The Information System in Local Health Enterprises:
Strengths and Weaknesses

1. Features of a Corporate Information System
The information systems of an enterprise is made up by the various information flows circulating within the firm, which are designed for its management and operation. The information system concept does not necessarily involve the employment of computer technologies for its operation; nonetheless, firms with a highly complex organisation and offering numerous activities and/or services require specific technologic support in order to manage their information resources.
The coexistence of a technological element, required to organise and store information, with the need to support the decision-making processes, which depend in turn on changeable organisational, environmental and personal circumstances of the decision-maker, involves a number of inherent issues which can only be partially solved by the planning features of the information systems currently in use. Indeed, decision-making processes are influenced by representative models of reality that people make up for themselves and use in order to make their choices.
Each model requires different types of information to be described and each decision-maker requires different types of information in order to carry out his/her function. Information only becomes useful when it has the ability to represent phenomena in the same way in which they are interpreted by the various members of the organisation. On the other hand, a computer system tends to organise such flows and standardise the information content; furthermore, it requires significant investments every time its organisation needs to be altered.
Despite certain innovatory trends in technological solutions, computer systems currently in use display, if compared to the dynamic flow of information, a rigidity that sets a limit to their employment as a support to management systems. (1).
The risk of creating a dichotomy between actual processes and the formal information system, therefore represents a constant feature within complex organisations and all the more so within professional organisations, such as those belonging to the healthcare system, which are characterised by a significant autonomy of operators as regards individual actions. Since their behaviour is scarcely influenced by overall company problems, involvement within the company’s objectives is not implied in the position occupied within the organisation, as in other types of organisation. (2).
An exceedingly restrictive application, has led to the design of information gathering and management systems characterised by: . An inclination not to focus on the firm’s overall objectives;
. A tendency to address partial results, restricted to the value of the activities and services supplied;
. A search for the objectivity of information; this aspect in particular has led to the planning of information system detection and updating without providing for the involvement of actual information users. On the other hand, the purpose of the information system is chiefly that of supporting the staff members who are responsible for ensuring operation of the firm, or of parts thereof, through their activity and within their specific field of competence. The process providing for an approach between the computer system and the overall system of information employed for management, even though involving a co-ordinated organisation of the information required to support planning and control tools, has in any case availed itself of the technological developments which have characterised the computer industry as a whole (3).
We can list a number of features that information systems have been able to develop thanks to technological evolution:
. Greater “dispersion”, within the organisation, of powerful computer technologies, with highly user friendly and flexible user interfaces; . Development of “universal” software tools, which allow processing by the user himself; . Circulation of computer technologies within “non structured” activities;
. Development of tools to support complex and not standardised decision-making processes;
. Increased communication possibilities within the organisation and with company operators, irrespective of the location from which they operate; We may actually state that the progressive expansion of the role of company computer science, from being a mere support to individual operating activities to being a source of information for control and planning activities has brought about rapid changes in the architecture of corporate automated information systems, which may be summarised as follows: (4)
. “computerisation island” information system, which does not provide for special opportunities or requirements concerning dialogue among the various computerised operating activities; . “technologically” integrated information system, through connection of the various islands to each other;
. “functionally” integrated information system. Traditional corporate information systems arise through the consecutive aggregation of components which the organisation attempts to connect to each other each time through interfaces allowing the various parts to communicate. An integrated system provides for a connection of all management functions into a single system, capable of planning, managing and organising all the company activities.
The expression “technological integration” describes the possibility of linking differently based technologies and hardware & software configurations, without establishing reciprocal restraints among the various components and without requiring these to be altered. This integration level only relates to the link among various system components through generalised computer tools, without however tackling the issue of interaction criteria. The expression “functional integration” describes the possibility of ensuring the actual consistency of the information systems with the operating requirements of the organisation: to this end, the individual applications are able to actively interact, through the exchange and use of consistent information and the reciprocal activation of complex functions.

2. The information system for Management Control The overall purpose of information systems is to supply information to the various levels of planning, programming and control activities. (5) According to the Anthony diagram (6), operations control is aimed at addressing individual executive activities in real time, management control identifies and checks the management objectives (financial objectives versus quality/quantity activity results), whereas strategic planning identifies the overall objectives of a company.
The following diagram graphically represents the flows of information according to a pyramid scheme, outlining three levels of responsibility, and the logical aggregation and synthesis relationship that links them.(fig1)
The three levels of planning identified by Anthony emphasise an information support that can be practically divided into 4 aspects: format, structure, frequency and source. The following diagram summaries such features for the three planning levels: (fig.2)
Operating control employs the detection of basic transactions taking place in a firm: withdrawal from warehouse, purchase of consumable materials and supply of services represent some of the normal operations in which the activity of a company is divided. The source is therefore inside the company and the frequency with which the operations control process is supplied is continuous, whereas the continuity of the control requires information from the structured and pre-set format. On the other hand, management control and strategic planning require concise information with a periodic or discontinuous frequency, whose structure is prearranged in the former case and variable in the latter. Furthermore, the source of the information required for strategic planning is chiefly external: the features of the reference environment and the competitive background need to be monitored whilst referring to the external environment, risks and opportunities need to be compared with the internal features of the company. (7). The information system is to support the planning, programming and control process in all its typical stages:
1. Analysis of the competitive background and of the general economic conditions and definition of the strategic choices. The analysis is based on information chiefly coming from external sources: surveys on users, epidemiological databanks and extemporary analyses.
2. The contribution to the preparation of the budget proposals is performed through a support to the definition of objectives by the organisation units, through the analysis of the results that have actually been achieved in the past and simulations as to the effects that future action will have on the performance. Once the budget system is running regularly, this activity may be decentralised and transferred to an individual responsibility centre (RC). However, this involves the need to identify at least a reference person to handle relations with the information system and the distribution of adequate decentralised and homogeneous computer equipment, to guarantee the unitariness of the budget process.
3. Budget consolidation, examination and approval; this is an activity that, from an information point of view, is divided into two aspects: of a technical and of a consolidation type. The computer medium on which the budget proposals are presented and filed must be able to ensure an automatic aggregation of resource requests and of activity objectives, in the form of an overall corporate budget. The second aspect relates to the evaluation of the budget versus its technical feasibility, resulting from a comparison among the various proposals.
4. Examination of specific projects, which are usually characterised by their temporary aspects and by the definition of specific goals to be reached, which represent the conclusion.
5. Routine reporting and related analyses. The preparation of periodic reports on the performance of the organisation units versus their budget objectives is a basic requirement to ensure an effective progress of the operations control and management functions. The production of periodic reports according to a prearranged schedule, whose usefulness is proportional to the frequency of such information flows, requires connection to accounting and extra-accounting detection systems, which put together the basic data in order to supply the necessary data to the reporting system. In order to guarantee this, highly standardised computer solutions are required in terms of communication and data exchange protocols, which are also flexible enough to also easily include data which are only required for management reporting purposes.
6. Pre-final balance and final balance. Since certain pre-final balances are required in connection with the whole budget year before this actually ends, it is necessary to produce estimates and outlooks, which are the result of routine procedures and are subsequently corrected through ad hoc adjustments. The following picture displays a summary of the significant features relating to the different phases: (fig.3)
The decision-making activity starts when the manager finds himself in a condition whereby he can or has to choose between two alternative “courses of action”, from which two different types of results are expected.
The manager’s ability to complete the decision-making process with an adequate level of rationality, besides depending on his personal knowledge and intuition, also depends on the information available with regards to the problem to be solved. The requirement for an adequate information system to support the decision-making process results from the structure of the latter, which, according to Mintzberg (8), starts the moment a decision-making problem is perceived and ends the moment the action to be accomplishes is decided, a process which goes through the following phases:
1) Awareness as to the existence of a problem and as to the consequent need to make a decisions;
2) Analysis of the problem;
3) Devising alternative “courses of action”;
4) Choice of a “course of action” that is deemed as the most suitable to solve the initial problem, taking into account specific environmental conditions, restraints and goals to be achieved;
5) Formalisation of the choice. The activation of the decision-making process, whether it refer to a programming or control activity, may take place spontaneously, through informal information mechanisms, as for instance in the case of relations with staff or patients benefiting from the services rendered, or else according to “prearranged” modalities, such as in the case of the analysis of periodical information sheets concerning the performance of the firm or of the external environment. The decision-making process hinges on the ability to promptly acquire the information that may support it, so as to make the process itself more effective, whilst also reducing the impact that subjective evaluations on the trend of the variables concerned may have on it. The information, typical of general and analytical accounting, is spread throughout the organisation thanks to the control reports, whose actual makeup may vary depending on specific corporate requirements, and adapt to the information requirements of the various organisation Irrespective of the practical features that are actually adopted, both the prevailing literature in terms of management control and the recurring applications in practice have led to the establishment of three standardised structures, linked to three different fields in which the decision-making process takes place: strategic, management and operations control reports (9).

3. The Information System in Healthcare
A firm’s information system may be described as an ensemble of elements, which may also differ significantly from each other, which gather, process, exchange and file data with the purpose of producing and circulating the information in question to the people who require it, at the time and in the place suitable to carry out their decision-making and control functions.
The information system of a healthcare enterprise or of a hospital enterprise may be described as an orderly range of information which plays a direct or indirect role in the management of the company, which is put together for specific purposes such as analysis, control, measurement and so forth. In other words, a well organised and effective
Information System represents the necessary support for the management and co-ordination of a healthcare enterprise (but also of the Hospital itself), in that it represents a prerequisite for making certain professional figures aware of their responsibilities in terms of management processes (whilst increasingly decentralising decision–making processes to a more operational level), and for carrying out a valid management control, both at an operational and at a management and strategic level.
The complexities inherent in every firm’s information system are greater in a healthcare environment, since the local healthcare enterprises and the hospital enterprises have an internal organisation structure characterised by the existence of highly autonomous or specialised positions.
The peculiarity of the activities carried out by healthcare and hospital enterprises, together with their “public” nature, result in the need to gather, for various purposes, a very significant and composite volume of data and process them into meaningful information, thus bringing about a particularly complex information system. Indeed, a complex network of information flowing among the various organisation units develops within the enterprise; the complexity of the system is further increased by the need that healthcare enterprises have to also effectively safeguard the data exchange with parties such as the regional authorities and other enterprises. The information systems of the healthcare and hospital enterprises can be analysed through a preliminary breakdown into “macro areas” with their specific information requirements, associated with the features of the activities performed and of the purposes pursued by each area. In this regard, we need to view the local/hospital information system as the ensemble of a number of sub-systems, which may be described as follows:
1) External relations sub-system, in charge of gathering data and producing reports concerning communication with users, with other enterprises and with institutional government organs;

2) Healthcare sub-system, which can be in turn broken down into: a. Hospital area sub-system, in charge of gathering data and producing reports concerning admissions to hospital, outpatient specialistic activities, rehabilitative medicine, etc.
b. Territorial area sub-system, in charge of gathering data and producing reports concerning:
i. Systems and procedures concerning the management of district activities (family medicine, pharmaceutics, rehabilitative medicine, etc.);
ii. Systems and procedures concerning the management of the Prevention Department activities (areas of Hygiene, Veterinary Science, Legal and Professional Medicine, etc.);
iii. Systems and procedures concerning the management of healthcare mobility:

3) Administrative sub-system in charge of gathering data and producing reports concerning:
a. systems and procedures concerning statement of accounts from administration;
b. systems and procedures concerning staff management;
c. systems and procedures concerning staff demand and reorganisation;
d. systems and procedures concerning the registration of activities carried out for institutional purposes;
e. systems and procedures concerning the analysis of administration running expenses;
f. systems and procedures concerning analytical accounting;

4. Management sub-system, in charge of gathering data and producing reports concerning:
a. systems and procedures concerning budget organisation;
b. systems and procedures concerning management control;
c. systems and procedures concerning budget-compliance assessment;
d. systems and procedures concerning staff evaluation. The following picture offers an overview of a public healthcare enterprise information system and identifies the chief flows of information.

Traslation by Interpres sas