Abstract

The Medical University in Varna, including the University Hospital, has quite a complex structure coming from the 45 departments it comprises and the 6 buildings spread over a distance of more than 5 kilometers throughout the city. The structure of the University can be expressed in four levels: departments, clinics, sectors and units (wards). Each of the departments and their corresponding clinics and minor units have a considerable number of computer facilities. There are also several computer rooms, used for the education of students and staff. The curricula for Medical Informatics for the students of medicine and for the students of health care management are developed according to the best European standards. Some attempts of implementing telemedicine has also been made. And yet, it is still not quite possible to implement the IT strategy in the University. This paper describes the aims of the IT strategy in the Medical University in Varna. It also points to some of the difficulties of the implementation of the IT strategy in the University. These difficulties have both objective and subjective origin. The objective difficulties come mainly from the transition period the country is undergoing during the last years, including the changes in the health care system, financial shortcomings etc. The main difficulties are the subjective difficulties, which are in fact closely related to the medical staff of the University. This paper also gives some ideas for how to overcome all those difficulties, the main task being to make medical staff understand the usefulness of the IT implementation.

Introduction

The term information technology (IT) is usually associated with computer-based and telecommunication-based handling of information. Technologies have two aspects: physical resources (materials and tools) and knowledge about these resources and how to manipulate them to achieve specific results.

Organizations of all sizes have come to rely on IT. It allows information to be generated and evaluated faster, causing an increase in the speed with which events occur and the pace with which managers and organizations have to respond. Health care organizations are not an exception. Information technology has played an important part in many aspects of change in health care delivery. From small private practices to the largest hospital systems, IT have enabled information to be collected, stored and manipulated for payroll and billing, diagnostics (both managerial and clinical), records management, facilities control and decision making. Because information transfer is required among all the major functional areas of the health care organizations, an integrated information system, where various departments and functional units can communicate and share information is of great importance. Several additional factors affect the increasing use of IT in the health care environment:

Expansion of the traditional health care delivery area. Health care delivery area is constantly expanding through the implementation of IT by use of video diagnostics, telemedicine, virtual reality. The development of lightweight, powerful computers and network technologies, have enabled many health care professionals to work outside the traditional premises of the hospital or the physicians’ offices. Hence health care delivery area is expanding rapidly because of the ability to access and deal with patient information no matter of its storage location.

Change at the point of delivery of health care. IT is everywhere. It is almighty. Most health care settings have workstations; bedside terminals are widely used; the use of electronic data interchange (EDI) is increasing and therefore many hospitals and other large health care settings are building powerful infrastructure for EDI. The technology expands to all health care settings including physicians’ offices, hospitals, long-term-care facilities, public health departments etc. Computers are interconnected via networks. In addition, all patient’s medical data is already organized in such a way, that the electronic patient record is no more just a dream. The use of systems and patient data is no longer restricted to hospitals and diagnostic functional laboratories. Patient data can be present at the place where the patient meets the medical specialist. In addition, the care for patients can be shared among different care providers (i.e. patients with chronic diseases or cancer). So, the modern IT allows for the simultaneous treatment of the patient by different care providers (physicians, nurses, other medical specialists) sometimes located at considerable distance from each other. This is the idea of the so called "shared care".

Alteration of the history. It is expected that with the implementation of new powerful computers and the constant improvement of the communication technologies, the information from hospitals and other health care organizations will be electronically connected in the nearest future. When more and more health care settings can share information and resources through this information highway, those outside the system will be at distinct competitive disadvantages.

The most important justification for IT investments in health care is their contribution to the quality and cost effectiveness of direct patient care. Information systems in health care must support the basic process of providing high quality, cost-effective health services. It is all about meeting the needs of the patients.

The implementation of IT in health care requires a proper information strategy. An information strategy is a strategy for both information systems and information technology. It is a formal plan for introducing, maintaining and supporting information systems and information technology in an organization. An organization’s information strategy is aimed at ensuring that its information systems and information technology are linked and support its objectives. Developing a useful and affordable information and technology strategy for any large and complex organization, particularly in health care, is exceptionally difficult.

An information strategy is above all a strategy and a plan for addressing gaps in currently available information through the implementation of new or modified information systems and information technology applications.

Consequently, the information technology strategy, derived from the health care organizations’ information strategy, normally specifies:

- Analysis of the existing information systems and technology

- Application requirements

- Standards for health care data organization, coding and classification

- Technical support

- What hardware and software will be purchased, and how

- Communications strategy, including standards for medical data/message interchange

- Staffing or training of the personnel

- IT audit and review

- Ifidentiality and security requirements, especially essential for medical data

- Management the information systems

- Costs efits implementation timetable.

The IT strategy of the Medical University of Varna

The Medical University (MU) of Varna is one of the leading medical universities in Bulgaria. It has two specialties – medicine (a 6 years masters’ program, covering both paraclinical and clinical education) and health care management (a 4 year bachelors’ and a 2 year masters’ program). The University comprises also the University Hospital. The structure of the MU, as a complex academic health care center, is very complicated, covering 45 departments, located in the main building of the University and 5 additional buildings spread over a distance of more than 5 kilometers through the city. The structure of the departments can be expressed in four levels: department – clinics – sectors – units (wards). On the other hand, all departments can be classified into several categories – paraclinical, clinical, managerial, administration.

Each of the departments in the Medical University of Varna and their corresponding clinics and minor units has a considerable amount of computer facilities. There are also several computer rooms, equipped with fairly modern computers and software (Pentium and above, networking, Internet) for the education of students and staff. The curricula for medical informatics are developed according to the best European standards in this field. There is a separate computer room, providing telemedicine facilities with the Medical University in Thessaloniki, Greece.

The IT strategy of the MU of Varna can be defined as: to use information technology to improve the quality of patient care as measured by outcomes (costs, benefits, patient satisfaction, care provider satisfaction, students education) and done in such a way that applications can be recognized and shared; supported by research and education.

Consequently, the main objectives of IT application, can be specified as follows:

To use computer technology to provide information in the most useful form when and where it is needed, including automated patient data acquisition, physician order entry, interactive patient management, integrated scheduling for patients, access to patient data in other health care settings outside the university hospital

To develop andmaintain an electronic patient record that integrates patients medical record and financial data

To improve quality and decrease the cost of patient care

To assist medical specialists with patient care decisions (intelligent decision support systems that will aid the medical specialists by alerting them of dangerous and/or potentially risky situations)

To assist performance and evaluation of patient care

To make the delivery of patient care more rewarding

To assist in delivering of the best care for patients

To provide effective computer tools to care providers

To create research data bases and opportunities for clinical and epidemiological studies

To assist in the development and the constant improvement of the measures concerning confidentiality, privacy and security of medical data

To contribute to longitudinal care

To contribute to implementation of structured data entry, use of recognized health care standards (EDIFACT), unified coding and classification systems (ICD-10), vocabularies

To provide constant education and training for the medical specialists

To provide education and training for the medical and health care management students (this means not only informatics and medical informatics); computer aided learning

To provide to the medical specialists and the students a current health care knowledge base consisting of the latest literature, available databases, expert opinions and cost and statistical data on line, including electronic libraries (MEDLINE etc.)

3. Difficulties of the implementation of IT strategy in the Medical University.

Although there is a large number of computers as well as other technical facilities in the MU, there are some difficulties in the implementation of the IT strategy. These difficulties are both objective and subjective.

3.1. Objective difficulties

The objective difficulties come mainly from the transition period the country is currently undergoing, including the changes in the health care system, financial shortcomings, inherited and legacy systems etc. However, no matter how serious these difficulties are, they can be relatively easily overcome. After all, this is mainly a question of money and organization skills and efforts. Here are some of these difficulties:

Financial shortcomings. This is a problem that is common for almost all academic health care settings not only in Bulgaria. However, in our case this is a major problem. Till now (and still) the University, including the University Hospital have been funded by the state and the funds were just covering the salaries and the health care expenses. The sad truth is that till now no one has ever tried to secure additional funds to purchase computer equipment so that to cover all computer needs of the University. As a result, some of the computers in the University (except the computers in the computer rooms) are rather old and evidently will not be changed in the near future. The current practice is that each department (or clinic) finds its own way of purchasing computer equipment. A large number of computers have been purchased with the funds, provided through different TEMPUS or other EC projects. The solution of this problem is in the proper utilization of the possibilities of the new health insurance policy, which is going to be implemented next year. Another alternative is a major computer provider that would be willing to help the health care.

Lack of network facilities. It is sad, but there isn’t a computer network in the MU. Only the computers in the computer rooms are connected in LAN’s and this is because of the Internet. This problem is one of the major problems we have. How to implement institutional information systems when there isn’t a network. Again the reason is evident – financial shortcomings. However, no matter what the financial state of the University, it is already decided that a university network is going shortly to be installed.

The nature of the organization. Modern health care settings are extremely complex. The Medical University is not an exception. It is a complex academic health care center. As it is obvious that the structure of the University cannot be changed, we will have to fit the information systems to it. There are typically quite different needs and priorities between the university component and the component that delivers health care. This arrangement causes major problems. So far, information systems are implemented in the general university structural units, i.e. non-health care oriented entity and cover areas concerning tuition, personnel, finance and administration. There are several information systems introduced in some of the clinics. However, the actual health care activities are still indirectly linked to the financial and administration systems. What has to be done is to introduce a hospital information system, managing the information needs and flows of the hospital and link it to the general university system. Having in mind that a comprehensive medical information system deals with the complete information processing and information storage of the health care setting, the right solution of this problem is to implement a distributed and heterogenous hospital information system along with the necessary clinical and ancillary information systems.

Diversity of information processing and applications. In the Medical University, including the University Hospital, there are involved many different methods of information processing and many different types of applications. In practice, some of the clinics have information systems that are tailored to their requirements. However, these systems have been developed years ago and on different platforms. The right decisions in this case will be to try to harmonize the existing systems, both from hardware and software point of view. This includes the implementation of proper communication protocols, message exchange protocols and the development of strict requirements concerning future implementation of new hardware and software standards.

Diversity of coding and classification systems. This is really a major difficulty for the implementation of the IT strategy especially in the university hospital. There exist a large number of coding and classification systems, developed or adapted to the health care environment. Some of the most widely used are: the International Classification of the Diseases, which every 10 years comes out in a new revision, the latest one being ICD-10; the International Classification of Primary Care (ICPC), which is recommended for primary care settings; the Read Codes, which are mostly used in the United Kingdom; the Systematized Nomenclature of Human and Veterinary Medicine which with its 11 axes forms a complete hierarchical classification system etc. However, most of the older applications used in the MU do not use neither of the recognized codes and classification systems. Most of these applications use some parts of ICD-9 and codes and classifications tailored to the requirements of the clinic. The right decision in this case will be to develop strict requirements for the usage of the recognized codes and classification systems. In this case, some of the older applications would have to be fixed accordingly.

Redundancy of data. In the University Hospital the practice is that data for the same patient are stored in all clinics where that patient has been accepted. Currently these data are stored on paper. However, with the implementation of the IT strategy, all these data should be computerised (most probably scanned). This means that a large amount of redundant data will occur. The solution of this problem will be in the development of special software that will organise the data in such a way that will result in minimising the redundancy of the data.

Lack of communication between the departments. This is due to the fact that the different departments are spread all over the town and the lack of networks, directly connecting the departments. For example, the therapeutic departments and the surgery departments are located at a distance of several kilometres and very often the physicians in the surgical departments are not aware what is the actual result of the initial therapeutic care for their patient. The solution of this problem is in the installation of network facilities and reliable communication facilities between the departments, located at different sites.

3.2. Subjective difficulties

The subjective difficulties are the real obstacles for the implementation of the IT strategy in the Medical University of Varna. Although they are not so many as the objective difficulties, they are closely related to the medical staff of the University. Here are some of the subjective difficulties:

The managers. The top managers of the University are quite pessimistic to the implementation of IT. The constant financial shortcomings as well as the numerous problems, concerning patients, students, salaries, other hospital expenses etc. make them forget all about the advantages of IT. So, the very idea of spending so much money for something that seems somehow unclear and promises a great risk frightens them exceedingly. Another aspect is that the organization wide implementation of IT means a thorough change in the organization including not only equipment but also personal attitude and skills. Let me cite one of Machiavelli’s most relevant statements for change managers: "There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things". So, what must be done is to persuade the managers and make them believe that the future is in IT, no matter what they think or do. Once they realize this, they will find the way to achieve it.

The medical specialists. As a whole, physicians and other health care specialists have a very diverse attitude towards computers. The general opinion is that medical specialists are still confronted with computers. Only a few medical specialists in the University (about 10%) state their positive attitude to computers, know how to use them and are really willing and eager to learn more and to participate in the actual implementation of IT. These are younger physicians (<40 years of age) and come mostly from the departments of surgery and radiology. Another part of the physicians (about 20%) consider the computer as an intelligent typewriter (as if living in the 60’s). They can use computers mainly for word-processing when writing their own reports or articles and think that their computer literacy is more than enough. They refuse to improve their computer literacy. Others (about 20%) announce with dignity that they have studied hard for six years to become physicians and not to press the keyboard keys. They firmly refuse to deal with computers. Their opinion is that a physician is a physician, let the nurse or the clerk deals with the computer. It is absurd, but there still exist individuals among the medical specialists (about 10%) who state that they are really afraid of computers. Another group of the physicians (about 10%) don’t know how to deal with computers and state that they never will. These are some of the oldest professors and associated professors who think that it is already too late for them to follow the pace of IT. The rest of the physicians (about 30%) don’t know how to use computers. However, they are willing and even insist on taking courses of computer literacy and really feel the necessity of learning how to deal with computers. The final result is that about 70% of the physicians are computer illiterate. The main reason for this absurdity lies in the curriculum of the students of medicine. Till recently informatics has not been included in the regular discipline taught to the students. They had informatics as elective discipline aimed mainly to acquiring basic computer literacy. It is only during the last year that medical informatics has been included in the regular curriculum of the students of medicine and the students of health care management. The syllabus for medical informatics is developed in conformity to the syllabus in some of the best European Universities (the Cambridge University, UK and the Erasmus University, the Netherlands). So, the problem with the computer literacy and the medical informatics education of the future health care specialists might be considered as being solved. What has to be done currently is to persuade the medical specialists in the necessity of using computers, to acquaint them with the strong and week points of the new systems and equipment to be introduced, to persuade them take part in the development of the new medical information systems. There is no sense in imposing an information system and force the medical specialists use it. Such a system will be a real failure. Additionally we are preparing courses on computer literacy and medical informatics for the medical specialist who missed that during their initial education as well as courses for constant improvement of the skills for those who wish it.

Lack of medical informatics specialists. Bulgaria is well known for her computer specialists, especially programmers. However being a skilled programmer is not sufficient for developing a medical information system (hospital, clinical, laboratory etc.). It is universally acknowledged that the development of a good medical information system is not possible without the corresponding knowledge of medical informatics. Medical informatics specialists are needed also for the maintenance and support of the medical information systems. This is already a major problem, as medical informatics is not among the academic disciplines in Bulgaria. The best way of solving this problem is to introduce medical informatics as a new academic discipline. As this is extremely difficult, for the time being we will have to encourage those young physicians and computer specialists who are willing to deal with medical informatics.
 
 

Medical University, Dept. Social Medicine and Biostatistics

55 Marin Drinov str.

9000 Varna, Bulgaria

Iskra Mirtcheva, assist.prof. medical informatics