Processing Health Information: Management Systems and Community and Public Health

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Contents

Introduction

Each of these various types of systems appear in different guises and to different depths in various aspects of the health system. In the following we look at the three broad areas to see where each fits.

Learning Objectives

With completion of this section it is intended that the student will have a high level understanding of the functionality and scope of the ‘non-clinician facing’ but never the less important systems that are widely deployed in the current health system in Australia to support hospital management and public health.

Aims of Unit

In this Section we review the different varieties of computer systems which are used managers and support staff to assist in the operation . These systems can sensibly be divided into:

  • Office Practice Administrative and Billing Systems.
  • Hospital Management and Administrative Systems.
  • Public Health and Community Health Systems.

At the end of this unit the student should understand the key functions provided by the systems discussed and how they contribute to support clinical care delivery. Chapters 4 and 5 of the Recommended Text cover this area - with slightly different but equally valid perspectives.

Office Practice Administrative and Billing Systems

Pragmatically the office practice environment is essentially a small business that has all the needs for automated support as would be found in any staffed customer facing business. The functionality required includes the following:

  • Patient appointment making and scheduling. In more advanced systems this can include the capacity for the patient to log on to the system and select a free time slot and arrange the appointment for routine visits.
  • Management of the patient demographic and contact details - that are used for both financial and clinical records.
  • A financial management package that covers the full scope of a practice’s activities from billing, invoice creation, electronic coding of patient related activities and claiming from insurers and Medicare as well as less obvious things such as inventory management, appliance lending management and so on.
  • A reporting system that provides the various financial and other reports which are needed to manage a practice.

In many Australian practice management systems one finds both the electronic patient record system and the administrative system integrated into a whole package designed to meet all the practice’s operational needs. It will be obvious to the reader that for any clinician (including specialists, allied health workers and possibly nurses) providing billable patient services these functions will be required. You can read a summary on the topic from Wikipedia at this link

Hospital Management and Administrative Systems

There are a wide range of systems that can contribute to the efficient and successful operation of a hospital. Among the categories of systems that will be reviewed are:

  • General Financial Systems (General Ledger, General Accounts Receivable and Payable).
  • Patient Billing Systems.
  • Supply Chain / Inventory Management / Equipment Inventory and Management Systems.
  • Customer Relationship / Donor Management Systems.
  • Patient Equipment Hire / Management Systems.
  • Building Management Systems.
  • Costing Systems.
  • Payroll / Rostering / Human Resources Systems
  • Executive Information Systems.

General Financial Systems

Absolutely central to all financial systems (be they manual or computerised) is the General Ledger. This ledger is a central organised repository of a hospital’s assets, liabilities, equity and so on. Feeding this central ledger there are a range of more detailed supporting ledgers covering accounts receivable, accounts payable, an assets register, project accounts and so on. Computerised ledgers are virtually always based on the double-entry accounting process where every transaction involves a credit to one account and a debit from another different account. At the heart of the general ledger is a so called ‘chart of accounts’ which contains a hierarchical arrangement of all the locations (accounts) that may be credited and debited. Typically the chart of accounts (which is usually unique for each organisation) takes an organisational view of the organisation and has transactions flow in and out of named entities such a ward, departments, administration, stores etc. A little more detail is found here

More information of Charts of Account is found here Each record in the chart of accounts is linked to a code and a description to assist is making the numeric data understandable when browsed.

Patient Billing Systems

Being able to accurately and fully bill patients for services they receive is an essential part of survival for any private hospital and indeed any hospital that needs to collect revenue from those it treats. Among the aspects of billing that need to be addressed are:

  • Accommodation Billing - this covers the basic daily charge for occupying a bed as well as various facility charges that may be relevant.
  • Diagnostic Test Billing (Pathology, Radiology etc.).
  • Supplies Billing (bandages, dressings, appliances, implants, medical gases etc.)
  • Pharmaceutical Billing.
  • Allied Health Care Services Billing (Physio etc.)
  • Theatre Usage and Other Facilities Usage Charges (see above).
  • Medical Services Billing and Emergency Room Services Billing.

Because of the importance of revenue collection - especially for hospitals in the US - billing was by far the most important early driver of hospital automation - and systems were typically designed with revenue capture as a key driver. The ATS system drove the accommodation billing, the departmental systems (pharmacy, laboratory) drove their respective billings, CPOE captured ward charges and so on. A focus on the clinical use of hospital systems for clinical purposes was something that only emerged in the last 1-2 decades. The lack of this financial driver in the UK and Australia probably slowed down the development and implementation of Hospital Systems in Australia.

Supply Chain / Inventory Management / Equipment Inventory and Management Systems

Besides the accommodation and the care providing staff a hospital has to also manage a range of supplies and provisions that are consumed by patients and staff during hospital operations. In that sense the IT (and management) task is similar to many businesses who source supplies, maintain inventories, consume from those inventories and organise orders and payments for these supplies. The task is made quite complex by a range of factors including:

  • Many supplies having use expiry dates that require management and stock rotation.
  • Supplies that have high unit costs and so may need to be held in limited numbers or supplied on a ‘just in time’ basis.
  • The need to hold sensible stock levels of many disposables in many locations.
  • The need to continuously monitor unit costs to ensure that the hospital is not being overcharged, while at the same time ensuring supply availability and continuity.
  • A need to ensure internal supply continuity and so to be aware of any supply chain disruptions.

For these systems to work well there also, of course, need to be linkages to supplier systems, financial systems and so on. Additionally the organisation needs to also manage procurement contracts, terms etc. and have a catalogue of the approved supplies, their sources and so on. This article provides a hospital specific view of many of the aspects that need to be appreciated.

To appreciate the complexity of this set of systems there are two useful articles from Wikipedia. First here And second here As a last point it is important to note that because supply chain efficiencies offer considerable financial benefit if they can be delivered the area is often the focus of considerable effort and both State and Federal agencies have a significant interest in the topic. You can read about the National E-Health Transition Authorities work in the area here

Customer Relationship / Donor Management Systems

Systems to provide ‘Customer Care’ for the patients who use Hospitals are a relatively new innovation. They have grown and developed from a previous generation of systems which aimed to take advantage of the patient demographic information that was captured in the PMI and ATS to allow regular contact with the patients typically seeking donations for special projects that might be funded in such a way - e.g. a new special piece of equipment etc. Improvements in these systems have added patient satisfaction survey systems as well as other functionality to assist the hospital both in quality control - from the patient’s perspective - as well as optimisation of the level of donations and bequests received. The database can also be used to conduct detailed surveys of particular aspects of hospital operations where patient feedback is useful. This can include satisfaction with food, patient facilities, staff and so on.

Patient Equipment Hire / Management Systems

This is a simple but important system as all sorts of expensive equipment can be loaned to patients to allow them to leave hospital earlier and save money. Clearly the benefit will be compromised if equipment is lost, not returned or whatever. A simple register, recording loans by patient, can ensure equipment that is loaned out to a patient can be followed up if not returned within a sensible period. In many hospitals this system can be operated by Hospital volunteers once developed and operational.

Building Management Systems

Management of the built facilities of a hospital is increasingly automated. Specifically, in modern buildings, there are a wide array of sensors that monitor temperature, humidity, smoke and so on which need to be monitored full time and the supervising system needs to be able to alert its operators when there is parameter variation than requires intervention. Other functionality that is also required may include parking and traffic management, CCTV control, building security, lift management as well as control of internal security monitoring via CCTV and intercom. There is an interesting brochure from Siemens that shows just how clever / smart such systems can now be. See here

Costing Systems

The reason costing information and costing systems are important is that it is only with an in depth understanding of the costs of the various components of care is it possible to adjust and optimise the costs incurred in care delivery - and minimise waste of both funds and resources. Hospital costing systems come in essentially two generations.

  • First generation system simply took all the input costs of care (staff, equipment, depreciation etc.) and added it all up and then divided it by the number of patients treated to reach an average cost. A small improvement on such an elementary system was to divide the costs by operational unit or ward and undertake similar analysis.

Of course both approaches were simply to crude to permit much in the way of useful conclusions to be drawn.

  • From the early 1990’s it has been recognised that improved approaches are needed. The background to the approach that has been adopted can be explored here

As applied to hospitals the basic concept is quite simple. First patients are grouped into diagnostic categories - using a coding system called Diagnosis Related Groups (DRGs). This is done by health information experts reviewing the patient record and allocating the appropriate diagnostic codes. This is done so that the patients of similar costs are treated as a group and their costs can be understood in a clinically relevant way in terms e.g. hernia operation patients are in one group and major cardiac surgery is in another group and so on. Next a diagnostic group of patients are tracked for their need for everything from accommodation, resources, nursing care and so on. Finally a matrix of the various costs that are possible is developed where overhead costs, patient group specific costs is developed. At the end of the process a cost is identified for each of the major clinical diagnoses that the hospital deals with which allocates for and takes account of all the relevant cost drivers (staff costs, consumables costs, infrastructure and accommodation costs, special services etc.).

  • These costs can be used in two ways - first to compare with other institutions and over time to identify opportunities for cost improvement in specific clinical situations. Second these costs can be used by Government or private hospital chains to determine the re-imbursement to be provided to the hospital for a particular clinical service.

In Australia we are adopting a path of developing a system of Activity Based Funding where information gathered from public hospitals is intended to be used to identify what is termed an “efficient price” which will be paid to the larger hospitals for a unit of care. Each different type of care (e.g. inpatient DRG) will be paid a fraction or multiple of the National Efficient Price. Smaller hospitals may receive block grants because of the extreme variability in fixed costs and variable patient mixes. There is a substantial website found here for the Independent Hospital Pricing Authority (IHPA) which manages the Australian system.

The FAQ found here provides a good explanation of the Australian system.

There are two final points to be made.

  • First there is a lot of work and computation required to implement the planned Australian system - and there is a very considerable change management task underway.
  • Second the system is yet to be fully implemented and until it is and has operated for at least 2-3 years it will be impossible to know if it is working as intended to contain hospital price inflation while supporting the delivery of quality and safe care.

Payroll / Rostering / Human Resources Systems

Given the importance of staff to the delivery of care in a hospital there is little doubt that these systems are almost of existential importance. Obviously the most important function here is delivered by the payroll system. While it may seem to be a relatively simple system it is complicated by the fact that many staff in hospitals work to varying rosters at various times with pay modified by both staff category, penalty rates and so it goes on. Because of this variation all rostered staff need to have their worked hours entered, approved and then the final pay calculated using the award provisions. The system also needs to be highly accurate in application of all the various calculation and deduction rules - as you can be sure there is no hospital document that is more scrutinised than the individual’s payslip. The complexity and number of awards found in hospitals have turned out to be a major issue in many implementations - especially when such functions are centralised at a State or system wide level. The recent debacle surrounding the new payroll system implemented last year for Qld Health, with huge time and cost overruns - makes this point clearly. Another pointer to the difficulty is found in the observation that once implemented and working major payroll systems tend to be run for 20+ years to avoid the pain of a new system! Also of importance to hospitals, given the staff intensity, are the various types of systems grouped under the Human Resources category. This includes staff rostering, staff leave management and staff recruiting and staff departure management systems. Integration of these systems with payroll can help reduce the data entry task. There is a useful generic summary of such systems and their various roles here

Executive Information Systems

From all the above the reader will now be away that operational systems within hospitals capture and process a great deal of information of all types. A considerable challenge for those executives who manage such organisations is to obtain the information they need from all these various systems to make their job possible and hopefully valuable. In the past, when the hospital computing was largely conducted on larger centralised computers applications termed (in aggregate) an Executive Information System. A description of such systems can be read here

With more information now being available and being held in a more distributed manner the functions are now delivered using techniques collectively described by some as ‘big data’ or ‘business intelligence’. For a general overview of the topic here is quite a good place to start.

Public Health and Community Health Systems

Public Health

As an introduction to public health we can start with the Wikipedia introductory paragraphs on the topic.

  • “Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals."
  • It is concerned with threats to health based on population health analysis. The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). The dimensions of health can encompass "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", as defined by the United Nations' World Health Organization.
  • Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health services. Environmental health, community health, behavioral health, health economics, public policy, insurance medicine and occupational health (respectively occupational medicine) are other important subfields.

The focus of public health intervention is to improve health and quality of life through the prevention and treatment of disease and other physical and mental health conditions, through surveillance of cases and health indicators, and through the promotion of healthy behaviors. Promotion of hand washing and breastfeeding, delivery of vaccinations, and distribution of condoms to control the spread of sexually transmitted diseases are examples of common public health measures. Modern public health practice requires multidisciplinary teams of professionals including physicians specializing in public health/community medicine/infectious disease, epidemiologists, biostatisticians, public health nurses, medical microbiologists, environmental health officers / public health inspectors, pharmacists, dental hygienists, dietitians and nutritionists, veterinarians, public health engineers, public health lawyers, sociologists, community development workers, communications experts, and others.” The full article is here

  • Information technology can be of great value for those who practice in the Public Health domain.

The most obvious applications are information management tools that assist with management and analysis of population level information - covering all sorts of things from disease registers, treatment registers, vaccination records and so on. Tools that support visualisation and statistical analysis of population information are also vital as are applications that can link geographic and mapping information.

  • Public Health is also an area where it can be rightly said that the Internet has changed everything. This is especially in the domains of public health education and probably more importantly in disease surveillance - in both the ability to permit rapid reporting of illness from multiple sites and in the tracking and monitoring of epidemics and even global pandemics.

There is an excellent article from the US Centers For Disease Control in Atlanta that does a very good job of explaining what might be termed Public Health Informatics. “The work of public health informatics can be divided into three categories.

  • First is the study and description of complex systems (e.g., models of disease transmission or public health nursing work flow).
  • Second is the identification of opportunities to improve the efficiency and effectiveness of public health systems through innovative data collection or use of information.
  • Third is the implementation and maintenance of processes and systems to achieve such improvements.

The informatics perspective can provide insights and opportunities to improve each of the seven ongoing elements of any public health surveillance system (3). Examples include the following:

  • Planning and system design – Identifying information and sources that best address a surveillance goal; identifying who will access information, by what methods and under what conditions; and improving analysis or action by improving the surveillance system interaction with other information systems.
  • Data collection – Identifying potential bias associated with different collection methods (e.g., telephone use or cultural attitudes toward technology); identifying appropriate use of structured data compared with free text, most useful vocabulary, and data standards; and recommending technologies (e.g., global positioning systems and radio-frequency identification) to support easier, faster, and higher-quality data entry in the field.
  • Data management and collation – Identifying ways to share data across different computing/technology platforms; linking new data with data from legacy systems; and identifying and remedying data-quality problems while ensuring data privacy and security.
  • Analysis – Identifying appropriate statistical and visualization applications; generating algorithms to alert users to aberrations in health events; and leveraging high-performance computational resources for large data sets or complex analyses.
  • Interpretation – Determining usefulness of comparing information from one surveillance program with other data sets (related by time, place, person, or condition) for new perspectives and combining data of other sources and quality to provide a context for interpretation.
  • Dissemination – Recommending appropriate displays of information for users and the best methods to reach the intended audience; facilitating information finding; and identifying benefits for data providers.
  • Application to public health programs – Assessing the utility of having surveillance data directly flow into information systems that support public health interventions and information elements or standards that facilitate this linkage of surveillance to action and improving access to and use of information produced by a surveillance system for workers in the field and health-care providers.

The evolving field of surveillance informatics presents both challenges and opportunities. The challenges include finding efficient and effective ways of combining multiple sources of complex data and information into meaningful and actionable knowledge (e.g., for situational awareness). As these challenges are met, opportunities will arise for faster, better, and lower cost surveillance and interpretation of health events and trends. The domain of public health informatics designs and evaluates methods appropriate for this complex environment. “ Source: The Role of Public Health Informatics in Enhancing Public Health Surveillance Supplements July 27, 2012 / 61(03);20-24 Thomas G. Savel, MD Seth Foldy, MD Public Health Surveillance and Informatics Program Office (proposed), CDC The article is found here

  • No discussion of Public Health these days would be complete without a discussion of social media.

Over the last few years there have been some quite innovative uses for the internet, social media and mobile apps in the public health space. To discover just how wide the possible applications of social media are, this link is a great place to start.

Additionally Google, Facebook and especially Twitter have application in tracking things like flu outbreaks, food poisoning outbreaks and disaster responses. An example is Google Flu Trends

There is an article on the system here

The system is still being evolved having only started in 2008. Read about some of the issues here

Community Health And Support Systems

These systems can have a great similarity to the basic electronic health records as used by clinicians but differ in terms of the types of information they might manage. Examples might include client management systems that are used for community nursing services, rehabilitation services and so on.

  • In recent times the advent of mobile apps which can access central servers securely can greatly assist community health providers delivering and recoding care provided to patients in their home. An obvious benefit is where teams can provide co-ordinated care based on a care plan tailored for the patient / client and stored centrally and accessed by a number of different individual service providers.
  • In Australia another specific application is the use of such systems by Aboriginal Health workers who can use a centralised record to assist the care provided by individuals who are still at least partly nomadic and who seek care from multiple different sites over time.

Review Questions

  • Describe the nature of the information flows that are likely to pass between clinical and administrative systems in a medium sized hospital. (e.g. an obvious one is the use of the patient demographic information captured in the admission system for billing purposes).
  • Review what can be found in current literature to examine the impact of social media in the disease surveillance domain.

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