Ebook: Case - Based Telematic Systems towards Equity in Health Care

Equity and Ethics in Health is the theme of the 1994 forty-fourth session of the WHO-Europe Regional Committee of Health Ministries, to be held in Copenhagen 12-16 September 1994. Issues of equity and ethics are considered central to making effective choices about policy to cope with the major health challenges Europe faces today.

There are major disparities in health and in opportunities for promoting health between and within countries.

As stated in the introductory paper of the WHO-EUR session : “the stability and coherence of the whole European region is threatened if conditions deteriorate too far in some countries in relation to others. Within countries, we all pay the price of letting injustice continue. If the most disadvantaged in society are left to carry the heaviest burden, then increases in crime, in insecurity and in violence are seen for everyone”.

Simultaneously, Jacques Delors in the “White Paper” of the Commission of the European Communities underlines the progressive degree of maturity of the “information society”, the opportunity to put together what is already available and to move from a fragmentary to a coherent approach towards the common good. “What is missing is less money than the willingness to devote it to the essential”. Telematics in health care aims at improving quality, economy and efficacy of care and health services. AIM (Advanced Informatics in Medicine) is the Community programme of research and development is this area.

In 1994, a large number of information systems are operational. They can be used to improve health care delivery. If shared through telematics, they could become instrumental to reduce inequities in the European Region.

It was therefore felt necessary to organise an international symposium that assembled representatives from various organisations (WHO-EUR, European Union, experts in health care and in telematics) as well as representatives from a great number of Member States (from Ministries of Health, health services and informatics) in order to make specific recommendations for the WHO-EUR Regional Committee.

This volume presents the results of the EFMI/WHO-EUR cosponsored working sessions devoted to “Case-Based telematic systems towards equity in health care” held in Brussels, at the School of Public Health of the University of Louvain from June 22 to June 24th, 1994.

The symposium recommended, in particular to give a priority to “Case-based information systems”, (based on individuals and population-related) in order to make the appropriate choices for improving equity in health care. Telematics is readily accessible, for example with Internet, in an easy way that might be used directly by clinicians and epidemiologists.

The present book is the expression of common views that associate information systems, telematics and health care for the benefit of the patient. Actions proposed to improve progressively patient care, resource management and quality of care in Europe include curative as well as preventive measures. They should, therefore, give hope to achieve greater equity.

Recommendations are addressed to the WHO-Europe Regional Committee of Health Ministries, as well as to the relevant governing bodies of the Member States of the European Union, the scientific societies for medical informatics of EFMI and IMIA, for consideration and implementation.

The theme of this International Symposium, co-sponsored by EFMI (the European Federation for Medical Informatics) and WHO-Eur (the European Office of the World Health Organisation) is made of four components: (1) an ethical principle: equity in health care, that aims to social justice; (2) measurements of equity that should be case-based/population related; (3) communication of this information at a wide scale, using telematics, e.g. integrated computer systems at distance; (4) actions to improve health care and equity in its delivery by using resource management tools and developing quality of care.

The combination of these four elements is recommended as a coherent scheme for future actions of public authorities in health care. They were therefore associated in the somewhat complex title of the symposium. A special attention is given to the present degree of availability of a large number of case based/population related data sources in Europe, as well as on the need to develop generic models in telematics, rather than too strict standards at the user level. These information systems can be made easily accessible to clinicians and epidemiologists as an aid to their decision making in the European region.

The trend in the prognosis for female breast cancer patients was investigated by comparing Kaplan-Meier survival curves of different patient cohorts diagnosed during the period 1948-87. The study is based on 71,448 patients from the Danish Cancer Registry. The cohorts were defined by age at diagnosis, year of diagnosis, and residential area. The survival time from diagnosis nearly doubled from 1948-57 to 1978-87, the most important improvement taking place after 1978. Patients diagnosed in 1948-77 in the Copenhagen area had a far better prognosis than patients diagnosed during this period in other parts of Denmark. For patients diagnosed in 1978-87 the prognosis, however, reached an equal level in all parts of the country. Thus, it is reasonable to assume that the national programme introduced in 1977 by the Danish Breast Cancer Cooperative Group (DBCG) has played an important role and not only brought about therapeutic improvements in breast cancer treatment in Denmark, but also ensured equity in the outcome on a national scale.

The paper gives a brief overview of some national case-based information systems in Swedish health care together with an application from the Stockholm County Council. A background section on the Swedish health care system is also included.

Several case-based information systems have been developed within Swedish health care. They have different purposes and operate on different levels. General national registries include: discharge registry, medical birth registry, cancer registry and cause of death registry. They have been used mainly for research and planning of health services. Another type of national registries are related to specific patient groups. Such registries include information on results and complications of treatment. The initiative to these registries have come mainly from groups of consultants.

The Stockholm County Council has replaced the traditionally global budgets of clinical departments with an activity based income. An evaluation project on health care utilization in five surgical specialities are presented. Preliminary results were: no division of in-patient care into multiple hospital stays and an increase in the number of discharges among the elderly.

The Swedish health care system of today is characterized by organizational changes. Case-based information systems give the opportunity to study the developments of equity, quality and resource management in the new health care models. There is today an increased interest to use case-based information systems for quality assessment and continuous quality improvement. An increasing number of analyses are made at the local level. However, national case-based data are still very valuable to make regional comparisons possible and to produce relevant reference data in local applications.

Traditionally, telematics initiatives have mainly been used to link patients with specific conditions to monitoring services located in acute hospitals. However, latest application of telematics to the networking of integrated electronic records for ambulatory or community care has great potential to measure and assure the quality of health care delivery to a large sector of the population in a structured and comprehensive way. This paper categorises the major quality opportunities of a pioneering initiative now achieving operational status.

The management and control of diabetes throughout South West England has been assisted by the use of a networked computerised information system which is totally integrated with hospital and community information systems. The objectives of the diabetes system are to produce an aid to diabetes management, which includes the creation of a district diabetes register accessed and maintained by clinicians based in both the hospital and in the community, whilst at the same time providing auditable information.

OBSQID is a one-year project with the ultimate objective of identifying and validating European quality development indicators in perinatal care which will make it possible to exchange data at regional, national and transnational levels through the use of telematic and computerized information systems. This will make it possible to monitor, evaluate and identify “best practices” in order to use this experience to improve the quality and outcome of perinatal care in the European region. The project is a collaboration between WHO/EURO, counterparts in perinatal and obstetrical care in the Member States, and the Advanced Informatics in Medicine programme of the Commission of the European Communities.

The British Child Health System has been designed and widely implemented to support equity of access to preventive child health services, using case-based integrated records. Lately, telematics has been increasingly applied to improve the timeliness of data entry. A special project has been established to moniter overall quality of the system's use and of the resultant preventive services. The telematics application has been found to be a potential threat to quality in a way which would apply to all remote networked patient-based systems. The demonstration will show the methodology and interim results.

The Diagnosis Related Groups patient classification scheme has been evolving for over twenty years. The wide variety of DRG applications in the U.S. has resulted in the development of three major versions of DRGs. The alternative DRG systems are described and compared. Comparative statistical data for each DRG system are presented.

Hospital MBDS is a powerful tool for improving the knowledge on hospital performance. Within CAMISE, a BIOMED research, a databank of about 4,000,000 discharges from 420 hospitals in 12 countries has been collected, and a lot of effort has been devoted to make them comparable and therefore useful for research purposes. Results from CAMISE shows important opportunities from cooperation of European level. It points out the need for making them available to researchers under the suitable conditions of confidentiality, security and control.

Quality control has become a familiar concept in health care in The Netherlands in the last ten years, as it has elsewhere in the Western world. To achieve the goals of total quality, medical audit plays a central role in the process. An important issue for medical audit is to collect consistent and coherent data on the medical performance. As no widespread tradition exists to do this routinely using common widely accepted protocols and information technology, examples of routine quality control of medical services are scarce. In this paper a report is given of the process of collecting routine data on the surgical treatments and its complications in a Dutch general hospital. Based on the results of this and other local initiatives to control and improve the quality of surgical procedures the Dutch Association of Surgeons has recently adopted a policy document, which promotes to enhance quality Management. This paper presents also the increasing need among health care professionals to compare the results of treatment of similar patients. The role of Information Technology to achieve these goals is growing at an impressive pace. A more complete documentation of the care process will increasingly support a case based approach, which will be essential for a comprehensive analysis and Management of the care provided to patients. The paper supports a systematic collection of data documenting structure, process and outcome.

To secure the follow-up of children with congenital heart defects in Norway the Dept. of Pediatric Cardiology has developed a tailor-made database. This also simplifies the regular flow of information about these patients both inside the hospital and between the hospital and the others who are in charge of the patient care on various levels.

A telematic based system for antenatal care has been developed to be used in service integration between primary and secondary health care units. The system is based on low cost platforms and has a user friendly human computer interface. This system will provide better integration and coordination between the health care providers involved, improving the quality of the services. This experiment is being funded in the framework of the EC.Project - A 2007 - EPIC..Quality indicators, agreed in the “European concensus conference of quality indicators for perinatal care”, organized in conjunction with OBSQID project (AIM.2125) were integrated in the system. Data collection has started and the outcome will be used to validate the indicators on a transeuropean basis under the framework of the OBSQID Project.

The Diagnosis Related Groups patient classification scheme coupled with desk top PC technology permits sophisticated analysis of patient medical data. Individuals with no programming knowledge can produce sophisticated analysis. The functionality and structure of the 3M Analytical Workstation are described and example analysis reports are presented.

The particular logistical problems of collecting cancer registration data in the South-Western region of England are discussed. The Regional Cancer Registry has endeavoured to overcome these through developing electronic links to hospital-based patient-information systems. Some of these involve data transfer on magnetic media, but there are also interrogation facilities which operate on a real-time, interactive basis, and complement these other facilities. A PC-based program (SNODEV5), which can accept data from histopathology computer systems, translate SNOMED codes to ICD-9, and produce files suitable for processing by the registry's Batch Data Entry system is described. Its contribution to the achievement and monitoring of equity in health care provision is discussed.