A review of computerised information technology systems in general practice medicine

• Abstract
• Why is this an issue?
• The international scene
  • The United Kingdom
  • Australia
  • Canada
  • The United States
  • New Zealand
• The way to the future
• References

Abstract

Information technology has become an increasingly important factor in the health care sector of New Zealand. This paper aims to set the New Zealand information technology (IT) standard against that currently established internationally.

Ways of refining these systems are discussed and recommendations are made for developing practice information management in New Zealand health care for the next decade.

Why is this an issue?

Information technology (IT) has become the catch phrase of the 21st century. Businesses would be unable to survive in the current market without the use of IT and related methods of communication; furthermore, large portions of their budgets are spent on maintaining and advancing these systems. Constant discoveries and refinement of medical techniques ensure that medicine continues to advance as a science but, in terms of business, advances in IT have not kept up with other sectors .^{[ 1 ]} In the US, the health care industry spends 1% of the annual budget on IT, compared with 7% spent by banks and financial services.^{[ 1 ]}

Historically there has been little information on defining and quantifying IT use in general practice medicine, however recent times have seen the emergence of new data. Currently, medical practitioners are becomingly increasingly motivated to adopt IT systems because of government requirements for data capture, societal expectations and individual practitioner’s desires to extend their business to its full potential. Some countries, for example, the United Kingdom, are well advanced in the use of IT in general practice and progress is being addressed by refinements to existing systems, whereas other countries, such as the US and Canada are only just beginning to introduce these technologies.

Technology companies are coming to the aid of the healthcare industry, developing hardware and software, for example patient management systems (PMS).^{[ 1 ]} The key components of a PMS should include the electronic medical record (containing clinical notes, laboratory information and prescription records), the patient record (containing demographic information) and support for general administrative tasks such as billing. In the US, there is a trend towards single large organisations rather than multiple small companies providing this software.^{[ 1 ]} A major goal for all companies involved is to develop a common programme to integrate all health care tasks including communication with laboratories and pharmacies. While not all of the many PMS systems have achieved this goal, there are major vendors in New Zealand and elsewhere that have done so.

There is still some resistance from both health professionals and patients to the shift towards the "paperless practice". Many people are averse to adopting new technology because of the perceived cost (seen as being endless and ever increasing), the burden on time, the near certainty of technical glitches/malfunctions and security concerns about the ability to keep patient records confidential in "cyberspace". In addition to these problems, it is perceived that it is difficult to charge for services such as e-mail communication with patients and some doctors may feel that e-mail and web based medicine threatens the sanctity of the face-to-face patient/doctor relationship.^{[ 6 ]}

The international scene

Until recently, there has been a paucity of data on the state of practice management IT in individual countries, however, representative data is now beginning to emerge. Recent studies in the UK, US, Canada and Australia allow insights into these countries’ respective IT status in general practice medicine. The UK appears to be the most advanced, with a very high rate of computerisation, followed by Australia where adoption of technology systems is increasing. Both the US and Canada are at an earlier stage of development and, currently, IT has not fully penetrated general practice medicine.

UK
After much effort and government policy development to address the issues of IT in health care, computerisation of general practices reached 98% in 2003.^{[ 2 ]} Most practices are now paperless with regard to capture of patient demographics, prescribing and some pathology results, with regards to storage and transmission. This is a direct consequence of the October 2002 removal of a government requirement for paper-based records. ^{[ 2 ]} The UK is an example of a country that already has good IT systems in place and future targets relate to refinements to systems, for example, ensuring every GP has a desktop connection to e-mail and full electronic collection and storage of patients’ clinical notes. Another unique goal of the National Health System (NHS) is the introduction of standardised clinical terminology (SNOMED CT), including standardisation between primary and hospital care.^{[ 2 ]}

There are currently over 20 PMS suppliers in England but just three have a combined 85% share of the market,^{[ 2 ]} which is similar to the situation in other countries.^{[ 1 ]} In Scotland, for example, one clinical system alone dominates the market with an 82% share - the General Practice Administration System for Scotland.^{[ 2 ]} One of the major obstacles in advancing technology systems in the UK is that, according to figures from 2002, only 0.02% of GPs have access to a broadband (high-speed) internet connection.^{[ 2 ]} The NHS has implemented strategies to remedy this via the gradual introduction of high-speed internet connections for NHSnet users. Without high-speed Internet, data exchange can be very time consuming and potentially subject to failure with the unreliability of dial-up connections. Another issue, which is also faced by many other countries, is that technology systems used by GPs are not necessarily compatible with those used by pharmacies or laboratories. As an example, 89% of UK prescriptions are computer-generated but only 62% are endorsed by a pharmacy computing system.^{[ 2 ]}

Australia
In 2001, a study by Western et al found that 86% of Australian general practices had at least one computer and projections indicated that within two years 95% of practices would be computerised.^{[ 3 ]} An interesting finding in this study was that larger practices and practices in rural areas were more likely to be computerised than smaller urban practices and computers were more likely to be used for administrative rather than clinical tasks.^{[ 3 ]} Computerisation was initially promoted by the Australian General Practice Strategy Review Group in 1989 in its Strategic Framework for GP IM & IT.^{[ 4 ]} It was also aided by federal government’s funding of the General Practice Computing Group, which aimed to develop a framework for strategic activities in general practice information management and information technology 2001-2005, and was included in the practice incentive programme. ^{[ 3 ]} The key goal in 2004 is to ensure that GPs have access to the information resources needed to support good clinical decision making.^{[ 4 ]} Adopting IT/IM systems may benefit doctors (in terms of better clinical decision making), patients (for better health outcomes) and the government (access to population health data). The main problems experienced to date by GPs include the disruption caused by equipment installation, the lack of IT support, a lack of confidence in computer use, and the cost. In some cases there has also been difficulty in achieving consensus in group practices, when using clinical decision-making tools.^{[ 4 ]} There is currently valuable research being conducted in Australia on the future of health IT, moving on from the storage and retrieval of data, which has already been largely achieved, to integrated systems for the capture of data and knowledge.^{[ 11 ]} The legal issues involved in the move from paper-based to electronic patient notes have also been considered.^{[ 12 ]}

Canada
A study conducted in 2000 showed that only 12% of GPs in Canada were using a PMS to store full patient notes - a total of 57% used a PMS, the remainder were only using a PMS for administrative functions.^{[ 5 ]} Approximately 30% of respondents in this study said they would never or were unlikely to ever adopt a PMS. Canada’s health care sector has not yet adopted IT to a level sufficient to support clinical systems and few laboratories distribute results electronically. Canada is, therefore, an example of a country that needs to focus on the introduction of IT in general practice in order to keep up with international standards. It was found that 70% of practices used some sort of computer programme to perform electronic billing. Therefore, the rudiments of IT are already in place, with IT systems commonly used for administration, and this can provide the basis for moving into IT use in clinical care.^{[ 5 ]} It is likely that the situation has improved since this study was conducted four years ago, however, there is still much progress to be made. Canada Health Infoway was established in 2000/2001 for the purposes of accelerating the development and implementation of electronic health information systems.^{[ 9 ]} Several other provincial initiatives have been established such as Alberta’s Physician Office System Program and Ontario’s Family Health Network ePhysician Project.

US
In 2002, only 17% of primary care physicians in the US used a PMS system for the storage of clinical notes. At the time, this compared to 58% in the UK and 90% in Sweden.^{[ 6 ]} In 2001, only 6% of US prescriptions were written electronically, but this figure has been growing.^{[ 6]} Like Canada, the US has much work to do to get its technology up to the same level as countries such as England. The US Institute of Medicine has urged a renewed national commitment to IT in the health care sector, leading ultimately to the elimination of hand-written clinical notes.^{[ 6 ]} A PMS should be slowly introduced to gain the confidence of the GPs and other users of such systems. This would start with a system including patient demographics, reason for encounter, medication lists and reminder prompts only. Another alternative would be a full Electronic Medical Record (EMR) system, web-based to eliminate the need to purchase software and hardware with back-up power supplies, disaster recovery strategies, etc, included. However, this would introduce problems with keeping confidential information secure.^{[ 6 ]} As with other countries, several initiatives for managing health IT have emerged in the US, for example HIPAA (The Health Insurance Portability and Accountability Act of 1996) and Medical Error Reduction legislation. In January 2004, President Bush pledged his administration’s support for computerised health records in his State of the Union address - "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care".^{[ 10 ]}

New Zealand
Prior to 2003, the most recent data on IT in general practice in New Zealand came from a study conducted in a small geographical area of the country. In 1999, 61.8% of GPs in the South Auckland region were recording their clinical notes on computer.^{[ 7 ]} A nationwide study was conducted in 2003 by the Royal New Zealand College of General Practitioners (RNZCGP) Research Unit and in yet to be published data, it was found that New Zealand is performing well in international terms, ranking almost equal to England in its level of computerisation and use of technology. The three key components of health care IT are: first, possessing the appropriate hardware; secondly, purchasing PMS software; and, thirdly, a connection to the internet for transfer of data. New Zealand ranks very highly in these areas and is superior to UK in that many practices already have broadband internet connections. It seems that New Zealand has managed to achieve a high standard of health care IT without any specific government intervention in comparison to Australia and the UK.

The way to the future

In New Zealand, the backbone for the use of IT in health care is already in place, with almost all practices computerised. The next step must be to refine these systems and ensure compatibility and standardisation between general practices, laboratories, pharmacies, secondary health care services and national data collection facilities. One key area is the standardisation of clinical terminology and the universalisation of its use between practices and hospitals, as is the goal in the UK.^{[ 2 ]} In New Zealand, the Read Code system is predominantly used by GPs, however, diagnoses are not consistently coded. Hospital discharge diagnoses are classified using ICD-9 and ICD-10 (International Classification of Disease) codes. The standardising of such coding across the services would be invaluable in terms of electronic communication between primary and secondary care and other health care providers. In addition, the scope for health care research and national data repositories would be greatly enhanced.

With the introduction of new technologies into the healthcare sector, comes the need for training medical professionals in the use of IT, both in order to eliminate errors and negative perceptions. The machine is only ever as good as the user. The major objection towards adopting new IT systems is the cost involved, which includes the initial cost of the hardware and ongoing costs associated with software vendors and support services. It is possible that, in future, Independent Practitioner Associations (IPAs) or Primary Health Organisations (PHOs) will take on the cost of equipment and will hold all patient information in a central server, rather than individual practices managing their own systems. Amalgamation of practices within these organisational structures, ie, the IPAs and PHOs, means greater buying power for technology. This also takes responsibility for maintenance away from GPs whose practices generally do not have IT departments or the resources to handle the maintenance and technical support required.).^{[ 8 ]} This is the situation in the UK where primary care trusts (similar to PHOs) will become responsible for funding computer technology and keeping data secure.^{[ 2 ]}

PMS technology must mirror health care needs and to achieve this, PMS software vendors must work alongside health care policy makers and health care professionals in developing products that benefit doctors, patients and health care research and development. This would also mean co-operation with other health care agencies, for example, laboratories and pharmacies, to ensure that systems are compatible. Guidelines for the use of electronically stored and transferred data must be carefully reviewed by key stakeholders to ensure patient confidentiality is fully protected.

There are many new technology systems that could be adopted in general practice medicine, such as e-mail communication between patients and doctors, patients booking their own appointments online and receiving e-mailed reminders for repeat medications and scheduled tests. This would eliminate the often-cited problems of overloaded telephone systems and the difficulty in making contact with someone in a practice. In the US, the idea of using interactive websites to manage tasks such as scheduling reminders, entering glucose levels and other patient-managed functions has been considered.^{[ 6 ]} With the application of technology in this way it is difficult for a practice to charge for such services and, once again, security and confidentiality are concerns.

Some specific key areas have been identified in the UK for improvement of technology systems and, given that New Zealand is at a similar level of computerisation, it is likely these areas would also be of relevance in this country. One of the proposals is to send discharge summaries and clinical letters electronically (from hospitals to general practices).^{[ 8 ]} This is an example of the advantage of standardising computer and coding systems between primary and secondary care providers. Following on from this, it would be of much benefit to allow the electronic transfer of records between practices when a patient changes providers and also a facility for dual providers (such as a GP and a specialist) to share information electronically and jointly view patient notes.^{[ 8 ]} This could be achieved by having notes on a central server.

New Zealand should be proud of its progress in introducing IT into health care. The idea behind PMS software and standardisation between systems is a move towards a population-based approach to health care, in which patients are grouped by diagnoses and clinical risk strata.^{[ 6 ]} If health care is a business and good patient health outcomes are the measure of success, then the continued commitment to introducing and refining electronic technology and systems, can only be of benefit to all concerned.

References

1. Anonymous. Business: Hardly wired. The Economist 1998; Oct 24; 349(8091):68.
2. Royal College of General Practitioners. General practice computerisation. In: RCGP Information sheet no 7. 2003.
3. Western M, Dwan K, Western J, et al. Computerisation in Australian general practice. Aust Fam Physician 2003; 32(3):180-5.
4. Commonwealth Department of Health and Aged Care. Information technology in general practice: A study into levels of and attitudes towards information technology in general practice. April 1999.
5. Kazimirski M, Renaud C, Sawaya L, et al. Computer literacy and electronic medical records. The College of Family Physicians of Canada. 2000.
6. Bodenheimer T, Grumbach K. Electronic Technology: A spark to revitalize primary care? JAMA 2003; 290(2):259-64.
7. Kenealy T, Arroll B, Kenealy H, et al. General practice changes in South Auckland from 1990 to 1999: A threat to continuity of care? NZFP 2002; 29(6):387-90.
8. Majeed A. Ten ways to improve information technology in the NHS. BMJ 2003; 326:202-6.
9. Canada Health Infoway. Annual Report 2003.
10. Bush G W. State of the Union Address, January 2004, United States Capitol, Washington DC..
11. Cesnik B. The future of health informatics. Int J Med Inf 1999; 55(1):83-5.
12. Cheong I. The legal acceptability of an electronic medical record. Aust Fam Physician 1997; 26(1):37-41.

Corresponding Author
Rebecca Didham, RNZCGP Research Unit, Department of General Practice, Dunedin School of Medicine, PO Box 913, University of Otago, Dunedin, New Zealand. Email: rebecca.didham@stonebow.otago.ac.nz