Consumers

Consumers make decisions about when and whom to consult in the health system. This can be dependent on the information available to them, although sometimes consumers are not in a position to make choices due to their injury or illness. Consumers also need information about their treatment, prognosis and ongoing management, particularly when managing a chronic condition. Consumers are also being encouraged to participate in the health care system and the way that it operates. To do this consumers need information for example about the safety and quality of the health care services being delivered. See Chapter 5 for further information about consumer participation in health care.

Direct caregivers

Direct caregivers need to determine what tests to conduct, therapies to prescribe, procedures to perform or to whom the patient should be referred for a second opinion or additional care. The next level of decision-making for this group involves a decision about when to deliver care, where it should be delivered and which material and labour resources should be used. This is where the treating health care professional interacts with other direct and indirect caregivers. Such interactions determine what information needs to be communicated to whom and when. Direct caregivers also need information about the quality and outcomes of the treatments they have delivered. Providing this type of information in formats that are readily accessible, timely and understandable is increasingly important in health care organisations. A national framework for clinical information capture, storage, representation and use to underpin electronic health information interchange and to facilitate interoperability of clinical information across the Australian health system is now under development (Clinical Information Program 2004).

Health service managers

Health service managers are concerned with:

the financial management of their organisations;

managing organisational change and renewal;

performance management and improvement;

organisational aspects such as procedure scheduling;

material and labour resource procurement and allocation;

rostering;

the policies and procedures to be followed to ensure that the processes of care delivery are well organised and delivered on time;

the use of the most appropriate resources to achieve the desired outcomes of the organisation — importantly, that these outcomes have been delivered in a way that ensures the safety and quality of those who interact with the health care organisation (including staff and patients);

establishing the physical environment within which services are provided; and

meeting reporting requirements to third parties such as payers, governments and registration authorities.

Consequently, health service managers need information to support them in their management of these areas.

Government health administrators

Government health administrators are concerned with resource allocation and the distribution and delivery of health care services to defined populations. They make decisions about how available resources are best distributed to meet competing demands. Information about demographic characteristics, health service utilisation, patterns of disease, and costs form the basis of the information requirements of government health administrators. At this level it is also important to have information to assess the performance of the health system and to assess the factors that impact upon health status and outcomes. Increasingly agreement is being sought on the type of data items that need to be reported in order to assess health system performance, particularly in relation to the safety and quality of health care services. Health information is also used as an integral part of the policy-making function of health care organisations.

Researchers

Researchers are concerned with answering questions and solving problems and need information to support their arguments. Research results also need to be disseminated so that work practices may change to achieve better results. This includes the collection and dissemination of evidence on processes and outcomes of clinical and/or managerial practices. There is a tendency for research to focus on the generation of new knowledge, and as a consequence the role and contribution of existing knowledge tends to be neglected (WHO 2004, p 40).

This overview of the decisions made by stakeholders serves to demonstrate the many and varied decisions made every day within health care organisations. Each has a need for data, information and knowledge. The assumption is that better and timelier information will lead to improved decision-making. This should result in more efficient and effective health services. Health information and knowledge constitute one of the industry’s greatest assets enhanced through the use of appropriate information and knowledge management systems. Such systems can only be developed and implemented when the stakeholders and the users of information and knowledge have a sound understanding of their data requirements.

‘Business case’ development

In order to acquire an information system, a health care organisation will usually develop a business case. A business case is the formal document that is prepared to persuade management of the financial rationale for an information system and to secure funding for it. A business case is a comprehensive document that outlines the purpose, scope, costs and benefits of acquiring the information system.

Business case formats will vary from organisation to organisation, but typically a business case will require you to collect information about the cost of the system, the human and physical resources required, the purpose of the system and how it fits within the corporate goals and objectives of the organisation. Appendix 10.1 presents a sample business case.

Resource allocation

The health industry tends to be a slow adopter of IT and invests less than other sectors. It could be expected with its requirement for knowledge and information and its educated workforce that the health industry would be a rapid adopter of IT applications (England et al 2000, p 176). Operational systems aimed at cost reduction, such as accounting and payroll, have been most widely adopted while strategic systems such as the electronic health record remain in development. This is due in part to the complexity of health care organisations and difficulties in measuring IT benefits (England et al 2000, p 183).

Health care organisations need to balance many competing priorities, and the allocation of resources to areas such as IT can be contentious. Resources may need to be assigned to maintain IT infrastructure and to implement new information systems. Health service managers participating in the development of budgets will need to consider making allocations of resources to IT and information systems.

Implementing information systems

Management of information systems, or, more precisely, realising the benefits of information systems for an organisation, is an important part of the job of managers. Often information systems are ‘sold’ by vendors as the panacea for fixing myriad problems that they clearly will not be able to fix. Information systems ‘add value’ to an organisation only where they are used to support and help an organisation to realise its business goals. It is also crucial for health service managers to remember that an information system is only a computer that processes, stores and analyses data. In the past many information systems have merely automated the poor manual systems, work practices, procedures and processes that existed within the organisation. As a consequence, promised benefits have not been reaped.

An important stage in the acquisition of an information system is the detailed specification of user requirements and needs as defined by the anticipated users for the information system. This document forms the basis of a proposal (sometimes referred to as a request for proposal, or RFP) document and tender specifications that are then used in the process of evaluation and selection of information systems.

After an organisation has decided to acquire a system based on the preparation and submission of a business case, there are a number of approaches that can be taken. These include:

build or develop an ‘in-house’ information system;

modify an existing information system;

purchase ‘off-the-shelf’ software; and

purchase of ‘bundled’ hardware and software; that is, a ‘total information system solution’.

Request for proposal (RFP) documents

Regardless of which option an organisation selects to acquire an information system, usually a request for proposal (RFP) document will be prepared. The RFP allows the organisation to explain its needs to potential information system suppliers. The RFP may be distributed to potential vendors or an advertisement may be placed stating that the organisation is calling for proposals for a system. Once responses to an RFP are received the organisation will undertake an evaluation of them to determine which vendors meet the organisation’s requirements and how well. Usually, during the evaluation phase the following will occur:

each requirement and the supplier’s response will be examined and scored for degree of fit to the specification;

the reputation and reliability of the supplier will be examined;

the supplier will be asked to perform a demonstration of the system to assess flexibility and ease of use;

the organisation will carefully review contracts and ensure that all items are covered in clear language for hardware, software, training, maintenance, upgrades and implementation;

hardware capacity and performance will be reviewed;

software performance will be examined and verified;

system adherence to accepted standards and connectivity issues will be examined;

vendor support and services will be determined and references checked;

cost will be thoroughly considered and what is included and what is not included will be discussed with the supplier;

the ability of the vendor to meet delivery date will be determined;

an examination of the documentation for the system and its users will be undertaken;

configuration flexibility and expansion capability will be evaluated; and

compatibility with the organisation’s present computer system (if one exists) will be explored.

During the evaluation process a scoring method, such as a weighted score technique, can be used. In a weighted score technique the specified requirements or criteria for the information system — such as ease of use, type of functionality, expandability, maintenance and support — are ranked. For example, ease of use may be the most important requirement and be given a score of 10 (important) and support a rank of 1 (not very important). Using the weighted score technique a mark for each supplier would be given for each functional requirement and these scores then multiplied by the weighting, giving a weighted score.

Project management

When implementing information systems it is important that a project management methodology is used. This will help to ensure that the system is implemented within scope, budgetary and time constraints. A detailed project plan is usually developed and should include a number of items, including:

project description and objectives;

project scope;

project schedule;

project budget and resource schedule;

stakeholder identification; and

Gantt chart to show the expected time frame for the scheduling and completion of key activities.

A project manager is usually given the responsibility to ensure that the information systems project delivers what is expected. This involves change management as well as the technical aspects of the implementation. Project management techniques and tools are used to facilitate the completion of the project. These tools also help to ensure that the scope of the project is managed. ‘Scope creep’ is a major cause of information system project delay and/or failure.

Successful health care information systems

Many health care information system implementations have failed either partially or totally. Failed systems include those that have been abandoned, are grossly over budget or those that are not used as intended. The implementation failure rate of IT systems is estimated to be as high as 70 per cent, costing billions of dollars annually! Failures are more common where there has been an emphasis on the technical aspects of information system development and where social and organisational factors are overlooked. Successful system implementation requires a balance between all of these factors. Organisational issues of structure, culture, power, politics, control, leadership, commitment, communication, training and resistance are likely to be of critical importance to the ultimate success or failure of a system as well as more technical and managerial issues (Markus 1983, Sobol et al 1999, Southon et al 1999). Underlying assumptions, work flow and work practice expectations and viewpoints of users and other stakeholders contribute to the success or failure of health information systems. It is imperative that IT systems meet the users’ needs and fit with behavioural health care realities. The involvement of users at all stages of the process of information system acquisition and implementation is needed to achieve this imperative — that is a good fit and complementary to acceptable work practices.

Frequently decisions about IT system purchases are made by those who do not have a comprehensive understanding of what users need, so they are not in a position to evaluate systems prior to purchase. The bigger the gap, the greater the likelihood of failure (Heeks et al 1999). A further complication is that users are often inexperienced in defining and articulating their data requirements to information specialists. Users can also over specify and change their requirements, leading to difficulties in system development and implementation. It is important that a balance is obtained to manage the cost of information system implementations while still enabling the required information to be collected.

Users need to work closely with information technology specialists and to have their input considered during the information system analysis, design, development and implementation phases. The implementation of health information systems requires behavioural and cultural changes in order to achieve greater efficiency and other desired benefits. These changes are ongoing as staff become familiar with what such systems have to offer. New information, previously requiring time-consuming and laborious study, is now more accessible. This requires a sound knowledge of the data that reside in the system, the types of decisions being made by various people, the information needed to enhance decision-making, and skill in organising and analysing the available data to produce such information when required.

It has become clear that ignoring the sometimes irrational and non-technical organisational and people issues greatly adds to the risk of failure of any project (Lorenzi et al 1997, Sauer 1993). Systems that are successful in one organisation are not necessarily successful in others, even though the organisations have similar roles and functions. This is because organisational structures, cultures and work practices influence day-to-day realities. Work practices in the health sector vary not only because of differences in philosophies underpinning practice, organisational structures and cultures but also because of variations in physical surroundings, locations of supplies and access to additional services needed to provide the health service. According to Plummer (2004), four of the best success factors for the implementation of information systems include:

organisational leadership and commitment;

the establishment of an appropriate coordinating body or mechanism;

adoption of participatory approaches to information system development; and

an iterative approach to development.