Special Projects

Chapter four

Special Projects

No health-care system is an island.

A few years ago, a new Microsoft employee was called back to his home state because his mother had suffered a mild stroke. When she was well enough to leave the hospital, Mrs. Jones (not her real name) stayed with her sister while her son completed plans to move her near him. Mrs. Jones largely recovered but was never able to live on her own again, and her periods of good health were interrupted by hospital stays to treat more and more serious problems.

The medical events of the last two years of Mrs. Jones’s life show the best and the worst of the American health-care system. She received good care, including a number of very new treatments, from three different hospitals and more than a dozen doctors in two different states. As her physical abilities declined, her middle-class family was able to find good facilities providing greater degrees of care. Medicare and her own private insurance paid most of the bills; she and her family paid the rest. Her many doctors, nurses, and other care givers were professional and kind.

But the system was far from perfect. When Mrs. Jones left the first hospital for her sister’s hometown fifty kilometers away, a communication failure between doctors meant that her medicine was kept at full strength when Mrs. Jones should have been on a declining dose. By the time she arrived in the North West, side effects of the high dose meant that she had to go into hospital immediately. Because her records didn’t come with her, a number of expensive tests had to be repeated.

The same thing happened when she changed hospitals a year later. Her final three-week hospital stay, which did not involve any surgery, still cost $25,000. At one point, a doctor confused her with another patient and told her next doctor that her recent hospital stays were “an abuse of the system.” This was less than a week before Mrs. Jones died.

These and other problems went on even though Mrs. Jones had her family to help her work through the confusing medical and social services options. Her son and daughter-in-law took turns spending many hours standing in line at one agency or on the phone with another. And it took a year before they could persuade one hospital to stop billing them for services that had been paid for in full.

Because of the many hospitals, doctors, care facilities, and public and private agencies involved, the amount of paperwork was enormous. Consider the number of people this paperwork represented. For every doctor and nurse who treated Mrs. Jones, there must have been a dozen billing people in several different organizations. It was like an old-fashioned military operation. For every soldier in the field, you had twenty people behind the lines handling administration.

Most experts estimate that 20 to 30 percent of the annual trillion-dollar cost of the US health-care system is spent on paperwork. In hospitals that number could be as high as 40 to 40 percent. A single week’s stay can create as many as a hundred pieces of paper. And, making things worse, about 13 percent of the one to two billion claims each year in the United States are returned for errors.

Paperwork and complexity have risen even as the US health-care industry has shifted to “managed care” in an effort to reduce costs, prevent fraud, and provide appropriate care. With managed care, an organization will contract with a group of doctors to provide medical services toward managed results, and for fixed fees. More than 160 million people in the United States were in managed-care plans at the beginning of 1997, the last year for which figures are available.

Doctors understand the need to control costs but feel buried in rules and layers of management. They’re afraid that their medical options may be limited and that the care of patients may suffer. They have also made the situation more complicated by treating patient files as business records and often hesitating to share them with competing doctors. And they’ve largely been opposed to computers, although that’s mainly because early medical systems were clumsy and expensive. Oddly, the managed care that many doctors love to hate may become the primary force that extends information systems into patient care and returns control of patient care to doctors. When you put enough clinically helpful information in front of doctors, they see the benefits and ask for more.

Patients, meanwhile, are recognizing how much more information is available to them on the Web and how this information gives them a sense of control and responsibility in maintaining their own health.

Clinical benefits have also encouraged health-care bosses to push for better information systems. Until now, health care has applied only 2 to 3 percent of its earnings to information technology, compared with the banking industry’s 15 percent. Although health care is a high-technology field, the technology has been applied to individual treatment systems, not to information flow. Often the information software that is used is not designed to work with other information software, despite all the health-care areas that should share data: the laboratory, the blood bank, charting, billing systems, and the machines that watch over patients.

Organizations have had to build special interfaces between the different software programs. A typical health-care organization can have hundreds of these interfaces. One organization currently manages 1,800 different interfaces. This complexity is one reason it has typically taken two years for a health-care organization to buy a new system and another two years to install it - too slow by any standard.

Today the situation is more encouraging. The US government has passed laws that require a standard to be defined for electronic finance and administrative dealings, including computer-based patient records. Better information handling in medical organizations will be a requirement in the future. Some health organizations, recognizing that their patients’ needs can’t wait, are showing strong leadership. They’re proving that a digital nervous system can be enormously valuable in all areas of patient care: from emergency services through hospital treatment, keeping in touch with patients, and long-term trend analysis.

Imagine you had a health-care system in your local community built from digital parts. An intelligent emergency system gets you to the hospital quickly, and all the important information on your medical history and current medical condition feeds immediately into the hospital’s computers. A doctor uses a touch screen, keyboard, or pen to order your treatment. Digital instructions are sent off to the laboratories. Computers supply laboratory results electronically. These and other reports are online for easy review by any doctor, on site or off. The system will tell doctors about any possible problems with the treatment or differences from the approved clinical path. Billing is handled automatically. Systems that process computer deals uncover fraud or unusual use.

Instead of spending half their time on paperwork, doctors and nurses spend almost all their time treating you and their other patients. Test results and bills reach you in simple, understandable language. All the information about your treatment and medicine is assessed automatically over the longer term to help prevent problems.

Your care after hospital is also scheduled automatically. You find medical information on the Internet and so your meetings with health workers are more informed, whether you communicate with them over the Internet, by e-mail, or you meet in person. You use e-mail to ask routine questions of your doctor and to be reminded about continuing health programs.

When you change health plans, all your medical history goes with you instead of being lost or following after you several months later. Doctors use your history to identify trends in blood pressure, weight, and other patterns that might reveal a serious developing problem. Systematic medical analysis of the whole community makes the authorities aware of any worrying public health trends much sooner and more accurately than has been possible before.

If health-care communities take an approach based on PC and Web technologies, abilities like these do not have to cost a fortune. PCs enable a step-by-step approach using standardized software. PCs are also now being used to control specialized machines such as blood and tissue analyzers, reducing their costs and enabling their data to be shared.

PCs are powerful enough to handle hundreds of thousands of claims or inquiries per hour. All together, the technologies described in this chapter would cost less than $5 million for a typical health-care organization. This is not a small amount of money, but it is minor compared with the amount most health organizations spend on paper-based work and stand-alone computer systems today. With paperwork making up 20 to 30 percent of the $1 trillion-plus per year earnings of the US health-care system, the current cost is $200 billion to $300 billion annually - more than the entire earnings of many countries.

Today the lack of information systems in doctors’ offices is the biggest barrier to improving patient care. Only about 5 percent of offices in the United States use computer systems in their clinical work. Computerizing a doctor’s office will cost from $10,000 to $50,000 for each one, but doctors can quickly recover the costs. A five-doctor office in Hammond, Louisiana, invested about $50,000 in PC patient systems that made it easy for doctors to enter data; the office saved $60,000 the first year in typing costs alone.

It will take a big effort from health-care providers to improve health care through digital information. The technology is available today. An investment in a shared infrastructure and tools will enable not just a huge reduction in costs, but better health treatment for everyone. Change will be driven by two groups: patients who insist on being better informed and more involved in their own health, and health professionals who use these new tools to provide better care. Together they’ll use a digital nervous system to turn the islands of health care into a single continent.

Take government to the people.

Government, maybe more than any other organization, can benefit from the efficiency and improved service that flow from digital processes. Developed nations will lead the way in creating paperless processes to reduce administration. Developing nations will be able to provide new services without ever having to deal with clumsy paper methods.

But most governments are far behind business in using the tools of the digital age. Businesses going digital are stuck with many paper forms because governments are not yet online. The reason for this delay is a lack of organizational purpose. Because government processes use a lot of paper and people, in the past making them more “efficient” often meant a reduction in service. It’s common for governments to forbid agencies to close any offices, which simply forces them to struggle to do more with less.

At the same time, there are few pressures to provide better service. Citizens can’t take their business to another tax agency or vehicle-license office. Government agencies tend to concentrate on their own internal organizational needs rather than the broad needs of citizens and businesses. As an example, consider the paperwork involved in hiring a child-care provider in the United States. The employer has to know that there are five agencies involved, each with its own set of forms. This complication, rather than a desire to avoid paying the taxes, explains why so few people follow the rules. In this and many other cases, to the average citizen government remains a threatening knot of separate agencies and rules.

But digital processes and the Web lifestyle give government the opportunity to change so that it is organized around citizens rather than administration. Governments can take five major steps to help make the digital age a reality in their countries. The first two involve improving government services; the last three involve creating an infrastructure so that a country’s businesses can compete in the digital age:

1. Put government employees on e-mail and get rid of paper filing. Make sure that all information inside government is digital.

2. Put government services online with an interface designed for the user. Publish everything on the Internet.

3. Attract investment by technology companies and encourage electronic commerce, sometimes with financial help, but more often with joint projects. Create a standard for the electronic identification of businesses and citizens.

4. Remove the rules that stop the communications industry from working efficiently. Encourage major investments in the communications infrastructure.

5. Improve the skills of citizens by using technology as part of education and training systems at all levels.

Government, like businesses, can make better use of software tools and e-mail to get far more benefits from technology investments. In developed nations many government employees and public officials already have PCs on their desks, and developing nations can put in a PC infrastructure for a small cost. The use of e-mail alone promotes cooperation between agencies and enables public officials to respond better to inquiries. Some US politicians are beginning to use e-mail to stay in touch with citizens, and Australia’s national parliament is using digital work flow to make sure that inquiries are followed up.

Governments need to make the decision to use digital information flow instead of paper. Internet publishing should be standard. Printed documents should be rare. The savings would be immense. The US government alone spends one billion dollars annually printing documents that are already available on the Web. Most copies of these documents are for public officials whose offices are already online. Most of the printed copies end up in the trash in the nation’s capital. Web publishing of all government documents can reduce costs and make information far easier to find. Digital systems are also better for complex documents. The government description of a transport plane, which companies need if they want to bid to build it, weighs more than a house in printed form, but the data would easily fit on a couple of CDs.

An online approach does more than simply reduce paper expenses. Web technology makes it possible for governments to provide a single point of contact for the public, a single online “face” to structure information according to what is important to the citizen.

In several Swedish cities, for example, webpages organize a variety of services from various levels of government. Citizens can quickly find passport offices, tax authorities, and national insurance offices. They can get reports from public meetings and other public documents. They can even get real-time reports on public transport, based on electronic information from the vehicles, either using the Internet or kiosks. A kiosk is just a PC designed for public use.

As the Internet provides the best way to interact with government, all citizens need to use it, even if they don’t have PCs themselves. If electronic kiosks that work like bank cash machines are placed in post offices, libraries, schools, and other public buildings, they can help governments improve services while reducing the cost of delivery.

Online systems are most useful for citizens and most efficient for government when they have more than one purpose. Governments should review all their dealings with citizens that require them to stand in line or fill out forms. Government should bring together all the agencies involved to develop a single system for handling all contact with citizens.

The Irish government, using An Post, the Irish postal service, has done this best. An Post kiosks process bill payments, issue passports, issue licenses for vehicles, pay benefits, offer savings and investment plans-even sell stamps. Each kiosk is a tiny city hall, covering the work of half a dozen agencies. With many of the 1,000 An Post sites in small towns with fewer than 2,000 residents, the kiosks serve 1.26 million people each week-half the Irish population - and handle more than $9 billion each year. Changing or adding new operations is very easy.

For government dealings like these, as well as for all commercial deals, security is essential. Security has two elements: protection of personal data while it’s moving over the network and identifying the person carrying out the operation. Today there is encryption technology that is strong enough to protect the security of any electronic movement on a network, but US export controls on encryption technology restrict US firms from building it into their products. Since this does not keep encryption technology out of the hands of criminals, the software industry is working to change the US government’s mind on this issue. In practice, the encryption that can be used is strong enough that in most cases the security of data in a network is not the weak link. Electronic data is as safe as data in other forms.

Identifying the user is equally important. You don’t want someone else getting into your government records or your bank account. Smart cards are a solution to identity problems, as with the cards for bank cash machines. In Spain a new kiosk system will let anyone find out general information about social benefits by going through a touch-screen menu, but the person needs a smart card to find any personal information.

Though such cards are just like the bank cards used around the world, some people are worried that the government might collect too much information about citizens. Some nations have privacy laws that prevent a single card or database from containing all information about a citizen, so in some nations there will be two cards: one for financial operations with business or government and another for health care.

Widely available information and the ability to put a lot of information on smart cards will cause societies to look again at the question of how information can be used. Should any employer be able to see a job candidate’s police record? Or just organizations such as schools, which hire people who work closely with children? In the end these are political questions rather than technological issues. Each country will have to decide on the kinds of personal information that will be allowed on smart cards. Even if their use is restricted to identity only, the efficiency gains and the prevention of fraud are worth the investment. In London, 200 trial kiosks of a system like An Post’s reduced benefit payment fraud by 750,000 pounds in the first year. When installed at all 1,500 post offices, the kiosks are expected to save 150 pounds million per year.

Less developed countries may assume that a digital approach to government is out of reach, but countries without systems can start fresh with new technology, which will be less expensive than manual approaches. Developed countries have older systems that often must be joined together.

Examples from around the world make it clear that many of the advances are happening in smaller governments - smaller nations and cities, counties and provinces, and the state levels of larger nations. Smaller governments are less complex and they can experiment and work out solutions on a smaller scale. For larger governments, the lesson is to start with smaller projects to develop the necessary skills and see how citizens respond. Concentrate at first on projects that directly touch citizens and particularly ones that get rid of organizational complications for the public.

King County in my home state of Washington is probably ahead of many governments in the amount of information it publishes online, but the county does not yet package information or operations simply. To get a building permit in rural King County, you must obtain information from many sources: the phone book, phone calls to the county office, two or three printed documents, and the department’s website. A single well-structured website, with all the information and links involving all steps in the building permit process, would remove most of the complications, and could automate some of the steps.

Savings from new digital systems would represent a significant portion of every government’s budget. The US military recently found that it was spending more money to process and approve travel permits, $2.3 billion, than it was spending on travel itself, $2 billion. The US government budget is $27 billion for food stamps, $25 billion for social benefits, and $13 billion for public housing. These programs all have enormously expensive paper-based administrative systems that eat up 30 percent of the money. Good digital systems could push this below 10 percent.

Citizens are becoming more aware of the power of the Web and they are no longer willing to accept the idea that government service should be slow or confusing. No customer would stand in line for two hours to get service from a private business. Why should a worker stand in line for two hours at a government office and lose two hours of pay, when by using the Internet he could get his license or pay his fees and be at work on time?

Government alone, by building key services around the Internet, will provide a big reason for citizens to move to a Web lifestyle. If the government, usually the largest “business” in any country, is a leader in the use of technology, it will automatically lift the country’s technical skills and drive the move to an information market. Building an information economy will make all the companies in the country more competitive. The Information Age benefits from having more people involved. As more and more countries join in, the importance increases for all countries. World trade will be done digitally.

No government can put a fully digital approach in place immediately, but every government can begin now with strong first steps that benefit citizens and make them feel that the government is working for them. The main principle should be that citizens should never again have to fill out lots of forms or go to lots of places to get information.

As one government official said in conversation about his new website, which lets people download a hundred years of county records online, “People can tell when you’re trying to help. They know the difference between a government agency trying to help them and one that’s just getting in the way.”

Create connected learning communities.

PCs can give more power to teachers and students than any other group of knowledge workers. Students are pure “knowledge workers,” since learning is all about acquiring knowledge. Teachers will be able to use the Internet to share with each other and to allow students to explore a subject in new ways. With a solid infrastructure in place, some schools are already benefiting from PCs in the classroom. Many schools struggle to find the resources for these new tools, but clever programs have shown that there are rewards for the effort.

The success of PCs as educational tools requires teacher involvement. Without teacher training and making PCs central to the teaching program, they will not have a big effect. Many PCs have gone into computer “laboratories” where they sit, seldom used. Schools need to shift from treating the PC as a subject - teaching about technology -to including it in all areas of the teaching program: teaching with technology. More and more schools are now showing that PCs used as learning tools can have a strong influence.

In the Western Heights Independent School District, just west of Oklahoma City, Oklahoma, teachers were enthusiastic when the district provided training the summer before it introduced PCs. More than 200 of its 230 teachers signed up. Most teachers have a great love of learning and they’ll get excited about anything that will help kids learn. What teachers don’t want is to be thrown into something they have not had the opportunity to learn about and become comfortable with.

Western Heights is a small, seven-school district with a moderate industrial tax base. The student population contains a mix of cultures. About 65 percent of the kids qualify for free or reduced-cost school lunches because they come from homes with lower incomes. This is not the school district that you might expect to lead the advance into the Information Age. But in the past three years the district has voted three times to spend a total of more than $6.8 million in local funds to create maybe the leading technology - based teaching program in the country. The community sees the investment as the only way to break the cycle of poverty that could trap these children if they go unprepared into the digital world.

A PC can be a powerful new teaching tool for teachers. They find they can make kids more interested in lessons by including photos, films, and links to Internet pages. One teacher at Western Heights starts his class each day with fresh news from the Internet. PCs are part of each teacher’s life in class at Western Heights. Teachers also use e-mail to communicate with one another about common issues. They don’t have to wait for the district meetings that occur a couple of times a year. They can reach out to fellow teachers with questions and get answers back quickly.

“People may not realize how alone teachers are in the classroom,” Joe Kitchens of the Schools Department at Western Heights says. “Most teachers remain behind closed doors all day. They have little time for sharing experiences or interacting with other teachers. There are only a few times a year when they can gather together. E-mail stops them being isolated.” Kitchens also jokes that teachers are able to complain to him more than before. They expect him to answer their questions immediately over e-mail.

An important way to take advantage of investing in technology is to use the school infrastructure to benefit the entire community. Basic computer skills are one type of education that can be applied in any job. In most countries, one out of every ten information technology (IT) jobs is not filled. The United States and Europe each need more than half a million new trained IT professionals in the next several years. Rapidly developing areas such as India and Latin America may have greater shortages.

Highdown School in Reading, England, is paying for the infrastructure it needs through a mix of private and public money. Highdown School expects the community to contribute. Adults can get online technical training either at the Reading schools, which open on evenings and weekends for that purpose, or at home. Fees for this service go toward maintaining and expanding the IT system.

Most knowledge workers in the United States have their own PC, but even at the best of schools there are usually more than seven students for every PC. It’s expensive for schools to buy PCs for every student, especially when PCs become out-of-date every three years or so. For this reason there’s a fear that the gap between the “haves” - those families that can afford PCs at home-and the “have-nots”-those that cannot afford PCs at home - will create a major gap in opportunities. Creative approaches in providing PCs to every student are beginning to help solve this problem.

One project started in the early 1990s in Melbourne, Australia, where Bruce Dixon, a teacher interested in technology, saw significant differences in teaching results when he could use half a dozen computers for his classes instead of just one. He realized that, for the best results, students had to use PCs as a tool for all their work - in all their classes and at home as well as at school.

Out of many meetings came the idea of having all the students finance their own machines. Dixon, by then a technology advisor, worked out a financial plan. For a monthly fee, students get a machine and software. The seller provides service, and when the student graduates the family keeps the machine. It’s still difficult for all families to afford the fees. Families that are wealthier can afford the typical forty-dollar monthly fee over a three-year period. Many families can afford to pay a small amount. Business and community organizations can make up the difference. Whatever the amount, the family contribution is basic to this program, as it gives the students and their parents a sense of owning and being responsible for the computer and for its role in the students’ education.

Programs like this have spread to schools all over the world. The effects have been impressive. A recent report shows that students who regularly use computers gain many skills. They write more often and better; they have better analysis skills; they express themselves more creatively; they work more independently, and they are better at problem solving and critical thinking.

One of the most forward-looking ideas is to use PCs to offer a variety of ways to learn. About fifty different major theories attempt to describe individual learning styles. Most of the theories identify similar qualities. In the simplest terms, some people learn better by reading, some by listening, some by watching someone else do a task, some by doing the task. Most of us learn by a mix of all of these methods. And all people have different levels of ability and different personalities and life experiences that affect how well they learn. New software is helping students learn, whatever their learning style or ability. Software can present information in many different forms that can be adapted to the individual student much more easily than paper methods.

PCs can help change the learning experience from the traditional approach - a teacher talking at the front of a classroom, with reading tasks - to a more hands-on approach that takes advantage of the natural curiosity of students of all ages. PCs enable students to explore information at their own speed, to learn from sound and pictures as well as from text, to do experiments, and to work together with other students.

PCs are the primary tools for working and communicating in the digital age. The PC and the Internet change one thing completely: they provide every student in every school and community with information and ways of working that, before now, were not available even to students at the best schools. Educators will take advantage of that to help their communities. PCs are a new teaching and learning tool, and educators who use them will be the agents of change.