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National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System; Reid PP, Compton WD, Grossman JH, et al., editors. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington (DC): National Academies Press (US); 2005.

Cover of Building a Better Delivery System

Building a Better Delivery System: A New Engineering/Health Care Partnership.

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Engineering and the System Environment

Paul C. Tang

Palo Alto Medical Foundation

I will address three questions: (1) how engineering can help determine characteristics of a desirable information infrastructure; (2) how engineering can help establish data standards; and (3) how engineering can help build an information infrastructure for health care.

Ethnography, the social science method of studying human cultures in the field, is a useful technique for understanding information needs in the health care environment. A derivative technique, video ethnography, includes the video recording of subjects in their natural state. With the consent of patients and physicians, we used observational ethnography and video ethnography to study the information-seeking habits of physicians.

Time and motion studies have shown that physicians spend up to 38 percent of their time foraging for data in the paper medical record and creating more data for the record (Mamlin and Baker, 1973). Formal studies of physicians' information needs showed that 81 percent of the time they were unable to find one to 20 pieces of information (four pieces on average) important to a specific patient visit at the time decisions were being made (Tang et al., 1994). Although physicians often spent additional time trying to track down the missing information, including asking patients what they might have heard, they often ended up making decisions without the information, even though they had the paper-based medical record 95 percent of the time. In summary, although clinical decision making depends on the availability of patient data, domain information, and administrative information, these data are routinely not available when physicians make patient-care decisions.

In Crossing the Quality Chasm, the Institute of Medicine stated that “American health care is incapable of providing the public with the quality health care it expects and deserves.” Furthermore, “if we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes” (IOM, 2001). There are many challenges to be overcome in transforming health care via information technology. Some of the environmental barriers to the adoption of information technology are: high capital acquisition costs for electronic medical records (EMR); an inadequate supply of fully functioning EMR systems; high training costs for EMR implementation; and uncertainty about who will pay and who will benefit.

Another challenge facing the health care system is the lack of an effective mechanism for knowledge diffusion. Even though medical knowledge is increasing very rapidly, the diffusion of medical knowledge into practice has been limited by the absence of decision support at the point of care. Compliance with the guidelines for influenza vaccinations is a good example. It is well known that administering the influenza vaccine to eligible adults can halve the death rate, halve the hospital admission rate, and halve the costs associated with outbreaks of influenza. Nevertheless, because of human oversight, physicians immunize only 50 to 60 percent of the eligible patients they see during flu season. Simple computer-based reminders at the time of a patient's visit have been shown to increase adherence to the simple clinical guideline by 78 percent compared to controls (Tang et al., 1999). Engineering techniques, such as EMR systems that remind physicians at the moment of opportunity, have been proven effective.

Another area of opportunity for engineering is in resolving cross-organizational issues that impede health care delivery. Health care is delivered in many settings, by multiple providers, and over a period of time. Yet, because of an absence of standards, neither the paper system nor computer-based systems allow for the seamless, reliable exchange of data across settings of care. The current health care delivery model is highly fragmented and poorly designed. Furthermore, current health care financing schemes create disincentives to the creation of any kind of system of care. Engineering could make a major contribution by applying systems design and analysis techniques to the health care delivery system.

Another area of opportunity is at the interface between devices and information systems. As living beings, patients constantly emit signals, but there is no instrumentation to capture and filter those signals. At best, information is gathered at random intervals determined by the vagaries of matching schedules rather than by clinical events. As the care of patients is transferred from one clinic to another or to a specialist or to a hospital, the inefficiency of these “handoffs” further impedes the delivery of coordinated care. We have also failed to provide patients with tools to help themselves. We must do a better job.

Engineering can help provide methods for the continuous gathering of data at patients' homes, the automatic filtering of data, and alerts to care providers when there are deviations from expected control points. EMRs with evidence-based decision support can improve the diffusion and implementation of best practices. Collaborative work technologies—among providers and between patients and providers—could be applied to patient care.

In short, twenty-first century clinicians have been practicing medicine with twentieth-century information tools. We need a National Health Information Infrastructure (NHII) to support the information-driven practice of contemporary medicine. This infrastructure would consist of standards for connectivity, system interoperability, data content and exchange, applications, and laws. The challenge is to design, develop, and implement these necessary systems in a resource-constrained environment. Financing NHII and reimbursing the costs of ongoing operation will be key to the widespread adoption of engineering and information technology that supports the delivery of care.

There are many engineering opportunities in building the NHII. First, we will need a technical infrastructure that includes standards to enable systems to interoperate technically and semantically. Second, the system must have an application infrastructure that supports mobile, secure, and robust functionality that can access patient information wherever it is stored. Third, there must be an interoperable method of storing structured, executable knowledge that can be used at the point of care by any qualified provider. Fourth, policies must be in place to protect sensitive, confidential patient information stored and transmitted by these systems. And finally, there must be a financing and incentive model that provides investment resources for the implementation and continuing operation of patient care systems.

Engineering opportunities abound to address the information-technology needs of health care. At the top of the list is the need for a systems perspective and repertoire of methods in the study and design of a rational health care system that serves the diverse needs of current and future patient populations. Monitoring technologies that process and interpret high-volume data and mine the important information therein would be useful. A secure, wireless infrastructure would support patient and provider mobility. Interoperability, for both computers and people, would be important for collaboration among providers and patients. Knowledge diffusion tools would be important to help physicians keep up with fast-paced advances in medical knowledge. Tools to assist with distributed authoring of key technical standards would help accelerate the development of essential technical standards. Methods of managing the constant queues in scheduling scarce medical resources would help distribute medical services to those who need them.

In summary, delivering patient-centered, evidence-based, safe care is an expectation of twenty-first century health care. To deliver on that expectation, we need sophisticated, computer-based tools, and an NHII. That is the engineering challenge—and the engineering opportunity.


  1. IOM (Institute of Medicine) Washington, D.C: National Academy Press; 2001. Crossing the Quality Chasm: A New Health System for the 21st Century.
  2. Mamlin JJ, Baker DH. Combined time-motion and work sampling study in a general medicine clinic. Medical Care. 1973;11(5):449–456. [PubMed: 4744980]
  3. Tang PC, Fafchamps D, Shortliffe EH. Traditional medical records as a source of clinical data in the outpatient setting. Proceedings of the 18th Symposium on Computer Applications for Medical Care; Philadelphia: Hanley & Belfus Inc. Medical Publishers; 1994. pp. 575–579. [PMC free article: PMC2247843] [PubMed: 7949993]
  4. Tang PC, LaRosa MP, Newcomb C, Gorden SM. Measuring the effects of reminders for outpatient influenza immunizations at the point of clinical opportunity. Journal of the American Medical Informatics Association. 1999;6(2):115–121. [PMC free article: PMC61350] [PubMed: 10094064]
Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK22875
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