Reinhold Haux Alfred Winter Elske Ammenwerth Birgit Brigl Strategic Information Management in Hospitals An Introduction to Hospital Information Systems 2 2 Basic Concepts 2.1 Introduction Each domain usually has its own terminology which often differentiates from the ordinary understanding of concepts and terms. This chapter presents terminology for hospital information systems and its information management, as used in this book. It is, therefore, essential to read this chapter carefully. All relevant concepts can also be found in the thesaurus at the end of the book. After this chapter, you should be able to answer the following questions: • Which basic concepts are needed in order to work on hospital information systems? • What terms do we use? 2.2 Data, information and knowledge Data constitute a reinterpretable representation of information, or knowledge, in a formalized manner suitable for communication, interpretation, or processing by humans or machines. Formalization may take the form of discrete characters or of continuous signals (e.g., sound signals). In order to be ‘reinterpretable’, there has to be agreement on how data represent information. For example, Peter Smith or 001001110 are data. A set of data which is collected for the purpose of transmission and which is considered to be an entity is called a message. There is no unique definition of information. Depending on the point of view, the definition may deal with the syntactic aspect (the structure), the semantic aspect (the meaning) or the pragmatic aspect (the intention or goal of information). We will simply define information as specific knowledge about objects such as facts, events, things, persons, processes, or ideas. For example, when a physician knows the diagnosis (facts) of a patient (person), then he or she has information. Information as specific knowledge contrasts with general knowledgeabout concepts (for example diseases, therapeutic methods). The knowledge of a nurse, for example, comprises how to typically deal with patients suffering from decubitus. For the sake of simplicity, we will often use the term information processing, when we mean processing of data, information and knowledge. 2. Basic Concepts 19 2.3 Information systems and their components Systems and subsystems Before talking about information systems, let us first define the concept system. As defined here, a systemis a set of persons, things andor events which form an entity, together with their relationships. We distinguish between natural systems and manmade systems. For example, the nervous system is a typical natural system, consisting of neurons and their relationships. A manmade system is, for example, a hospital, consisting of staff, patients and relatives, and their interactions. If a (manmade) system consists of both human and technical objects, it can be called a sociotechnical system. A system can, in principle, be divided into subsystemswhich comprise a subset of all objects and the relationships between them. For example, a possible subsystem of the nervous system is the sympathetic nervous system. A subsystem of a hospital is, for example, a ward with its staff and patients. Subsystems themselves are again systems. Models of systems When dealing with systems, we usually work with modelsof systems. A model is a description of what the modeler thinks to be relevant of a system. In the sciences, models commonly represent simplified depictions of reality or excerpts of it (see Figure 17). Models are adapted to answer certain questions or to solve certain tasks. Models should be appropriate for the respective questions or tasks. This means that a model is only ‘good’ when it is able to answer such a question or solve such a task. For example, a model which only comprises the patients of a ward cannot be used for nurse staffing and shift planning. Information Systems An information systemis that part of an enterprise which processes and stores data, information, and knowledge. It can be defined as the sociotechnical subsystem of an enterprise which comprises all information processing as well as the associated human or technical actors in their respective information processing role. ‘Socio’ refers to the people involved in information processing (e.g., health care professionals, administrative staff, computer scientists), whereas ‘technical’ refers to information processing tools (e.g., computers, telephones, patient Figure 17: A model of a computer is not the real computer. 20 Strategic Information Management in Hospitals records). The people and machines in an enterprise are only considered in their role as information processors, carrying out specific actions following established rules. An information system which comprises computerbased information processing and communication tools is called a computersupported information system. The subsystem of the information system where computerbased tools are used is called the computersupported part, the rest is called the conventional part of the information system. Components of information systems When describing an information system, it can help to look at the following typical components of information systems: Enterprise functions, business processes, application components and physical data processing components. An enterprise functiondescribes what acting human or machines have to do in a certain enterprise to contribute to its mission and goals. For example, patient admission, clinical data management or financial controlling describe typical enterprise functions. Enterprise functions are ongoing and continuous. They describe what is to be done, not how it is done. Enterprise functions can be put together in a hierarchy of functions, where a function can be described in more detail by refined functions. Enterprise functions are usually denoted by nouns or gerunds (i.e. words ending with ing). An activity is an instantiation of an enterprise function working on an individual object. For example, Dr. Doe admits patient Jane Smith is an activity of the enterprise function patient admission. Just as enterprise functions, they can be put together in a hierarchy of activities. In contrast to enterprise functions, activities have a definite beginning and end. To describe the chronological and logical sequence of a set of activities, business processesare useful. They describe the sequence of activities together with the conditions under which they are invoked, in order to achieve a certain enterprise goal. Business processes are usually denoted by verbs (for example, dismiss a patient, document a diagnosis or write a discharge letter). As they are composed of individual activities, they also have a definite beginning and end. We will only refer to enterprise functions and business processes in respect to information processing. Whereas enterprise functions and business processes describe what is done, we now want to have a look at tools for processing data, in particular at socalled application components and at physical data processing components. Both are usually referred to as information processing tools. They describe the means used for information processing. Application components support enterprise functions. We distinguish computerbased from conventional application components. Computerbased application components are installations of software products on computers. A software product is an acquired or selfdeveloped 2. Basic Concepts 21 piece of software which is complete in itself and which can be installed on a computer system. For example, the application component patient management system stands for the installation of a software product to support the enterprise functions of patient admission, management, and discharge. Conventional application components are realized by conventional means such as organizational plans which describe how to use conventional data processing components. For example, the application component nursing documentation organization contains rules how and in which context to use the given forms for nursing documentation. The communication respectively the cooperation among application components must be organized in such a way that the business processes can be executed. Physical data processing components, finally, describe the information processing tools which are used to realize the computerbased and the conventional application components (see Figure 18). Physical data processing components can be human actors (such as the person delivering mail), conventional physical tools (such as printed forms, telephones, books, patient record), or computer systems (such as terminals, servers, personal computers). Computer systems can be physically connected via data wires, leading to physical networks. Architecture and infrastructure of information systems The architecture of an information system describes its fundamental organization, represented by its components, their relationships to each other and to the environment, and by the principles guiding its design and evolution. 13 The architecture of an information systems can be described by the enterprise functions, the business processes, and the information processing tools, together with their relationships. There may be several architectural views of an information system, e.g. a functional view looking primarily at the enterprise functions, a process view looking primarily at the business processes, etc. Architectures which are equivalent with regard to certain characteristics, can be summarized to a certain architectural style. 13 Institute of Electrical and Electronics Engineers (IEEE). Std 14712000: Recommended Practice for Architectural Description of SoftwareIntensive Systems. September 2000. http:standards.ieee.org. Figure 18: Typical physical data processing components on a ward. 22 Strategic Information Management in Hospitals When the focus is put onto the types, number and availability of information processing tools used in a given hospital, this is also called infrastructureof its hospital information system. 2.4 Hospital information systems With the definition of information systems in mind, a hospital information system can easily be defined. A hospital information systemis the sociotechnical subsystem of a hospital, which comprises all information processing as well as the associated human or technical actors in their respective information processing roles. Typical components of hospital information systems are its enterprise functions, business processes, application components and physical data processing components. For the sake of simplicity, we will denote ‘enterprise functions of a hospital’ as ‘hospital functions’. As a consequence of this definition, a hospital has a hospital information system from the beginning of its existence. Therefore the question is not whether a hospital should be equipped with a hospital information system, but rather, whether its performance should be enhanced, for example, by using state of the art information processing tools, or by systematically managing it. All groups of people and all areas of a hospital must be considered when looking at information processing. A sensible integration of each hospital function and of different information processing tools in a hospital information system is important. Hospital staff can be seen in two roles: In one, they are part of the hospital information system. For example, when working in the department for patient records, or as operator in an ICT department, they directly contribute to information processing. In the other role, they use information processing tools (e.g. a nurse may use a telephone or a computer), in other words, they are users of the hospital information system. Each employee may continuously switch between these two roles. The goalof a hospital information system is to sufficiently enable the adequate execution of hospital functions for patient care, including patient administration, taking into account economic hospital management as well as legal and other requirements. Legal requirements concern e.g. data protection or reimbursement aspects, other requirement can be, e.g., the decision of a hospital executive board on how to store patient records. In order to support patient care and the associated administration, the tasksof hospital information systems are: • to make information, primarily about patients, available: current information should be provided on time, at the right location, to authorized staff, in an appropriate and usable form. For this purpose, data must be correctly collected, stored, processed, and systematically documented in order to 2. Basic Concepts 23 ensure that correct, pertinent and uptodate patient information can be supplied, for instance, to the physician or a nurse (see Figure 19); • to make knowledge, for example about diseases and side effects and interactions of medications, available to support diagnostics and therapy; • to make information about the quality of patient care and the performance and cost situation within the hospital available. In addition to patient care, university medical centers undertake research and education to gain medical knowledge and to teach students. When hospital information systems make available • the right information and knowledge • at the right time • at the right place • to the right people • in the right form • so that these people can make the right decisions, this is also described as the information and knowledge logistics of a hospital. Hospital information systems have to consider various areasof a hospital, such as • wards, • outpatient units, • service units: diagnostic (e.g. clinical laboratory, radiological department), therapeutic (e.g. operation room) and others (e.g. pharmacy, patient records archive, library, blood bank), • hospital administration areas (e.g. general administration, patient administration and accounting, technology, economy and supply, human resources), • offices and writing services for (clinical) report writing. In addition, there are the management areas, such as: hospital management, management of clinical departments and institutes, administration management and nursing management. These areas are related to patient care. They could be broken down further. For university medical centers, additional areas, needed for research and education, Figure 20: Different people working in a hospital (here: an emergency department). Figure 19: A health care professional accessing patient information. 24 Strategic Information Management in Hospitals must be added to the above list. Obviously, the most important peoplein a hospital are the patients and, in certain respect, their visitors. The groups of people working in a hospital (see Figure 20) are • physicians, • nurses, • administrative staff, • technical staff, • health informaticians, health information management staff, etc. Obviously, within each group of people, different needs and demands on the hospital information systems may exist, depending on the tasks and responsibilities. Ward physicians, for example, will require different information than physicians working in service units or than senior physicians. 2.5 Health information systems In many countries, the driving force for health care and for ICT in health care during the last years has been the trend towards a better coordination of care, combined with rising cost pressure. One consequence is the shift towards better integrated and shared care. This means that the focus changes from isolated procedures in one health care institution (e.g. one hospital or one general practice) to the patientoriented care process, encompassing diagnosis and therapy, spreading over institutional boundaries (see Figure 21). In the US, e.g. health care organizations are merging into large integrated health care delivery systems. These are health care institutions that join together to consolidate their roles, resources and operations in order to deliver a coordinated continuum of services and to enhance effectiveness and efficiency of patient care. The situation in Europe is also changing from hospitals as centers of care delivery to decentralized networks of health care delivery institutions which are called regional networks or health care networks. Enterprise boundaries are blurring. Hospital information systems will increasingly be linked with information systems of other health care organizations. The future architecture of hospital information systems must take these developments into account. They must be open to provide access or to exchange patientrelated and general data (e.g., about the services offered in the hospital) across its institutional boundaries. Figure 21: A general practitioner, contacting a hospital. 2. Basic Concepts 25 A lot of technical and legal issues have to be solved before the vision of transinstitutional computersupported health information systems will adequately support transinstitutional patient care. For example, general willingness to cooperate with other health care providers must exist; optimal care processes must be defined, and recent business processes be redesigned; accounting and financing issues must be regulated; questions of data security and data confidentiality must be solved, together with questions on data ownership (patient or institution) and on responsibilities for distributed patient care; issues on longterm patient records (centralized or decentralized) must be discussed; and technical means for integrated, transinstitutional information processing must be offered (‘telemedicine’, ehealth), including general communication standards. When dealing with hospital information systems, we will keep these aspects of health information systems in mind. 2.6 Information management in hospitals In general, management comprises all leadership activities that determine the enterprises’ goals, structures, and behaviors. Accordingly, information management in hospitals are those management activities in a hospital which deal with the management of information processing in a hospital and therefore of its hospital information system. The goal of information management is systematic information processing which contributes to the hospitals strategic goals (such as efficient patient care and high satisfaction of patients and staff). Information management therefore directly contributes to the hospital’s success and capability to compete. Information management encompasses the management of all components of a hospital information system: the management of information, of application components, and of physical data processing components. The general tasks of information management are planning, directing, and monitoring. In other words, this means • planning the hospital information system respectively its architecture; • directing its establishment and its operation; • monitoring its development and operation with respect to the planned objectives. Information management can be differentiated into strategic, tactical, and operational management. Strategic information management deals with information processing as a whole, and lays down strategies and principles for the evolution of the whole information system. Tactical information management deals with the execution of certain projects concerning just part of the information system, e.g. the introduction of an application component for a certain hospital function such as patient administration or documentation of operations. Operational information management, finally, must secure the 26 Strategic Information Management in Hospitals smooth operation of the information system, e.g. planning of necessary personal resources, failure management, or network monitoring. 2.7 Examples Example 2.7.1 Architecture of a hospital information system In the following, an extract of the description of the architecture of the hospital information system of the Plötzberg Medical Center and Medical School (PMC) is presented. As mentioned, PMC is a fictitious institution, which will be used in examples and exercises in this book. The hospital information system of Plötzberg Medical Center and Medical School (PMC) supports the hospital functions of patient treatment with patient admission and discharge, decision support, order entry, clinical documentation and service documentation; handling of patient records; work organization and resource planning; and hospital management. Those hospital functions are supported by some bigger and over a hundred smaller application components (partly computerbased, partly conventional). The biggest application component is the patient management system (PMS), the computerbased application component which supports patient admission and discharge, management of patient treatment, part of administrative and clinical data management, and handling of patient records. In addition, several computerbased departmental application components are used for work organization and resource planning (e.g. in the radiological department, in the laboratory department and in outpatient units). Nearly all computerbased application components are interconnected, using a communication server. Some computerbased application components are isolated systems without interfaces ... Conventional application components are used for special documentation purposes (e.g. documentation in operation rooms), and for order entry and communication of findings. … The application components are realized by physical data processing components. As computerbased physical data processing component, approx. 40 application and database servers are operated, and over 4,000 personal computers are used. Over 1,000 printers of different types are installed. Most computerbased physical data processing components are interconnected to a highspeed communication network. … As conventional physical data processing components, over 2,000 telephones and 800 pagers are used. Over 2,000 different paperbased forms are used to support different tasks. More than 400,000 patients records are created and used each year, a dozen archives are responsible for patient record archiving. A conventional mailing system allows for conventional communication between departments. …” 2. Basic Concepts 27 Example 2.7.2 Comments on the future of health information systems For the physicians of the 1990s and beyond, computer workstations will be their windows on the world. Much of the necessary technology already exists. Desktop or bedside, in the office or at the hospital, computers can respond to a simple click of a mouse pointing device. … In the future, the physician will be able to access the patient record largely by using the mouse and doing very little typing. Moreover, the record will include graphics and images as well as extensive text. Outpatient records will be integrated with inpatient data by using the capabilities of communications networks that link hospitals with the clinics and private offices of their medical staff members. … 14 “Through the further development of information systems at the university hospitals, the following goals are of special importance: • Patient based (facilitywide) recording of and access to clinical data for teambased care. • Workflow integrated decision support made available for all care takers through uptodate, valid medical knowledge. • Comprehensive use of patient data for clinical and epidemiological research, as well as for health reports. ... The following tasks shall have priority and will be worked on in the next years: • The introduction of a patient based, structured, electronic health record. • The stepwise introduction of information system architectures which support cooperative, patient centered and facilitywide care. Workflow support in the area of patient care. • The establishment of a suitable network and computer infrastructure in order to be able to, via the Internet, inform about the care offered at a particular hospital. • The introduction of efficient, usable mobile information and communication tools for patient care. ...” 15 From the experience gained so far ..., a number of direct benefits from health telematics can be identified: ... 14 Ball M, Douglas J, ODesky R, Albrigh J. Health care Information Management Systems A Practical Guide. New York: Springer; 1991. p. 3. 15 Deutsche Forschungsgemeinschaft (DFG): Informationsverarbeitung und Rechner an Hochschulen Netze, Rechner und Organisation. Empfehlungen der Kommission für Rechenanlagen für 20012005 (information processing and computer systems for universities; in German), Kommission für Rechenanlagen der Deutschen Forschungsgemeinschaft. Bonn: DFG; 2001. http:www.dfg.de. 28 Strategic Information Management in Hospitals • More people can be diagnosed and treated at their local clinics or hospitals, though without the facilities of urban referral hospitals. For the first time, it is technically feasible to contemplate the provision of universal health care. ... • Health telematics allows the global sharing of skills and knowledge. Access to international centers of excellence for various specialties becomes possible from many locations. Medical expertise can be available to anyone on request. ... • Cost savings can be achieve by reducing the transport of patients and travel of health care professionals, as well as by allowing home care of patients who would otherwise require hospitalization. ... 16 The future tasks of health care include: greater cooperation, more quality and economics and greater adjustment to the needs of patients. The information age offers great possibilities to solve these tasks, maybe even possibilities that we can’t begin to imagine today. The neuralgic point though in the discussion of telematics in health care is the uniting of data. Especially with regard to personal patient data, we are forthright dealing with the most personal of all data, and special caution is to be exercised when dealing with these data. Afterall, questions of power are raised through the uniting of data: greater transparency also means greater control. 17 2.8 Exercises Exercise 2.8.1 HIS as a system As introduced, a system can be defined as a set of people, things andor events, which form an entity, together with their relationships. Which people, things or events can you find when looking at a hospital information system? In what relationship do they stand to one another? To solve this exercise, take into account the components of hospital information systems as defined in section 2.8. Exercise 2.8.2 Goals of models Find two models which represent a city. What are the goals of these models? What are their components? 16 World Health Organization (WHO). A Health Telematics Policy, Report of the WHO Group Consultation on Health Telematics 1116 December 1997, Geneva. World Health Organization: Geneva; 1998. 17 Speech of German Minister for Health, Andrea Fischer, at the occasion of the first meeting of the symposium ‘telematics in health care’, August 19th 1999, Bonn. 2. Basic Concepts 29 Exercise 2.8.3 Information processing tools in a hospital Look at the following Figures 22 25, taken from a University Medical Center. Which information and communication tools are used? Which hospital functions may be supported by those tools? Exercise 2.8.4 Information processing of different health care professional groups Please have a look at the different groups in a hospital (e.g. : physician, nurse, administrative staff, hospital manager, patient, visitor), and describe some of their typical information processing needs. Exercise 2.8.5 Information and knowledge logistics Select one typical business process in a hospital (such as admitting a patient, requesting an examination, planning of therapeutical procedures, documenting diagnoses etc.) and find three examples how information and knowledge Figure 25: In a laboratoryunit. Figure 22: In the office of a senior physician. Figure 23: Admission at a general practitioner. Figure 24: In an intensive care unit. 30 Strategic Information Management in Hospitals logistics can fail. Which consequences may arise for the quality and for the costs of patient care from this failure? Exercise 2.8.6 Buying a HIS Is it possible to buy a hospital information system? Please explain your answer. What do ‘vendors of hospital information systems’ really sell? Exercise 2.8.7 Health information systems Please have a look at the statement on the comments for the future of health information systems (example 2.2). Which chances are discussed, and which problems? 2.9 Summary When working on hospital information systems, we must distinguish between data, information and knowledge: • Data can be defined as a representation of information, or knowledge, suitable for communicating, interpreting or processing. • Information can be defined in connection with objects which have a particular meaning in a specific context (specific knowledge). • Knowledge can be defined in connection with a certain discipline using specific terminology (general knowledge). Systems can be defined as a set of people, things andor events which can be regarded as an entity. Systems can be divided into subsystems and represented using models. Models commonly represent simplified depictions of reality or excerpts of it. Remember that models • usually form a simplified representation of reality, • should be adapted to a specific question or task, and • should be appropriate to provide answers for these question or tasks. A hospital information system can be defined as the sociotechnical subsystem of a hospital which comprises all information processing functions and the human or technical actors in their information processing role. Thus, when looking at a hospital information system, try to identify the following components or objects: • The enterprise, where it is located. • The hospital functions supported. • The business processes which take place. • The information processing tools used. • The human actors involved (both as part of the information system and as users). The goal of a HIS is to 2. Basic Concepts 31 • adequately enable the execution of hospital functions for patient care, • taking financial, legal and other requirements into account. Information and knowledge logistics means to make available • the right information (about patients, ...) and the right knowledge (about diseases, ...) • at the right time • in the right place • for the right people • in the right form • so that these people can make the right decisions. When working on a hospital information system, you must consider • all areas of a hospital, such as wards, outpatient units, service units, administration departments, writing services, management units, .... • all groups of people in a hospital, such as patients, visitors, physicians, nurses, administrative staff, technical staff, health informaticians, .. Information management in hospitals are those management activities in a hospital which deal with the management of information processing and therefore the management of the hospital information system. The architecture of an information system describes its fundamental organization, represented by its components, their relationships to each other and to the environment, and by the principles guiding its design and evolution.