Megatrends in EM Informatics

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Barthell - Megatrends Megatrends that Will Accelerate Information System Deployment in Emergency Medicine Edward Barthell January, 2000 Not to be distributed without written permission from the author

Transcript of Megatrends in EM Informatics

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Megatrends that Will Accelerate Information System Deployment in Emergency Medicine

Edward BarthellJanuary, 2000

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Introduction

Well known social forecaster John Naisbitt popularized the term Megatrends with his first major book in 1982.1 He has identified megatrends as a means for explaining how emerging technologies and social forces will affect our lives. This paper identifies nine megatrends that will affect the importance of information management systems in the field of emergency medicine. The first five of these trends focus on changes in technology that will be applied to emergency medicine information systems, while the next four trends focus on changes occurring within medicine in general and emergency medicine in particular.

The trends identified include internet improvements, the year 2000 effect, standards development, the application service provider model, mobile computing, emergency caregiver labor changes, changing reimbursement methods, demands for quality, and an increased emphasis on public health.

The discussion of these trends leads to an inevitable conclusion that information systems based on modern technology will increase in importance in the future. These trends provide a compelling case for increased urgency with regard to the implementation of these systems. The improvements in technology that are becoming available provide a marvelous opportunity for those involved with emergency medicine to improve the quality and efficiency of the care process, benefiting both individual patients and the health of society at large.

Background

The American College of Emergency Physicians has encouraged activities to stimulate a vision of the future use of information technology to support emergency medicine. ACEP has published an overview of the future of the specialty.2 The organization has helped participate in data standards development, has helped sponsor an Emergency Department of the Future display at its annual Scientific Assembly, and has presented a number of didactic sessions on the topic at various meetings over the past several years.

Cordell and Waeckerle have published a significant paper to address the need for further emphasis on informatics in emergency medicine in the future. The paper provides recommended strategies as derived from an emergency medical information management work group.3 The four primary recommendations include:

1. The evolution of standards and uniform data sets should be funded and promoted.

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2. Health care information systems should be integrated to meet clinical, management, and research needs.

3. Health care professionals should be trained to use information technologies to transform data into information.

4. Future trends, opportunities, and risks regarding information technologies should be systematically studied.

A further suggestion is that collected information can be “reused” to conduct clinical and public health research, manage patient populations, develop health care guidelines and policies, and educate emergency health care workers.

The National Coordination Office for Computing, Information and Communications has defined fourteen distinguishing characteristics of revolutionary applications that will utilize the internet in the future.4 Seven of these apply directly to systems that will be used in emergency medicine. These include:

1. Security – systems shall include effective multi-tiered approaches for maintaining security and confidentiality.

2. Data sharing – systems shall allow for data sharing by clinicians, public health authorities and medical researchers.

3. Software sharing – system software shall run on both local and distant servers and will be shared by entire regions of providers.

4. Scalability – systems shall have the ability to scale from single hospitals to regions of hospitals to inter-linked regions across the nation.

5. Portability and Interoperability – systems shall be designed to operate in a wide range of hospital emergency department environments, ranging from small rural community hospitals to urban trauma centers.

6. Ease of Use – the intensity of the emergency medicine environment demands that systems be easy to use and integrated within the workflow. An open system design should permit rapid and easy expansion of the network.

7. Reliability – providers will demand accurate and reliable responses with a minimum tolerance for problems in the fast moving emergency environment.

Smith and Feied have published an article on the future use of technology in emergency medicine.5 The authors describe an optimistic view of how informatics will ultimately improve the care delivered in the next generation emergency department. The paper suggests new developments in emergency medical informatics will drive advances in clinical care, administration, research and education. Information activities will transform from a “hunter-gatherer” information model to a “publisher-subscriber” model in which the right information will almost always be available at the right time. Computers are expected to be both ubiquitous and almost invisible.

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Megatrends Impacting Emergency Medical Informatics

1. Internet Improvements

The National Library of Medicine has encouraged the use of Internet based resources to support health care. Dr. Donald Lindberg, Director of NLM, has stated: "One of the most important aspects of the next generation internet in the health sciences is the use of computer and telecommunication technology for medical diagnosis and patient care”.6 The Internet has been advocated as a means for communication between physicians and patients7, and to support medical decision making.8

While the growth in the use of the Internet has been astounding, problems with the use of the Internet persist, and have limited its widespread use in medicine. According to the July 20, 1998 issue of Hospitals and Health Networks, it is estimated that less than ten percent of the nation’s 4500 emergency departments, and less than five percent of the nation’s ambulance firms have direct internet access.9 The article quotes David Nevins, executive vice-president of the American Ambulance Association in Sacramento, stating the primary reason is the lack of internet reliability. More recent data collected by the author in the spring of 1999 confirm these numbers, although more than 20% of emergency departments have plans to install internet access in their clinical care areas in the next year.10

New Internet technologies will greatly enhance the Internet’s speed and service, making it a much more potent medium for collaboration, e-commerce and entertainment. Today’s modems may operate at transfer speeds of 56 Kilobytes per second (Kbs) and today’s T1 lines operate at 1.54 Megabytes per second (Mbs). At current speeds a popular interpretation of the WWW acronym is now the World Wide Wait. However, new technology is now being implemented in many cities across the country. Technology such as Digital Subscriber Lines (DSL) and cable modems, provide potential transfer speeds of up to 10Mbs. Moreover, programs such as the federal Next Generation Internet (NGI) initiative will lead to technology that will vastly improve bandwidth available to end users. The goal of the NGI is to provide end to end data transfer at speeds of at least 155 Mbs, or 100 times that of a T1 line.11 An entire industry dedicated to providing this “broadband” availability is well financed and rapidly growing. More than just speed, evolving technology promises to improve the quality of service (QoS), including the ability of users to prioritize information flows.

2. Year 2000 Effect

During the past few years, an enormous amount of work was dedicated to required updates in information systems to prepare for the change in date to the year 2000

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(Y2K). While healthcare organizations have furiously pursued potential last minute Y2K snafus, purchases of new systems have been delayed. Dollars that might have bought new products have been spent bringing systems into compliance for Y2K. According to Kenkare, US hospitals had spent $7.5 billion as of midsummer 1999, and an additional estimated $1 billion was spent as necessary to update physician offices, clinics, laboratories and state agencies before the year-end. Thus $8.5 billion was spent on Y2K activities that might have been spent on infrastructure improvements.12

Although the effort expended may be presumed to be unproductive, this effort

allowed forward looking companies to update their systems to architectures that will more easily support advanced functionality in the near future. The process also caused companies to adapt to an increased budget for information systems activities. As stated by John Roth, CEO of Nortel Networks, many companies “looked at their systems not just to get past the date change but to get ready for the web”.13

The successful passing of the looming Y2K threat promises to free up resources among health care organizations to begin to pursue other activities. Capital and information systems staff time will be available to be assigned to projects of more immediate benefit to clinicians and their patients. Other major demands will be put on health care IS groups in the near future, particularly compliance with forthcoming HIPAA regulations for maintenance of security and confidentiality, as will be discussed further below. However, unlike Y2K work, this effort will have more direct impact on clinicians and the systems they use, and in fact may further encourage implementation of more effective systems for managing information.

3. Standards Development

This trend is described with a broad context, including data standards, messaging standards, integration standards, and security standards. The highly regarded Institute of Medicine study14 and the more recent Macy study on Emergency Medicine15 both identified a lack of data standards as an impediment to more effective use of information systems in emergency medicine. However, significant progress is being made on a number of fronts.

Perhaps one of the most important messaging standards is the Transmission Control Protocol / Internet Protocol (TCP/IP) which is established as the language of the Internet. TCP/IP and related internet standards remain under the auspices of the World Wide Web consortium and the Internet Engineering Task Force (IETF).16 In the health care world, most messaging standards are the domain of Health Level Seven (HL7).17 Most successful health care information systems companies today are well versed in HL7.

The National Center for Injury Prevention and Control (NCIPC) of the Center for Disease Control and Prevention (CDC) has coordinated a national effort to develop uniform specifications for data entered in emergency department (ED) patient records. The initial

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product is Data Elements for Emergency Department Systems, Release 1.0 (DEEDS).18 The recommendations in DEEDS are intended for use by individuals and organizations responsible for maintaining record systems in 24-hour, hospital-based EDs throughout the United States. If the data definitions, coding conventions, and other recommended specifications are widely adopted, then incompatibilities in ED records can be substantially reduced. Further, because the recommendations incorporate national standards for electronic data interchange, implementation of DEEDS in computer-based record systems can facilitate communication and integration with other automated information systems.

With regard to security standards, the National Research Council (NRC) of the National Academy of Sciences in March, 1997 issued the report “For the Record: Protecting Electronic Health Information”.19 Concluding that the current practices at the majority of health care facilities in the United States are insufficient, the Council delineated both technical and organizational approaches to protecting electronic health information. Researchers have implemented all thirteen NRC recommendations in the security architecture of the CareWeb system that has been used in a number of emergency departments in the Boston area.20,21 In the year 2000, the federal government is expected to publish a final version of the HIPAA security regulations22, so that security standards will no longer be a moving target but can be effectively planned for and implemented. This will undoubtedly be a major focus for health care information systems groups in the near future.

4. Application Service Provider Model

The application service provider (ASP) model is evolving as a dynamic sector of the technology industry. GartnerGroup’s Dataquest research arm believes the ASP market will grow annual revenues from $2.7 billion to over $22 billion in the next two years.23 In this model applications are hosted by a service provider in a secure data center, and access to these applications is provided via the internet to end users that need only a web browser. The service is provided for an agreed upon lease fee, with no need for high start up capital expense by the end user. This approach removes the barrier of capital expense from the implementation process, the user pays for the service on an as needed basis, and the service provider takes responsibility for maintaining the application, security, and data storage. Particularly in an industry such as an emergency medicine, which does not have a history of high capital expenditures, this approach will lead to easier access to needed information systems.

The application service provider model is already gaining acceptance as it addresses various needs in health care. For example, library and reference services are now available on a lease basis, with an example being MDConsult.24 This service provides internet based access to a wide range of frequently used textbooks and periodicals for emergency medicine and other specialties. By accessing this data through such a service, problems such as outdated textbooks, or lost or stolen periodical issues, can be avoided.

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Ultimately, patient care systems will also be increasingly available using the ASP model. All of the expense of maintaining secure systems is outsourced to the host agency, allowing caregiver organizations to concentrate on their core competency, providing care for patients. Again, the savings in capital costs can allow providers to install systems that might otherwise be unavailable to them.25

5. Mobile Computing

Long considered to be too slow and suitable only for niche operations such aswarehouse inventory, wireless networks are ready to shake off many of the shackles restricting their deployment within the enterprise. So-called third-generation wireless products, which will be available within the next 12 to 18 months, will give users the robust throughput and, more important, the internet protocol (IP) compatibility required to make wireless an integral part of healthcare organizations’ networking arsenal.26

Slow transmission speeds have limited implementation of wireless systems to date. On average, most wireless devices today don't operate much above 9.6 Kbps. In order to facilitate improvements, the International Telecommunication Union has agreed upon a framework of standards for supporting data speeds much higher than today'sbest throughput of 19.2 Kbps for mobile devices. The ITU's International Mobile Telecommunications 2000 initiative will make it possible for all wireless communications, from handheld devices to satellites, to share a common infrastructure.

At the same time, the 3G.IP focus group, comprised of nine major telecomm vendors, is trying to further tighten the link between wireless technologies and IP, enabling over-the-air devices to handle such services as voice, high-speed data Internet access, imaging and videoconferencing. Wireless networks and devices, some of which may be used optimally by including voice recognition services, promise to finally bring medical information systems directly to the caregiver for use at the point of care.

The point of care is the focal point of the modern health care organization. It is estimated that more than 80% of the one trillion dollars spent for health care is initiated at the point of care by a physician. Systems that support an effective point of care strategy create the greatest competitive advantage, the most cost effective delivery of services, and the highest quality of care.27 Web-enabled wireless systems available at the point of care enhance a physician’s ability to access relevant patient information in a manner that provides immediate value to the care process and the physician’s workflow. Particularly given the trend toward fixed ambulatory care group reimbursement as discussed below, systems available at the point of care enable real time guideline and protocol support so the caregiver will maintain efficient care practices.

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6. Emergency Physician Labor Pool Changes

Increasingly, physicians in the emergency department are being subject to market pressures to negotiate managed care agreements, demonstrate productivity and quality, and otherwise respond in ways that are best accomplished through physician group arrangements. Consolidation of physician practices from small independent office settings into large organizations, including publicly held corporations, is one of the results of this market driven process. Between 1983 and 1994, the percentage of employed physicians rose from 24.2 to 42.3. Solo practitioners fell from 40.5 to 29.3%. Self employed physicians diminished to 28.4%. Emergency medicine practices appear to be following a similar curve.28

In the early 1980s emergency medicine became a recognized medical specialty by the American Board of Medical Specialties. Subsequently, the specialty of emergency medicine has become very popular among graduating medical students, and a large number of emergency medicine residency training programs have been created. As a result, the supply of specialty trained and board certified emergency medicine specialists has burgeoned during the past decade.29 In many cities the supply of well qualified emergency physicians now exceeds the demand.

A workforce study sponsored by the American College of Emergency Physicians showed that 32,000 physicians fill 24,500 full time equivalent positions in emergency medicine, staffing the nation’s 4280 emergency departments. 58% of the physicians were residency trained and board certified in emergency medicine. 47% of hospitals use nurse practitioners and or physician assistants to supplement their physician staffing.30 This study is continuing with an effort to define future workforce needs in the evolving national healthcare market.

The trend toward a more abundant and qualified emergency physician workforce will likely have several implications with regard to information systems in the future. Competition for good jobs will require physicians to be able to document their competence with data in ways that were previously unavailable. Ability to show a practice profile of quality will become paramount. Physicians can expect skill in using computers to become a prerequisite for many jobs. At a different level, physician groups pursuing hospital contracts will need data driven objective evidence of the quality and productivity of their physicians. Finally, information systems that provide support for less expensive mid level practitioners may enable the use of nurse practitioners and physician assistants in environments that were previously deemed to be the sole domain of physicians. This may put further pressure on the tightening job market for emergency physicians.

7. Changing Reimbursement Methods

Seventeen years after the launching of Diagnosis Related Groups (DRGs), the prospective payment system (PPS) that regulates reimbursement for inpatient hospital

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care, the application of a similar PPS system to emergency care is imminent. The Ambulatory Payment Classification (APC) system, scheduled for implementation later this year, will regulate reimbursement of most outpatient Medicare costs and may be adapted by other insurers as well.31

Under the PPS system, in many situations payment will be fixed and will not be increased if extra tests or other expensive utilization occurs. In this environment hospitals will be under increasing pressure to provide efficient emergency care in order to remain profitable. This pressure will most likely lead to increased efforts at measuring the effectiveness of care strategies, benchmarking, and determining best practices. The level of cooperation between physicians and hospitals will need to increase. For example consistency in coding visits will need to improve when claims are filed by both hospitals under the PPS system and physicians for professional fees.

The PPS methodology compounds a situation in which providers must already deal with various insurer and health management organization requirements. Some use capitated approaches to reimbursement, others use fee for service. Some follow current procedural terminology (CPT) guidelines for documentation, others do not. The complexity of the situation requires data systems that can efficiently collect data as care is provided, and analyze this data so that billing systems meet requirements. Very few current health provider information systems support the requirements for this type of analysis of outpatient services. Newer systems with this capability will undoubtedly be required to meet this challenge.32

8. Demands for Quality

Demands for quality will become increasing prevalent in emergency medicine and all of healthcare as the nation attempts to justify the enormous amount of resources spent on care delivery across the country. Quality demands will come from patients, hospitals and third party payers. Since the government is the nation’s largest third party payer, quality demands may be increasingly the subject of government regulation in the future. Compliance with all of these demands will require data systems that can measure the quality of healthcare delivery.

Hospitals may not necessarily be informed or sophisticated purchasers of emergency physician services. As presented by Bredeson33, hospitals are interested in several key issues:

1. Are the emergency physicians “adequate”?2. Do they keep patient complaints to a minimum?3. Are they “contract capable” with all other health plans with which hospitals do

business?4. Do they have similar and predictable practice patterns and do they follow them?5. Are there valid data that reflect individual physician practice patterns? Are

outliers dealt with appropriately through education or other action?

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Hospitals seeking to hire an emergency physician group will increasingly demand objective measures of quality beyond a listing of credentials such as board certification. Data to support quality claims is likely to be derived from a number of different systems, such as those that document patient satisfaction, benchmarking of best practices, compliance with practice guidelines, and patient outcomes. While the information systems required to adequately acquire and analyze this data are currently lacking, their development is proceeding at a rapid pace.

Provider profiling is becoming common among health care systems, as those that are paying for or “managing” health care seek ways to make providers more accountable for the care they provide.34,35 Developing and disclosing profiles to consumers is a crucial element of the proposed Consumer Bill of Rights and Responsibilities and is considered an important part of creating efficient health care markets.36 Managed care organizations and other payers have valid reasons for measuring physician performance, including efforts to improve quality and cost containment. However, payers often confront fragmented data and caregiver resistance when they use information technology in physician profiling networks. The science of physician profiling is still in its infancy.37

Dr. Tim Hofer, et al. have published a study in JAMA that showed how high outlier physicians could dramatically improve their profile simply by pruning from their panel the 1 to 3 most difficult management cases in their practice. While the authors acknowledge that profiling may have some advantages, they state that effective use of profiling in order to hold physicians accountable first requires improved ability to measure individual performance.38

Interestingly, this potential management of the case mix to improve performance is less likely to occur in the emergency department setting. In most emergency departments a single physician sees all patients that present for care regardless of their complaint or difficulty in managing the case. As long as shifts are randomly distributed among physicians, and if the denominator is kept sufficiently large, case distribution should be relatively similar among physicians working at a single hospital. The different types of case mixes seen at various hospitals leads to challenges in comparing performance at different hospitals, so that some type of case mix adjustment would be required. While care must be taken in the interpretation of reports from profiling systems, the market is likely to demand their increased presence in emergency medicine.

9. Increased Emphasis on Public Health Initiatives

An increased emphasis on public health initiatives will impact emergency medicine in several ways. National interest is growing with regard to improving our ability to carry out surveillance for injury patterns and emerging infectious diseases. A national strategy for surveillance through the nation’s emergency departments has been proposed.39 The Clinton administration has recently proposed a $65 million dollar plan to pursue this type of initiative, a 50 percent increase in funding from previous years.40

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A number of federal agencies have already initiated a variety of programs for medical surveillance, particularly with regard to surveillance of injuries and infectious diseases, but most of these programs have limitations and do not take advantage of emerging internet technology. National mortality statistics on injuries are collected by the National Center for Health Statistics (NCHS) and are based on the International Classification of Diseases (ICD) codes. Data on motor vehicle crash deaths and injuries are collected by the National Highway Traffic Safety Administration (NHTSA) as the Fatal Analysis Reporting System (FARS) and the National Accident Sampling System (NASS). The Consumer Product Safety Commission (CPSC) collects data on injuries and fatalities associated with consumer products (excluding motor vehicles, guns and a few other products) through the National Electronic Injury Surveillance System (NEISS) which samples data from a series of hospitals. Problems include limited data (i.e. fatal injury statistics but none for morbidity, limitations associated with sampling techniques), difficulty in collecting data (i.e. retrospective labor intensive manual searches), delays in distributing results (i.e. up to three years for some systems), and no local population based data for local injury control efforts.

Sentinel networks are recognized for their potential to eventually serve as readily accessible mechanisms to address urgent public health infectious disease problems rapidly.41 Three sentinel networks are currently receiving funds through CDC: Infectious Disease Society of America Emerging Infections Network; Emergency ID Net, a network of academically affiliated emergency departments; and GeoSentinel, a network operated by the International Society for Travel Medicine. Given emergency medicine’s role as the “front line” of clinical medicine, emergency departments present unique opportunities for disease detection, research and prevention.42,43 However, in each case the Internet is not utilized, and the systems do not permit real time interventions.

In addition to improving approaches to surveillance in the future, systems based on new technology and the Internet promise to facilitate population based research methods not currently possible. Current research methods often are based upon cumbersome, expensive manual and paper-based processes. Many clinical studies are limited to relatively small patient populations because of the difficulty and expense of providing large-scale research. Future use of electronic capture of clinical data, and use of the internet to pool this data into large research databases, will allow for much more efficient research using entire populations as the study group. For example, an architecture for national scale clinical trials has been proposed in the form of a national cancer information infrastructure.44 The use of the Internet specifically to facilitate clinical trials in emergency medicine has also been encouraged.45

Conclusion

This paper has attempted to review significant trends in the fields of emergency medicine and medical informatics, and discuss how these trends will undoubtedly lead to increased importance of medical information management in the future. Caregivers,

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administrators and other stakeholders are urged to consider these trends as they plan for their future involvement with emergency medicine.

Successful implementation of a electronic medical record systems still requires completion of the task that McDonald et al termed “the difficult side of medical record systems,” namely, data acquisition and in particular acquisition of data from clinicians. Sustainable integration of clinician data entry into daily clinical workflow involves social engineering, clear institutional mandates, and significant financial investments, in addition to any software architectural decision.46

As noted by Teich and Waeckerle, emergency medicine has special information needs.47 One concerns the rapid pace and acute nature of emergency care. Emergency physicians must rapidly assimilate information and distill the significant data items from the whole presentation. With regard to medical informatics, the authors go on to state: “as with any other innovation, the proof is in the data. It is not enough just to build clever systems; we must also evaluate them and test their ability to achieve specific goals in well-designed experiments. To confirm the value of a new idea in information science, we need to measure its performance not just in terms of system usage, but in terms of improved care processes, reduced morbidity, fewer bouncebacks, greater patient satisfaction, better reimbursement, and other real-world measures – just as we would evaluate a new drug or a new intubation technique“.

As the megatrends discussed above influence the industry of emergency medicine and help drive increased use of information systems in the specialty, it is the hope of the author that the results of this impact are measured and appropriately studied. Ultimately these trends and their impact on the specialty are likely to result in significant improvements in the emergency care process, benefiting both providers and patients.

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