An Overview of Health Information Technology and Health Informatics

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Contents

Aims of this Unit

  • Being a an introductory unit - in a course designed for Health Managers - rather than having the objective of commencing on a path of creating Health Informatics Practitioners - the objective is to provide those who complete the Unit with the capabilities of understanding what it is Health Informatics Practitioners do, where they add value to the health enterprise and what expectations should be placed on both Health IT and its practitioners.
  • The Unit also has a core objective of situating Health IT in the overall set of tools and skills the Health Sector manager needs to deploy for overall success.

Definitions of Health Informatics

  • There are as many definitions as there are ‘stars in the sky’. Every organisation which owns an acronym seems to have one.
  • At its simplest it is a discipline in which practitioners are trained to use broad health sector and information technology skills to improve the overall efficiency and effectiveness of the sector.
  • Other definitions that seem sensible are:
    • Health informatics (also called Health Information Systems, health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, and (bio)medical research. Wikipedia
    • Health Informatics: The systematic application of information and computer science and technology to public health practice, research, and learning. PHIERS
    • Health Informatics is ... the use of computer technologies in healthcare to store, share, transmit and analyse clinical knowledge and data. OpenClinical This page contains a large number of additional definitions which fill out a range of perspectives.

Scope Of Health Informatics Covered In This Unit

  • In this introductory unit the objective is essentially to have those who have completed it ‘know what they don’t know’ while appreciating the potential for change, facilitation and improvement that is offered. In concrete terms the unit aims to provide the background to be a successful consumer of Health Informatics services and capabilities, understand the risks, benefits and opportunities offered and to develop an effective capability to set reasonable expectations and facilitate their delivery. It is important to also know enough to not be baffled by zealots and snake-oil salesmen who are often thought to abound in many Information Technology sales organisations. Thus the unit will have a practical, managerially-focussed approach leaving aside much discussion of technical complexity - except where discussion of that complexity is key to successful management performance and understanding.
  • The scope to be addressed can simply be put as covering those aspects of the larger Health Informatics discipline, as defined above, that are relevant to managers in the clinical, public health, academic and administrative a domains of the Heath Sector with lesser coverage of speculative and ‘bleeding edge’ areas.

History of Health Informatics

Health Informatics can be seen as having evolved in parallel with the progress of Information and Communications Technology. Leaving to one side the period before the initial development of electronic computers, we can fairly suggest that practical computing which had some relevance to the Health Sector emerged in the late 1950’s. To get a small flavour of the optimism of that very early period this short video is both amusing and instructive.

Broadly it seems sensible to divide the history into three phases.

  • Phase 1 was dominated initially by the mainframe computers (with their sealed rooms and specialist staff) and later by the mini computers which started the democratisation of access to computer capabilities.
  • Phase 2 was dominated by the emergence of the personal computer which saw rapid evolution as individuals experimented and learned about what was possible.
  • Phase 3 has really been dominated by the emergence of the Internet and other networking as well as the continued evolution of computing and communication technology and more latterly the emergence of mobile computing and the use of networking to deliver computing resources wherever they are needed.
  • Useful sources which should be reviewed to fill out for the student the global perspective on this topic.
    • Cesnik B. & Kidd MR, 2010 History of health informatics: a global perspective in Health Informatics - An Overview, Edited by Evelyn J.S. Hovenga, Michael R. Kidd, Sebastian Garde, Carola Hullin Lucay Cossio. Studies in Health Technology and Informatics Volume 151, 2010.
    • Shortliffe EH (.ed), 2006. Biomedical Informatics - Computer Applications in Health Care and Biomedicine. (3rd Edn). Springer. See Chapter 1. The Computer Meets Medicine and Biology (Shortliffe EH & Blois MS) pp 3-45.

Later in this section there is some historical context and background provided to reflect what has happened in the last 20 years in Australia.

The Reasons For Introduction of Health Information and Communications Technology

The most important perspective that needs to be derived from this section is that Health IT is only very rarely a solution of itself to anything. What is can do is help to address pre-existing issues that exist within the Health Sector. We are fortunate that in the last few years there has been a comprehensive review of the overall Health Sector (termed the National Health and Hospitals Reform Commission or NHHRC) that was commissioned by the incoming Rudd Labor Government and which reported in July, 2009. It is true to say that we are only at the beginning of the implementation of the recommendations of this two year process - and which already has seen significant change to the original plans. The Commonwealth Department of Health and Ageing has an archive web site which contains the reports, submissions and other material. This site is presently found here (Accessed September, 2012).

  • The first few paragraphs of the Executive Summary of the Final Report identifies many of the key issues:

“Taking action A Healthier Future For All Australians – the final report of the National Health and Hospitals Reform Commission – provides the governments of Australia with a practical national plan for health reform that will benefit Australians, not just now but well into the future. The case for health reform is compelling. The health of our people is critical to our national economy, our national security and, arguably, our national identity. Our own health and the health of our families are key determinants of our wellbeing. Health is one of the most important issues for the Australian people, and it is an issue upon which they rightly expect strong leadership from governments. While the Australian health system has many strengths, it is a system under growing pressure, particularly as the health needs of our population change. We face significant challenges, including large increases in demand for and expenditure on health care, unacceptable inequities in health outcomes and access to services, growing concerns about safety and quality, workforce shortages, and inefficiency. Further, we have a fragmented health system with a complex division of funding responsibilities and performance accountabilities between different levels of government. It is ill-equipped to respond to these challenges. We believe we can do better, and now is the time to start.

  • This report identifies actions that can be taken by governments to reform the health system under three reform goals:
    • Tackling major access and equity issues that affect health outcomes for people now;
    • Redesigning our health system so that it is better positioned to respond to emerging challenges; and
    • Creating an agile and self-improving health system for long-term sustainability.” (Page 3)

It is the issues of quality, safety, sustainability, connectedness and efficiency that there is good evidence the Health IT can facilitate and improve - as will be explored in later sections.

Concepts of Enabling and Facilitation

A key theme for the whole unit is the idea that properly implemented information technology has two macro capabilities that it brings to the business processes (or methods) by which health care is delivered and supported.

  • The first of these is that use of information technology enables improvements in the speed, accuracy, cost, consistency or reliability of an already existing business process.

An example of this might be making the transformation from the use of a postal letter to the use of e-mail. It is still the same objective being met - written communication with another party - but many other aspects of the interaction are changed through the interposition of newer technology. Clearly e-mail can be treated like postal mail - with the receiver simply printing out the received message and proceeding as previously - or new processes can evolve where filing and retention are undertaken electronically. Within the first category there are at least two sub-categories. In the first the current process is simply replicated with a technology underpinning and that of itself offers advantages - i.e. simply printing out the e-mail.

  • The second category is where the business process changes to take advantage of various aspects of the new system - such as filing the e-mail electronically and then being able to rapidly locate relevant as well as associated e-mails

The second macro-capability is the enabling of a business process which, absent the relevant technology, is simply not possible or is just prohibitively time-consuming or expensive. An obvious example that falls into this category is CAT Scanning - or Computed Tomography. The images we are all familiar with are simply not possible without a very large amount of computing power (and expertise) being deployed to take the information gathered from the sensors in the scanner gantry into the images we familiar with. The same can be said of both MRI and PET Scanning. In summary technology can simply replicate what is already being done in a business process, can allow it to be modified and hopefully improve it, or can enable some activities which are essentially impossible absent ICT.

Examples Of Health ICT Implementation

In this section we review and discuss a number of case studies which provide some encouragement regarding the good that can flow from well-planned implementations of Health ICT as well as some cautionary tales of just how badly things can also go with an absence of quality leadership, planning and management. Three often quoted examples of successful substantial implementation projects are the following.

Kaiser Permanente

Kaiser Permanente (KP) is a not-for-profit Health Maintenance Organisation (HMO) or Integrated Delivery Service (IDS) that serves almost 9 million members in the USA. Geographically it has member organisations across the US in nine different states and the District of Columbia with the largest population concentration in California. KP, as a health system, is frequently compared with nation states recognising it has a client / patient base almost twice the population of Denmark and at least as large as Scotland and Wales combined. It has over fourteen thousand physicians to do that across the USA and has a total of about 170 thousand overall employees. The KP IT organization has about 6500 to 7000 employees and spends about 3 billion dollars a year on IT (It needs to be recognised that as well as clinical systems KP also operates major backend systems to operate what is a very large health insurance fund and all the associated financial and personnel management systems). If KP were a company, our public records would indicate we generate about 44 billion dollars a year in revenue (2010). For the IT expenditure, after at least one major false and very expensive start, the organisation now has:

  • A really excellent ambulatory care (office practice) system which is used by all its physicians. This system supports a full electronic medical record, excellent decision support, preventive care reminders and so on.
  • Comprehensive automation of all its hospitals
  • A state of the art consumer portal which is used by almost half of the plan members to communicate with their care providers.

The KP HealthConnect Portal offers the following member services:

    • Your allergies
    • Your immunizations
    • Your lab test results
    • Your ongoing health conditions
    • Past office visit information
    • Online prescription refills
    • Email your doctor
    • Your future appointments
    • Your eligibility & benefits
    • Request a change to your medical record

The following two KP videos provide a feeling for what has been achieved.

(Both Accessed September, 2012) There are many more available on line.

  • A very large repository of clinical information extending back over a number of years. It is said this repository contains more data than the US Library of Congress. When combined with current data analytic and mining tools the organisation is able to monitor what is happening to its patients to an extraordinary extent while also able to conduct research on disease patterns, treatment outcomes and so on.

It is worth noting that KP has taken nearly a decade from start to end to achieve this successful outcome in terms of implementation (which began in 2004). A recent review from the Commonwealth Fund entitled Kaiser Permanente: Bridging the Quality Divide (2009) is essential reading to understand how the technology is being deployed (Accessed September, 2012) The study is available here (Accessed September, 2012)

Denmark

Denmark is a small Scandinavian country with a population of approximately 5.5 million. The country is an advanced Western Constitutional Monarchy with its GDP per capita in the top ten in the world. Being a Scandinavian country provision of Healthcare is largely funded via taxes with approximately 85% of the costs sourced from government. The Danish health sector is divided into a primary care service which is delivered by individual practitioners who are reimbursed by the Health Care Reimbursement Scheme (covering GPs, Specialists, Dentists and Pharmacists) and a hospital sector which is operated by the counties. Serious work began on Health ICT in approximately 1996. At present (2012) the following is in place:

  • Near universal use by GPs of Electronic Record Systems
  • Near universal use of secure electronic messaging for communication between clinicians.
  • High levels of automation within all public hospitals
  • Widespread access to hospital records electronic records for GPs
  • A richly functional consumer portal where consumers can access most of their own health information on line as well as a range of consumer information services.

Denmark is widely acknowledged as having taken a steady, consultative, incremental approach to implementation which has clearly now been recognised as having been remarkably successful globally. The most useful document I have this found which describes the present state and current plans is the following: eHealth in Denmark - eHealth as a part of a coherent Danish health care system which is a April 2012 review of E-Health in Denmark which was published by the Ministry of Health/ The report is found here (Accessed September, 2012)


New Zealand

New Zealand is a small country with a population of a little over 4.2 million which lies in the South West Pacific Ocean. It is culturally an advanced Western democratic state with an strong UK heritage and a significant aboriginal minority (the Maori). New Zealand and Australia were both founded as colonies of the United Kingdom over 200 years ago. The GDP per capita is just below $US 30,000 p.a. which is just below that of the richest developed nations. The New Zealand Health System is based on a partially subsidised primary care sector and a virtually fully subsidised (via taxes) secondary and tertiary sector. New Zealand is unique in having a state funded no fault accident care and compensation system where anyone who is accidentally injured for any reason is care for and supported free of charge. The health system is well rated by virtually all international comparative reviews for quality, clinical outcomes and cost efficiency. In 2003 New Zealand spent 8.1% of its GDP on Healthcare (both public and private) which is a little below the OECD average of 8.8%

  • New Zealand took the strategic decision many years ago to develop a well-resourced primary care system as its key health service delivery entity and to develop secondary and tertiary services to support the primary care sector. Indeed the New Zealand health system was one of the first in the world to truly embrace a primary care led health strategy.

Under such a health strategy general practices become the key managers of personal healthcare, entrusted with the ongoing care of individual patients. Many now argue that a primary-care led health strategy is the most logical, cost-effective way to improve delivery of healthcare in a first-world economy. The IT based support of the NZ Health Sector is frequently recognised as being excellent and the infrastructure has evolved to support both Hospital and GP care very effectively at what appears to be very reasonable cost.

  • There are two useful recent documents that provide a substantial level of detail as to what is going on.
    • The first is from the Commonwealth Fund in the US.

Here is the abstract, citation and a link to the brief. Electronic Medical Record Adoption in New Zealand Primary Care Physician Offices August 24, 2010 Authors: Denis Protti and Tom Bowden Contact: Denis Protti, Professor, Health Informatics, University of Victoria, dprotti@uvic.ca Editor: Deborah Lorber Downloads • Issue Brief (599K PDF) (Accessed September, 2012) Overview Compared with other developed nations, New Zealand's use of information technology (IT) in health care is among the highest in the world. All of the country's 1,100 general practices use an electronic medical record system with comprehensive functionality to manage patient's problem lists, enter clinical progress notes, perform electronic prescribing, and order laboratory tests and x-rays, among other tasks. Physicians are also increasingly using information technology to communicate with patients and allow them to schedule appointments. New Zealand also stands out in terms of interoperability, with primary care providers, hospitals, radiology providers, and pathology laboratories, as well as most specialists able to use standard messaging to communicate with each other. This issue brief describes New Zealand's primary health care system, discusses its successes and challenges in adopting and promoting health IT, and draws lessons for the United States. Citation D. Protti and T. Bowden, Electronic Medical Record Adoption in New Zealand Primary Care Physician Offices, The Commonwealth Fund, August 2010. Link(Accessed September, 2012)

    • The second is a white paper from the NZ Government in 2012.

Better Information for Better Care – New Zealand’s Approach to Efficient and Affordable Healthcare White Paper APRIL 2012 You can download the report from this link (Accessed September, 2012) Review of these two papers will provide a clear understanding of the paths NZ is following and the success they are having with a very much ‘bottom up’ strategic approach. Current events can be monitored by occasional reference to this blog which is written by the CEO of the Secure Messaging Provider for the NZ Health Sector. (Accessed September, 2012) The key lesson I hope students take away from reading about all three programs is that success is possible but that it really seems to take time, planning, leadership and commitment.

  • We now highlight two really inglorious Programs from which there are many lessons to be learnt.

These well-known highly problematic attempts and at Health ICT implementation include:

The UK National Program for Health IT (NPfIT)

The UK National Program for Health IT is often seen as the poster boy for what can go wrong and be badly managed in large scale national Health IT programs. Much has been written about this program and I believe it would be fair to say that there has been rather too much concentration on the problems with the program and not enough on the fairly considerable successes that have been achieved.

  • The following is a brief summary of the early years of the Program:

In 1998 a key strategy document on the use of information technology in the NHS was published by the NHS Executive. It was entitled “Information for Health - An Information Strategy for the Modern NHS 1998 – 2005 - A national strategy for local implementation as Health” and it had been written by Frank Burns, Head of IM&T for the NHS, NHS Executive. Critically just before the release of this document support for the general directions being recommended came from the very top. To quote: “The challenge for the NHS is to harness the information revolution, and use it to benefit patients.” Rt. Hon. Tony Blair, All Our Tomorrows Conference, Earls Court, London. 2nd July 1998. The last paragraph of the introduction to the strategy, written by the then UK Secretary of State of Health, Frank Dobson, is quite clear eyed about the challenge that was faced and the hoped for outcome. “The details of this strategy are complex but the overall position is simple. We must grasp the opportunity which new information technology offers to improve both health care and health. All NHS organisations will have to play their part in delivering this key component in our programme to modernise and improve the NHS. Senior clinicians and managers throughout the NHS and senior members of professional bodies will have to show leadership and commitment. There are formidable educational, cultural and management challenges to overcome. But they are more than matched by the scale of the benefits the success of this strategy will bring for patients, professionals and the public.” The strategy committed (over a seven year period to 2005) to the following objectives.

  • Lifelong electronic health records for every person in the country.
  • Round-the-clock on-line access to patient records and information about best clinical practice, for all NHS clinicians.
  • Genuinely seamless care for patients through GPs, hospitals and community services sharing information across the NHS information highway.
  • Fast and convenient public access to information and care through on-line information services and telemedicine
  • The effective use of NHS resources by providing health planners and managers with the information they need.

The purpose of the strategy was made quite clear in the document. “The information strategy is to put in place over the next seven years the people, the resources, the culture and the processes necessary to ensure that NHS clinicians and managers have the information needed to support the core purpose of the NHS, in caring for individuals and improving public health.” The strategy documents from that period are still available here (Accessed September, 2012) As is clear from the sub-title of the original “Information for Health” strategy it was intended that there would be local implementation of the necessary systems in the health service delivery organisations using additional funds provided from the central Health Department. By late in 2000 it was clear that while the Year 2000 bug had been successfully managed, there had not been the level of progress desired, especially in the area of information sharing. This was due, in at least a considerable part, to the ‘bleeding off’ of funds intended to Health IT to other purposes.

  • In response to developments both internal and external to the NHS, an update to Information for Health – entitled “Building the Information Core” – was issued in December 2000 to reflect the changing NHS priorities as set out in the NHS Plan, as well as a new e-government strategy.

This document is available here (Accessed September, 2012) In early to mid 2002 it was becoming clear that things were not going according to plan and that it was unlikely the 2005 goals would be met. Professor Denis Protti was writing – having been asked to conduct a review during mid to late 2001 – the following: “One of the many observations I made this year was the apparent shift from the primary intent of Information for Heath in supporting day-to-day clinical practice to one of collecting data for retrospective analysis such as clinical governance. The original intent of Information for Heath was akin to providing parents and their children with the means to make their lives more productive and satisfying. The apparent shift in priorities seems aimed at providing friends, counsellors, and government agencies with information that they can use to help parents and children understand their state of affairs and behaviours. Both sets of communities have important needs; the challenge is deciding which ones to concentrate on given the political realities of the day. The current state of affairs has a comparable, and uncomfortable, feel to when the 1992 IM&T agenda was ‘hijacked’ by a political imperative to move to an internal market and establish systems to manage competition and contracts. It was most disconcerting to learn that 70% of the hypothecated funds intended for investment in IM&T in the 2001/2 national allocations were diverted to other purposes. If this problem persists in 2002/3 the NHS will fail to deliver key Information for Health objectives, particularly the development of electronic records, and this will undermine the clinical modernisation agenda in the NHS Plan. If it happens again, Information for Health will be irrelevant.” Along with these findings Professor Protti also identified that there had been little progress in resolving some contentious issues (such as consent) and with gathering effective learning and experience from the range of project undertaken under the Electronic Records Development and Implementation Programme (ERDIP).

  • Progress was then made in ‘fits and starts’ and a range of organisational, technical and managerial issues eventually culminated in further reviews and discussion - with the scale of the expenditure for no obvious outcome moving into the political domain.

The saga from this period (2006 on) is documented here with a huge range of links to audits and other documents. http://www.editthis.info/nhs_it_info/Main_Page (Accessed September, 2012)

  • The last year or two has seen a few things happen. First we have had some very useful reviews of the program from the perspective of the whole effort being reshaped by the incoming Coalition Government.

Two especially useful documents are the following in this context.

    • Greenhalgh, Trisha, Morris, Libby M. M., Wyatt, Jeremy C. and Thomas, Gwyn (2012) Lessons learned from implementation of nationally shared electronic patient records in England, Scotland, Wales and Northern Ireland. The Health Service Journal . pp. 28-37. ISSN 0952-2271

Abstract Electronic access to a summary of key details from a patient’s medical record from wherever they are being treated is a goal of many health systems. England, Scotland and Wales addressed this by developing the Summary Care Record, Emergency Care Summary and Individual Health Record respectively; Northern Ireland adopted Scotland’s technology. Whilst all four schemes shared a similar vision, they differed widely in their strategy, budget, implementation plan, approach to clinical and public engagement and approach to evaluation and learning. We compare the four countries’ experiences and draw lessons from the mixed fortunes of these programmes to date. This document is found here (Accessed September, 2012).

    • The second is Trisha Greenhalgh, Jill Russell, Richard E. Ashcroft, Wayne Parsons. (2012)

Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History. DOI: 10.1111/j.1468-0009.2011.00642.x Abstract: Context: Policymakers seeking to introduce expensive national eHealth programs would be advised to study lessons from elsewhere. But these lessons are unclear, partly because a paradigm war (controlled experiment versus interpretive case study) is raging. England's $20.6 billion National Programme for Information Technology (NPfIT) ran from 2003 to 2010, but its overall success was limited. Although case study evaluations were published, policymakers appeared to overlook many of their recommendations and persisted with some of the NPfIT's most criticized components and implementation methods. Methods: In this reflective analysis, illustrated by a case fragment from the NPfIT, we apply ideas from Ludwig Wittgenstein's postanalytic philosophy to justify the place of the “n of 1” case study and consider why those in charge of national eHealth programs appear reluctant to learn from such studies. Findings: National eHealth programs unfold as they do partly because no one fully understands what is going on. They fail when this lack of understanding becomes critical to the programs’ mission. Detailed analyses of the fortunes of individual programs, articulated in such a way as to illuminate the contextualized talk and action (“language games”) of multiple stakeholders, offer unique and important insights. Such accounts, portrayals rather than models, deliver neither statistical generalization (as with experiments) nor theoretical generalization (as with multisite case comparisons or realist evaluations). But they do provide the facility for heuristic generalization (i.e., to achieve a clearer understanding of what is going on), thereby enabling more productive debate about eHealth programs’ complex, interdependent social practices. A national eHealth program is best conceptualized not as a blueprint and implementation plan for a state-of-the-art technical system but as a series of overlapping, conflicting, and mutually misunderstood language games that combine to produce a situation of ambiguity, paradox, incompleteness, and confusion. But going beyond technical “solutions” and engaging with these language games would clash with the bounded rationality that policymakers typically employ to make their eHealth programs manageable. This may explain their limited and contained response to the nuanced messages of in-depth case study reports. Conclusion: The complexity of contemporary health care, combined with the multiple stakeholders in large technology initiatives, means that national eHealth programs require considerably more thinking through than has sometimes occurred. We need fewer grand plans and more learning communities. The onus, therefore, is on academics to develop ways of drawing judiciously on the richness of case studies to inform and influence eHealth policy, which necessarily occurs in a simplified decision environment. This is found here (Accessed September, 2012)

  • Both these articles provide a view that is both useful to assist in understanding what happened in the UK and also provide some pertinent warnings regarding Australia.

Second it has been realised that, although expensive, there have been some major outcomes and benefits achieved - albeit not in the timeframe hoped for. The current situation is that - among other things:

  • General Practice is virtually fully automated with high quality systems.
  • National Applications such as Choose and Book (Specialist Appointments), e-prescribing, electronic medical record transfer between practices and a national health identifier are in place.
  • There is in place a National Picture Archive Communications System.
  • Most hospital have basic computing infrastructure with investment in that area continuing in a less restrictive way.
  • There is a reasonably wide Health Information Standards infrastructure in place.
  • The centralised Shared Care Record (SCR) which was one of the most difficult parts of the program to implement is increasingly being used and adopted.

This article documents recent progress: Put another record on Rebecca Todd speaks to Dr Charles Gutteridge, the national clinical director for informatics at the Department of Health, about progress on the Summary Care Record project. 20 September 2012 After a slow, then steady, then stop, then start again beginning, the Summary Care Record programme is on track to reach 40m people by early 2014 and the whole population soon after. More than one third of the population now has an SCR, which contains basic demographic details about them along with allergies, current medications and adverse reactions. The record is uploaded and automatically updated from a GP practice system to the national data Spine, and the summary information is available at any site with the application needed to view the records. The justification for the project has always been that a patient who gets sick or who has an accident outside their local area can go to an out-of-hours provider and staff will have some information about them. However, the chances of that holiday-maker having an SCR - or their receiving hospital or out-of-hours surgery being able to see it - are still fairly slim, as uptake varies across the country. While Bury and Darlington have reached 100% coverage, some areas such as Hampshire have not started deploying SCRs at all (the county has its own shared record project). The full article is found here (Accessed September, 2012). So it is clear progress is being made and investment continues despite the change of Government. I suspect in five years we may look back and conclude that ‘yes it was slow and expensive, but they have pretty much got to where they hoped to be’! There is no doubt this saga has a lot to teach and needs to be studied closely.

The Victorian HealthSMART Program

The HealthSMART Program was announced in 2003 as an total revamp of Health IT in the State of Victoria’s public health system. The estimated cost was of the order of $320 million over an initially planned 4-5 years. Fortunately for those interested in the saga that then followed the program web site is still available for review. See here (Accessed September, 2012).

  • Some five years later it became clear things were not going quite as planned. The following report in the Age in 2008 summarised the then situation.

Health upgrade gets poor diagnosis Nick Miller April 17, 2008 THE State Government is grappling with another multimillion-dollar computer fiasco, this time involving a major upgrade of health technology systems. Weeks after a scathing report on the introduction of the myki public transport ticket system, Auditor-General Des Pearson has raised concerns about the progress of the $323 million HealthSMART project. HealthSMART was announced in 2003 to overhaul mismatched technology running the state's health system and introduce new systems such as electronic prescriptions to improve patient care and combat fraud. But Mr Pearson, in a report released yesterday, said the original targets were overambitious, it was already two years behind its intended 2007 completion date and likely to slip further. The report also found the program was already $34.8 million over budget and would need an extra $61 million in running costs, although the Government and Health Department dispute the first figure. The worst-performing part of HealthSMART was a $96 million "clinical systems" plan to computerise prescriptions and diagnostic services. The report found that of 10 agencies that could use the system, only four planned to do so, and none would likely meet the June 2009 deadline. More here (Accessed September, 2012). The audit report - which is crucial reading can be found here (Accessed September, 2012). A bad sign at around the same time was the resignation of the Director of the program as reported here (Accessed September, 2012).

  • A later report on the procurement functions of the system blamed the HealthSMART systems for many of the issues associated with cost over-runs.

This report is found here (Accessed September, 2012). With the election of a new State Government the new Health Minister reviewed and ultimately cancelled the program. Here is a report of the final outcome: Vic scraps HealthSMART system By AAP, and Luke Hopewell, ZDNet.com.au on May 18th, 2012 The Victorian Government has made the decision to scrap its HealthSMART system, which was years overdue and had run hundreds of millions of dollars over budget. HealthSMART was launched in 2003 and had been designed to run as a single electronic foundation for the state's public health service. The single platform would combine a finance system, as well as patient-management and clinical-applications services. However, Health Minister David Davis today confirmed that the government had scrapped the continuation of the roll-out of HealthSMART, with the government to now work on a hospital-by-hospital basis, to set up individualised systems. Davis said the government is determined not to "throw more good money, after bad" and would set up an expert panel to advise it on the best way to upgrade the hospital information and communication technology (ICT) systems. "In those hospitals where it has been put in place or partially put in place, health services will make their decisions from that position, but going forward, beyond that, health services will be able to examine what is appropriate for their particular service," he said. The new ICT projects would be payed for through the $100 million innovation fund, allocated in this month's Budget. The road to the system's cancellation is one littered with blowouts and delays; $323 million was originally budgeted for the system and a deadline for completion was set for the end of 2007. More here (Accessed September, 2012) What can be learned from all this. Having watched this program since its inception it seems to me the major problem that was encountered related to clinician resistance to selection and the tailoring by committee of key clinical applications which left many people in many institutions frustrated and annoyed. It is a fundamental critical success factor with clinical system implementation that clinician by-in and support is obtained. If this is not present, and local needs are not responded to, the risk of project failure is very high.

The Background to and Present State of Health ICT In Australia

Review Questions

  • What are the three top reasons managers in the health sector need to understand the potential of and difficulties associated with Health ICT?
  • What do you feel are the attributes of successful Health ICT projects and what outcomes would you be seeking from such projects?
  • What do you see as the top three things you would like to learn about ICT having read and considered the first section?

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