Analysis o


f the Health Care Management and Information System in NHS London.

Virender Singh

Research Proposal MBA

Table of Contents

Rational of Research…………………………………………………………………………………………………..3

Specific Aim………………………………………………………………………………………………………………3

General Objectives……………………………………………………………………………………………………..3

Literature Review ………………………………………………………………………………………………………4

Statement of the Problem ……………………………………………………………………………………………5

Scope of the research…………………………………………………………………………………………………..6

Research Methodology…………………………………………………………………………………………………6

Significance of research ………………………………………………………………………………………………6

References………………………………………………………………………………………………………………….7

Rational of Research

A Management Information System (MIS) gives data that is required to oversee associations effectively and successfully. MISs are not just computer systems, these systems include three essential segments: engineering, individuals (people, groups or associations), and information for decision making. Assessment is one of the beginning steps in any planning process and one worry of evaluation is recognizing nature of problems, their magnitude of severity, conveyance and patterns. It serves to focus quality and shortcomings of the current existing system. Evaluation is an efficient collection and investigation of information required to make decision, a methodology in which most well-run projects captivate from the start. Enhancing any data framework implies as a matter of first importance distinguishing qualities and shortcomings of existing framework in order to concentrate on areas functioning the least. Healthcare Management Information System (HMIS) appraisal is then the early step in the procedure for strengthening and enhancing it so it is paramount to identify data issue at its root and arrangement for more coordinated methodology for development at each one level.

Specific Aim:

To assess the current Health care Management Information Systems to find out its focus quality and shortcoming.

General Objectives:

1. To create solutions for improving the current issues, improving existing framework to have well reported framework in order to meet the demand of end user.
2. Developing strategies to enhance automated documentation of information.
3. Developing strategies so that the employees can use information legitimately for proper planning and surveying the current circumstances.
4. Encouraging the use of Health care Management Information System for enhancing clinical consideration.
5. Evaluating the capacity of front line employees for the best possible utilization of electronic information system.

Literature Review

Information needs to be decently characterized at each level in the event of information collection, processing of data, information transmission and there ought to be fitting feedback system. Computer technology can enormously improve and facilitate the data processing storage and retrieval so it is critical to upgrade computer systems, have proper security and proper insurance of the software.

There ought to be constant appraisal on relevant timeliness and use of data at all levels. Planning ought to be contrasted with the actual performance in order to reflect changes and timely feedback the significant obstacles to viable and enhanced healthcare administration in the third world countries as absence of data is for the most part present. Well designed routine information framework guarantees that services are conveyed as per the standard as decision making methodology uses quantitative and objective data. Health information system is essentially needed for three major services. These include patient management, management of health units and management relating to health systems.

Healthcare Management Information System exists to bridge the gap between when a patient becomes sick and the response of health service providers. This is due to the fact that initially health care information systems were in existence only to gather data relating to the problem the patient is having, or in some cases a disease and health services outputs; however later on the health information systems are becoming the part of health systems and hold paramount significance in the planning and decision making of healthcare services.

The WHO theory is that the advancement of judiciously organized information system closely adjusted to the data needs of health services at all level including at the communities level can possibly help general improvement of health services management. The WHO has likewise accentuated that the absence of enhanced HMIS does not help in decision making process (Lippeveld, Sauerborn and Bodart, WHO, Geneva 2000).

The Healthcare Management Systems have potential significance, however despite this fact it is practically a major problem for third world countries in collection, compilation, analysis and utilization of healthcare information. Numerous nations have chosen to handle the issue of HMIS by tending to at its root, and arrangement for more coordinated methodology to enhance it. Nations like Cameroon, Tanzania, Pakistan, and Mozambique focused on routine Information System for primary care facilities (Lungo, 2003).

According to Rodrigues and Israel (1995) as cited by Lungo (2003), the drive for a change in HMIS has concurred with the data innovation since 1980s. WHO has additionally emphatically accentuated on the utilization of machine innovation in the outline of district-based health information system. However a considerable amount of countries which have computerized their HMIS are experiencing absence of properly trained staff and hardware and software Maintenance Problems (Campbell, 1997), (Hedberg 2003), (WHO 2004).

According to Braa et al (2003) as cited by Lungo (2003), the national health information systems in numerous developing nations have been unequivocally focused around the Primary Heath Care (PHC) administration. The district gets then the most fitting level for facilitating top-down and bottom up planning, for sorting out community involvement in planning, and execution, and for enhancing the coordination of government and private care. A broad participatory action examination began in South Africa which has additionally spread to different nations like Mozambique, Tanzania, and India. Health Information System Program (HISP) shows solid methodologies and address how to create district–based health information systems that is offered by open source software.

The contention is that local or provincial and district health managers and planners in the third world nations have not had the capacity to examine and translate such information for planning, and ought to be engaged through solid decentralization. Sandiford et al (1992) as cited by Lungo (2003), Computer-based data framework ought to be implemented to encourage better storage, investigation and dissemination of health information. However introducing computer technology in the improvement of health information system is not so much the silver-billet that tackles the efficiency issue of the health service.

Statement of the Problem

Regular issues in the utilization of IT incorporate absence of user-friendly hardware, poor framework support, and absence of sustainable energy source and deficiency of enough trained staff. Accordingly, it must be taken into consideration the primary thing in any case that the information entered must be precise; management must be equipped for controlling the computer system into meaningful data particularly when non-medicinal staff or low-level experts do the information gathering. In any case, the key issue to meaningful information lies in the faultless inputting of pertinent information and an institutionalized practical IT framework (Keen 1994). Under the technology of information administration; computers get vital to handle substantial volume of information or data in an organized and quick way for speed, quality, precession, clarity, consistency, dependability and proficiency. However, it cannot produce information rather it can just process it.

Despite the credible use of HMIS for evidence based decision making like strategic planning, enhanced patient care, proficient allotment of scarce assets and effective focusing of intervention to those in the greatest need heading for better result, however there is an enormous sympathy towards the improvement of the health care services delivery systems, which is generally seen to be attributed to the weaknesses of HMIS in the developing nations.

Scope of the research

The research will be based on Service Reporting System in the HMIS and is restricted to health facilities and management units at national health services.

Research Methodology

The research will involve choosing four primary care units from City of London. The questionnaire will be filled by all the individuals involved in the handling of HMIS. A questionnaire to be filled by the individuals who are directly involved in taking care of and utilizing HMIS at Primary health care centres, working for National Health Services (NHS). Individuals will complete the questionnaire and from these, the researcher will assess the current ongoing framework to determine strength and shortcomings, developing strategies and solutions to improve the flaws. Also analyzing the data on the latest version of Statistical Package for the Social Sciences (SPSS).

Significance of the research

Exploring the current HMIS situation in the area to recognize the qualities and weaknesses of the framework to address the problem areas. The concluding results of the research is relied upon to be useful and will input in improvement efforts of the HMIS and in the dissemination of learning picked up in the research.

References

Beaumont R ( ). Evaluating Health Information System, Introduction to Evaluating Health Information System.

Braa J (2003). Strategies for developing Health Information System in Developing Countries, South Africa.

Campbell, B B (1997). Health Management Information System in Lower Income Countries, Analysis of system design, implementation and utilization in Ghana and Nepal, WHO, New York.

Hiaasen D S and Striver D J (2004). A Framework for assessing HMIS in Developing Countries: Latvia as a case Study. (Proceedings of the 37th Hawaii International Conference on System Science).

Lippeveld T, Sauerborn R, Bodar C T (2000). Design and Implementation of Health Information Systems, WHO, Geneve.

Lungo J H, May 2003. Data Flows in Health Information Systems, University of Oslo, Department of Informatics, Norway.

O’Brien, J (1999). Management Information Systems – Managing Information Technology in the Internetworked Enterprise. Boston: Irwin McGraw-Hill.

1

Case Presentation

Mr. AS is a 68 y/o AAM who presents to his primary care physician (PCP) for his annual routine checkup. He has a past medical history (PMH) of HTN, HLD, and a 50-pack year of tobacco smoking. He drinks a couple of times a week, especially when he “plays poker with the fellas”, and an unrestricted diet. During his exam his PCP detects a moderate to severe bruit on the left side. Mr. AS’ physician is concerned and decides to send him for a carotid ultrasound (U/S) right then and asks him to return to clinic once the U/S is complete.

The ultrasound done in the outpatient clinic revealed a 60% stenosis at the bifurcation of the left internal/external carotid artery. An appointment was scheduled for the following day at the vascular surgeon’s office to assess the need for intervention and revascularization. At the appointment the vascular surgeon also detects a bruit on auscultation. The patient denies any history of focal neurologic symptoms but does admit to some lightheadedness and dizziness on occasion that he attributes to “just getting older”. The vascular surgeon prefers his own in-office sonographer and therefore, repeats the carotid U/S, which more accurately reveals an 80% stenotic lesion of the left carotid artery.

Introduction

Carotid artery stenosis is one of the most common causes of ischemic stroke (CVA) and transient ischemic attacks (TIA).1 The incidence of stroke becomes considerably increased with the extent of artery stenosis.1 Over the last 10 years there have been many significant improvements in how we care for patients with internal carotid artery (ICA) stenosis.1-3 The improvements seen in pharmacologic agents cannot be understated, especially when it comes to the management of high cholesterol, hypertension, and diabetes. These newer drugs have made terrific strides towards the risk reduction of stroke in patients with both symptomatic and asymptomatic carotid disease.  Next, there have been clinical trials that have compared carotid endarterectomy (CEA) to carotid artery stenting (CAS) amongst patients with symptomatic and asymptomatic disease.4-6

In addition to assessing the degree of stenosis, a good history and physical is crucial when deciding how to manage the patient with carotid disease. A good history and physical can help guide a clinician’s decision making on surgical management, or conservative treatment with other options. Ischemic strokes account for more than 80% of all strokes and roughly 20% of those are due to stenotic carotid arteries.1 While recent advances in pharmacologic management has helped to reduce the number of patients developing carotid stenosis, in the U.S. population, obesity remains on the rise and, unfortunately, despite public health warnings, many Americans continue to smoke.7 Both of which remain significant contributors to systemic vascular disease, not the least of which is carotid artery stenosis.1

The approach to carotid disease is largely based on symptoms and degree of stenosis. There are generally three possible scenarios to evaluate. Patients that are asymptomatic, yet, have an 80% or greater stenosis should be revascularized as soon as possible to prevent stroke.7 In patients that have completed a stroke, the approach is a little different, in that revascularization should be done within a two-week period following the initial event.1 During the two-week window, optimal medical therapy should be initiated.1,7 Thirdly, the patient that is actively having a TIA needs to be taken to the operating room urgently to revascularize the stenosis, with the goal of preventing an all-out stroke.1 The approach to these three potentially different clinical presentations are based on recommendations from the landmark CEA trials published in the mid 1990’s (NASCET, ECST, ACAS, ACST).1,7

Diagnostic Tools

Carotid artery stenosis can be diagnosed using several options. As it is non-invasive and lacks radiation exposure, duplex ultrasound (U/S) is currently the screening test of choice. Other options include CT angiography (CTA) and magnetic resonance angiography (MRA).3 CT exposes the patient to high-dose radiation and CT and MRA are very time consuming and costly. Also, to note, CTA will often times underestimate the degree of stenosis, while MRA will overestimate the degree of artery occlusion. CTA and MRA are usually only used in highly selective patients with lesions high in the neck, referred to as “high lesions”, where advanced imaging techniques would yield information the surgeon felt would be particularly helpful intraoperatively. Since most carotid lesions arise at the bifurcation of the internal and external carotid, the use of CTA and MRA are used less frequently by experienced vascular surgeons that perform frequent endarterectomies.

Symptomatic Carotid Stenosis

In patients with symptomatic carotid artery stenosis, the risk of stroke, recurrent stroke, or TIA can be minimized with revascularization of the internal carotid artery.1,8 The big question at this point becomes whether your patient is a better candidate for surgical intervention via CEA or the less invasive, CAS. With either of these choices, the clinician should always implement intensive pharmacologic therapy.1,9 To date, CEA remains the superior choice for carotid revascularization among asymptomatic and symptomatic patients that meet certain ultrasound criteria.7,10 Below is a list of ultrasound flow velocities that are used in vascular surgery to determine the degree of stenosis that is present in patients.11 These criteria are used to help guide decision making for revascularization.  If the patient is asymptomatic but has a lesion that is stenotic 80% or greater, revascularization is indicated and should be considered.8 If the patient has a stenotic lesion of greater than 70%, and is asymptomatic, revascularization is then considered.8

Velocity grading criteria based on the NASCET angiographic method11

Data that was published from the carotid revascularization endarterectomy versus stenting trial (CREST) indicated that CEA was superior to CAS.4 However, in a recently published 10-year follow-up to the CREST trial, new data have been published.5 The new data from the follow-up reveals that CEA was superior to CAS in the periprocedural period, resulting in fewer strokes.5 Nonetheless, once patients made it past the periprocedural timeframe, CEA and CAS were shown to be equal in terms of long-term treatments that can be employed for preventing an ischemic stroke in patients with symptomatic carotid stenosis.5

In terms of timing, the best possible time to revascularize a patient that is symptomatic is within two weeks of the inciting event.1 If it is decided between the patient and care team to wait past this two-week window, the overall benefits of revascularization have a sharp falloff.1 During the time period immediately following the CVA or TIA, at which revascularization can occur, patients should be started on intensive medical therapy.1,2 The recommended regimen for intensive medical therapy for these patients includes a high-intensity statin with a target LDL of < 70mg/dl, dual antiplatelet therapy agents, blood pressure (BP) regulation to maintain a systolic BP of < 140mmHg or < 130mmHg if diabetic, and a hemoglobin A1C < 7%.1,2,6 Other helpful therapies include lifestyle modifications that consists of smoking cessation, moderate exercise, and a goal to reduce their weight to ideal body weight.1

Carotid Artery Stenting

While CEA is currently the gold standard for revascularization of carotid stenosis, CAS is a second plausible option for patients.2,3 CAS materials and the technology to safely deploy them have improved significantly in the last decade.3 In addition to being an alternative to CEA for patients that are at risk for having surgery, CAS remains an option for those with advanced age, aberrant anatomy, or patients that have had radiation exposure to their neck.1,7 One potential concern with CAS is the periprocedural risk of stoke that exists. Therefore, the risk-benefit options should be discussed at length with the patient who is considering CAS.

As stent technology has been rapidly evolving, few stents have yet to deliver results superior to CEA. Though, in 2018 a study was published in Austria with very encouraging results.3 The study looked at a new stent design called the Casper Stent System, that was used in 138 patients.3 This double layered stent which demonstrated supreme vessel conformity, was deployed successfully without any technological failures or adverse neurological events within a ninety-day period, post stent placement.3 The main purpose of this new stent design is to lower or avoid altogether, the periprocedural stroke risks which were seen in the CREST trial as well as the ten-year follow-up from the CREST trial.3,4,12 The investigators from the Casper Stent System study suggest that the reduction in stroke and embolic events seen with their stent, are possibly as a result of its one of a kind dual layer design.3

 

Conclusion

The patient that was included in the introductory case presentation of this paper, despite being asymptomatic, did have a greater than 80% occlusion of the left internal carotid artery (ICA). He was taken to the operating room the day following his office visit and a CEA was successfully performed. Left, is a picture of the atheroma that was removed. Postoperatively he was admitted to the ICU where he developed some hypertensive issues requiring a continuous IV Nicardipine drip to help maintain an acceptable blood pressure. He didn’t experience any postoperative bleeding, neurological symptoms, or swelling.

Most patients that are seen on the vascular surgery service can be adequately assessed for the need of carotid revascularization based on the degree of stenosis and whether or not they are experiencing symptoms or remain asymptomatic. Currently the method of choice for carotid revascularization remains CEA.1 However, in select high-risk patients with special anatomic considerations such as a “hostile neck” secondary to trauma, past surgery, or radiation, it is reasonable to consider pharmacologic or CAS therapy.1,9 Fortunately, CEA comes with a very low (<1%) risk of intraoperative or postoperative stroke if done by an experienced vascular surgeon, and offers the patient a significant risk reduction of experiencing stroke or TIA in the future.

Lastly, while the use of balloon angioplasty and stenting for coronary artery disease has been very successful, the use of stents in carotid disease has yet to prove superior to CEA in randomized controlled studies.6,8,9 CAS has emerging promise for those suffering from carotid disease in the not too distant future.3 As stent design evolves and pharmacologic protection of against embolus formation improves, CAS may be the way of the future for many vascular surgery services.2,3 The results of the CREST-2 Trial that are expected in 2020, will be interesting to see and will likely help reshape how we approach various aspects of carotid disease treatment.7 Stay tuned!

References:

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5. Brott TG, Howard G, Roubin GS, et al. Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis.

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6. Howard VJ, Meschia JF, Lal BK, et al. Carotid revascularization and medical management for asymptomatic carotid stenosis: Protocol of the CREST-2 clinical trials.

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2017;12(7):770-778.

7. Safian RD. Asymptomatic Carotid Artery Stenosis: Revascularization.

Prog Cardiovasc Dis.

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8. Yu C, Han X, Zhang XL, Yu B, Dong Q. Long-term effects of white matter changes on the risk of stroke recurrence after carotid artery stenting in patients with symptomatic carotid artery stenosis.

J Neurol Sci.

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9. Cremonesi A, Castriota F, Secco GG, Macdonald S, Roffi M. Carotid artery stenting: an update.

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10. Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis.

J Vasc Surg.

2017;66(2):607-617.

11. Simpson RJ, Akwei S, Hosseini AA, MacSweeney ST, Auer DP, Altaf N. MR imaging-detected carotid plaque hemorrhage is stable for 2 years and a marker for stenosis progression.

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12. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients.

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