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Strengths and weaknesses of the ICTs in the clinical and medical care evaluation.

Author: Carlos Campillo Artero
Sub-director of medical care evaluation, Health Service in Balearic Islands, Palma de Mallorca, Balearics, Spain.

The Information and Communication Technologies (ICT) are at present key tools for the evaluation of the clinical effectiveness and of the medical care in the health centres. Very often, the evaluation is a missing link in the step sequence of a process that may be either a research project or a model aimed at knowing and managing in an efficient way the medical care work of a hospital or a primary healthcare center. We do a lot of things but we evaluate very few and most of these evaluations have deficiencies that cast doubt on their validity. The causes are very varied.

ICTs have developed at a very fast pace in the last few year. However, for their application to be successful at a large scale in the healthcare centers, a number of obstacles must be overcome. The clinicians´knowledge about evaluation methods and ICTs is poor and their level of communication with the informatics specialists is very low; they do not receive the required support and informatic advice and sometimes, they lack some of the essential resources to make rigorous evaluations.  Fortunately, 80-90% of ICT-linked deficiencies in clinical and medical care evaluation are known, and above all, preventable.
This lecture will describe those causes that are directly or indirectly attributable to problems derived from the implementation of ICT in the health care field and their solutions. The adopted perspective will be centered on the communication between clinicians and informatics specialists and based on several years of experience in the use of the ICT for clinical and medical care evaluation.

None of the ICTs is an isolated element but one of the many components of a system that may be either a research/ evaluation project or a clinical, medical care or managerial information system.  Its raison d´ etre is determined by the questions that are intended to be answered with an evaluation project and by the objectives that are to be met with the said project.  In the clinical evaluation, the structure, the contents and the functionalities of the ICT applications must be consistent with the objectives of the project and should provide enough data to meet the information requirements, to display the necessary functions to process them and offer such information in a reliable, easily intelligible, timely and lasting way. The low usefulness and inefficient use of an ICT is sometimes due to the fact that its structure, its contents or its functions have not been sufficiently anticipated in the design phase; because they are not completely consistent or they do not accurately respond to all the information needs demanded by the project; or because the underlying questions and the objectives of this project have been confuse from the very beginning.

Three very common elements in the sphere of ICT implementation in the healthcare services are ignorance of the exact information that is required, non gathering of all the information that one wants to obtain and, except for very few cases, the workload involved in introducing and keeping the informatics applications and evaluating the data collected by using them fall on the shoulders of the medical care staff, which performs this activity free and as an additional task to its daily work.

Before implementing an ICT for the clinical and medical care evaluation, a feasibility study should be made and this will firstly include the estimation of the necessary information technology and human resources. Regarding informatic resources, special attention should be paid to the existing informatic platform, to the chosen ICTs compatibility with the rest of the operating and information systems already in place in the healthcare center, to the approved equivalence of the system contents (fields, variables, indicators, classifications, form creation), to consistency and compatibility between systems and data gathering, mechanization, debugging, extraction and migration, to the setting of data validation regulations,  the data flow management as well as to access profiles of the ICT application users. Any of these applications should be aimed at the integration of the medical care information systems.

When estimating the human resources for ICT incorporation into an evaluation project, it is of vital importance to assess the need of full-time or part-time database managers and of system integration specialists. The medical care staff can no longer assimilate the workload involved in the functions of these two specialized categories.  The more the significance of the project and the quantity of required data, the more this need becomes obvious. If the above-mentioned is ignored, then the project permanence will be at risk.

Likewise, the feasibility study must foresee the detailed design of relational databases (dice models) and the different types of data that are needed in the evaluation: clinical, health care, managerial and/or epidemiological. This demands, among other obligations, that the project design be unequivocal, the relational databases mirror it and the information flow management faithfully reproduces the evaluated medical care processes. Regardless of these profiles, the collected information must be exact, accurate, careful, easily accessible and safe.  (It must be remembered that this last attribute makes the observance of the present personal data protection laws compulsory).

The advantages and services of the ICTs sometimes overshadow one principle, that is, the information reliability largely depends on the data quality in their origin. Forgetting this often leads to a paradoxical situation in which we handle huge data volumes very fast, but the ICTs applications reinforce the original data deficiencies.  Nowadays, datawarehouse allows systematically building and changing result tables and control panels in a very easy way, thanks to the simple handling and versatility that their free operation modules offer; however, omitting that aforementioned principle explains why we frequently keep working with a far from negligible amount of unreliable information.

Every ICT application should undergo a pilot test with prototypes before coming into operation.  Various doubts that we know might appear during the mounting, prototype testing and operation phases must become consultations and be part of the said feasibility study. To this end, it is useful to ask for the opinions from the most experienced clinicians and from the information technology companies. In this last case, we must be very careful with those ICTs coming from other sectors, whose implementation in the health care sector is on the initial phases.

Eighty percent of the efforts in a project should be focused on the phases of evaluation project design, feasibility study of the necessary ICTs to carry it out and starting, whereas the remaining 20% should be spent in its full implementation. Unfortunately, these figures continued to be reversed in many settings.

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