Information technology in patient care:
an unexploited potential to increase effi ciency in the swiss healthcaresector

Current situation

When compared to other countries, Switzerland makes little use of information technology (IT) in outpatient healthcare. To make a comparison, in Norway, over 95 per cent of doctors were already keeping medical records in electronic form ten years ago, as opposed to only ten per cent of doctors who do so at present in Switzerland. According to a pan-Swiss survey, two-thirds of doctors indicate no intention of switching over to utilizing electronic medical records in the next three years. In contrast to the situation in outpatient healthcare, many hospitals manage their patient fi les electronically. However, research has highlighted that there is a requirement for stronger coordination and improvement in the hospital sector as some hospitals have departments using different IT systems and, furthermore, data exchange between hospitals is not assured.
In overall terms, the medical sector invests substantially less in IT than other service sectors. For example, in the banking and insurance industry, fi ve times more was invested in IT per employee than in the medical sector over the last ten years.

What could IT achieve?

In the area of patient care, very large quantities of data are acquired and collected in highly specific formats. Such data include information on medical history, findings from physical examinations, results from laboratory investigations, information on prescribed medicines and follow-up clinical observations of patients with chronic illnesses.
With the support of IT, such data can be recorded and saved utilizing a structured approach; it can, therefore, be made easily accessible and presented in a visual format as required. The subsequent benefi ts as opposed to keeping medical records in handwritten form are:
entries are easier to read
laboratory data are entered and saved automatically
data are aggregated
entered data can be searched
generation of reports in various formats is made easier data can be presented in a visual format, providing a rapid overview, for example, of the development of various progression parameters for those patients, in particular, with chronic illnesses.
Further benefits include the telemedical acquisition of relevant data for patients with chronic illnesses. Blood pressure for hypertonia patients, lung function for asthma patients and blood sugar readings for diabetics can now be transferred electronically from the patient‘s home computer to the doctor‘s computer. When necessary, doctors have the possibility to issue instructions to change treatment via the same route. In the case of asthma patients, for example, this means that deteriorations can be detected at an early stage so that suitable medications can be prescribed or adopted; this provides a direct means to reduce the numbers of emergencies and hospitalizations.
Modern IT systems are not limited to recording data; computers can also assist doctors with making decisions. Various systems are already available to support doctors with establishing diagnoses or to draw their attention to possible undesirable interactions between medications. So, for patients with restricted renal function, certain systems provide recommendations on the dosage of medications.
Doctors also have the advantage of using a computer to gain rapid access to guidelines based on the latest scientific knowledge and the recommendation of experts. Furthermore, as computers can be programmed to search the Internet automatically for relevant recommendations and up-to-date knowledge, and also display the information on the screen during a consultation, this enables doctors to be informed without the need for lengthy searches.
Various surveys and studies have indicated that the doctor‘s level of efficiency increases as a consequence of using IT. The results indicate that repeated examinations of patients become superfluous and error rates are reduced, especially when prescribing medications. Moreover, the data can also be used to check and document the quality of treatment, so with one mouse-click, a doctor can check which of his diabetic patients have been prescribed the recommended annual eye examination. The data collected by doctors can additionally be used for clinical research.

What are the reasons for low IT usage?

In seeking explanations for the scant use of computers to document patient fi les, a separation must be made between hospitals and private medical practice. Although some explanations apply to both parties, there are also specific reasons which are pertinent to one or other party. The general reasons for the relatively low utilization of IT are highlighted as follows:
concerns regarding data security
apprehensions that doctor-patient communication could be disrupted by computers
reservations about hardware and software not matching the requirements
the question of cost, i.e. investment costs and initial expenditure of labor
deficiency in IT standards with long-term stability
low level of readiness to gear the user‘s own working habits to new technical possibilities which are still undergoing development and therefore entail a risk of “learning in vain”
fear of monitoring and duty concerning accountability since IT creates transparency.
These concerns are worthy of a brief explanation.
Patient files not only contain facts and findings about individual patients, but also the personal notes and comments made by doctors. It has become repeatedly apparent that a 100% guarantee regarding data security does not exist and breaches in security networks occur time and again. In order to alleviate this concern, the highest security requirements must be implemented for IT systems in the medical sector. Otherwise neither patients nor doctors will trust the systems and, as a result, will obstruct any change to utilizing electronic medical records. In addition, there are also major concerns that health insurers or pharmaceutical companies could access this data and exploit it for their own purposes.
One frequently heard argument against using computers in the doctor’s practice is the fear that doctor-patient communication could be disrupted by working with computers. Many doctors believe that using a computer to enter data or search for information during a consultation is disruptive. However, when examining the results of the various studies, the evidence indicates that patients do not have a problem with this and are not generally concerned if a doctor uses a computer during a consultation.
Programs for the electronic management of medical records are now offered on the market by several software companies. Nevertheless, according to various doctors, manufacturers of this type of software pay insufficient attention to doctors‘ needs and requirements. In some cases, the software which is currently available is deemed to be complicated and difficult to use. Therefore, operating such software should be as simple and intuitive as possible and must support the doctor‘s working procedure rather than impeding it. There is also the key requirement that the hardware and software must be stable. Computer system crashes are very unpleasant in a practice as access to data and documentation is no longer possible. Hospitals also experience these problems, but have the added benefit of inhouse IT support personnel who are mostly able to rectify such difficulties within a very short time scale. In comparison, individual or small group practices cannot afford such an overhead.
Converting a practice from handwritten medical records to an electronic storage system for its data costs time and money. Even in a one-person practice, more than a single computer is required, so the hardware costs per practice amount to at least CHF 30,000 and then there are the annual maintenance costs to consider. Together with the software investment and maintenance costs, a price tag in the region of CHF 120,000 must be expected for transferring data from handwritten to electronic medical records.
So far, virtually no incentives have been implemented to support such an efficient changeover in the utilization of IT in the Swiss healthcare sector. As small entrepreneurs, doctors argue that even though they are paying for such investments, the primary beneficiaries are in fact the patients and health insurers.
Another serious reason for the low uptake of computers in doctors‘ practices is a lack of standards applied to hardware and software alike, for example, standards for interoperability, performance profiles, software interfaces and mobile diagnostic and communication devices.
The absence of these standards makes it difficult or impossible to transfer data from one system to another, for example, from a hospital to a private ambulatory care practice. In addition, and with some justifi cation, doctors are afraid that if a new system is launched on the market, which after a few years would be incompatible with the old system, then they would once again need to learn how to operate a new system. In terms of the computer industry, the absence of these minimum standards means that investments in these products are prevented or delayed as they are a fundamental prerequisite for IT development.
When examining working procedures, those applied in hospitals are more complex than in individual or group practices. Furthermore, when taking into account the use of resources, players from the various disciplines and professions would need to work together effectively and efficiently to benefit their patients. Effective IT usage in hospitals is critically dependent on reliable and well-structured processes, which enable activities that can only be partially planned to be executed as smoothly as possible; these must also be in line with patients‘ needs.
Reliable and expediently designed processes and work routines develop from combined management and structuring efforts and it appears that most Swiss hospitals need to catch up in these areas. It is also evident that there is a problematic asymmetry between a high level of specialist medical and nursing expertise and a low level of “system competency” vis-à-vis interdepartmental organization and management. Therefore, the facts indicate that the key benefits of modern IT can only be exploited if the organizational requirements are clarified in advance. Currently, Switzerland‘s hospitals offer few incentives or abilities in this area.
With the aid of IT, it is relatively simple to generate data on the efficiency of processes, prescribing behavior and the quality of medical care. Thus, such data provide transparency regarding the services provided. Most doctors welcome the use of this data for internal discussions on organizing and improving processes and quality. However, total transparency of all these data in respect of insurers, media and hence the general public is perceived to be neither good nor desirable as such. Overall, a development of this nature is evaluated very critically by many doctors and their concerns are not entirely unjustified.

What should be done?

The first step would be to define a minimum set of standards which will enable the alignment of different service providers. In a first instance, standards create a platform of security for both doctors and the industry. Standards for recording and billing services already exist and others could be applied from abroad to some extent. The main objective is to define which data should be recorded, how the data are to be coded and in what manner the information exchange of data, findings and images should be organized. In terms of designating responsibility for the definition of these standards, this does not belong to government. Its task is to create a framework of conditions to enable the standards to be developed and to declare that these standards are binding in Switzerland once they have been established.
The computer industry’s role would be to cooperate closely with the clients to develop user-friendly software that can be adapted to the individual requirements of doctors.
Real incentives need to be implemented which highlight that a transfer to utilizing electronic medical records would increase efficiency in the Swiss healthcare sector. It is our belief that these incentives can be primarily created by the insurers.
An academic hospital, a university hospital or an alliance of hospitals and a group of doctors established in practice (for example) should adopt a leadership role and initiate a pilot project. As part of this project, the managing organization would coordinate the stipulation of standards and the development of user-friendly software and then evaluate the various incentives for introducing electronic medical records. This in turn would create incentives for other companies to prepare doctors for this changeover, train them and offer a customer-friendly service when technical problems occur.