by
Jean de Kervasdoué
Chair of Health Economics, Conservatoire National des Arts et Métiers, France
Introduction
France has launched an ambitious programme of systematic computerisation of doctors’ offices, cre- ation of an Intranet network for health professionals, and distribution of “smart cards” to all those covered by national health insurance (Sesame Vitale I) and ultimately to all French people (Sesame Vitale II).
Health professionals will also receive a specific type of card. The goal of this operation is, in particular, to transmit health insurance claims to the national health insurance bureaux.
The present writer was requested, in February 1997, by the office of M. Jacques Barrot, the then Min- ister of Labour and Social Affairs, to evaluate these computerisation projects and to consult with relevant experts as necessary. In November 1997, a report entitled “The microprocessor and the stethoscope:
information and computerisation in the health sector. Is failure in this area unavoidable?” was presented to Mrs Martine Aubry, Minister of Labour and Social Affairs.
This article only gives an analysis of the reasons why medicine is no longer possible without comput- ers, networks and software.
Why the practice of medicine is no longer possible without computerisation A few brief remarks will make this clear.
The domain of medical knowledge has expanded to such a degree that a human mind can no longer retain it all.
There are now some 20 000 medical journals in the world.
A professor of medicine spends on average one day a week to remain abreast of studies in his/her field of interest as well as for his/her research. What can a generalist physician do? How much time can he/she devote to “keeping up”?
In France, there are some 7 000 prescription drugs based on some 3 500 active ingredients. A physi- cian has the right to prescribe them all. Can he/she be familiar with all of them? He/she must also be aware of some 300 medical references, some 800 biological tests, over 1 000 imagery tests, and more than 1 500 surgical interventions.
If he/she prescribes six drugs, he/she must also be aware of some 720 potential sources of interac- tion. The figure reaches 3 328 800 if ten drugs are prescribed.
In addition to the therapeutic value of each molecule, the physician should also know their price and potential effect on specific population groups (diabetics, the obese, children, the elderly, etc.).
The growth in knowledge has necessarily led to specialisation, which too often in France has meant
“balkanisation” and lack of co-ordination, especially in hospitals but also in private practice.
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As knowledge is shared, responsibility and decisions about treatment should be shared as well, as has long been the case in cancer centres; however, this is the exception rather than the rule.
Access to knowledge through continuing training, which is now mandatory, cannot be the only response to the problems evoked here. Medical schools today recognise 56 different specialisations and in fact there are at least a hundred. If each generalist spent only half a day a year to learn about trends in each of these fields, this would mean between 28 and 50 days of retraining a year. This is unthinkable.
What is needed today is to know how to gain access to knowledge. One needs to be able to sift the body of information available.
Computerised information systems may give an answer to the question of access to knowledge. One can imagine:
– Data banks (involving text and images as well as figures) which act as medicine’s memory to be used for research (clinical, pharmacological, epidemiological, etc.).
– Knowledge banks (bibliographies, sites for exchanges among professionals, etc.) which make it possible to have access at any moment to the state of the art and can help in making a medical decision (diagnosis or treatment).
– Software to help with diagnosis and prescribing which does not replace the physician but act to extend their knowledge, just as the backhoe effectively extends the arm of the construction worker.
Medicine will nonetheless remain an art, like architecture, despite its many uses of computer appli- cations.
This “art” has evolved greatly in the course of the past half-century: in their work, physicians use technical devices (medical imaging, for example) and chemical, immunological or genetic principles which are close to exact sciences. As it is used by and for human beings, there is risk in the use of repro- ducible and scientific methods. In this sense, which is not common sense, medicine would be a human science or rather a practical art which finds it legitimacy in scientific knowledge.
These data banks can be readily accessed through a network (Internet or intranet) if the user has at his/her disposal a workstation, software, passwords that give access to these networks and their different sites.
The system is flexible, adaptable in time and space, and can be customised: each physical can, when he/she wishes, consult one of the banks or receive specific information on the fields which he/she has chosen in advance. Access need not be limited to physicians alone, but can also be made available to health professionals and the public, and the latter could adapt behaviour to help prevent the onset of illness.1
Of course, these data banks have to be organised, updated continuously and meet users’ expecta- tions by allowing them to ask questions and to engage in discussions among themselves. Researchers throughout the world who use the Web have had this modern forum available to them for several years.
For the use envisaged here, it is indispensable that each source contain the following information: author, date of last update and mode of accreditation, so that it is always possible to evaluate the quality of the information consulted.
If the market can be expected to offer software diagnostic and prescription aids, it is up to the public authorities to invest so that the elements of this “knowledge network” can be created. The amounts required, while substantial, are not excessive.
The knowledge network can also make it possible to consult experts located elsewhere and to transmit images and other elements of a patient’s file to a colleague to obtain an opinion, a practice currently known as “telemedicine”.
Technically possible for more than a decade, telemedicine has essentially only been developed between university centres. This is because it raises three types of question which, being unresolved (but are they even raised?) slow its dissemination to private practice. They concern the sharing of responsi- bility between the person who enters the information and the person who interprets it, the sharing of fees
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and thus of income, and finally the sharing of patient confidentiality. When will the public authorities and the medical insurance bodies address these questions?
Finally, it is worth recalling a fact that is plain to all: electronic mail is quicker and cheaper than the mail service or fax. It is therefore an ideal medium for transmitting information about a patient: letters from hospitals to the attending physician, results of medical tests, specialist opinions, follow-up of the assignment of a private nurse, etc. However, there is the question of the confidentiality of e-mail, unless it goes through a secure site. However, we should face facts. Today, fax, telephone, audio and video doc- uments all work in a haphazard way. Faxes do not always reach the right person. The excessive rigour or modesty that affect the implementation of the health network contrasts with current practices in other areas. Coherent action is needed in all these areas.
Why financing bodies: Do health insurance bodies need computerisation?
The first reason is an old one. Computers are totally compliant, incredibly quick to carry out certain types of repetitive tasks, lacking in initiative and intolerant of ambiguity, and they have increased pro- ductivity in claims departments by relieving the staff of certain tasks with such characteristics.
Until recently, claims offices were no more than immense machines for reimbursing medical expenses, and computerisation has definitely helped them to do this work. A few simple comparisons between offices show that important productivity gains would still be obtained if all were organised along the lines of the most productive. If employment is to be maintained, it follows that a share of the person- nel would have to be oriented towards new activities.
If the health insurance system ceases being simply a blind, if rapid, reimbursement mechanism and begins to act instead as an attentive and informed payer, both the nature of the information it treats and its computer system and internal organisation will change as well.
In the name of those insured that the health insurance system is supposed to represent, it should only reimburse what is medically justified and not, as it does today, reimburse physicians’ prescriptions on no other basis than the correspondence of the prescribed drug to an agreed nomenclature.
This is not yet (at the end of the 20th century in France) a simple case of financial means, as the pub- lic considers that health spending is a priority and should be financed where necessary.
But what is a “necessary” expenditure? The notion of necessity comes from the encounter between a patient’s situation and the state of technical and medical services that make it possible, at a given point in time, to cure him/her or relieve his/her suffering. What allows us to say, from this point of view, that the French system is not optimal and that it is therefore necessary to implement risk management tools?
Among the thousands of examples that could be cited, it is worth noting the following:
– French people use 20 medicines per person per year, whereas Germans use 14 and the English 8.
– France is the only western country to prescribe in private medical practice certain types of drugs that are not or rarely prescribed in hospital, as their therapeutic value is very questionable.
– Certain hospitals treat certain diseases at costs that are three times below those in others, although it has not been shown that the quality of care justifies the difference in costs.
– Depending on where the consultation takes place, the charge for the same category of specialist may differ by a factor of three, although there is no medical justification for the difference.
– The health insurance body (CNAM-TS) has shown that the frequency of certain surgical interven- tions also varies from region to region to a degree that cannot be explained by demography or epi- demiology (operation for cataracts, appendectomy, etc.).
– More that a quarter of emergency admissions to hospital appear to be due to illnesses brought on by medical treatment and particularly by dangerous side effects of drugs. Clearly, doctors do not always prescribe appropriately. Such problems appear to lead to three times as many deaths as traffic acci- dents. (This figure is an extrapolation to French hospitalisation figures of a study done by a Harvard team on medical accidents in the state of New York in 1983. The estimate is probably low; see Wecler et al., 1993.)
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– According to the limited studies available, side effects due to hospital treatment appear to be very high (over 15%), in certain departments of certain institutions.
– The Mutualité Sociale Agricole (Agricultural Health Assurance) has also demonstrated that the neces- sary precautions to take proper care of a patient are not always taken and that, for example, there is not always a record of eye examinations in the treatment of diabetics.
There therefore appears to be both over- and under-consumption of medicine.
There is a two-pronged reason for this: the complexity of medicine, on the one hand, and the absence of control, on the other, in a system with collective financing. As the line between prescription (including prescription of a further visit) and income is obvious, this link itself justifies controlling medical appropri- ateness and number and price of the prescribed medical treatment. Whether insurance is private, as in the United States, or socialised, as in France, the basic justification for controlling medical expenses is every- where the same. This point, moreover, not only concerns France. In the United States, George Anders (1997) has written that “one can simply no longer have confidence in doctors and hospitals that lack controls”. The latest North American figures seem to indicate that there is no difference in the quality and effectiveness of care obtained by Americans who pay their doctor by the consultation and those who belong to an HMO, whose physicians are, in most cases, salaried.
The first group pays 22% more (Rothman, 1997) than second (around FRF 150 billion as an equivalent percentage of total health costs in France), but, in the second group, patients are more dissatisfied as they have been unable to choose their physician themselves.
Without entering into a discussion about whether or not one should be free to choose one’s physi- cian, it is clear that the health insurance system must, in order to build a means of control, meet a certain number of technical conditions. It must:
– Choose points of reference that it cannot produce on its own for reasons of conflict of interest.
– Collect data that allows it to compare, at least in certain cases, the treatment actually applied (price and amount) and the treatment that serves as a point of reference.
– Be able to act to modify behaviour that is deemed inappropriate, in other words be able to offer incentives and apply sanctions (lack of reimbursement, removal from the National Health list).
What is needed is to design a potentially exhaustive means of control in real time, rather than a sta- tistical control. Local health authorities need to have rapidly the tools that will allow them to play the role they are allotted by law. If there are no national points of reference, these will be locally determined and heterogeneous and will raise questions of equity.
For this process to begin, it is necessary to:
– Be able to assign a code2 to illnesses or the reasons that lead a patient to consult a physician (a classification of the type made by R. N. Braun is necessary for private medical practice).
– Be able to assign a code to the medical treatment.
– Be able to assign a code to prescriptions, including drugs.
– Transmit these data (illnesses, medical treatment, prescriptions).
– Process them and react rapidly, sometimes in real time, to ask the reasons for a prescription, con- tinuation of a hospital stay or the price of a prosthesis.
This instrument should be a secondary product of medical work and not heavy and ineffective bureaucratic red tape.
Finally, physicians should be able to contest, in ways to be defined, any decision that would appear inappropriate for their patient. The system should be “reasonable” and not bureaucratic and look to the desired goal and the underlying philosophy, and thus be founded more on a delegation of responsibility than on the production of laws that will one day necessarily become inappropriate.
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Can computerisation contribute to meeting the expectations of the French public and of health professionals with respect to the organisation of the health care system?
Citizen, patient, beneficiary
Citizens want the system that they pay for to be well managed. Through parliament, an accounting should be made to citizens every year.
The persons ensured, for their part, want the highest level of financial coverage and rapid reimburse- ment. The waiting period today is less than five days on average but is still too irregular.
Finally, patient-beneficiaries would like:
– Minimal bureaucracy.
– Flexibility.
– Access to their personal information and general information (databases).
– Reasonable use of medical data.
– To be able to benefit from knowledge about the latest treatments for his/her problem.
This argues in favour of:
– An access card for each beneficiary.
– A simple and efficient procedure if the card is lost or forgotten.
– Possibility of access to one’s medical history.3 This would be a choice on the patient’s part and not an obligation, and would therefore require the organisation of an archiving system for medical records. Many French people are ready to pay for this service, for which a medical card will never be adequate, as it will always remain partial, if indeed it ever exists. The medical record would always be accessible; it would not be lost, and the data would be trustworthy, exhaustive and ver- ifiable.
– An effective legal procedure that would make it possible to prosecute any improper use of an indi- vidual’s information.4
– The possibility of access to health education locations and to specific medical data in the case of serious illness.
The physician
For the physician, computerisation is not a goal.
We have seen that networks give access to data banks. However, it is necessary:
– That they exist.
– That they should be of easy access.
– That their contents should be in French.
– That consulting them should not be too expensive.
– That their contents are trustworthy.
As a pedagogical tool, computerisation allows for initial training, continuing training, regular atten- tion to themes of particular interest, following trends in certain areas, etc. Access to bibliography allows the physician to reassure him/herself as to the appropriate steps to follow, and it is an important safe- guard and a powerful and flexible tool: at any hour of the day or night, he/she has access to the great libraries of the world. Today, all knowledge is available, but the problem is to know what is needed and its price. Finally, computerisation can help every physician to mobilise his/her experience optimally by using self-evaluation mechanisms.
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How will the computerisation of physicians’ offices modify medical practice?
In his/her daily practice, the physician is faced with the problem of treating a great quantity of infor- mation so as to:
– Orient and then establish a diagnosis.
– Understand the patient’s illness.
– Envisage an appropriate treatment. Where necessary, ensure that this treatment does not conflict with others already being carried out. This is important for patients with chronic illnesses, which are ever more prevalent.
Clearly, this requires bringing various types of information together and finding the relations between them, something that a computer, by its very nature, can do.
For the physician, computerisation will therefore be a formidable aid to decision making. However, he/she only has two or three minutes per consultation at most to enter, consult and produce information.
In what way is this tool likely to modify medical practices?
The broad lines of this modification are described below.
Standardisation of medical practices
It is legitimate to suppose that the possibility for the physician to refer to best practice tools or to compare his/her options to reference points will encourage him/her to exercise his/her profession differ- ently. The large range of practices that exist today are likely to be narrowed, and there will soon be greater standardisation than there is today.
This is a tool that will make possible the diffusion and easy use of the tables contained in reference works and the easier this is (and business people will know how to accomplish this), the quicker the goal will be reached (contrasting medical points of view, drug incompatibility, etc.).
Better knowledge of one’s own practices/an end to isolation
Computerisation and ease of access to databases will show the physician (who is, again, often alone when a decision must be taken) that others have asked themselves the same question, have searched for the best solution and have sometimes found it.
This will tend to limit the “halo” effect that a medical profession unconsciously creates [realise] with respect to an illness or a patient.
Moreover, the use of data banks can allow the physician to examine his/her own practices, with respect to costs or effectiveness.
Relations/exchanges among medical practitioners
Exchanges of information among medical professionals will be facilitated and will therefore multiply in both volume and quality. It will no longer be necessary to give up information in order to pass it on to a colleague.
All health professionals who are involved with a patient will be able to communicate and one can expect to see better co-ordination of the care given. At the same time, the physician will have closer rela- tions with colleagues and teamwork will be greatly encouraged.
Physician/patient relations
It has been said that the presence of a computer in a physician’s office and the fact that the physician uses this tool and types instead of looking at the patient who is describing his complaints could modify the relations between physician and patient and perturb the well-known “doctor-patient relationship”.
In point of fact, it appears that patients, already accustomed to this tool in almost all areas of life, are not perturbed by this new application and even find it quite natural. It is not the tool that will make the rela-