HEALTH –MIC: WORTH THE EFFORT?

The Argument for an R and D Agenda in Support of

Healthcare Management Informatics and Computing

Christopher Bain

Convenor, SIG in Healthcare Management Infornmatics and Computing

Information Manager - WCMICS

Albert St. East Melbourne Vic. Australia

Keywords: Health management, Computing, Informatics.

Abstract: In this paper I make the case for a research and development (R and D) agenda in support of the evolving

discipline of healthcare management informatics and computing (HMIC, pronounced “Health-mike”). The

aim of the discipline is to provide healthcare managers the information technology (IT) tools they need to

address the health needs of our communities, with the often inadequate resources they have at their disposal.

Given the needs of our communities in relation to healthcare, the establishment of this agenda and

subsequent work towards the relevant goals are critical to improving our healthcare systems, particularly in

the Western world.

1 INTRODUCTION

This paper seeks to make the case for a Research

and Development (R and D) agenda in support of the

discipline of Health Management Informatics and

Computing (HMIC). This discipline can be thought

of as sitting at the intersection of health

management, computing and the relevant sciences.

More precisely, HMIC could be defined as that

subset of health informatics dedicated to the study,

design and implementation of information

technology solutions in support of the practice of

healthcare management in all its forms - including,

but not limited to, primary care and general practice,

sub acute and rehabilitation care, and hospital care.

Furthermore, HMIC involves the study of the needs

of healthcare management practitioners, including in

information presentation and in decision support.

Whilst far from complete, that definition should

suffice to allow readers to understand the argument

that follows.

In the Western world in particular, our

communities, our patients, are telling us about the

problems they experience as consumers of our

healthcare systems. Some of the biggest concerns

facing patients, and the cause of many complaints,

are in relation to access to care and services, the

physical environment in which they receive care,

and the quality of that care. All of these things are in

the sphere of influence of healthcare managers.

For the purposes of this paper I will define a

healthcare manager as anyone who has at least

partial responsibility for the management of a care

or support service in the health industry. The key

distinction here is with the clincian role which is

primarily about the provision of care. Clearly,

however, some managers are clincian managers.

2 BACKGROUND

In recent years there has been an increase in interest

in using scientific methods, including some

techniques well known in the world of management

science (Butler 1995) (Fannin 1997) to attempt to

address the problems confronting those managing

our healthcare systems. By way of illustration is the

establishment of the UK based Nosokinetics group

(Group 2006)

As stated previously, patients experience a

number of problems in our healthcare systems,

either identified by them, or evident to those of us

who work in the industry. In many cases these

problems are clearly in the domain of managers in

terms of resolving them, sometimes representing

systems failure, but often not the responsibility of

351

Bain C. (2009).

HEALTH –MIC: WORTH THE EFFORT? - The Argument for an R and D Agenda in Support of Healthcare Management Informatics and Computing .

In Proceedings of the International Conference on Health Informatics, pages 351-356

DOI: 10.5220/0001745603510356

 SciTePress

individual clinicians alone. An example is

medication errors associated with role overload

(Wilkins and Shields 2008).

3 THE RATIONALE

3.1 Drivers for HMIC

Outlined in the section that follows is what could be

considered some key drivers of this work. The

categorization of these drivers is not to ignore their

fundamental interrelationships, but to allow a

crystallization of thought around some of the key

issues facing healthcare managers.

3.1.1 The Patient Experience

In this section of the paper I will outline some of the

patient led drivers for improving healthcare systems

in more detail.

By way of scene setting, there is the worrying

assertion by certain authors that “In some cases,

health care delivery directly contributes to increased

suffering“ (Daneault, Lussier et al. 2006)

Certainly many of the problems patients report in

relation to the healthcare they receive are related to

problems that are under the direct responsibility of

healthcare managers. For example, patients have

identified staff responsiveness (Tea, Ellison et al.

2008) as a key factor in determining their

satisfaction with health services.

In patient satisfaction surveys (Research 2006)

for example, some of the following factors have

been identified as being positively associated with

improved patient satisfaction:

 discharge experience

 waiting experience

 amount of time spent in hospital

 hospital facilities and

 admission experience

These and other complementary findings are also

demonstrated in other patient satisfaction surveys

(UltraFeedback 2007). In a cancer specific

satisfaction survey (Heading, Mallock et al. 2007) –

in inpatients, access to care again rated poorly as

compared to other dimensions; and in outpatients,

waits for radiotherapy and chemotherapy again rated

more poorly than other dimensions. Another

example from the cancer setting is consumer

feedback to a key 2003 report by the Clinical

Oncology Society of Australia. (Initiative 2003) In

it, it was stated that consumers want their treatment

to be “timely (no unnecessary long waits) and

organised around their wider needs, for example, the

need to travel.”

Factor like these are all influenced by the way

facilities and systems are funded, designed and

managed, much more so than they are affected by

the delivery of care by individual clinicians.

3.1.2 The Professional and Organizational

Experience

The following section of the paper outlines some

key areas of concern for healthcare professionals and

organizations, which support the argument for an R

and D agenda in support of HMIC.

As described previously, the interrelated issues

of patient satisfaction and management imperatives

around quality and safety of care are key areas for

healthcare managers.

Managing access problems of various kinds is

another ongoing issue for healthcare mangers (Allen,

Shelton et al. 2008) (Zavagno, De Salvo et al. 2004).

The dimensions of this problem include access to

services and equipment.

Of course there is always the imperative to

manage the bottom line (Young-Schmidt 1999) -

particularly in many public institutions that

chronically run over budget – but which are

arguably, therefore, under-funded. In an era of

shortages of skilled staff across the globe,

particularly nursing staff, the challenge of finding

and retaining sufficient qualified staff to run

facilities is a huge concern. (Francis 2008) (Doiron,

Hall et al. 2008) (Kober and Van Damme 2006)

Changing care models, for instance the

introduction of multidisciplinary (MD) care (Davies,

Deans et al. 2006) (Kane, Luz et al. 2007) also have

significant workforce and logistic implications for

managers, thus increasing the decision making load

upon them. Importantly also, patients support the

introduction (Initiative 2003) of such models.

Adding to this load on managers is the challenge

of integrating these various problems and views

from a management perspective given the complex

and intertwined relationships between all of them, in

the context of the ever advancing competencies

required of health managers. (Nishiyama, Wold et

al. 2008) (Kleinman 2003)

3.2 An Analogy – The ICU Patient

There is potentially a good analogy when thinking

about HMIC in relation to hospitals, although the

scope of this agenda could extend far beyond acute

hospitals, to healthcare facilities of all types and to

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352

private general practice, and allied health practices.

The analogy is that of the intensive care unit (ICU)

patient. This analogy is only intended as a

framework for thinking about the problems rather

than, for instance, an argument for equity of

investment.

Using this analogy, many of our public hospitals,

in particular, have been on “life support” at different

times, in the form of constant management re

structures (sometimes government imposed) and

extra financial grants and concessions. Arguably if

they were private businesses they would have gone

into insolvency; but, arguably these hospitals are

also under funded. Effectively they are like ICU

patients who are very unwell and need constant

monitoring.

In terms of information (gages, reports and

readouts) available to the manager of the critically ill

patient on a ventilator (the ICU specialist, and his or

her team), there is a large amount of information

available to them. In the case of the respiratory

system alone, these pieces of information include for

example:

 oxygen (O

) saturation

 full measurement of all blood elements related

to breathing function (arterial blood gases) and

 daily Chest x-rays to visualise the lungs.

In terms of controls (levers, dials and switches)

which allow the ICU specialist to control or improve

respiratory function, these include:

 the ventilator itself – these have volume,

pressure, rate and delivery mode settings, all of

which allow optimisation of the patients

respiratory status in any given clinical scenario

 the amount of oxygen that is delivered through

the ventilator and

 a range of drugs in support of improving

respiratory function.

If one now moves to the management of an

unwell hospital, the information and controls

available to the managers of that system pale into

insignificance in comparison.

By way of illustration, let us consider the

example of managing the respiratory system of a

patient on a ventilator, and specifically the

measurement of oxygen saturation (the accepted

means of monitoring, in real time, whether the

patient has enough oxygen in their blood to sustain

life). In this case, the following pre work has been

done:

 the basic physiology has been described

and understood and the concept defined in a

universal way

 the biomedical engineering work to develop

sensors to precisely measure this has been

done

 the clinical trialling of the equipment has

been done, and

 the real world uptake and acceptance of the

evidence around the practical application of

the tool(s) has occurred.

Let’s now compare that to the concept of

hospital occupancy (think of it as “bed saturation”)

as an example. This analogy again highlights the

size of the gap between this knowledge and

application area, and the clinical domain:

 the drivers and definition of hospital occupancy

are not described in a universally accepted and

scientifically proven way.

 there are no universally accepted and robust

tools to allow monitoring of hospital occupancy

in real time

 there have been few real world trials of many

developed tools (as opposed to in vitro tools e.g.

- simulation studies, see (Sobolev and

Kuramoto 2005) (Ledlow and Bradshaw 1999)),

and

 there has been limited, if any, real world uptake

and acceptance into routine use, of the tools that

are available

It bears a much more in depth analysis as to the

reasons for these differences, and that is beyond the

scope of this paper – in effect that is the work of

HMIC, or at least an important example of it.

4 WHAT WOULD AN “R AND D”

AGENDA ACHIEVE

4.1 Overview

There has certainly been work relevant to HMIC

going on for 30 or more years, especially in core

business areas like nursing scheduling systems

(Ballantyne 1979) and patient acuity and

classification systems (Coetsee 1985) (Cochran

1979)

Many of the major problems confronting the

health care industry in the Western world remain

management problems, rather than problems directly

in clinical care provision (Armstrong, Gillespie et al.

2007) which is generally of a good standard. Given

that, there seems to be a distinct lack of coordinated

effort in terms of understanding what role

information technology (IT) can have in supporting

solutions to these problems. This is particularly the

HEALTH –MIC: WORTH THE EFFORT? - The Argument for an R and D Agenda in Support of Healthcare Management

Informatics and Computing

353

case when compared with the clinical informatics

domain.

4.2 Establishing Answers to Core

Questions

More specifically are the following unanswered

questions in this regard:

 what are the key information and decision

support requirements of health care managers?

 how do we harness some of the groundbreaking

work in scheduling, forecasting, and data

presentation (Duckett, Coory et al. 2007). In

particular, how can such innovations be

operationalized and incorporated into robust,

integrated IT systems?

 we know that standards based approaches can

have significant benefit in facilitating IT

development (Ludwick and Doucette 2008)

(Bouhaddou, Warnekar et al. 2008) but are there

standard definitions for management concepts

such as "congestion", for example; and how do

we represent them in a way that IT practitioners

and developers can incorporate them into

practical IT systems?

 how do we ensure that HR, finance, PAS and

predictive systems (Bottle and Aylin 2008)

(Emendo 2006) can work in an inter-operable

fashion given the complex and intertwined

relationships between issues such as staffing,

finance and bed management in health care

organizations?

The establishment of an R and D agenda for

HMIC would seek to answer these questions

amongst others.

4.3 Coordination

Arguably there has been no coordinated effort since

then especially in comparison with clinical

informatics; hence it is a good time before there are

too many vendors in the space, to create common

definitions and standards, to define use cases and

common management scenarios that systems can be

built to support. These kinds of activities can only

assist in achieving greater coordination of effort in

regard to solving some of the core problems outlined

previously in this paper.

4.4 Flow on Effects

There are some potential flow-on effects from the

establishment of this agenda that include:

 Attracting further funding

 Attracting technological development

 Attracting interested and skilled people to work

on these problems

 Fostering the kind of scientific and industry

collaborations that can allow the closure of the

gap between real world problems and viable

solutions.

5 WHY NOW?

In the context of what I have stated previously, a fair

question from a sceptic may be – “why now?” Why

is it important to define, establish and implement

this R and D agenda at this point in time? The

following represent some of the key reasons:

 The available technologies, now more than ever,

offer a great opportunity to advance this agenda.

New, especially mobile, devices (Garrett and

Jackson 2006) (Lin and Vassar 2004) (Siracuse

and Sowell 2008) capable of supporting rich

levels of functionality, make it easier than ever

to deliver functional software solutions to

managers at the point of decision making, whist

accommodating their workflows.

 It is time to operationalize many of the scientific

innovations in this area. Too much work has not

been translated into practice, international

experts in the area acknowledge this (Brailsford

2005). Even the lessons from the work

performed in this space have not been drawn

together to inform practice. For example, where

are the systematic reviews of, and lessons from,

the multiple simulation studies regarding

management problems? The work by Fone et al

is one notable exception. (Fone, Hollinghurst et

al. 2003)

 The dire financial state (Frizelle 2008)

(Werntoft, Hallberg et al. 2007), and complex

financial environment (Wagner, Valera et al.

2008) (Buchan and Evans 2008) that public

health care, in particular, operates in is a key

reason to act in this area now. The availability

of funding to support healthcare will be under

ever greater pressure as expensive care delivery

technologies and products continue to evolve.

 If we do not move quickly towards establishing

and working on this agenda, the danger is that

the core needs, and robust standards and

approaches will not be defined before vendors

and solutions proliferate, leaving us with the

same sorts of inter-operability problems and

debates (Wright and Sittig 2008) (Hammond

2008) (Engel, Blobel et al. 2006) that plague

clinical informatics.

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6 CONCLUSIONS

In conclusion, the rationale for this work is that:

 patients continue to experience problems as

consumers of healthcare, and there are also

problems identified by those of us working

in the healthcare system

 there are often insufficient resources

available in our systems to address these

problems

 this combination of factors represents a

complex challenge for healthcare managers

 information technologies can have a role in

assisting with the rationale use of limited

resources and system management, and

 there has been little of the scientific ground

work done in this area to underpin the

development of robust tools, even in the

presence of adequate funding and interest in

these problems.

This is the remit of HMIC, and an R and D agenda

in support of this discipline would assist enormously

in solving some of these very important practical

problems in healthcare.

ACKNOWLEDGEMENTS

I wish to acknowledge Prof Peter Millard, founder of

the UK Nosokinetics group, who has shown the

drive and vision necessary to take the international

health community to its’ current point of evolution

in relation to these issues. I also wish to

acknowledge the assistance of Assoc Prof Caroline

Brand and Dr Gitesh Raikundalia in reviewing the

manuscript.

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