Further Evidence of How Technology Availability Doesn----t Guarantee Usage

• Abstract
• 1. Introduction
• 2. Methods
  • 2.1 Methodology
  • 2.2 Field Work
    • 2.2.1 Ethical approval and Identification of target practices
    • 2.2.2 Survey techniques
• 3. Results
• 4. Discussion
• 5. Conclusions
• 6. Acknowledgements
• 7. References
• 8. Footnotes

Abstract
International and New Zealand health care organisations are seeking to improve the use of computerised clinical decision support (CDS) in health care.^[1,2,3] This research uses case study methodology incorporating both qualitative and quantitative methods to explore CDS within the New Zealand health care environment. A subset of pilot study results are presented in this paper which illustrates current information technology (IT) used by General Practitioner (GP) practices belonging to a primary health organisation (PHO). Results demonstrate that the practices surveyed were generally well equipped suggesting there is the potential for them to be able to utilise similar levels of CDS. However, three commonly available technologies used by 80 percent or more of practices were all found to be used by fewer practices for CDS. This suggests that barriers other than the availability of technologies are important inhibitors to the utilisation of IT for CDS. Knowledge of practice IT infrastructure and barriers to its use for CDS would enable management organisations to formulate appropriate strategies to encourage better use of technologies and the decision support capabilities they provide.

Keywords: Primary health care; Primary health organisation (PHO); Information Systems (IS); Information Technology (IT); General Practitioner (GP); Clinical Decision Support (CDS); Case study.

 

1. Introduction
International and New Zealand health care organisations are seeking to improve the use of computerised clinical decision support (CDS) in health care.^[1,2,3] A report prepared for Australia’s health sector defined CDS as "Access to knowledge stored electronically to aid patients, carers, and service providers in making decisions on health care",^[2] and it is this broad definition which is followed in this research.

New Zealand’s primary health care sector has undergone changes in recent years and is now structured around not-for-profit Primary Health Organisations (PHOs). PHOs’ membership comprises health care professional individuals and practices, including General Practitioners (GPs), Nurses, Pharmacists, Maori and Pacific Island Providers, and community representatives,^[4] supported by a PHO management body/organisation. Awareness of how IT infrastructure is used by members would enable their PHO management organisation to formulate appropriate strategies to encourage better use of technologies, and the decision support capabilities they provide. This paper presents preliminary results which profile the most common IT supporting patient care in primary care GP practices belonging to a medium sized New Zealand PHO. Three of these technologies, the practice management system (PMS), the Internet and email, which had previously been found to support clinical decision making (CDM) by general practices,^[5] were studied further. Their availability for general use was compared to their use for CDS by the PHO GP practices. The findings are discussed in the light of information on the use of computerised information systems (IS) for CDS by the same practices, detailed in an earlier paper on the same study.^[6]

Various approaches and tools for the assessment of IT use in health care have been reported.^[5-13] In New Zealand, a postal questionnaire survey with a high response rate of 80 percent of all GP practices provided much information. Practices were asked about their computerisation and technologies, and were found to have a high level of both, with most practices also being able to exchange information electronically with other providers. When compared to international statistics the results demonstrated that New Zealand is one of the best-developed countries in this respect.^[7]

Australian researchers employed interviews and telephone surveys to benchmark usage patterns for general practice computerisation.^[8,9] They described computerised primary care functions and divided them into the three task groups of clinical, patient oriented administrative, and general administrative functions. Functions such as the use of computerised CDS systems were found to be used less than other computerised functions despite their potential for improving clinical outcomes for patients generally.^[8,9] The findings support other research which has reported varying or low rates of CDS adoption in clinical practice.^[6,10] Part of a mail survey of US physicians, including those in primary care, consisted of five questions about IT use with respect to email, CDS during consultations and on-line activities. The results indicate that although the technologies studied are relatively easy to acquire, they are only being used by a minority of physicians to support clinical care.^[10] Canadian and US researchers have also used postal questionnaires to determine the IT sophistication in groups of secondary care facilities, and compare them to other similar groups.^[11,12,13]

From these examples it can be seen that profiling the IT infrastructure of health care facilities can provide useful assessments and enable inter- and intra-organisational comparisons. Such profiles have also highlighted aspects of CDS, the focus of this research. By studying New Zealand PHOs and their contributing GP practices it was intended that a detailed profile of their IT infrastructure would be ascertained, which would enable further exploration of the use of those technologies within the organisation. A greater awareness of how general practices utilise technologies for CDS and the issues surrounding such use would contribute to improving the acquisition of knowledge informing safe and effective health care.
 

2. Methods
 

2.1 Methodology
The research consisted of a literature review, and a multiple case study of three medium-sized New Zealand PHOs, consisting of a pilot and two other case study PHOs. A mixed approach employing both qualitative and quantitative methods was used, and triangulation^[14] was achieved by the use of face-to-face interviews, a postal questionnaire survey and the collection of documentation at each case study organisation. Where possible, interviews with a GP, a practice nurse and an administrator were conducted in three GP practices, together with at least five management staff, for each of the PHOs. A sub-set of the pilot case study questionnaire results, and extracts from interviews with GP practice staff belonging to the pilot case study PHO are presented in this paper, with further results forthcoming.
 

2.2 Fieldwork

 

2.2.1 Ethical approval and Identification of target practices
Ethics committee approval for the project was received from both the Massey University Human Ethics and the Central Regional Health and Disability Ethics Committees. PHOs in the Lower North Island were invited to take part in the project. The pilot case study PHO was chosen because of its geographical accessibility and existing research connections, including ongoing consultation with the local Iwi Council of Elders.^[a] The PHO suggested practices which would be appropriate to contact, and which would cover a range of practice sizes and IT usage, to reflect the spectrum of practice types in the organisation. These were then approached by either letter or email and invited to take part in the research.
 

2.2.2 Survey techniques
Face-to-face semi-structured interviews were carried out with volunteers, including three GPs, two practice nurses and two administrators from a total of three member GP practices from the pilot PHO. Most interviews lasted for approximately one hour during which time the interviewees were asked about the use of computerised IT and clinical decision support in their practice. This qualitative component contributed to the research in two ways. Firstly, it provided information on the use, and attitudes to the use, of IT in the support of CDM in the practices studied. Secondly, data collected through the interviews contributed, together with information from published sources, to the preparation of the postal questionnaire. This was then pre-tested, and submitted for approval by the Central Regional Ethics Committee. The questionnaire was sent to 23 GP practices in the pilot PHO, excluding only those practices which had contributed already to the study by having staff members interviewed. After the initial mail-out and subsequent return of completed questionnaires, a follow-up letter and second copy of the questionnaire were sent to non-respondents.
 

3. Results
Almost eight hours of interview data were collected and analysed, and the questionnaire prepared and administered. Of the 23 GP practices surveyed, 10 completed questionnaires were returned giving a response rate of 43.5 percent. Clinicians had completed six of the questionnaires with administrators completing the other four. Although the number of responding practices was small they represented a total of 65 practice staff members. The size of individual practices varied with full time equivalents of 1 to 5 GPs and 3 to 21 total staff. All responding practices used computers and one of two types of PMS, with 80 percent using the currently most predominant system found in New Zealand GP practices. Computer network architectures and broadband connections were employed by 80 percent of respondents.

Table 1 shows the range of technologies used in the support of patient care by 30 percent or more of practices responding to the questionnaire. PMSs, fax machines, printers, PCs, Healthlink^[b] connections, and word processing software were used by 100 percent of the practices. The Internet/external websites or databases were used by 90 percent, and email by 80 percent. However, some technologies such as laptops and risk assessment software were only used by 30 percent of the practices.

Figure 1 illustrates the practice sizes and the percentage of the technologies which are listed in table 1 that are used by each respondent practice. The individual practice use of these technologies varied between 45.5 percent and 95.5 percent, with all but the smallest practices using more than 50 percent of them, and there appeared to be little evidence that increasing practice size corresponded to increased technology infrastructure.

Figure 2 shows that PMSs, the Internet/external websites or databases, and email were used by 100 percent, 90 percent and 80 percent of practices respectively. However, when asked about their use of these systems specifically in the support of CDM when caring for their patients, the percentage of practices found to use the systems in that way was smaller, being 60 percent, 70 percent and 30 percent respectively.

Table 1 - Practice use of technologies

Figure 1 - Practice size and corresponding % of technologies available in individual GP practices (as per Table 1)^[c]

Figure 2 - Practice use of three technologies

A qualitative analysis of the interview data revealed some of the reasons for this lack of use of available IT for CDS. For example, one practitioner interviewed does not use the PMS for clinical notes, but does use alerts and reminders for drug interactions, cervical smear recalls and vaccination notices. The same practitioner does not use email or the Internet and cited security as a main concern.

Similarly, a practice nurse at another practice also uses alerts and reminders contained within the PMS, but indicated that user skills could influence system utilisation:

"It’s got the capability to do that [provide alerts and reminders]. It’s only as good as the operator . . . We all do our own [setting up]. . . . I use it a lot, especially for over-dues."

In some cases, access issues for some members of a primary care team can result in underuse of a facility. For example, the same nurse would use the Internet more if given ready access:

"I can gather [needed information] but I have to go outside of work to do it . . . you see [the doctor’s got the Internet for "travel" which he looks up and . . . I have a lot of queries about travel and I have to go to him for that because I can’t directly access it myself . . . "

In other cases personal preferences result in widely varying use by different people in the same practice. A doctor at one practice doesn’t use the Internet much and doesn’t use email at all for CDS, whereas, in the words of an administrator in the same practice:

"Our doctors do use that [email] quite a lot: for special authorities^[d] – if they’ve sent one away and they haven’t got it back; for ACC,^[e] if they have a lot of clients who come in and say "ACC declined my claim. What do I do now . . .?" We have a lot of interaction with WINZ,^[f] because a lot of our clients are beneficiaries, so we have a lot to do with working with the case managers . . . "
 

4. Discussion
A study of US physicians in 2004 concluded that most of them did not use "basic, inexpensive, and widely available IT tools in clinical practice".^[10] This New Zealand study shows that the respondent practices were using a wide range of available IT technologies. However, when studied at greater depth, three of these technologies which were used by a high proportion of practices, were found to be utilised by fewer practices for CDS. Results presented here are in agreement with findings that New Zealand primary care practices are at the forefront of general practice IT adoption and use, with almost a 100 percent rate of computerisation.^[7] The usage of IT by a respondent practice varies depending on the technology type but does reach 100 percent for some technologies such as PMS.

Although profiling the IT used in organisations will provide useful information, it will not necessarily provide insight into how technologies are being used or how much they are utilised. To obtain a picture of the value derived from IT by practices one needs to know if a technology is being used rather than languishing in a cupboard or only being switched on for a short time to perform its function occasionally. Also, the most powerful and integrated systems will not be used for optimal CDS if practice staff have limited time, skills or inclination to exploit them. If the lack of technologies to support decision support is the sole reason for a lack of CDS, then practices with a high level of technology should have a high level of CDS. However, results from other parts of the current study, focusing on the use of IS for CDS, demonstrate wide differences between practices in their utilisation of available technologies for CDS.^[6] This is investigated in more detail in this paper by looking at the use of three specific systems, previously identified as used for CDS in primary care GP practices,^[5] those being the PMS, the Internet and email. These were found to be used for CDS by only a proportion of practices where the technologies were available. PMSs are used for a variety of tasks which provide CDS as well as administrative functions,^[5,7] but some practices only use a limited number of their systems’ functions.

The finding here that there appears to be little evidence that increasing practice size corresponds to increased technology infrastructure contrasts with other findings on practice size and use of IT for CDS.^[6] Results have indicated that the use of email in CDS was more prevalent in larger practices, and an absence of use of PMSs, the Internet and email for CDS was more likely to be found amongst the smaller practices studied.^[6] Therefore, smaller practices could, for example, increase their use of email but it does not automatically follow that they will then increase their use of email for CDS. This suggests that beyond a certain point IT infrastructure ceases to have as much influence on systems use than other factors, ie, once technology saturation is reached, other factors become responsible as barriers to adopting the technology for CDS.

Such additional barriers have been discussed by the authors in an earlier paper, and by other researchers, and may include resource and clinical issues such as time, cost, training, credibility, and skills in using CDS programmes and, less importantly, technical and systems considerations.^[6,15,16] These findings are re-enforced by this study which also illustrates that actually having access to popular technologies within an organisation or even within one practice does not necessarily guarantee either use or optimal use in terms of CDS. Resources directed at reducing some of these barriers could result in better use of existing technologies and advantages gained through enhanced CDS.

This study also indicates that technologies which have the potential to provide CDS, eg, risk assessment software, have not been found to be currently widely used by the practices in the group. Examples of such software include Enigma’s Predict and BPAC’s bestpractice^[16,17] which can assist chronic disease management through eg, cardio-vascular and diabetes risk assessments. Given that chronic disease management in population health is a focus for PHOs, and there is interest in software supporting such management, this study suggests that a two-part strategy might be appropriate for the introduction and implementation of such systems. Firstly, the technologies should be available but, secondly, attention should be paid to their utilisation. Reasons for their lack of adoption and how these issues can be addressed, together with studies on the differences between patient care and administrative IT, primary care integration and CDS, are the subject of current research.

These results are preliminary and based on a small number of respondent practices with generalisability limited to GP practices in medium-sized New Zealand PHOs. Although some differences in IT utilisation between staff of both similar and dissimilar roles were noted, research reported here focused on the practice as a unit rather than on the individual. However, information gained from the two subsequent case studies will extend the work presented in this paper and be reported on at a later date.
 

5. Conclusions
The results demonstrate that within one PHO, GP practices can have similarly high levels of IT in some areas, which should enable them to achieve similar levels of CDS to each other by utilising available technologies. However, there is evidence to the contrary. In order for primary health care managers and practices to improve CDS a detailed knowledge of practice IT infrastructure and how it is used, together with a clarification of barriers to the use of available technologies for CDS, would be beneficial.
 

6. Acknowledgements
With thanks to the staff of the pilot case study PHO management organisation and health care practices for their generosity in sharing their knowledge and time, and the local Iwi Council of Elders, Te Mauri O Rangitaane O Manawatu, for their support and advice. Also to the Tertiary Education Commission for the support provided by a Bright Future Top Achiever Doctoral Scholarship.

The support of a travel grant from the Maurice and Phyllis Paykel Trust is also gratefully acknowledged. The grant contributed to the presentation of a poster based on this research which was presented at Medinfo 2007, 12th International Health (Medical) Informatics Congress, 20–24 August, Brisbane, Australia, and included in the proceedings CD ROM.

Health and Disability Ethics Committee reference: CEN/05/08/053.
Conflict of interest statement: The authors have no declared conflicts of interest.
 

7. References
 

1. WAVE Advisory Board. From strategy to reality, the WAVE project, kia hopu te ngaru. Wellington: Ministry of Health; 2001.
2. National Electronic Decision Support Taskforce. Electronic decision support for Australia’s health sector. National Health Information Management Advisory Council (NHIMAC). January 2003. http://www.ahic.org.au/downloads/nedsrept.pdf. Accessed October 2004.
3. Metzger J, MacDonald K. Clinical decision support for the independent physician practice. First Consulting Group. California HealthCare Foundation. Oakland, California; October 2002. http://www.chcf.org/documents/ihealth/ClinicalDecisionSupport.pdf. Accessed November 2006.
4. Ministry of Health. The primary health care strategy. Wellington: Ministry of Health; 2001.
5. Engelbrecht J, Hunter I, Whiddett R. Information systems support for the clinical decision making process for general practitioners. Proceedings of the Health Informatics New Zealand (HINZ) – Towards a Healthy Nation conference and exhibition. Wellington, New Zealand. July 2004.
6. Engelbrecht J, Whiddett R, Hunter I. The use of information systems for clinical decision support by primary health care practices in a medium sized PHO. HCIROTM. September 2006. /journal/index.cfm?fuseaction=articledisplay&FeatureID=060906. Accessed October 2006.
7. Didham R, Martin I, Wood R, Harrison K. Information technology systems in general practice medicine in New Zealand. N Z Med J. 2004 Jul 23;117(1198). http://www.nzma.org.nz/journal/117-1198/977/. Accessed October 2006.
8. Western M, Dwan K, Makkai T, Del Mar C, Western J. Measuring IT use in Australian general practice. Commisioned by General Practice Computer Group. Funded by General Practice Branch, Department of Health and Aged. Australia: University of Queensland; August 2001.
9. Western M, Dwan K, Makkai T, Del Mar C. Computerisation in Australian general practice. Aust Fam Physician. 2003 Mar;32(3):180-5.
10. Grant R, Campbell E, Gruen R, Ferris T, Blumenthal D. Prevalence of basic information technology use by US physicians. J Gen Intern Med. 2006 Nov; 21(11):1150-5.
11. Paré G, Sicotte C. Information technology sophistication in health care: an instrument validation study among Canadian hospitals. Int J Med Inform. 2001 Oct;63(3):205-23.
12. Jaana M, Ward M, Pare G, and Wakefield D. Clinical information technology in hospitals: a comparison between the state of Iowa and two provinces in Canada. Int J Med Inform. 2005 Sep;74(9):719-31.
13. Culler S, Atherley A, Walczac S, Davis A, Hawley J, Rask K, Naylor V, Thorpe K. Urban-rural differences in the availability of hospital information technology applications: a survey of Georgia hospitals. J Rural Health. 2006 Summer;22(3):242-7.
14. Yin RK. Case study research: design and methods. 3rd ed. Applied Social Research Methods Series, vol 5. California: SAGE Publications; 2003.
15. Leung GM, Yu PLH, Wong IOL, Johnston JM., Tin KYK. Incentives and barriers that influence clinical computerization in Hong Kong: a population-based physician survey. J Am Med Inform Assoc. 2003 Mar-Apr;10(2):201-12.
16. Wells S, Jackson R. Online management of cardiovascular risk in New Zealand with PREDICT™ – getting evidence to the "moment of care". HCIROTM. March 2005. /journal/index.cfm?fuseaction=articledisplay&featureid=010305. Accessed May 2006.
17. Best Practice Advocacy Centre Inc. (BPAC Inc). Decision support for health professionals. DSS Forum Presentation from Best Practice. Health Information Standards Organisation (HISO) Workshop. http://www.hiso.govt.nz/moh.nsf/pagescm/440/$File/dssbestpractice.pdf. Accessed June 2007.

8. Footnotes
a An Iwi is a Maori (indigenous people of New Zealand) tribe, the largest social group within Maoridom. Iwi are divided into hapu (sub-tribe), which in turn are made up of whanau (households).

b Secure network for health sector electronic messaging

c Practices 1-3 are the same size, based on the total number of staff and GP FTEs in each practice

d Authorities needed for the prescription of certain subsidized medications

e The Accident Compensation Corporation

f Work and Income New Zealand