Younass Aboulghit and Arjen Kamphuis
We live at a time when information technology is drastically changing our lives. We can see the digital process all around us in information systems and the change in our working procedures. People always expect to be able to get information quickly and share it with each other if it's important. In healthcare there are opportunities and a new generation of patients has high expectations. The question is: how do we embrace the potential of information technology while maintaining quality and professionalism? How do we prevent the indiscriminate use of IT making the work of the specialist more difficult, rather than easier? That things can go badly wrong with healthcare projects has been demonstrated with the case of the Electronic Health Records (EHR).
EHR and related IT projects in healthcare often confuse medical and logistical functions. Different groups within a health institution experience different problems that they want to see solved through IT. Non-medical planning and logistics work is often an important way to improve the efficient use of manpower and resources. However, from the perspective of front-line healthcare providers, this can mean that they feel treated like a cog in a machine, and this does not fit with their sense of professional autonomy. Certain lessons of the logistics of care can be drawn from the tailor-made principles of 20th century industry. However, a hospital is not a widget factory and a patient is certainly not a widget. The factory metaphor is useful, but also has its limitations. And, by not recognising these distinctions, software vendors and corporate buyers over the last 20 years have often gone wrong.
The fundamental problem began with the introduction of the national EHR. Since the mandatory imposition of a national administrative system was considered unfeasible, the decision was taken to centralise and maintain the existing IT systems from 9,000 health care institutions as efficiently as possible. Merging all these systems into one structure was a political and administrative nightmare. Unfortunately, the quality, speed and reliability of the overall national EHR relied on the standards used by each of the individual 9,000 institutions. A critical care professional cannot make decisions based on medical data of questionable reliability. Since no one knows how all these institutions store potentially relevant data about a specific patient, nor how reliable the information is, care professionals are reluctant to use the system. Gendo raised this fundamental problem back in 2005 after a test hack of two hospitals initiated by writer and privacy campaigner Karin Spaink.
Now the First Chamber has quashed the idea of a national EHR, the field is clear for local and regional initiatives to apply lessons learned.
A mistake often made in healthcare is the implementation of large-scale IT systems basically not designed for healthcare. These systems compel hospitals and care institutions to align their processes to the IT rather than vice versa. This ultimately leads to a lot of frustration among service providers. We need to listen to the medical professionals who rely on IT systems in order to perform their job. A successful system should be based on a clear answer to the problems it solves. What are the needs of different stakeholders? Besides a clear definition of the problems, it is very important that stakeholders agree on the way forward. In other words, a shared IT strategy.
A clearly defined strategy can be learned from the experiences of the St Anthony Hospital, which in 2008 began to build its own EHR based on open standards and open source software. The St Anthony consciously chose a longer route where the problem was not fixed by an external supplier, but developed its own solution. One of the steps the hospital took was to establish a steering committee consisting of different types of caregivers. Together they defined the vision and controlled the implementation. The principal reason for choosing open standards was the guarantee of future interconnectivity with other systems and organisations. The choice of open source makes it possible in future to develop new systems jointly with other institutions,without one party having all the control.
The healthcare professionals most closely involved in developing the system need to be assured that they are actually helping their business. Both IT workers and health professionals need to be interested in each area and have the patience to learn. IT professionals are not surgeons, but can understand the problems of surgeons; good surgeons can grasp the basics of IT architecture, learning how to use it without the IT worker having to be present. Only through cross-pollination of knowledge is it possible to create solutions appropriate to both the medical and IT technical reality.
Medical information is complex, and careful handling of patient information is a legal and moral obligation. The IT systems that process such information must be reliable. To ensure reliability, the IT architecture has to meet certain requirements, such as: modular, secure, transparent and easy to audit, scalable, reliable and interoperable. To make these architectural requirements a reality, proven methods and components must be used. Transparency is achieved by using open source and providing proper documentation. IT systems need to be scalable and have built-in redundancy to allow for a comprehensive back-up, recovery, and restoration strategy. To ensure that different IT systems can communicate with each other, they should be based on open standards like DICOM and HL7 messaging for information processing and image sharing. In addition to the above, it is also important that the architecture complies with the laws and regulations laid down for health care institutions, such as NEN7510.
One of the goals of an IT strategy is a vision of the method of software development. An important part of the development philosophy is always to start small and modular. The basis for this is discrete units - 'blocks' - performing one very simple function, that are interoperable with other blocks. By such a process of small steps we can clearly prevent out-of-control monster projects costing many millions. A system that has modularity as a design principle will always remain future-proof: new or individual modules can be added to adapt to new medical insights or changing legislation. Another important philosophy is to maximize the use of proven technologies and methodologies: in other words, use technological components where a consensus exists that they are reliable and future-resistant. The Unix OS is a common example of what can be achieved with this method of development. The UNIX family of operating systems currently runs TomTom, super computers, phones and all Apples (including the iPhone and iPad). For those willing to to use it, the modular philosophy has proven to be flexible, scalable, secure and free.
Building an EHR should involve close collaboration between medical professionals and IT architects, and result in compliance with key framework policies. The main challenge is for these two groups of professionals to explain clearly to each other their needs and expertise, and build an EHR structure, block by block, that will encompass everything.
(The authors gave a keynote at the Dutch Surgeons' Day 2010. We are looking forward to talk with health care professionals who are interested in the above vision to work towards building an EHR)