How do Health Informatics Systems Improve Quality and Cost Efficiency in ACC Contracted Community Rehabilitation Teams

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Contents

Abstract
Introduction
System Requirements
Use of Technology
Measurement of Systems

• End User Satisfaction
• Accessibility versus security
• Communications
• Report Writing
• Invoicing and Accounting
• Support of Best Practice
• Administrative Features

Methodology
Implications
Discussion
References
 
Abstract
New Zealand’s accident compensation scheme, administered by the Accident Compensation Corporation (ACC), provides accident cover for all New Zealand citizens, residents and temporary visitors to New Zealand.^[1] All health care related to accidental injury is funded by ACC. Many small private companies around New Zealand are contracted by ACC to provide community rehabilitation services to people with injury related disabilities. Each company uses its own health informatics system to carry out a range of functions such as process referrals, record maintenance, carry out quality control audits, ACC invoicing and generating reports. This paper will suggest a process for evaluating these systems that will help identify the features of a health informatics system that would facilitate the greatest cost efficiencies both for ACC and the private companies. End user satisfaction and clinical quality improvements will also be evaluated. It is hoped that this evaluation process will guide companies when developing health informatics systems and, therefore, improve cost efficiency and quality service delivery.
 
Introduction
Health care provision, particularly rehabilitation, is increasingly offered in the patient’s own environment, be that the home, work place or in a community facility. This combined with the increasing acknowledgement of the value of interdisciplinary practice presents a challenge as to how information should be shared among the various members of the rehabilitation team. An interdisciplinary rehabilitation team should work together towards a common, client-centred goal. Communication is a key aspect in the success of interdisciplinary practice. This can be difficult when team members spend the majority of the day in the community visiting patients. The challenge of how to ensure all team members are provided with all essential information regarding the referral and progress of a patient is one that does not appear to have been addressed. To work together towards a client’s goals, each team member must be aware of what the other members of the team are doing and ensure that their intervention is complementing the actions of the rest of the team.
 
This paper will explore the specific challenges faced by private rehabilitation companies providing community-based services for Accident Compensation Corporation (ACC) claimants. In addition to clinical challenges, there are administrative and management challenges related to monitoring and tracking referrals and ACC approvals, invoicing and quality audits.
 
Currently, several private rehabilitation companies are exploring and/or developing systems to manage the clinical and administrative information requirements, and doing so at significant cost. This paper will suggest an evaluation of system requirements and the relative benefits of the individual components of existing systems related to clinical quality and cost benefits. The results of such an evaluation will help guide companies and ACC in the development of health informatics systems resulting in more efficient and interoperable systems.
 
System Requirements
Accident related community rehabilitation funded by ACC is provided to patients in their own environment, their home, workplace, Marae, anywhere the person spends the majority of their time. A community-based rehabilitation team presents a challenge to efficient health informatics as the clinicians are rarely at their office base and infrequently "cross paths" with their colleagues to share information. The different members of the rehabilitation team will all be working towards a shared client goal and because of this it is important to ensure information input is not duplicated or contradictory. A shared client record is a valuable way to pass information between professionals involved in a case; however, that can also present challenges when the file is required by more than one person at a time. A health informatics system in this context should enable sharing of information while maximising accessibility for all and also preserving data integrity and security. In any health-care setting, but particularly where care is taking place in the community, hours can be lost trying to track down reports, other team members to discuss the client’s progress or even looking for the file itself. Interdisciplinary practice is reliant on communication and a robust health informatics system reduces the amount of time a team sits in meetings sharing information. In the context of a private rehabilitation company, lost time equates to lost revenue.
 
Community based rehabilitation teams who are contracted by the ACC to provide post-injury rehabilitation are required to provide an interdisciplinary service and to meet contractual reporting and invoicing requirements. Reports must be completed within a strict timeframe and on standardised templates and must report on the interdisciplinary goals that should be written to a specific criteria. Several of these privately owned companies exist in New Zealand and are developing or have developed health informatics systems to try and meet these needs. A health informatics system must serve a number of purposes. Firstly, the system must process and monitor the progress of referrals, both clinically and related to the level of funding approved by the ACC case manager. Referral agents (ACC case managers) must be kept informed of the progress of the referral including if and when the claimant has been contacted and assessed, and whether reports have been submitted.
 
Secondly, it must be capable of using ACC’s reporting and rehabilitation planning templates in addition to incorporating a level of flexibility to serve all contracts held, both with ACC and other referral agents. The system should also support communication between team members. For safe, high-quality patient care, the team must work synergistically, remain focused, and effectively communicate the patient information that individual team members need to do their jobs effectively. Without effective communication team members may inadvertently be working at cross purposes, which can lead to sub-optimal care, compromised patient safety and increased costs.^[2]
 
As the rehabilitation teams are running as small businesses the system should also allow for invoicing and accounting procedures including payments to staff as well as offer the accessibility needed to carry out quality control audits. Time savings will result in the biggest economic benefit. Systems that reduce billable hours would be desirable to ACC whereas systems that reduce non-billable hours, including administration tasks would be of greatest interest to the companies.
 
Use of Technology
Electronic systems can address many of the requirements stated above. The literature, however, offers little supporting evidence that systems will deliver what they promise and such systems are often associated with high capital investment^[3] although there is some suggestion that costs can be recouped over time.^[4-6] Cost savings have been identified with the use of electronic health records (EHRs) and costs are often averted where there are improved time efficiencies.^[6] This, however, must be balanced against the costs of development or purchase of software, licensing and hardware and the temporary productivity losses during training on or introduction of a system. Cost is highlighted as a significant barrier to the implementation of EHRs.^[4-7] Therefore, it is appropriate to attempt to gather evidence of how an EHR can improve cost efficiency and improve the quality of clinical care.
 
To date research has focused on larger-hospital-based EHRs.
 
Large acute hospitals have the most to gain from EHRs simply because of the scale of the services they provide. Further, the cost savings and quality improvement gained have greater implications for wider health care provision. The focus of research on the larger organisation can also be explained by the level of investment made and their frequent association with research institutions.
 
The literature offers no evaluation of systems such as those used by a community rehabilitation team.
 
There are numerous publications that report evaluations of EHRs; however, the measures of success, eg, reduction of adverse drug events, adherence to guidelines and use of decision support systems, are not the primary focus of these systems.
 
Montori et al^[8] has highlighted how electronic systems can improve documentation of clinical activity, adherence and to performance measures, although the performance measures used in this study would differ from those used to measure a system used in the ACC community rehabilitation environment.
 
Orr^[9] commented that a significant proportion of clinicians’ time can be spent pushing, pulling and producing information that needs to be shared with many people and that technology can be integrated into clinical processes so as to help manage the flow. Orr also noted that systems need to be scalable, affordable, flexible to meet the needs of the individual, and equitable in terms of providing advantage to potential users. These are areas that need to be considered when evaluating systems that have been developed by the private rehabilitation companies.
 
Although health information or case management systems such as Medtech or Intrahealth are available in New Zealand, no system exists that meets the needs of the private companies providing rehabilitation in services in the community. It would be difficult to make these systems compatible with the ACC contracts, codes and invoicing systems. However there may be value in developing such systems once there is improved awareness of the most valuable and cost-effective system requirements.
 
Measurement of Systems
The measurable parameters^[10]10 for these systems have been considered in the context of what benefits a system could or should provide to the rehabilitation company and to ACC. These parameters have been narrowed down to seven areas: End User satisfaction; accessibility versus security; communications; report writing; invoicing and accounting; support of best practice; and its administrative features.
 
End User Satisfaction
"Usability" is a quality that assesses how easily a system will be accepted.11 The consideration of the end user and usability of a system is recommended when designing or implementing any system.^[10-14] This is an important factor when it is considered that clinicians’ technical skill has been identified as a barrier to use of technology systems in health care.

^{, 15]} Inefficient use of any system is likely to increase the non-productive/non-billable time of the team members.
 
Accessibility versus Security
While it is essential that team members share information relating to the patients they share,2 security of information is also essential. The New Zealand Privacy Act 1993 and the Health Information Privacy Code 1994 set the requirements that systems must meet. Security of information, however, is not limited to confidentiality; the integrity of the information should also be considered. Measurement of accessibility and security needs to be considered relating to the following parameters: confidentiality; integrity; authenticity; non-repudiation; auditing; and accountability.^[14]
 
Communications
The systems need to be evaluated on their facilitation of communications between team members, case managers, referral agents and other health care providers, eg, GPs. This will include internal communication such as ease of entering and accessing the clinical records for all clinicians involved in the case, sharing of appointment schedules to provide co-ordinated care, access to referral information and previous reports and support of direct communication by e-mail, pager, cell phone, etc. External communication will consider linkages with other healthcare providers, eg, GP, referral agents, ACC case manager and the clients themselves.
 
Report Writing
ACC provide contracted companies with templates that must be used to complete reports and rehabilitation plans. All these templates must be completed electronically. In 2006, the templates for one of the main rehabilitation contracts were automated so much of the information "self populated". The systems need to be evaluated as to how well each incorporates these templates but also allows other reporting formats to be used.
 
Invoicing and Accounting
As these companies are run as small businesses and most have a combination of employed and sub-contracted staff, invoicing and accounting can be a time-consuming and, therefore, costly exercise. Systems need to be evaluated for their efficiencies and, therefore, cost saving in this process.
 
Support of Best Practice
Access to the evidence base needs to be considered. This will include accessibility to the Internet or databases such as Medline, storage and access to guidelines and training and development resources.
 
Administrative Features
A system’s facilitation of quality audits needs to be considered. This will include access of managers/administrators to all records and the ability to review clinical records. It is important that quality audits can be audited against the contractual requirements as well as clinical quality audits separating therapists, disciplines, assessment versus treatment, etc. The ability to monitor progress of referrals, eg, acceptance, allocation and timeframes as well as associated invoicing, will also be evaluated for its quality control implications.
 
Methodology
The tools used to measure each parameter and the implications of a system’s success in this area are outlined in table 1. Unrelated questions could be eliminated from the published measures although wording of questions will remain unchanged.
 
Table 1: Measurement Tools
 

 
Each participating company should be visited to complete the evaluations. Visiting the sites allows direct observation of the system and offers the best opportunity to collect data and user opinion on how systems benefit the organisation by actually seeing how it achieves its aims.^[3]
 
Semi-structured interviews should be conducted with administrators, managers, and clinicians working within each company. ACC case managers should be asked to complete a questionnaire relating to their experience working with the systems used by each company. All answers need to be provided using a 5-point Likert scale.^{[13, 14]}
 
In addition to the measurable parameter data collection, some more general demographic information needs to be collected on the staff interviewed, such as length of time working with ACC systems, the employing company, age range of the interviewee, their designation and a self-rating of their computer competency. It is important to understand the impact that end users’ technology knowledge and experience may have.
 
The informatics systems are likely to improve access for ACC auditors or investigation teams. The system should also assist a company in their ability to meet and be measured against accreditation standards such as disability standards that increasingly private rehabilitation teams are striving to use as benchmarks.
 
Implications
Currently, private, ACC-contracted companies are developing health informatics systems independently of each other and without the benefit of a literature base to demonstrate the benefits and cost effectiveness of the system being developed. The uncoordinated development of these systems prevents any interoperability between the companies and the ACC, as little consultation occurs during a system’s development. The non-standardised recordkeeping and audit capabilities prevent comparison of a team’s efficiency. It also means that as a there is only a small staff base, professionals would be required to learn a new system should they change jobs or contract to a number of companies.
 
An evaluation project as described in this paper will provide valuable information to guide companies in their decisions towards developing a system that will maximise efficiencies, quality and cost savings. If systems across the country all have similar features this could be a step toward a more interoperable system that enables the transfer of information between companies and ACC and creates a more efficient referral and case management process, which will in turn result in cost savings for ACC.
 
Discussion
Evaluation of a health informatics system in this context must be multi-faceted. Consideration of the system’s administrative, financial, clinical, internal and external communication and security requirements is essential, along with system usability, development and running costs. Only when all of these areas have been considered can we evaluate the clinical and cost benefits of the systems.
 
The private companies independently developing health informatics systems are doing so without considering the long-term benefits of collaboration. As these systems have been developed independently of each other it is reasonable to assume that if there has been any evaluation of them it would only measure activities against the design specifications rather that the wider potential of a system. While a system may well meet the current needs of the company, benefits of potential interoperability with other providers, ACC and the public sector systems may not have been explored. A comparison with other systems allows wider consideration of approaching challenges. A more comprehensive evaluation as suggested in this paper would allow a more objective measure of the system’s efficiency and cost effectiveness rather than consideration of whether it does what the company intended it to do. Such an evaluation needs to consider the wider needs of ACC and the private providers, the clinical team’s ability to provide quality care, and the learning benefits to the field of health informatics.
 
Community rehabilitation increases the challenges for health informatics because of the nature of rehabilitation, often involving several disciplines working with a client at different times but towards a shared goal. Despite this, there has been no published assessment or evaluation of the health informatics requirements for community rehabilitation in New Zealand. The evaluation proposed in this paper is intended to go some way towards evaluating and documenting the needs of this branch of health care and, at the very least, ask the question "How can the field of health informatics address the challenges faced in this context".
 
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