Introductory Remarks

The concern over information systems is solely that they should
support health and health services, and the purpose of technology
is that it should support the necessary information system.

George A.O. Alleyne
Director of the Pan American Health Organization

The implementation of healthcare information systems and technology has become critical to the delivery of cost-efficient and quality healthcare. Information systems applications have contributed to better health service management and delivery of care by creating an environment conducive to increased access and quality of patient care and by supporting the knowledge base required for clinical and administrative decision making.

Indeed, the dominant objectives for the deployment of information systems are: facilitation of the logistical aspects of healthcare; enabling health institutions to function efficiently; assisting care providers to act effectively; improving access to individual and collective administrative, clinical, and epidemiological data; and simplifying the access to biomedical reference. These benefits are achieved through automated patient and clinical data management, support to diagnostic and therapeutic services, image-based systems, resource management, integration of administrative and clinical data, remote access to medical information, access to knowledge databases, and appropriate physical resource and financial management.

1. The Relevance of a Cautious IS&T Implementation

In the area of information systems and technology (IS&T), health services seek appropriate responses to issues related to the possibilities offered by IS&T and want to be advised on feasible expectations, benefits, and constraints associated with the introduction of information systems and technologies.

In what is becoming increasingly known as the Information Society, the public, politicians, and professionals all expect information to be readily available to improve services, and thus to improve health and healthcare. However, information and the organization, resources, and technology to make it happen are not cheap — they are expensive commodities that rapidly become obsolete. Information per se is a perishable asset and one that can be hazardous, if misused. Data collection and information generation, storage, and retrieval cost money and time to establish and process in a consistent manner. Information is also perishable, and must therefore be regularly maintained and updated. It has no intrinsic value, but becomes invaluable in the appropriate utilization setting. Its utility is in the illumination it provides to problems under consideration, or which should be considered. Investment in successful information systems has a high cost-benefit ratio. Furthermore, investment in information collecting, processing, and archiving activities has to compete for financing against other healthcare activities with more immediately obvious and immediate benefits.

Moreover, the past investment experience in information systems has been sometimes disappointing. In the United States, it has been said that the healthcare industry's significant investments in patient information systems over the last thirty years failed to meet many expectations, and a large-scale study showed that only one-quarter of the built-in functionality of hospital information systems was actually used. Many projects resulted in disillusionment with information systems that were built with little regard to user’s day-to-day needs. Lack of relevance to actual practice or clear-cut benefit to operational staff results in systems that are not properly used, and thus are prone to deliver inaccurate information. Therefore, though there are compelling reasons for investment in information systems, there are also significant risks to avoid.

The broad spectrum of country and institutional development level requires implementation strategies that range from very basic to very sophisticated. The variety of requirements and possible solutions demands that each project must be approached in a unique and individualized manner. Any strategy, however, must consider the long-term outlook of healthcare IS&T and focus on practical and tactical implementation issues directed to the solution of immediate informational problems faced by countries, organizations, and healthcare services. The reform processes of the last years, occurring in the healthcare sector and the society in general, and the fast-paced advances of information systems industry, mean an increased level of complexity, detail, and interdependency of decisions and actions.

In order to assist Latin American and Caribbean countries and their local decision-makers in developing appropriate and effective information systems, the Pan American Health Organization has described very clearly in an earlier document the challenges and potential solutions for the introduction of information systems and technology. The subsequent and practical companion document is the present publication.

2. Emphasizing the Role of Information in Healthcare

Information systems should be related to need, in exactly the same way that health services should be needs-led rather than provider-driven. The essential first task of setting up any information system is, therefore, the identification of the healthcare issues under consideration, and the factors that may influence them, so as then to define the appropriate information requirements. When investing in information systems, the core purpose ("the business") of the organization must be clearly identified. In the case of health services, the core purpose is to improve the state of health of individual citizens and the health of communities, by improving the systems of health and healthcare. This core purpose should always be kept in mind when designing information systems — as it is not at all rare for health managers to permit systems technical staff to come to crucial decisions in the design of systems that are technically driven and may result in inappropriate applications.

Decisions made without good information may be appropriate decisions or may be very inappropriate ones, and the need and value of information relates directly to their contribution to decision making. The availability of relevant and appropriate information is the essential ingredient that transforms a decision into an informed decision — and one that is thus much more likely to be the correct one. It is of significance to understand how the resource of Information relates to Data and to Knowledge.

• Data are the raw items, such as a blood pressure reading, a temperature, the name of a pharmaceutical product, the date of a patient’s hospital discharge. By themselves, data have no meaning; they are totally isolated facts.

• Information is produced when data are grouped by a specified set of common factors. Thus an assembly of biometric facts becomes information about a patient’s vital signs or the serial grouping of discharge dates related to one individual patient becomes the pattern of hospitalization, whereas dates of discharge for different persons within a specified calendar period indicate a hospital’s rate of activity. Information, in many circumstances is also the "middle part" of an information continuum, being both a product and an input.

• Knowledge is created when information is put into an overall setting. For instance, it relates to the expected pattern of vital signs for a particular illness, the available pharmaceutical products and their known side effects, or the level of activity of a hospital as it relates to budget and catchment population.

The key issue is, therefore, context — information can be described as data put into a specific context, whilst knowledge is information put into a general context. Thus definition of the context for which information is required is essential to developing appropriate information systems, and relates directly to wider decision-making processes.

From the perspective of health services, three broad levels of information are required for decision support: Clinical, Operational, and Strategic. These can be further refined to five core functions: Case Management, Caseload Management, Operational Management, Strategic Management, and Political Accountability. The actual utilization of information by clinical and administrative managers can be further refined considering the specific areas of application.

Having defined the nature and role of information, one should consider the development of a systematic approach to both the production and use of information. This is important for two reasons:

• In the health sector, the responsibility and burden for nearly all data capture fall squarely to the clinical and operational levels. Staff responsible for primary data capture may not understand the objectives or problems to be addressed, nor see it as important and the original data supplied may be inaccurate and thus the information compiled will be either incorrect or of limited usefulness. One-off-a-kind data collection to provide information for a specific decision is difficult, expensive, and a burden to line staff and should rarely be employed.

• In many decision-making situations, not least with regard to health status itself, a key technique is the analysis and interpretation of trends. This means that information must be compiled and compared on a regular basis to standardized definitions.

To meet both these challenges, a methodical approach to information is required to ensure that data flows regularly and smoothly to meet the desired objectives and purposes of implemented systems.

3. The Institutional Context of Information Systems

If information systems must be developed considering context, what are the settings that determine requirements? In this direction, five important contextual aspects of healthcare must be examined when designing information systems:

• Healthcare model
• Patterns of healthcare provision
• Primary care and community orientation
• Information infrastructure
• Appropriateness

There are a number of models of healthcare, with regard both to funding and delivery. Healthcare may be funded publicly, it may be insurance-based, or consumers may pay directly (with or without co-payments from a third party). Those alternatives are not mutually exclusive — for instance, insurance companies may offer supplementary services in situations where there is a basic publicly funded service. Similarly, the supply of healthcare may be rendered by public sector services, by private or not-for-profit providers, or by a combination of them.

It is the prevailing model of care of a defined country that will ultimately determine the types of decisions being made, and thus the requirements for information. Most Latin American and Caribbean (LAC) countries have models which are more closely aligned to European, Canadian, or Australian models, and indeed many countries in the LAC region have already established fruitful links with agencies and information service suppliers in these countries. The examination of the installed healthcare infrastructure shows the relatively small size of most LAC hospitals. In the 1996/1997 period, 76% of the region’s 16,500 hospitals were 100 beds or fewer (with 61% having 50 beds or fewer) and only 215 hospitals (1%) had more than 500 beds. Most ambulatory care is provided in offices or clinics with rather limited diagnostic resources. This suggests that advanced hospital information systems modeled on those of highly industrialized countries will not be appropriate for those institutions.

The challenge is to identify the health provision infrastructure and their information requirements, as it enables to focus where priority information systems are mostly needed — in secondary or tertiary sites, or at primary care at the community or local level. Focus at the patient level and the development of patient-based and community-oriented health information systems is in accordance to the World Health Organization recommendations, which have global endorsement. This perspective should underpin our thinking in all strategic healthcare information solution development. It is within primary care that the greatest volume of healthcare activity takes place, including almost all preventive healthcare, and thus where health status is determined. Also, it is at the community level that basic information about the health of citizens and communities should reside, and it should constitute the core information for policy and service development at all levels.

There is a tendency to consider information systems in terms of high-technology computerized systems, but this is likely to be inappropriate in many settings in developing areas or small organizations. Latin America and the Caribbean has the lowest per capita expenditure on information technology, and with the growth of communications-based information applications, essential infrastructures such as telephone lines are still a major problem — telephone lines range from 1.7 telephones per 100 persons in Nicaragua to 31.8 in Barbados, whereas in developed countries telephone connectivity reaches 70 to 80 per 100 persons. Power supply is also variable in many places and power outages may be a daily occurrence. Unsuitable technical investment will simply be a waste, and even when the capital cost is donated, as in many international cooperation projects, the time and effort of trying to operate inappropriate systems will merely divert resources from more productive tasks, as well as creating a bad image for information systems generally.

Another important concept is that of appropriateness, particularly regarding the selection and deployment of technology. Many places in the region are already too familiar with other inappropriately deployed technologies, such as clinical equipment that cannot function without reliable physical infrastructure or for which replacement components cannot be obtained, or cannot be maintained. One should avoid replication of this situation with regard to information technology, and appropriateness of technological components and potential use must be a principal guiding element.

4. Purposes and Nature of the Guidelines

This publication contains practical guidelines to be used by health and systems professionals when embarking in the technical activities related to requirement analysis and the initial technical specification of computer-based applications. These include a number of tasks which health professionals are expected to have a minimum level of competence and be prepared to manage: preparation of Request for Proposals (RFP) for information systems, technology, and services; evaluation and selection of providers; and contracting information systems and technology (IS&T).

4.1. Objective and Scope

It is expected that the judicious use of the concepts and recommendations detailed in this publication will contribute to improve decisions regarding IS&T design and acquisition, and the deployment of information systems and technology at all levels of management and clinical settings. The material was prepared considering the needs of health executives and practitioners and systems professionals involved in the definition of user requirements, in reaching consensus regarding desired functions in computerized applications, and immersed in the complex process of procurement and acquisition of information equipment and services. Although the principles for requirement analysis and procurement hereby described can be applied to any health information project, they were specifically written considering the needs of healthcare services professionals. In addition, this text may prove to be of great usefulness to those involved in policy making or to anyone who desires to develop a critical vision of healthcare services information systems and related technology.

The experts that participated in the writing of the document and in the development of recommendations and guidelines were concerned with the following realities:

• Lack of a comprehensive source for guidelines — There are many written publications that can be used by healthcare and systems professionals to assist their work in user requirement analysis, technical specification, and the procurement of information systems and technology. Unfortunately, few are related to the health sector area of application.

• The need for a comprehensive source for desired functionalities of health services operation and management computerized applications — To be used as a departure point for user requirement analysis and as a template for the preparation of Requests for Proposals and evaluation of provider bids, proposals, and products.

• The demanding changes occurring in the health sector in Latin America and the Caribbean — These changes include the merger of the traditional vertically constructed and frequently overlapping stakeholders of the healthcare process (regulators, providers, payers, employers, and consumers) into new and integrated organizations, whether virtual or real. These are known as integrated delivery systems (IDS), health maintenance organizations (HMO), preferred provider organizations (PPO), managed care organizations (MCO), and others. The consequent impact on information needs is enormous and changing at a fast rate.

• The rapid developments in the information technology industry — Improvements in all aspects of computers and communications are enabling health and healthcare organizations to link together disparate sources of data, share information electronically across previously impassable distances and borders, and bring clinical practice and administration alike to the healthcare professional’s environment as never before.

Against this changing backdrop, the current state of readiness for the deployment of modern information systems in Latin America and Caribbean countries lies across a wide range. In some areas or sub-sectors, users already enjoy a high degree of sophistication, many with pioneering clinical information systems and networks. In others, well-established, stand-alone, and relatively straightforward departmental systems such as laboratory, radiology, pharmacy, basic medical records, and others are still awaiting initial automation.

The scope of this publication is to balance preparation for long-term decisions with the practical needs of today’s diverse healthcare institutions. The publication is intended to serve as a guideline to the planning and initiation of healthcare service IS&T implementation. To that end, it should be viewed as a general source of information, with references to applicable sources for further details. It is not the province of this document to provide highly specific guidelines for individual systems or users, or even the endorsement of specific standards.

4.2. Intended Audience and Utilization

• The document was written for the technically initiated and conceived as a manual with a utilitarian objective.

• This publication does not delve into general conceptual aspects of IS&T, with healthcare services managerial models, or the operational aspects of healthcare organizations or services.

• It is specifically targeted to healthcare executives, health services administrators, information technology professionals and managers, and other interested professionals working in healthcare institutions with an immediate and pragmatic interest in information systems and related technology.

• The reader is expected to have a fair knowledge about information systems and information technology, about health services organization and management, and to be comfortable with technical terms related to the above areas.

• The Editors and Collaborators earnestly expect that this documentation will be profitably used as an instrument to assist health organizations currently involved with or anticipating the planning of IS&T in their services.

• Guidelines and recommendations, regarding infrastructure and dealing with technology and service suppliers, were drafted considering the particular needs of health managers, care providers, and policy makers in the Latin America and the Caribbean Region.

4.3. How this Document Was Developed

The recommendations and concepts hereby presented grew out of a review of the voluminous published material in the subject and from extensive consultations with prominent healthcare professionals, IS&T experts, and interested vendors and consultants, from Latin America, the Caribbean, the United States, and Europe.

The consultations and writing of the document followed a structured approach. A number of prominent health sector IS&T experts from Latin America and the Caribbean were identified and commissioned to prepare extensive individual position papers for preliminary input. These consultants were later interviewed for additional details and clarification. A team of health IS&T professionals from Latin America, the Caribbean, United States and Europe was then commissioned to edit the material, combine it with other publicly available information on healthcare IS&T trends, and then to assemble the voluminous material into a cohesive set of technical reviews, guidelines, and references. The resulting draft was brought before a panel of managers, health professionals of different levels and fields of expertise, clinicians, consultants, and vendors for a thorough review and subsequent revision.

The document is, therefore, the collaborative product of a large number of professionals. A great amount of time was spent by the Editorial Team in bringing a unified format to the variety of viewpoints and experiences related to information systems in the Region.