Historical Perspectives of Medical
Informatics in Countries at Different Stage of Developement
- Introduction:
- A reflexion about where the current projects fit in an
historical perspective, raising questions about possible need of
difeerent approaches when introducing informatics in new regions for
the first time ?
- Early adopter of informatics in developed countries:
- Prehistoric situation:
- Before 1970 computers were nearly not available in healthcare.
- Accurate descrition of symptoms were written in medical
textbook at last since the 17th century.
- Around 1900, careful handwritten records of individual
patients did become usual practice in some hospitals. At that
time the undestanding of infections did make sucessful surgery
possible,
although no antibiotics were available before 1950.
- In 1968 a visionary mile stone was the publication of "The
problem Oriented Medical Record" by L Weed, a professor of Family
Practice in an US university. He had already a vision of what
could be achieved using computers. Since he had actually no
computer at hand, but in order to manage the follow-up of patients with
multiple issues, he did require his assistants to keep updated
summaries of the current situation, rewriting the full page of paper
every time some issue did change, what we can get today on a screen in
miliseconds.
- +- 1970: Epidemiology:
- Since about a century the WHO did epidemiological survey and
did develop the ICD, International Classification of Diseases.
The
manual processing of large collections of statistical information was
very laborious and epidemiologist were the first to take advantage of
the
potential of informatics.
- +- 1975: Administration:
- The next step was to use computers in hospitals in order to
facilitate labor intensive tasks as the production of invoices.
- +- 1980: Lab:
- The first large scale medical application was the handling of
laboratory data inside the lab, e.g. typically facilitating
10.000 elementary transactions a day. The set of available lab
tests was growing and the workload become difficult to manage with
pencil and paper.
- +- 1985: Communication:
- The first use of electronic communication was to make lab
reports rapidly available in the wards of the same hospital.
Indeed
wired communications accross several hundred meters become available at
affordable price.
Large labs still distributing paper reports did begin to send via
private postal services
which were faster than the official postal system. Reports
printed up
to 20:00 h were distributed before 07:00 h the next morning to a list
of frequent destinations at regional level.
- 1995-2005 : "Personal Computer":
- PC did become largely available and some doctors did begin to
keep their notes on a computer.
- This was initially a "personal" computer, not particularly
intended to share information with anybody, except some "Email like"
echange of messages, e.g. lab reports in encrypted Emails as "HL7"
minded messages, although nearly every lab system has his own way to do
it.
- The market was and is still today very fragmented in hundred
of "medical
record" softwares, generally focusing on only one specific target group
of users, GP or nurses or cardiologist or dermatologist, etc...
- Since all these systems were proprietary software there was
absolutely no incentive to interoperability. Official
standardization commissions exist for many years but did not much
succeed up to now, in practice, in the field.
- BTW the current generation of doctor were not particularly
educated for collaborative work. Indeed in universities most
professors are
naturally the best specialist in their own domains.
- Economic model issues. In countries where doctors are
independent workers, they are paid in function of the number
consultations.
Maybe an excellent incentive for their involvment in the care of their
own patients and for the quality of their work, but actually to some
extend a conflict of interest with the notion of collaborative work.
- Today in 2010 in Europe it seems that less than 25 % of
doctors are really working 100 % with electonic support for medical
purposes. The other doctors still use paper either partially or
even in some cases completely.
The claim that in some countries 100% of doctors own a computer will
not say they are using it for medical purposes. The case in
France where the declarations to the Social Security must be elctronic.
- The most important concern related to "personal computer" is
that most medical record systems currently in use, provide not much
more than "narrative approaches". In fact more or less an
electronic simulation of the traditional paper record. The
structure remains rougly the same as before i.e:
- Essentially a chronologic directory of the narrative
reports about consultations, i.e. contacts with the patient. It
is good to have such an event narrrative, but the problem is that this
is the only way to retrieve information.
- Then what if one would like to review all the current
medications of the patient. It is difficult because prescriptions
may have been given during different previous contacts, as well by
specialists who did send reports, if any report has been send to the
GP, and probably nothing for other specialized partners.
Hopefully the patient will be able to tell exactly what he is currently
taking.
- The same tradional chapters of the paper chart, the lab,
history of admissions, the vaccinations, etc... an hierarchic
architecture in which the only way to get a la report is to enter the
chapter in which all the lab reports of any kinds are archived.
- 1990-2000: Discharge diagnoses codes:
- In some countries the Social Security did begin to require
the reporting of ICD codes for every discharge from hospital, as a
mandatory condition for the refunding of costs. However this has
no added value for individual patient care. Moreover from the
point of view of Public Health management, the information was limited
to hospitals and nearly no information was
yet available for all healthcare activities outside hospitals, primary
care as
well independent specialists.
- 1990-2010: Trend toward concentration:
- There is a trend to group hospital activities in larger
centers. Small hospitals were converted in elderly care
institutions for the growing number
of aged population. Independent doctors begin to create group
practices of 3 to 8 colleagues, providing services 365 days a year and
sharing a common premise with a secretary.
- 1980-2010: Electronic archives:
- The price of space in electronic archives did decrease
progressively of a factor 10.000 . Today data compression is no
more a
concern and large images can be archived a very low cost.
- Electronic archives are now more reliable than paper
archives,
because they can easily duplicated at low cost and backup can be saved
in more than one location, making the risks of data destruction very
low.
- Electronic archives of large radiology image cost les than
the
one minute of the mean salary of personnel necessary to handle manual
archives, at least in developed countries.
- In
tropical countries the maintenance of paper archives can be a concern
for other reasons,
due to organisational problems and climatic conditions, although the
cost of the work force is currently still much lower.
- 2005-2010: Networks:
- Although local networks inside hospitals did exists since
about 1980, large networks accross organization boundaries are just
beginning. Several factors play here a role:
- Lack of understanding and of agreements about
confidentiality rules.
- Fears and lack of trust about power or status issues
between healthcare professional. Indeed networks require clear
rules
and agreements about who has power to do what. As an example how
far
do doctors agree to share patient record information with nurses,a
question encountering very different opinions.
- Exaggerated anxiety about the security of new networks,
maybe to some extend as an indirect expression of the previous point
(?).
Although this question is on itself of course critical, there is a
discrepancy between this anxiety and the usual way things are going in
practice, with a lot of negligence about which nobody complaints.
As an example medical information is often provided by ordinary
telephone, without any serious check about who is really at the other
side of the line, like " You are speaking with Dr XXX, please the
latest lab results from patient YYY".
- The availability of fast communication technologies, as
ADSL covering all the territory is relatively recent in the latest 5
years.
- Evolution from messasage exchanges toward on-line networks:
- The medical sector is relatively behind other applications
domains like travel agencies or banking.
- Although the use of on-line access to shared information
has many advantages, up to now this approach did take off relatively
slowly in medicine. This evolution does not preclude that message
exchanges will continue to represent a significant proportion of the
communication traffic.
- Later adopter of informatics in developing regions:
- Today 40 years later, emerging regions can take advantage of
the current telemedicine opportunities and should not necessarily go
through the same path of trials and errors.
Migration to a more advanced work methodology and technical minded
maturity will always need some efforts, but could now go through a
shorter path?
- In developing countries wireless communication is growing much
faster than wired networks. Africa seems to have already more
than 100
millions mobile phones.
- Having very few resources, efficiency of healthcare is much
more critical than in developed countries. Getting more qualified
professionnals in remote areas is difficult and takes much
time.
Installing telemedicine networks can contribute to solutions of the
problems and is relatively earlier possible.
- The brain drain remains a problem in healthcare because the
most qualified people are attracted by more affluent countries,
although if possible they would prefer to remain in their original
environment. Good telecommunication can alleviate the burden of
intellectual isolation.
- .....