It’s the patient level that counts

What happens in healthcare happens to patients. Not to wards or theatre or specialties, far less HRGs, DRGs or Clusters. Ultimately, the only way to understand healthcare is by analysing it at the level of the individual patient.

Much of the information we work with is already at that level or even below. An inpatient stay or an outpatient attendance is specific to a particular event for an individual patient. We need to be able to move up a level and link such event records into care pathways.

Much information, on the other hand, is held at a level far above that of the patient. Financial information from a ledger, for example, tells us how much we spent on medical staff generally but not on a specific patient. Most pharmacy systems can tell us what drugs were used and how much they cost but usually can’t tell us is which medications were dispensed for which patients.

On the cost side, one answer to this kind of problem is to build relatively sophisticated systems to apportion values – i.e. to share them out across patient records in as smart a way as possible. For example, an effective Patient Level Costing system uses weights reflecting likely resource usage to assign a higher share of certain costs to some patients than to others. The effect is to take high-level information down to patient level.

In some areas, that's the only approach that will ever work. For nursing costs, one can imagine a situation where patients have bar-coded wrist bands that nurses read with wands, giving an an accurate view of the time taken over each patient. But the approach would be fraught with problems:

• it would be expensive and impose a new task, designed only to collect information without contributing to patient care, on nurses who already have more than enough to do
• it would be subject to terrible data quality problems. Just think of the picture we’d get if a nurse wanded himself in to a bedside, and then forgot to wand out, which it wouldn't surprise me to see happen with monotonous frequency
• even if all nurses could be persuaded to use the wands and did so accurately and reliably, it’s not clear that we would get a useful view of nurse time use: after all, when staff are under less pressure, a nurse might take longer over a routine task such as administering drugs, but it would be nonsense to assign the patient a higher cost as a result

For resources like nursing, it seems sensible to share the total figure across all the patients, in proportion to the time they spent on a ward, as though they were incurring a flat fee for nursing care irrespective of how much they actually used. This suggests that apportionment actually gives the most appropriate picture.

But with other kinds of cost, we really ought to be getting the information at patient level directly. We ought to know exactly which prosthesis was used by a patient, how much physiotherapy was delivered, precisely which drugs were administered. If we don’t, then that’s because the systems we’re using aren’t clever enough to provide the information. In that case we need cleverer systems.

For example, pathology systems tend to have excellent, patient-level information already. We just need to link the tests to the appropriate activity records, making intelligent use of information such as the identity of the patient and the recorded dates. This has to be done in a flexible way, of course, to allow for such occurrences as a pathology test carried out some time after the clinic attendance at which it was requested.

Linking in pathology information would immediately make pathway analysis richer. When it comes to costing, we still need an apportionment step, to calculate individual test costs from overall lab figures, but then the calculated value can be directly assigned to the patient record.

The same kind of approach can be applied to diagnostic imaging, the therapies and many other areas. For example, we can calculate a cost for a multi-disciplinary team meeting and then assign that cost to the patient record, as long as the information about the meeting is available in a usable form.

Then, however, there are other areas of work where we should be able to operate this way but generally can’t. Few British hospitals have pharmacy systems that assign medications to individual patients. If they did, and given that the pharmacy knows the price it is being charged for each dose, we could link the prescription to the patient record and assign its actual cost to it. Given that pharmacy is the second biggest area of non-pay cost in most acute hospitals, after theatres, this would be a significant step forward.

The same is true of similar services in other departments, such as blood products.

Getting this kind of information right would greatly enhance our understanding both of care pathways and of patient costs. As I’ve already pointed out, that would be a huge improvement in the capacity of hospitals to meet the challenges ahead.