Editorial - Success in Health Care - Making IT work (Part 2)

Welcome to this March 2006 edition of Health Care and Informatics Review Online which  continues the series focused on making information technology (IT) effective in health care settings, which we started in June 2004. This edition follows the "making IT work" theme and contemplates some of the barriers that need to be overcome for success in this, in particular in the New Zealand health setting.

Investments in systems such as the National Health Index (NHI) to provide a unique patient identifier, the development of the National Minimal Dataset (NMDS) for inpatient services and other national data set collections for data on cancer and medical warnings, have placed New Zealand at the forefront of developed nations with regard to health information management. These systems have been described as “fundamental reference points, or ‘anchors’ for the safe management of health care delivery to New Zealanders”.^{[ 1 ]}

The next stage is to tackle the next round of information system challenges for improving the health and wellbeing of New Zealanders, which includes:

• Addressing the ongoing constraints in ability to collect, share and exchange data in a secure environment. In some instances, there is no information available and in others, manual systems are used for tasks which should be automated.
• Increasing the willingness of providers to share information with other providers where that will improve the care consumers receive.
• Developing and implementing standards that allow multiple organisations to exchange information.

Addressing the next round of opportunities for information system advances demands recognition that the different parts of the health care sector are at very different evolutionary stages.

The high degree of diversity and variation in the capability and use of information systems within the sector is illustrated in the figure below.

Figure 1: Diversity of information system capability across the sector ^{[ 1 ]}

A significant consideration that underpins the above and continues to challenge ICT advances towards an integrated health sector ( the goal of the New Zealand government health care information management and technology strategy launched in 2001) is the background of extensive public health system restructuring that took place in New Zealand throughout the 1990s.

This challenge is the focus of our first paper The Troubled History and Complex Landscape of Information Management and Technology in The New Zealand Health Sector from Dr Robin Gauld, PhD, Senior Lecturer in Health Policy in the Department of Preventive and Social Medicine, University of Otago, Dunedin New Zealand, where he teaches on the postgraduate public health and health management programmes.

The review paper by Dr Gauld appeared in its original form in Government Information Quarterly^{[ 2 ]}. We are delighted to include in our publication an abridged and updated version of that paper.

In this paper, Gauld reviews the three distinct restructures of the New Zealand health system in the 1990s through which New Zealand’s current information and technology systems emerged. That period saw a shift in structure through a competitive internal market system to the most recent shift to facilitate localised population-based planning and service coordination.

Progress through the restructuring period was variable, and many information and ICT problems identified at the start of the decade remained unresolved.

Gauld highlights the minimal central oversight and development of information systems in isolation from one another by purchasers and providers in that period.

As a result, New Zealand now has a highly complex and well-established architecture and an array of problems in need of correction. This situation, along with current decentralisation of health structures, limits the government’s capacity to influence health sector activities.

Gauld then reviews the information management and technology requirements that must be in place to support the success of New Zealand government’s WAVE project.

Finally, Gauld considers developments since 2001, including the updated 2005 health information strategy, along with the prospects for achieving the WAVE objectives.

The article concludes with a review of current developments. Gauld notes an expectation of incremental progress by government towards it goals and points to key areas requiring considerable effort:

• “fixing” problems associated with the restructuring era including overlapping databases, data collection inconsistencies and lack of information coordination across the health sector;
• updating incompatible systems; and
• managing complex organisational, planning and policy issues such as development of national systems architecture guidelines, development of security and privacy policy, consolidation of information strategy and creation of a an institutional basis for developing sound ICT policy and ICT coordination.

Our second paper, Heath Care Consumers, Security and Electronic Health Records comes from Prajesh Chhanabhai and Alec Holt, from the Department of Information Science, University of Otago, Dunedin, New Zealand, and Inga Hunter, Information Systems, Massey University, Palmerston North, New Zealand.

Chhanabhai et al consider the position of consumers as stakeholders in the transition from paper-based to electronic health information system and the importance of security concerns.

The authors note their view that consumers have not received enough attention in relation to a move to electronic health records (EHRs). Developments in communication technology have contributed significantly to an increasing consumer focus on the need for security of information.

Several studies highlight security, which encompasses privacy and confidentiality, as the main issue that health consumers have regarding electronic record systems.

The authors highlight that much of this concern stems from poor understanding of available security measures, such as firewalls, encryption, etc. The authors highlight that, in order for EHRs to become an effective global technology, it is critically important to allay consumer fears related to security by improving consumer understanding of key security requirements (authentication, access control, accountability, authorisation, and availability) and their application in EHR.

The authors go on to describe and present initial results from a current New Zealand study of health consumers perceptions of EHRs. Preliminary results indicate concerns with record security, perhaps as expected, but also indicate that improving those consumers’ understanding of available security measures does appear to assist them to feel more at ease with electronic security. New Zealand.

Our edition closes with a commentary piece from Mark Wills, Former CEO of ProCare Health Limited, Auckland, New Zealand, who is currently in the position of Entrepreneur in Residence, The Icehouse (University of Auckland’s business incubator), The University of Auckland, Auckland, New Zealand.

From his perspective as a former manager of a healthcare organisation in New Zealand, Wills considers whether primary health care in New Zealand is benefiting from the potential gains information technology has to offer for solving problems efficiently and creating attractive gains in performance and productivity.

Wills notes that, while international health IT investment stories may have been viewed with some envy when he was CEO at ProCare, there are examples of IT working very well in primary health care, including the advancement of general practitioner’s practice management software and the introduction of electronic claiming and clinical decision support.

Wills considers challenges to the wider use of and investment in IT in the health care sector. He highlights a main challenge being the ability to get clinicians to adopt new IT systems; “clinicians are a tough audience to impress and even tougher to shift to the use of these new systems”. He goes on to notes that it is not only the IT solution itself that determines the success of the approach but other factors such as:

1. a real problem being addressed by the IT solution, ie, one that is recognised as needing a solution;
2. a solution that is not too complicated;
3. time spent with the clinicians to convince them of the merit of the solution;
4. a solution that is the path of least resistance (or close to it) in order to encourage adoption; and
5. a “reward” for clinicians for using the system.

The tightness of resources most likely assists in driving the innovation and resourcefulness that is evidenced in New Zealand. Additionally, the successful implementation of an IT system is as much to do with resolve and the sound preparation of the users of the system as it is to do with good design of the system itself.

Wills sees the significant increase in the use of IT in health in New Zealand as encouraging and expresses his belief that New Zealand can look forward to a future which realises the potential that exists through effective implementation of IT solutions delivering real benefits to patients and clinicians alike.