Professor of Health Informatics at the University of Auckland New Zialand.
It is no secret that ‘business as usual’ in healthcare delivery is an unacceptable option. Beyond the desire to improve equity and quality of care, inexorable rise in demand with an ageing population and increasing rates of chronic illness are set to outstrip society’s ability to supply current levels of service no matter how we might mix public and private funding. Information Technology (IT) is looked to as a source of solutions to break out of this situation.
Health IT is not a panacea for the health system’s woes. Indeed, the evidence base for improved health outcomes from health IT, although growing, is quite limited. As recently as 2006, a major systematic review evidence on the effect of health information technology on healthcare delivery found the compelling results to be confined to a few areas of preventive care and questioned whether typical healthcare organisations could emulate the results coming from academic institutions with internally developed system. The situation is, however, changing rapidly; for instance, the International Medical Informatics Association (IMIA) has a new journal Applied Clinical Informatics entirely dedicated to publishing practical findings about clinical and administrative use of health IT.
In New Zealand, health IT is being pursued systematically as an enabler of the transformations needed to achieve sustainable high-quality healthcare.
New Zealand (NZ) has several key elements already in place that are powerful enablers for further innovation; most notably:
NZ also benefits from national leadership and organisation in health IT. The IT Health Board (ITHB) is a sub-committee of the National Health Board that provides leadership on the implementation and use of information systems across the health and disability sector. The ITHB’s national health IT plan lays out two phases of work building on the existing infrastructure:
The National Shared Care Planning Programme (NSCPP) began a proof-of-concept pilot in early 2011, indicating the start of field experience directed at Phase 2.
NIHI is a research unit of the University of Auckland based at the School of Population Health. NIHI’`s mission in health IT is to promote its innovative use for improved equity and outcomes in health delivery. NIHI has been working closely with the ITHB to support implementation of the national health IT plan. Below we present three cases of NIHI research and evaluation where health IT is enabling the kind of transformation needed to enable a sustainable future healthcare system. We conclude with thoughts about the importance of iteration and evaluation in health IT implementation and the opportunities for incremental as well as more radical transformation.
In 2010 and 2011 NIHI was commissioned by the ITHB to evaluate three existing regional NZ implementations of electronic referrals (eReferrals) and to liaise with a larger project, in pilot at the time of the study, that would introduce eReferrals for the Auckland metropolitan area. The earliest of these regional implementation, for the area surrounding Hutt Hospital (serving the Hutt Valley region just outside of the capital city of Wellington), began operation in 2007. For this, 16 service-specific referral forms and one generic form were developed to encompass all Hutt Hospital services except the Emergency Department.
The Hutt Valley implementation allowed GPs to transmit referrals from their general practice software over the area health messaging network to the clinical workstation server of Hutt Hospital. The GP receives electronic notification of key events including receipt of the referral at the hospital, and when the referral is reviewed and prioritised for a specialist appointment. This greatly improved the visibility of referral status for the referrer. Within the hospital, in lieu of a paper referral sitting on someone’s desk, an electronically managed eReferral could be reviewed by any appropriate staff member (including Emergency Department staff should the patient be admitted while awaiting their appointment); and electronic workflow management makes for easy identification of eReferrals in need of action. The system saw steady uptake in the first year of operation, rising to over 1000 eReferrals per month in 2008, and thereafter seeing sustained use and moderate growth to 1200 eReferral per month in 2010. eReferrals, as opposed to conventional posted or faxed referrals, constituted around 56 per cent of referral traffic into Hutt Hospital in 2010 (over 70 per cent of referrals from sites using the electronic solution, with the remainder being referrals from outlying areas). Introduction of the system was associated with a significant reduction in the time until a referral was prioritised, with eReferrals being processed more quickly on average than paper referrals, but with processing of all referrals (paper and electronic) speeding up.
A second implementation in the north of New Zealand (the Northland region) was more incremental, starting with a referral form for colorectal investigation and expanding to subsequently include breast screening and diabetes services. This implementation was more lightweight on the hospital side as compared to the Hutt Valley solution, using a web based solution and thereafter proceeding to the pre-existing manual solution for routing and review within the hospital. This solution also has seen sustained uptake by area GPs.
In the Canterbury region (the area around Christchurch), eReferral was taken up as an outgrowth of a broader initiative around Health Pathways. These pathways define care processes as Web based guidelines with clear steps and / or flowcharts. Over 300 pathways had been developed at the time of our review (May 2011). The pathways are developed through a systematic process of specialist and GP workshops and aim to empower community based services to deliver care without referral where possible. Dissemination of pathway knowledge is promoted by information evenings for GPs and by specific online feedback to GPs where referrals are declined for not meeting public service criteria. Moreover, training and funding has been provided to community based services to take on expanded roles. This has led to significant demand reduction (and thus reduced waiting list) in a number of previously-overstretched hospital-based services including gynaecologic ultrasounds and dermatology (for excision of minor skin lesions). The pathways are seeing high and sustained interest from community based users with 2,500 distinct Canterbury health professionals making over 10,000 webpage visits in May 2011. The dynamic health pathway content management system allowed earthquake-specific pathways to be provided during the 2010 and 2011 events (e.g. for management of frail / at-risk individuals and of anxiety).
Shared care is defined as “an approach to care which uses the skills and knowledge of a range of health professionals who share joint responsibility in relation to an individual’s care.” Collaborative intervention using E.H. Wagner’s Chronic Care Model (CCM) can be seen as a type of shared care and places emphasis on the role of the ‘activated patient’ as well as the ‘prepared, proactive care team’. Shared care is sometimes associated with care planning. The UK Department of Health has suggested that every long-term care patient should have an “integrated care plan” developed and reviewed with a lead healthcare professional from the care team. NSCPP aims to provide an IT infrastructure that facilitates shared care and care planning for patients with high need.
NIHI evaluated the proof-of-concept and ‘limited deployment’ phases of NSCPP in 2011, and is now following the more extended rollout in 2012. The proof-of-concept phase focused on coordination of cardiac patients; in limited deployment the scope expanded to also include a respiratory service and gout management. In each of these three cases, a hospital based service used the IT solution to share data with general practice staff (GPs and practice nurses) at a number of participating community practices. Various other healthcare providers, such as pharmacists, were also given access to the shared care record, and a few patients have been given access to their own record on a pilot basis. As of 31 October 2011, 73 patients had been recorded in shared care planning system, of which 48 had care plans created and eight had been provided with Patient Portal access.
The software was actively used by the general practice and hospital staff to coordinate care through shared notes, messages and assignment of tasks. This transformed a situation where a patient might be formally referred from community to a specialist into a more collaborative approach among the healthcare professionals. Both doctors and nurses from community and hospital participated in the shared care dialogue. Indeed nurses were the most active users by a wide margin. A more challenging shift is the uptake of care planning and patient engagement, although training on care planning was provided as part of the project. Who pays for the time to sit with the patient and develop a care plan? And whose job is it to respond to a message posted to the portal by the patient in a timely fashion? While the technology is an enabler, there is a need for transformation in procedures and funding models if healthcare workers are going to commit fully to the use of shared care planning.
While not specifically set as a work area in the national health IT plan, implementation of the plan will enhance the already significant ability for clinicians to track their patients’ medication supply in NZ. Using the NHI, matching GP prescriptions to pharmacy dispensing records is straightforward and can provide insights on the management of long-term conditions in the community at both an individual and population level.
Large opportunities for improved long-term condition management exist around medication adherence (i.e. the degree to which patients take medications as directed by their physicians). Medications can significantly reduce the impact of conditions such as hypertension, diabetes and high cholesterol, but only if patients take them regularly. One measure of adherence is medication possession ratio (MPR) – the percentage of days in given time period that a patient has sufficient medication supply to match the dosing regimen set by their doctor. When MPR falls below around 80 per cent, it is assumed that long-term management has been significantly compromised.
NIHI researchers have been examining the effectiveness of monitoring long-term medication adherence using the electronic records in general practice systems and making comparison for validation against national pharmacy claims data. We looked at MPR over 15 months for six of the most common long-term medications and found that fully 50 per cent of patients failed to maintain MPRs of at least 80 per cent across those medications. We also found that patients with diabetes and hypertension who maintained a good medication possession pattern were three times as likely to meet their recommended target blood pressure as those with poor medication possession.
We have organised an intervention to improve medication adherence for Pacific Island patients. Working with a Pacific-led practice in West Auckland we identified some 200 patients with a history of low MPR for blood pressure medication. Practice staff used this list to direct follow-up with these patients to discuss issues that may be inhibiting their ability to take medication regularly, and to provide motivation and reminders. The result was a significant improvement in medication adherence as compared to a control practice with similar caseload.
Evaluation should be integral in all projects involving innovative use of health IT. Plan to assimilate user feedback and continue to improve. Monitor uptake and impact to sustain the effort and build the case for extended roll-out.
In all cases where a new health IT system (or new feature) is deployed, one source of evaluation data is the database of transactional electronic records resulting from the use of the system itself. A key measure of success can be tracked in terms of plotting transaction volume on the new system to document system uptake, and thus user acceptance. Further quality measures may be possible depending on the system, such as completeness of records. In an environment where the new system integrates with existing technology, comparison to historical performance is relatively easy. This was the case at Hutt Hospital where referrals received conventionally by post or fax had already been tracked electronically upon receipt for several years before implementation of eReferral from the community. This allowed us to compare the mean (and variance) of times from receipt to specialist prioritisation and document the speedup as eReferral use became substantial. Look for such process measures as early signals that things are on track – over the longer term the benefits may translate to measurable productivity gains, but they may not in every situation since there are so many steps in the healthcare value chain that the benefits of a single change may be swamped by noise.
The value of qualitative data should not be underestimated. A wide selection of users should be interviewed after they’ve had some experience of using the system in the field. Their insights on how the system is adding value (improving quality of care or efficiency) will help to target quantitative studies. Equally, end-user concerns about difficulty integrating the system with real-world workflow, or potential threats to quality of care, should be taken seriously, confirmed by interview with more users and set an agenda for iterative improvement of the solution. In the language of philosophy, we should view the impact of IT as a social phenomenon and not restrict our evaluation to a mechanistic positivist view as is appropriate, say, for trialling the effectiveness of a new medication.
IT can be deployed in many ways to effect positive transformations in healthcare delivery. We have illustrated this in terms of electronic referral management, shared care planning and long-term medication adherence. Many worthwhile transformations can be achieved incrementally; e.g. electronic referrals can be introduced for a few high-volume services, or referral management protocols can be made available as online guidance in advance of implementing eReferrals at all. Pick a level of innovation that fits your current level of IT infrastructure and addresses a large area of opportunity. With a good system of patient identifiers and strong uptake up computing by community based physicians, however, much more is achievable. When deploying health IT, pursue user feedback early and often and make evaluation integral to the project plan. Don’t view IT as a ‘big bang’ solution with a discrete start and end – view continuing IT-enabled improvement as an integral aspect of your business.
Disclaimer: The views expressed herein are those of the author and should not be taken to represent the ITHB.