e-HealthExpert.org - Primum non nocere

The World Health Organization (WHO) published a list of errors to avoid when designing, installing or supporting an Healthcare Information System / Hospital Information System / HIS:

1. Don't depend too much on one pioneering innovator, and do not leave any such innovator in charge - they will become too rigid and narrow-minded in their views, and stifle change and development.
2. Don't spend a large amount of time creating a detailed, rigid specification - it will be out of date before being designed, built, and implemented; rather, specify core principles and functionality together with a design-and-build or prototyping methodology.
3. Don't leave performance criteria, both in terms of functions provided and maximum percentage downtime to chance, but include them in the procurement contract.
4. Don't forget error correction and maintenance - write minimum standards into supply contracts, and ensure that there are sanctions, e.g., part of procurement payment held back until satisfactory functioning over a specified period; maintenance payments paid partly at the end of each period with reductions for loss of service.
5. Don't let the supplier determine needs or performance; instead, ensure that the customer remains in control.
6. Don't exploit your supplier - whilst the customer should lead, an aggrieved supplier provides a poor service and a bankrupted supplier disappears and leaves the customer stranded.
7. Don't impose "solutions" on end users and data suppliers; rather, ensure that they feel they are valued and want the system.
8. Don't automate today's paper processes - look at what new functions and methods automated Information Systems can undertake.
9. Don't specify too futuristically - there is a limit to how much people or an organization can change in one move; instead allow an evolutionary path.
10. Don't treat the organization or the specification as rigid structure, but instead allow for organizational and end-user learning, as well as technological and environmental change.
11. Don't stop evaluation at the point of installation testing - there will be ongoing organizational and personal behavioral change that must be identified and appropriate adjustments made.
12. Don't stop investing in a "successful" system - it will soon become out-of-date, and disillusionment will set in thus, to the dismay of users and paying parties, the "success" will soon evaporate.
13. Don't be complacent with a "successful" system - the very word of its success will increase usage, overload access, and degrade performance — this applies to all elements, including data networks and communications.
14. Don't confuse Education (concerned with changing professional practice and performance) with Training (about how to operate a system).
15. Don't change practice and switch on a system in one activity, but also don't computerize old practice - separate the two change processes, even though this will mean a short period of dysfunctional working, so as to ensure that the different changes are fully understood, and any problems can be traced to the correct source to facilitate rapid adjustment.
16. Don't rely on memory or suppliers - persons can forget, become ill, or leave; suppliers can go out of business or be taken over. Ensure that everything is properly documented, including performance agreements, and all systems specifications, functionalities, applications, and operational routines — the constant test must be "Could a new person take over that task tomorrow?".
17. Don't overlook the need for convincing answers on confidentiality - it will be a prime question from all health professionals before they use a system.
18. Don't think that removing names from records creates confidentiality - other factual combinations in records can effectively identify indirectly by implication or circumstance.
19. Don't assume that any types of data item are of low confidentiality - for some individuals any specific item may be very confidential because of personal circumstances, e.g., address or blood group.
20. Don't touch anything which does not run on open standards, is of a closed proprietary nature, or cannot accommodate modern recognized data and other standards - any short-term gain will be minimal compared with the cost of the dead end up which you are committing your organization.
21. Don't think that any Information System project is ever finished - if it successful, people will want more of it; if it unsuccessful, adjustments are clearly needed; and in any eventuality circumstances will change.

This list, named "A Don't List in Setting Up an Healthcare Information System", first appeared in the manual Setting up Healthcare Services Information Systems: A Guide for Requirement Analysis, Application Specification, and Procurement, edited in 1999 by PAHO (Pan American Health Organization) - a branch of the World Health Organization (WHO).

Choosing the best manual to help someone else on the difficult journey of setting up an Healthcare Information System / Hospital Information / HIS is, by itself, no simple endeavor. But, if we had to pick a single book on the subject, it would certainly be the World Health Organization's time proven manual:

Setting up Healthcare Services Information Systems: A Guide for Requirement Analysis, Application Specification, and Procurement, ISBN 9275122660, edited in 1999 by PAHO (Pan American Health Organization) - a branch of the World Health Organization (WHO).

This manual was assembled from the contributions of dozens of knowledgeable and experienced collaborators and according to its editors:

"This book discusses the implementation of information systems and the application of information technology in terms of the requirements in health care services, and provides a comprehensive review of information systems and information technology solutions."

"contains practical guidelines and suggestions to be used by healthcare and systems professionals when embarking in the initial stages of planning and developing healthcare services information systems and information technology (IS&T) applications."

From the manual:

• "A successful implementation is one that promotes and supports the institution's ability to execute its plans and meet its goals."
• "Organizations are discovering that successful information systems implementation in the health services institution requires a firm understanding of the organization's overall strategic plan."
• "A health services information system has the purpose of improving the overall performance of the institution."
• "The system being implemented must be recognized as a strategic tool and corporate asset that represents an investment in the organization's viability. "
• "A technology that is appropriate to an advanced, sophisticated user such as a large teaching institution in an urban area may not be appropriate for an emerging health services organization in a rural setting."
• "The social and economic context must always be considered along with issues related to availability of resources and personnel, health information infrastructure, sustainability and continuity of the decisions, and appropriate flow of financial resources."

We couldn't agree more.

UMIT, an Austrian University specialized in Health & Life Sciences, has a page where they keep an account of reported incidents in health care where Health IT (Health Informatics ) was the cause or a significant factor: UMIT - Bad Health Informatics Can Kill

The Government HealthIt site has an interesting article - The mountain cure -, about the work of Dr. Brent James at the Intermountain's LDS Hospital.
Dr. James has been applying W. Edwards Deming doctrine on improving outcome quality as a means to improve health system's security and reducing costs of operation.

You may find the full article at the Government HealthIt site

Complexity is a prominent characteristic of any healthcare organization.

The Wharton School [of Business - Univ. Pennsylvania, USA] just published a joint work with the George Group about Complexity in Products and Services and how it affects an organization.

In the Wharton tradition that report is clear and concise. Most of the problems pointed also show up in our hospitals and healthcare organizations and for that reason the report deserves a few minutes of you attention.

Taken from the report:
"...three important rules of complexity:
One, eliminate complexity that customers will not pay for;
Two, exploit the complexity customers will pay for;
And three, minimize the costs of complexity you offer."

"Complexity is not easy to recognize, and typically doesn’t raise red flags in financial statements. Very few organizations successfully capture the costs of complexity in their standard accounting systems
...It’s a bit like pollution, It builds up over time, it’s hard to see, but it definitely affects the overall health of the business. It’s a systemic issue created by multiple people so no one person is really accountable."

You may download the full report in .pdf format from:
http://knowledge.wharton.upenn.edu/index.cfm?fa=weblink&linkID=175

You may find the report page at:
http://knowledge.wharton.upenn.edu/index.cfm?fa=SpecialSection&specialId=45

The "Healthcare Informatics" magazine, January 2006 issue cover story is about Six Sigma Practices for the Healthcare Industry.

Six Sigma is a process-improvement methodology that is highly data-driven, and highly focused on achieving very specific, data-documented efficiency improvements, cost savings, and customer satisfaction enhancements.

It seems that executives at hospitals and health plans who have led Six Sigma initiatives are proud of the process changes and cost savings it has brought. They seem to love Six Sigma's focus on the bottom line and quantifiable results.

It is believed that the Six Sigma work can bring important benefits in healthcare for at least three substantial reasons:

• The funding for improvement projects at healthcare organizations is limited, so when one is undertaken, senior executives are demanding increasingly solid ROI--a strong orientation of Six Sigma.
• The complexity of healthcare processes requires objective data as the foundation of any improvement-driven activity.
• The rigorousness of Six Sigma work is particularly appropriate for the rather unorganized delivery of care and management of business operations in healthcare.

The full article is available at: Six Sigma Practices

Related article: Lean, Sigma, Kaizen - will they work for healthcare?

The Artemis project is an European Commission funded project that aims to define a Semantic Web Service-based P2P Infrastructure for the Interoperability of Medical Information Systems.

Among its main purposes are:

• the ability to provide the interoperability of medical information systems through semantically enriched Web services (using a to phase process through, first a Message Ontology Mapping Process and then a Message Instance Mapping);
• to find and retrieve clinical information about a particular patient from different healthcare organizations where concrete sources are unknown.

The project started in 2004 and is a joint effort of Turkey, UK, Greece and Germany teams.

More information at the The Artemis Project home page.

The US Government published (2005.12.23) a list of the 20 messaging and vocabulary standards that from now on will be used at the US Government funded health care information systems.

“The portfolio of 20 adopted standards will be used in all federal agencies implementing new, and to the extent possible, in modifying existing health information technology systems, as well as related business processes”

These seem to be big news as this list has the potential to be the basis for further Health IT Interoperability initiatives.

The main adoptees are: HL7 2.x, DICOM, SNOMED CT, LOINC and HIPAA (Trans. and Code Sets).

The list may be freely downloaded from the US Gov. Printing Office.

(The e-HealthExpert.org members will have to log into the e-HealthExpert.org site to be able to download a copy by following the "attachment"/"fr23de05-78.pdf" link presented bellow these lines.)

The International Journal for Quality in Health Care published this month (Dec 2005) the preliminary results of a study about the the World Health Organization (WHO) sponsored "Performance Assessment Tool for quality improvement in Hospitals" Project (PATH).

The article is titled "A performance assessment framework for hospitals: the WHO regional office for Europe PATH project"

The following was taken from that article's abstract:

Objective . The World Health Organization (WHO) Regional Office for Europe launched in 2003 a project aiming to develop and disseminate a flexible and comprehensive tool for the assessment of hospital performance and referred to as the performance assessment tool for quality improvement in hospitals (PATH). This project aims at supporting hospitals in assessing their performance, questioning their own results, and translating them into actions for improvement, by providing hospitals with tools for performance assessment and by enabling collegial support and networking among participating hospitals.