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Eyeing World Healthcare

February 1, 1998
by Polly Schneider
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Eyeing World Healthcare

By Polly Schneider

The advent of advanced communications technology and its increased availability worldwide is promoting ties between people and nations where before there were none, bridging the gap between isolated rural communities and major metropolitan areas and providing a higher quality of life. At the same time, concerns in healthcare are swiftly becoming more global. Many regions of the world are confronting the same pressing issues-spiraling healthcare costs, demand for better quality of care, and a lack of data on effective treatment methods.

Increasingly, other countries are recognizing that information technology is the essential missing link to address these needs. Healthcare executives around the world realize that their goals with IT are shared: developing clinical information systems and the CPR, achieving standards, safeguarding patient privacy, exploiting the Internet, and networking systems in an enterprise. Making the effort to work with other nations on these initiatives can help us all reach solutions more quickly. In some areas of standards, our international counterparts are way ahead of the game: In Europe, for instance, work on privacy, confidentiality and security standards is quite advanced. Collaboration can prevent wasteful duplications of effort.

The problems facing IT leaders in other countries will also affect our plans here in the U.S. The Europeans are having to adapt their systems for the Euro, the common currency scheduled to debut in 1999: American companies doing business in Europe will have to program their software to accommodate the new currency. And in preparing for the year 2000, it is in our best interest to ensure that our overseas counterparts do the same. In an interview on page 96, international healthcare informatics expert Marion Ball discusses the importance of international awareness and partnerships: "The bottom line is we have no choice. We either stand together or we fall." Ball is convinced that healthcare-both technology and knowledge-will be a major export of this country in coming years.

The tech firms are already broadening their domestic perspective. Industry experts predict that American healthcare information system companies are at the brink of an explosion in demand from abroad. More than 25 of the leading vendors are churning revenue streams overseas, and companies that have been in foreign markets for years, like MEDITECH, Westwood, Mass., are seeing growing potential in healthy economies like the United Kingdom: The company has products installed in 20 U.K. hospitals. The purchase of Medic Computer Systems--the fourth-largest healthcare IS firm in 1997--by U.K. software giant Misys, and HBOC’s acquisition of two U.K.-based AT&T businesses last fall are likely just a taste of the kinds of deals we’ll see in the industry this year and beyond.

Europe may well become a lucrative market for American products and services since reforms in healthcare structuring and financing have been sweeping the continent over the past few years, bringing more private companies and resources to the table.

And in the Tiger economies of the Pacific Rim, government-mandated construction and modernization in healthcare is attracting Western firms hand over fist to places like Malaysia, Singapore and Hong Kong.

Still, technology is not the panacea for the world’s ills. Unrest and instability persist in every major region. The spectacular collapse of financial markets in Asia has threatened that region’s vital business and economic relationships with the U.S., invoking fear and distrust in investors and politicians alike. Despite such setbacks, a return to isolationism is nearly impossible in today’s world.In an effort to monitor the trends in healthcare occurring around the globe, Healthcare Informatics introduces with this issue a new section devoted to international coverage. In coming months, look for news by region of emerging healthcare IT initiatives. In the meantime, we welcome both your news and your thoughts on healthcare IT around the world.


Technology Ambassador

With feet on three continents, Marion Ball is devoting her career to uniting worldwide healthcare

By Polly Schneider

Marion J. Ball, EdD, is one of the leading voices for clinical informatics in the international community, having served in leadership roles at the International Medical Informatics Association (IMIA) and several academic medical centers in the U.S. She consults overseas regularly for First Consulting Group and continues as an active member of IMIA. A champion of international collaboration on such pressing issues as security, privacy, standards and the computer-based patient record (CPR), Ball is a firm believer in the growing impact of the world market on the delivery and use of healthcare information technology. In talking about U.S. initiatives for an expanded role overseas in healthcare, her enthusiasm abounds: "America is the most fabulous country in terms of sharing its knowledge worldwide. I’m very happy to be part of that initiative."

From her German heritage and experiences growing up in South Africa under the tutelage of her physician father, a pioneer of sports medicine in the United States, Ball brings a unique perspective to the industry. She has devoted a lifetime to the pursuit of clinical automation: Her passion is to improve the quality of healthcare worldwide through the advancement of information technology. Ball sees the globalization of healthcare as an inevitable consequence of economic progress.

How important are international groups like IMIA becoming to the industry?
Information cannot be imprisoned in any one country or any one region. Through the financial market and the airline industry we’re seeing partnerships that go way beyond the borders of the U.S. I think IMIA saw it even earlier on as it pertained to healthcare. Now IMIA is becoming even more important because we all realize that the problems we have in our country are so similar to what others are experiencing in places like Scandinavia and the Pacific Rim.

How can we learn from each other’s mistakes, capitalize on each other’s successes and share in the knowledge about the enabling technologies that will help us improve the health of the world, not just the health of the nation? Technology is a wonderful ambassador that knows no politics, and health transcends politics as well. IMIA’s influence will escalate to a tremendous degree in the next 5-10 years because we are realizing that we are a global economy and a global healthcare delivery system.

Why do we need to know what other countries are doing in this industry?
It’s really a political question. Right now, if we were to ignore everything that Saddam Hussein is doing, the world could come to an end. Think of it as an epidemic-could we close our eyes to the fact that other countries may be developing germ warfare? We are one planet and one people. With the kind of communications we have now, we are no longer able to be isolationists. The bottom line is we have no choice. We either stand together or we fall.

How can we learn from our international counterparts?
We are not nearly as sophisticated in the area of data protection, security, confidentiality and privacy as the Europeans. The Germans have done probably more work on that than anyone. Work that’s being done in Scandinavia is seminal. These are policy areas we are only now beginning to address. In the area of the CPR, some of the early work by Scandinavian Hans Peterson in setting up computer records for Kuwait and Sweden offers good models. This was done more than 15 years before the documents on the CPR came out of the Institute of Medicine.

And the whole concept of primary care is the foundation of healthcare in Europe. In the Netherlands, general practitioners are much more automated in their practices. In Holland, 70 to 80 percent of the private-practicing physicians and GPs are computerized. There is a definite humbling experience going on in the American informatics community. They are realizing that they no longer, or never were, the only kings of the mountain. Now that we can work together globally we can be far more powerful than trying to develop things in parallel.

Why has progress on international standards in healthcare been so slow?
I think we’re at the stage where we had narrow gauge railways and wide gauge railways. It took 100 years to get a standard railway tie internationally. Things like traffic lights and putting the stamp in the upper right hand corner of the envelope sound primitive, but those are the kinds of standards we have to come to grips with as we put together the electronic patient record. The electronic patient record is a process, not an end. It will never be complete. It is an enabler to improve clinical practice and move the U.S. toward evidence-based medicine. It is the underpinning for the whole way in which clinical information will be standardized and accurate.

What do other countries look to the U.S. for?
One of the things that Americans can do better than other countries is change more rapidly. What was positive about the Hillary Clinton healthcare initiatives is that they really shook up the country, and the private sector decided it did not want a government-run healthcare system. That doesn’t mean we have the answer yet, but the point is we are evolving, changing and experimenting. This reinventing and reexamining of the administrative, cultural and behavioral aspects of healthcare is showing results in our country and the Europeans are starting to take notice.

However, it’s almost curious when you consider that our percentage of healthcare spending is almost twice that of Europe and other regions.The two ideas are not incongruous. My current affiliation is with Johns Hopkins Medical School and they get three percent of their total revenues from international patients. Why do they come here? Because the best healthcare is still in America. Sure it costs a bloody fortune. But they’ve got the money and they’re paying because they cannot get it anywhere else. You get what you pay for. A lot of the future will lie in the ability of enabling technologies to get costs into line and hopefully get good quality of care.

Have you seen any technological innovations from abroad that we could benefit from here in the U.S.?
Despite significant activities elsewhere, the U.S. is still the leading innovator. Smart cards are the only area we might copy soon.

How significant will the overseas market become for U.S. healthcare IT companies in the next few years?
I think it will be a steady change. The curve is starting to rise, but it’s only just begun. And I think it’s going to go both ways. Right now the stock exchange is a very good example. Look how affected we are by what’s happening in Hong Kong and in the Japanese market. Health, not only in technology but also knowledge and medical consultation will be one of our biggest exports.

Where do the best opportunities for American companies lie?
For Americans, language is still a tremendous barrier, so if we look to those countries that were part of the British empire, that’s a very good place to start. There is also a lot of activity in the Asia Pacific region--Singapore, Hong Kong, Australia, New Zealand, Malaysia. Those countries are on the springboard to jump head first into a very deep pool of assets and move into the developing world. Even though they are huge markets, it will be a lot more difficult to infiltrate China and Eastern Europe.

What makes your international work meaningful for you?
I think I can make a difference. I do believe that every individual has a responsibility to their society. My ability to work with people and see how we can affect the improvement of healthcare on a global basis is important to me. I’m proud to have been able to do that over the last 30 years. Now I’m in a position to work with power players. These are people who have funding, who listen, and who value knowledge. I feel that being in this setting I can help improve healthcare for the world community. I will keep going and I will never retire. I will do this until the day I die.


Marion Ball: Cultural Intersect

It is only after you speak with her on several occasions that you begin to detect a faint accent beneath the fervor in her voice for her work and the field of medicine. Marion Ball was born in South Africa to German parents who had the foresight to leave Germany in 1932 and begin a new life on the African continent. The family later emigrated to the United States when Ball was in high school.

Ball is fluent in German and speaks Afrikaans, and travels across the globe to speak on healthcare and clinical informatics, and to advise foreign healthcare systems on behalf of First Consulting Group. She also lectures widely as a representative of various academic institutions and professional organizations. She was on the ground floor of the formation of the International Medical Informatics Association (IMIA) from its humble beginnings as a working group of the International Federation of Information Processing, and served as IMIA’s first female and first American president from 1992-1995.

"My long involvement with IMIA, over 20 years now, has helped me realize some of my dreams of bringing information when, where and how it’s needed in an international arena," Ball says.

Ball began her career in computing before it was even considered a field. In 1956 during high school, she began taking computer courses at the University of Kentucky, and went on to earn a B.A. and M.A. in differential equations. Even though there were no degree programs in computer science at the time, Ball notes: "I took every computing course I could get my hands on." As a programmer and instructor in the medical center, she was involved in the development of one of the country’s first clinical lab information systems. "I’ve been so fortunate in having grown up with the field of health informatics from the get go," Ball says.

Ball is also an educator: She taught high school briefly and later earned a doctorate in continuing medical education at Temple University in Philadelphia. To this day, she maintains strong ties to the academic medical community, recently moving from the University of Maryland to Johns Hopkins University where she is an adjunct professor in the school of nursing.

Ball gives credit to her father, Dr. Ernst Jokl, a pioneer in American sports medicine, for her passion for healthcare. Last year, the main plaza at the Sports University in Cologne, Germany was named after him. She attributes her determination to excel to her mother, Erica Jokl, a gold medalist in the 1928 Olympics.

More than 30 years working in the field has not dampened her enthusiasm--if anything she is even more motivated. In 1996, she left a full-time career in the academic world to join First Consulting Group for the chance to expand her outreach internationally. Her goals in the field, she says, are "life-long learning," and the application of "enabling technology to enhance the learning of the health scientist."


Polly Schneider is senior editor at Healthcare Informatics.


U.S. Exports managed care successes

By Lisa Paul

The United States is becoming an expert in two areas: controlling healthcare costs and creating applications software, according to D. Clive Ashenden, president of the International Federation of Health Funds and managing director of the Medical Benefits Fund of Australia. "Information technology and consumerism are the two forces coming together that will change the world," said Ashendon, speaking to healthcare executives from 40 countries at a recent summit on international managed care in Florida. The summit was sponsored by the Academy for International Health Studies, Davis, Calif.

Although the United States does not provide universal healthcare for its population, as do most other countries, the advent of managed care has brought some good to the healthcare industry. Costs are going down.However, lack of choice has been one of the casualties caused by the switch to managed care. Primary care physicians act as the gatekeepers to more specialized care; and procedures that can be done on an outpatient basis usually are. Still, consumer demand continues to help redefine today’s U.S. healthcare system, and newer offerings like point-of-service health plans are giving Americans an alternative to the traditional HMO or PPO.

But most Americans remain skeptical of managed care. According to Michael Herbert, chairman of the board for the American Association of Health Plans, the American media continue to "comfort the afflicted and afflict the comforted."Despite the many short-comings of American-style managed care, healthcare officials around the world are interested in the methods and madness that are cutting costs in the U.S. healthcare system--and the IT tools needed to gather and analyze the data.

Information collectionNowhere is there as much technological investigation and innovation as in the United States: Bill Gates, Steve Jobs and Andy Grove are just a few of the leaders shaping the future of the digital world. Many countries look to the United States not only for its technology, but also for its expertise.Information technology can help healthcare officials in other countries address two main needs: the migration toward managed care business models and the integration of information. Some regions, such as Latin America, are beginning to embrace the idea of managed care by setting up health plans. Since these organizations are starting from scratch, physicians and administrators may not need the latest and greatest technology.

When Manolo Centeno, MD, director of Cuidamed HMO in Caracas, Venezuela, started investigating computer systems in the United States, he was convinced that his organization had to begin with an Oracle database. However, over time, Centeno realized that he had to worry about his immediate needs first. "You don’t need a Mercedes when a Ford will do," he says.

According to Catherine Roth, president of Health Systems Design in Oakland, Calif., these new companies need to start with the basics--financial and claims information systems. Databases and other technology important to collecting outcomes data will come later.

At the beginning of IT implementation, vendors can help managed care organizations become more standardized in the processes everyone should be doing electronically, Roth says. "Don’t get stuck on the idiosyncrasies most managed care organizations get stuck on," she warns. "Marketing leverage comes from providing quality care--not from how you create cute ID cards."

Meanwhile, in the Pacific Rim and Western Europe, IT needs are often more sophisticated--interface engines and other integration tools are in demand.

Although each region of the world presents a unique set of challenges to IT vendors, information systems will play a large role in breaking down the walls between people and cultures. U.S.-style managed care may not be global, but it certainly is becoming an exportable model for containing healthcare costs in other regions of the world.


Lisa Paul is editor of InfoCare.



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