Success in Health Care – Making IT Work

• Abstract
• Introduction
• International investment low
• Significant gains there for the taking
• Compulsory or voluntary, which works best?
• Is health a special case?
• Squeezing maximum blood out of the IT investment stone
• Can the system deliver real value to clinicians?
• Conclusion
• References

Abstract
Despite a relatively low level of investment in IT systems internationally and in New Zealand, there are good examples of the successful implementation of systems in primary care. Some keys to successful implementation of systems include ensuring: a real need exists and is recognised, that the system is not complex and that clinicians operating the system are incentivised to use it. The primary care sector in New Zealand is not corporate in its structure and tends to expect voluntary adoption of new systems. With good preparation and implementation these systems can deliver positive and cost-effective results.

Introduction
The effective use of information technology (IT) has the potential to solve problems efficiently, creating attractive gains in performance and productivity. Is primary health care in New Zealand benefiting from these potential gains? There are some promising steps being made towards realising these benefits, however the potential for investment and further significant progress is very large. From my perspective as a former manager of a healthcare organisation in New Zealand, international health IT investment stories were viewed with some envy. However, there are some examples in New Zealand from which we can take heart and which prove that it is not just about money, but is also about resolve and relationships.

International investment low
Health care systems generally are considered to be low level investors in information technology when compared to other sectors. As noted in The Economist’s Health-Care Survey “The Health of Nations” (15 July 2004): “The medical sector has been slow to invest in information technology, which holds great potential to reduce errors and improve efficiency and quality.”

Many international comparisons look at the sums spent on health IT as a basis for determining how advanced or effective the IT systems are in each country. I believe this is a poor measure, as the complexity of health systems has a significant impact on the effectiveness of these IT systems. Additionally, dollars spent on an IT system do not always equate to its effectiveness, as many Chief Information Officers will testify.

Nonetheless, there is much potential for improved IT solutions to deliver value to the sector. So, why is investment and uptake in health IT in New Zealand not as high as it should be? Why does the health care sector not see the same value in IT investment as many other sectors? And what works in health IT to deliver benefits to patients, clinicians and administrators alike?

Examples can be found 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. These examples of progress are delivering measurable benefits and are, no doubt, encouraging for those aiming to maximise benefit from their IT investment in health.

Health care information and communications technology (ICT ) specialist Bankix Systems noted in its recent newsletter “Developments in Global Health ICT Investments” (6 October 2005) that experts were predicting “that the developments in the industry that will continue to create opportunities for both new services and business growth would likely include the shift towards multiple health ICT implementations, and the increasing importance of business process re-engineering in the health sector”. The article also reported that less than 3 percent of European and American hospitals have implemented “computerized physician order entry (CPOE) with clinical decision support”.^{[ 1 ]}

Significant gains there for the taking
Providing helpful and worthwhile systems to clinicians’ desktops at the point of patient care can contribute to significant improvements in health care and help build patient confidence in the health service. Information truly is power when that information can be used to improve systems, quality and outcomes. Indeed, having information can be hugely enabling, opening minds to alternative ways of doing things.^{[ 1 ]}

The first challenge to the wider use of and investment in IT in the health care sector is simply getting 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. It is not just the IT solution itself that determines if the approach will be a success. A number of other key factors are also important:

1. The problem that the IT solution aims to address being real, ie, one that is recognised as needing a solution.
2. The solution not being too complicated – “very simple” works more often than “slightly complex” and “simple” definitely works better than “very complex”.
3. Time spent with the clinicians to convince them of the merit of the solution.
4. The solution being the path of least resistance (or close to it) to encourage adoption and therefore achieving the outcome/output intended.
5. There being a “reward” for the clinicians for using the system; this reflects the findings of studies in ICT generally which tend to show the uptake of systems by users is reluctant, and will only occur effectively if there is a willingness and an incentive.^[2,3]

Indeed, all of the patient satisfaction surveys conducted by ProCare and others that I became aware of in primary health care have indicated a very strong level of satisfaction with and confidence in the clinical competence of the clinicians (general practitioners and nurses). Patients often, however, articulated much lower levels of satisfaction in relation to the customer service aspects of accessing primary health care. An effective IT solution can certainly assist in improving the customer service aspects associated with primary health care and create the perception (and reality!) of good service and organisation. This can only help to build patients’ confidence in the health system and the practice.

As with any new technology there will be “early adopters” – those willing to metaphorically “crawl over broken glass” to use the system and who are willing, because of their passion and commitment, to put up with the faults in the system. The true test is (as it is with any product) whether the general mass of users willingly adopt the system.

Compulsory or voluntary, which works best?
All of the above assumes that use of the system is voluntary. Even if the use of a system is not voluntary, it is good practice to approach the development of the system as if it were. This helps in a number of ways. Firstly, it enforces a discipline on those wishing to introduce the system to ensure they are not forcing a difficult or unattractive solution on the users of the system. Secondly, it helps build the relationship between the developers and introducers of the system and the users. For example, changes made to the practice management system software are most successful when there has been GP input into how the change may work at the user interface level. New system introductions will always be easier where all parties are credible and there is rapport between those developing the new system and the ultimate users of the system. Finally, successful adoption of a new IT system by practitioners is very much more likely where the person recommending the use of the system is an influential member of the team that will ultimately use that system.

Like many changes, changes in IT systems can be perceived as a threat or an opportunity. The Internet is one such change which has effected massive change on the whole of the international health system. The introduction of the Internet has been perceived by some clinicians as a threat and by others as an opportunity. Those inclined to view the glass as half full, as opposed to its less attractive, half-empty alternative, will naturally gravitate to seeing the availability of the Internet as an opportunity. There is no doubt that there is more “rubbish”, including poorly presented and erroneous information, available to consumers than ever before with even less effort required of them to seek it out. It is also true that there are credible sources of information on the Internet which can be informative, educational, rewarding and comforting to patients and their loved ones. The fact remains, nonetheless, that the Internet provides a facility for the enhancement of health system IT.

The real power of the Internet is not the infinite amount of information available (a Google search for “health information” resulted in 1.2 billion items in 0.23 seconds!), but the opportunity to harness that information and the connectedness of the computers on it.

Is health a special case?
Health care is often referred to by clinicians as a “special case” – and it is true that our health and the health of our families and loved ones invokes a lot of emotions. Additionally the health sector is subject a lot of political influence, which can frustrate progress. However, regardless of political perspective, there is no doubt that the New Zealand system benefits by being less complex than some others as it essentially has a single funder for the subsidised component of the system as opposed to other international jurisdictions which have multiple funders (including insurance companies). Centralising the benefit of risk management in health at the government level removes some of the incentives which would motivate investment in systems, including IT systems, to improve the effectiveness and efficiency of risk management in health. I would argue that innovation and boldness are not usually the domain of central planners. For this reason, such investment in New Zealand is primarily seen on the margins in the primary health care sector. Additionally, a lot of the investment is quite fragmented and is centred on projects which have been funded by, for example, a Ministry of Health (MoH) or District Health Board (DHB) contract, a Primary Health Organisation (PHO) initiative, or by the goodwill of the sector through organisations such as community groups, Independent Practitioner Organisations (IPAs), grant providers, etc. There is a lot of potential to be realised if only the incentives existed to stimulate the investment of time, energy and money.

Squeezing maximum blood out of the IT investment stone
On the positive side, this tightness has meant that organisations have had to maximise what they get from their relatively small investment and this has driven the New Zealand health sector to implement IT systems on a very cost-effective basis. ICT efficiency in New Zealand is evidenced by 99 percent of GPs using an ICT system to manage their clinical practice, and 80 percent of these using the same system, a position that would be the envy of a number of other countries. On the negative side, there are significant limitations to what can be achieved on a nationwide scale with this fragmented approach. Imagine what could be achieved if those limitations could be overcome.

Typically, primary health care in New Zealand is not run like a corporate entity. Corporate entities tend to make decisions and develop solutions at the centre and to enforce implementation of IT advances across the organisation. As Ken Leech, CIO at ProCare Health, New Zealand’s largest independent practitioner association pointed out, the fragmentation in primary care funding in New Zealand has meant there has been a lot more “selling” involved to achieve uptake of systems than there would have been if it the primary health care sector had been structured more like a corporate entity. Clinicians in independent practitioner associations in New Zealand usually have complete discretion as to whether they adopt an IT system/solution and the organisation needs to convince them of the merits of the solution being offered. This demands a discipline of the team involved in developing and implementing solutions that might not exist if system use was compulsory for the clinician. In some respects, this is a good thing and it certainly helps create a sustainable solution; as in most sectors, a system that users (ie, clinicians) have elected to adopt voluntarily is likely to be employed more productively than those that have been forced on them.

Can the system deliver real value to clinicians?
As set out above, the willingness of clinicians to adopt a new IT system is also affected by the ability of the system to deliver real value to those clinicians. The nature of clinical work presents some significant, if not unique, challenges to IT system implementers: the mobility of the clinical workforce and the nature of their work with patients can often mean that it is difficult (but not impossible) to provide an appropriate IT tool to enter the information that needs to be collected. Also, many clinicians cannot see the value in collecting much of the data necessary for the system to deliver value. This is a key determinant in establishing whether a system is going to be willingly adopted and used correctly – it must deliver value to those users. The health care systems are so complex and the health of individuals and populations has so many different variables affecting it that it creates a substantial and complex system need. Aligning these activities within the system to minimise waste, maximise efficiency, learn more and maximise effectiveness is ideal. This nirvana is not easily achieved!

At present, primary health care in New Zealand does not have the resources, financial or human, or the critical mass to achieve a comprehensive IT solution to manage large populations of patients and in particular to assist in health risk management. However, there are some very good examples where progress is being made in creating systems which arm clinicians with information that assists them in being more effective and, as such, will progressively provide some measurable gains in health status.

A successful example of this is the Enigma Predict® clinical decision support system which has been adopted by a number of primary health care providers around New Zealand. This system has shown that, in a relatively fragmented primary health care health system, significant improvements in systems can be achieved and delivered to clinicians’ desktops.^[1,4]

One of the keys to the adoption of this system has been its integration to general practitioners’ practice management system software. This integration has simplified the use of the system and provided real benefits for general practitioners and their patients in real time. This integration has also delivered efficiencies through reducing the need to enter data in both the Predict and the practice management systems.

However, a significant and more important factor in the successful implementation of this system has been the preliminary work that went into validating the system and proving its worth to GPs. After the substantial work of a group of complementary clinicians and academics, countless hours were invested in facilitating peer group discussions, running continuing education sessions and providing substantial background support for the system. This work has been carried out in many cases by people with very good relationships with the primary care clinicians, supported by people with strong credentials in the cardiovascular field. This has lent a lot of credibility to the performance of the system and to the merits of using it.

Conclusion
I think we can be encouraged by the significant increase in the use of IT in health and 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.

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.

References

1. Bankix Systems. Developments in Global Health ICT Investments. Newsletter. 6 October 2005.
2. Collins T, Bicknell D. Crash: Learning from the world’s worst computer disasters. London: Simon and Schuster; 1998.
3. Hoque F, Sheehan R, Aruza C. Aligning business and technology: the principles of business technology management. White paper. Enamics Ltd: Stamford CT; 2001
4. Horn E, Wells S. Improving health outcomes through electronic decision support – the findings of a recent study in ProCare Network Auckland in collaboration with the University of Auckland and Waitemata District Health Board. Conference paper presented at IPAC 2005 (The IPA [Independent Practitioner Associations] Council of New Zealand): Delivering Value – Getting results in the PHO environment.