This year's design seminar is concerned with some important issues in the
area of health care delivery and management. Participants will have a truly
unique opportunity to work for a real client, on real world design problems,
in a rapidly changing technological environment.
The client is the Harvard University Health Service. The management
of HUHS has invited ES 96 participants to help them resolve some shortcomings
in their present system for distributing and tracking medical records.
The initial phase of the seminar's activity will be devoted to study and
analysis. First and foremost, participants will meet with HUHS staff members
to learn about the current information system and to understand how the
client would like to improve that system. However, the participants will
also be expected to examine the problem in a larger context that includes
a more general study of how health care information systems are evolving
at HUHS and other medical centers. In the second phase of the seminar's
activity, participants will formulate a set of design tasks and divide
into small working groups to deal with these tasks. The working groups
will, of course, address the problems perceived by the client, but will
also deal with other problems identified in the initial study phase. In
particular, it is of central importance that design proposals should be,
in some sense, globally optimized to help HUHS improve its
overall performance. There is nothing gained when the performance of one
element of a system is improved at the expense of the performance of other
elements. In the final phase participants will refine the design tasks
and develop appropriate solutions. Specifically, each working group will
build and demonstrate proposals to enhance the means by which HUHS health
care providers acquire and report clinical information.
Medical Information Systems: General Context
Any attempt to introduce change into the way of doing things in health
care must be judged in an intricate context of competing priorities and
goals. The practice of medicine is obviously becoming exceedingly complex
and expensive. The practitioner operates in a swiftly changing, information-rich,
but time-constrained environment. Increasingly, the quality of clinical
care depends on the effectiveness of team work and, thus, the coordination
of patient-care tasks is crucial. As test modalities and treatment strategies
proliferate, it becomes ever more difficult to make rapid, well informed
medical decisions. Needless to say, economic considerations are critical
and the whole health care system is in a chaotic state of reorganization.
In the quest for cost containment, third-party payers insist on and monitor
documentation intended to measure the efficacy of health processes. In
these and in a myriad of other ways, information technology is playing
a more and more important role in medicine.
The design and implementation of effective clinical information systems
to serve the evolving needs of health care is a daunting challenge that
has generated much research and commercial activity. The design process
is highly constrained by economics and history. Medical record keeping
may be as old as the medical profession itself. Early in their training
medical students are taught the importance of records as a tool in reaching
clinical management decisions and in the actual physical delivery of care.
Much of medicine hinges on the ability to capture, retrieve and otherwise
operate on clinical information.
The classic medical record is a folder filled with a chronological (usually)
record of an individual's history of "encounters" with care providers and
test results generated by such encounters. Although the paper-based record
is a key element in current practice, its significant limitations have
been long appreciated. From the early days of the computer era there has
been a tenacious effort to find effective means to automate the storage,
retrieval, and analysis of clinical information. Many clinical elements
-- e.g. chemical testing and pathology laboratories -- have developed very
sophisticated automation tools, but integration of these subsystems into
a complete clinical information system is still far from a reality in most
major medical centers. Ultimately, the goal is to build information systems
that facilitate the delivery and management of care by helping providers
make better decisions.
Client Perceived Deficiencies in the Present System
The HUHS clinical information system is at a relatively advanced stage
of evolution, but the paper-based record still holds sway as a central
element in organization of care and is likely to remain important for the
next five to ten years. While there has been a significant investment in
computerization at HUHS and computers are used extensively by some of the
clinicians, the paper record or chart is still the only truly complete
and integrated record of patient information. Ideally, it should be available
and completely updated for every encounter with a care provider.
Most of the HUHS medical record folders are stored and processed in
the Medical Records and Data Entry Departments which are located on the
basement level in Harvard's Holyoke Center (see Appendix C). There are
also records stored at satellite clinics at the Business, Law and Medical
Schools as well as at an off-site facility in Milton, New Hampshire. As
needed, requested charts are delivered to the offices of the health care
providers -- see the oversimplified diagram below -- and, in principle,
all charts are returned to the basement area at the end of day. After every
patient visit or phone call, the provider records, in summary form, data
and comments in an encounter sheet or Record of Ambulatory Visit (RAV).
The clinician may also generate other information such as a dictated clinical
note for inclusion in the RAV, prescriptions for medications, referrals
to other providers, and orders for tests and/or X-rays. When the chart
is returned to the Data Entry Department, information from the RAV and
test results are entered into the computer database and incorporated into
the medical record folder.
An Oversimplified Flow Chart of the Present Record System
The client seems to be generally satisfied with the overall performance
of this system. But, as is always true, there is pressure to reduce cost
and to improve the services provided to the clinicians. A preliminary assessment
of client's perceived problems may be categorized as follows:
A. Architectural or building problems: The actual physical circulation
of medical record folders among departments at HUHS is impeded by some
inherent structural limitations of the building in which it is housed.
These limitations are complicated by the fact that the building -- Holyoke
Center -- is used for many purposes.
A dumb dumb-waiter: A small non passenger elevator or dumb-waiter is used
as a principal means for circulating records at HUHS. There appear to be
a number of problems associated with its use -- viz.
a. The dumb-waiter is very awkwardly located for optimal usage and may
not be re-locatable.
b. It is slow and not always available since it is shared with other HUHS
services
c. Insuring the privacy of records in transit is exceedingly time-consuming.
Conflicting uses of shared service elevator: At the beginning of day most
of the charts are delivered to the various departments by means of carts
which carried to a given floor by a service elevator. Unfortunately, this
elevator is used for a variety of other -- largely incompatible -- functions.
Difficult record room access: The aforementioned difficulties with the
dumb-waiter and service elevator could be easily remedied if it were not
for the fact that the floor of record storage room is two steps below the
basement floor level. Record carrying carts cannot be rolled in or out
of the record room to use other HUHS passenger elevators.
B. Data flow and record tracking problems: A second class of problems relate
to a set of more fundamental issues in information management.
Difficulties at data entry stage: As the figure above suggests, the integration
of medical information occurs in the Data Entry Department. At that stage
in the chart's journey, data from the RAV, results of tests and information
about referrals is entered into the individual patient's record in the
computer database. When this process is completed, under normal circumstances,
the chart is returned to the Medical Records Department for storage. Unfortunately,
data entry is a laborious task that must be done with great care to insure
the accuracy of the record. At present there is a considerable backup in
this process that has been estimated to be as long as two weeks. Obviously,
things get very complicated when a patient is seeing several different
providers and when an incomplete chart is delivered to a clinician.
Difficulties in tracking chart locations: The Medical Records Department
keeps an account of where charts are initially sent and, thus, should know
where to retrieve a given chart if it is required by another provider.
Unfortunately, there are a number of factors that complicate the retrieval
process. The chart, for a variety of reasons, may not have been returned
to the basement at the end of the previous day or a provider may have given
the chart to a colleague without notifying Medical Records.
Accessibility and presentation of medical information: There seems to be
considerable division of opinion among the providers at HUHS on how information
should be made available. The chart is essentially a chronological file
that incorporates a record of all, or nearly all, of a patient's encounters
with HUHS. To retrieve a given piece of information, such as a test result
or an inoculation record, the provider must know the date of the encounter
or manually sort through the whole file. Some providers would like to see
the folder divided by function while others have sufficient computer sophistication
to find information through on-line sources.
Time consuming population or statistical studies: It long has been recognized
that studying and caring for the health of an individual is influenced
and informed by studying and caring for the health of populations. At HUHS,
as in most medical practices, the records concern the treatment of individuals.
In order to get a recordâ for the population, it is necessary to
perform an abstraction, or aggregation, from the individual records. This
requirement has often been something of an afterthought when creating individual
records; if analysis is required, the aggregation may be performed at leisure
by hand. This situation is increasingly unsatisfactory. Individual clinicians,
associations of medical practitioners, and third-party payers are demanding
this type of data and meeting these demands imposes a significant burden
on the current health care record system.
Inadequate processes for exchanging medical information with other institutions:
HUHS patients are often referred to other local institutions -- e.g. Boston's
Brigham and Women's Hospital -- for further medical care. At present, the
exchange of information with these institutions is quite informal and,
generally, unsatisfactory. A small pilot project with BWH is just getting
under way, but the problem is difficult one. A particular complication
results from the fact that a wave of consolidation is sweeping hospitals
and there is deep uncertainty on matters of hospital administration.
