The literature in the 90's identify and analyze new trends occurring in Latin-American countries which suggest that a fundamental transition in the nature of healthcare delivery is taking place (Bra-Vin 94). The large teaching institutions, as presently configured, is approaching its end. In future, hospitals and clinics will no longer be all things to all people on the one site but will be reorganized into specialized components. Many of these need not to be in close geographic proximity to each other. The need for all the elements of a clinic or healthcare organization to be physically at the same place was previously a matter of both convenience and necessity. Now, with Telemedicine, teleconferencing, multi-user access to mainframes, wide area networks, E-mail, facsimile technology, the electronic medical record and patient data contained on smart-card technology, physical proximity is no longer a necessity.

There will be a core facility which will be linked by advanced information and communication technologies to separate pathology, imaging, day surgery, community health, home care, primary care and rehabilitation units. Other services including information technology, catering, cleaning, linen services and security, once provided within the walls of every healthcare organization can be outsourced.

Across the continuum of care, there are five underlying issues that all the protagonists of the healthcare system (physician, hospital, home health, nursing home, pharmacy, laboratory testing center, Healthcare Management Organizations, etc.) need to address collectively:

The IT requirements for integration across the healthcare system can be evaluated through two major categories:

A new generation of information systems must be developed to face the challenges which the requirements mentioned above represent. The Healthcare System will increasingly become more used to the IT. A new class of integrator will emerge to provide solutions economically reachable.

Typical Healthcare Information Systems today show a trend focused on the needs of single providers (physicians, hospitals, nursing, laboratory, etc.). The reasons are that each provider demands that its requirements are unique and software providers segmented the market on this basis; information systems traditionally evolved from financial and reimbursement requirements to clinical applications structuring them by provider type; integration has not been seeing as important as a "business" area from the industry.

Under today's conditions, "facility-centered" architectures interfere with the coordination of care that is necessary for success for capitated and managed care payment structures. Hospitals have been the revenue-profit centers which could afford automate their operations. However, many hospitals have also outpatient services with significant volumes. When they required online information about patient encounters their information systems were ill prepared to fulfill this demand.

First solutions to integration are coming from other industries. However, these solutions provide Back-End integration tools. Client-Server and open-systems become to be the rule to be able to satisfy the new requirements.

Among the most important topics to cover regarding healthcare management supported by information systems methodology, can be considered:

Recent developments in technology which coupled with expanding needs for health services have led uses of computer networks not envisioned before. Telemedicine for instance, provides remote consultation and medical records management via high-speed computer linkages. Such networks are ready to complement existing formal health care professionals and support groups to individuals too sick, too busy, or otherwise unable to leave home. Health services effectively delivered via computer networks include counseling, social support, health education, access to health literature and data bases, and clinical decision support.

Two general types of multiservice computer networks are relevant to the deliver of health services. One "exclusive " type employs a dedicated computer network to give a target group access to a specific set of interrelated computer programs or services. One important example today is the electronic library, virtual medical library, and scientific medical data bases, like GENOMA. The second model is to add specific health care applications to existing computer public networks. For example, the program to train smoking cessation via Compuserve included support for groups interactions, messaging services, and individually tailored interventions.

Another important issue to address under this topic is network use. The scope of use can be designated generally to any human information-processing activity in which output from a computer session (paper or screen) is employed in a larger cognitive process such as decision making. For information systems methodology system use an be treated as either an independent or dependent variable. Independent can be analyzing the computer network services on organizational behavior and task fulfillment. It can be dependent studying user acceptance and innovation diffusion. Ideally, conceptual and operational definitions of information systems use correspond with the reference theory guiding an investigation.

Human-computer interaction theories form the most appropriate basis for characterizing health care delivery system use, seeing as a function of the system and the user. A general framework for characterizing use must be both complementary and subservient to the theoretical models that guide research studies. This characterization is congruent with the evaluation of health care and social service delivery. Both require methods for determination of adequacy and effectiveness, establishment of a scope of services necessary to ensure successful outcomes of care, and a basis for allocating charges (number and duration of contacts, volume of services delivered, etc).

System level use measurement indicates how often all caregivers access the system and reveal the extent to which selected services are actually used, but can not record the number of times that users experience appropriate needs for use that are not translated into actual use.

Probably the most important development during the 90's will be the standardization of an electronic medical record. This electronic document will be the basis for a networked healthcare system with the proper methodology to measure its use, effectiveness and application.

The basic assumptions on which an structured record of the patient care is developed are: principle purpose of the medical record is to support individual patient care deriving research, audit, finance or planning; and that clinical information will be held in a structured representation which can be manipulated by the healthcare system.

The goal of developing analyses and models for the medical record is therefore, to create an architecture for structured information which is both faithful to the process of clinical care and adequate for the other uses of the information collected. The greater the demands to make multiple use of information, the more important it is that the underlying models reflect accurately the nature and structure of that information. Many of the difficulties experienced in attempting to generalize existing systems stem from the fact that they have pre-selected and distorted information in order to fit into particular applications. The models omit much of the information actually used in clinical care and do not accurately reflect the real status of the healthcare services.

The first consequence of this view is that information in the medical record is not about what is true of the patient, but what was observed and concluded by the clinicians. The second consequence is that the model should be descriptive rather than descriptive.

There are some requirements for the structure of the electronic medical record:

• To allow conflicting statements
• To accept uncertain and negative statements
• To allow expressions at the clinician level of abstraction
• To allow description to an arbritary level of detail
• To include the context of observations
• To facilitate decision making

A major transition in healthcare services in Latin-America is taking place. Healthcare reform is working as an accelerator to introduce our continent into the information technology revolution. Physical boundaries are vanishing and the need for an integrated and distributed concept of healthcare care information systems is now a main requirement for hardware and software providers. The requirements to be integrated are already defined, although a deeper analyze of its consequences has to be studied. The organizational impact of this methodology for the healthcare system as well as the technological factors which will be incorporated represent a big scope for researchers and managers to join efforts and to work on, pursuing the objective to make this vision a reality.

Healthcare sector is also moving from individual providers to global contracts with general rules and more effective services. General formats and common interfaces are requested to facilitate communications and financial transactions. However, the condition to return to the "patient-centered" models is the most important element for the development of managerial and information systems supporting the healthcare system. Here the electronic medical record enhancing confidentiality, security and legal documentation, turned to become the basic issue to be addressed. Problem orientation becomes a special case of more general techniques for recording the decision making process. Increased detail and a more complex structure of the medical record will fit through new technical resources.

On the other side, networking will be the media to link institutions and individuals demanding and offering healthcare services. This technology is changing dramatically the once solid paradigms of healthcare services, documentation and billing, that a new generation of healthcare professionals and providers will emerge. Appropriate interpretation of various measures use will facilitate determining service units of computer network employed in the delivery of health care.

The field for a brand work on Medical Informatics research is open for multidisciplinary groups committed to take us to the global village information era.

Transition is the common rule at the Healthcare System in Latin-America. Throughout the Institutions responsible for the definition of the minimal level of healthcare delivery, the vast majority of organizations in charge of the acute care services for decades, is being reconceptualized. Here will be analyze the organizational and technical trends which clearly indicate that the concept of the Healthcare services is changing through the introduction of the networking Information Systems. The emerging model consists of a core facility comprising only the most acute services, intensive care, operating theaters and an accident and emergency unit, with all other services, units and home care linked by information technology to each other and to the core facility. Some management challenges confronting those who will be responsible for taking their organization through the transition to the boundary-less healthcare arrangement are explored, and a number of the existing conditions and problems with the actual healthcare system which the new model has the propensity to resolve.

Keywords: Healthcare management, Networking Information systems, organizational structure

Dr Jose Amado Espinosa Lobato

Medico Cirujano, Escuela de Medicina de la Universidad Autónoma de Puebla, México. Maestría en Ciencias de Administración, Universidad Autónoma de Puebla. Maestría en Computación y Sistemas de Información, Universidad de las Américas, Puebla.

Doctorado en Informática Aplicada a la Medicina, Escuela Superior de Medicina de Hannover, Alemania. Tiene el titulo de especialista en Informática Medica otorgado por la Sociedad Alemana de Documentación, Informática y Estadísticas Medicas.

Extensa experiencia académica y clínica, desde 1990 es Director del Instituto de Informática Medica de la Universidad Autónoma de Guadalajara, México.

Miembro de varias sociedades científicas. Presidente Fundador de la Asociación Mexicana de Informática Medica y actual Presidente de la Asociación Internacional de Informática Medica para Latinoamérica y Caribe (IMIA-LAC).

18 publicaciones en el área de sistemas de información.