International Journal of Health Care Quality ...

International Journal of Health Care Quality Assurance Emerald Article: Coordinated computerized systems aimed at management, control, and quality assurance of medical processes and informatics Yossy Machluf, Avinoam Pirogovsky, Elio Palma, Avi Yona, Amir Navon, Tamar Shohat, Amir Yitzak, Orna Tal, Nachman Ash, Michael Nachman, Yoram Chaiter

Article information: To cite this document: Yossy Machluf, Avinoam Pirogovsky, Elio Palma, Avi Yona, Amir Navon, Tamar Shohat, Amir Yitzak, Orna Tal, Nachman Ash, Michael Nachman, Yoram Chaiter, (2012),"Coordinated computerized systems aimed at management, control, and quality assurance of medical processes and informatics", International Journal of Health Care Quality Assurance, Vol. 25 Iss: 8 pp. 663 681 Permanent link to this document: http://dx.doi.org/10.1108/09526861211270622 Downloaded on: 04-11-2012 References: This document contains references to 27 other documents To copy this document: [email protected]

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Coordinated computerized systems aimed at management, control, and quality assurance of medical processes and informatics Yossy Machluf, Avinoam Pirogovsky, Elio Palma, Avi Yona, Amir Navon, Tamar Shohat, Amir Yitzak, Orna Tal, Nachman Ash, Michael Nachman and Yoram Chaiter

Coordinated computerized systems 663 Received 20 December 2010 Revised 19 February 2011 Accepted 10 March 2011

(Information about the authors can be found at the end of this article.) Abstract Purpose – As part of the routine work of the medical committees in the Israel Defense Forces, a unique nationwide computerized control system is being implemented to assess and manage medical processes. The purpose of this paper is to report on that implementation. Design/methodology/approach – The computerized system consists of three main components: a specific status indicating the processes in each file, an appointment system, and an internal computerized system that uses a magnetic card for the regulation of the local waiting lists. Findings – The combined computerized system improves the control and management of the medical processes and informatics from the point-of-view of both the patients and system operators. Different parameters of quality control regarding the medical and administrative processes are assessed (such as efficiency), and solutions are sought. Computerized system-based design and re-allocation of human and medical resources were implemented according to the capacities and limitations of the medical system. A reduction in the daily number of invited recruits improved the quality of the medical encounters. Specific combined status codes were introduced for the efficient planning of the medical encounters. Implementation and automation of medical regulations and procedures within the computerized system make the latter play a key role and serve as a control tool during the decision-making process. Originality/value – The computerized system allows efficient follow-up and management of medical processes and informatics, led to a better utilization of human and medical resources, and becomes a component of the decision making by the system operators and the administrative staff. Such a system could be used with success in clinics, hospitals, and other medical facilities. Keywords Quality control, Recruitment centers, Computerized follow-up, Management, Medical profiling, Medical management, Medical informatics Paper type Research paper

Introduction Adolescents in Israel are obliged by law to enter military service. The National Military Service Act requires all 17-year-old Israelis to present themselves at local recruitment centers. The medical process at the recruitment centers utilizes information from the family physician and is based on a medical interview and physical examination, which are undertaken by a medical committee consisting of physicians. It also includes the

International Journal of Health Care Quality Assurance Vol. 25 No. 8, 2012 pp. 663-681 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/09526861211270622

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measurement and recording of blood pressure, pulse, height, and weight; the checking of visual acuity and color vision; and the performance of a urinalysis by technician soldiers. The committee chairman has to decide whether additional tests, such as a specialist consultation, laboratory tests, imaging, or other measures, are required or if the information is sufficient to implement suitable functional classification codes (FCC) and to assign the recruit’s medical profile (Chaiter et al., 2010). The medical profile reflects the recent medical health status of the recruit and is used by the Personal Directorate to assign the recruit to a military occupation that fits his health status. Although, at a first glance, it appears that the medical process of young adolescents at recruitment centers is mainly diagnostic by its nature, it shares many common characteristics with the typical diagnostic-therapeutic loop of curative medicine. Briefly, complex and dynamic medical processes proceed in parallel; information is generated and collected from different sources; and decisions are made by the medical and administrative staff in order to precisely grade the various medical conditions according to severity and the possible effect on functional performance and to determine the medical profile of the recruit. For instance, each year, about 100,000 new recruits start the medical processes, and more than 400,000 medical encounters are performed at the recruitment centers (2, and our unpublished data). About half of recruits have two or more encounters, most with specialists or in hospitals, in order to determine their medical profile (,13 percent of recruits have $4 encounters) (IDF, 2001-2008; and our unpublished data). Most recruits ($75 percent) have at least one FCC, while many (,20 percent) have three or more co-existent medical conditions, in spite of their age (IDF, Israel, 2001-2008). Furthermore, it is not just the prevalence of medical conditions but also their severity and morbidity. For instance, ,8 percent of recruit suffer from chronic asthma, while ,1.5 percent and ,10 percent suffer from various cardiac anomalies and mental disorders, respectively (Chaiter et al., 2011). About 10 percent of the recruits have FCCs that are modified, added, or cancelled after the completion of the medical process due to the discovery of new conditions, accidents, operations, or a change in the severity of the medical conditions from the first check-up until the draft of the recruit into the army for service (IDF, 2001-2008; and our unpublished data). This may lead to the determination of a new medical profile. It is noteworthy that the thorough examination at a recruitment center might reveal a new, previously unknown, medical problem that warrants further follow-up or treatments at a primary clinic by the primary care physician. In these cases, the diagnostic-treatment loops need to be closed. In order to control and improve the quality and efficiency of the medical processes leading to the medical profiling, a unique computerized system for the follow-up and management of medical processes and information is used at the recruitment centers (Chaiter et al., 2008). Quality control and assurance is employed with increased frequency in medical processes with the aim of improving the quality of medical services (Landon et al., 2003; Mandel et al., 2003). A unique quality control system was set up more than ten years ago (Chaiter et al., 2008; The State Comptroller and Ombudsman Office, 2002). The control system operates in two main ways: (1) by directly assessing the medical committees’ clinical work; and (2) by data mining and processing from the computerized medical database. The findings and achievements of the control system, at different medical levels (e.g. physical conditions, personnel staff, administrative and technical aspects of the

medical process, as well as data analysis) were described previously (Chaiter et al., 2008, 2010, 2011; IDF, 2001-2008). The computerized medical database contains information about the processes involved in medical profiling, such as referrals to specialists, tests, imaging, medical documentation, past and planned visits of recruits to recruitment centers or other medical facilities, etc. This system has now been operative on a nationwide level for more than 20 years, during which the second component of the computerized appointments was introduced in 1993 and the third component was introduced during 1996 and was made functional at all recruitment centers in 1999. Each component system is aimed at answering a particular need, and although each is independent, they are all compatible with one another, and provide the user with a comprehensive view of the medical process and information. There are numerous computerized systems for the follow-up of medical processes that have been described in literature; they include modern wireless mobile technology, Radio Frequency Identification (RFID) tools, and multimedia streaming (Yu et al., 2008), the permanent patient record system and the resource and appointment scheduling application of Baystate Medical Center in Springfield, Massachusetts (Megliola, 1991), The University of Michigan Medical Center’s computerized clinic scheduling system (Coffey et al., 1991), automated systems that ease the load for patient schedulers (Jossi, 2004), a computerized physician order entry system (CPOE) (Callen et al., 2006; Niazkhani, 2008),. However, most of these systems have been used locally at one or a few medical centers and have not been used on a nationwide basis. Some systems, such as the CPOE, employ a process of electronic entry of the medical practitioner’s instructions for the treatment of patients under his or her care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or imaging) that are responsible for fulfilling the order. The ordering process includes a display of the patient’s medical history, current results, and evidence-based clinical guidelines to support treatment decisions. In emergency departments (ED), in which efficient information management and communication is essential (Taylor, 2004), computerized whiteboard systems have so far been used mainly for tracking purposes (Boger, 2003; Horak, 2000) rather than for broader analytical goals (Gillam et al., 2004). Yet implementation of monitoring tools, with narrow applications (late-arriving abnormal laboratory results), in computerized reminder system has been reported (Cai et al., 2002). Most of the systems described above focus on the information of the single patient with access to the patient’s medical records and thus narrowly apply to certain qualified personnel. These are also mainly non-integrative local systems that are used in a certain ward, in ER, or at a limited group of medical centers. Most are very complicated, require a long time for assimilation, and necessitate large computer resources. However, the promise and importance of meaningful use of electronic health records was already recognized by federal authorities (Blumenthal and Tavenner, 2010). In Israel, computerized patient record-based integrated system solutions (named Clicks) now serve over 90 percent of the primary and secondary medical care professionals throughout the country, covering over 90 percent of the population across the medical fields with all healthcare providers at primary clinics. Online verification of members’ rights, embedded business rules, and medical protocols, as well as Preventive Medical Assistance (PMA) rules are incorporated into the system (Zuker, 2003). Nevertheless, the data from Clicks is usually used to evaluate the use of health services by the patients (Kokia et al., 2006). From the medical and administrative

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staff’s point-of-view, it mainly serves as an electronic health record system, with a limited contribution to decision making and to regulating and management processes. Therefore, it is rarely used as a clinical quality assurance tool. Similarly, another computerized patient record system (CPR) is used at the primary clinics of the Israel Defense Forces (IDF) (Heymann et al., 2007), but that system still doesn’t provide sufficient tools for process management. We describe here the methods used to operate a nationwide computerized system for the management, quality assurance, and control of medical processes and informatics. These complementary systems have been used successfully for about two decades at the recruitment centers of the IDF. Application of informatics analysis tools, e.g. reports and on-line patient-surveillance status, allow the utilization of the system as a tool for quality assurance. Methods The basic instruction set architecture, within a computer cluster including all the recruitment centers and headquarters, was a 32-bit VAX (Virtual Address eXtension). It was subsequently replaced by a high performance 64-bit Alpha system. Both run an openVMS (Virtual Memory System), a high-end computer server operating system. Reports, for various purposes, were generated by TAMI version 4 – a database management system software for VMS platform. The computerized system consists of three main components: (1) The status system: a specific status is assigned to each file/recruit using code numbers reflecting the specific specialist, test, or documentation needed. This system is based on a four-digit status code number. The first digit points out the main stage of the process. For instance, stage two will usually mean that a recruit is in the process of medical profiling. The last three digits stand for the specific process involved (for instance pulmonology, cardiology, etc.). A status code has a beginning date and an end date. It allows the medical department to actively and dynamically follow up and manage the medical and administrative processes, on both the individual and collective levels, by computerized reports and an on-screen display of each record. The other use of this system is to keep the recruits at a specific status even if there are no current vacant appointments for a given specialist or to return the file to the specialist for the final summary of the case after receiving further documentation or test results. More recently, combined statuses were introduced. Combined statuses serve to indicate recruits that are in parallel medical processes, usually a general medical examination in addition to waiting for a specialist/lab test/imaging etc. (2) The appointment system: this system uses another set of code numbers that enable the administrative medical personnel to know exactly the purpose of the recruit’s visit. This system is used to assign a specific date for an appointment to a certain specialist or medical procedure. The computerized system defines for each date a certain quota of requested available places for the various processes or specialists and determines for each appointment the beginning and end times with a specified duration of the appointment. The system generates for the recruit an individual invitation, which can be given by hand or by mail/telegram, telephone, or internet notification. Once the recruit arrives for the appointment, the administrative personnel records that in the computerized system. After completion of the appointment another entry is made to certify

whether the process was completed successfully or not (due to an appointment postponement/cancellation/change or the fact that the recruit did not arrive or left before the appointment ended). The system is flexible and, according to requests and needs, new entry codes can be generated. Combination of the status and appointment systems permits a distinction between recruits that have an appointment date for a specific medical process, those waiting for a vacant appointment date, or those who need to send relevant medical documentation and are not required to arrive at the recruitment center. (3) A directing, monitoring, and controlling system (abbreviated as NASHAB in Hebrew): this system is used locally at each recruitment center for real-time follow-up and regulation of the waiting lists of patients at each station. It consists of three-digit code numbers. Each recruit is assigned a smart card at the entrance, and the NASHAB directs the recruit to the first available station out of all of the stations that he/she needs to pass through his/her visit to the recruitment center. This system allows coordination between the various medical stations (medical committee, measurements, laboratory, specialist examinations, etc.) and other non-medical processes that the recruits are required. The recruit’s personal information and health data appears on the computer screens of the physicians, the technician soldiers, and the administrative medical personnel, thus providing an updated view at all times of both the individual recruit’s stage in the process and the queue for each station (Figure 1). It is notable that the NASHAB system automatically directs recruits either to an available station or according to priorities pre-set by the medical personnel. The system offers the recruit information about the stations to which he/she was assigned, his/her place in the queue, and the estimated time at each station until being received.


These three systems operate independently, but in co-ordination. For management and control purposes, locally at each recruitment center and in globally in headquarters and by the quality assurance committee, reports are generated routinely to regulate the queues, to plan the availability of the medical services involved, and to evaluate the performance of the different stations at each recruitment center. The reports allow us to assess specific medical processes that services suffer from – long waiting lists or long

Figure 1. A typical computer screen of the local directing, management, and controlling system

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waiting periods – and where there is a specific need to add services or local intervention to overcome obstacles. Furthermore, reports also uncover discrepancies between the coding of the different systems. For instance, if a recruit is issued an appointment with a cardiologist, both his status and the appointment coding should reflect this fact. Results In this section, we will describe and evaluate the impact of the system as a key component in decision-making processes and as a quality control and assurance tool. We will also illustrate its effect on user behavior and medical practice. However, the first part will be devoted to the implementation process, which had crucial features that enabled the successful integration. The implementation process Each of the three components of the computerized system was implemented according to the same procedure. First, all medical processes were mapped and particular medical/technical/management/administrative needs were characterized by experts from inside and outside the medical and computer divisions. The computerized system was designed to address various needs, in line with the general medical processes and goals. Then, an alpha version was launched. Following a deep and comprehensive de-bugging and stimulation process, it was operated as a small-scale pilot program at a recruitment center. For this purpose, a special staff, made up of personnel from all of the medical process departments, was trained. The use of experienced medical staff members as testers allowed an efficient feedback process for the discovery of errors and drawbacks. It also contributed to them feeling that they were part of the process, increased their confidence, and made them receptive to the system. The system was redesigned and modifications were assimilated accordingly. The same procedure was carried out with the beta version. Following a successful pilot program, the computerized system was gradually implemented at other recruitment centers until full implementation of the system throughout the whole organization was achieved. The gradual implementation process allowed for both full support at each recruitment center and an assimilation of adjustments to the system according to specific local needs. A comprehensive and ordered training program was carried out at each recruitment center prior to, during, and following the implementation. The program was set up to prepare and support the medical personnel, computer experts, managers, etc., both as individuals and as a team, in all aspects of their work. These goals were achieved by instruction days, workshops and hand-on sessions, lectures, simulations, demonstrations, online support, and guided tours for the users of the system. Also, at this stage, division heads and experts from the recruitment centers were appointed to “thinking teams” to define the needs and preferred modes of action. Moreover, the teams also reported that users of the system acknowledged the need for the changes, suggested improvements, and contributed to the success of the project. Control and surveillance of the implementation process was carried out by trained personnel using various means: direct observations and conversations with local personnel, as well as computerized reports to find discrepancies, discover mistakes, and eradicate erroneous working procedures. Noteworthy, the implementation model described above, practically starting during the design phase, was aimed to answer the different needs of different medical personnel, to improve the likelihood of uptake by medical personnel, and to ensure the

proper and efficient use of the computerized information system. This is in agreement with other models to facilitate the implementation of medical information systems, such as the CONTEXTual Implementation Model (CIM) (Callen et al., 2008). The computerized system as a component of the decision-making processes Although the three components of the computerized system address different needs, they complement each other and together, serve as a tool for decision making. With regard to decision making, the computerized system plays a key role before, during, and after the recruits’ visits, at both the individual and collective levels. The status and appointment systems facilitate the daily operating procedures of the medical committees and specialist consultations along with laboratory and imaging tests and documentation received from or sent to other medical facilities. These systems allow a continuous and consecutive evaluation of the needs of each medical process, as compared to available resources, and prioritization of the various medical processes. A flexible and relatively user-friendly computer-based report-generating system enables a follow-up of the medical processes on an individual, as well as on a collective, level in real time and according to a constant or on-demand definition. Therefore, these systems provide the managers and administrative staff with a tool for monitoring the actual needs and capabilities of each medical process, which can enable either a better allocation of resources or better planning of individual care (Table I). Moreover, these systems also assist the medical staff since a complete medical history of each recruit is available, providing them with an authentic picture about past and present processes, as well as previous medical committee decisions and expert recommendations. These are required for decisions about the recruit’s medical profile or future required processes. In the past medical processes were carried out sequentially, namely only after issuing and completing one medical process could the recruit start another medical process, until all the medical processes were completed and the profile was assigned. Later on, improvements in these computerized systems allowed multiple appointments to be

Status/date Eye specialist (2210) Cardiologist (2250) Orthopedist (2270) Pulmonologist (2233) Neurologist (2290) Laboratory (2200) Appointment to chairman (2300) Documents (2400) Mental evaluation (2205) Psychiatrist (2220) ENT specialist (2240) Ergometry (2251) Echo Doppler (2252) Dermatologist (2281) Urologist (2280) Nephrologist (2232)


10/1998 11/1998 12/1998 02/1999 04/1999 10/1999 02/2000 n n n n n n n 1,923 758 731 1,140 565 1,578 1,958 2,819 178 432 278 3 262 358 94 58

Note: Based on data from the status system

1,680 711 667 1,126 510 1,350 2,300 2,868 154 585 279 4 220 347 98 55

1,116 666 436 1,124 502 1,277 2,255 3,543 114 680 202 4 92 364 63 77

544 477 461 1063 378 826 2,595 3,054 276 827 110 7 59 216 49 9

339 227 315 667 381 477 2,699 2,320 378 906 80 3 42 126 27 34

245 209 268 350 304 373 1,630 1,514 339 736 252 8 10 65 34 17

258 213 344 302 301 391 1,867 1,657 459 626 128 1 14 68 29 22

Table I. Number of patients waiting for medical processes at recruitment center 1 on different dates

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Figure 2. Percentage of recruits whose medical process was completed during the first assignment to the recruitment center, stratified by gender and recruitment center

issued for different dates, following medical and administrative decisions, thus enabling a recruit to carry out parallel processes. Today, novel status combinations and combined appointments allow efficient planning and parallel medical processes to be performed on the same day, thus reducing the number of times each recruit is required to come in to the recruitment center or other medical facilities. Furthermore, analysis prior to (2003-2004) and following (2009-2010) the implementation of the combined status and parallel multiple appoints systems, revealed a dramatic increase in the percentage of recruits which completed the medical process during the first assignment to recruit center (Figure 2), implying decreased patient throughput times. Not only do these computerized systems and improvements serve as components of the decision-making process, they also allow improved control of the medical processes at the individual and collective levels, shorten the average time period until the assignment of the medical profile, and improve the service for recruits. While the status and appointment system serves the medical personnel and managers before and after the recruit comes to the recruitment center, the NASHAB system is the main player on the day of arrival. It allows an effective real-time regulation of the processes and queues at the recruitment center. Each recruit is assigned a magnetic card on entry to the recruitment center, and all pre-required processes, as well as newly assigned ones, are documented in the NASHAB system. All parameters regarding medical queues are available on-screen (graphically and numerically) for the managing authorities at the local centers and headquarters. The medical and administrative personnel retain the possibility of prioritizing certain stations and regulating queues through an override feature but rely almost exclusively on the NASHAB system, which automatically assigns the recruit to the most vacant station of all the stations to which he/she is assigned. This decision-making process of managing queues and directing recruits to stations is now a computer-based or computer-aided process. Moreover, typically, if the waiting time at a certain station exceeds a pre-defined threshold, the system will issue a warning about long waiting

times to the queue manager. Daily reports summarize the performance of the medical sections, according to desired parameters (such as average waiting time at each station, number of recruits, etc.), and also show all unusual cases, which help the medical and administrative staff to learn from these cases for the future. The medical and administrative staff reported that these features of the system led to a lower error rate in directing recruits to stations, better queue management, and a reduced average waiting time in each queue. This, in turn, caused almost all of the recruits to complete all of the medical stations according to the plan, which also left them more satisfied. Computerized reports on performance and quality control parameters and interviews and questionnaires of recruits strongly support these findings (see below). The computerized system as a quality assurance tool A quality assurance control committee continuously analyzes data from the computerized system (mainly by means of reports) in order to assess and evaluate the performance of the medical and administrative processes, as well as to identify errors and discrepancies in individual files. In light of its findings, the committee warns about mistakes, works toward their correction, and proposes solutions or local intervention programs to overcome difficulties in global processes. Reports during previous years revealed a significant number of recruits waiting for specific medical processes (ophthalmologist, cardiologist, pulmonologist, orthopedist, neurologist, etc.). Table I describes the situation encountered during the late nineties at one of the recruitment centers (according to the status system) and the improvements that followed after the implementation of interventions that included the reinforcement of specialists and the cancellation of unnecessary appointments following re-examination of the medical files. For most statuses examined (13 of the 16 most common medical statuses, . 81 percent), during a period of 16 months, a reduction of at least 50 percent was recorded in the number of recruits holding a specific status, while the most dramatic reduction was observed in Echo Doppler and eye specialist statuses (-94.6 percent and -86.5 percent, respectively). Nevertheless, in a few of the statuses either no pronounced change (appointment with chairman -4.6 percent) or even an increase in the number of recruits (mental evaluation þ 157.9 percent, psychiatrist þ 45 percent) was detected. Another key parameter is the interval of time that passes as each recruit waits for a specific medical process (Table II). The analysis uncovered the number of recruits waiting for different intervals of time (0-7 days, 8-30 days, 31-60 days, 61-90 days, and more than 90 days) for a given specialist/process. For example, a higher rate (,30 percent) of recruits who waited for medical processes for a very short period (up to 1 week) was found in recruitment centers 1 and 5 (as compared to 12-16 percent in other recruitment centers). A low rate of recruits who waited for a very long period (more than three months) for medical processes was also found in recruitment centers 1 and 5 (,5 percent, as compared to 12-23 percent in other recruitment centers). Moreover, in recruitment center 1 .75 percent of recruits invited for all of the most common medical processes waited up to 1 month, whereas in other recruitment centers the rate did not even get to 75 percent (usually it was within the range of 45-70 percent). It is notable that while 95 percent of the recruits invited to see a neurologist in recruitment center 1 waited up to one month, much lower rates were found in other recruitment centers, for example 36 percent in recruitment center 2 and around 50 percent in recruitment centers 3 and 4. In recruitment center 4, there were only a few recruits waiting for specialists, and most of them were waiting for a


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Table II. Number of male recruits waiting for specialists and medical processes at recruitment centers according to time intervals (25/01/07)

Center 1 Eye specialist Psychiatrist Pulmonologist Cardiologist Neurologist Documentation Total (all process) Center 2 Eye specialist Psychiatrist Pulmonologist Cardiologist Neurologist Documentation Total (all process) Center 3 Eye specialist Psychiatrist Pulmonologist Cardiologist Neurologist Documentation Total (all process) Center 4 Eye specialist Psychiatrist Pulmonologist Cardiologist Neurologist Documentation Total (all process) Center 5 Eye specialist Psychiatrist Pulmonologist Cardiologist Neurologist Documentation Total (all process)

0-7 days n %

8-30 days n %

16 26 17 40 10 22 347

17.2 31.0 41.5 51.3 47.6 64.7 29.4

59 42 1,434.1 30 10 9 489

25 17 12 8 5 3 167

17.9 36.8 14.8 16.7 20.0 20.0 15.7

19 19 2 7 2 44 167

63.4 50.0

No of days 31-60 days 61-90 days n % n %

.90 days n %

Total

38.5 47.6 26.5 41.4

15 9 7 7 1 1 225

16.1 10.7 17.1 9.0 4.8 2.9 19.0

2 5 3 0 0 0 57

2.2 6.0 7.3 0 0 0 4.8

1 2 0 1 0 2 64

1.1 2.4 0 1.3 0 5.9 5.4

93 84 41 78 21 34 1,182

71 9 32 23 4 8 374

50.7 20.5 39.5 47.9 16.0 53.3 35.2

27 14 25 13 9 2 254

19.3 31.8 30.9 27.1 36.0 13.1 23.9

13 4 6 1 4 1 139

9.3 9.1 7.4 2.1 16.0 6.7 13.1

4 0 6 3 3 1 128

2.9 0 7.4 6.3 12.0 6.7 12.1

140 44 81 48 25 15 1,062

14.2 21.6 50.0 16.3 9.1 31.4 14.6

53 30 1 16 9 43 329

39.6 34.1 25.0 37.2 40.9 30.7 28.7

38 29 0 11 4 18 271

28.4 33.0 0 25.6 18.2 12.9 23.6

15 5 1 4 3 13 126

11.2 5.7 25.0 9.3 13.6 9.3 11.0

9 5 0 5 4 22 253

6.7 5.7 0 11.6 18.2 15.7 22.1

134 88 4 43 22 140 1,146

0 0 1 0 2 2 105

0 0 718.5 0 13.3 25.0 12.1

1 2 36 1 5 3 244

50.0 50.0 39.1 100.0 33.3 37.5 28.2

0 1 14 0 3 0 169

0 25.0 15.2 0 20.0 0 19.5

0 1 21 0 0 2 149

0 25.0 22.8 0 0 25.0 17.2

1 0 4 0 5 1 199

50.0 0 4.3 0 33.3 12.5 23.0

2 4 92 1 15 8 866

9 12 9 21 28 32 163

23.7 30.0 21.4 30.0 34.6 36.8 29.7

14 14 11 29 27 19 188

36.8 35.0 26.2 41.4 33.3 21.8 34.2

11 9 14 18 21 18 134

28.9 22.5 33.3 25.7 25.9 20.7 24.4

3 3 3 1 3 5 36

7.9 7.5 7.1 1.4 3.7 5.7 6.6

1 2 5 1 2 13 28

2.6 5.0 11.9 1.4 2.5 14.9 5.1

38 40 42 70 81 87 549

pulmonologist. This stands in contrast to the other recruitment centers where there were many more recruits waiting for specialists, including the pulmonologist. In all of the recruitment centers, the higher rate of recruits who were waiting for more than three months was found for recruits who were in the process of medical documentation (centers 1 and 5) or those assigned to see a neurologist (centers 2-4).

These differences between the recruitment centers may be attributed to differences in the availability of human and medical resources, demographic factors, cooperation of recruits, etc. Specific lists of names of the recruits waiting for more than a month have been generated, the process in their files has been carefully checked for efficiency, and solutions are being sought to reduce the waiting period for specific processes. Discrepancies between the systems are also assessed. The reports are distributed to the appropriate personnel at the local recruitment centers and headquarters. For instance, discrepancies between the status and appointment codes are more common at recruitment centers 1-3, while having status codes for long periods of time (. 4 months) is a major problem at recruitment center 5 (data not shown). Moreover, according to the rules, when an appointment is scheduled for a date that is very close to the date of assignment (up to two weeks), then the invitation should be made via telephone rather than by mail. In all of the recruitment centers, we found this rule being violated. The reports from the NASHAB system revealed that at one recruitment center the number of recruits examined exceeded the allowed number of examined recruits. Detection of such events is crucial and reflects far-from-optimal conditions in both the medical process and in the service given to the recruits. After intervention by the quality control and assurance committee, the instructions were clarified and a reduction in the number of recruits invited for the medical committee examinations was observed, thus improving the quality of the medical encounters. One parameter of the systems’ performance is to calculate the percentage of recruits (between the ages of 17-18) who were born on the same calendar year and had not yet finished the medical process. A lower percentage reflects high performance and efficiency, although it does not necessarily indicate the quality of the performance. Such analysis (Figure 3) revealed that over the years there was a clear trend of improvement in the medical system’s performance since the percentage of 17-year-old male and female recruits from each year who had not changed their status is gradually but consistently decreasing (from 23.6 percent to 10.3 percent (Pearson’ correlation


Figure 3. Percentage of recruits in medical and pre-medical statuses, stratified by gender and age

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coefficient r ¼ 2 0.91) and from 13.7 percent to 4.1 percent (r ¼ 2 0.86), respectively). Interestingly, a major improvement in this parameter was observed during 1999 and 2000, years in which the internal directing, monitoring, and controlling system was integrated at all of the recruitment centers, further supporting its importance in managing and better utilizing the human resources. Altogether, the computerized system is a key component in the assessment of the quality and performance of the medical processes, at both the individual and collective levels, in their medical, administrative, and procedural aspects. Over time, the use of computerized systems, among other quality control and assurance tools, led to a pronounced improvement in a wide range of parameters. Questionnaires for recruits, as well as for medical personnel, clearly demonstrate a gradual and consistent increase in the rate of satisfaction from the medical process and its components among recruits and recruitment center personnel (data not shown). Users’ attitude and behavior-oriented effects The users of the system are partners in the process to change and improve the medical system. Since users have taken part in many stages, from design to analysis, their positive attitude helps to “welcome” a new component. One may even claim “personal responsibility” and commitment as major factors in the successful implementation and operation. This is critical when facing difficulties during the pilot or implementation process. It also enables significant changes in user behavior, beyond the modifications in the working procedures and learning how to use and operate the new system, which are integral parts of the implementation process. First, users acknowledged that each of the three components of the computerized system provided them with high-resolution information, in a clear and friendly format, about the recruits’ different processes and his/her detailed medical history, which permitted root-analysis. The computerized system enabled a better understanding and control of the medical process, which led to the users’ increased awareness and comprehension of the medical procedures. Routine exams and interviews following the implementation of each component system indeed strengthened and supported the notion of contributing toward a deeper understanding of the medical and administrative process, acquired expertise, and higher efficiency. Moreover, algorithms, structured restrictions and rules, and automated user warnings and notifications make the computer system an integrated part of the users’ work, as a tool for decision making, process regulation, and quality control. This also increased the confidence of the users and managers. After a short period of adaptation, the department heads and managers, as well as the rest of the users, learned how to take advantage of each of the new computerized systems, especially with regard to flexibility and ease in formulating reports according to need. With time, not only was the use of the system better, but also the users actively took the initiative and asked for new applications. Furthermore, the collaborative computerized systems together bridged between the medical, administrative, and managing authorities and established a continuous working connection between them. The combined and integrated work rather than the separate procedures broaden the user’s view of the medical process as a whole, and although it requires more knowledge and skills, the computers help to fill the gap. From a long-term, global view, we can say that the medical process has changed and has become more controlled and efficient due to the introduction of these systems. Following the successful implementation process of different computerized systems, specific forums involving the administrative medical personnel, the physicians, and the

managing authorities have been established and meetings are held on a regular basis in order to update all involved personnel on the novelties introduced into the system, to exchange ideas, and to formulate improved working methods. The NASHAB system, even more so than the status and appointment systems, has brought about a significant improvement in the services provided to the recruits (clients) and a significant change in the behavior of the medical personnel (providers of service). For the first time, the concept of providing service to recruits was assimilated by the users. The information on different parameters of service, such as waiting time, waiting lists, etc., has become available not just to the managers but also to the users in clear and friendly graphic and numeric presentations. This led to a significant change in the users’ attitude towards the recruits and in their behavior towards providing better service in line with medical and administrative instructions and regulations. Discussion Originally, the status code system, which reflects the stage of the recruits within the process of medical profiling, was developed before the introduction of a computerized database in the IDF. The development of specific combined status codes (Figure 4), which enables the system to recognize recruits who are expected to appear before a medical committee as well as complete a specific specialist examination on the same day, according to prior medical documentation that was received, led to a significant reduction in the number of visits required to finish the profiling process of the recruits (IDF, 2001-2008). A few years later, a complementary appointment system was introduced, enabling the administrative medical personnel to properly plan and document the purpose and the course of each recruit’s visit and to assign as many appointments as required to each recruit (Figure 4). Soon after, a local system for directing, monitoring, and controlling the processes at each recruitment center was implemented in order to coordinate medical processes as well as follow-up and regulate the waiting lists of the patients at each station (Figure 4). The computerized three-component system is used for the management of the medical processes and information at the recruitment centers. The three components of the computerized system are linked to each other but are, at the same time, independent. This allows the full exploitation of specific characteristics and advantages of each component, as well as additional control to help identify discrepancies. The status system allows the administrative personnel to generate reports regarding a specific step in the medical process of each patient. It also serves as a management tool for analyzing the comprehensive needs of the whole medical system. Furthermore, the assignment system can distinguish between patients who already have an appointment for a specific specialist or test and those who are on a waiting list (have a specific status but do not have an appointment date yet). The third component allows for the regulation of the waiting time of the recruits inside the recruitment center on the day of their visit, by automatically assigning them to a more vacant station. Another application of this system is to detect an excessive number of patients directed to a particular medical station / specialist, which by itself is a violation of the regulations and negatively affects the quality of the medical encounters. The combined system described above could be used with success in medical practice at clinics, hospitals, and other medical facilities in order to manage, regulate, and follow up the medical processes for each patient, as well as to monitor the utilization of different medical services, especially those that need more resources in order to provide better medical care, and to plan them accordingly.


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Figure 4. Schematic representation of the medical process flow before (a) and after (b) the implementation of the combined status and the NASHAB systems

Furthermore, the combined system also permits a proper diagnostic-therapeutic loop. When a new medical condition is discovered during the examination at the medical committee, when additional documentation or tests are required from external medical authority, or when a medical condition (such as fracture, surgery, trauma etc.) dictates a profile of temporary inadequacy for service, the medical committee will actively follow-up the medical findings / documents / treatment to conclude the recruit’s medical profile. The primary physician is notified about the diagnosis and investigation, and is involved in the treatment and follow-up. In all these cases, a specific status is assigned and appointments are issued, indicating the medical condition involved and the required investigation by specialists / test etc, respectively. At each stage when new medical information is available, the status and appointment systems are updated accordingly, until a stage when all necessary information exists and medical profile is assigned. During this period of time, reports utilizing data from the status and appointment systems, serve to monitor and control a desired population of interest, and ensure proper follow-up and management. Because both the status and appointment systems use numbered code, they are safe for use and viewing and do not contain medical history records that can be viewed by unauthorized personnel. It is also the only fully integrative system that has been used with success on a nationwide basis with minimal exposure of patient medical records and yet allows communication between the medical and non-medical staff; generates reports in the form of lists of names as well as statistical analysis; is used as a quality assurance tool by assessing loads, waiting time intervals, availability of medical services, etc.; and facilitates the planning of medical services. One clear drawback of the computerized system is that it does not contain evidence-based clinical guidelines to support treatment decisions. However, such information can be incorporated into the system, either as an integral component or as a linked appendix. As mentioned before, the computerized system has the capacity to incorporate new components as part of its databases, with or without connecting to external devices, such as smart cards, etc. Smartcard-based healthcare information systems hold great promise and have already been developed and implemented in medical centers (Kardas and Tunali, 2006; Liu et al., 2007). As shown here, the applications of such systems are diverse and yield benefits for both the patients and the organization. While the ED Indiana system (Horak, 2000) bears similarities to our NASHAB system, it gives information only to the medical staff, does not prioritize medical processes, and does not provide information to the patient and his/her family. Furthermore, it does not provide the benefit of having a magnetic card’s barcode that can be read by terminals in various places. The system was also not operative on a nationwide basis like our NASHAB system. Today, in the environment of primary medicine in Israel and other places in the world, there is less engagement on the part of the medical and administrative personnel to actively follow-up on whether the patient completed the required procedures and consultations with specialists, especially when they are done outside the primary clinic facility. Primary clinics get the results of the various tests performed by the patient but do not actively follow-up patients who fail to complete the required additional procedures, unless a physician checks the file or initiates such a follow-up. Rarely does a patient get the chance to perform multiple parallel medical processes on the same day or in a short period-of-time. These problems are mainly due to the lack of efficient tools for follow-up and for the generation of reports of lists of certain patient populations of interest.


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In emergency wards worldwide most instructions are handwritten and are carried out by the medical staff, consultants, the patient, and the family of the patient who may have a limited understanding about the required medical procedures. Most of the information is recorded upon the admission and discharge of the patient, thus limiting the ability for follow-up and regulating the processes during and after the time of hospitalization. Our system can efficiently change the picture by giving the administrative and medical personnel efficient and simple tools to handle the processes and to overcome the above mentioned (and other) shortcomings. The system is simple, efficient, flexible, and allows for follow-up of the individual patient by the medical and administrative personnel, thus enabling the active management of a case instead of embracing passive management and waiting for the patient to carry out the medical processes that are needed. The system also permits the patient to find out the list of medical examinations that need to be carried out and helps to assign the patient to the waiting list of each procedure and to know the exact status of the patient at any given minute. For instance, once admitted to the ED, a patient can get a magnetic card and all of the stations that he has to go through can be entered into the computerized system. Thus, the personnel can know at each minute where the patient is, what his next examination will be, if blood samples were taken, and what the status of the laboratory or imaging tests is (exact placement on the waiting list). The patient himself can also be aware of the remaining tests that are left to be carried out, and how long they can take, thus quickly receiving online information and assurance. Statistical reports about each medical procedure can be generated easily for use by medical personnel and the managing directors. Implementation of computerized information systems in ED was shown to support patient care (Aronsky et al., 2008), to improve ED efficiency (Baumlin et al., 2010). The described integrated information system, including its unique features, might extend these and other benefits. Implementation of the status and appointment component of our system in the setting of primary clinics would facilitate an active and dynamic follow-up of the various medical processes carried out, and would enable parallel processes to be carried out efficiently. It could further strengthen the collaboration of the medical staff with the administrative staff, by involving the administrative staff in active managing of the medical process and in quality assurance processes, by giving them tools to generate computerized reports at all stages of the process. Furthermore, introduction of the magnetic card system at primary clinics could improve the workflow and allow efficient regulation of queues of patients waiting in the clinic to be examined by a specific physician. The same tool, as mentioned before, can generate computerized on line reports for managing authorities. As the design principles and standards and general and common to various processes, this coordinated computerized system could be adjusted and integrated to a wide range of processes. Therefore, ongoing and future research focus on the effects of these information systems on other parameters of quality control and assurance, data management, and process efficiency, with regard to both medical, medical-supporting and non-medical processes. Our cumulative data highlight the major contribution of the described information systems to other processes within recruitment centers (data not shown). This might, at least in part, support and serve as proof of concept for the transferability of practice to other medical systems.

In summary, we have described and demonstrated the use of a multi-component computerized system to manage, control, monitor, and follow medical information, medical processes, and resources at the IDF’s medical facilities. It also serves as a quality assessment tool to access the utilization of different medical services. The computerized system is simple, efficient, flexible, user friendly, and supports a collaborative and integrative work environment. On the one hand, it provides a comprehensive and global view of the medical committees’ performance and a database that can be exploited for ad hoc queries to answer diverse operational, clinical, research, or educational questions. On the other hand, the real-time availability of cross-sectional and patient-centric data helps to improve patient flow, to create transparency and accountability, and to maximize effective communication within and outside the medical process. We believe based on our long-standing experience that such information technology and procedural principles can dramatically improve the service and health care provided to patients in every medical system.

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Author affiliations Yossy Machluf, Weizmann Institute of Sciences, Rehovot, Israel, and Quality Assurance and Control Committee, Medical Corps, Israel Defense Forces, Haifa, Israel. Avinoam Pirogovsky, Division of Community Medicine, Ministry of Health, Tel Aviv, Israel. Elio Palma, Department of Occupational Medicine, Clalit Health Services, Afula, Israel, and Quality Assurance and Control Committee, Israel Defense Forces, Haifa, Israel. Avi Yona and Amir Navon, Quality Assurance and Control Committee, Medical Corps, Israel Defense Forces, Afula, Israel. Tamar Shohat, Israel Center for Disease Control, Ministry of Health, Tel Aviv, Israel. Amir Yitzak, Department of Pediatric Neurology, Assaf-Haroffeh Medical Center, Zerrifin, Israel, and Israel Defense Forces, Medical Corps, Tel-Hashomer, Israel. Orna Tal, Israeli Center for Technology Assessment in Health Care, The Gertner Institute for Epidemiology and Health Policy Research, Emerging Technologies Unit, Tel Aviv, Israel. Nachman Ash, Medical Corps, Israel Defense Forces, Tel-Hashomer, Israel. Michael Nachman, Potential Department, Conscription Administration, Personnel Directorate, Israel Defense Forces, Rishon Lezion Israel. Yoram Chaiter, Quality Assurance and Control Committee, Medical Corps, Israel Defense Forces, Haifa, Israel. About the authors Yossy Machluf (PhD) is a Senior Intern at the Department of Science Teaching, Weizmann Institute of Science, Rehovot and a member of Quality Assurance and Control Committee of the Medical Corps of the IDF. Avinoam Pirogovsky (MD, MHA) is a pediatrician and imaging specialist, Head of the Division of Community Medicine, Ministry of Health, and a member of the Quality Assurance and Control Committee of the Medical Corps of the IDF. Elio Palma (MD, MPh) is Head of the Department of Occupational Medicine, Afula, Clalit Health Services, and a member of the Quality Assurance and Control Committee of the Medical Corps of the IDF. Avi Yona (MA) is a Clinical Psychologist and a member of the Quality Assurance and Control Committee of the Medical Corps of the IDF. Amir Navon (BA) is studying for a MA degree in Public Administration at the University of Haifa, Israel. Tamar Shohat (MD, MPh) is a public health specialist and Director of the Israeli Center for Disease Control. Amir Yitzak (MD, MBA) is a pediatrician and a Fellow at Pediatric Neurology and Child Development, and Former Head of the Department of Medical Classification of Recruits of the Medical Corps of the IDF. Orna Tal (MD, MHA) is former Head of the Medical Assessment Branch of the Medical Corps of the IDF. Nachman Ash (MD) is a Chief Medical Officer with the Medical Corps of the IDF. Michael Nachman (MA) is Head of Potential Department, Conscription Administration, the Personnel Directorate, Israel Defense Forces, Israel. Yoram Chaiter (MD, MSc) is Head of Quality Assurance and Control of Medical Committees of the Medical Corps of the IDF, head physician of a recruitment center, an epidemiologist, and a researcher in quality assurance, public health and cancer epidemiology. Yoram Chaiter is the corresponding author and can be contacted at: [email protected]

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