The health sector is being transformed as national medical information is collected and shared among healthcare providers. Malcolm Hutchinson examines the knowledge revolution in health.
In a knowledge economy, the production and distribution of information is something that underpins all other activity, in much the same way that steam power supported the activities of the old industrial economies.
South Auckland Health is embracing the knowledge economy concept in the extensive use of information systems in the hospital and out-patient settings, both for patient administration and for clinical systems. The organisation is actively seeking to extend information systems into the primary sector. Standardising on an Auckland district solution is a goal made possible by the recent establishment of the District Health Board.
Integrated care is the strategy employed at South Auckland Health. Information chief Phil Brimacombe says the strategy covers the secure and efficient exchange of health information between various providers, particularly at the primary and secondary levels. The aim is to improve the quality of care to patients and to improve the health of the population.
South Auckland Health continues to improve its business processes and practices to take advantage of new technology, says Brimacombe. He gives as examples the use of electronic results from lab and radiology tests being delivered to a clinical workstation on the wards, which in some cases is a mobile wireless laptop.
"To make this strategy a reality, we require national standards for security and data access, minimum data sets, and a national health network to allow GPs, specialists and other health care providers to work together to send and receive the information required for efficient health care delivery."
Those national standards have been in place for at least a year. The New Zealand Health Information Service (NZHIS) administers the National Minimum Data Set, a collection of clinical information which is aggregated to form statistical data made available to the Ministry of Health and other health researchers. The NMDS is keyed to the National Health Identifier (NHI), a unique ID allocated to each individual that makes contact with the secondary healthcare system in New Zealand. The NHI is generated automatically for each patent as they arrive, and GPs must use this identifier when they claim for services offered.
This information forms the keystone of a national health information network, connecting primary and secondary healthcare institutions to the NZHIS via a secure health intranet. Information technology offers great benefits in the form of sharing information between GPs, hospitals and other healthcare providers, helping to reduce costs associated with patent care. In theory, this technology enables medical staff to make better decisions about care in a more timely manner, and to inform their patients in more detail.
Health has always been a highly knowledge-intensive industry, says the information services manager at Waitemata Health, Ray Delany. "Catchphrases may be politically significant, but they do not alter the basic issues confronting the industry," he says. "We have not made any changes to our plans as a result of discussion around this issue, but we do think that technology will have a significant impact on the way in which healthcare is delivered in the future." Martin Jorgensen, IT manager at Manor Park, a private healthcare facility for the elderly in Upper Hutt, says information is money these days. "Accurate information on the operational costs of running a hospital is critical," he says. "There is increasingly upward pressure on costs and a static revenue base to pay for those costs," he says.
"The management at Manor Park is always proactive in support of information technology," says Jorgensen. "The only restrictions are self-imposed as part of the development cycle." He says Manor Park has made extensive use of IT since day one, and this has had significant impact on the day to day operation of the hospital. "The reporting requirements to external organisations are extensive, and the amount of time involved without access to relevant data means this is time consuming for any private hospital. It needs to be an integrated system, covering all aspects of operations, in order for it to be successful."
The internet has been the enabling technology, not just in the opportunity it affords for cheap networking and communication. Over the years, hospitals and primary providers have developed their systems to meet their own individual needs. Open standards allow for interconnectivity between organisations employing widely different systems, meaning information can be readily shared.
Most commentators agree that information technology can only have a positive impact on the provision of healthcare in New Zealand. Jorgensen sees the benefits as being mostly concerned with lowering costs, and greater efficiency in complying with external reporting requirements. The faster staff can access data and prepare reports, the more time can be spent on resident care.
IT systems are often used in decision support, and the health industry is no different. According to Delany, being able to offer patients better, more timely information about their condition will give individuals the knowledge they require to make good decisions concerning their health.
"The biggest benefit will be to the the patient," he says. "Clinicians will have much better tools to convey information to patients to support informed consent. Electronic prescribing at the bedside will provide automatic alerts for drug interactions and allergies. There will be teething problems along the way, because ultimately clinicians will be changing the way in which care is delivered, and that sort of change won't come easily."
Brimacombe says the greatest impact will be that clinicians will have all of the information that they need about their patients, when they need it, at the point of care. "There is no negative to this scenario, except that the IT systems will need to have outstanding levels of performance, reliability and resilience in order to meet these critical clinical needs."
Not all is rosy, however. Phil Brimacombe believes that although the minimum data set and the facility for sharing information offered by the NZHIS is a good start, not all health providers in the country are on board with the scheme.
"The building blocks for this health network are in place in the shape of the National Health Index, the NZHIS national minimum data sets and the Health Intranet," says Brimacombe. "But what is missing, and which we at South Auckland Health are currently attempting to address, is the commitment to follow through and convert these building blocks into an active, working environment for the whole sector."
The national systems have to be designed with flexibility to deal with the variety of legacy systems in the health sector at the moment. Standardisation may be a good thing within an organisation but it would be costly and time consuming to insist all hospitals, GPs and clinicians replace their existing systems with a national standard.
"It would be a complete disaster for the health sector if the government were to listen to the demands made from some parties that health IT needs to be standardised on to the same IT system for all providers," says Brimacombe.
"It would set the sector back many years to change to a single standard system, which would probably suit nobody. In health, one size does not fit all." Instead, Brimacombe calls for a national agreement on a single set of standards for the security and exchange of data, and agreement on national minimum data sets for the different providers.
"This is the role that we at South Auckland Health are encouraging government to take. In this vision we have, it does not matter what system you have as long as it conforms to these nationally agreed data, interchange and security standards," he says.
For Delany, one of the primary concerns is the lag in legislation governing business interactions enabled by information technology. "The law in New Zealand is a significant problem, especially around the concept of tangibility," he says. There is, for example, legally no such thing as an electronic document. This is an example of where technology has outstripped the legislators. It's an urgent problem and needs to be fixed quickly." Even so, Delany believes New Zealand has the technological know-how to develop our own solutions, given the appropriate industrial environment.
"Government needs to define meaningful strategies to enable the market to provide solutions within New Zealand rather than importing them at great cost from overseas," he says. "There is a lack of leadership in the health sector when it comes to the implementation of technology change, and there have been some high-profile failures as a result."
As a counterpoint to criticism of the legislative process, Brimacombe points out that New Zealand's privacy legislation has been well considered and poses no barrier to building a knowledge economy in health. "New Zealand is fortunate in having very well defined privacy legislation which protects individual consumers and at the same time allows the reasonable exchange of health data between a patient's different providers," says Brimacombe.
IT skills crisis
Like other industries, the health sector suffers from a shortage of talented people in the IT field. Graduates who incur large student loans are being tempted by higher rates of remuneration overseas, and are leaving New Zealand short of essential skills.
"The Employment Relations Act may help workers in other industries, but it does nothing for IT, where people are in strong demand," says Delany. "A more useful action might be to address the student loan problem, via tax breaks or other incentives. There is simply too much competition overseas for top people."
Lack of IT skills is a major concern in health as it is in other sectors, says Brimacombe. "We have the double burden of requiring not only good IT skills, but also experience in health which is a very complex area. It imposes a long learning curve on those new to the sector, and we have great difficulty in recruiting the skills we need. We also struggle to afford the consultants and contractors who have priced themselves for a market where demand outstrips supply."
In the coming five years Jorgensen would like to see more aggregated information across the industry made available to medical staff.
"What would be nice to see in future is the establishment of databases in the health sector that can be accessed and researched by nursing staff," he says. "Statistics on resident care allowing things like benchmarking for incident and accident reporting, providing ongoing training and education for nursing staff at all levels."
In health, like everywhere else, computers have become ubiquitous. All hospitals now have various computer systems that are fundamental to certain processes, particularly in the area of patient admission, registration, transfer and discharge. Computer systems are also becoming increasingly critical to clinical functions, for example, recording, updating and enquiring upon clinical notes, electronic results for lab and radiology tests, digital radiology images.
General practitioners as well as hospitals are now starting to move into connectivity issues, something the National Health Intranet is available to take advantage of.
"In the next five years we will see a similar update of these sophisticated systems into the secondary and tertiary providers and a constant flow of clinical data between these different provider levels," says Delany. "All to the benefits of patients, of course."
Brimacombe predicts in five years time the use of clinical information systems will be extended even further so that computerised devices are readily used at the point of care, whether it be on the wards, in the theatre, or in the GP practice. Technology will enable the improvement of health care delivery along the continuum of care from GP and primary provider right through to specialist care at the hospital in-patient and out-patient setting.
Technology should be used to enable better quality healthcare to New Zealanders, according to Delany. "We see the benefits increasing exponentially as technology becomes cheaper, faster, mobile, more featured."