PROCEEDINGS OF SPIE

SPIEDigitalLibrary.org/conference-proceedings-of-spie

Optimizing the use of information

technology in medicine

Jeffrey J. Guterman

Jeffrey J. Guterman, "Optimizing the use of information technology in

medicine," Proc. SPIE 2102, Coupling Technology to National Need, (7
March 1994); doi: 10.1117/12.170606

Event: Coupling Technology to National Need, 1993, Albuquerque, NM,

United States

Downloaded From: https://www.spiedigitallibrary.org/conference-proceedings-of-spie on 9/8/2018 Terms of Use: https://www.spiedigitallibrary.org/terms-of-use

 Optimizing The Use of Information Technology in Medicine

Jeffrey J. Guterman
UCLA School of Medicine
Olive View - UCLA Medical Center

INTRODUCTION

Medicine has long enjoyed being on the cutting edge of technology. Operative procedures that
once required a twenty centimeter incision are now performed through a one centimeter
laparoscope. Blood vessels proliferating in the retina of a diabetic patient leading to certain
blindness are now easily ablated with a laser. The revascularization of a coronary artery
requiring a foot long incision through the sternum can now be accomplished with a small
catheter. These are but a few of the success stones made possible by the application of leading
edge technology.

However, medicine has not been as successful in the application of hospital information systems
to the delivery of health care. This paper discusses the history of hospital information systems
and their future as they are called upon to support and enhance both medical and management
directions in the face of health care reform.

HISTORY OF HOSPifAL INFORMATION SYSTEMS

During the last decade hospitals began automating their business practice, significantly lagging
behind the more than three decades of computerization in large financial institutions.
Frequently, hospitals chose closed proprietary systems that performed single organizational
functions. Sharing data in a useful way was not a requirement. In general, existing hospital
information systems focus on the nonclinical aspects of patient care. While reasonably good
at supporting back office functions, most are woefully inadequate at tracking clinical
information.

THE FUTURE DIRECTION OF MEDICAL CARE

If there are two phrases to appropriately describe the future direction of medical care, they are
cost control and quality improvement. Many agencies have begun to link payment for medical
services to a formula for achieving these two goals. The favored process of this decade is called
managed care. Without debating the merits of managed care, I will assume this direction for
at least the near future of health care delivery.

0-81 94-1387-9/94/$6.00 SPIE Vol. 2102 Coupling Technology to National Need (1993) / 17
Downloaded From: https://www.spiedigitallibrary.org/conference-proceedings-of-spie on 9/8/2018
Terms of Use: https://www.spiedigitallibrary.org/terms-of-use
 What are the needs and desires of the four major stakeholders in health care reform? Patients
want high quality, affordable health care and the freedom to choose a health care provider.
Physicians and other health care providers want autonomy, financial security, minimal
paperwork and relief from the constant threat of malpractice. Hospitals want to play a dominant
role in the future of health care delivery. They want prestige, which often means offering
expensive, high technology medicine. They also want a high quality medical staff. Their focus
of concern is on patient populations over individuals. The government's and payors' interests
are four-fold: cost control, cost restraint and cost reduction, all while providing a measurable
degrees of quality.

On the surface, the goals of these four groups may appear to be in conflict. Perhaps, however,
they are not. Many observers see the future of medicine as a never ending chain of
corporatization and depersonalization of medical care. I would submit to you an alternative
view, one that replaces this hostile vision with a future focused on interdisciplinary team work.
The key to this new age of medicine, one which truly improves our system, is the appropriate
application of information technology.

How can one argue that physician desire for fmancial security is not in conflict with the
government's desire to reduce cost? Let us examine why medical care is so expensive in the
United States. The answer appears obvious - Doctors. More complex is the question of what
we need to control in order to reduce costs. Historically, the first response is to reduce
physicians' salary or name expensive technology such as CT scans or exotic pharmaceutical.
Unfortunately, this list provides an inadequate view. The most important piece of technology
that we have to control is the doctor's pen on the order sheet. Physician fees make up only a
small percentage ofhealth care expenditures; however, physician's actions control 90% of health
care expenditures in this country. Optimal health care reform will allow physicians to make
quality medical judgments for their individual patients while still reducing costs.

How do we achieve this goal? Let us look at the fundamental problem. Physicians control the
nation's health care expenditures. Physicians want autonomy, less paperwork, quality patient
care and relief from malpractice. Pleading with physicians to behave in a more cost efficient
manner have generally failed, not because physicians care little about costs, but rather because
they have not had the tools to manage resources efficiently without sacrificing the quality of
individual patient care or increasing their malpractice risk.

Todays solution for modifying physician behavior is to place administrative hurdles to the access
of high cost care. For example, referrals to specialists often require a written request and

18 ISPIE Vol. 2102 Coupling Technology to National Need (1993)

Downloaded From: https://www.spiedigitallibrary.org/conference-proceedings-of-spie on 9/8/2018
Terms of Use: https://www.spiedigitallibrary.org/terms-of-use
 review by a Patient Care Committee. Delays associated with this method are significant, and
while these techniques work, they often do so at the expense of patient care and convenience.

DECISION SUPPORT

While medical science has made great advances over the past few decades, it has not been
paralleled by similar advances in the human capacity to remember. The exponential growth of
medical information has made it impossible for any individual to learn and retain the universe
ofknowledge within even one specialty of medicine. Using appropriate decisionsupport systems
we can provide information to clinicians in real time. This will allow physicians access to cost
and efficacy data regarding the use of resources enabling them to make inteffigent, cost-benefit
decisions. Now that computer technology is affordable, we can organize information and re-
format data in a way that is meaningful to the clinician. This new methodology is far superior
to the current retrospective review and delay associated with prior authorization procedures.

For example, suppose a physician wishes to prescribe Ciprofloxacin, a very expensive drug.
With the traditional implementation of managed care, the pharmacist or case manager receives
the prescription for Ciprofloxacin, and, since it is not considered a "first line therapy" drug,
contacts the physician to request an explanation. The time spent by both the physician and
pharmacist could be better spent providing direct patient care.

A computer-assisted system would allow the physician to select Ciprofloxacin from a menu of
medications. A list of appropriate indications for Ciprofioxacin would be shown on the screen.
If the physician selects "osteomyelitis", the system would print the prescription, as there is no
significantly less expensive appropriate substitute for treating osteomyelitis on an outpatient
basis. If "Urinary Tract Infection" were selected, the computer would present a list of less
costly, yet efficacious medications that could be chosen with a single keystroke. Alternatively,
the physician may elect to retain the original choice. The physician would always maintain
control over the fmal decision. In institutions that desire review of physician decisions, the
physician would type a few lines of information supporting his or her decision for the use of a
more costly medication. Later review by the medical staff could determine whether the
physician's behavior was appropriate. The key element remains - physicians maintain control
of the medical care provided to their individual patients, assuring that the medical judgment of
the most highly trained and experienced member of the medical team prevails.

The computer method may be slower than hand writing a single prescription for an episodic
visit. However, by maintaining patient-specific drug profiles, refills for patients will require
only one keystroke. In addition, the computer can check drug interactions on a patient's

SPIE Vol. 2102 Coupling Technology to National Need (1993) / 19

Downloaded From: https://www.spiedigitallibrary.org/conference-proceedings-of-spie on 9/8/2018
Terms of Use: https://www.spiedigitallibrary.org/terms-of-use
 pharmacy proffle, as well as print an information sheet for each drug ordered by the physician.
The goal is to produce a substantial benefit in patient care or convenience that more than offsets
the burden of using the computer.

A simple way to lower medical costs by more than 10% without sacrificing quality, autonomy
or access to care is immediate price and result feedback. We know from clinical studies that
simply displaying prior laboratory results to physicians at the time of order entry reduces
laboratory utilization by 13 % .' Even more impressive is Tierney's 1991 trial of inpatient order
writing.2 They compared computer workstations coupled with physician feedback to traditional
paper charts. There was an average expenditure decrease of eight hundred and eightyseven
dollars per patient for those on the computer teams. This was accomplished without hiring extra
staff to monitor physicians, a system which in itself creates animosity by placing an
inappropriate professional between the physician and patient. Currently, the limiting factor is
the scarcity of systems with appropriate physician-user interfaces and robust databases. It will
not be difficult to cost-justify the appropriate system if the results of these small experiments
hold true for the general case.

MANAGED CARE IMPLEMENTATION - RELATION TO DEFENSE TECHNOLOGY

Managed care changes the relationship between patients, providers and health care institutions.
Historically a patient's provider had a close working relationship with a few specialists.
Communication concerning the patient was often verbal with congenial follow-up letters.
Physicians choose which hospitals would provide care and which specialists would receive
referrals. Managed Care present the network concept. The payor defines the network based
upon its perception of cost and quality. Primary care physicians may no longer have a close
working relationship with the specialists or the institutions to which their patients are referred.

The provider network presents an ideal opportunity for the integration of existing, but previously
restricted, military communication technology. Let us analyze battlefield requirements for the
effective movement and operation of troops. There is the central command and control, the C3.
The C3 needs to receive information from and transmit information to each of its battlefield
divisions. The divisions, in turn, act on the information while collecting additional information.
These messages must be transmitted with absolute certainty and privacy. In addition, the C3
must be connected to the Pentagon which is typically a great distance away.

Now, simply replace command and control center with hospital; battlefield group with multi-
specialty provider groups; and Pentagon with payor and you have the configuration of a 1990s
health care provider network. The communications needs are usually identical. Wide area

20/ SPIE Vol. 2102 Coupling Technology to National Need (1993)

Downloaded From: https://www.spiedigitallibrary.org/conference-proceedings-of-spie on 9/8/2018
Terms of Use: https://www.spiedigitallibrary.org/terms-of-use
 communication, between multiple disparate systems, in a secure and reliable way, is an area
where traditional medical communication systems fail.

The new provider paradigm necessitates sharing clinical data among groups who heretofore may
not even have known each other. Current systems are often appropriately described as islands
of data with little information. While open distributed systems are a goal that all can agree
upon, we must provide information access to physicians now. The integration of existing
databases along with development of the communication tools are the keys to the future of
effective health care delivery.

While there is great promise in the activities mentioned earlier, there are some areas which will
not yield a high return in investment in the short run. One of them is the desire to replace
physicians with the computer. While the diagnostic skills of artificial intelligence systems may
some day rival the best clinicians, it will not be in the foreseeable future. As computer
technology expands into the field of medicine, we should consider a few principles. Like the
microscope, the computer can see what the naked eye cannot, but the vision must be evaluated
by an intelligent, trained provider. As with all other tools in medicine, the computer is only a
means to an end, not an end in itself. It is another technology to expand our ability to gather
and process subjective and objective data. It can help in the assessment of a patient's problem
or problems. It may aid in selecting the most effective treatment at the lowest cost. But, the
computer is not a surrogate for thinking; it will not replace clinical judgement; it cannot
provide the wisdom about people, families, and communities that is the art of medicine.
Technology should complement, not replace, good judgement. We must always remember to
use these systems to augment our skills, not replace them.

As the country slows its health care spending, which must be done if we are to remain globally
competitive, we are faced with a choice. We can do less, and do it less well or we can change
the way we do business. Instead of developing more administrative barriers to health care, we
can provide tools for the clinician which help, rather than hinder care. We can shape the future
and it is in the best interests of all to do so well.

Downloaded From: https://www.spiedigitallibrary.org/conference-proceedings-of-spie on 9/8/2018 SP1E Vol. 2102 Coupling Technology to National Need (1993) /21
Terms of Use: https://www.spiedigitallibrary.org/terms-of-use
 References

1 Tierney WM, McDonald C!, Martin DK, Hui SL, Rogers MP. Computerized
Display of Past Test Results. Effect on Outpatient Testing. Ann Intern Med
1987; 1O7:569574.

2 Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician Inpatient
Order Writing on Microcomputer Workstations: Effect on Resource Utilization.
JAMA 1993;269:379-383.

Downloaded22 / SPIE
From: Vol. 2102 Coupling Technology to National Need
https://www.spiedigitallibrary.org/conference-proceedings-of-spie on (1993)
9/8/2018
Terms of Use: https://www.spiedigitallibrary.org/terms-of-use