National Health Care Systems Globalization and Virtual Infrastructures

American Medical Informatics Association Spring CongressOrlando, Florida

May 22-24, 2007

Ann C. Séror, MBA, PhD

eResearch CollaboratoryURL: http://www.eresearchcollaboratory.comEmail: annseror@eresearchcollaboratory.com

OBJECTIVES:

To present a framework for study of virtual infrastructures in national health care systems.

To suggest issues for future research andintervention.

INTRODUCTION

The Commonwealth Fund Report:

Mirror, Mirror on the Wall: An International Update on the Comparative Performance ofAmerican Health Care (May, 2007)See www.commonwealthfund.orgRanking of UK, Germany, New Zealand, Australia, Canada and the US on quality, access, efficiency, equity and healthy lives

Health Care SystemsA health care system is a dynamic set of interconnected individuals, institutions, organizations, and projects offering products and services in health care markets:

Information Research Education Public health Patient care - preventative and curative

Virtual Infrastructures

Overlapping distribution networks, systems brokerage functions, and the adoption of a software perspective emphasizing the devices and channels through which information is processed and distributed.

Accessibility through Internet websites and gateways designed to facilitate integrated use of the resources.

“VIRTUAL” describes any web-based service, organization or institution arising from the technical infrastructure defined above.

Economic analysis of national health care systems shows that the important positive correlation between gross national product and indicators of health care quality such as life expectancy is mediated by variables related to equitable distribution of wealth as well as rates of public expenditure in the healthcare sector.

Source: Sen A. Economics and Health. The Lancet 1999;354:20

According to evolutionary economic theory, the transformation of organizational systems must be examined within their social and institutional contexts. This transformation emerges through the “co-evolution of physical and social technologies”where social technologies include institutions and their network configurations.

Sources: E. J. Castilla, "Organizing Health Care: A Comparative Analysis of National Institutions and Inequality Over Time," International Sociology, vol. 19, pp. 403-435, 2004; and R. R. Nelson and B. Sampat, "Making Sense of Institutions as a Factor Shaping Economic Performance," Journal of Economic Behavior & Organization, vol. 44, pp. 31-54, 2001.

Global health care services markets and networks exert powerful influences on the institutional ecologies of national health care systems. These pressures pose the convergence hypothesis.

Compatibility between organizations and the characteristics of their environments. Response to external requirements for legitimacy rather than functional efficiency or effectiveness in local service delivery.

Source: P. DiMaggio and W. Powell, 1983, "The Iron Cage revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields," American Sociological Review, vol. 48, 147-160.

Ideology: integrated theories and values that constitute a coherent socio-political system expressed in patterns of stakeholders’participation in financing, administration, and regulation of health care.

Research ProgramNational Health Care Systems

Infomed – Cuban national health care network and portal, Ministry of Health See Séror ACA Case Analysis of INFOMED: The Cuban National Health Care TelecommunicationsNetwork and PortalJournal of Medical Internet Research, 2006;8(1):e1<URL: http://www.jmir.org/2006/1/e1/>

Ministry of Health and Family Welfare - IndiaMinistry of Health Online – UgandaKaiser Permanente – USABritish National Health Service – NHS – UK See Séror ACInternet Infrastructures and Health Care Systems: a Qualitative Comparative Analysis on Networks and Markets in the British National Health Service andKaiser PermanenteJ Med Internet Res 2002;4(3):e21<URL: http://www.jmir.org/2002/3/e21/>

COMPARATIVE COUNTRY CONTEXT

Country Cuba Uganda UK India USA

Population (millions) 11.3 28.8 59.7 1,103.4 298.2

Total Health Expenditure per capita (Int. $-2004

229 135 2,560 91 6,096

External Resources (% of total health exp.)

0.2 28.5 0.0 1.6 0.0

Private exp. (% of total health exp.)

13.2 (2003) 69.6 (2003) 14.3 (2003) 75.2 (2003) 55.4 (2003)

Out-of-pocket exp.-percentage of private exp.

75.2 (2003) 52.8 (2003) 76.7 (2003) 97.0 (2003) 24.3 (2003)

Life expectancy (m/f –WHO 2004)

75/80 48/51 76/81 61/63 75/80

Child Mortality (m/f per 1000 population-WHO 2004)

8/7 144/132 6/5 81/89 8/7

Physicians per 1000 population (WHO 2004)

5.91 0.08 2.30 0.60 2.56

Literacy(CIA World Factbook2003)

97.2/96.9 79.5/60.4 99/99 59.5/48.3 99/99

Qualitative Case AnalysisQualitative case analysis is a research methodology particularlyappropriate to the study of the health care sector. Ragin CC. The distinctiveness of case-oriented research. Health Services Research, 1999, 34(5 Pt 2):1137-1151.

Technological innovation and economic globalization drive rapidchanges rendering nomological model identification elusive. Idiographic case research methods offer tools for descriptive analysis and assessment of complex health care management systems within their social, economic, and cultural contexts. Sources: Séror AC. Internet infrastructures and health care systems: a qualitative comparative analysis on networks and markets in the British National Health Service and Kaiser Permanente. Journal of Medical Internet Research, 2002, 4(3); Yin RK. Enhancing the quality of case studiesin health services research. Health Services Research, 1999 ,34(5 Pt 2):1209-1224.

Multiple sources of data include:Published research. Internet sites of the health care institutions. Network configurations.Interviews.

Health Care Markets: Four Models

Control

MarketDynamics

Clans Hierarchies

SupplyPush

ProfessionalCovenents

NationalConstitutions

DemandPull

Free Markets BusinessContracts

Norms and Standards : Behavioral Control- CLANS Institutional Infrastructures : HIERARCHIES

SUPPLY-PUSH

PROFESSIONAL COVENANTS* PROPRIETARY NETWORK STRUCTURE (WAN/LAN).*Distributive multi-agent system architecture.*Subject gateways. *Associative clinical process integration. (medical specialties)

*Access controlled by healthcare professionals.

*Decentralized professional authority. *Professional criteria for presentation of Web content and other

electronic healthcare information.*Professional certification of healthcare workers, services and

institutions.____________________________________________PROFESSIONAL VALUESExample: American Medical Association -http://www.ama-

assn.org/

PRINCIPLE: Professional norms, Hippocratic oath.

NATIONAL CONSTITUTIONS*PROPRIETARY NETWORK STRUCTURE (WAN/LAN). *Federation architectures.*Institutional gateways.*Federative structural integration.

*Access controlled by institutional and telecommunications network structures.

*Centralized national and regional hierarchies.*Institutional standards for presentation of Web content and other

electronic healthcare information.*Institutional certification by network affiliation.

_____________________________________________CITIZENSHIP VALUESExample : British National Health Service -http://www.nhs.uk/

PRINCIPLE : System performance effectiveness: Universal service and citizen equality. Social contract.

DEMAND-PULL

FREE MARKETS*OPEN INTERNET NETWORK STRUCTURE.*Search engines.*Dynamic associative integration.*Access controlled by individual consumer choices and

availability of products and services in the market. *Decentralized and deprofessionalized authority with individual

consumer participation. *Certification of products and services by independent evaluators.

*Criteria for individual consumer evaluation of web content andother electronic information developed with consumer participation.

_______________________________________________ CONSUMER VALUES PRINCIPLE: Responsible self-regulation. Emergent norms.

BUSINESS CONTRACTS*PROPRIETARY NETWORK STRUCTURES.*Corporate gateways. *Federative business process integration. (business transactions) *Access controlled by collective choices and network structures.

*Managerial authority with enterprise hierarchies governing institutions.

*Certification of products and services by institutional evaluators, consumer organizations, and accreditation agencies.

*Criteria for collective consumer evaluation of web content and other electronic information by accreditation agencies.

___________________________________________MANAGERIAL VALUESPRINCIPLE: Consumer contract efficiency.(cost/benefit)

Health Care System Transformation

Pressures for collaboration, data-sharing and access to distributed resources increase the focus on interconnection of services both within and across institutions.

Technological trends and commercial pressures foster service decomposition and distribution through networks rather than host-centric systems.

Three generations of medical informatics system evolution:System creation at the enterprise or institutional level beginning in the 1960’s.

Integration of enterprise architectures in the 1980’s

Horizontal linkage and coordination across contemporary system boundaries.

Effective contemporary systems encompass components of all three generations.

The Cuban National Health Care System

Evolution of the CNHCSDevelopment of a science base and infrastructure (1959-1973):early transformation of the health care system and creation of integrated polyclinics (1963) to serve the Cuban population.

Elaboration of a centralized management model (1974-1989): integration of information from various sources through institutional information architectures. Introduction of community medicine (1974) and subsequently (1984) the family doctor-and-nurse model.

Horizontal coordination and globalization through virtual infrastructures (1990-present): emphasis on national infrastructure for institutional linkage through Infomed and integration in international telecommunications infrastructures.

The Virtual Medical LibraryElectronic access to diverse publications through the Cuban VirtualMedical Library (1992): - The U.S. National Library of Medicine.- Medline. - The Cuban National Library of Medicine.- The collection of specialized Cuban medical journals.

Foreign authors contribute articles translated into Spanish, thus creatinga controlled electronic information market in medicine and healthsciences.

The Cuban VML integrates resources from the developed anddeveloping world with a view to present the most advanced scientificresearch, accounts of medical experience in developing countries, anddocumentation of natural and traditional approaches to medicine.

The Virtual UniversityInaugurated by the Ministry of Public Health in 1999, the VirtualUniversity offers: - An international center for postgraduate education in

medicine and related disciplines. - Linkage between the health care publication infrastructure

and Cuban university resources. - Linkage to international content such as the supercourse,

Epidemiology, the Internet, and Global Health. - A Virtual Clinic for expert consultation among associated

physicians and healthcare professionals. - A forum for discussion of cases presenting particular

pedagogical value.

The interactive design of the Virtual University promotes a market for reciprocal sharing of expertise and learning.

An Example: The Pediatric Surgery National NetworkRed Nacional de Cirugía Pediátrica (RENACIP)

Selection of the lead network institution: the Pediatric TeachingHospital "Octavio de la Concepción de la Pedraja" of Holguín by the Cuban Ministry of Public Health in 2001:

To develop the specialty of pediatric surgery throughout thecountry.To make available high quality research results for thepractice of this specialty.To link the resources of all the concerned health care institutions across the country.

Source: Trinchet Soler RM, Pedrianes Vigo M., Origen, estado actual y perspectivas de la RedNacional de Cirugía Pediátrica. Acimed 2004; 12(3). Available at: http://bvs.sld.cu/revistas/aci/vol12_3_04/aci11304.htm

Network DevelopmentIdentification of regional experts.Creation of a discussion list for cases treated by designatedexperts or through collective consultation and analysis.

Best practice protocols.- Evidence-based development.- Face-to-face discussion for approval.Provincial university and enterprise alliances with the CubanEmpresa de Servicios InformáticosA virtual library specialized in pediatric surgery.Linkage to international discussion lists focused on this andrelated specialties.

Characteristics of the CNHCSA systems perspective integrating health care service delivery, research, information resources and education.

Horizontal coordination and integration through INFOMED and telecommunications infrastructures with vertical control throughMINSAP and government hierarchy.

Government and health care administration serving social control, universal citizen access and humanitarian service.

Dual health care service market structure with emphasis on open information markets in education, research and practice supporting trade on international services markets.

Ethical Considerations

Privatization of information and science.

Protection of intellectual property.

Individual privacy and the common good.

Transferability and System Development:Critical Issues

System scale.Ideology

Intellectual property and innovationIndividual privacy and confidentiality

Government and health care administrationPublic and private sectorsModern and traditional medicineCultural, ethnic and linguistic diversityEducational attainment – literacyResearch community and innovationExternal ControlRole of human resourcesEthics

FUTURE RESEARCH

Evidence-based design of sustainable social systems.

Development of quantitative and qualitative methodologies for system description and evaluation.

Cross-national research programs.

References

1. Séror A. A Case Analysis of Infomed: The Cuban National Health Care Telecommunications Network and Portal. Journal of Medical Internet Research 2006;8(1):e1. Available at: http://www.jmir.org/2006/1/e1/

2. Séror A. Internet Infrastructures and Health Care Systems: A Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser Permanente. Journal of Medical Internet Research 2002;4(2). Available at: http://www.jmir.org/2002/3/e21/index.htm

3. Dallago B. The Organizational Effect of the Economic System. Journal of Economic Issues 2002;36(4):953-979.

4. Séror A. The Internet, Global Healthcare Management Systems and Sustainable Development: Future Scenarios. The Electronic Journal on Information Systems in Developing Countries 2001;5. Available at: http://new.ejisdc.org/ojs/index.php

5. Ashby WR. Design for a Brain: The Origin of Adaptive Behavior. New York: Wiley; 1960. 6. Ostrom E. Designing Complexity to Govern Complexity. In: Hanna S, Munasinghe M, editors. Property

Rights and the Environment: Social and Ecological Issues: The Beijer International Institute of Ecological Economics; 1995. p. 33-45.

7. Reich M. Reshaping the State from above, from within, from Below: Implications for Public Health. Social Science & Medicine 2002;54(11):1669-1675.

8. Mechanic D. The Comparative Study of Health Care Delivery Systems. Annual Review of Sociology 1975;1:43-65.

9. Mechanic D, Rochefort D. Comparative Medical Systems. Annual Review of Sociology 1996;22:239-270. 10. DiMaggio P, Powell W. The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in

Organizational Fields. American Sociological Review 1983;48(2):147-160. 11. Baum J, Oliver C. Toward an Institutional Ecology of Organizational Founding. Academy of Management

Journal 1996;39(5):1378-1428. 12. Yin R. Case Study Research: Design and Methods. London: Sage; 2002. 13. Yin R. Enhancing the Quality of Case Studies in Health Services Research. Health Services Research

1999;34(5):1209-1224.