Decision-Making With and Without Information Technology in Acute ...

Journal of Medical Systems, Vol. 22, No. 6, 1998

Decision-Making With and Without Information Technology in Acute Care Hospitals: Survey in the United States Myron Hatcher1

These survey results are from a national survey of acute care hospitals. A random sample of 813 hospitals was selected with 115 responding and 33 incorrect addresses resulting in a 15% response rate. The purpose of the study was to measure the extent of information systems integration in the financial, medical, and administrative systems of the hospitals. Decision making with and without information technology is explored based upon the survey data. The results indicate why and how meetings are held. Necessary changes in the decision-making environment are identified for decision making utilizing information technology to be successful. These results will provide a benchmark for hospitals to determine their technology transfer position and to set goals for computer assisted decision-making. KEY WORDS: decision making; face to face decision making; decision support systems; expert systems; technology transfer; survey; acute care hospitals.

LITERATURE REVIEW

Since this is a descriptive study, the theoretical formulation is very general. The newest technologies are in group decision systems, video conferencing, etc. The first step in this analysis is to evaluate and weight the purposes of face-to-face meetings. These purposes are idea generation, selection of alternatives, financial concerns, non-financial concerns, process concerns, product concerns, problem solving, making a decision, negotiation, coordination, resource allocation, morale building, and social structuring. It is true that a vast percentage of information systems are transaction processing in nature. These systems feed data into business information systems that produce information and knowledge. The new systems are decision support systems, group decision support systems, groupware, electronic meeting systems, expert systems, etc. The primarily purposes of these new systems are planning, negotiation, 1 Information

Systems and Decision Sciences, Craig School of Business, California State University, Fresno, California 93740. 397 0148-5598/98/1200-0397$15.00/0 C 1998 Plenum Publishing Corporation

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and decision making.(1-3) Few hospitals actually have operational group decision support systems; therefore, to provide guidance for their development, the approach used in the survey was to evaluate the reasons face-to-face meetings are used in decision making.(4-6) Reasons for using face-to-face meetings in decision making include enhancing participation, encouraging acceptance, increasing the quality of ideas generated, increasing the quantity of ideas generated, promoting cooperation among participants, and preventing domination of the group by particular members. Many examples exist for using information systems in decision making. Most of these examples are demonstration or research in nature. Hatcher and Connelly present a decision support system (DSS) for negotiating hospital rates.(7) Within the DSS the decision-maker and the computer system form one closed loop system and a decision is reached in an iterative manner. Martin and Harrison used an expert system for health care cost management.(8) Jeang developed a staffing model that met patient needs efficiently, economically and remained flexible to meet changing patient demands.(9) The model considered both full and part time staff and provided administration with a budget management tool. Hatcher et al., present a model for triaging hypertension patients into health education treatments.(10) Shao and Grams designed a computer diagnostic system for malignant melanoma.(11) The information system's model components are described in detail. Grams et al., provide an excellent overview of medical diagnostic in their discussion of MDX—A Medical Diagnostics Decision Support System.(12) Sear develops a model for determining medical eligibility.(13) This article demonstrates the contributions from understanding the system under study. Once the medical eligibility system is understood, it becomes clear why consumers behave in certain ways. Stevens and Rasmussen discuss remote medical diagnosis and its impact on access to health care.(14) Aleynikov and Micheli-Tzanakou developed a system to classify retinal hemorrhage based upon images.(15) This neural network system achieved a training performance of over 95% and a 79% operational performance. Papaconstantinou and associates utilized an expert system based upon Bayesian networks for assigning patients into clinical protocols.(16) As is more common with decision support systems, the system directed the physician interactively in the process. Zelic et al., used a Bayesian Classification method for diagnosis of sport injuries.(17) Knowledge was extracted from medical databases to develop the rules for identification of sport injuries. Expert defined diagnosis rules were added because of limitations of the medical database. Unique information was obtained from each individual in the classification process. As artificial intelligent (AI) software improves, the ability to identify medical disorders will improve. Solin et al., developed a software program that can identify women with carcinoma of the breast from prior claims in a health maintenance organization (HMO) database.(18) The prediction rate was approximately 84%. Kaspari et al., used a neural network in radiotherapy to predict the target volume of detected tumors.(19) Another extension of diagnosis and treatment assignment is patient management. Austin, Iliffe, Leaning and Modell developed a Prototype Decision Support System (DSS) that manages asthma patients.(20) The system is based upon rules of thumb and is applied in the primary care setting. Modai et al., developed a patient

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management system for psychiatric disorders.(21) A neural network, which is an artificial intelligent system, employed the adaptive resonance theory. Results were favorable when compared with senior psychiatrists' recommendations. An important problem in health care is prioritizing alternatives that impact resource allocation decisions. Hatcher discussed this issue in depth and placed it in the context of a group decision support system.(22) The analytic hierarchy process (AHP) is used to prioritize alternatives where both qualitative and quantitative data can be used. Kwak and Lee developed a goal programming (GP) model for resource allocation within health care organizations.(23) Specifically, employees are assigned to shifts based upon criteria. Kwak et al., applied AHP to laboratory personnel assignments.(24) They believe that their model assists in understanding perceptions, insights, and general realization of health care decision making and strategic human resource planning. Vitiello and Levary developed a simulation model that forecast the appropriate mix of physicians in a health maintenance organization (HMO).(25) Changes in population demographics and lifestyle can be studied with the model and their impacts determined. Another important field in medical decision making is simulation or uncertainty inclusion. Potential applications are varying demands and policy analysis. Simulation modeling is difficult and often is combined with decision support systems design.(26) Hatcher applied uncertainty to staffing and rate setting in a health promotion center.(27) Bulter analyzed patent care policies using simulation.(28) Shuman, Wolfe, and Gunter applied simulation to emergency medical systems.(29) Lilienthal discusses more advanced uses of Internet and decision making applications.(30) Defense Simulation Internet, DSI, is a network of sites that allow decisions such as emergency medical needs to be evaluated. Access is limited and secure; therefore, sensitive management topics can be evaluated.

SAMPLE SELECTION PROCEDURE, AND QUESTIONNAIRE The sample size is 813 acute care hospitals in the United States. The sample was taken at random from the American Hospital Association to the Health Care Field, 1995-96.(31) Hatcher reviewed the complete questionnaire, data collection procedure, and sample selection in the initial article.(32) A brief summary will assist readers in understanding the results and discussion of results. The survey was mailed in June 1997 with three follow-up postcards. The survey was again mailed in February 1998 with responses arriving through April.

RESULTS Face To Face Meetings 29. What is the purpose of face to face meetings in your hospital organization? Not at all

Quite Extensively 1

2

3

4

5

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Idea generation Selecting alternatives Financial concerns Non-financial concerns Process concerns Product concerns Problem solving Making a decision Negotiation Coordination Resource allocation Morale building Social structuring

X X X X X X X X X X X X X

= 3.5 = 3.5 = 3.7 = 3.6 = 3.6 = 3.3 = 3.8 = 3.8 = 3.3 = 3.8 = 3.4 = 3.0 = 2.7

SD SD SD SD SD SD SD SD SD SD SD SD SD

= .82 = .84 = .80 = .67 = .76 = .91 = .76 = .81 = .89 = .76 = .86 = 1.04 = 1.10

C C C C C C C C C C C C C

= 111 = 111 = 111

= 110 = 110 = 1.06 = 112 = 110 = 110 = 112 = 111 = 112 = 109

Decision Making 30. Do the most important decisions made in your hospital utilize computer generated information? Not at all

Quite Extensively

1 2 3 4 5 X = 3.5, SD = .87, C = 115. 31. Purposes in face to face group decision making Not at all Quite Extensively 1 2 3 4 5 Enhance participation X = 3.7 SD Encourage acceptance X = 3.9 SD Increase the quality X = 3.7 SD of ideas-generated Increase the quantity X = 3.5 SD of ideas generated X = 3.5 SD Promote cooperation among participants SD X = 3.9 Prevent domination of the X = 3.0 SD group by specific members

meetings are:

= .73 = .72 = .73

C = 111 C = 111 C = 111

= .85 = .85

C = 111 C = 111

= .75 = .95

C = 111 C = 110

DISCUSSION The director of the Information Systems area completed the questionnaires. This person was with the hospital an average of 8.7 years. In acute care hospital, it is very difficult to measure decision making and how information systems effect the process. Information systems that support decisionmaking exist in hospitals, but they are not routinely implemented.


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A critical question "Do most important decisions made in your hospital utilize computer generated information?" received a rating of 3.5 on a 1 to 5 scale. This result reflects acceptance of information produced by computer systems as reliability and accurate. There are opportunities for greater acceptance of information systems either through training or user involvement in systems design. The questions on the purpose of face to face meetings were rated on a 1 to 5 scale and have an average score of 3.5 to 4.0. "Coordination," "problem solving," and "making a decision" all received the highest rating with 3.8. These results strongly support decision-making expectations of face to face meetings. "Financial concerning" has a rating of 3.7 and “nonfinancial concerns” and “process concerns” have ratings of 3.6. These results indicate that process or operational level questions are the focus of face to face meetings for both financial and non-financial problems. "Idea generation" and "selecting alternatives" having ratings of 3.5 indicate they are secondary purposes compared with decision making and how to improve the process. "Product concerns" has a rating of 3.3 since there is limited product development. "Negotiation" and "resource allocation" have ratings of 3.3 and 3.4, respectively, indicating that conflict resolution is not a purpose of face to face meetings, which tend to concern decision making and process improvement. Ratings for "morale building" and "social structuring" of 3.0 and 2.7, respectively, indicate that they are the least important reasons for face to face meetings. A more precise set of questions concerning face to face meetings in decision making was rated on a scale of 1 to 5. "Encourage acceptance" and "promote cooperation among participants" with ratings of 3.9 were the most important reason. These goals would require little information technology since the purpose is bringing everyone into agreement and working together. Ratings of 3.7 for "enhance participation" and "increase the quality of ideas generated" indicate that refinement of the decision is allowed. This conclusion is further support by "increase the quantity of ideas generated" having a rating of 3.5. Further supported to the idea that the purpose of face to face decision-making meetings is informing staff and getting them vested in the program by allowing small changes in the chosen alternative is a rating of 3.0 for the question "prevent domination of the group by specific members." These results indicate a strong orientation for face to face meetings and face to face decision-making meetings to be for informing staff and gaining their commitment to the program. Creative problem solving occurs after the main alternative or limited set of alternatives is chosen and takes the form of refinements. Unfortunately, computerized information systems tend to share information and encourage decentralization of decision making. Given the current decision making environment, the acceptance of modern information systems for decision support may not be in the immediate future. APPENDIX A: PARTIAL HEALTH CARE SURVEY June 1997 Questionnaire on Computer Systems and Decision Making The purpose of this survey is to measure how computer technology has been adopted in acute (Average length of stay, 30 days or less) care hospitals. Your re-

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sponses will be kept confidential. The summary results will be displayed at home page http://www.craig.csufresno.edu/dprtmnt/faculty/myronh/top.htm. By checking the home page, you will find the results and evaluation. You may also e-mail any questions or comments from this home page. Your speedy response to this survey will be appreciated. Answer all questions to the best of your ability. Thank you for taking the time to answer this survey. Systems and Management Information Systems apply to admissions, administration, patient billing, medical records, and financial reporting. Face to Face Meetings 29. What is the purpose of a face to face meetings in your hospital organization? Not at all Quite Extensively 1 2 3 4 5 (a) idea generation 1 2 3 4 5 (b) selecting alternatives 1 2 3 4 5 1 (c) financial concerns 2 3 4 5 (d) non-financial concerns 1 2 4 3 5 1 (e) process concerns 2 4 3 5 (f) product concerns 1 2 3 4 5 1 (g) problem solving 2 4 3 5 (h) making a decision 1 2 3 4 5 (i) negotiation 1 2 4 3 5 (j) coordination 1 2 4 5 3 1 4 (k) resource allocation 2 3 5 1 4 (1) morale building 2 3 5 (m) social structuring 1 4 2 3 5

Decision Making 30. Do the most important decisions made in your hospital utilize computer generated information? Quite Extensively Not at all 1 2 3 4 5 31. Purposes in face to face group decision making meetings are: Quite Extensively Not at all 1 2 3 4 5 (a) (b) (c) (d) (e) (f)

enhance participation encourage acceptance increase the quality of ideas generated increase the quantity of ideas generated promote cooperation among participants prevent domination of the group by specific members

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5


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