Health informatics as a tool to improve quality in non-acute care — new opportunities and a...

International Journal of Medical Informatics 56 (1999) 141–150

Health informatics as a tool to improve quality innon-acute care — new opportunities and a matching need

for a new evaluation paradigm

Michael Rigby *Centre for Health Planning and Management, Darwin Building, Keele Uni6ersity, Keele, Staffordshire ST5 5BG, UK

Received 27 August 1998; accepted 9 December 1998

Abstract

Whilst most health care is delivered to people living at home, the focus of innovation in health informatics conceptshas been largely on acute hospitals. However, delivery of services in community settings, and often related tolong-term conditions, is complex, and involves multiple professions and agencies, delivery of care in several locationsincluding home settings, and individually tailored care for episodes lasting over long periods of time. This challengeis poorly supported by current information systems. However, computer-based record systems have a major potentialto improve quality of care by enabling integrated care delivery through multi-professional electronic patient records,whilst also providing quality assurance processes. In turn, though, this requires a new evaluation paradigm. Firstly,the multi-disciplinary and holistic ideal of integrated care requires an as yet inadequately developed framework to givestructure to assessment of the value and utility of the data recorded and the way in which they are processed andpresented, mapped to clinical processes and to the views of consumers as prime stakeholders. Secondly, a deeper andlonger-term evaluation philosophy is needed which does not stop after the initial confirmation of system functioning,but continues on with a deepening into the effects on the individual clinical services, and then on the host userorganisation. This paper maps out the new paradigm, and suggests specific issues which merit practical research toreset evaluation and assessment tools to this new setting and viewpoints. © 1999 Elsevier Science Ireland Ltd. Allrights reserved.

Keywords: Informatics; Non–acute care; Community care; Electronic records; Evaluation; Quality

www.elsevier.com/locate/ijmedinf

1. Background — an overview of non-acutecare

There is currently an imbalance betweenthe main focus of health information systeminnovation, and the location of the majorityof health care activity. Despite the predomi-

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M. Rigby / International Journal of Medical Informatics 56 (1999) 141–150142

nance of interest in hospitals, most care isdelivered to persons still living at home. Fre-quently the patient goes to the health profes-sional or treatment centre, but the delivery ofcare to persons in their own homes is animportant element. Additionally, care may bedelivered in day hospitals or other commu-nity facilities, and in non-acute settings rang-ing from community hospitals to residentialmental health facilities. This is the delivery ofhealth care to people in the real world —their environment of normal living — asopposed to the (to them) artificial world ofthe hospital [1]. However, in this communitysetting care is often fragmented, and recordsare usually uni-disciplinary and also paper-based [2].

By contrast, the focus of a high proportionof innovations and investment in health in-formatics, and particularly in integrated elec-tronic records systems, is in acute hospitalcare. Furthermore, most of those applicationswhich do exist in primary or community careare predominantly registration and activitysystems, and are restricted to one professionor one client group. Also, there is only lim-ited practical work (normally disease-specific)in systems which cross the organisationalboundaries between hospital care, primarycare, and home and community care. Thus,any attempt to fulfil the need for truly inte-grated and holistic person-based care requiresa paradigm shift in the processes of healthcare organisations and professionals. Thismay either require a new approach to inte-grated care delivery to meet legitimate con-sumer expectations, or changes to matchimportant service reconfiguration and reori-entation (as with mental health). Certainly,health care practice must adjust to managedelivery of integrated care within the dis-persed and uncontrolled setting of total com-munity [3].

1.1. Types of care

In addition to the brief inter-current ill-nesses presented solely to primary care(which are outside the main focus of thispaper), there are other particular and impor-tant types of care which are very largelythe domain of non-acute care. These includepreventive services, the management oflong term and chronic conditions, mentalhealth care, health care of persons withlearning disabilities, rehabilitation and re-education following acute episodes of ill-ness and trauma, and palliative and terminalcare.

Thus, there is a major focus on the qualityof life — through effective prevention, andthrough maximising the functional potentialof those persons with chronic conditions byminimising the adverse and disabling effects.It is also a significant part of health caredelivery — mental health alone accounts forsome 10% of morbidity and a similar propor-tion of health care expenditure; the propor-tion of frail elderly in the populationcontinues to increase; and chronic conditionshave major effects upon society and onhealth care resource demands.

1.2. Client groups and clinical interests

Whilst no professions nor clinical speciali-ties are excluded from an interest in non-acute care, nevertheless there is a particularemphasis in certain specialities. Most impor-tant within these are child health andpaediatrics, general medicine (especiallymetabolic and respiratory interests), mentalhealth, learning disability services, care of theelderly, community nursing and health visit-ing (sometimes referred to collectively as pub-lic health nursing), and those specialising inpain relief and palliative care.

M. Rigby / International Journal of Medical Informatics 56 (1999) 141–150 143

1.3. Modalities of care deli6ery

These services are delivered by a number ofprofessions and groups, particularly primarycare physicians, community and domiciliarynursing services, the therapeutic and remedialprofessions, community psychiatric services(through domiciliary visiting and in commu-nity facilities), and non-acute units such ascommunity hospitals and day hospitals.

1.4. Locations of care

Because non-acute care is focused on thepatient in their normal daily setting, it may(and should) be delivered in any locationalsetting as necessary. This includes not onlyhealth premises, but potentially any domestichome, as well as residential institutions,schools, and employment premises. Addition-ally, care needs to be delivered when neces-sary to squats, shop doorways and otherregular resting places for the vagrant, thestopping places of travelling people, and mo-bile premises such as needle exchange vans.Thus, no setting can be excluded as a carelocation, whilst formal addresses of premisescannot alone define scheduled care deliverypoints.

1.5. Organisational aspects

A number of autonomous health care or-ganisations may be contributing contempora-neously to the care of a patient, leading toissues of co-ordination and control. Further,health care needs to be co-ordinated withsocial care and other support.

2. Challenges of non-acute care

By its nature, therefore, non-acute caredistributed throughout the community and

dispersed health care facilities, with its fur-ther complications of frequently beingmulti-organisational as well as multi-disci-plinary, brings particular organisationalchallenges. Hitherto, these have nearly al-ways resulted in practical characteristicswhich militate against providing qualitycare to the patient. Highest amongst theseare an organisational focus by each con-tributor rather than an integrated holisticview, fragmentation by locality, separa-tion of professional records and views,and task based delivery. At the same timethere is often a challenge to quality throughservice overload, as cases are difficult todefer.

2.1. IT potential

The above challenges are difficult to ad-dress in a context of manual records andwritten communication. However, the newera of distributed IT systems, powerfulportable computing, and electronic commu-nication, gives major opportunities to ad-dress these issues constructively. The longstanding needs, which now have the poten-tial for new solutions through health infor-matics, include a patient focused, integrated,holistic view point; a patient focus to caredelivery; objective care, orientated to in-tended outcomes; and proactive quality as-surance in a dynamic and turbulentenvironment.

The underlying objective must be toachieve truly patient-orientated quality incare delivery, namely to give the right treat-ment to the right patient, at the right timeand in the right place, regularly and reli-ably. It has not has been possible to guar-antee this hitherto, using only paper recordsand communication.


2.2. The new information system en6ironment

A new generation of integrated yet dis-tributed patient-based information systems isnow realistic, and is beginning to be devel-oped, to support the delivery of qualityhealth care outside the acute hospital setting.Indeed, the harnessing of informatics to sup-port quality and equity has been a particularEuropean theme, the important enabling fac-tors being distributed data availability in nearreal time, creation of a common clinical pic-ture and common treatment objectives, plan-ning within capacity, co-ordinatedscheduling, and service delivery monitoring[4,5].

Information strategies based on the humanmetric can now be visualised [6,7], and pa-tient based care support systems in non-acutecare are now being implemented [8,9], butthese themselves set up a new and morechallenging research and evaluation agenda.There is still much more work to be done insystem development, though, not least inmental health [10], but this cannot detractfrom the new achievability of the vision ofseamless information to support seamlesscare [11].

3. The challenge of the non-acute careevaluation agenda

3.1. The need for more considered e6aluation

It is unfortunately a truism in health careinformatics, as in many other branches ofhealth care innovation, that evaluation is un-dertaken rarely and inadequately. However,the issues at stake are major, as is the invest-ment of effort and money, and therefore theresearch agenda for health care informatics insupport of non-acute care needs to be betterarticulated, developed, and implemented.

One American study indicates that half of allmedical information systems failed to be usedproperly because of staff resistance [12] andother studies show that only one quarter ofsystem abilities or functionality (of acute hos-pital systems) was utilised [13].

Important texts exist on concepts, frame-works, and methods in health informaticsevaluation, from both America and Europe[14–16]. However, since so much of the focusof health informatics systems investmenthitherto has been on acute hospital care,naturally this is also the focus of the develop-ment of evaluative tools. Complex though theissues are as shown in these sources, never-theless acute care informatics has two advan-tages compared with the non-acute setting —first, most clinical measures and other dataitems are empirical, or have other inherentquality criteria such as image clarity, andsecondly the organisational setting is compar-atively small and well circumscribed. Further-more, the timescale of each episode, and thusthe numbers of clinical participants and theduration from input to outcome, are compar-atively restricted.

3.2. The non-acute paradigm shift

By contrast, non-acute care is based farmore upon intuitive professional assessments,qualitative analyses, the use of subjectivemeasures, and delivery of programmes ofcare to achieve objectives and intended out-comes. The organisations are dispersed andmultiple, and care (and thus effects) oftenhave long (indeed possibly life-long) timehorizons. New viewpoints and measures areneeded, and these are still open for discus-sion. In summary, non-acute care supportsystems need to be part of a paradigm shiftfrom delivery-based to person-based thinking[17,18], and the same paradigm shift is there-fore needed in the evaluation techniques.


This fundamental realignment must be notonly in approach, but in duration and depth,as the effects over a longer period of timeacross dispersed and federal organisationalstructures, and above all upon the outcomefor patients and the benefits and disbenefitsto semi-autonomous health professionals [19],become the focus of consideration using hu-man values [1,3] as much as clinical measures.

4. Issues for discussion and development

As yet there are no well-developed andclear-cut measures or methodologies in thenon-acute healthcare domain. However, avaluable first step is the identification of is-sues and aspects which are important andthus need addressing. The following evalua-tive themes are put forward as justifying at-tention, and thus requiring furtherconceptual development, with subsequent ap-plication to the evaluation of new emergentsystems.

4.1. E6aluating the information recorded

Information is only as useful as the valuegiven to it; such values may be inherent orperceived (and there may be discordance be-tween these). The following data and infor-mation evaluation aspects are suggested:� the perceived value of the information

recorded,� data comprehensiveness versus excess data

richness,� data swamping,� the selection or suppression conundrum

(who decides, and by what criteria?),� who prioritises and interprets the informa-

tion and the resultant treatment regimes?,� interpretation of meaning of assessment

and evidence (across professions andagencies).

4.2. The clinical 6iew and its reporting

Moving from uni-professional clinicalrecords to a multi-professional and integratedrecord produces new challenges which needresearching in practice, including:� which common language really integrates

the professions [20]?� are terms and language commonly per-

ceived and interpreted?� which concepts effectively link professions

[21–23]?These are all essential points concerning thesafety and effectiveness of the integratedrecord as a means of clinical communicationand recording as the underpinning of healthcare delivery.

4.3. Objecti6e-based care

The move towards objective-based care isitself often a new departure for all healthprofessionals to use in a similar manner [24].The evaluation agenda here might include:� common taxonomies for care planning,� intended outcomes,� how health professionals handle uncer-

tainty in treatment and outcome,� recording of, and adjustment to, attitudes

(including those of patients and carers).

4.4. Health care practice

Shared records, and a common set of treat-ment objectives for the patient, should im-prove quality and co-ordination of care.However, this subjugation of professional au-tonomy in favour of a total patient focus willbe challenging to many clinicians. Informa-tion systems design and functionality shouldseek to minimise the negative impact of theseaspects whilst maximising the enablement ap-proach. Aspects for evaluation might include:


� does the integrated health care informa-tion system give a better view of thepatient to the clinician?

� does the inter-professional sharing ofrecords lead to co-operation or conflict?

� does it lead to de-skilling or re-skilling?

4.5. Organisational beha6iour

The effect upon individual organisations,and upon the federal local care network oforganisations, must be considered. Thus, it isnecessary to ask:� does the information system give a better

view of patients’ health care needs?� does it give an overall picture of therapeu-

tic and supportive responses?� do health professionals find the monitor-

ing function supportive or threatening?� do the organisation and its staff adjust the

recording of information to meet the sys-tem’s expectations?

� how does the role of middle managementchange with better informed operationalstaff?

� who monitors overall service delivery?

4.6. Consumer 6iews

The intention of IT support to non-acutecare is to be beneficial and supportive. How-ever, the collection of large amounts of datafrom different sources may seem threatening;moreover there is a risk of a ‘picture’ of thepatient becoming fixed and subsequentlyrigid, even if alternative interpretations arelegitimate. Therefore evaluation should ask:� what are patient attitudes to integrated

records?� can the patient influence appropriately

their clinical presentation and treatment?� are patient preferences adequately

accommodated?

� does the patient have the same view of thesalience of data items [25]?

� is the form of data recording and holdingacceptable or impersonal?

� are the ethical and data protection aspectsproperly considered [26–29]?

4.7. Outcomes and future e6idence

Looking at the longer term, integrated in-formation systems also give new opportunityto provide effective health care service evalu-ation, and thus a much more robust futureevidence base upon which to found goodpractice. This suggests a current evaluation-based learning agenda as follows:� how best to link activities to episodes of

illness,� how to factor out aspects of care extrane-

ous to that episode,� the measurement of true outcomes,� the measurement of true use of resources.Hitherto, apart from special clinical studies,these have been almost imponderable ques-tions. New opportunities now open up, butmay be challenging both in the evaluationmethodology and in the nature of thefindings.

5. Stages, timescales, and dimensions

Such radical and challenging new types ofevaluation, for a new family of systems basedupon ongoing care delivery, cannot be under-taken to a simple single evaluation model.Instead, a step-wise approach, taking firstimpressions and straightforward functioningfirst, then deepening over a period of timeinto the more profound effects, is needed.The following three conceptual stages arepostulated as being appropriate:

Stage 1: Unit-level and function basedpost-implementation evaluation


Stage 2: Service-level evaluation of theeffect of integration offunctions

Organisation-level evaluation ofStage 3:overall effects of the fullsystem.

However, most systems are implemented inphases, and also are likely to be further de-veloped and enhanced, so that when Stage2–3 evaluations of early functions are inprogress, Stage 1–2 evaluations of later de-velopments would also be occurring.Timescales also will deepen: Stage 1 evalua-tions will be brief and undertaken a shortperiod after implementation, graduatingthrough to Stage 3 evaluations which will bemore complex and reflective, and undertakenwell after first implementation.

Though produced from first principlesfrom a user and organisational effectviewpoint, these proposed stages map wellto the three classes of medical informaticsapplications, and related evaluation ap-proaches, put forward by Gremy and Bonnin[30], which can be summarised as shown inFig. 1.

This convergence of concept is reassuringbut not a source of surprise, as it underscoresthe maturing of use and resultant deepeningof effect as integrated patient-based systemssupporting non-acute care delivery reach fullfunctionality, and build up richer operationaldatabases.

As a result the changing focus of study ofsystems can and should be expected tochange, as shown in Fig. 2.

Fig. 1. Information system classes, perceived functions, and evaluation approaches (after Gremy and Bonnin).


Fig. 2. Evolving focus of evaluation with system maturity.

6. Conclusion

Information systems to support non-acutehealth care delivery are strategically highlysignificant, and bring the benefits of modernhealth care management and health care in-formatics to a much wider group than thatsubset of the population which needs acutein-patient admission. At stake are major is-sues of quality of life, as determined by thequality of care delivered — both at the microlevel of the individual patient contact and atthe macro level through the overall servicedesign and delivery modalities, and not justin the short term but more significantly overthe longer period for which patients so oftenneed healthcare support.

A whole range of new issues arises, whichneeds to be addressed by dedicated researchand evaluation methods and programmes.The importance of these issues hinges on thefact that support to non-acute health carerelates to the core issue of the health and wellbeing of people in their real lives. The appli-cation of information systems to this domainprovides a quantum leap in the developmentof health care delivery, and as yet we do notknow how to represent the total picture ofclinical need, patient view, and thus overall

health care service need. We do know thatsuch systems will involve the handling oflarge volumes of data from many sources,and their use by many individuals, and thatthere will be a significant effect upon healthcare practice, and consequently upon profes-sional roles. There will also be a significanteffect upon health care organisations, theirstructure, and their operations, whilst thebenefits and disbenefits to quality and effi-ciency need to be assessed and evaluatedagainst costs and savings.

Some of the issues raised in this paper canbe addressed by applying in the non-acutedomain existing evaluation tools, others willneed new methodologies developing. Aboveall, though, evaluation will need to be ongo-ing, yet should be focused and targeted toavoid an unwieldy process and production ofoverwhelming unstructured results. The pur-pose of this paper is paint the broad picture,so that as individual aspects are selected forfurther study and application they can beseen in the holistic context, in the same waythat care itself should be seen holistically.

It is hoped that the totality of the issuescan now be seen as a key agenda for thefuture. This agenda merits careful anddetailed attention.


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