- Smart Healthcare, Wednesday 2 January 2008 15.12 GMT
When Dr Orna Blondheim talks about Israel's past record in managing healthcare information the experiences sound very familiar. Until this decade it was plagued by missing clinical information, time wasted in searching for documents and test results, and clinicians making decisions without a full knowledge of the patient's history.
It didn't help that the country has a large immigrant population, so that many had medical records residing as far away as the US, and that it is an insurance based service, with patients going to one of four health maintenance organisations (HMOs) responsible for running hospitals and clinics. There is a large variety of clinical systems and hardware platforms, isolated information repositories and a lack of integration all round.
Blondheim, chief executive officer of the Emek Medical Center, makes it clear that this created a lot of difficulties as soon as a patient had to go to different sources for care.
'Go bring'
"Under the previous circumstances in Israel patients or their families were often sent to 'go bring' results, letters, etc, and physicians often had to take medical decisions based on only partial information," she says. "It wasted time, and affected the quality of those decisions.
"In addition, hospitals, and their various departments, each had different systems and were not communicating with each other. We realised that we had to do something to address this situation."
Clalit Health Services, the parent of Emek Medical Center, took the lead. It is the largest HMO in Israel, accounting for 57% of the market with 5,500 physicians and 9,000 nurses looking after 3.8m patients.
In the late 1990s it began to work on its Ofek network for sharing medical information. The aim was to provide real time integrated medical information, available in less than 10 seconds, at the point of care, with the ability to drill down into the data. It was based on a decentralised structure, with security and privacy safeguards and the ability to scale up for wider use.
The system's key to success is its ability to create a virtual patient record - essentially an integrated electronic health record comprised of information from disparate sources that can be made available anywhere in the network.
The Ofek system began life under a pilot project at Soroka Hospital in the south of the country in 1999. The technology was provided by a company named dbMotion, which was then a start up but has since become larger.
It was then steadily developed over the next few years. Blondheim says the thrust of the work was to provide information to clinicians in a smart manner, so it would be quickly available wherever it was needed.
"For example, if the patient had results from different laboratories they could all be collected in one place; the same for diagnoses."
It works on the principle of a minimum data set being made available on the first screen. This includes the most recently added details in a number of areas, such as medication, hospital procedures, laboratory results and diagnoses. The clinician can then drill down into the earlier details for any section.
Blondheim says that when a user enters the system they enter the patient's name, which is then sent out to all of Clalit's hospitals and clinics, and that it receives a reply from the relevant one within seconds. The information appears on the screen very quickly - a big asset considering the usual impatience of physicians for information.
None of the previous information can be changed, but clinicians can add further details to the patient history in the individual clinical systems, which will appear on the front screen of the integrated Ofek record the next time a request is made.
Arrangements are in place to protect patient confidentiality. Only the patient's primary clinician, the medical director for their district, and those who are registered for access against the patient's name, are allowed to see the record. Any other users, such as consultants, need the patient to provide access through the smart card that Clalit provides to all of its customers. The only information on this card is to confirm that the patient is who they say they are and is covered by Clalit.
A clinician who has to see all the patients in a hospital may have special permission to access all of their records, but there are limitations on the rights of nurses and assistants, who are excluded from pathology and genetics information.
"But the system itself is very flexible," Blondheim says. "Any organisation can choose who it allows for access."
She says another big advantage is that it is very intuitive, especially for anyone who is comfortable using the internet. Its use has spread without any formal training programme, with most users picking it up with a minimum of instruction.
"It's also very important to realise that, in order to integrate the medical information from different medical systems, you do not have to change the computer systems they are working with. This is very hard and it often puts people off.
"The beautiful thing about this solution is that it enables people to integrate with their own systems."
This is an important point, when even the coding, clinical language and data structures differ, and some hospitals work with complete health information systems while others rely on departmental systems.
As the solution has been rolled out around Clalit's treatment centres it has identified a number of benefits. On the clinical front it supports faster, more accurate diagnoses, reduces duplicate testing and procedures, increases patient safety and helps to shorten the care cycle.
Administratively, it eases the management and follow-up of the care process, ensures better communication between care providers, provides more time for the encounter between patient and clinician, with less time spent chasing paper, and provides for a dramatic improvement in the dialogue between the care provider and the patient. It also lays the ground for more proactive and preventative care, enables efficient clinical work flows, reduces costs for the healthcare system and increases patient satisfaction.
The Ofek system for integrated electronic health records has proved successful to the point where it is now covering all of the company's 14 hospitals and thousands of clinics, plus two government run medical centres - Sheba and Ramban, which asked to join the system.
Proven concept
"It proved the concept that it could be extended to other hospitals," Blondheim says. "Once we proved we could connect to the two big government hospitals we covered a lot of the technology and ethical issues. It can all be solved.
"Theoretically it could be the basis of a national healthcare record, but there are issues that have to be overcome. It's a political issue, in that the other HMOs are competitors and this raises obstacles. It's also a financial issue, in that somebody has to put up the money.
"It's in the air all the time, and I hope that people will demand that they shouldn't have to come to the point of care without all their information available there."
She does not dismiss the idea of overseas access to the virtual patient record but qualifies it heavily by saying it's "for the future".
More immediate ambitions include providing patient access to the records from home and building a dialogue on the patients' involvement in their medical records. But more pressing is to make the system more responsive to the needs of physicians.
Surveys have shown that those working in different specialties would like different information in the minimum data set, while keeping all the information in the background, and Clalit is looking to respond to the demand.
"They are always in a hurry and looking at those first two or three screens is very important," Blondheim says.
