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sefulness of a Regional Health Care Informationystem in primary carecase study

arianne C. Maassa,∗, Paula Asikainenb, Tiina Maenpaa a,lli Wannea, Tarja Suominenc

Satakunta Central Hospital, Department of Administration, Sairaalantie 3, 28500 Pori, FinlandSatakunta University of Applied Sciences, Department of Social and Health Care Technology, FinlandUniversity of Kuopio, Department of Nursing Science, Finland

r t i c l e i n f o

rticle history:

eceived 13 December 2006

eceived in revised form

April 2008

ccepted 9 April 2008

eywords:

egional Health Care Information

a b s t r a c t

The goal of this paper is to describe some benefits and possible cost consequences of com-

puter based access to specialised health care information. A before–after activity analysis

regarding 20 diabetic patients’ clinical appointments was performed in a Health Centre

in Satakunta region in Finland. Cost data, an interview, time-and-motion studies, and

flow charts based on modelling were applied. Access to up-to-date diagnostic information

reduced redundant clinical re-appointments, repeated tests, and mail orders for missing

data. Timely access to diagnostic information brought about several benefits regarding work-

flow, patient care, and disease management. These benefits resulted in theoretical net cost

savings. The study results indicated that Regional Information Systems may be useful tools

etwork

iabetes

osts and benefits

ealth Information Systems

eamless care

to support performance and improve efficiency. However, further studies are required in

order to verify how the monetary savings would impact the performance of Health Care

Units.

© 2008 Elsevier Ireland Ltd. All rights reserved.

regional and national level. In fact, the Finnish Ministry of

lectronic Health Records

. Introduction

oday, the adoption of Regional Health Care Networks is aop priority in the field of medical and health care informat-cs [1–3]. There are a great number of diverse Informationystems in use, the goal of which is improved efficiencyf health care services. There is an urge for standards and

nteroperability of systems in countries which have in theecent decades gradually adopted Information Systems [4,5].

egional Networks strive towards the shared use of Regional

nformation Systems by networking entire regional admin-strative areas, such as Health Care Districts. The goal is to

∗ Corresponding author. Tel.: +358 50 4682987.E-mail address: marianne.maass@hotmail.com (M.C. Maass).

169-2607/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights resoi:10.1016/j.cmpb.2008.04.005

support seamless care and patient care chains throughoutprimary, secondary and tertiary care, and within the homecare section by providing timely, high quality care, based onthe most recent diagnostic data. Health Centres offer pri-mary care services. Secondary and tertiary care is providedby Central Hospitals and University Hospitals, respectively.There is a need for integrated Information Systems, and fora comprehensive information infrastructure at intra-hospital,

Social and Health Affairs promotes efforts towards buildingRegional Information Networks based on a reference registry[6].

erved.

s i n

176 c o m p u t e r m e t h o d s a n d p r o g r a m

The recurrent lack of diagnostic information is generallyrecognised [7]. On the other hand, the quality of care hasbeen connected with the level of communication betweenprimary and secondary care units [8]. Information Systemsmay offer efficient alternatives to support trans-institutionalco-operation, to reduce the use of written documents, paperprocessing and telephone calls [9], and to reduce operatingcosts [10]. There are studies which suggest that timely avail-ability of diagnostic information not only improves patientcare, but also brings about cost savings [11]. Furthermore,the effectiveness of the use of Information Systems com-pared with traditional activity has been established, i.e. thatcosts were lower and medical benefits were greater [12].The adoption of Health Information Systems including Elec-tronic Health Records has progressed slowly; consequently theexpected benefits have not been fully realised [13]. Some 15years ago, it was foreseen that the transition to fully electronicactivity might take up to three decades in some medical spe-cialities [14]. Currently, this seems to be applicable to manyInformation System efforts.

It has been established that Health Information Systemsmay improve the performance of medical personnel, as wellas diagnostic quality, disease management, and patient out-come, although the relationship between these systems andthe benefits remain understudied, and methods and resultsare inconsistent [15]. The diversity of clinical settings, thevariety of study methods, and the general immaturity of theresearch field challenge the comparison of results [16,17]. Therelative newness of the field, the absence of a sufficient, ade-quate and compact research community, and lack of fundinghave all prevented the achievement of solid results. However,there is general consensus that widespread use and network-ing of Health Information Systems could eventually inducecost savings, especially in the area of preventive medicine andchronic disease [18]. In fact, it has been demonstrated thatthe use of Information Systems supports clinical performanceand preventive care [19], and there are indications that theimproved performance may enhance the revenue of a healthcare unit [20].

Diabetes may be regarded as an information intensivedisease. Therefore it may be regarded an excellent study tar-get to explore the usefulness of Information Systems. As achronic, advancing disease its outcome depends on preven-tive medicine, follow-up programmes, and timely proceduresembracing specialities such as amputation surgery, cardi-ology, clinical physiology, endocrinology, eye imaging, footcare, internal medicine, nephrology, nutritional therapy, oph-thalmology, radiology, specialised nurse services, or venalsurgery. Furthermore, diabetes is increasing rapidly; its totalcost exceeded one billion euros already at the beginning ofthe 21st century [21]. It has been established that the qual-ity of care connected with proper management of the diabeticcare continuum may provide a means to control the outcomeand cost of the disease [22]. There were 7585 medicated dia-betic patients in the Satakunta Hospital District [23]. Primarycare was provided by Health Centres, and secondary care was

available in Satakunta Central Hospital.

Satakunta Central Hospital has adopted a Regional HealthCare Information System service, the aim of which was toenable all Health Centres of the region to have access to sec-

b i o m e d i c i n e 9 1 ( 2 0 0 8 ) 175–181

ondary care diagnostic information regarding all patients. Thestudy included a typical Health Centre serving approximately20 000 inhabitants, which represented nearly 10% of the totalpopulation of the region. The Health Centre has organised afollow-up programme for the treatment of its 461 diabetic resi-dents [23]. A more comprehensive study including four HealthCentres was performed [24].

The goal of this paper is to highlight the possible useful-ness of the Regional Health Care Information System. Theconcept of usefulness is applied, in the sense of the possi-ble costs and benefits of having real time access to the mostrecent diagnostic data. The following particular questions areaddressed:

• Does access to real time diagnostic information changeworkflow?

• Does access to real time diagnostic information changepatient care?

• Does access to real time diagnostic information change dis-ease management?

• Does the use of the Regional Health Care Information Sys-tem induce net savings?

2. Methods and materials

In 2005 a before–after activity analysis regarding the clini-cal appointments of twenty diabetic patients was conducted.The study setting consisted of two Health Care Units, namelySatakunta Central Hospital, and a Health Centre located in theSatakunta region. The Regional Health Care Information Sys-tem (FujitsuInvia Ltd./Finnish Post Ltd., Itella) enabled accessthrough a reference register to any entered patient data [6],and each local Information System automatically created areference to the register [25,26].

In the preparatory phase of the study a semi-structuredthematic interview was conducted. The physician in chargeof diabetes care was interviewed for background informationfor 90 min. The interview was tape recorded and transcribed.The goal of the interview was to ensure that the study wouldbe focused on relevant issues, and that the staff would beinvolved in the study. In addition, its aim was to provide thenon-medic researchers’ with a comprehensive understandingof the health care delivery system of this particular region,and of the work procedures of these particular health careunits. The themes of the interview included medical aspectsof providing primary care for diabetic patients at generallevel, cross-organisational co-operation with secondary care,patient care and diagnostic information needs. In addition,the following themes came under scrutiny: the patient flowbetween primary and secondary care; procedures triggered byunavailable diagnostic information; and the impact on patientcare, organisation and personnel working conditions.

Time and motion studies were applied to study the clinicalappointments. A stopwatch was used in order to determinethe crucial work processes, and their duration. The time-and-

motion studies were performed by an independent researcher,starting when the patient was called in, and ending when thepatient left the examination room. The researcher could laterask questions about both the logic and the reasons behind

c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 1 ( 2 0 0 8 ) 175–181 177

Fig. 1 – Flow chart showing the traditional “before” work processes. There was a parallel use of traditional and electronicrecords. Several work processes had already taken place before the arrival of the patients. Approximately seven days beforethe appointment patients had undergone blood sample tests. The physician became acquainted with the patient history,and called in the patient. Home care follow-up cards were checked. Treatment decisions and possible new treatmentg e ap

epcifl(

wfiltHtqtmSoccmb

Fa

uidelines were entered to the Information System when th

ach action, in order to check her understanding and inter-retation of the role of the Information System in patientare. Based on the results of the clinical observations, thenterview and the time and motion studies, the before–afterow charts were drawn by using a modelling software

QPR Finland Ltd.).The total cost of the Regional Information System project

as calculated based on information given by the projects’nancial manager. The cost consequences at communal

evel were estimated based on information retrieved fromhe Financial Statements and Report of Activities of theealth Centre [28]. Cost savings were estimated based on

he assumption that unsuccessful appointments, and conse-uently repeated visits and tests would be reduced. Duringime and motion studies those appointments were deter-

ined, which without the use of the Regional Informationystem would have been unsuccessful due to unavailabilityf most recent diagnostic information. The cost of one clini-

al appointment was determined based on its length and theost of wage of medical personnel. The cost of tests was deter-ined by using the price of the less costly test, such as a simple

lood test [23,27–29].

ig. 2 – Flow chart showing the new “after” work processes. Worccess to the latest diagnostic information located in the second

pointment was due.

3. Results

The consequences of the computer based access were 100%availability of latest diagnostic information, based on which itwas estimated that redundant clinical appointments and/ortesting could be eliminated in the future. Missing informationwas requested by telephone, fax orders, or tests were repeated.The patient was rescheduled for a new appointment, or givena phone call reception time, usually some two weeks later.The unavailability of information prolonged treatment, led toredundant appointments and testing, causing extra workload,uncertainty and discomfort (Fig. 1).

Workflow and patient care changed when the RegionalHealth Care Information System was used (Fig. 2). Access toRegional Health Care Information System reduced the num-ber of work processes. The time and motion study revealedthat workflow was simplified and accelerated in 4 of the

20 cases followed. Availability of the latest diagnostic dataassisted in concluding successfully these clinical appoint-ments. The treating physician felt that the result reflectedthe quotidian reality. The treatment was shortened by one

k processes were reduced, because the physician now hadary care Information System.

178 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 1 ( 2 0 0 8 ) 175–181

Table 1 – A summary of the medical appointments

Patient no. Medical problem Quality of diagnostic information Use of IS Description of benefits

1 Ordinary check-up Sufficient No Increased personnel confidence2 Cardiac symptoms Insufficient Yes Faster treatment decision3 Ordinary check-up Sufficient No Increased personnel confidence4 Ordinary check-up Sufficient No Increased personnel confidence5 Ordinary check-up Sufficient No Increased personnel confidence6 Ordinary check-up Sufficient No Increased personnel confidence7 Ordinary check-up Sufficient No Increased personnel confidence8 Ordinary check-up Sufficient No Increased personnel confidence9 Ordinary check-up Sufficient No Increased personnel confidence

10 Ordinary check-up Sufficient No Increased personnel confidence11 Ordinary check-up Sufficient No Increased personnel confidence12 Ordinary check-up Sufficient No Increased personnel confidence13 Ordinary check-up Sufficient No Increased personnel confidence14 Ordinary check-up Insufficient Yes Latest eye imaging results were accessed15 Ordinary check-up Sufficient No Increased personnel confidence16 Ordinary check-up Insufficient Yes Latest disease state-of art results were accessed17 Ordinary check-up Insufficient Yes Latest disease state-of art results were accessed18 Ordinary check-up Sufficient No Increased personnel confidence

19 Ordinary check-up Sufficient20 Ordinary check-up Sufficient

to two weeks. The access to real-time information assistedin providing adequate, high-quality patient care. The pre-requisites for the improvement of patient safety and carewere also enhanced. The Information System allowed in situdecision-making which encouraged confidence, and increasedprofessional performance. There was no longer confusionarising from the absence of required documents, which previ-ously had triggered several procedures. However, the use of theInformation System prolonged the individual appointmentsby an average of four minutes, from 22 min to 26 min (Table 1).

3.1. Patient case 2

A patient presented with cardiac symptoms. The patientwas not aware of what procedures had been carried outin Satakunta Central Hospital. The discharge summarywas unavailable. With the patients’ consent the physicianretrieved the latest examination results from the InformationSystem: these together with the symptoms indicated, that thepatient was in need of an urgent intervention. The patient’scare was accelerated.

3.2. Patient case 14

A patient had had eye imaging performed in Satakunta Cen-tral Hospital. The imaging results were lacking; nor had theseresults been sent by mail to the Health Centre. The physiciansigned in to the Information System, and reviewed the imagingresults, as well as the latest treatment guidelines. There wasno need to order a copy of the imaging related information,and thus a redundant appointment or a repeated examinationwas avoided.

3.3. Patient cases 16 and 17

The physician received these patients who possessed out-dated health insurance cards, no longer covering the

No Increased personnel confidenceNo Increased personnel confidence

compensation of medication costs. In order to write accu-rate and valid reports the most recent illness history datawas retrieved from the Information System. The necessarydocuments were completed during the appointment, and thecompensation process was accelerated. There was no need toorder the latest test results from the Satakunta Central Hospi-tal, or to repeat the tests, or to reschedule new appointments.

Disease management was related to information man-agement. There is a great need for information exchangeconcerning the diabetic patient, in order to prevent spo-radic or irreversible worsening of the disease. Data is created,stored, and sent back and forth between treating physicians,specialists of several fields, archives, wards and clinics, andeven between different organisations. It was inferred thatcomputer access was more crucial in complicated patientcases the than in straight forward cases. The study indicatedthat timely decision-making enabled better and faster carepractice. Access to latest diagnostic information might alsoprovoke fewer errors.

Availability of the discharge summaries was regarded ascritical. It should be delivered to the treating physician as astandard procedure. The arrival of the summaries officiallyreturns the care of the patient to the Health Centre, and isnecessary for appropriate care.

The Regional Health Care Information System allowed afocussed search for the precise information required (Fig. 3).Access to medical speciality related data by computed selec-tion was rapid and convenient, whereas paper documentsmust be read from beginning to end, which is time consuming.

The total cost of the project to the Satakunta Central Hos-pital was some 800 000D . The estimated net saving for theHealth Centre was over 600 000D , a sum which represented10% of the total primary care cost. Satakunta Central Hos-

pital charged for access to the Information System 41.000D .The net savings were calculated based on the results of theactivity analysis—the finding that 20% of the tests and clinicalappointments were redundant. There were 200 000 labora-

c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 1 ( 2 0 0 8 ) 175–181 179

Fig. 3 – Computer interface of the Regional Health Care Information System. The monitor view is simple. There is a list ofpatients’ speciality related sheets in alphabetical order beginning with physiatry (Fysiatria), and followed respectively byphysiotherapy, surgery, imaging, laboratory, nutritional therapy, rheumatology, ward treatment, and clinical appointments.T clickd

t[wtclt

4

TstLttthtrivmamTdd

he number of data references is on the right. The user mayata sheet arrives within seconds.

ory tests, and over 40 000 appointments during the year 200428]. Each appointment was assigned 20 min of the physicians’orking time. The savings in wage cost were over 80 000D , or

he equivalent of 1.2 labour years [29]. The estimated yearlyost savings resulting from the redundant testing were calcu-ated by multiplying the number of the estimated unnecessaryests with the cost of the less costly test, which was 4D .

. Discussion

oday, there is general consensus about the need to createeamless care and health care service chains, and to moveowards patient-, rather than organisation-centred activity.ate treatment decisions may lead to the deterioration ofhe illness, and successful treatment of diabetes includeshe avoidance of irreversible damage. The results indicatedhat overall disease management may improve. This mightinder the worsening of the disease and thus lead to fur-her considerable cost savings. Updated information wasequired for insurance purposes in two out of four cases, whichs not insignificant from the disease management point ofiew. It may be argued that patients are more prone to useedication when the costs are compensated. Thus, avail-

bility of diagnostic information for bureaucratic purposes

ight be regarded as one aspect of disease management.

he Regional Information System enhanced the quality ofecision-making and professional confidence. Work processesiminished and became simpler; as a consequence working

the box next to the information desired, and the speciality

satisfaction might improve. Redundant tests and appoint-ments were avoided, which might provide a possibility for theallocation of increased resources to patient care.

The findings indicate that it is possible to achieve netcost savings by networking the Health Care Information Sys-tems. The consequences of the widespread use of the RegionalHealth Care Information System might induce further costsavings, or increased efficiency, and possibly enhanced per-formance. These findings do not contradict the previous studyfindings of other authors. The use of the Information Systemdid not induce additional costs in other areas of the HealthCentres activity. The Central Hospital was responsible for therisks and for all managerial, adoption-related, developmental,and financial issues of the undertaking, which was a benefitfor the Health Centre. The end-user was merely committedto purchasing the electronic access cards. The parallel use ofpaper suggested that the full potential of Information Sys-tems was still not fully exploited. Further reduction of theuse of paper documents would introduce further cost savingsthrough the modification of work processes. The use of paper-based discharge summaries might be reduced by introducingelectronic discharge letters. Moreover, the computer interfacecould be designed in such a way that uncompleted patientcases remain in a pending list, as a reminder for the treatingphysician.

Access to specialised health care information improvedworkflow, a fact which might at first sight indicate the pos-sibility of achieving cost savings. The use of the InformationSystem reduced unnecessary returns to the Health Centre—a

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180 c o m p u t e r m e t h o d s a n d p r o g r a m

benefit for all parties involved. In some patient cases theaccess to updated diagnostic information may be urgent, anda matter of life and death. Unnecessarily rescheduled patientsrepresent an obstacle to efficient care. Updated, ubiquitouslyand simultaneously accessible diagnostic information is aprerequisite for providing efficient care. In fact, there was awaiting-list of several months for appointments at the dia-betes clinic. However, rather than monetary benefits, theremight merely be an increase in the performance rate, orreduced queuing. This would have to be verified by the follow-ing years’ Financial Statements and Report of Activities. Onthe other hand, the use of the Information System prolongedthe individual appointments by an average of 4 min. It is to beexpected that this time will be reduced as users become morefamiliar with the system behaviour.

The aim of the study was to increase understanding of thebenefits by describing the consequences of the use of the Infor-mation System. The interaction of changes in patient care,costs, workflow, information flow, disease management, andInformation Systems, is complicated, and the consequencesare manifold. It is challenging to describe parallel and simul-taneous phenomena, which might have different outcomes indifferent clinical settings. Even a relatively superficial descrip-tion of different health care services delivery systems andpractice of medicine would be a research project per se. Thebefore–after layout of the study did provide reliable indicationsof changes in workflow. The study outline did not embracenegative results; in fact also none emerged, either in the inter-view, or in the activity analysis. The number of observedclinical appointments was low, but the intensive interviewand the presence of researchers at the studied site added tothe credibility of the results. The study was both quantitativeand qualitative. The qualitative approach does imply subjec-tivity, and therefore a parallel use of quantitative methods wasincluded in order to increase the applicability of the resultsto other similar systems. In fact the results of a more com-prehensive cost-benefit analysis performed in the region gaveidentical percentages regarding redundant appointments andtests.

5. Conclusions

The access to the Regional Health Care Information Sys-tem was useful. Improvements in workflow, patient careand disease management were observed. These benefitsresulted in theoretical net savings. The results may beapplicable to other patient groups suffering from chronicmulti-symptom diseases with complicated treatment proce-dures, where up-to-date speciality-related information is ofthe utmost importance in order to provide the best possiblecare. It has been estimated that 20% of the population con-sume most of the health care resources. The improvement ofthe entire treatment chain for regular health care consumersmight have a more beneficial effect on performance than inthe case of average health care consumers.

The study embraced economics, human sciences andhealth informatics. The planning and execution of proper clin-ical trials still face scientific, economic, and organisationalchallenges. The research target is becoming more familiar,

b i o m e d i c i n e 9 1 ( 2 0 0 8 ) 175–181

although new applications are introduced regularly. Furtherresearch is justified in order to guide technological devel-opment in a favourable direction through the creation ofuser-friendly interfaces which will assist personnel to adaptwork processes in order to promote interorganisational paper-less cooperation. It may be assumed that when changes inactivity are made, work processes will also change. Accessto information will assist personnel in their work processes,and allow the development of care chains. In the future thereshould be a set of valid criteria which may be applied to evalu-ate the usefulness of Health Care Information Systems—theyshould be measurable and unambiguous, and preferably inter-nationally applicable. These criteria could include qualitativeas well as quantitative assessment.

Acknowledgements

The implementation project (Salpahanke) manager TerttuLuojukoski, along with her team members, as well as theDepartment of Administration and Statistics, the Health Cen-tres’ physicians and the technology service providers – FujitsuInvia and the Finnish Post Ltd., Itella – are warmly thanked forfruitful co-operation.

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