short periods of time. As
malicious attacks on HMIS are expected to be on the rise, it is crucial for healthcare services or-
ganizations to endure the cost of installing the best security mechanisms so that the sensitive
healthcare information under their custodianship is well protected.
Aside from computer hackers, another common security threat is that of computer viruses,
which are program codes used to clog the capacity of an organization’s system and eventually
alter and/or destroy data in the server database, thereby ruining the entire system. Viruses
spread popularly through spam e-mails; in light of this, security procedures to protect against
viruses from organizational networks may include:
● Scanning incoming e-mails and installed software with an anti-virus program.
● Updating anti-virus, firewall, and anti-spam programs on a regular, even daily, basis.
● Using and enforcing effective security codes and changing passwords for network users.
● Periodically running anti-virus software on network servers, workstations, and nodes.
There are also firewalls that regulate access to organizational computer systems, which,
through the usage of ports and IP addresses, admit based on a certain determined level of trust.
The most significant danger that has been introduced along with wireless technology into an
organization’s HMIS is the ability for thieves to bypass physical security measures that had been
counted on in the past by healthcare professionals.
In the end, each of us must take an active role in keeping our personal information safe; for
example, we must safeguard the personal information that is stored on our home computers,
because it can also be at risk. As noted, one of the ways to address the security issue is to imple-
ment controls at various levels: systems control, procedural control, and facility control as
shown in Figure PB1.1.
Procedural controls are an important aspect of systems security. These controls specify how
the information services of the healthcare services organizations should be operated, such that
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maximum security can be achieved, along with high accuracy and integrity of the HMIS func-
tions and operations. There are three major means of achieving procedural controls:
1. Separation of duties.
2. Standardizing procedures and documentation.
3. Authorization requirements.
To prevent the possibility that a single group will gain unrestricted access to related HMIS
functions, systems development, computer operations, and control of health data and program
files should each be assigned to a separate group. Development of standard procedures, through
manual and software help displays, promotes uniformity and minimizes errors and fraud. In ad-
dition, to further enhance system uniformity and minimize potential destruction, there should
be a formal review and authorization on any major system development projects, program
changes, or system conversion by the chief information officer (CIO), the departmental head,
or a supervisor, all of whom are expected to have reached a certain level of security clearance.
Procedures for effective health data backup include preparing for disaster recovery through
regular copying or duplication of programs, files, and databases; adequate logging of transac-
tions to reconstruct any lost data; detection of missing or incomplete records; and institution of
other backup operational procedures for use during system failures—such as having an alterna-
tive manual or computerized system ready and functional in the shortest possible time. Fault-
tolerant procedures, which are designed specifically for fault treatment, error detection, and
recovery, provide a high degree of system stability and reliability.8 Policies governing the
process, as well as the frequency of the procedures, are also crucial in protecting the integrity of
health data. Whereas duplicated data can be secured and stored in a location separate from the
central site, for instance, procedures must exist during any downtime experienced at the primary
286 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M S TA N D A R D S
Physical Facilities Controls
Procedural Controls
Information System Controls
Information System Security
Physical Protection, Computer Failure Controls,
Telecommunications Controls, Insurance
Separation of Duties, Standard Procedures,
Documentation, Authorization Requirements, Auditing
Input, Processing, Output,
and Storage Controls
FIGURE TB5.1 Levels of Security Controls.
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site, whether scheduled or unscheduled, so that systems can continue operating. In addition,
highly sensitive files should be backed up on disks and the disks secured to prevent unautho-
rized access.
Because computer hardware and software undergo replacement in most healthcare services
organizations from time to time, security measures to protect these investments are essential.
Such essential measures include the location of workstations, servers, printers, and other acces-
sories in lockable, secure areas when not in use. Name tags, organizational labels, access codes,
and physical cable-lock systems are examples of inexpensive ways through which newly ac-
quired hardware and software can be protected.
All sensitive health information should be maintained in designated areas and subjected to
strict security control. Such information should only be used in areas that are considered private
and inaccessible to unauthorized personnel. For example, terminals should shut down automat-
ically when not in use, and mechanisms should be in place to disconnect terminals after a spe-
cific number of invalid attempts to access the system. Written policies should delineate who can
access what information and for what purpose; for instance, researchers may only access a spe-
cific population’s health information for the purpose of research and education. Oftentimes,
this means that de-identification is critical to safeguard patients within the specific population
used for research and education objectives. Health records personnel must be trained experts in
aspects of confidentiality, record access, and storage and should become excellent resources in
policy development and implementation.
HIPAA clearly states that no information shall be released without written consent from the
data owner (patient), unless otherwise legislated, such as in emergencies or unusual situations.
Thus, policies and procedures are essential to guiding health professionals and health records
personnel in safeguarding confidential information for both normal and emergency or unusual
circumstances. Examples of unusual circumstances where access to a patient’s record may be re-
quested include review by a coroner in preparation for an inquest; litigation against the hospital
or physician; and potential for litigation because of serious misadventure, alleged malpractice,
or complication.
Attention on security and confidentiality regarding electronic health records (EHR) add an-
other layer of complexity. On the one hand, concern about the confidentiality of patient
records typically underlie the positive attitude that many patients maintain toward EHR.
Ornstein and Bearden interviewed 16 patients of eight different physicians from a medical uni-
versity.9 One strategy to ease the concern they found was to have patients kept informed about
their records and uses. Borst10 noted that most patients thought computer-based medical
records were unsafe, particularly due to their vulnerability to blackmail. Inevitably, insurance
companies and future employers can use these records to make decisions on who to (or not to)
insure and/or hire. The potential does exist for discrimination against cases of mental illness, peo-
ple with HIV infection, or other ill-fated problems. On the other hand, technologies have been
developed and are available to ensure the security of EHR. These include Internet security soft-
ware such as firewalls, intrusion-detection programs, digital certificates, and authentication and
authorization software. For example, Andreae11 discussed how public key cryptography could
be used to reliably enhance authentication and authorization of data transfer, thereby eliminating
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access to confidential information on networks. Unfortunately, nearly 60 percent of all cyber
crime goes undetected or unreported, so nobody really knows the extent of cyber-attacks to-
day. However, the same legal requirements that apply to paper records still apply to computer-
based records. Waller and Fulton12 argued that “insiders” (i.e., employees who use the
computers on a daily basis) pose the greatest threat to security, given that they are the “closest”
to accessing the data.
Retention of records is another major issue of concern because patient records and other in-
formation may be needed for legal defense. The retention period should be at least as long as
the limitation period during which the organization can face a targeted lawsuit. Thus, these re-
tention periods may vary depending on the type of facility and the governing legislation. The
courts have also extended limitation periods depending on the patients involved. Destruction
of health information is also controlled by legislation; therefore, written institutional policies
must specify the methods of destruction to be used, such as shredding or burning. Routine de-
struction methods of daily paper accumulation that contains health data and periodic destruc-
tion methods of inactive or outdated recorded health data should also be specified, with
particular attention to the designation of personnel who will witness or attest to the destruction
in writing. Methods of erasing health information that has been recorded or stored by elec-
tronic means should also be specified. The point is that issues related to confidentiality, security,
and privacy should not impede patient care.
All employees and health data users should also be asked to sign a pledge of confidentiality
that incorporates computerized health information within its scope. How to report breaches in
security should be included in the policies as well, along with a statement of disciplinary mea-
sures for violation of computerized data security. It may be important to note that the accept-
ance of the electronic signature as a legal signature for admissibility as evidence in court is still
not clearly established. Principles of documentation, in the context of computerized health in-
formation, should meet legal and professional standards. Appropriate orientation programs, on-
going educational seminars, and attendance at conferences are essential to ensure that
managers, health record professionals, and other hospital staff are fully aware of the policies and
procedures governing information access, security measures, and confidentiality expectations.
Finally, essential aspects of HMIS security are the use of audit controls and the enforcement
of original policies and procedures, with regard to systems and information access. For example,
users should only have authorized access to data files that are necessary for completing their as-
signed work, and breaching of policies must be swiftly and professionally handled to ensure
confidence in data integrity and protection of confidentiality. In this business, it should be
noted that the biggest concern is the loss of public trust and image. Imagine how patients
would feel about giving away their personal information to an organization incapable of and
unable to safeguard this information.
Conclusion
In conclusion, the Health Insurance Portability and Accountability Act is a major accomplish-
ment of the U.S. Congress in signifying to the general public that an interest is being taken to
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protect their personal private health and medical records. If the information was not carefully
protected, then the trust between the patients and their caregivers would be jeopardized. The
federal government can now assure individuals that healthcare services organizations responsi-
ble for transmitting and storing their personal information have to adhere to legally enforceable
standards and regulations. Individuals now have more control over their health records and can
obtain a copy for their own medical records at any time. They are allowed to file a complaint if,
in the healthcare services organization’s HMIS, there is a violation of the HIPAA ruling per-
taining to the safekeeping of their personal information. Healthcare services organizations now
also have a set of guidelines and procedures that they must follow when handling private med-
ical records. These organizations have to hire workers who have knowledge of HIPAA require-
ments. They have to make sure that the organization respects the law and does not receive a fine
from the federal government for not obeying regulations. Failure to follow all procedures and
rules can result in a significant penalty against the organization.
HMIS encompasses each aspect of life. Just as the sun is an information system, the same
goes for each of us as a human being. Our bodies are information systems that contain every-
thing we will ever need for survival, even in our increasingly complex environment. Our heart is
equipped with the necessary software and hardware to pump blood through our complex sys-
tem of veins; our brains are wired with information useful for transmitting and exchanging sig-
nals with all the other parts of our body so that our organs can keep functioning correctly and
so we can have the proper use of each of our limbs. We, just as with any other information sys-
tems, need protection. Therefore, our bodies have built-in “anti-virus software” that is in-
tended to protect us from certain attacks, such as the common cold. But if our defensive system
breaks down, we can always go to a physician for advice on how to enhance that protection
against viruses, which our bodies may not always be naturally able to fight. Because the infor-
mation contained in our bodies is important to our survival, it is also similar to the information
that is significant for our continued well-being. Information such as our name, date of birth,
and social security number is just as important as our vitals. If our vitals are low, we need the
proper care to bring them back to normal. To safeguard our personal information, guidelines
and standards must be used to maintain a healthy personal life. With advancing technologies,
ensuring the privacy of personal information will have to improve and adapt, just as medication
must do for any and all illnesses.
Notes
1. “Status of HIPAA,” Online Image, LRG Healthcare, http://www.lrgh.org/default.aspx, ac-
cessed December 5, 2007.
2. “What, Who, How, When, Penalties,” Online Image, IT Defense Magazine, http://www
.itdefensemag.com/7_06/images/hipaa.gif, accessed December 5, 2007.
3. “HIPAA Compliance Lifecycle,” Online Image, HIPAA Learning Module, Health Care
Education and Training, http://www.hcet.org/graphics/hipaa/cycle.gif, accessed December 5,
2007.
4. J. B. Earp and F. C. Payton, “Information Privacy in the Service Sector: An Exploratory
Study of Health Care and Banking Professionals,” Journal of Organizational Computing and
Electronic Commerce 16, no. 2 (2006): 105–122.
N O T E S 289
56918_CH12_Final_Tan 4/6/10 1:01 PM Page 289

5. U.S. Department of Human and Health Services, “Medical Privacy—National Standards to
Protect the Privacy of Personal Health Information,” April 2007, http://www.hhs.gov/
ocr/hipaa/, accessed September 29, 2007.
6. U.S. Department of Health and Human Services, Office for Civil Rights, “Standards for
Privacy of Individually Identifiable Health Information,” December 4, 2002, http://www
.hhs.gov/ocr/hipaa/finalmaster.html, accessed December 5, 2007.
7. U.S. Department of Health and Human Services, “Standards for Electronic Transactions
and Code Sets,” HIPAAdvisory, August 17, 2000, http://www.hipaadvisory.com/regs/final
trans/summary.htm, accessed December 5, 2007.
8. T. Anderson and P. Lee, Fault Tolerance: Principles and Practice (Englewood Cliffs, NJ:
Prentice Hall, 1981).
9. S. Ornstein and A. Bearden, “Patient Perspectives on Computer-Based Medical Records,”
Yearbook of Medical Informatics (1995): 247–251.
10. F. Borst, “Synopsis: Computer-Based Patient Records,” Yearbook of Medical Informatics (1995).
11. M. Andreae, “Confidentiality in Medical Telecommunication,” Lancet 347 (1996): 487–488.
12. A. Waller and D. Fulton, “The Electronic Chart: Keeping It Confidential and Secure,”
Journal of Health and Hospital Law 26, no. 4 (1993): 104.
290 H E A LT H M A N A G E M E N T I N F O R M AT I O N S Y S T E M S TA N D A R D S
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Health Management Information
System Governance, Policy, and
International Perspectives:
HMIS Globalization through E-Health
Anantachai Panjamapirom and Philip F. Musa
291
13
CHAPTER
Editor’s Note: The readers should be informed of the choice for including this chapter near the
final part of this health management information systems (HMIS) text. Apparently, the appli-
cation of e-health extends the use of information and communications technologies (ICT) in
healthcare as much as HMIS in healthcare services organizations. Accordingly, HMIS used in
the context of this text is a broad term encompassing all healthcare information systems and
technologies applied in a healthcare services organizational context, whereas e-health is used
specifically in the context of this chapter as an umbrella term encompassing all ICT and related
applications in a global healthcare services context. Hence, there is true parallelism in terms of
the need for ICT governance, policies, and sharing of innovations among developed, develop-
ing, and underdeveloped countries both for HMIS and for e-health. As the editor, I have there-
fore inserted the term “HMIS” where appropriate to sound the underlying message of the
similar challenges facing designers and administrators of healthcare systems—whether deployed
as a system for healthcare providers (health informatics), healthcare services organizations
(HMIS), or entire populations (e-health). The placement of this chapter near the end of this
text represents an attempt to move the readers toward an international perspective of HMIS
and to see how the much more organizationally focused discussions in earlier chapters now have
the opportunity for embracing a wider and higher perspective to be applied along a global scale.
Readers who are interested in this perspective can consult J. Tan (Ed.), E-Health Information
Systems: Introduction to Students and Professionals (San Francisco: Jossey-Bass, May 2005), a
book entirely devoted to the subject of e-health.
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292 HMIS G O V E R N A N C E , P O L I C Y, A N D I N T E R N AT I O N A L P E R S P E C T I V E S
S c e n a r i o : TriZetto and TeleDoc Alliance1
With the increasing expense of providing healthcare for employees, companies are looking for
value-based solutions to complement their existing medical coverage. In response to this trend,
the TriZetto Group and TelaDoc Medical Services have recently announced a distribution al-
liance to provide TriZetto’s customers with telephone access to TelaDoc’s national network of
licensed primary care physicians (PCPs). This consumer-centric approach gives patients with
noncritical health issues access to care 24 hours a day, 7 days a week, 365 days a year.
Michael Gorton, chief executive officer of TelaDoc, is quick to praise this telephone-based
healthcare approach, called tele-health. “Telehealth emerges as a high-value, mainstream model,
and TriZetto’s extensive client base allows TelaDoc to bring this valuable service to the largest
population of consumers served by an industry leader with best-practice access, convenience,
and savings.”
CHAPTER OUTLINE
Scenario: TriZetto and TeleDoc Alliance
I. Introduction
II. Tele-Care, Telemedicine, Tele-Health, and E-Health
III. Types of Telemedicine
IV. The Economic Perspectives of ICT and E-Health
● Production Possibility Frontier
● Positive Externality
V. Factors Influencing the Adoption of E-Health
● Technology Acceptance Model
● Theory of Planned Behavior
● Diffusion of Innovation Theory
● Technology-Organization-Environment Model
VI. Barriers to E-Health Adoption
VII. Stakeholder Analysis
VIII. WHO’s Strategic Framework for E-Health Development
IX. Flow of Resources between Developed and Developing Countries
X. Conclusion
Notes
Chapter Questions
Mini-Case: M&P Cardiovascular Center Inc.
Chapter Appendix: Glossary of Terms
56918_CH13_Final_Tan 4/6/10 1:06 PM Page 292

The service is simple and straightforward. Once a TriZetto customer is enrolled in TelaDoc,
plan members can call to request a consultation. TelaDoc guarantees a return call from a doctor
within three hours, upon which the doctor will provide a brief consultation and may offer
follow-up advice. In addition, the physician has the ability to prescribe short-term, over-the-
counter medications if appropriate.
“TelaDoc services improve access to care and can deliver significant savings to self-insured
organizations,” notes Jeff Gary, executive vice president of TelaDoc. “Employers value TelaDoc
for its role in sustaining a healthy, productive workplace and providing access to care for indi-
viduals who travel and cannot connect with their regular doctor.”
Now, imagine that such a service is acceptable and available to everyone throughout the
world. How would it affect future healthcare services delivery?
I. Introduction
As the world shrinks and nations become increasingly more intercon-
nected, no one nation can afford to turn inward and focus solely on
health status, health professions education, or health system development
and enhancement simply for the sake of its own citizenry.
—Roger J. Bulger, David Hawkins, and John Wyn Owen2
Globalization is a comprehensive phenomenon exhibited throughout the long history of the
growth of population and the advancement of civilization. Although it may be traced as far
back as the 14th century,3 the phenomenon of the global exchange of ideas, goods, and services
has gained much popularity since the close of the 1980s.4 The antecedents of globalization sub-
stantiate an understanding of the current circumstances, whereas the results and their implica-
tions are the agents that stimulate changes and future development. Globalization encompasses
an array of interactive factors that greatly affect the world in different ways. The term generally
has an application on at least six major diverse discourses: economic, technological, environ-
mental, political, social, and cultural contexts.5,6 It is the intertwined connection among these
facets that has transformed the world into its new millennial era.
The world has recognized extensive advantages of globalization. The most common benefits
revolve around economics. Economists assert that globalization can lead to free trade, greater
competition, economies of scale, more efficient approaches for resource allocation, and increase
in economic prosperity, which in turn result in poverty reduction.7–9 Through the globalized
system, nations and their citizens are engaged in exchanging information, embodying cross-
cultural diffusion, and creating unprecedented global cultures. As a result of the economic and
social globalization, nations have formed relationships in which agreements must take place.
Therefore, international political organizations such as the United Nations (UN)10 and the
World Trade Organization (WTO) provide rules and regulations that are utilized to manage the
rights of, and relationships among, nations.
To date, many international initiatives have been established to address global degradations
in our environment through air and water pollution, as well as global warming.11,12 Such integral
I . I N T R O D U C T I O N 293
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efforts have informed us that globalization is an imperative process to which we must pay close
attention. As the achievement of any process requires the right tool, globalization cannot occur
without technological advancements. Technology acts as both the catalyst and the enabler of
globalization. While the introduction of logistics and information technologies allow the world
population to connect and access resources around the globe, the need for more effective and
efficient means have prompted constant creation of innovative technologies.
Paradoxically, some people have argued that globalization has given rise to some detrimental
effects such as inequality and vulnerability.13 However, empirical studies have shown that devel-
oping countries that have open policies for globalization exhibit lower poverty rates than those
that are using inward-oriented policies.14 Moreover, the World Bank15 reported that the open-
ness to international integration is a vital factor that contributes to less inequality among coun-
tries. Evidence also shows that even though the effect of gross domestic policy (GDP) volatility
on developing countries was greater than that of developed countries, the overall volatility on
both GDP and export growth for developing countries significantly decreased during the
1990s, except for the East Asia region due to the 1997–1998 financial crisis.16 Accordingly,
these negative effects should not be perceived as adverse consequences of globalization, but
rather a result of the unorganized involvement of nations in the global network.
One suggestion is that ideas from globalization in the major contexts can be adapted to the
healthcare services industry. If properly implemented, this industry can wholly benefit from
globalization. The healthcare services industry can take advantage of the current advancements
in information and communications technologies (ICT). A number of empirical studies show
that ICT play a prominent part in the solution to various predicaments confronting the global
healthcare environment such as an upward spiral of medical costs, unacceptably low quality of
care in many countries, increasing medical errors, and administrative inefficiencies.17
As a background, calls for the globalization of health care started to gain momentum in
the mid-1990s when ICT came to be employed as a new channel to deliver care to patients
in remote locations. Since then, various terms such as tele-care, telemedicine, tele-health,
and e-health have been used interchangeably. While the ultimate goal of these nomenclatures is
to build an integrated, globalized healthcare system that will create values to all populations of
the world, they have certain differences in their characteristics and scope. The differences will
be explained shortly. To this point, various organizations in both public and private sectors at
local and federal levels have remained independent in their efforts toward the same goal. The
synergy through the integrated healthcare system18 would permit developed, developing, and
underdeveloped countries to contribute both tangible (i.e., human resources, money, and tech-
nology) and intangible (i.e., infrastructural shifts, knowledge, and skills) assets that would other-
wise be limited.
We utilize two economic applications—the production possibilities frontier and positive ex-
ternalities—to analyze the economic perspectives of ICT deployment in health care. This chap-
ter also investigates the barriers to e-health adoption. Using the e-health strategic framework
developed by the World Bank19 and the World Health Organization (WHO), the current status
of telemedicine and e-health adoption in developed, developing, and underdeveloped coun-
tries is explored. Moreover, we propose methods by which developed and developing countries
294 HMIS G O V E R N A N C E , P O L I C Y, A N D I N T E R N AT I O N A L P E R S P E C T I V E S
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can contribute to this supreme healthcare management information systems (HMIS) globaliza-
tion initiative.
II. Tele-Care, Telemedicine, Tele-Health,
and E-Health
Numerous definitions have been proposed for various terminologies that are used to identify
ICT deployment in health care. However, no one definition has been universally accepted.
Even though many of these terms share common and overlapping characteristics, each one con-
veys a different semantic and covers a different scope or boundary.
Barlow, Bayer, and Curry20,p.397 define tele-care as “a set of services bringing care directly to
the end-user” at a remote location via ICT deployment. Among the most commonly cited def-
initions of telemedicine is that given by Dr. Salah H. Mandil, WHO Director of Health
Informatics and Telematics, as “the practice of medical care using audio, visual, and data com-
munications: this includes medical care delivery, consultation, diagnosis, treatment, education,
and the transfer of medical data.”21,p.4 As referenced by the American College of Nurse
Practitioners, tele-health refers to “the removal of time and distance barriers for the delivery of
health care services or related health care activities. Some of the technologies used in tele-health
include telephones, computers, interactive video transmissions, direct links to health care in-
struments, transmission of images, and teleconferencing by telephone or video.”22 To enhance
the understanding of these interrelated terms and bring them into harmony, we borrow from
the works of Norris,23 as presented in Table 13.1.
As shown in Table 13.1, the definitions reveal similar aspects, yet each focuses on different
users and recipients of the services. While tele-care is central to medical services provided to pa-
tients, telemedicine involves services benefiting both patients and physicians. In addition, tele-
health serves patients, physicians, and administrators. Readers who are interested in an in-depth
treatment of how these various terminologies relate to each other may also refer to Tan.24 For
completeness of this review, we elaborate on the prevailing view of telemedicine in the next
section.
II . T E L E -C A R E , T E L E M E D I C I N E , T E L E -H E A LT H , A N D E-H E A LT H 295
Table 13.1 Definitions of Tele-Care, Telemedicine, and Tele-Health
Term Definition
tele-care “the use of information and communication technologies to transfer medical
information for the delivery of clinical services to patients in their place of
domicile” (p. 4)
telemedicine “the use of information and communication technologies to transfer medical
information for the delivery of clinical and educational services” (p. 4)
tele-health “the use of information and communication technologies to transfer medical
information for the delivery of clinical, administrative, and educational services”
(p. 4)
Source: Adapted from Norris, 2002, p. 4. This table is created with permission from Dr. Norris.
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III. Types of Telemedicine
Norris25 identifies four major current categories of telemedicine; the categorization is not
meant to provide an exhaustive list of services provided through telemedicine. Whether or
not the scope of telemedicine can be expanded depends heavily on the innovative progression
of ICT.
Tele-Consultation
This type of telemedicine can occur in the context of real-time provider–provider or provider–
patient interactions. Telephone and videoconferencing are the basic ICT used to deliver these
services. The more advanced technologies used for tele-consultation are mobile health technolo-
gies26,27 and a combination of “a high-speed network, a medical image database, a super-high-
definition imaging system, and an IP-based video conferencing system.”28 The main application
is tele-radiology in which X-ray files are transmitted 24/7 to obtain result interpretations and
consultations around the world. Some other applications include tele-ophthalmology, tele-
dermatology, and tele-oncology. Illustrated by their names, these applications represent the uti-
lization of telemedicine in a particular branch of medicine such as ophthalmology, dermatology,
and retinology. For example, tele-opthalmology refers to the use of ICT to facilitate the provision
of care to patients with visual pathway diseases.29 Some applications of tele-opthalmology are
ophthalmic imaging and visual rehabilitation consultations.30 Basically, tele-opthalmology is
the practice of telemedicine of eye care. Tele-dermatology is the use of ICT to assist dermatolo-
gists and other related health professions to provide care to patients with skin diseases.31 Tele-
oncology is used to facilitate the delivery of cancer care covering the entire episode of care
ranging from diagnosis to supportive care and follow-up services.32
Tele-Education
Knowledge is power. Being able to access and retrieve information and knowledge anywhere,
anytime is another service of telemedicine. The most common use of tele-education is continu-
ing medical education (CME) in which physicians are not required to participate in live confer-
ences or workshops, but can learn and gain the most up-to-date information or practice
guidelines about particular diseases through accessing the Internet. In the United States, the
Accreditation Council for Continuing Medical Education (ACCME) is the accrediting body of
continuing medical education, ensuring the quality and reliability of information utilized by
physicians to maintain their competence and incorporate new knowledge.33 Therefore, physi-
cians can rely on ACCME-accredited programs that are offered online. Tele-education benefits
not only practitioners, but also consumers. Patients are able to access information regarding
their symptoms and diseases from multiple legitimate websites, which are provided by highly
reputed healthcare services organizations such as world-renowned academic health centers and
governmental health-related institutions. The indirect advantage for the patients is that they
can have some control over their own health and participate in the shared medical decision
making and practice.34,35 Moreover, this application can act as a new conveyor of medical edu-
cation, adding value to conventional text-based classrooms. The academics can also benefit
296 HMIS G O V E R N A N C E , P O L I C Y, A N D I N T E R N AT I O N A L P E R S P E C T I V E S
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from the availability of online publishing and literature searching, as well as collaboration,
which will enhance the diffusion of knowledge. The quality of publications can be ascertained
among the peer-reviewed journals, popular publications, and authoritative academic databases.
Tele-Monitoring
This type of telemedicine is important; through its use, patients can be consistently monitored
even after they are discharged. They can communicate with their physicians concerning their cur-
rent status, and the ongoing treatment scheme can be modified accordingly. Patients are able to re-
cover in their place of residence rather than being institutionalized in hospitals or other healthcare
delivery settings. Tele-monitoring can play an important role in life-threatening and time-sensitive
conditions such as those arising from a heart attack. One of the tele-monitoring applications is
tele-cardiology. Tele-cardiology can be used to facilitate disease management among patients with
coronary artery disease and chronic heart failure.36 The patients can self-monitor electrocardio-
gram (EKG), body weight, and/or blood pressure at home and consult the results with physicians
or nurse practitioners. Researchers have found that tele-cardiology is effective in improving pa-
tient compliance, increasing the quality of life, and potentially reducing costs.37
Tele-Surgery
This is a relatively new concept compared with the others just mentioned. There are two types
of tele-surgery: tele-mentoring, where specialists provide assistance to the surgeons from a re-
mote location, and tele-presence surgery, where surgeons utilize robotic arms to carry out surgi-
cal procedures from a distance. International evidence has confirmed the benefits of both types
of tele-surgery. Anvari38 observed the utilization of tele-mentoring and tele-robotic surgery and
reported that knowledge from these practices can be translated rapidly and effectively. He also
predicted that these services would eventually transform the surgical world because more ad-
vanced HMIS can be deployed. A group of Japanese surgeons and researchers also reported the
safety and efficacy of tele-robotic surgery in patients with mucosal or submucosal lesions.39
E-Health
Apart from the aforementioned nomenclatures, e-health is the recent buzzword that combines
everything related to the use of ICT and computers in medical practice and health care. Similar
to telemedicine, there are many definitions of e-health. In fact, a review of the literature yields
more than 50 unique definitions of e-health.40 Eysenbach41 provides a broad definition of this
new concept:
E-health is an emerging field in the intersection of medical informat-
ics, public health and business, referring to health services and infor-
mation delivered or enhanced through the Internet and related
technologies. In a broader sense, the term characterizes not only a
technical development, but also a state of mind, a way of thinking,
an attitude, and a commitment for networked, global thinking, to
improve health care locally, regionally, and worldwide by using in-
formation and communication technology.
III . T Y P E S O F T E L E M E D I C I N E 297
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The WHO is currently focusing on e-health as a central theme that connects ICT and health
care. Thus, it simply defines e-health as “the use of information and communication technolo-
gies (ICT) for health.”42,p.1 The WHO categorizes the application of e-health into three broad
areas. These areas are related to the types of telemedicine identified earlier. The categorization
also places an emphasis on the services provided to patients and practitioners.
1. Public services. These services provide information to people via the Internet.
2. Knowledge services. These services are comparable to tele-education in that they aim at
conveying medical information, knowledge, and education to the healthcare profession-
als who are in training and practice.
3. Provider services. These services focus on the utilization of e-health applications to de-
liver healthcare services to others.
For conciseness, we now present these four major terms in the same diagram, as illustrated in
Figure 13.1. As shown, tele-care is a subset of telemedicine, and telemedicine is a smaller level of
tele-health. E-health is an umbrella term that embraces the entire medical-related interventions
being delivered and connected through ICT. For this reason, the term e-health will be used
throughout this chapter, as it is the most encompassing term in the globalization of health care.
IV. The Economic Perspectives of ICT
and E-Health
Through the innovative advancement of ICT, the world is getting smaller, yet more dynamic.
While individuals are connected around the globe by means of information technology (IT)
networks, healthcare services organizations have adopted HMIS for both strategic and support
purposes. As a consequence, HMIS has become an integral part of the healthcare services in-
dustry. With a rapid increase in IT adoption rates, the tremendous advantages of IT have been
extensively recognized. Atkinson and McKay43,p.1 stated that “[t]he integration of IT into virtu-
ally all aspects of the economy and society is creating a digitally enabled economy.” In effect, IT
provides social and economic benefits to the adopters and society as a whole. Therefore, this
298 HMIS G O V E R N A N C E , P O L I C Y, A N D I N T E R N AT I O N A L P E R S P E C T I V E S
Tele-Care
Telemedicine
Tele-Health
e-Health
FIGURE 13.1 Tele-Care, Telemedicine, Tele-Health, and E-Health in Perspective.
56918_CH13_Final_Tan 4/6/10 1:06 PM Page 298

notion reflects the beneficial implications of the integration of ICT into health care and offers
increasingly robust opportunities for globalized e-health.
However, as society strives to attain maximum utilization from limited resources, at least two
concerns arise among economists: efficiency and equity.44 Economists are concerned with pro-
duction efficiency because it identifies “whether the [products or] services (for a given level of
quality) are produced at the lowest cost.”45,p.405 To reach such a goal, products and services must
be produced in the most effective way. The other issue is how limited resources can be equitably
distributed to the population. As previously discussed, the World Bank found that there is less
inequality among nations participating in globalization. Therefore, nations adopting healthcare
globalization should permit their citizens to have equal opportunities to access better medical
care. Research also supports the notion that telemedicine provides social efficiency.46 Two theo-
retical tools—production possibilities frontier and positive externalities—are employed to
demonstrate the economic benefits of HMIS or ICT in health care.
Before these two theoretical tools are discussed, we make an assumption to differentiate two
periods of e-health adoption. The periods may be illustrated using the rate of adoption theory
and an S-curve.47 The theory states that the adoption of innovation is slow at the initial stage, is
followed by a rapid growth, moves into the stabilization, and eventually declines. As illustrated
in Figure 13.2, the first period starts from the initial adoption to point A, and the second pe-
riod is from point A forward.
We argue that both quality and quantity of care increase in the first period, while the second
period experiences an increase in quality and a decrease in quantity. These arguments are dis-
cussed later.
IV. T H E E C O N O M I C P E R S P E C T I V E S O F ICT A N D E-H E A LT H 299
Time
0 A
N
u
m
b
e
r
o
r
P
e
rc
e
n
ta
g
e
o
f
A
d
o
p
te
rs

Period of
Rapid Growth
FIGURE 13.2 Rogers’s S-Curve Representing Rate of Adoption of an Innovation over
Time. Source: Adapted from Rogers, 2003. The S-curve diagram has been adapted from
Rogers’ (1962) written work. E. M. Rogers, Diffusion of innovation (New York: Free
Press, 1962).
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Production Possibility Frontier
Under the assumption that the society only produces two goods and all factors related to pro-
duction are completely utilized, the production possibility frontier (PPF) model or curve repre-
sents all efficient combinations of outputs.48 The PPF model also illustrates the concepts of
“trade-off” and “opportunity costs.” In this particular circumstance, we use a PPF curve to ex-
plain the trade-off between quality and quantity of care provided to people in the society. As de-
picted in Figure 13.3, the x- and y-axes represent the quantity and quality of healthcare services
delivered in society.
The assumption is that at point A, e-health globalization does not exist. The global health-
care system provides A(QL) amount of quality to A(QN) people. Once the benefits of ICT are
realized, and ICT is brought into the system, the PPF curve is shifted upward and outward. At
the new PPF curve, the system can increase the quality of care to B(QL) and increase the num-
ber of people receiving care to B(QN). This phenomenon takes place in the first period because
the production of quality and quantity of medical services provided without ICT are limited.
But once the ICT is introduced and its adoption starts to take off, the society as a whole will
benefit from the efficiency that ICT brings to the healthcare system. This trend will continue
until the society moves into the second period, in which the utilization of ICT in healthcare be-
comes a commodity and adoption is leveled off.
Thus, with ICT adoption and diffusion, we have the scenario in the second period, where
the quality of care continues to increase to C(QL), but the quantity provided will decrease to
C(QN) because at this point e-health has become an ordinary practice in the global healthcare
system from which the majority of citizens in nations can benefit. Because the majority of people
300 HMIS G O V E R N A N C E , P O L I C Y, A N D I N T E R N AT I O N A L P E R S P E C T I V E S
A(QL)
B(QL)
C(QL)
C(QN)
Legend:
QN = Quantity
QL = Quality
A(QN) B(QN)
Q
u
a
lit
y
A
B
C
Quantity
Period 1
Period 2
FIGURE 13.3 Production Possibility Frontier between Quality and Quantity in
Health Care Delivery System at the First and Second Periods.
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have had access to better healthcare services, they are likely to be healthy. Healthy people in
turn require less care, and thus lead to the reduction in the amount of medical services pro-
duced. This process should be perceived as a cycle. Whenever the new application of ICT is em-
ployed in health care, people would continue to gain benefits from it. The notion of positive
externality can also be used to substantiate our call for globalization of health care through
e-health implementation.
Positive Externality
Goods or services with positive externalities provide benefit to members of society who are not
directly involved in the production, transaction, and consumption of the goods or services.49
Presented in Figure 13.4, the supply curve S is treated as a social marginal cost, which is also
equivalent to private marginal cost, and the demand curve D1 represents an individual bene-
fit.50 Point A represents the free market (i.e., actual equilibrium), where private marginal cost
equals private marginal benefit. When a good with positive externalities is present in the mar-
ket, which results in the socially optimal level or point B (i.e., ideal equilibrium), the problem
becomes that there is a discrepancy between the demand curve D1 at the free market and the
social marginal benefit curve, which is D2. While we want the society to have Q(2) of e-health
and its benefits, the demand at the free market is only D1. For that reason, a public and/or
IV. T H E E C O N O M I C P E R S P E C T I V E S O F ICT A N D E-H E A LT H 301
P(3)
P(FM)
P(2)
Q(FM)
Legend:
FM = Free Market
P = Price
Q = Quantity
Q(2)
P
ri
ce
A
B
S
D2
D1
Quantity
Additional benefits to
the society
Social Marginal Cost =
Private Marginal Cost
Social Marginal Benefit
Private Marginal Benefit
FIGURE 13.4 E-Health as a Good with Positive Externality.
Note: This figure illustrates the increase in social benefit when a good with positive
externality is present in the market. Source: Adapted from B. Sen, “Externalities,”
University of Alabama at Birmingham, September 13, 2005. This diagram is created
with permission from Dr. Sen.
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international policy regarding the price and supply of goods or services with positive externali-
ties is among one of the top priorities of nations and related international organizations.
E-health is considered to be a service with positive externalities that will bring values to the
society. The positive externalities of e-health can be derived from two major sources: ICT and
health care. Atkinson51 provided the case that the necessary applications of ICT utilized in
e-health, such as broadband telecommunications, lead to positive externalities. An obvious ex-
ample of how e-health produces positive externalities in healthcare services settings is the in-
crease in preventive care and reduction in infectious disease.52 If individuals receive care for
their infectious disease at the early stage of the contagion, they reduce the risk of infection for
other members of the society. In essence, these individuals do not only produce a positive exter-
nality by getting care of their conditions, but also avoid a negative externality that could have
occurred. Some other benefits to the society include, but are not limited to, the increase in pro-
ductivity of healthy people and the federal budget savings from fewer needs in healthcare ser-
vices that can be utilized in other social programs such as education and transportation. While
the benefits are initially accrued at the individual level, the positive consequences of these bene-
fits will lead to the socially optimal level. At point A, e-health (a good with positive externality)
gets undertraded, and the society would like to reach the ideal level at point B. However, the
problem at point B is that an investment in e-health costs P(2), while the market is only willing
to pay P(3). The amount that healthcare delivery organizations, or even the government of de-
veloping and undeveloped nations, are willing to pay for e-health infrastructures might be lim-
ited due to scarce resources. In this situation, international organizations such as the World
Bank and WHO have to take action in order to provide the global society with the optimal
benefit level.
V. Factors Influencing the Adoption of E-Health
To study adoption of innovation, researchers have extensively utilized four different theoretical
paradigms from which they draw antecedent factors. These frameworks include the technology
adoption model, the theory of planned behavior, the diffusion of innovation theory, and the
technology-organization-environment framework. Based on these models, a number of techno-
logical and nontechnological antecedents influencing the adoption of e-health are discussed.
Technology Acceptance Model
Developed by Davis,53 the technology acceptance model (TAM) has become one of the most
influential theoretical foundations used in studying an acceptance of new technology at an indi-
vidual level. Two main constructs included in this model—perceived usefulness (PU) and per-
ceived ease-of-use (PEOU)—are related to the perception of users toward the new technology.54,55
This model is used to study the acceptance of telemedicine technology among physicians in
Hong Kong and is found to have a reasonable prediction.56 TAM has also been modified based
on studies in developing countries that identified accessibility as a factor that played a major
role in ultimate adoption of technology.57 In another related study, TAM was extended to study
sustainable adoption of technologies for human development in developing countries.58 Some
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studies in the healthcare context included additional factors to the original TAM and still
found PU and/or PEOU to be strong determinants of intention to use Internet-based health
applications or telemedicine.59,60 Over the past several years, numerous studies have shown
that TAM is a valid and parsimonious theoretical framework for examining adoption of tech-
nological innovation.61,62
Theory of Planned Behavior
Extended from the psychological theory of reasoned action (TRA) by Ajzen and Fishbein,63 the
theory of planned behavior (TPB)64–66 suggests that an individual’s intentions to adopt and use
technology can be explained by three factors:
1. Attitudes toward behavior, or an individual’s perceptions toward his or her performance
of particular behavior (i.e., adopting technology).
2. Subjective norms, or an individual’s perceptions about particular behavior that are influ-
enced by social normative pressures (i.e., significant others’ beliefs on whether an indi-
vidual should or should not adopt technology).
3. Perceived behavioral control, or an individual’s perceptions about ease or difficulty of per-
forming a particular behavior (i.e., adoption of technology can be influenced by his or
her efforts).
Utilizing a theory comparison approach, Chau and Hu67 employed both TAM and TPB in
examining physicians’ intentions to accept telemedicine technology. Their findings suggest that
TPB may be less applicable than TAM in a study of ICT innovation acceptance.
Diffusion of Innovation Theory
Initially introduced in 1962, Rogers’s diffusion of innovation theory (DOIT) has become a
seminal theory employed among researchers in studying adoption of innovation.68 Unlike
TAM and TPB, DOIT focuses on the attributes of innovation as predictors of adoption and
may be applied at an organizational level. To lend itself more readily to be adopted, an innova-
tion must contain five attributes: relative advantage, compatibility, complexity, trialability, and
observability. Menachemi, Burke, and Ayers69 provide an informative analysis of how these at-
tributes can affect adoption of telemedicine among physicians, patients, hospital administra-
tors, and payors.
Apart from these attributes, Rogers also emphasizes several other important factors that play
a major role in adoption of innovation. Rogers asserts that a communication channel is an im-
portant means through which messages are passed along from one individual to another. He
further explains that even though mass media are a great means to rapidly communicate with
the public and potential adopters, interpersonal communication or word-of-mouth is more effec-
tive in persuading people to espouse an innovation. The interpersonal communication channel
is even more powerful if individuals share similar socioeconomic status and educational level.70
In addition, because potential adopters are a member of the society, social norms, behaviors,
structures, and systems are inevitable factors that researchers must take into considerations when
studying adoption of innovation.
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Technology-Organization-Environment Model
Tornatzky and Fleischer71 developed the technology-organization-environment (TOE) model, a
comprehensive framework, to study adoption of technological innovation at an organizational
level. They argue that technological, organizational, and environmental aspects of an organiza-
tion influence its adoption and implementation of innovative technology.
The technological facet refers to the availability of technologies that an organization can ac-
cess internally and externally. These include existing technologies currently available in-house
and other technologies that an organization can acquire in the market. The organizational facet
describes the characteristics of an organization, such as firm size, type of organization structure,
complexity of managerial structure, and the amount of slack resources. The environmental as-
pect encompasses many factors regarding the industry structure, competition, suppliers, and
politics and regulations.
One of the advantages of this model is that it more closely reflects the nature of an organiza-
tion’s operation. While researchers utilized this model as a theoretical framework to conduct
studies of adoption of innovation in other industries,72–74 it has not been employed for such
studies in the healthcare services industry.
VI. Barriers to E-Health Adoption
Researchers have classified different types of barriers to the diffusion and adoption of e-health.75
This discussion focuses on four major issues: financial, technological, social/cultural, and le-
gal. The awareness and comprehension of these barriers are important because they prevent
the society from achieving the ultimate goal of healthcare globalization through initiatives
such as e-health.
Financial Barriers
Even though HMIS development costs have significantly dropped over the past decade, some
nations still find it difficult to acquire the necessary infrastructure. Some developing countries
argue that an investment in HMIS is not prudent or possible when their citizens still lack basic
necessities such as water, food, housing, and basic education. Lam76 stated that the limited re-
sources, different needs, and healthcare settings in developing countries should serve as an ur-
gent need for us to search for new treatment methods that are more effective and efficient than
existing practices utilized in developed countries. Even for developed nations that have the
means, the cost of fully implementing e-health and telemedicine in all locales and regions is
considered a major undertaking.
Another financial barrier is rooted in the cost-effectiveness analysis. Researchers have at-
tempted to conduct cost-effectiveness analysis of telemedicine, but they are confronting some
uncertainties such as the rapid change of HMIS and the costs of implementing such systems,
joint costs among different ICT used in health care, and multiple uses of HMIS.77,78
However, recent research studies have found that widespread utilization of telemedicine can
contribute to a considerable reduction in costs. Spaulding79 and his research team reported that
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the cost of tele-consultation dropped from $7,328 when only one tele-consultation was per-
formed to below $150 when 200 tele-consultations were achieved. As a result, the true financial
benefits of telemedicine or HMIS can be realized when there is an economy of scale. Thus,
e-health makes complete sense if it is globalized.
Technological Barriers
Whenever technologies, especially HMIS, become the center of discussion, we must deal with
the problems of infrastructure, standardization, compatibility, reliability, capacity, availability,
assistance, and maintenance. E-health and telemedicine cannot be accomplished unless a
telecommunications infrastructure is sufficiently available to handle the transmission of tele-
medical data and information. Even though standardization and compatibility are critical issues
for HMIS implementation, assistance and maintenance are inevitable for ongoing operations.
The initial investment in HMIS infrastructure is more problematic in underdeveloped and de-
veloping countries than developed countries. The strategies used to overcome this barrier are
covered in a later section.
Social and Cultural Barriers
Obviously, there are social and cultural differences among nations around the world. As neither
ICT nor HMIS are artifacts, it is almost impossible to ensure that a specific e-health application
would be acceptable similarly across various societies and cultures. Therefore, most such appli-
cations would normally need to be modified to fit local contexts. This requires that healthcare
processes that affect interactions among global, regional, and local levels be understood.80
Moreover, countries take different approaches in handling and managing healthcare planning
and policies. Lack of political will is another important issue. Whether an e-health system will
be fully implemented depends on the commitment among various groups in the society, espe-
cially the political group and the government that leads the country. These fragmented systems
only obstruct the growth and successful development of global e-health.
Legal Barriers
Legal conundrums are the top concern among physicians, healthcare managers, and policy
makers. An overwhelming list of key issues includes “confidentiality and security, patients’ right
of access, data protection, duty of care, standards of care, malpractice, suitability and failure of
equipment, physician licensure and accreditation, physician reimbursement, intellectual prop-
erty rights,” and income taxes.81,p.37 These obstacles add another critical facet to the complexity
of e-health at a global level.
Altogether, these various barriers imply a high need for an establishment of a central entity
that will act as a strong advocate of global e-health, organize the collaborative efforts among na-
tions of the world, and provide a practical strategic framework. The framework can then be uti-
lized as a map and a compass that would guide all nations of the world to the same destination
of healthcare globalization. Because e-health processes involve various stakeholders, we now
present some of the key constituents with a major stake in e-health.
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VII. Stakeholder Analysis
E-health is a systemwide integrated process innovation; thus, the level of success in its wide-
spread adoption must be accelerated by various stakeholders and is dependent upon multiple
factors. The power of e-health to affect healthcare services delivery systems at the global level
not only is beneficial to humanity, but also contributes to the complexity of its adoption.
Therefore, the involvement of major stakeholders and their perspectives concerning this process
innovation must be addressed.
This section illustrates an extensive, but not exhaustive, list of important stakeholders in-
volved in the process of planning, adoption, and implementation of e-health. No single group
of stakeholders is more important than another. Each and every stakeholder plays an important
and unique role in the process of adoption.
International Organizations
Because e-health is a worldwide paradigm shift in healthcare delivery systems, the major inter-
national entities such as WHO, the World Bank, and the United Nations take on key roles in
setting the strategic directions; acting as central collaborating organizations; providing both
monetary and nonmonetary resources; and enacting international policies regarding the adop-
tion, implementation, and utilization of e-health. WHO has built a strategic framework that
nations could employ as a guideline in adopting and implementing e-health.82 Details of the
WHO strategic framework are presented in a later section.
Government
At the national level, the government of each country is an influential body that can support
and expedite the development of e-health policies and its standards, as well as the adoption and
implementation of e-health among other relevant stakeholders. A number of countries, such as
the United States, Canada, and the United Kingdom, are placing e-health at the top priority of
their national agendas. The political will shared among the members of the government leader-
ship is inevitable to the success of this systemwide process innovation. However, even though
the government is playing a highly supportive role, the federal government of various countries,
including both developed and developing countries, is confronting the most fragile issue of
minimal available funding. Nevertheless, some countries, such as Canada and Ireland are heav-
ily investing in e-health.83,84
Physicians/Clinical Providers
Physicians and other clinical providers, such as nurses, form another group of vital stakeholders
of the e-health system because they are the direct users of the system and are arguably assumed
to have a share in taking the responsibility for such an investment. Physicians and nurses must
be directly involved in the design process of any e-health platform simply because this system
will eventually replace their routine activities. Moreover, they have to contribute the medical
knowledge to be incorporated into the system. One of the major barriers among the care
providers is the lack of time,85 which might prevent them from participating in the various steps
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of e-health adoption and implementation. Moreover, the alteration of routine practices might
lead to the decrease in productivity and efficiency for both administrative and clinical staff—at
least for a time.
Hospitals
Hospitals have a comprehensive awareness of e-health and have been a leading entity in its in-
vestment. Hospitals are a major provider of healthcare services, are most ready in terms of facil-
ity and infrastructure, and thus are assumed to acquire ICT needed for e-health. As with other
stakeholders, limited funding and increasing IT costs are the major concerns for all hospitals.
Moreover, most hospitals, especially those with for-profit status, are reluctant to share informa-
tion that could benefit competitors. However, if fully implemented, e-health could help reduce
the asymmetric pattern of information distribution among all hospitals, as well as between the
hospitals/providers and consumers/patients. In effect, if the hospitals and providers have access
to the same types and amounts of information and are not concerned too much about using
unrevealed information to create competitive advantages, they may turn their attention, time,
and effort to focus on improving quality of care and saving lives.
Patients
As the world moves farther into the information age, patients and/or health consumers have
better awareness of information regarding diagnosis, symptoms, and available treatment alter-
natives. They tend to support the concept and completion of e-health. However, a large per-
centage of population of the world is living in underserved areas that bar them from necessary
infrastructure, as well as the knowledge and information about e-health. Although patients are
more likely to support this innovation, they are still addressing some imperative concerns. The
most critical concern is privacy protection because with this system, patients’ individual infor-
mation and personal health records are transmitted electronically and can be accessed by multi-
ple people, ranging from bill collectors to physicians associated with various types of healthcare
services organizations. In some countries such as the United States, where the majority of the
population relies on the provision of private or employer-sponsored health insurance, con-
sumers are also concerned that insurance companies will use their information to limit benefits,
increase premiums, or possibly eliminate their insurance coverage policy. Under employer-
sponsored health plans, employees are afraid that their employers will terminate employment
upon having knowledge of their adverse health status.
Application Vendors
This group takes a completely supportive role in the e-health system because it has a direct ben-
efit from developing an e-health platform. However, the competition among vendors is a major
concern. There are many components related to the applications of e-health (in most geo-
graphic markets), so it is unlikely that any one vendor will have a dominant market share.
However, the first mover will be able to take advantage of initial occupant of a market segment.
As many entities are trying to set a standard for e-health, vendors are uncertain about what will
happen to their existing or in-development platforms and products. Also, many approaching
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policies on e-health standards and products in different countries are threatening the stability of
many vendors. Because of the fact that different medical services providers might have different
needs in their system and might require some customization, vendors cannot take advantage of
fixed cost allocation for mass production.
Third-Party Payors
Third-party payors include different entities such as insurance companies, government agen-
cies, and employers. These groups have important stakes in the development of e-health. First,
when patients do not directly pay for their medical services, the third-party payors are the
source of reimbursement of payment for medical bills charged to the patients by hospitals and
physicians. Thus, they indirectly act as the provider of funding of any programs in which hospi-
tals or physician practices want to invest. Second, third-party payors play a vital role in the suc-
cessful implementation of e-health because they are involved in the daily transaction of an
innumerable amount of health information. The data they collect can benefit both providers
and patients in numerous ways, such as elimination of repeated diagnostic orders, prevention of
prescription errors, and improvement of overall quality. However, similar to hospitals, insurers
are concerned about availability of information to competitors, which could be manipulated
against their competitive advantages.
Even so, while government agencies are inclined to publicly support e-health, some private
insurance companies are still suspicious about the financial and time benefits.86 The principal
goal of insurance companies is to keep the “medical loss ratio” as low as possible. The medical
loss ratio is “the percentage of the insurer’s premiums paid out in medical claims” and is used
by Wall Street for judging their performance.87,p.1250 Therefore, the lower the medical loss ratio,
the higher the profits insurance companies will make. Whether or not e-health can really reduce
the amount paid out in medical claims is uncertain and requires further evidence-based studies
or more business cases. Regarding the time savings for medical claim processing, insurers argue
that slow adjudication is caused by the presumption that every claim is subject to errors and
misrepresentation and thus requires scrutiny for potential frauds and abuses. However, insur-
ance companies should benefit a great deal from using the administrative portion of e-health to
track frauds and abuses.
VIII. WHO’s Strategic Framework for
E-Health Development
Based on the World Bank’s logical framework on e-strategies, the WHO has developed the
e-health development model,88 which is illustrated in Figure 13.5. The model encompasses
three tiers and constructs a solid foundation for enacting policies and actions toward the provi-
sion of e-health systems. Specifically, it is a guideline for strategic planning and implementa-
tion, as well as monitoring and control. It also offers assistance to nations in terms of
preparation for the aforementioned challenges.
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The bottom tier in Figure 13.5 is the basis for e-health implementation in nations. The na-
tional commitment to this innovation is vital to further development at the top two tiers.
Established at a national level, a governing entity must include multiple stakeholders, delineate
the vision, and bestow leadership and directions. It is also responsible for creating e-health poli-
cies and funding approaches and mechanisms for infrastructure development that supports
e-health systems.
The second tier defines enabling actions that link foundation policies and strategies to the
e-health applications. This level addresses the barriers and quests for strategic solutions that are
appropriate and practical. The enabling actions involve citizen protection, equity promotion,
multilingual capabilities, groundwork for cultural diversity, assurance of interoperability among
e-health systems, and enhancement of HMIS and ICT capacity and capabilities among health-
care professionals and students.
The top tier is the linkage between the e-health systems and the citizens of the nations. It is
the e-health services that are delivered to consumers and providers. The success of e-health ap-
plications relies heavily on the strong foundation and proper execution in policies and strategies
determined in the first two tiers.
In 2005–2006, the WHO utilized this model as a background framework to conduct a
global survey to examine the current status of e-health across various countries. WHO empha-
sizes the components in all three tiers. The participating countries are divided into income
groups defined by the World Bank89: high, upper-middle, lower-middle, and low. The results
indicated a projected relative growth of 35 percent in national e-health policy by 2008, which
VIII. WHO’ S S T R AT E G I C F R A M E W O R K F O R E-H E A LT H D E V E L O P M E N T 309
e-Health
Applications
Public services,
Knowledge services,
and Provider services
Enabling Policies and Strategies
Citizen protection, Equity,
Multilingualism and cultural diversity,
Interoperability, and Capacity building
Foundation Policies and Strategies
Governance, Policy, Funding, and Infrastructure
FIGURE 13.5 Framework for Strategic-Health Development. Source: Adapted from
WHO, 2007, p. 15.
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would result in a total of about 85 percent of the countries. This number exhibits a promising
trend of e-health development around the world. The overall prediction is that as e-health ap-
plications become more widespread, countries in the lower-middle- and low-income groups
would remain less progressed in e-health development than those in the high- and upper-middle-
income counterparts, suggesting that developing and undeveloped countries would need addi-
tional guidance and support from WHO and other international entities in both public and
private sectors.
IX. Flow of Resources between Developed and
Developing Countries
This section briefly discusses the possible flow of tangible and intangible resources between de-
veloped and developing countries. Although the results of the WHO global survey imply
higher needs among developing and undeveloped countries, they can—at the same time—con-
tribute to the development of healthcare globalization. While the developed countries have ad-
vantages in supplying tangible resources such as capital for investment, they can in turn gain
knowledge, which is the most powerful intangible asset, from developing and undeveloped
countries.
World Bank focuses on development through knowledge. It identifies the importance of
knowledge in the process of transforming limited resources into things that meet our needs.
Knowledge-sharing through ICT is the highlight of e-health that is expected by both interna-
tional organizations and countries. Through continuous knowledge-sharing, the healthcare sys-
tem will gain inner coherence because scientific medicine is enforced by accountability and
legitimacy.90
Researchers in developed countries can learn and benefit from the studies conducted in de-
veloping and undeveloped countries. Many empirical studies related to telemedicine as well as
HMIS have been conducted in developing parts of the world, and the results from these studies
can lead to more care and research and may introduce alternative treatments to some existing
diseases.91,92 Along with a rapid increase in international travel, the emergence of serious infec-
tious diseases, such as human immunodeficiency virus (HIV) and the recent international out-
breaks of severe acute respiratory syndrome (SARS), has prompted countries around the world
to prepare for these global threats. We believe that e-health globalization would provide some
much-needed intervention in these circumstances and countless other scenarios.
The use of directly observed therapy, short-term (DOTS) for treating tuberculosis is a good
example to show that developed countries can learn and adopt the practices from developing
countries. This particular treatment for tuberculosis was found to be effective in Africa and Asia
in the early 1950s and has since become the standard method of treatment, but the U.S. Centers
for Disease Control and Prevention (CDC) first recommended it for tuberculosis patients only
in 1993.93 Even though developing countries might lack sophisticated technology and hefty re-
search and development funds, they do have some natural resources and can conduct efficient
but innovative research that can produce a lot of knowledge that could be shared with the rest of
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the world. Research experience can also be transferred among various contexts across the world.
X. Conclusion
E-health has widely opened more channels for distributing medical information and knowledge
across international boundaries. We suggest that the production possibility frontier (PPF) eco-
nomic tool theoretically demonstrates that e-health can improve the wellness of the world popu-
lation and increase efficiency and effectiveness in the healthcare delivery system. The implication
of external, positive effects of e-health calls for urgent political support and investment from pri-
vate sectors. To help accelerate the adoption of e-health development, international entities such
as the WHO and World Bank should take action in restricting or controlling the price of ICT,
co-fund research and major international efforts in HMIS implementations, and/or encourage
developing and undeveloped countries to adopt and invest in e-Health by providing some levels
of subsidies and transferred expertise.
The international agenda should increase the emphasis on social values while maintaining the
focus on the economic value of trade. Through this combination, policies and actions can aim
toward maximizing the economic values without imposing negative consequences on citizens of
the world. Several theories that help with the understanding of the factors that influence e-health
adoption were presented, as well as some of the barriers to e-health adoption. We also presented
a discussion on key stakeholders in e-health, because understanding each stakeholder’s perspec-
tive and role enhances the implementation and adoption process. The strategic framework set
forth by WHO can serve as a strong foundation for the healthcare globalization through e-health.
Furthermore, the current status of e-health development in developed and developing countries
shows a positive trend. The collaboration among countries and international entities is impera-
tive in the process of design, implementation, and evaluation of e-health endeavors.
While developed countries have the ability to provide tangible supports to this global health
and wellness initiative, developing countries are also able to contribute in terms of natural re-
sources and knowledge sharing. Research has shown that developed countries can attain benefits
from innovative research studies conducted in developing countries. Through mutual exchange,
the world can achieve the ultimate goal of an integrated, globalized healthcare system.
Notes
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