Guest editorial

In his editorial for the last edition of HCIRO, Professor Peter Davis hoped to see “more empirical evidence, more evaluation, and more reference to an international literature” in future articles. In this edition, authors have risen to the challenge under the theme of creating quality in primary health care through the use of electronic health records. Perhaps it is not surprising to see a wide variety of views being expressed in the three papers presented. We have viewpoints ranging from the strategic, where all things seem possible, to the pragmatic, with the international context as a background.

Karolyn Kerr has endeavoured to provide a definition of what the electronic health record consists of, the potential impact that such a model might have on the delivery of health care and the steps that are being made toward realising the electronic health record in New Zealand and in other countries. Primary care would be at the heart of this vision, with patient self-care being improved by informed decisions enabled by technology.

Ken Leech argues cogently for a concept he calls the “Virtual Patient Record” where information is specifically targeted and shaped for specific sets of patients, with particular requirements for disease management where well-understood clinical outcomes can be achieved. Leech provides us with some useful insights into the difficulty of implementing information systems in the turbulent primary care arena.

Both Kerr and Leech have used the term “Holy Grail” to describe the classic electronic health record. One argues that we are well advanced towards realising this long sought after vision, and the other that the “Holy Grail” will never be realised quite as it has been envisioned.

Rebecca Didham and Isobel Martin have provided a review of the current state of technology use with respect to electronic health records in general practice in the UK, Australia, Canada and the US. As usual, we find that New Zealand is right up there with the leaders in the world. It might be surprising that there is little information on the use of information technology in general practice. It has been noticeable that there has been a great divergence of opinion as to what the reality is today, and how it has changed in recent years. In these matters, the voices of special interests can often carry an inappropriate weight. Didham and Martin have provided a useful insight into the difficulty of establishing the facts of the case in different countries around the world. We will await the publication of their New Zealand study with great interest.

Some might say that Leech is really arguing for an incremental approach to the classic electronic health record , with real tangible benefits apparent to clinicians along the way. An evolutionary approach to development is a concept that has been advocated before in this journal and elsewhere, and no doubt will continue to be supported in the future. It is well understood by those that have made the hard yards implementing systems in the hard, real world of healthcare technology that it is important to make small steps. Each step must have clear benefits and rewards for the effort – which can be enormous – so that we are encouraged to take the next step.

In contemplating these futures, it is sobering, but not surprising, to hear from Statistics New Zealand ^[1] recently that people on lower incomes - who are more likely to have poor health outcomes in the first place - are considerably less likely to have access to the basic enabling technology that will be required to support these visions. This “digital divide” will undoubtedly have an increasingly effect on the development of electronic health records, whatever form they take.

While we work hard to achieve the pragmatic small steps that collectively constitute progress, it is also valuable to stretch out our minds farther than we can easily perceive, and retain a vision of how things might be in the future.

Let us continue to hear these differing views, while allowing the visionaries to have their say also. Perhaps in the dialogue thus created, the path to the future will emerge more clearly.

1. Statistics New Zealand. March 2004. The Digital Divide. Available at www.stats.govt.nz