Editorial - HINZ 2005: Telling the New Zealand story - A sharing of innovation ideas and experiences

I am delighted to present you with this December 2005 edition of Health Care and Informatics Review Online which showcases a selection of papers from the Health Informatics New Zealand (HINZ) Conference and Exhibition 2005, held 2-5 August 2005 in Auckland, New Zealand. Health Care and Informatics Review Online is in its second year as the official journal for HINZ and a key part of that role is coverage of this important event.

Titled "Telling the New Zealand Story: A sharing of innovation ideas and experiences", the conference was dedicated to sharing experience and learning from innovative use of health information technologies.

New Zealand is a world leader in technology innovation. Achievements in health information technologies include the unique patient identifier, web-based clinical information systems and Clinical Context Object Workgroup integration technology (CCOW), a vendor independent standard that allows clinical applications to share information at the point of care. New Zealand is one of the earliest adopters of Health Level Seven messaging standards for electronic laboratory results reporting¹.

New Zealand continues to drive ahead with new innovation such as the unique provider identifier system and ongoing efforts to contribute to standards developments at an international level.

The edition opens with a guest editorial from Stephen Chu, Associate Professor of Health Informatics, The University of Auckland, Auckland, New Zealand. Chu presents a fascinating account of health information technology (IT) as proactive strategic weapon to improve quality of care and services delivery in healthcare systems. He highlights phases of transformation in the healthcare industry since the 1950s which have brought health care to the present point where healthcare industry and governments worldwide now place high priority on improving the quality of healthcare systems. Critically however, Chu points to problems with implementration of effective effective quality improvements, which can be attributed to the complexity of the healthcare system, the culture of medicine and a lack of enabling tools to monitor and feed back quality data to healthcare practitioners and other parts of the system. 

Chu goes on to consider the contribution which health IT can make to quality improvement and the issues in maximising the benefits of health IT in this application. He specifically provides a note of caution on the extreme difficulty of determining return on investment for health IT initiatives but hastens to remind us that this is simply "another challenge  that the health informatics community needs to take up".
  
The edition includes two top papers and one top student paper from the conference selected from an aggregation of the paper score from the scientific programme committee and points obtained from feedback submitted by the conference delegates.

We also include an additional paper of great interest from the plenary presentations, which reviews The University of Auckland’s contribution to the Physiome Project. The Physiome Project is an international effort to understand and describe the human organism, its physiology and pathophysiology, and to use this understanding to improve human health. In "Creating the Virtual Human", Andrew Pullan and Nicolas Smith from the Bioengineering Institute and Department of Engineering Science, The University of Auckland, Auckland, New Zealand, and Peter Hunter from the Bioengineering Institute, The University of Auckland, Auckland, New Zealand, describe the progress being made at The University of Auckland for handling the hierarchy of computational models and associated experimental data as advances are made towards the Physiome goal of the virtual human.

The top student paper "Integrating RFID Technology into a Drug Administration System" is from Bryan Houliston, School of Computer and Information Sciences, Auckland University of Technology, Auckland, New Zealand.

Houliston discusses radio frequency identification (RFID) technology as an alternative to the use of barcodes to uniquely identify both patients and drugs, in the ongoing quest to reduce errors in the administration of drugs to patients.

The paper documents the design and development of an extension to an existing barcode-based anaesthetic drug identification system, IDAS, which would allow functional replacement of barcodes with RFID technology. While the IDAS system appears to reduce the incidence of adverse drug events, the system’s effectiveness may be limited by issues with useability, in particular the need to scan a drug’s barcode label before administration. A prototype system using RFID was effective in indicating that RFID technology could functionally replace barcodes but also illustrated a number of issues in working with RFID in a hospital settings and additional functionality requirements that would need to be addressed.

The first of the two top papers is "Improving Post-operative Pain Management Using the CIS Model" presented by Annie Fogarty, Hamish Murdoch, Guangyu Han, Xiping Tan, Michael Chen and Bindee Holland, A+ Network Centre for Best Patient Outcomes, Auckland District Health Board, Greenlane Clinical Centre, Auckland, New Zealand.

These authors consider a technological solution aimed to help to address the spiralling costs of health care: computerised clinically integrated systems that will capture information at the point of clinical services delivery, now recognised as the place where the most significant health costs are initiated.

In 2000, the Clinically Integrated System (CIS) Model of a computerised clinically integrated system was developed by the A+ Network Centre for Best Patient Outcomes. The CIS Model is an interdisciplinary electronic system that links evidence based care, clinical redesign, outcome management and participatory action research into a single framework to improve patient care. The prototype was introduced in the Orthopaedic Department at Auckland City Hospital for use with patients with a fractured neck of femur.

Patients who received their health care via the CIS Model had a reduced median length of hospital stay compared with patients who did not. Further analysis of data for patients receiving their treatment via the CIS model showed high variance in post-operative pain management. It was initially presumed that the high pain variance incidence was associated with poor assessments and inadequate medication regimens. However, the CIS Model was used to demonstrate that this assumption was incorrect and that patient compliance was a major factor; a high percentage of patients were declining medications based on a variety of misperceptions regarding pain relief.

Subsequent integration of pain data into the CIS Model monthly reports, which can link demographics, clinical variances, financial data, and patient and relative/whanau participation outcomes together, revealed a relationship between a patient declining pain medication and a subsequent failure to meet the expected mobilisation criteria emerged. In turn, this finding was linked to an increased length of stay.

The underpinning of systems and processes with a computerised programme to support their implementation effectively uncovers the interrelationships and complexity of care delivery. The project clearly demonstrated how clinical practices supported by computerisation can have a direct, beneficial impact on patient health care delivery and organisational outcomes.

The second top paper is presented by Paul Harper, Consultant Haematologist, Honorary Senior Lecturer, Thrombosis Unit, Department of Haematology, Auckland City Hospital, Auckland, New Zealand and Joseph Harper, Independent software developer, New Zealand. Harper and Harper propose a model to manage anticoagulant therapy using a web-based anticoagulant programme accessible to both general practitioners and patients performing self-testing.

Warfarin is a valuable anticoagulant drug but requires close monitoring to prevent overdose and bleeding. In New Zealand anticoagulant monitoring is not managed consistently and the "safe use of medicines" group has recommended improvements to anticoagulant control using warfarin in primary care.

A number of different approaches to anticoagulant control exist, each with advantages and disadvantages. All approaches can achieve good anticoagulant control in the well motivated, reliable patient but the patients at most risk of bleeding are those with poor compliance, poor attendance at clinics or their GP’s practice and frequent changes to other medication. Thus, an effective monitoring system must be able to easily identify these high risk cases, which none of the existing systems reliably does.

Harper and Harper propose a centralised, internet-based, computerised anticoagulant monitoring system that allows both clinician-based monitoring and patient self-testing. The central client program would run a dosing algorithm based on a published dosing formula to predict a patient’s dose and review the stability of results to recommend the date of their next test. INR². results would be entered from a web-based browser or downloaded directly from laboratory computer systems. Additionally, the system would:

• Store details of all other medication for each patient and identify drug interactions automatically
• Identify patients requiring high doses of warfarin
• Identify patients with poor anticoagulant control
• Identify patients with poor compliance.

A GP would remain responsible for their patient’s anticoagulant control at all times; in some other models it is not always clear which doctor has responsibility for anticoagulant control, eg, in a laboratory based model, dose adjustments would be made by a clinician who is not the patient’s primary care physician and who, therefore, might not have access to all the clinical information necessary to make safe dose adjustments. The proposed model also has the advantage that patients performing self-testing remain supervised by their GP rather than becoming isolated with little clinical support.

A pilot study to test this model is being developed and will be trialled at a GP practice in Auckland and on a small group of patients who manage their own warfarin using near-patient testing devices. If the results prove favourable, the process could be extended.

Louise Kirkwood
Managing Editor

Footnotes