Sharing health information meaningfully and safely has long been a goal of health providers around the world, including New Zealand. For example New Zealand is in the process of implementing strategies from theNational Health IT Plan 2010. Another example is the United States of America’s Meaningful Use regulations that has as one objective to provide a summary of care record for transitioning, or referring, patients to other health providers (Blumenthal and Tavenner, 2010). This leads to using a patient’s health information collected in one context e.g. a patient’s primary health care
CHAPTER 2. BACKGROUND, MOTIVATION AND RESEARCH PROBLEM Table 2.1: New Zealand Health Sector information volumes and flows circa 2006.
17,000 Primary Care Organisations 21 District Health Boards
x 50,000 GP visits x 105,000 prescriptions x 40,000 lab tests x ? NGO interventions x 1,200 hospital admissions x 2,000 Emergency Department visits x 4,000 outpatient visits
provider (GP), and using it in another context e.g. a hospital’s Accident and Emergency department, by a health practitioner who did not originally collect the information. Sharing means that a health practitioner can access the health information of a person they are treating at the point of care. Sharing of health information also occurs with, and for, secondary use, but for this research, it was the health practitioner’s perspective that was of interest.
The NZHS handles large volumes of information and complex information flows e.g. 1,300,000 referrals per annum from GPs alone. Access and effective use of this infor- mation is needed for efficiency gains in this sector as a lack of appropriate information is costly, both in financial terms and in adverse outcomes for patients. However, this information must be used safely, especially in clinical decision making. The effective, but safe use, has become a key driver for the sector.
It is helpful to look at the amount of data being collected on a daily basis throughout the NZHS. This is to gain an understanding of data volumes and flows, that systems within the Sector are currently collecting. Table 2.1 shows daily health interventions for New Zealand (circa 2006) divided into primary care and hospital interventions. More detailed data on information volumes and flows is given in Table 2.2. This represents General Practice information flows per annum, with “out” being information coming from General Practice and “in” being information going to General Practice.
Tables 2.1 and 2.2 represents an enormous amount of information, both in volume and differing types, collected and recorded about patient’s health. At issue is not only the amount of data but also that the data is not readily shared, and stays isolated with the system it was collected in. This means it is not available for use by health practitioners who are outside of those systems. The situation leads to isolated “silos of information”, problems with the quality of the data captured, and continued fragmentation of both data and systems (NZ National Health IT Board, 2010).
The need for efficiency gains that reduce costs in the NZHS is highlighted in the Or- ganisation for Economic Co-operation and Development’s (OECD) biennial economic survey for New Zealand 2009. The report states that increasing health sector costs are
CHAPTER 2. BACKGROUND, MOTIVATION AND RESEARCH PROBLEM Table 2.2: New Zealand general practice information volumes and flows circa 2006.
Out In
x 340,000 cytology requests
x 180,000 patient records
x 390,000 vaccination reminders
x 270,000 new patient registrations
x 4,100,00 pathology requests x 260,000 patient reports x 20,000,000 prescriptions x 1,300,000 referrals x 760,000 reminders x 331,000 cytology results x 435,000 discharge advices x 534,000 discharge letters x 185,000 mammography results
x 710,000 after hours reports
x 2,163,000 outpatient letters
x 6,409,000 pathology results
x 426,000 radiology results
x 400,000 screening results
the largest threat to New Zealand’s long term fiscal sustainability. Also, that spending in the health sector, has been the fastest growing aspect of public expenditure for many decades (twice the rate of GDP growth since 2001), and is the countries’ most pressing financial challenge (OECD, 2009).
In New Zealand, efficiency gains through use of, and greater access to, health informa- tion are to be achieved through strategies and initiatives spelled out in theNew Zealand National Health IT Plan 2010 published by the New Zealand Ministry of Health. The Health IT Plan 2010, along with an update produced for 2013/2014, is the latest in a series of strategy documents that are being implemented, designed to realise the desired gains in the NZHS. The strategy documents are augmented with implementa- tion standards produced by New Zealand’s Health Information Standards Organisation (HISO).
Along with greater access to health information is a requirement that the information be used safely, without adverse outcomes for patients. An example that safe use is required comes from a report from the Institute of Medicine of the National Academies 1999. The report estimates that as many as 98,000 deaths were the result of medical errors in the United States for the year 1999 (Institute of Medicine, 1999). A proportion of these deaths is attributed to absent or faulty information regarding prescriptions, and treatments (Leitheiser, 2001). The implications of poor quality information in health is explored in detail in Section 2.7.3, and Chapter 3 Section 3.5.4.
2.3.1 Health Sector Direction - Tension for Change
For this research, aggregation of data from disparate sources into a single view at the point of care was the premise that the information use was based on. This focus
CHAPTER 2. BACKGROUND, MOTIVATION AND RESEARCH PROBLEM
is in line with proposed initiatives for health information use within the NZHS (NZ National Health IT Board, 2010). Further, it was only interested in data for the current, required context of patient care. With the desire to make more, and better, use of health information, and information from disparate sources, at the point of care, factors regarding characteristics of the information, and its use, become important. These factors include:
• The quality of the information that is to be relied upon.
• Is there enough accompanying information (meta-data), or enough desired infor- mation, to allow for a judgement to be made as to the information quality?
• Ensuring patient safety is not compromised by a judgement to use the information (NZ National Health IT Board, 2010).
• Out-of-context use of the information, where determinations of quality are espe- cially challenging due to GPs becoming more remote from information creation, and information sources (Fisher et al., 2003).
The last point above needs some explanation as to what is meant by out-of-context use of information. The following section provides a definition for this term.