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10 December 2001
A serious problem exists in the use of information technology in caring for patients by primary care practitioners in the U.S. There is currently no identifiable National Strategy for the Use of Information Technology and Management in Primary Health Care addressing this problem and there is a critical need to establish and fund a centralized, coordinating group to provide strategic leadership in its development.
The Primary Care Informatics Working Group of the American Medical Informatics Association has, through its national meetings and subgroups, been developing a Strategic Plan for Primary Care Informatics. This Plan is divided into four sections: Clinical, Education, Research and Infrastructure, and the Working Group has acknowledged that significant progress is dependent upon a funded infrastructure that effectively brings together relevant stakeholders. This paper is the product of the Primary Care Informatics Working Group, endorsed November 2000, and is a work in progress.
The future of US health care depends on the development of high quality, cost effective primary health care. This will require widespread utilization of usable, effective ambulatory primary care information systems, including an electronic medical record and systems delivering “just in time” clinical information at the time and place of care.
It is generally agreed (Starfield **), that improvements in primary care services will significantly improve the overall quality of US health care, improve access, and significantly decrease costs. For these and other reasons addressed below, there is widespread support for promoting and enhancing primary care practice. This support has come from: the public; organized medicine; medical educators; managed care organizations, insurers, and other payers; government agencies; and individual practitioners.
The United States is a world leader in medical informatics. The development and use of information technology in Primary Care in the U.S., however, has lagged far behind the growth of Primary Care Informatics in many other countries and the advances of U. S. medical informatics in general. This is evidenced by the small percentage of U. S. primary care providers who use electronic medical records (Wilson and Purves**), the absence of primary care medical informatics fellowships (NLM bulletin**) the quantity and quality of primary care informatics research (**) and the lack of funding for primary care informatics training and research.
A paucity of divisions of informatics in primary care educational settings and the absence of Fellowships result in only a few primary care practitioners trained in informatics. For those who are trained, the availability of funded positions is limited. The lack of a concerted national effort or spokesperson minimizes the attention paid to informatics within primary care. The absence of national standards or specifications for primary care systems creates barriers to progress toward technological solutions. Each of these impediments will be favorably influenced by an appropriate infrastructure.
It is the position of the Primary Care Informatics Working Group that the United States Federal Government, and other public and private agencies, can and should advance primary care informatics by supporting and funding a nationwide primary care infrastructure, and by providing incentives for the participation of other entities including practitioners, academic departments, training programs, vendors, and existing medical informatics centers.
The following sections of this paper will discuss the identified causes, and discuss how funding of an infrastructure would address them.
No Effective Voice: There has been no centralized, coordinating group in the U.S. addressing the use of Information Technology in Primary Health Care. This is not the case in other countries such as the U.K. and Australia that have been very successful in developing and implementing national strategies and initiatives. The Primary Care Informatics Working Group of the American Medical Informatics Association has, over the past two years, brought together senior representatives from the major primary care societies in the United States that have met, agreed to explore the concept of a central coordinating group and endorsed the following Vision Statement:
“In order to provide all U.S. citizens with high quality, affordable health care, every primary care provider must be given the opportunity of using an electronic ambulatory information system, including a fully functional elecrtronic medical record and with ability to access needed clinical information at the time and place of care.”
This group has been named the National Alliance for Primary Care Informatics.
Tertiary Care Concentration: Historically, advances in health care have been developed and advanced in academic health centers. As a result of the Flexner Report in the 1900′s, medical schools focused more and more on tertiary care. This led to a decrease in the production of primary care physicians, maldistribution of providers, problems of access, and fragmentation of care, that continued until the Millis and Willard Reports in the 1960′s that laid the foundation for the establishment of family practice departments in academic medical schools and a resurgence of primary care.
Medical informatics has also developed primarily in tertiary academic centers. Funded from sources including the National Library of Medicine and the Agency for Health Care Policy and Research, premier schools such as Duke, Harvard, and Stanford have become centers of excellence. The result is strong, excellent divisions of medical informatics in tertiary care settings. Much of the research and training in these settings is inappropriate for primary care and is not relevant to care of the general public. At the same time, there has been little or no development of informatics training or research in the primary care setting. A clear factor in this “informatics gap”is the lack of funding for divisions of primary care medical informatics,
fellowships in primary care medical informatics, research in primary care medical informatics, and other projects.
The natural history of new technology and/or knowledge is to progress over time from the embracing by a few academicians to increasing acceptance and growth within prestigious centers to eventual widespread dissemination among institutions and practitioners. For Primary care to play a key role in addressing some of the serious problems facing health care today, a prolonged “lag time” in the development and implementation of primary care electronic information systems is simply not acceptable, and it is imperative to minimize delays and expedite the dissemination process.
Financial Focus: In earlier days, both clinical and administrative records in physician’s offices were kept manually. In time, the availability of computers and telecommunications led to increasing automation of the business side of health care. Non-clinical personnel concerned with financial matters took responsibility and control of computerization of the business side of medicine, and the resources and the authority to make decisions about automated systems has been vested in those with a predominately economic interest in health care, such as administrators of large facilities, HMO’S, and third party payers. The use of computers for blling, collections, and administrative purposes led to two misconceptions: 1) Computers are primarily useful for business, not clinical, purposes, and 2) Computers are therefore appropriate tools for administrative functions, but not for clinical records or direct patient care.
As a result, the development of clinically relevant information tools for nonacademic ambulatory care has been slow. Much money and effort have been spent developing information systems that focus on the financial and business aspects of practice without capturing significant clinical data. In most cases this focus has been short sighted. Health care providers have found the systems unhelpful in direct patient care, and, lacked the clinical components necessary to provide the types of information needed to make important administrative decisions required in today’s increasingly complex and competitive environment.
Limited Training Opportunities: At present, there are only a few identified divisions or centers for primary care medical informatics in the U.S.Without established academic presence and centers of excellence, and without a cadre of trained informaticians, Primary Care informatics has not had the national voice or influence to effectively compete for funds. Up until now, National Primary Care professional organizations have not found medical informatics to be a high priority and their usual effectiveness has not been available to this initiative. With medical schools and academic medical centers facing increasing financial hardship, funding for the establishment of divisions of medical informatics is not available from current resources.
Research: In contrast to traditional academic research efforts, many of the important questions in primary care informatics are in the area of applied research, and most medical informatics studies reported in the current literature have little application to primary care. There is a great need for research addressing the issues of ambulatory primary care. To be meaningful, these studies must be conducted by primary care practitioner/researchers, carried out in real primary care settings, using valid, standardized research methods, especially usability and performance studies.
Need For Standards: There are no U.S. standards for structuring or coding primary care medical records. No specifications exist for the optimal hardware, software, or user interfaces suited to the primary care setting. This lack of standards hinders the development of primary care systems and constrains the deployment of those systems that have been developed.
Lack of Infrastructure: All of the above arise from the absence of a nationwide infrastructure to support primary care medical informatics.
Centralized Coordinating Group for Primary Care Informatics
The first step must be the establishment of a centralized coordinating group, made up of key stakeholders, serving as “One Voice” for Primary Care Informatics that will provide strategic leadership, guidance, and support in the development and implementation of a dynamic strategy for the use of information technology in U.S. Primary Health Care. The National Alliance for Primary Care Informatics, developed through the American Medical Informatics Association’s Primary Care Informatics Working Group, demonstrates the commitment of both the information technology and primary care societies to this concept.
In the present financial climate of health care, with its strong emphasis on cost-containment, return on investment, and near-term profits, it is unlikely that adequate funding will be available from health care institutions. It is imperative that the federal government makes funds available to establish and operate this infrastructure.
A sufficient budget, estimated at $20,000,000, is needed to support the establishment and operation of a central coordinating group that will collect data, convene key working groups, undertake specific preojects, prepare reports and support the partnership of the key stakeholders.
Strong primary health care is essential to the future of overall health care in the US. This will require access to and widespread use of electronic information tools in primary ambulatory care, especially the use of electronic patient clinical records and the delivery of “just in time” clinical information at the time and point of care. The use of such information tools in U.S. primary care now lags far behind their use in other developed countries. It is doubtful that U.S. primary care medical informatics will close this “gap” unless specific emphasis and resources are directed to this goal.
A nationwide primary care informatics centralized coordinating group, funded by the federal government and/or private foundations, is a practical and achievable means toward this end.
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