Testing the Viability of a Cultural Formulation Template (Matalafi Matrix) within an Electronic Health Record (HCC)

Abstract
The absence of a formal cultural perspective within an electronic health record can potentially compromise or stagnate assessment and treatment planning processes for the client. A mental health service responding to the needs of Pacific peoples under the umbrella of Waitemata District Health Board, Auckland, New Zealand has implemented a cultural formulation template called the Matalafi matrix within an electronic health record (HCC) to help resolve this concern. The key findings of this pilot project highlighted the importance of accessing key information such as an informed cultural perspective to help inform diagnosis. The inclusion of the Matalafi matrix template within the HCC electronic information system has also prompted opportunities to share information amongst practitioners and encourage collaboration between the cultural arm and the clinical arms of the services.

Introduction
In "Formulation of a Plan of Care for Culturally Diverse Patients",^[1] Walsh discusses the challenge for health care workers to provide appropriate care for an increasingly diverse population. In this study health workers proactively designed a care plan from a cluster of nursing diagnoses to develop a resource for the health care team in providing culturally competent care. It is important to note that this care plan was inserted into the nursing diagnosis-based nursing documentation computer system for easy access when needed. The result of including this care plan into the nursing electronic information system was enhancement of respectful and excellent care for every patient.

Health Knowledge Management (KM) is fast becoming the norm within health care, acknowledging that the ability to share information and access key information almost instantaneously leads clients and clinicians to make informed choices about treatment planning in an appropriate and timely manner.

According to Orr,^[2] Health Knowledge Management (KM) has many benefits:

The ability to access a whole range of clinical data rapidly can be of considerable assistance to a clinician. Similarly, enabling GPs and hospitals to send referrals and discharges electronically and to access risk prediction and disease management information can contribute greatly to safer, integrated, co-ordinated care, without having to change the underlying clinical processes fundamentally.

Beveren^[3] suggests that Health KM needs to be a patient centred and, therefore, information needs to be shared in a transparent way with care providers facilitating informed decision-making processes for the patient.

There are current strategies in place in New Zealand, such as the 2005 National Mental Health Information Strategy Implementation Plan^[4] and the 2005 Health Information Strategy (HIS),^[5] which provide a framework for the development of Health KM over the next five years.

However, the HIS offers little in terms of the identification and relationship between key cultural perspectives and Health KM.

In the absence of a cultural responsiveness component within the strategic framework, there is a risk that any assessment and treatment planning processes reliant on a Health KM system may inadvertently exclude key categories as outlined in the DSM-IV^{[6 ]} cultural formulation guidelines:

1. Cultural identity of the individual.
2. Cultural explanations of the individual’s illness.
3. Cultural factors related to psychosocial environment and levels of functioning.
4. Cultural elements of the relationship between the individual and the clinician.
5. Overall cultural assessment for diagnosis and care.

The cultural diversity that exists within New Zealand requires social and health sectors to place a high importance on "cultural sensitivity" to maximise engagement leading to a facilitation of informed responsiveness. Excluding a cultural perspective can potentially lead to a perceived non-compliance or to information gaps within the assessment and treatment planning processes. The formal inclusion of a cultural perspective would be relatively new to Health KM systems but would go a long way towards helping to unravel the level of complexity, inform diagnosis and minimise the potential risks of excluding such a perspective.

This paper provides insight as to how cultural formulation can add value to an electronic health record (EHR), using the example of a cultural formulation template for use with Pacific peoples accessing mental health services in New Zealand.

An electronic health record (EHR) system (HCC – Health Care Communities) was implemented in the Waitemata District Health Board in 2004. Since the establishment of HCC, mental health practitioners, have wanted to formalise cultural input with the objective of supporting clinical teams and informing diagnosis. This paper reports on the findings of a project to test the viability of a cultural formulation template incorporated within this EHR.

Context of Pacific People in New Zealand
Pacific peoples have been migrating to New Zealand since the early 1900s, with numbers increasing markedly from the 1960s when the government relaxed immigration regulations to utilise the Pacific nations to help address a labour shortage.^{[a ]}

The demographic profile of Pacific peoples in New Zealand has changed over the two to four generations since the 1960s and key points are that:^[7,8] 

• An estimated 40 percent of children and young people share ethnicity with Maori and/or palagi (people of European descent). 
• The New Zealand born Pacific population now comprises 58 per cent of all Pacific people.
• Children under 15 years make up 38.2 percent of New Zealand’s Pacific population compared with 23 percent for New Zealand’s total population. 
• It is expected that the Pacific population will increase between 2001 and 2011 by 26.9 percent compared with the New Zealand population overall, which is expected to increase by 7.9 percent.

However, the social and health status of Pacific peoples has not changed significantly from the 1960s in comparison with that of the New Zealand population as a whole.

For example, in the recent New Zealand Mental Health Survey 2006,^[9] the prevalence of mental health disorders in any period is higher for Maori and Pacific people than for others. For disorders in the past 12 months, prevalence is 29.5% for Maori, 24.4% for Pacific people and 19.3% for other composite ethnic groups. Much of this burden appears to be due to the youthfulness of the Maori and Pacific populations and their relative socioeconomic disadvantage. The prevalence of mental health disorders is higher for people who are disadvantaged, whether measured by educational qualification, household income or index of deprivation.

Methodology
The project to test the viability of a cultural formulation template incorporated within the HCC electronic health record was undertaken over a six-week period. The project included a pilot phase followed by focus group interviews.

Prior to the pilot, four cultural assessor/advisors (CAAs) – specialists in the area of Pacific language, tapu (a value and belief described as sacred or forbidden) and family systems in the context of mental health – received two-hour training in the use of a the "Matalafi matrix". The Matalafi matrix is a cultural formulation template accommodating current Pacific worldview and context of the service user.

The Matalafi matrix was selected based on two studies undertaken 18 months apart, which had looked at the utilisation of the Tupu service, a cultural service specialising in addiction treatment for Pacific people. Both the Tupu Service Utilisation Study June 2003–November 2005 by the Clinical Research and Resource Centre, Waitemata District Health Board and the Tupu Service Utilisation Study November 2002–October 2003 by Natalie Ledger showed that completion of and compliance with the Matalafi matrix was high and that it also complimented the DDS (drug dependence) and AUDIT (alcohol), mental health screens and Risk Alert Sheets. The collated and analysed results are shown in table 1. NB: The matrix was completed in paper based form in Tupu as the service does not have HCC and still uses paper-based files to store client information.

Table 1: Completion of cultural tools by alcohol and drug workers in Tupu services

Interviews with the alcohol and drug workers about the completion of and compliance with the Matalafi matrix suggested that the completion of this tool was high because the template had a simple format and complimented the other tools such as the alcohol and drug screens, mental health screens and Risk Alert Sheets, by providing a cultural context.

The CAAs used the Matalafi matrix template on HCC for six weeks between August and October 2006. Data were extracted from HCC at the end of the six-week period to determine completion rates of the Matalafi matrix. The CAAs who piloted the Matalafi matrix came from Malaga. Malaga is a Pacific Mental Health Liaison Service that provides cultural case support for service users and families and works closely with mental health practitioners from clinical teams.

Key informant interviews involving the CAAs and mental health practitioners who participated were conducted to support the analysis of the data from the pilot and was supplemented by key themes identified in the literature. Edward De Bono’s six thinking hats, a technique designed to help individuals deliberately adopt a variety of perspectives, was used as an interview framework.

Results
The CAAs completed 20 Matalafi matrix templates during the pilot. The completion rate for the Matalafi matrix on HCC was 100 percent.

One-third of the completed Matalafi matrix templates on HCC were accessed by mental health practitioners such as social workers, clinicians and nurses to help inform assessment and treatment planning processes.

The following feedback was generated from the key informant interviews using De Bono’s six thinking hats method. The results were overwhelmingly positive.

Health practitioners accessing the completed Matalafi matrix templates appreciated the inclusion of formalised cultural information within HCC, noting that it allowed them to be more responsive to clients. They also noted that the matrix prompted good clinical cultural discussion and deliberate thinking about the importance of being culturally safe. As such, it informed diagnosis and treatment planning and has the potential to significantly improve outcomes.

Health practitioners found that the Matalafi matrix template complimented clinical tools and helped provide good insights from a Pacific perspective.

 "I can begin to integrate the Matalafi matrix perspective into assessment and treatment planning."

The CAAs saw the inclusion of the Matalafi Matrix on HCC as a great development despite their initial apprehension. CAAs were comfortable with the implementation and easy utilisation via HCC. They noted that use of the matrix prompted some good debate and discussion about clients and allowed them to better appreciate the context for treatment.

The CAAs were surprised at the amount of interest generated by health practitioners regarding access to cultural information on HCC. CAAs also acknowledged that their perspective was valued as a result of this input being formalised on HCC in clinical reviews and other forums. The CAAs also found that accessing information via HCC promoted confidence in their understanding of mental health jargon.

Both CAAs and health practitioners noted the holistic view captured by the template and its simple and easy-to-use format. It was seen to add value to other tools and provide important insights.

However CAA’s noted initial problems understanding HCC business rules and some issues with their ability to articulate English language on HCC as English was a second language.

Discussion
Data from the pilot and the key informant interviews indicate that the CAAs quickly found their way around HCC and came to grips with the concept of cultural formulation. This suggests that the CAAs could transfer their tacit knowledge base quite comfortably into an electronic information system. However, support needs to be given to the CAAs to ensure their tacit knowledge is articulated in such a way that mental health practitioners can understand their notes.

The key findings from key informant interviews supported the inclusion of cultural perspectives by way of cultural formulation templates within EHRs. In this project, health practitioners were excited that they could access the Matalafi matrix via HCC, which has highlighted opportunities for collaboration between cultural and clinical services and has also strengthened relationships. However, the literature did question the rigour and vigour of some cultural formulation templates and therefore further testing is required to promote confidence in some of these tools.

The key findings from the pilot show that the completion and compliance rates of the Matalafi Matrix on HCC are consistent with the results from both previous studies evaluating Tupu Service utilisation (June 2005–November 2005 and November 2002–October 2003). This suggests that the Matalafi matrix is transferable from its existing paper base to an EHR format. The issues surrounding its utilisation were more related to the CAA’s technical skills: for most English was their second language and their ability to translate their tacit knowledge onto HCC proved to be struggle at times, however continued support from the organisation made the task less onerous.

There is limited literature nationally and internationally regarding the testing of a cultural formulation within an EHR. However there is evidence to suggest that a link between cultural formulation and health KM is important from an informed diagnosis perspective and can easily be implemented (eg, Walsh 2004^[1]). Furthermore international literature supports the use of cultural formulation within mental health settings.

Panos and Panos^[10] used case examples from Navajo, Laotian and Cambodian cultures. They suggest that cultural formulation is required when an ethically diverse client presents to a service:

A sensitive assessment provides recognition of how the patient’s cultural roots affect their healing process. Cooperation and compliance to the advice given by healthcare professionals may be enhanced by understanding the patient’s cultural perceptions.

They endorsed cultural formulation processes as being able to assist in developing informed recommendations to other health practitioners involved in the care of the client.

Kirmayer et al^[11] reported findings from an evaluation of a Cultural Consultation Service (CCS) for mental health practitioners and primary care clinicians. This service responded to the mental health needs of a culturally diverse urban population including immigrants, refugees and ethnocultural minority groups within a mainstream setting. The CCS team used cultural formulation from the DSM-IV as a framework for consultations. As a result clinicians were highly satisfied with the support from the CCS and viewed cultural formulation as an important part of determining diagnosis.

These findings substantiate the importance of cultural formulation within informed mental health diagnosis and, furthermore, validates the presence of a cultural perspective within mental health settings.

The literature does question the rigour and vigour of cultural formulation templates within mental health settings. Although some practitioners choose to use varying versions of cultural formulation templates, the literature suggests that current screening and assessment tools could be adapted to capture and accommodate cultural formulation information and considerations.

Regardless of the form used, the key is culturally appropriate processes and expertise that maximise client input rather than a focus on the tool itself.

The latter requirement was also noted by Rait et al,^[12] who suggest that current screening tools could be adopted as long as the approach was right. This endorsed clinicians’ beliefs that they could use templates they were familiar with. However, they also realised that they should approach a person from another culture in a culturally appropriate way and it is important to ensure that practitioners can access people who have cultural expertise (tacit knowledge) to ensure engagement, assessment and treatment processes can be maximised for their clients.

In the abovementioned evaluation of a CCS for mental health practitioners and primary care clinicians, the team used an expanded version of a cultural formulation from the DSM-IV as a framework for consultations with cultural consultants and cultural "brokers" – experts on cultural protocols and processes responsible for facilitating the relationship between clinician and client/family. Kirmayer et al highlighted that this approach needed to include support for clinicians working with cultural consultants and cultural brokers due to the potential for miscommunication.

Guerrero et al^[13] describe how mechanistic case diagramming provides a framework for biopsychosocial-cultural formulation. Their aim was to teach students the importance of linkages between biological, psychological and sociocultural factors. A desired outcome of this framework would eventually lead these future mental health practitioners to making informed diagnoses.

The implementation of the cultural formulation template within an EHR does align with Orr’s F.I.R.S.T (fast, intuitive, robust, stable and trustworthy) principles of a successful health information system implementation.^[14]

Given this and the positive responses by mental health practitioners, the use of the Matalafi matrix is likely to increase.

Conclusion
The mental health practitioners who accessed the cultural formulation template on HCC found that the information assisted in facilitating informed diagnosis and treatment planning. Responses from the key informant interviews suggested that the Matalafi matrix complemented existing assessment tools and processes, however further in-depth research into and evaluation of such cultural formulations frameworks is required.

The key findings from the literature, pilot project and key informant interviews give us some confidence that a cultural formulation template like the Matalafi matrix can enhance health KM systems. In the HIS, there is a possible pathway to support the implementation and development of a cultural formulation template ("Matalafi matrix") within its Action Zone Implementation Plan.

References

1. Walsh S. Formulation of a plan of care for culturally diverse patients, Int J Nurs Terminol Classif Jan–Mar 2004;15(1):17-26.
2. Orr M. Evolution of New Zealand’s health knowledge management system. Brit J Healthc Comput Inf Manage December 2004;21(10):28-30.
3. Beveren JV. Does health care for knowledge management? J Knowl Manage 2003;7(1):90–95.
4. Ministry of Health. National mental health information strategy implementation plan 2006. Wellington: Ministry of Health; 2006.
5. Health Information Strategy Steering Committee. Health information strategy for New Zealand. Wellington: Ministry of Health; 2005.
6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th Ed. Washington, DC: American Psychiatric Association; 2000.
7. Ministry of Health and Ministry of Pacific Island affairs.Tupu ola moui: Pacific health chart book 2004. Wellington: Ministry of Health; 2004.
8. Ministry of Health. Te orau ora: Pacific mental health profile. Wellington: Ministry of Health; 2005.
9. Oakley Browne MA, Wells JE, Scott, KM, eds. Te rau hinengaro: the New Zealand mental health survey. Wellington: Ministry of Health; 2006.
10. Panos PT, Panos AJ. A model for a culture-sensitive assessment of patients in health care settings. Provo, UT: School of Social Work, Brigham Young University; 2000. Social Work in Health Care 31(1): 49-62, 2000.
11. Kirmayer LJ, Groleau D, Guzder J, Blake C, Jarvis E. Cultural consultation: a model of mental health service for multicultural societies. Division of Social and Transcultural Psychiatry, McGill University, Culture and Mental Health Research Unit. Sir Mortimer B Davis – Jewish General Hospital, Montreal, Quebec. Canadian Journal of Psychiatry April 2003; 48(3):145–153
12. Rait G, Burns A, Baldwin R, Morley M, Chew-Graham C, Leger ASS, Abas M. Screening for depression in African-Caribbean elders. Fam Prac Dec 1999;16 (6):591–595.
13. Guerrero AP, Hishinuma ES, Serrano AC, Ahmed I. Use of the mechanistic case diagramming technique to teach the biopsychosocial-cultural formulation to psychiatric clerks, Department of Psychiatry, University of Hawaii John A. Burns School of Medicine. Acad Psychiatry 2003;27(2):88–92.
14. Orr M, Day K. Knowledge and learning in "successful" IT projects: a case study. Health Care and Informatics Review Online 2004. /journal/index.cfm?fuseaction=articledisplay&FeatureID=040531 . Accessed 13 November 2006.

Footnotes
a In 1973 the New Zealand economy declined and immigration regulations were tightened up; at that time Pacific people were perceived by politicians as a burden of the state for overloading social and health services.