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- Health Informatics in New Zealand
- Health Informatics Literature in Australia and New Zealand
- "Health Informatics: A Socio-Technical Perspective"
- Part 1: Foundations of Health Informatics
- Part 2: Health Informatics Tools, Techniques and Applications
- Part 3: Health Informatics in Action
- Conclusion
- References
Health Informatics in New Zealand
The health care industry, both in New Zealand and internationally, has seen a dramatic surge in the use of and investment in Health Informatics (HI), particularly over the last five years. So much so that the importance of information to a health care provider now rivals that of good financial management within health care business operations and this is being reflected in such organisations with appointments to senior executive roles such Chief Information Officer (CIO) and Chief Knowledge Officer (CKO). These are broad roles, for example CKO encompasses management of an overall framework that guides knowledge management, sets up knowledge infrastructure, facilitates connections, coordination and communications.
Furthermore, the impact of technology on the health care sector has meant that everyone involved in health care provision is increasingly involved in managing information. The sheer speed of uptake of information and communications technology (ICT) has been such that ICT training of health care workers has lagged behind requirements and there are many training needs in this area. Further, there is a widening gap between the required health informatics skills and what is available through education.[1]
It is fair to say that internationally and in New Zealand, HI itself is in a precarious position. The health care industry is in the dangerous state of not having enough skilled health informaticians and, more importantly, the ICT skill level of the average person working in the health sector is lower than that required for them to work with managing information.
Health Informatics: A Socio-Technical Perspective, by Sue Whetton is, therefore, timely in that it has filled a niche and is an appropriate text for students and teachers across a number of areas, such as public health, information and computer science. 
Health Informatics Literature in Australia and New Zealand
While there have been many HI books and encyclopaedias published in recent years, Health Informatics: A Socio-Technical Perspective stands out for an Australasian audience because of its broad coverage of Australasian HI practice and its socio-technical approach. A socio-technical approach incorporates organisational and cultural analysis with traditional information systems, tools and resources. It is important as it highlights the broader impact and potential of HI systems on the health care environment.
The overriding benefit of this book for a New Zealand audience specifically is that it includes New Zealand information and has direct relevance for New Zealand HI practitioners.
Whetton’s is the first book to offer a fully Australasian perspective. Purely Australian texts, such as Coiera[2] and Hovenga et al,[3,4] been available for several years and there are other books with some New Zealand content, such as Cullen’s Health Information on the Internet: A Study of Providers, Quality and Users,[5] Carr’s material in Weaver et al’s Nursing and Informatics for the Twenty-First Century.[6] and two chapters in Gauld & Goldfinch’s[7] Dangerous Enthusiasms E-Government, Computer Failure and Information System Development, on ICT in New Zealand’s health sector. Conference papers from the annual Health Informatics New Zealand (HINZ) conference and articles in Health Care and Informatics Review Online, which are specific to health informatics, contribute to the body of New Zealand HI literature.
"Health Informatics: A Socio-Technical Perspective"
Health Informatics: A Socio-Technical Perspective has 11 contributors drawn from Australia’s University of Tasmania, New Zealand’s University of Otago, the Tasmanian Department of Health & Human Services, Australia, and the University of Georgia, US. Principal author and editor Sue Whetton lectures in Online Educational Development in the Department of Rural Health, University of Tasmania. Thus, Health Informatics is almost entirely an Australia/New Zealand production.
Health Informatics covers various current HI issues. It contains useful practical examples and it poses thoughtful questions to readers which help to contextualise the theory. Most sections have web links to further useful examples. A system of summary boxes on the page has been used effectively to highlight significant issues and current practice and to provoke critical debate. Each chapter includes an overview, statement of objectives and definition of main concepts discussed and this structure assists readers as they move through the book.
HI is a difficult area to cover in one book. Whetton takes a socio-technical perspective on HI in the health care environment and this runs strongly through most chapters, although less so in Chapters 8 and 9 "Electronic Health Records" and "Decision Support Systems" by nature of the subject matter. This is an excellent contemporary Australasian textbook. It is easy to read and covers the topic very well at the undergraduate level. It does not have the depth required of a postgraduate text, such as, for example, Shortliffe et al’s[8] Medical Informatics: Computer Applications in Health Care and Biomedicine.
HI and its associated work force are still developing. Whetton has overstated the case for HI as a discipline in its own right. In fact, HI is a multi-disciplinary domain inhabited by a diverse workforce with diverse needs. And, as Hersh has suggested in "Who are the informaticians?",[9] there is, as yet, no overall picture of who works with health care ICT. Whetton herself, in an article published after Health Informatics, has asked "Health Informatics: Who Am I (And Does It Really Matter)?".[10] It is very difficult to write an all encompassing text about HI, especially if it is unclear who the HI people are. Instead of writing for all health care professionals, Whetton describes her intended audience: health professionals and consumer groups wanting an introduction to the field or HI professionals wanting to develop their skills and knowledge. She sees the book’s structure as meeting the range of needs of this broad audience and uses the metaphor of a beach to explain the style, saying readers "may paddle around in the shallower waters, or occasionally venture out into deeper water".
Whetton has maintained the book within this introductory brief and highlights that readers must seek out more in-depth information as required. Therefore the coverage of the more technological side of HI in this book is low.
The book is written from a socio-technical slant and the content is often illustrated with US and British examples and a strong New Zealand/Australia focus. There are excellent examples of New Zealand and Australian HI in practice and this is recognised in this text.
Health Informatics is organised into three parts:
Part 1: Foundations of Health Informatics
- Chapter 1. The Health Care Environment and Health Informatics
Chapter 2. What is Health Informatics?
Chapter 3. Building the Knowledge Base
Part 2: Health Informatics Tools, Techniques and Applications
- Chapter 4. Tools: Promises and Pitfalls
- Chapter 5. Doing Databases
- Chapter 6. Health Information Systems
- Chapter 7. E-health
- Chapter 8. Electronic Health Records
- Chapter 9. Decision Support Systems
Part 3: Health Informatics in Action
- Chapter 10. Health Informatics in Action: Rural and Remote Health
Part 1: Foundations of Health Informatics
Part 1: Foundations of Health Informatics The first three chapters introduce the reader to the HI discipline and its environment whilst tethering it to social and cultural dimensions such as understanding the environment, who is involved, what their roles are, change management, global views and the impact of technology.
Chapter 1 explores the dynamics between HI and the socio-cultural environment of health care from the basic position that "our understanding of HI as a discipline and a profession will be enhanced by understanding the social context within which it is located". This is quite a different perspective to that of the software development process of making ICT systems. Taking a socio-technical perspective is interesting as HI has the potential to be a catalyst for dramatic change in health care, cutting across traditional structures, roles, processes and relationships, and changing the manner in which health systems are organised and delivered. The socio-technical viewpoint is of value because HI is not simply about the introduction of ICT to health care; it is also the change management and innovation that results from this introduction.
Chapter 2 focuses on the emerging discipline of HI, and explores the parameters of the discipline and its subsets. HI is described in a pragmatic manner and defined generally as a facilitator for the effective collection, management and use of information in the health care environment.
Chapter 3 swings heavily back to the socio-technical perspective and discusses key concepts and theories that are used to develop the knowledge base that underpins HI and inform the practice of HI. The strong theme of models, the visual representation of an entity, for example, the model of general practice surgery, in a number of contexts is used well. It assists in structuring and organising abstract and complex entities, which allows the reader to analyse, manipulate and model the real world. Various theories, for example, relating to education, change management and systems, are introduced.
Sociological concepts, such as organisation, culture, structure, status, roles and power structures are introduced. This is important, especially as the socio-technical perspective seeks to understand the organisational and cultural aspects of information management.
Diffusion of innovation was discussed with the general thread being that if an innovation is perceived as better than the idea it supersedes then it is more likely to be adopted. There are theories on innovation that were not discussed, for example, the concept of disruptive innovation, meaning technology that brings a more affordable product or service that is much simpler to use in the market. The personal computer is one such example, which allows a new population of consumers to own and have the skills to use a product (service). This is a critical subject as there are parts of HI that will be exhibit disruptive innovation yet will ultimately contribute to a better way forward.
Part one of the book is aimed at making HI, which is itself an innovation, more acceptable to and adoptable by the health care industry by using the social and cultural approach to make it appear non-disruptive and planned. However, disruptive innovation, non-disruptive innovation and other theories of innovation do co-exist and the book would have benefited from acknowledging this. The speed of diffusion and hence the innovation’s success is also an issue. The political climate, management and organisation structure substantially alter speed and patterns of diffusion. It seems the speed of diffusion is generally slower in health, possibly due, at least in part, to health care being decentralised and highly politicised.
Part 2: Health Informatics Tools, Techniques and Applications
Part 2 is by far the largest part of the book and focuses on tools, techniques and applications.
Chapter 4 deals with the promises and the pitfalls of HI tools. Most of the chapter is pragmatic, looking at hardware, types of computers, software, types of files and types of computer networks. The material is very rudimentary and should have either been made longer to be useful or omitted altogether.
Chapters 5 and 6 are likely to be the chapters that the majority of HI people would use most heavily.
Chapter 5 covers databases and discusses database structures, security and usability issues. In addition, it covers more paramount issues such as steps for planning and implementing a database and the issues of legacy database systems.
Chapter 6 on health information systems (HIS) is possibly the key chapter of this book. The components of HIS, the types of HIS and their applications are described. The environment that software engineers or developers work in, the systems development life cycle and data modelling are briefly discussed, as are standards and data sets. Whetton demonstrates that failures in HIS may be linked with a poor fit to clinical practice requirements, the dehumanising of patient care and the poor integration of clinical decision support systems into clinical workflows. Whetton continues the socio-technical perspective by proposing that such failures point to the need for emphasis on effective project management, requirements analysis, and extensive understanding of the environmental context, the technical system and the organisational/management infrastructure.
Chapter 7 discusses e-health in general terms and includes some technical material. However, it undersells the current and future global impacts of e-health: impacts on the link between databases and the Internet; doctor–patient relationships and the Internet; the Internet and medical education (eg, Harvard and other universities offering specific continuing medical education courses using new media techniques); and health information and the Internet (as a delivery platform).
Chapter 8 describes and discusses electronic health records (EHR). This chapter is well balanced. It covers the types of EHR, their purpose, levels of integration and connectivity, and centralised and distributed EHR models. Most importantly, it discusses issues relating to clinical adoption of EHR. This chapter also presents the views of EHR held by various stakeholders such as consumers, health professionals, health administrators, government and health care providers.
The final chapter in Part 2, chapter 9, concerns decision support systems. This is a particularly important chapter because this is the area where clinicians and patients could benefit most from HI, for example, from alerts of evidence-based practice messages, and patients being more responsible in managing their health. The chapter defines decision support systems, how they are used and what they are used for, and provides a snapshot of some of the artificial intelligence tools that might make up a decision support system.
E-health, EHR and decision support systems are the critical enablers of HI. In fact, an HI system would commonly comprise E-health, EHR and decision support systems, which are covered here by chapters 7, 8 and 9 respectively.
Part 3: Health Informatics in Action
The last section of the book discusses HI in action. It consists of a single chapter that explores the use of HI in the rural and remote health care environments. Part 3 is underweight by comparison with Parts 1 and 2; and this is not for want of information. HI in action is evidence all around us and a few more chapters on applied HI would be beneficial.
Unfortunately, Chapter 10 does not have the same richness and complexity as the earlier chapters in parts 1 and 2 and makes an inconclusive ending to the book. The addition of an epilogue or conclusion wrapping up the major themes could have addressed this limitation in the structure.
Conclusion
Health Informatics: A Socio-Technical Perspective is of a high standard. It is easy-to-read and comprehensive. It is very well structured, for the most part logically sequenced, and the author covered most of the important areas in relation to HI. It could be enhanced as a textbook with a version 2 edition. Further discussion could have been included in areas such as terminology, evaluation of systems, usability, workflow, consumer empowerment, open EHR, Standards New Zealand Health Information Service (NZHIS) is mentioned but no mention is made of the initiatives of the New Zealand Health Information Standards Organisation (HISO) and the Health Information Strategy Action Committee (HISAC), evidence-based practice alerts, hand held devices, voice-over IP (internet protocol) and Web 2.0+ type opportunities For example, Web 2.0 are web-based applications that allow users to contribute information, opinions and annotations to web sites, and which provide communication and information sharing spaces for communities of users.
Web 2.0 are "social media" tools that are becoming in standard practice and soon most companies will have some sort of social media attached to their services. Already the NHS has a "my space" within it for patients, which they can invite family to join. Thus, it is postulated that health software companies, the Ministry of Health and even general practitioners in New Zealand will develop social media sites.
This is important as social media and on-line communities together with the move to make more information and resources available for the responsible patient, are, in effect, indicative of foresight on the part of Whetton in recognising the socio-technical perspective to HI as the best way forward.
- Kerr K, Cullen R, Duke J, Holt A, Kirk R, Komisarczuk P, Warren J, Wilson S. Health informatics capability development in New Zealand. A report to the Tertiary Education Commission. 2006. http://www.mcs.vuw.ac.nz/~peterk/healthinformatics/tec-hi-curriculum-report-23-11-06.pdf. Accessed 23 March 2007.
- Coiera E. Guide to medical informatics, the internet and telemedicine. 2nd ed. London: Chapman & Hall; 2003.
- Hovenga EJS, Kidd MR, Cesnik B. Health informatics. an overview. Melbourne: Churchill Livingstone; 1996.
- Hovenga EJS, Mantas J. Global health informatics education. Amsterdam: IOS Press; 2004.
- Cullen R. Health information on the internet: a study of providers, quality, and users. Westport: Praeger Publishers; 2006.
- Weaver CA, Delaney CW, Weber P, Carr R, eds. Nursing and informatics for the 21st century. Chicago: HIMSS; 2006.
- Gauld R, Goldfinch S. Dangerous enthusiasms: e-government, computer failure and information system development. Dunedin, NZ: Otago University Press; 2006.
- Shortliffe EH, Wiederhold G, Perreault LE, Fagan LM, eds. Medical informatics: computer applications in health care and biomedicine. 2nd ed. New York: Springer Verlag; 2000.
- Hersh W. Who are the informaticians? What we know and should know. J Am Med Inform Assoc. 2006 Mar-Apr;13(2):166-170.
- Whetton SG. Health informatics: who am I (and does it really matter)? Presented at HIC 2006, 20–22 August 2006, Sydney, Australia.
