MEDINFO 2004 M. Fieschi et al. (Eds) Amsterdam: IOS Press 2004 IMIA.

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A Management Information System Model for Process-Oriented Health Care

Anna Andersson, Niklas Hallberg, Henrik Eriksson, Toomas Timpka
MDA, Departments of Computer Science and Department of Health and Society, Linkping University, Sweden Anna Andersson, Niklas Hallberg, Henrik Eriksson, Toomas Timpka

Abstract Objective: To develop a conceptual model of a management information system for process-oriented health care organizations. Methods: Qualitative data was collected from two case studies in process-oriented health care settings. The first study addressed the information requirements of health care managers and the second study focused on organizational activities and clinical practice. From these data, preliminary models were iteratively developed, interpreted, and further revised. Setting: A county hospital in southern Sweden with 30 clinics and 3,200 employees. Results: A conceptual model of a management information system for process-oriented health care organizations was developed in two parts: one part that describes the organizational interface of the model and the other part that describes the architecture of the model. Conclusion: A conceptual model has been developed for locallevel integration of management information systems and organizational procedures in process-oriented health care organizations. Keywords Process-oriented health care organizations, health care management, Health care Information Systems (HIS).

councils, hospitals and clinics, and that clinical practitioners and other staff members in any situation have different duties and demands with regard to collecting and reporting data, depending on which organizational level care staff address [4]. The aim of this study is to develop a conceptual model of a management information system that suits process-oriented health care organizations. Health care managers increasingly seek opportunities in the field of HIS to enhance their potential to furnish health care more effectively and efficiently, and to improve the quality of services provided [5-6]. When developing HIS for process-oriented health care organizations, attention has however to be paid to the integrated use of the information at the hospital, process and functional unit levels [7-8]. One known difficulty within information systems is finding a connection between the resources use and actual cost [9]. Hence, the systems need to support data collection from operational processes and supply health-service management with information about how resources invested in the organizations have been used [10]. One solution to problems with primary data collection for management information systems is using pervasive networked devices and extracts from computerized patient records. In this manner, data can be unobtrusively collected to supply health care management with information about present medical outcomes, costs, and the status of patient satisfaction [11]. To take advantage of the large amounts of unprocessed data, the organizations also need an integrated information system for rapid data structuring and analysis and for the distribution of the resulting information to manager and care provider [12].

Introduction
Today's health care organizations are both highly specialized and structured to rapidly adapt to changes in social and financial environments. The more complex the organizations become, however, the more composite is the need for analysis and decision support methods for organizational problem-solving [1]. One of the greatest challenges that health care organizations face at present is the establishment of management information systems that are flexible and that have sufficient expressiveness to handle highly complex environments. In these settings, managers are seldom able to choose a single method to handle prevalent problems. To analyze health care systems, consequently, managers require information systems that supply data for sets of different analysis methods and tools [2]. In Sweden, health care providers have, in response to escalating costs, commonly adopted process-oriented organizational model [3]. One problem with this approach is that a health care organization is distributed over multiple organizational levels. Such as county

Methods
The study was performed at a county hospital in southern Sweden. The hospital had 30 clinics and 3,200 employees. For quality control, the hospital adopted a broad quality program in 1996, based on Total Quality Management (TQM) and a Plan- DoCheck-Act cycle. For cost control, the Balanced Scorecard [12] was introduced in 2000. The primary study site was a functional unit, the pediatric clinic. The clinic cooperated with maternity wards and Child Health Centers (CHCs) throughout the county. The clinic was also involved in a network of specialist clinics in southern Sweden for an exchange of knowledge and experience. At the time of the study (2000), the pediatric clinic employed 12 senior physicians, 21 physicians, 91 nurses, 77 pediatric nurses (specialized nurses aides), and 13 secretaries. During the time of the study, the pediatric clinic supplied approximately 16,000 bed-days to inpatients, performed 5,000 scheduled surgical in-

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terventions, and managed 6,000 emergency room visits by children. The clinic had the responsibility for one surgery and three wards each with a physician responsible for medical matters and a nurse as ward manager. The internal strategic objectives of the clinic were to have the patient in focus and to support co-determination. The management group consisted of six senior physicians, seven nurses and one secretary, representing the clinic and the wards.

tion at a county level. The county council formally required that hospital management controlled and reported on service production with regard to quality and cost. The objective was to increase cost-efficiency ratios and patient empowerment. As a result, hospital management requested information about the use of resources and the quality of health care from the hospital organization.

Data collection and analysis

Data collection and analysis were based on a qualitative research strategy [13], using case studies for the collection of primary data. In a case study, it has been suggested that it is important for the researcher to have contextual data available to understand the setting for the case. The primary type of data in this mode of analysis should be the qualitative, and the primary level of analysis should be holistic [14]. Each case is, thus, seen as a bounded system. In this study, the primary data from two case studies were used to develop a management information system model for process-oriented health care organizations. The first study addressed the information requirements of health care managers [4], while the second study focused on organizational and work activities [15]. In both case studies, data was collected from documents and archives [16], interviews [17], observations [18] and focus groups [19]. It has been suggested as desirable in interpretative studies to preserve a considerable degree of openness to field data, and a willingness to modify initial assumptions and theories. These approach results in an iterative process of data collection and analysis, with initial theories being expanded, revised or abandoned altogether [20]. Therefore, the data was first preliminarily categorized [21]. Thereafter, the health care management activities were modeled [22]. Finally, the data were structured to reports that were sent to participants in the case studies for reflection and critique. The reports supported a feedback loop for refining the findings in a process between researchers and practitioners [23].

M IS H ealth care Control System

The M IS and the health care m anagement M anagem ent level Organizational output Reports of Health care quality Resource u se Reports of Resource u se W ork satisfaction

Hospital management

Resource Control System

Functional unit management

Service Quality Control System

Process unit management

Reports of M edical service quality Nursing service quality

Figure 1 - Model of the interface between a MIS for process oriented health care organizations, the management processes and their outputs. Data requested: Cost and quality data delivered from functional units. Information delivered: Specification of allocated resources, quality indicator profiles and templates for cost summaries to functional units. MIS module: Healthcare Control System. Hospital management was in need of a system that would support control over quality and cost. Information systems that can support methods, such as TQM and the Balanced Scorecard are therefore suitable for this level of management. To obtain control over cost and quality, hospital management requested data from the functional units, but hospital management first had to define which data the functional units were to produce. Process unit management Process unit management focussed on the development and maintenance of a level of high quality in the medical and nursing care processes. The process unit had the responsibility for at least one PNGP, including documentation and quality control operations. The size of the units differed, but they always included at least one physician, one nurse and one secretary. Information requested: Medical and nursing quality level directives from the functional unit management. Medical and nursing data collection templates from the functional unit management. Information produced: Medical and nursing quality data to the functional unit management. Best practice guidelines and deci-

Results
The study hospital employed a networked management structure in which responsibility was distributed from hospital management to functional unit and process unit management. The functional units consisted of clinics and wards. The process units were based on Patient Need-Group Processes (PNGPs), which were defined in terms of the medical and nursing care for specific patient groups. The units were inter-organizational and multiprofessional, and when necessary, several clinics, hospitals and county councils were involved in one process. System-organization interface The model management information system is interfaced to the process-oriented health care organization at three levels (Figure 1). Hospital management Hospital management focussed on supplying emergency and specialist medical care and rehabilitation services to the popula-

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sion support protocols to clinical practitioners involved in the clinical process. MIS module: Service Quality control system. Management of the process units was in need of an information system that could extract data from and support decision-making in medical and nursing care. Functional unit management Hospital management provided the functional units with a specification of resources available and methods for planning, over time, the amount of these resources the units could spend. Hence, the cost control tools that were used by hospital management were distributed as tools of analysis even to the functional unit management. Functional unit management comprised both managers of the clinic and ward managers. Clinic management organized monitoring the resources invested in the clinic and the ward managers managed the exchange of information at the wards. Information requested: Specification of resource allocation and templates for expenditure reports from hospital management. Templates for collection of patient satisfaction and staff work satisfaction data from hospital management. Data produced: Resource spending, patient satisfaction and staff work satisfaction data to hospital management. Medical and nursing quality level directives sent to process managers. System requirements: Functional unit management was in need of data concerning the perception of patients and staff of the services provided at the unit. Functional unit management also needed to put its expenditures in relation to resources used. This level of management was therefore mainly in need of data collection, storage and access tools. It needed data from clinical activities, but not at an individual and contextual level. Instead, it needed systems that could provide data for use at a composite level, e.g., about how much labor hours and financial and human resources were used in specific care activities. Management information system architecture To control service delivery, the management units in the process-oriented health care organizations need data from three areas: (1) the medical and nursing care of patients, (2) patient flows and (3) the use of human and material resources. Even though the management units can share access to a common data warehouse, the requirements on data analysis and presentation are considerably different. Correspondingly, data collected in daily work routines from the health care organization can be shared, but primary data must be converted into information that is useful for health care managers. Data collection should preferably be located in places where data are available in ordinary health care activities (Figure 2). For instance, networked devices can be used to register the use of pharmaceuticals. Smart devices can also be connected to equipment to keep track of their use, and materials storage and use (i.e., diapers, sheets, etc.) can be traced, for instance, with bar-code systems. Furthermore, patients and health care staff can be registered by using smart cards when they arrive and leave the health care setting. However, for data collection from the clini-

cal setting, the computerized patient record (CPR) is the natural central resource. Data that are documented in the records can be used to monitor the clinical actions that have been performed. The CPR can also provide data about work activities that have accrued at the health care organization. Such data from a single patient is of little interest. Instead it is useful to analyze generalized data, for example, the number of radiology investigations that have been conducted on leukemia patients. The purpose of the data warehouse is to maintain the data that have been collected from the different data sources. The application interface and the application are those parts of the MIS that health care managers interact with and are those parts that users think of as the MIS. The applications therefore must support health care managers use of information and must supply the right information from the databases to the appropriate health care managers. Also, the applications must be able to support the specific analysis methods, tools and data formats required by the actual organizational analysis procedures, such as the Balance Scorecard or quality assurance methods.
H e a lth c are M an ag e m e n t In fo rm atio n S ys te m D ata co llec tio n D ata w are h o u se Ap p lica tio n in te rfa c e A pp lic atio ns

P e rv a s iv e n e tw o rke d d e v ice s P a tie nts S taff C PR C om p u te r P a tie n t R ec o rd E q u ip m en t M a te ria ls P h arm a c e utic al T e rm inolog y Q u ality in d e x T em p la te s C o s t rep o rtin g T em p la te s

H e a lth c a re C o n tro l S ys te m

R e s o u rc e C o ntro l S yste m

S e r vic e Q ua lity C o ntro l S ys te m

Figure 2 - Model of a Management informaiton System (MIS) for process-oriented health care organizations, displayed by data collection, the dataware house application interface and applications.

Discussion
Several initiatives have recently been taken to fundamentally change the organization and delivery of health care. Most of these initiatives identify information technology as a means to improve the health care delivery system, such as the efforts of the Committee on the Quality of Health Care in America [24]. The areas in which information systems are expected to contribute to enhanced delivery of care, range from access to medical knowledge bases and improved patient and clinician communication to a reduction of medical errors. Although information systems have traditionally been most extensively used in admin-

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istrative and financial transaction [25], little attention has been paid to how integrated administrative, financial and clinical systems could be configured to optimally support process-oriented health care organizations. In other words, the organizational interface of these systems has been neglected. To address this shortcoming, the aim of this study was to develop a conceptual model of a management information system for process-oriented health care organizations. Results show, first, that the different management levels in process-oriented health care organizations require the same type of primary data, but presented in different ways. Second, results show how a management information system in the process-oriented health care setting can follow the structure and practice activities of the latter. These observations are relevant for system developers attempting to develop management information systems, including pervasive computing components, for future health care organizations. This study has several limitations that have to be taken into regard when interpreting the results. The model only describes the degree to which systems and technology are integrated with each other and with the organizational and business models within process-oriented health care organizations. Future studies need to address the external interfaces, e.g., between management information systems, consumers and external institutional stakeholders [26] Moreover, CPRs and other devices can be used for collecting management data directly where and when the activities take place, but the data is only useful if available in the analysis tools used by health care management. Therefore, future studies must also address the methods and tools that are required to refine the primary data into information that is appropriate for the organizational analysis and decision-making tools [27]. In studies that evaluate success factors for hospital-wide clinical computing systems, items such as coded laboratory results and problem lists have been identified as important, mainly due to that these form a basis for decision support applications [28]. It is noteworthy that even though computerized ordering systems, for instance, are mentioned, the degree of fit between organizational models and information system models is not identified as a success factor. There is clearly a need for systems that optimize clinical workflow on the one hand, and systems that support maintenance of equipment and supplies, on the other. Nevertheless, the systems will deliver optimal organizational value only if they support an integrated organizational model and business plan. The results of this study can be seen as the basis for developing such integrated models at local levels. In these efforts, specific local strategies to achieve this integration must be based on the needs, goals and cultures of each particular institution [29].

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