Capital and Coast District Health Board Information Services Strategic Plan 2002 - 2005
Written by: Darren Douglass, Manager Information Services
Table of Contents
1. Executive Summary
Background
The Information Services Strategic Plan (ISSP) presents the strategic vision for the Information Services department at Capital and Coast District Health Board (C and CDHB) for the period 2002-2005. The Information Services department is part of the Directorate of Information Management and Planning (DIMP). It is responsible for providing information systems, information technology and information management leadership, consultancy and solutions across the District Health Board. This encompasses both the business and clinical needs of healthcare providers (primary, secondary and tertiary) and the business needs of healthcare purchasers and funders.
The sponsor of the Information Services Strategic Plan is the Director of Information Planning and Management and the customers of the Information Services Strategic Plan are the stakeholders of the District Health Board. All information management and information technology projects within Capital and Coast District Health Board will need to take account of the Information Services Strategic Plan when considering and selecting information management and information technology solutions.
Vision and Objectives
Our vision is to enable seamless health-care through the provision of business solutions that support the provision of exemplary health-care.
The objectives of this plan are to:
Business Initiatives
The Information Services Strategic Plan was developed to support other District Health Board and sector strategic plans. The following common themes are apparent in these documents:
Information Services Principles
From the known business initiatives, we can visualize what the information systems will need to look like, what characteristics they will need to exhibit and what functionality and information they will need to provide to support the business. The following principles have been identified:
The principles of this Information Services Strategic Plan provide ways of reducing ongoing costs with limited capital investment. All projects undertaken to achieve the stated principles must themselves be independently cost-justified before they begin.
Strategic Goals
The specific goals that will enable the District Health Board's vision include:
Introduction
Purpose
The Information Services Strategic Plan (Information Services Strategic Plan) presents the strategic vision and proposed way forward for the Information Services department at Capital and Coast District Health Board (Capital and Coast District Health Board) for the period 2002-2005.
The Information Services department is part of the Directorate of Information Management and Planning (DIMP). It is responsible for providing information systems, information technology and information management leadership, consultancy and solutions across the District Health Board. This encompasses both the business and clinical needs of healthcare providers (primary, secondary and tertiary) and the business needs of healthcare purchasers and funders.
The Information Services Strategic Plan builds on work carried out in 1994 that resulted in the first Information Systems Strategic Plan for Capital Coast Health. That plan was last revised in July 2000, and similarly this plan is intended to evolve with Capital and Coast District Health Board as its business needs change during this period. It supports, and should be read in conjunction with the Capital and Coast District Health Board Strategic Plan for Information Management and Planning (IM and P) 2001-2005.
At the time of writing, the Capital and Coast District Health Board Strategic Plan, "A Picture Of Health", and the Capital and Coast District Health Board Strategic Plan for IM and P are complete but the Hospital Services Development Plan is not. The Information Services Strategic Plan will need to be reviewed on a regular basis to ensure alignment with these plans is maintained.
Audience
The following groups of people are the target audience (the stakeholders) for this Information Services Strategic Plan:
Usage and Ownership of the Information Services Strategic Plan
The Information Services Strategic Plan is a corporate document that is owned by the organization as a whole. The sponsor of the Information Services Strategic Plan is the Director of Information Management and Planning and the customers of the Information Services Strategic Plan are all the stakeholders of the District Health Board.
It is a business plan for the use of information and the management of information systems, not an internal plan for the Information Services Department. Any District Health Board stakeholder contemplating or progressing new information systems or planning for the future of systems should take this plan into account.
Terms of Reference
Our vision: We enable seamless health-care through the provision of business solutions that support the provision of exemplary health-care.
Our goals:
Our values:
Our mission/objectives:
Objectives of this plan:
Scope of this plan:
Includes
Excludes
Some or all of the actions listed as exclusions should be carried out in projects that flow from this Information Services Strategic Plan.
Where We Want To Be - Target Environment
In order to determine where we want to be we need to understand the strategic vision of the business. District Health Board and sector strategic plans were evaluated to identify the key themes/initiatives that would most influence Capital and Coast District Health Board information systems requirements.
These included:
Capital and Coast District Health Board Strategic Plan 2000-2005
The Capital and Coast District Health Board Vision is Seamless Health Care. This means the patient/client receives "the right services, delivered by the right people in the right place at the right time with the right tools."
The key strategic initiatives relevant to Information Services are:
Capital and Coast District Health Board Strategic Plan for Information Management and Planning 2001-2005
This plan underpins the Capital and Coast District Health Board Strategic Plan. It highlights the environmental trends affecting the public health sector, the opportunities presented by the District Health Board structure and the issues that need to be addressed if the objectives of the plan are to be achieved. The key themes in the plan that are relevant to Information Services are:
The Capital and Coast District Health Board Strategic Plan for IM and P defines the role of the Directorate of Information Management and Planning (and therefore of Information Services) as "to provide an effective, focussed support infrastructure that enables health providers to achieve business outcomes."
From Strategy to Reality: The WAVE Project
The WAVE (Working to Add Value through E-information) recommendations plan to improve health outcomes through effective use of health information at the least cost to the sector.
The sector's primary goal was identified by the project as the integration of health information systems. Ten top priorities were established, of which the following have been considered in this plan:
A number of the objectives and priorities relate directly to this Information Services Strategic Plan, and are referenced where appropriate.
Key Business Initiatives
The following themes are common to the District Health Board and sector plans evaluated and form the basis on which this plan is structured.
Seamless care
Seamless Care is a system of care, starting with the primary provider and continuing through secondary and tertiary systems, which is perceived by the patient/client as a continuum, and not one where there are artificial barriers between one provider and the next. The implication for our information systems is that they must provide access to all relevant patient/client information whenever and wherever it is required.
Patient focussed models of care
A patient focussed model of care is a system of health care delivery that is explicitly focussed on the needs/welfare/expectations of each patient.
For example, provision of prompt, high quality assessment and treatment which is sensitive to individual patient circumstances requires:
Such high quality healthcare delivery is only possible if the health professional involved is well and fully informed about each patient. This is only possible if access is provided to the pertinent, current patient record at point-of-care.
More timely access for patients and other stakeholders
The development of seamless care processes is dependant on introducing systems and processes which make it easier for patients and other stakeholders to access services and information in a timely fashion. The Strategic Plan for IM and P identifies one of the key ways that information, knowledge and technology enable the effective provision of health-care as "providing clinical information to patients and care-givers at point of care". To do that we need to:
Improved processes
Providers need the right information to interpret, develop and measure approaches for seamless care delivery. This means developing information management strategies that ensure alignment of technology strategies with business requirements and empowers stakeholders by providing them with timely access to accurate business and health information.
Using Financial Resources Wisely
As a District Health Board we will be funded by the Ministry of Health and other organizations (eg. ACC, other District Health Board's) to provide health services. In those funding agreements will be clear, measurable performance indicators. To achieve financial viability we must deliver only those services we are contracted to deliver, to the contracted volume and in accordance with the performance indicators. A key part of enabling delivery to contract, is provision of accurate and timely contract monitoring and activity information to inform the contract management and production cycles. This is heavily dependent on information systems and processes which are themselves timely and accurate.
In performing to contract, we can ensure that we are managing the Crown's investment in us effectively and efficiently getting the greatest possible return on their investment in health outcomes for our stakeholders.
It is also highlighted in the Strategic Plan for IM and P that information systems and technology costs at Capital and Coast District Health Board have risen in the past 5 years from approximately 5 million dollars per annum to around 12 million dollars per annum. In an environment of continued reductions in public funding, Information Services must pro-actively look for ways to deliver cost-effective solutions as well as targeting reductions in the cost of applications ownership.
Information Services Principles
Now that we have a view of the business future, we can visualize what the information systems will need to look like, what characteristics they will need to exhibit and what functionality and information they will need to provide, to support that business future. The following principles have been identified:
System Integration
Integration is defined as "making whole regardless of source". Technically, systems integration can be characterized in two ways:
Current Situation
Our current systems have at times been described as integrated however they do not consistently display either of the above characteristics in their entirety. The key factors preventing integration at present are:
Vision
The Strategic Plan for IM and P recognizes that "the infrastructure, including the number of operating systems and applications being run must be rationalized". WAVE also stated that the sector's primary goal must be the integration of health information systems and a number of the project's recommendations are intended to enable integration through implementation of standards.
Systems integration at Capital and Coast District Health Board will be achieved by:
Integration of systems supports the business initiatives identified by providing an integrated view of all Capital and Coast District Health Board data through an interface that can be accessed by all authorized users (health providers, purchasers and patients) regardless of geographic location. It is closely aligned with the priorities identified by WAVE with regard to the implementation of a National Provider Index, and fixing problems with the NHI.
It will reduce costs overall by removing the expense and inefficiency associated with supporting multiple systems and technologies and removing the inefficiencies inherent in maintaining multiple copies, often manually, of the same data. This cost reduction requires no single major capital investment; instead it is a consistent approach to system development and replacement each of which will need to be independently cost-justified.
Strategic Goals
All information available where required by authorized users
The business vision of seamless care requires access to all information at the time and place that the user requires, where the user may or may not be located on the District Health Board owned network. The only feasible solution available to Capital and Coast District Health Board is to provide access to information across the internet through a web browser.
Current Situation
The Clinical Record is the only application at Capital and Coast District Health Board that currently utilizes a web browser to provide access to patient/client data.
Vision
This requirement can only be met through integrated systems that can provide the user with an application that retrieves patient and enterprise data from source systems and presents it to the user in a consistent fashion. The Strategic Plan for IM and P clearly identifies a key goal to be a computing environment that is accessible from anywhere, is intuitive to use and is pertinent to the user. The initiative of more timely access to services will also mean an increase in health services delivered in the community rather than a hospital setting and in the demand for access to information from points outside of the District Health Board owned network. The Electronic Health Record cannot be reliant on a dedicated hospital network as access will be required in a diverse range of settings both inside and outside of the hospital environment.
Utilising a web browser and internet technology to access patient and enterprise data eliminates the reliance on a client application and a fast network to provide access to patient data. It will enable access in any place where an internet connection can be established and eliminates the costs associated with the implementation, support and maintenance of client software. The impact of this strategic principle is improved service without increased operational costs.
Technology advances such as tablet PC's and wireless networks will also provide another platform for browser access to data, making "any time and any place" a reality.
Strategic Goals
System Availability
As our reliance on information and the electronic delivery of information grows, the availability of that information will become critical. The Strategic Plan for IM and P defines the requirement as 24 hour per day, 7 day a week availability.
Current Situation
The requirement for high availability is not met by our current systems. Most systems, with few exceptions, require daily scheduled outages for backup or dayend processing purposes and in some cases additional monthly scheduled outages of multiple hours are required.
While the systems are relatively stable with very few unplanned outages, unplanned "functional" outages, such as an interface being down for a period, are experienced. This can impact on the availability of some specialist data in the Electronic Health Record such as Radiology or Laboratory results and this deficiency fails to fully support the seamless care paradigm.
While technical configuration approaches will allow us to address some of the availability issues with the current systems, it will not address the inherent limitations of the need for system outages for dayend processing. Accordingly, those systems requiring dayend processing such as Allegra are incapable of meeting this requirement.
Vision
The new seamless care paradigm means that health care can be delivered at any time and conceivably from a number of different geographic locations. It cannot be assumed that the need to access patient data can always be planned (for example a visit to the Emergency department is, by definition, unplanned). It also cannot be assumed that the patient record will only be needed in one place at any one time, or only at predefined times of the day (for example a clinician in Australia may wish to discuss a patient's radio therapy with a clinician in New Zealand).
In this setting, the Electronic Health Record is a mission critical system and high availability must be assured. The technology is available to ensure any required level of availability, but the higher the availability, the higher the cost. The Electronic Health Record, and its feeder systems, must have an availability of 99.999% or better while other systems may be mission critical but only at specific times, for example 8am to 5pm, NZ time.
The cost associated with ensuring a high level of availability can be significant, for example if full redundancy is implemented. All expenditure in this area must be independently cost-justified on a system by system basis, however as a general principle the selection of software systems that are inherently capable of high levels of availability carries little or no additional cost.
Strategic Goals
Capturing data only once at source
Capturing data only once at source is a key characteristic of an integrated system and is critical for our future systems as it improves the accuracy, quality and timeliness of the data. There are two aspects to this requirement; the ability of systems to be the single source for appropriate data and provide this data to other systems as required (ie. integration), and the ability of systems to be available at point of care.
Current Situation
Our current systems are not integrated and data replication is common. For example, there is no single source of provider data across District Health Board systems and provider demographics are manually entered into multiple systems even with the Hospital and Health Service. Analysis of the core systems with the Hospital and Health Service such as Allegra, RMS, Détente and the Capital and Coast District Health Board Intranet has shown that data for a single provider is frequently different between the systems and there is no common key that can be used to reliably identify a provider record in different systems.
The technology platform used by some applications preclude them from being developed to be the source of common patient or enterprise data. The ability of current Hospital and Health Service systems to be made available at point of care also varies, but overall they do not support this requirement well.
Vision
To fully support the vision of seamless care, patient data must not only be available in any place at any time it must also be accurate. Capturing data only once at source is a key characteristic of an integrated system and is critical for our future systems as it improves the accuracy, quality and timeliness of the data.
Also, the capture of patient/client data will not be confined to the Health and Hospital Service but spread across multiple health care providers and undertaken at point of care. Accurate data capture can only be achieved if it happens at source and once again the most effective way of achieving this is through an integrated system utilising browser technology. Technology advances such as tablet PC's and wireless will provide the platform for data capture "any time and any place".
Data capture at source reduces operating costs with little or no capital investment as it is more efficient in terms of resource utilisation and simplifies data quality audit processes.
Strategic Goals
Identify data used commonly through the continuum of care that is not captured at source and implement solutions that enable this to be done.
Data validation at source
Intelligent validation of data at source is a key strategy for ensuring that data is both accurate and in a form that is most effective for clinical and business use.
Current Situation
The level of data validation in current Hospital and Health Service systems is poor, however most of these systems could be modified to add some level of validation. The main constraint is the unintegrated nature of Hospital and Health Service systems as discussed previously; efficient data validation at source is only achievable with integrated systems.
Vision
To fully support the vision of seamless care, patient data must not only be available in any place at any time it must also be accurate and useable. Intelligent validation of data at source is a key strategy for ensuring that data is both accurate and in a form that is most effective for clinical and business use. Data quality is a theme throughout the Health Information and Technology Plan.
In most instances data entry can be validated against known business rules to ensure that it is accurate and effective. For example, the source of a referral can be validated against a pre-defined list when entered into the system to ensure that it is being captured accurately; analysis of hospital or specialist referral trends over time, by type, is then possible based on the finite list of possible referral sources. This is in contrast to invalidated free text entry which cannot be reliably used for anything other than information on the individual patient/client record.
Integrated systems simplify the application of business rules for data validation as they reduce the number of data sources. Conversely, without systems integration, data validation is a far more difficult task as business rules must be applied and synchronized across multiple data sources which in itself is problematic and prone to error.
Data validation at source is a principle that can be applied across sector wide systems incremently with little or no additional cost.
Strategic Goals
Identify business rules and apply them at source, or advise other stakeholders how they can be applied at source, to enable intelligent validation of data.
Information presented in appropriate format.
As the volume of available information grows it will become critical that information is presented in an appropriate format that is sensitive to the requirements of the user. This includes the availability of tools that can be used in conjunction with the information, the suppressing of unnecessary or inappropriate information and the highlighting and prompting of important items, for example laboratory results outside of the normal range.
Current Situation
The Hospital and Health Service Clinical Record does provide some capability in tailoring the presentation of information based on the user and includes tools to graph data. Deficiencies could be addressed through development.
Vision
It is important that the Electronic Health Record is capable of providing a view of patient data that is appropriate to the clinical setting and sensitive to individual patient/client circumstances. For example, sensitive mental health or sexual health information should only be made available to those users authorized to view. On the other hand, where such sensitive information might impact on the more general health care of a patient, the Electronic Health Record should direct general users to specific authorized user(s) for access to further information.
It is also important that the Electronic Health Record provides clinicians with an effective tool for patient care, by including the ability to tailor the presentation of patient data to individual clinician's or specialty's preferences and to perform appropriate functions on the data such as image manipulation and data graphing. For example, a clinician in the cardiology department of a hospital may want, as a preference, all test results for myocardial enzymes to be presented at initial logon and a clinician in the Intensive Care Unit of a hospital may prefer to see the results of blood gas tests, an orthopaedic surgeon in private pracyice, a midwife, pharmacist, or a nurse will have different preferences.
These features are a fundamental part of an Electronic Health Record and as such carry no additional cost. Should a decision be made to replace the current Clinical Record system, the associated cost must be independently justified.
Likewise for business information it is important that the same capability and tools are available.
Strategic Goals
Implement role based access control to enable presentation of information appropriate to the user.
Implement measures to allow the user to define preferences for the display of information.
Use financial resources wisely.
In an environment of continued reductions in public funding, Information Services must pro-actively look for ways to deliver cost-effective solutions.
Current Situation
Information Services currently use some measures to ensure the wise use of financial resources. Alignment with business needs is ensured through a formal project methodology that:
District Health Board Managment and Senior Business Managers within the Hospital and Health Service prioritise projects to ensure the effective use of resources and a standard contract format is helping to ensure robust and fair contracts with other stakeholders.
Vision
As with any other business area, the wise use of financial resources within Information Services will achieve the greatest return on investment in health outcomes by ensuring that:
Strategic Goals
Refine and utilize a standard project methodology
Rationalize systems and technologies to minimize ongoing system costs
Prioritize projects in conjunction with stakeholders and their business plans.
Provide leadership
Information Services must provide leadership to the organization and its stakeholders in information management and information technology.
Current Situation
Information Services currently spend a disproportionate amount of time on problem resolution and system maintenance due to the technical and functional deficiencies of the current applications. This makes it difficult to perform the role of leaders and experts due to a lack of time spent on research and development, maintaining a current knowledge of new technologies, fostering strong relationships with the stakeholders, understanding their needs and understanding changes in the health sector.
Vision
One of the values of Capital and Coast District Health Board as defined in the Strategic Plan is to excel. "We strive for innovation and improvement." Just as innovation and improvement is important in a clinical sense, it is just as relevant in Information Services. Continual advances in technology and information management capabilities generate opportunities for improvement in business and clinical processes that must be identified and exploited to their full potential.
We need to use Information Services expertise, in conjunction with strong business relationships and business understanding, to identify, explore and exploit opportunities to apply technology, information and processes for business benefit. In practice this means:
Strategic Goals
Pro-actively provide information to stakeholders on potential value adding solutions.
Maintain a current knowledge of business and clinical needs and of changes in the health sector.
Provide leadership and consultancy in project management, analysis, information technology, information management and process engineering.
How We Get There - Implementing The Strategy
This section describes how we will move from where we are now to achieve the Information Services strategic goals. In summary these goals are:
There is no "best" way to work towards these goals over the next 5 years. The way in which the Information Services strategic goals are achieved, and our ability to achieve them at all, will be influenced by external factors outside of our control.
The major factors will be:
Year 1
Information Services internal structure and processes
The Information Services department is a newly formed group (December 2001). Much of the initial effort of the group will focus on clearly defining its role, work practices, endorsed standards and performance criteria and communicating that to the District Health Board. This will include:
Shared Services
The need to explore opportunities for collaboration and improvements of outcomes through shared efforts with other health-care providers is a major part of the DIMP strategy. Discussions are currently underway with Taranaki District Health Board looking at the possibility of achieving savings on future information systems and technology expenditure through an effective shared services arrangement aimed at minimising duplicated effort and risk. While the initial focus of the District Health Board's will be on designing and implementing a single, shared infrastructure there are also opportunities for sharing business applications that perform functions common to both organizations.
System reviews
It is crucial that a review of all the major business systems at Capital and Coast District Health Board is undertaken to establish:
These reviews are urgently required to address other Information Services objectives, outside of the shared services initiative, but they do provide a basis for identifying opportunities for collaboration with Taranaki District Health Board through having a clear understanding of our current systems. They will also allow us to identify issues with systems that are the best available solution and formulate plans for resolving the issues.
The system reviews to be performed urgently are:
Some of these systems have been reviewed or implemented recently and will only require a re-validation of our understanding of their context and strategic fit. Others will require detailed reviews.
Info-Portal
Access to information and applications across both Taranaki and Capital and Coast District Health Board's will be provided through an enterprise information portal. This will be a web browser interface that provides appropriate access to authenticated users and to un-authenticated public users from the District Health Board owned network or from any internet connected device.
The Info-Portal will replace the existing Capital and Coast District Health Board intranet and internet sites and is a critical component of the shared services agreement.
Projects in progress
There are a number of projects in progress that either address an important business need, or are of strategic importance and should be continued to completion. These projects are:
This project provides a standard means of editing, authorising, and retrieving documents through a web-based front end. Documents are stored in either XML format if they are patient centric, or in a database in denormalized form if they are organization oriented. It provides a standard and transparent means of transferring such documents to other stakeholders in the District Health Board and as pilot documents, it provides two electronic discharge summary templates; for General Services and Mental Health respectively. As a necessity for document transmittal, it provides a reliable web-based Provider Demographics system which will be available to all users of the InfoPortal and may in future be integrated with the enterprise wide authentication database.
The Integrated Services Database holds a copy of the patient demographic and event data held in Allegra, previously accessible only through standard HL7 communications or specifically designed links to other systems. It is stored and accessed in a standard form based on the Microsoft multi-tier environment. Currently only the Hospital Emergency Dept Information System (EDIS) uses it, and soon the new Hospital and Health Service Pharmacy system (WinDose) will, but the intention is that this becomes the single authoritative source of patient and event data for all Capital and Coast District Health Board systems.
The Hospital Pharmacy currently uses a combination of four non-interfaced systems to perform basic core functions resulting in duplication of data entry and inaccurate, incomplete data within Pharmacy. These disparate systems are being replaced with a single system that is integrated with other appropriate Capital and Coast District Health Board Hospital and Health Service systems and is capable of future development to support electronic prescribing and nurse drug administration within the Hospital and Health Service.
The current RMS Radiology system limits our ability to access common sources of patient/client or enterprise data and requires the maintenance of a specialized skillset that is not readily available in the market. Data quality is a major problem and data corruption is common due to the absence of data validation and an audit trail to monitor and manage data quality. A replacement system based on an open architecture will address these issues.
High priority projects
There are a large number of projects that are considered high priority by the District Health Board. Priority is assigned for a number of reasons: the need to address patient or District Health Board/Hospital and Health Service staff safety issues, the need to address urgent business needs, the need to manage expenditure through the provision of management information, the need to commence strategic projects that are assumed by the regional hospital design and so on. It is envisaged that priorities will be largely determined by the 3 key business process reviews (First Presentation to Community Care, Employee Requisition to Termination and Requisition to Payment) and that as these projects mature and evolve, priorities will change. The number of these projects far outweighs the resource available, but within existing resource constraints, and given current known priorities, the projects that will be commenced (and in some cases completed) in 2002 are:
The TAG! initiative is a non-profit joint venture between Taranaki District Health Board, Capital and Coast District Health Board and Stargarden. TAG! is an integrated cross-functional workflow solution that will address generic business issues in both organizations through workflow automation and process improvement. Initial focus will be on the HR business processes which constitute the "employee requisition to termination" process defined in the Strategic Plan for IM and P. It will be delivered through the Info-Portal. The project requires no capital investment.
The lack of automation and standardisation in the referral and assessment process is a major cause of provider and patient dissatisfaction and financial waste. It is intended that community based providers (such as GPs) will be able to refer to the public hospital through the Info-Portal or transfer the referral documentation electronically from their own management systems. It is intended this system will manage the entire process from the referral through the specialist assessment to discharge or admission. The project will largely utilize existing infrastructure and internal resource and require minimal capital investment.
The information currently available at the Hospital and Health Service on prescribing practice is limited and not readily available. This project seeks to enable the Hospital and Health Service staff and contractors (in particular those who can influence outcomes) to fully understand pharmaceutical usage and the costs involved in order to provide sound decision support and reduce pharmaceutical costs. It will provide information on pharmaceutical usage through the Info-Portal. The project will largely utilize existing infrastructure and internal resource and require minimal capital investment.
The large volume of paper-based patient records at the Hospital and Health Service presents major cost and management issues, while hampering realisation of a comprehensive electronic medical record. The regional hospital design is based on a fully electronic health record and by delivering pertinent parts of previously paper based patient records as they are required this can be realized without a large up-front capital cost. The cost of scanning medical records on demand is estimated to be in the region of $800k, but further definition of project scope, costs, risks and outcomes is being performed.
Medical images (indeed images of many kinds) form an important part of the electronic health record. We need to capture and store medical images digitally, and transmit them on request to any authorized user for viewing either a specialist diagnostic workstation or through a browser as appropriate. The initial focus will be on radiological images as the regional hospital design assumes a near filmless environment in Radiology. The cost of providing radiological images on-line is estimated to be in the region of $8m; the business case for this is being prepared in conjunction with Radiology.
The current Hospital and Health Service Patient Management system, Allegra, is a proprietary software package built using old non-standard technology and designed for the American market. It is crucial that we quickly implement the recommendations of the Patient Management System review. The cost of implementing the recommendations of the review are unknown and further definition of project scope, costs, risks and outcomes is being performed.
Hospital and Health Service corporate business functions are currently supported by a number of disparate systems none of which are properly integrated and some of which have reached the end of their useful life. Annual cost of ownership of these systems amounts to $1.65m. It is crucial that we quickly implement the recommendations of the system reviews. The cost of implementing the recommendations of the review are unknown and a full business case will be required before this project proceeds.
The District Health Board's current casemix and costing system, Transition, is out-sourced and total cost of ownership is approximately $740,000 per year. It is crucial that we quickly implement the recommendations of the system review. The cost of implementing the recommendations of the review are unknown and a full business case will be required before this project proceeds.
Years 2 to 4
Priorities from 2003 on will be dependant on the outcome of the projects initiated and completed in 2002. It is clear that some long term projects, such as medical imaging and the replacement of key systems, will continue through this period. It is also clear that the Regional Hospital design and the shared services agreement with Taranaki District Health Board will continue to be major drivers and enablers. Other major drivers are likely to be collaboration opportunities with other providers and an increasing focus on non-public hospital aspects of the District Health Board.
Appendix I - Resource Requirements
The assessment of resource requirements is based on current knowledge of requirements and priorities as delineated below. As the major projects from the Strategic Plan for IM and P are defined and prioritized, this section will be amended.
Priorities for Resourcing
The responsibilities of Information Services can be divided into two broad categories: supporting existing business information requirements and information systems and implementing large, expensive or strategic projects. To enable us to be effective in both areas, Information Services is divided into a Project Office and Business Services group.
Business Services
The Business Services group priorities are as follows:
While the Business Services group have the expertise necessary to complete project work, because of the competing demands on their time and the extremely high workload in this area, projects targeted for completion within this group will be subject to delays. These projects will be managed closely with the relevant clinical or business groups as often the reason for delay will be a production issue or change in priorities in that area.
Project Office
The Project Office priority is to deliver high quality integrated solutions in a controlled and timely manner to meet business needs in a way that maximizes the effectiveness of the available resources. Strategic projects are primarily resourced from the Project Office which currently has 13 staff, although these numbers may be complemented by staff from the Business Services group and staff from external agencies as needs and funds allow.
Staff Resources
Based on the existing headcount of 13 in the Project Office, the following table shows the planned utilisation of this resource for the next year. This also indicates when the high priority projects are likely to commence.
| Projects Almost Complete: | Jan-Mar | Apr-Jun | Jul-Sep | Oct-Dec |
| Web Docs Editor/ISD | 3 | |||
| Pharmacy System Replacement | 1.5 | 0.5 | ||
| Radiology System Replacement | 0.5 | 1 | 2 | 2 |
| Short Term Objectives: | Supplemented by resource from the Business Services Group | |||
| Policies and Procedures | ||||
| System Owners | ||||
| Develop KPI's | ||||
| Refine Project Defintion Documentation | ||||
| Standards Based Reporting Tool | ||||
| Production Support Cross Skilling | 1 | 1 | 1 | 1 |
| System Reviews: | ||||
| Patient Management | 0.5 | |||
| Electronic Health Record | 0.5 | |||
| Casemix / Costing | 0.5 | |||
| HR /Payroll / Financials / Asset Management / Materials Management | 0.5 | |||
| Theatre Scheduling | 0.5 | |||
| Patient and Resource Scheduling | 0.5 | |||
| Inter-system communications | 0.5 | |||
| Emergency Department | 0.5 | |||
| Peri-natal/Neo-natal, Genetics | 0.5 | |||
| Other Prioritized Projects: | ||||
| Workflow automation (TAG!) Development | 2.5 | 2.5 | 2.5 | 2.5 |
| Workflow automation (TAG!) Implementation | 1.5 | 1.5 | 1.5 | |
| Referrals Management | 2.5 | 2.5 | 2.5 | |
| Pharmaceutical Usage | 1 | |||
| Virtual Workspace/Info-portal | 1.5 | 1.5 | 1 | |
| Scanning paper medical records | 0.5 | 0.5 | ||
| Radiology PACS | 0.5 | 0.5 | ||
| Patient Management System Replacement | 0.5 | 1 | ||
| HR system upgrade and integration | 0.5 | |||
| Casemix / Costing System Replacement | 0.5 | |||
| Materials Management upgrade | 0.5 | |||
| Integration system upgrade | 0.5 | |||
| Cut-off line based on current staff | 13 | 13 | 13 | 13 |
The following projects will be resourced from the Business Services Group:
| Project | Approximate resource requirement - (FTE months) | Approximate additional capex requirement |
| Radiology electronic reports | 1 | |
| External Laboratory Results | 1 | |
| Small system reviews | Ongoing | |
| Data Dictionary | Ongoing | |
| Flights Database | 4 | |
| Level J (TOP) system replacement | 3 | 10,000 |
Based on existing priorities and resource availability, the following identified projects (in no particular order of priority) cannot be resourced by the Project Office and so will not be completed, or in most cases even commence, before 2003. These projects will need to be resourced either by the Business Services group, outside of Information Services entirely, or be considered as project resources become available from 2003.
| Project | Approximate resource requirement - (FTE months) | Approximate additional capex requirement |
| Patient Management System Replacement | 18 | 2,000,000 |
| Casemix/Costing System Replacement | 18 | 500,000 |
| Electronic Prescribing | 18 | 1,000,000 |
| Drug Dispensing | 12 | 200,000 |
| Patient Scheduling Replacement | 18 | 500,000 |
| Radiology PACS | 72 | 8,000,000 |
| Medical Imaging | 72 | 1,000,000 |
| Radiology Result Dictation | 6 | 200,000 |
| Pathology Result Dictation | 6 | 200,000 |
| Laboratory System Replacement | 18 | 600,000 |
| Laboratory Order Automation | 6 | 100,000 |
| Genetics Web Development | 12 | |
| Electronic Health Record | 72 | 1,000,000 |
| On-line clinical documentation | 14 | |
| Theatre Instrument Tracking | ||
| Theatre Inventory Management | 4 | |
| Surgical Implant Management | 6 | 10,000 |
| Hospital wide patient and staff tracking | 6 | 200,000 |
| PeopleSoft Version Upgrade | 6 | 350,000 |
| Future Business System Upgrades | ongoing | ongoing |
| Theatre System Upgrade | 2 | 50,000 |
| Document scanning and imaging system | 12 | 800,000 |
| Patient monitoring | 12 | 100,000 |
| Digital dictation upgrade | 3 | |
| Financial systems replacement | 18 | 1,000,000 |
| HR systems replacement | 18 | 500,000 |
| Clinical consumables | 18 | |
| Total for un-prioritized projects (excluding those resourced from the Business Services Group) | 456 | 18,310,000 |
Skills Profile
As a general philosophy, we will encourage our people to become skilled towards the business process engineering end of the systems continuum rather than the programming end. The emphasis will be on communication with the business, process analysis, and systems design (activities that add a high degree of value). Although we will need to retain a reasonable level of programming skills, where practicable, this will be outsourced. These outsourcing costs will need to be included in the cost of the projects.
Currently our skills are primarily programming and some analysis which is acknowledged as a requirement for the support of the existing large systems. Once the Business Services teams are established, staff will be cross-trained across the various systems in order to provide backup and flexibility and to meet the increasing demand for information and support without increasing staff numbers.
Training and experience opportunities to encourage their development towards business process engineering will be provided to all staff, both in the systems support and project areas. Emphasis will be given to personal development, particularly self empowerment training.
Appendix II - Risks affecting the strategy
Without clear lines of accountability and proper governance structures in place, there is a high risk that systems will not meet the strategic needs of Capital and Coast District Health Board. Projects may also fail, or run out of control. The governance structures are currently under review and it is crucial that they provide clear guidance to Information Services and the wider organization.
The successful delivery of projects is dependent on having people with the right skills available to the organization. While some technology skills are generic and can be contracted in, there is a large learning curve for proprietary systems and technologies, information and organizational knowledge.
We intend to retain the people with this knowledge by continuing to invest in their training and valuing their contribution.
A high proportion of packaged software brings with it a high dependence on the software vendors. To some extent, Information Services' ability to deliver robust systems and good service is constrained by the quality of the support from vendors, especially for applications software.
To the extent that this can be handled through contract terms, it will be done. Before any software vendor is selected, rigorous exploration of their track record of support will be performed. Preference will also be given to New Zealand based vendors.
Capital and Coast District Health Board will work with other providers to provide combined leverage for common suppliers.
Being responsive to changes in technology and changes in an organization's structure and information needs is a key challenge for information specialists. There is often a trade off between over-engineering a solution that will become obsolete and taking short-term solutions that are cheaper, but expensive to expand or upgrade.
The use of commodity hardware, industry standard software and industry messaging and communication standards will help to reduce this risk.
The best information and information systems in the world will not be effective if there is not the right environment in which to exploit it. Cultural change is a cornerstone of Capital and Coast District Health Board's Strategic Plan, and will be an essential tool for mitigating this risk.
Business and Clinical ownership and accountability for the effective use of information and information technology is an important part of the required cultural change as highlighted in the Strategic Plan for IM and P.
The critical success factors (CSFs) and the actions necessary to avoid risk are summarized below.
| CSF | Action needed | Risk avoided |
| Needs before solutions | Every project has a clear and unambiguous statement of the needs to be met | Inability to measure progress or assess whether user expectations have been met |
| Ownership | Business units take ownership of all projects specific to the unit | Lack of business practice change needed to realize the benefits |
| Clinical involvement | Systems to support the process of giving care require clinical staff to determine system needs and then lead the implementation | Lack of balance between business and clinical needs |
| Adequate resourcing | Commit and dedicate adequate staff and project management resources | Poor definition and inadequate implementation of applications, resulting in lost benefits |
| Infrastructure investment | Provide a robust information systems infrastructure | Inability of projects to deliver quality solutions on time and within budget |
| Corporate system ownership | Corporate owners are accountable for making corporate data available to all authorized users | Lack of balance between local needs and wider corporate needs |
Appendix III - Applications Overview
Provides for scheduling of Theatre resources and records most of the data relating to Theatre cases. It receives demographic data from Allegra (PRS - Patient Registration System), and sends charge data Allegra (PAS - Patient Accounting System). Also provides medical procedure data to Transition. Supported by the vendor PerSe.
An application or component of Allegra (built using the Allegra tool set by SMS) that provides for electronic patient accounting. Activity records are received from PRS, RMS and ORSOS. Output activity records are sent to Transition via a batch file monthly. Supported by Information Services.
An application or component of Allegra (built using the Allegra tool set by SMS) that provides for electronic patient registration, bed management and event recording. This system is the primary source of provider demographics, patient demographics and event data. It also provides activity data to PRS. Supported by Information Services.
Provides functionality for film management, patient tracking and result reporting within the Radiology business unit. Also provides scheduling and clinic management functionality for outpatient services. It receives event and demographic data from PRS and electronic orders from the Orders system. It updates event information on PRS, supplies results and scheduling information to Clinical Records, activity data to PAS and order status updates to Orders system. Medical Records Tracking extracts scheduling data via a batch file (produced by a query) for inclusion in the "Pulling Reports". Supported by Information Services.
Provides the functionality for managing test requests, specimen tracking and analysis, and result reporting. It is also interfaced to a range of computerized test devices. It exchanges data with these devices, receives event and demographics from PRS, sends results to Clinical Record system and provides a batch file of activity records to EDAM.
Provides dispensing functionality. It receives event and demographic data from PRS and produces activity data for EDAM on the top 23 drugs. Supported by Information Services.
An application or component of Allegra (built using the Allegra tool set by SMS) that provides for electronic ordering. Currently only Radiology examination orders are implemented. It uses demographic and event data from Allegra and sends/receives order entry data to/from the Radiology Management System (RMS). It also sends order details to Clinical Record. Supported by Information Services.
An electronic clinical record, intended to be a single access point to a patients clinical data. Currently makes available Laboratory test results, Radiology examination results, some discharge summaries, Theatre notes, clinic letters, patient letters/reports, sleep study reports, upper endoscopy reports, some CCG/EEG reports, encounter data, assessment data and mantoux data. Data is received from Allegra, RMS, Détente (Laboratory system), Medlab, and dictated documents. There are no electronic outputs other than reporting. Supported by Information Services.
Database held by NZHIS that contains such data as patient demographics, medical alerts and patient ID number (NHI Number). An online request/update link is maintained through the Health Intranet.
Inpatient encounter data supplied to NZHIS. Contains elements such as NHI number, hospital service code and final diagnosis. It is supplied weekly as a batch file.
Inpatient booking data supplied weekly to NZHIS. Contains such elements as NHI number, expected procedure date, ICD code and status within the booking system.
Batch file for inpatients and outpatients, that is sent weekly to NZHIS. It contains such elements as services provided, NHI number, date of services, diagnosis and legal status.
System written by SMS using the Allegra tool set, used to request and track physical medical records within the hospital and off site storage. Clinic scheduling data is extracted from RMS for use in "Pulling reports". Its reporting is via CONNX and ACCESS. Supported by Information Services.
Patients are booked into PIMS within the first 3-4 months of pregnancy and the system then tracks them through antenatal, delivery and postnatal stages. It collects clinical data on the mother and baby. The system is written and supported by Terranova. An interface exists to PRS from which patient demographics are received.
This is a clinically orientated system used to collect data on babies that come to the neonatal unit. Data collected is such things as daily progress, feeding and procedure used. When a new patient is entered into NIMS, it queries PIMS for any additional data. This system was written by Terranova and is also supported by them.
System that matches patient events with services and resources used. Resource and service data is received from the Laboratories system, PIMS, Medical Genetics, Hutt Valley District Health Board, Pharmacy and the Dental system. Two files are produced, product volumes for the month and a file containing demographics, which are input to Transition. Supported by Information Services.
Consists of three integrated modules; Inventory, Purchasing and Account payable incorporating workflow and a General Ledger.
Provides for payment of all company accounts, by undertaking a three way match between purchase order, receipt of goods and invoice. Also produces cheques. Orders and receipts are received electronically from purchasing module. Outputs journal entries to Chairman general ledger system.
Provides for the management of stock items in store. Currently manages stores at Rongatai, Pharmacy and Theatres. Data is electronically received/sent to the purchasing module. Asset data is sent to accounts payable module.
Provides for requisitioning of goods and services. Receives replenishment data from inventory module. Outputs purchase orders.
Provides for the management of company assets. Outputs batch file of journal transactions to Chairman general ledger system.
This system provides for general ledger and accounts receivable functionality. Journal records are received from fixed asset system, payroll and accounts payable. Produces financial management reports and inputs financial data to Transition.
Provides staffing information and generates payroll payments. Outputs to general ledger via batch file, payslips to staff and management reports.
Provides rostering and staffing functionality. Predominately used by nursing and orderlies. Provides work details to payroll via batch file and management reporting.
Provides for the management of building maintenance requests. Caters for routine and emergency maintenance. Produces management reporting but has no external interfaces.
Provides for casemix and clinical costing. Runs at Allegiance, a bureau in Melbourne Australia. Data is entered via batch files from Allegra, EDAM, General Ledger, PIMS, and Women's Health Level J. Produces management reporting.
Provides dictation services for clinicians. Voice data is transcribed by typists into various written reports. Some of these are sent through to Clinical Record system.
Standalone system that allows for the dispatch management via pagers and electronic messaging. Messaging is achieved via an interface to the PABX.
Provides a web interface for communication to staff and the public. Supported by Information Services.
OpenLink is an interface engine that receives messages from other systems/businesses, reformats them and then routes them to the appropriate receivers. It is an SMS product and is also supported by them.
There are numerous small systems using a variety of products. Some are complex and critical to the business areas which use them (eg. Cardiac Catheter, Renal Dialysis. Level J).
Appendix IV - Applications Assessment
Major Software Packages Currently in Use
| Application | Name | Supplier | Effectiveness % | Exploitation % | Estimated Remaining Life |
| Patient Registration | Allegra | SMS | 70 | 70 | 3 years |
| Patient Accounting | Allegra | SMS | 50 | 50 | 3 years |
| Orders | Allegra | SMS | 70 | 10 | 3 years |
| Medical Records Tracking | Allegra | SMS | 90 | 95 | 3 years |
| Radiology (Note 1) | RMS | SMS | 60 | 70 | Limited |
| Scheduling | RMS | SMS | 70 | 60 | 2years |
| Laboratories (Note 2) | OmniLab | Detente | 80 | 70 | 2 years |
| Pharmacy (Note 3) | Mixed | Mixed | 40 | N/A | Limited |
| Genetics (Note 4) | Genie | In-house | 70 | N/A | Limited |
| Theatres | ORSOS | Per Se | 60 | 60 | 3 years |
| Clinical Record | ACR | SMS | 60 | 50 | 3 years |
| Rostering | One Staff | Per Se | 80 | 80 | 3 years |
| HR/Payroll | Leader | AMS | 90 (Note 5) | 95 | 3 years |
| Financials (GL/AR) | Chairman | CSI | 70 | 90 | 1 year |
| Accounts Payable | Peoplesoft | Peoplesoft | 50 | 50 | 7 years |
| Materials Management | Peoplesoft | Peoplesoft | 50 | 50 | 7 years |
| Booking system | N/A | In-house | N/A | N/A | Unknown |
| Telephone Dictation | Winscribe | Amtel | 90 | 50 | 3 years |
| Financial Asset Mgt | Hardcat | TAM | 10 | 40 | 3 years |
| Engineering Mgt | BEIMS | Mercury | 70 | 80 | 3 years |
| Perinatal/Neonatal | PIMS/ NIMS | Teranova | 90 | 90 | 5 years |
| Emergency | EDIS | HASS | 90 | 90 | 5 years |
| Casemix and Costing | Transition | TSI | 70 | 40 | 1 year |
Note 1: An upgrade or replacement is planned which will increase the expected life to 3 years.
Note 2: An upgrade is planned which will increase the expected life to 5 years.
Note 3: A replacement system has been approved and will be implemented this year (2001). This system will have an expected life of 5 years.
Note 4: The planned release of Genie in 2002 will increase the remaining life to 3 years.
Note 5: Assessment based on suitability for payroll purposes. HR fit is about 20%.