Path-finding in the Public Health Information Quagmire

• Abstract
• Introduction
• Understanding the Regional Health Surveillance System
  • What does RHSS do?
  • Advantages for Public Health
  • Making Work Easier
• Development Methodology
  • Development
  • Process
  • Technical Specification
• Outcomes
  • RHSS Benefits
  • Post Implementation Review
• Summary

Abstract
The Regional Health Surveillance System (RHSS) is a database designed by and for New Zealand public health services to improve information management, analysis and surveillance. It provides public health services with a structured way to collect, store and report on the work that they undertake. The RHSS brings together the diverse functions of public health services by standardising the collection of data about activities relating to public health and key reference and contact information including people, locations and organisations. RHSS is based on a population health approach to health and reflects the complex and intricate relationships between people, places and public health. It is flexible enough to cope with the changing needs of New Zealand’s health service yet robust enough to maintain accurate and reliable information. Key to the success of the RHSS is its ease of use and acceptance by the diverse user community within Regional Public Health.

Introduction
The Regional Public Health Service (RPH) of New Zealand’s Hutt Valley District Health Board^{[ a ]}(HVDHB) provides a range of public health services to the greater Wellington Region including programmes covering communicable diseases, health protection, child health, health promotion and Maori and Pacific People’s health.

Surveillance is an ongoing core public health function. It involves the standardised collection of data on the occurrence of hazards and risk factors that could lead to injury, illness, disability and death in human populations. Surveillance is carried out in order to identify factors that may lead to these events occurring so that appropriate action can be taken.

In April 2000, a project to develop a comprehensive database for RPH was undertaken. This was in response to the increasingly fragmented nature of database development and the frustrations of reporting and analysing data from different datasets.

RHSS is the culmination of two-and-a-half years’ work. RHSS has been designed to meet the key issues of information management within RPH.

Some of the significant issues that RPH faced related to the fragmentation of data, inefficient processes supporting the handling of key contact and reference information (people and places), duplication of effort and lack of communication and coordination between different teams within the service because each was operating as an independent island of information. The resulting fragmented data sources resulted in an inability to extract meaningful information in a timely manner.

This became apparent when the service received requests for information regarding public health activities and issues relating to ethnic groups, such as Maori or Pacific Peoples, or information regarding particular areas of public health interest, such as Porirua or Newtown. Collation of this information involved extracting the information from people directly involved with the issues and the delivery of those services. There was no system for collecting or maintaining this information and there was a need to rely on personal recall in order to answer these information requests.

Further, the lack of centralised coordination, data capture and data standards resulted in poor data integrity and data quality; compounded by inefficient processes for capturing and tracking data electronically. Frequently health information systems have been developed using the "number 8 wire" approach and RPH was no different. This was evident with the attempt to amalgamate the five different schools’ databases; all of the databases obtained their information from independent sources, no common identifier was present and even the names varied depending on the source of the information.

Understanding the Regional Health Surveillance System
What does RHSS do?
RHSS allows for the collection of core public health data in a systematic manner. Events are recorded along with the Location where the event occurred and the People and / or Organisations involved. Regulatory Events such as Chemical Spills and Health Promotion Projects are recorded on a daily basis. RHSS supports staff in managing their day-to-day workloads and responsibilities via the incorporated "bring up / reminder" system and a document management facility. The system includes a number of search options to rapidly find events and information stored.

Information can be provided in the form of standardised reports, customised reports and standardised export datasets. The system is based, where possible, on national standards make sharing information and linking with other datasets possible. RHSS enables analysis and use of the data collected that was not possible in the previous information systems environment and reduces the need to maintain multiple systems for using and storing the same data.

Advantages for Public Health
The systematic collection of core public health data, using National Standards where possible including Department of Statistics and Ministry of Health standards, enables improved data quality and reporting capabilities including a flexible reporting environment that meets the day-to-day needs of the end users. Additionally, data are easier to analyse and there is an enhanced ability to link with other datasets.

By addressing data fragmentation through the collection of data by RHSS, the effort required to maintain information systems has been reduced. In addition, it creates a profile of events that have occurred for a Location, Organisation and / or People. It also allows access to information on specific areas, eg, District Health Board (DHB) or Territorial Local Authorities, and access to comprehensive information for reporting to other agencies such as DHBs.

Making Work Easier
"Ease of use" is a key factor in the collection of good surveillance information. This has been seen as a priority during the development of RHSS and has been accomplished by the closer involvement of public health practitioners and developers skilled in usability issues. Good surveillance information can only be achieved if the front line users want to use the system, thus, there must be real and tangible results and benefits for these users.

Validation of data at the time of entry is a key component of a robust database. Within RHSS this takes many forms including date validation, the use of look-up lists, address validation and geocoding and duplicate record checking.

Development Methodology
Development
In 1999 the need to develop a way to manage public health information was identified. This arose when RPH was investigating the implementation of geographic information systems (GIS). A report by Explorer Graphics Ltd identified the need to develop a information systems infrastructure to support such a GIS. The assistance of a Data Architect was obtained. This provided RPH with a logical means of capturing and linking all of RPH’s different information needs into one model. Once the architecture had been developed, users’ needs were identified by undertaking a detailed Needs Assessment. It became apparent that many needs were similar in nature even though the area of work varied.

Figure 1:Overview of representation of complex relationships within the RHSS

It is complex and difficult to represent the real world in databases. Figure 1 gives a high level overview of how these complex relationships are reflected within the RHSS. For example, in real life people play a number of roles throughout their lives (eg, a health care user, a student, a doctor, etc). Each role has a different relationship to physical locations and public health events. People will often form relationships with other people (parents, children, families, hapu). Similarly, the use of physical locations will change over time and it is important to maintain a history of a site’s use (eg, a landfill that becomes a school that may then become residential housing). The RHSS has a relationship model that is expansive and attempts to allow real life to be reflected as far as possible.

Following this process "The Simpl Group", a reputable Software Development Company, was contracted to fully develop and document the proposed system. Simpl applied sound project management methodologies, which were critical in the successful completion of the system. Development involved the co-location of two RPH staff members within the developer’s Wellington office for three months.

The core system was developed using proven methodologies, such as a Software Development Life Cycle (SDLC) processes, followed by extensive testing by RPH staff and the Institute of Environmental Science and Research Ltd. (ESR).

The system went live at RPH in April 2002, from which time individual teams progressively undertook peer delivered training and implemented the system in their area.

Process
The development flow chart shown in figure 2 illustrates the process of development of the data model and the RHSS and indicates key points of interaction by the various relevant parties.

Figure 2: Development flow chart

Technical Specification
The technical specification for RHSS is shown in table 1.

Table 1: Technical specification for RHSS

Outcomes
RHSS Benefits
RHSS has been designed to allow monitoring of contract delivery to provide the basis for reporting (both contract and other reporting requirements) and as a tool in the evaluation of health programmes.

A solid data architecture, developed on a proven technological platform by a professional development team, has produced a system that is flexible in response to RPH’s changing environment and has a high degree of stability coupled with a comprehensive support package. The system allows for the early identification of community need and provides an evidence base for decision-making.

The RHSS has provided RPH with an effective tool to assist in prioritisation of service delivery in a number of areas including targeting of work with early childhood centres and delivery of services to schools. It provides for increased opportunities for communication between teams, which reduces duplication of activities and improves coordination of services to schools.

Several key features that contributed to the project’s success have been identified. The first was the use of proven technology combined with a flexible system design that was capable of handling a small user right through to a large user community. Quality control was an important feature of this system and involved independent assessment of every step of the design and build process. Importantly, the data model was independent and validated.

Post Implementation Review
The post-implementation review considered 19 deliverables as set out in table 2.

Four key recommendations arose from this post-implementation review:

1. Greater contingency budgets should be built into design and build projects to manage unforeseen requirements which arise during the design and development process.
2. Greater time and budget allocations should be devoted to the functional specification stage of such projects, to allow for the development of greater levels of detail and the inclusion of the test plan development.
3. RHSS should be promulgated to other DHB Information Technology Managers, the Ministry of Health and other Public Health Units as it represents a significant advance in public health information management.
4. Budget and resources must be allocated to the continued development of the system.

Summary
The RHSS database provides public health services with a structured way to collect, store and report on the work that they do every day. The RHSS brings together the diverse functions of public health by standardising the collection of data about activities and key reference information. The initial design and build of the RHSS was always seen as a first step in a longer journey. Already reviews, changing needs and feedback from the user community have resulted in a number of enhancements to the original system.

We believe that the RHSS would provide benefits to other public health services and could provide a basis for national public health information collection and surveillance should it be implemented across the New Zealand.

Acknowledgements
We would like to thank Jodene Tuau for her work as analyst and project manager for RPH and also the team at Simpl for working in partnership to make the RHSS a reality.