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| Journal of the New Zealand Medical Association,
23-July-2004, Vol 117 No 1198
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Information Technology systems in general practice medicine
in New Zealand
Rebecca Didham, Isobel Martin, Richelle Wood, Ken
Harrison
Information technology (IT) has become an integral part of
communication in the 21st century. In general
practice medicine, a certain level of IT is required to support aspects such as
clinical care, health services, administration, and research. Several countries,
such as the United Kingdom (UK), have implemented government policy to ensure
that 100% of GPs are computerised. The UK Government launched a strategy in
October 1998 (Information for Health) and yearly targets were set for advances
in IT.1
New Zealand does not have any specific healthcare policy
regarding IT in General Practice. The main reasons for adopting IT in a practice
are time efficiency, better access to services, linking to other healthcare
services (such as electronic transfer of pathology results), and also the public
expectation of a modern healthcare facility. Because the use of IT allows a
greater level of data capture, GPs are also pressured to become computerised to
meet the obligations imposed on them from the Ministry of Health (MoH), District
Health Boards (DHBs), and Primary Health Organisations (PHOs). There has to be a
balance between the value to medical practice of these IT advances, and the cost
in time and money to the general practitioner.
There is a paucity of national and international published
data on IT capabilities in general practice. The aim of the present study was to
ascertain the current state of IT in general practice in New
Zealand—focusing on the level of computerisation, the use of patient
management systems (for electronic medical records and other functions), and the
use of other electronic communication such as the Internet and Healthlink (a
web-based network for downloading and transferring health information between
providers). This information can then be compared and contrasted with
international figures to show where New Zealand general practices rank globally.
The elicited information can also be used to inform policy, so impossible
requests are not made of general practices.
MethodsA pilot questionnaire was
developed—including the use of specifically designed patient management
system (PMS) software, other uses of computers, and communication systems in
general. The questionnaire was posted to an initial group of 100 general
practices in New Zealand (selected alphabetically from a list compiled from
public directories—Telecom white pages and Internet listings). Completed
questionnaires were assessed and some refinements were made to increase response
rate and understanding of certain questions. The final copy of the questionnaire
(see Appendix 1) was then sent to the 1088 remaining general practices
(therefore a total of 1188). After approximately 1 month, practices who had not
responded were sent a follow-up letter and a further copy of the questionnaire.
Questionnaires returned with incorrect addresses were also redirected where
possible. Completed questionnaires were all received by September
2003.
Questionnaires were entered into a Microsoft Access
software database (Microsoft Corporation). Answers and comments were directly
entered as recorded on survey forms. Results were quantified and analysed using
Microsoft Access. Percentages were expressed as a result of the number of
responses to each specific question.
ResultsGeneral—A
response rate of 80.0% was achieved, comprising 938 responses from a total of
1188 eligible practices (after identifying merged or terminated practices). Of
the practices that responded, 73.9% (690 out of 934 responses) were urban, 25.6%
(239) were rural or semi-rural, and 0.5% (5) were unknown (ie, unable to be
classified into either category from information given). Practices ranged from
0.1 to 12.5 full-time equivalent (FTE) general practitioners, with a mean (SD)
of 2.6 (2.5) FTE GPs per practice. However, 64.0% of practices had 2 FTE GPs or
less (Figure 1). Some practices noted that they employed several part-time GPs
to make up each FTE.
Almost two thirds of the practices (65.2% or 608 out of 933)
have a practice manager, employed at mean (SD) of 0.93 (0.6) FTEs—with 82%
(467 out of 569) of these practices employing their manager between 0.5 and 1.0
FTEs. Several practices noted that their practice nurse, general practitioner,
or receptionist also undertook practice manager duties.
Figure 1: General practice staffing (n=910)
 Practice
hardware—Only two (0.2%) of the surveyed respondents did not have a
computer in their practice. The number of computers per practice ranged from 1
to 50, with a mean (SD) of 7.3 (6.1). Figure 2 shows the distribution of the
number of computers per practice.
Figure 2. Number of computers per practice
(n=923)
 Practice
software—Almost all practices (99.0%, or 920 out of 929) use
specifically designed PMS software to assist with recording of patient and
clinical consultation details and to help with the daily running of their
business. Figure 3 shows the proportion of practices using software from each of
the main PMS vendors. Table 1 shows the percentage of practices using each
specific PMS type. Most practices (80.9%, or 744 out of 920) are using one of
three PMS software packages (for PC or Mac)—Healthtech Medtech 32, Houston
GP, or Intrahealth Profile. Almost half of the respondents (48.0%, or 430 out of
895) have experienced problems with their PMS after it has been updated to a
newer version.
Figure 3. Proportion of market share of main Patient
Management System (PMS) software vendors (n=920)
 Note:
Healthtech Medtech includes editions 16 and 32; Intrahealth includes MMAS;
Profile for Mac and Profile for PC; Houston includes GP professional and VIP
2000.
Table 1. Types of Patient Management System (PMS)
software used in general practice (n=920)
*Company = 1MEDtech
NZ, 2Houston Medical,
3Intrahealth System Ltd,
4Developed by Ashwin Patel.
The proportion of practices who reported that their GPs use
their PMS to store full clinical notes was 71.8% (670 out of 933). Of these
practices, 19.3% (127 out of 659) store full clinical notes on paper as well as
electronically. Of the practices that do not use their PMS to store full
clinical notes (or if not all GPs within the practice use the PMS), 89.6% (216
out of 241) use their PMS to record that the consultation occurred. Most
practices utilise additional functions of their PMS. Electronic laboratory
request/results are used by 81.3% (752 out of 925) of practices, 89.7% (838 out
of 934) use their PMS to record prescriptions, 97.3% (907 out of 932) record
immunisations, 85.9% (795 out of 925) record allergy information, 92.9% (858 out
of 924) record vaccination events, and 93.3% (867 out of 929) record ACC details
(government accident compensation).
Most practices (94.6% or 883 out of 933) record screening
information or keep disease registers on their PMS, however it is not known how
in-depth, or complete, these registers are. Almost all of these practices record
cervical screening (97.8%), and most keep a diabetes register (86.4%), record
breast screening (83.1%), keep an asthma register (64.6%), or record blood
pressure (60.4%). An additional 31.6% of practices indicated that they also
record other parameters.
Consultation diagnoses are medically coded in 64.7% (597 out
of 923) of practices, however 24.6% of these practices voluntarily indicated
that they only ‘sometimes’ or ‘occasionally’ use codes,
or only code for ACC purposes. Of the practices that code, 94.5% use Read Codes,
2.3% use custom-designed codes, 1.9% use ICD-9 or ICD-10, and 1.2% use ICPC.
Internet, electronic and
general communication—A large proportion of practices (80.3% or 749
out of 933) connect to the Internet; 93.7% (868 out of 926) connect to
Healthlink, and 35.8% (307 out of 858) connect to the Health Intranet.
To connect to these services, 47.6% (411 out of 864) of
practices have a permanent high-speed link (of which an ADSL connection is the
most common), and 80.6% (696 out of 864) have a dial-up modem (with 56 Kbps
being the most frequently used connection speed). Of these practices, 19.6%
(169) have both a high-speed link and a dial-up modem.
Email is used in 77.6% (699 out of 901) of practices for at
least one purpose. Of these practices, 93.7% use email for external purposes,
and 6.3% use email for internal use only. The reasons indicated for email use
were: communications (83.4%), health information (72.5%), administration
(70.4%), personal (59.0%), education (51.8%) and other (9.4%).
In general, 62.4% (570 out of 913) of practices are
satisfied with their communication systems (including telephone, network, and
Internet). The majority (63.1% or 571 out of 905) of respondents reported that
their communication systems are reliable. Just over three-quarters of practices
(78.4% or 687 out of 876) claim to have a ‘disaster recovery plan’
for their computerised information.
Research and
education—Of the practices that responded to this portion of the
questionnaire, 96.0% (838 out of 873) contribute to at least one data
collection: 79.7% (684 out of 858) send electronic age/sex registers for
HealthPAC-claiming, 60.8% (508 out of 836) send anonymous clinical data to an
IPA (independent practitioners association), 38.6% (323 out of 837) contribute
data to a research group, and 35.1% (299 out of 851) send clinical data to a
PHO. It should be noted that some of these organisations may undertake only
minimal research and education at present.
DiscussionThe results of this study show that
general practices in New Zealand have an almost 100% rate of computerisation,
and that the current levels of IT appear to be adequate to support the functions
required of a modern healthcare professional. The response rate in this study
was excellent (80%), compared with similar studies in other countries that
experienced a much lower rate of response—20% in a Canadian
study2 and 55.5% in an Australian
study.3
This response rate ensures that the sample is representative
of all New Zealand GPs, without any geographical or other biases. The
computerisation rate (99.8%) is very favourable compared to that of other
countries, and New Zealand GPs appear to have a good history of use of computer
technology—in a 1996 study conducted on a random selection of GPs in New
Zealand, it was found that computers were used for at least one task by 84% of
doctors.4
A similar study in Canada showed that only 81% of practices
were computerised in 2002,2 a number which may
be further biased by the low response rate. Australian practices were slightly
better in a 2003 study, which reported that 86% of respondents had at least one
computer,3 and at least 98% of UK respondents
in 2003 were using a computer.1
New Zealand has achieved its high level of computerisation
without specific government legislation or policy dictating standards. In the
UK, the reason for the recently high rate of computerisation is due mostly to
the implementation of a government strategy from
1998.1 The USA tried to follow a similar
strategy with a national campaign implemented in 2001 to increase the level of
computerisation, with the aim to eliminate most of the handwritten clinical data
by the end of the decade;5 however, it
hasn’t been as successful so far (although the plan is still in its early
stages).
Almost all New Zealand GPs use a PMS software application
(99%), with the majority (61.5%) of these practices using a system from one
major software vendor (see Table 1). Domination of the market by one or two
software vendors is a phenomenon also experienced in the
UK1 and likely to be seen in many other
countries. Interestingly, it was reported in New Zealand (in 2001) that MedTech
32 held the market share (with 42% of practices using MedTech 32). Its closest
rivals were GPDAT and Houston, which had 17% and 15% of the market respectively.
These numbers were drawn from a sample of 2650 GPs with a 90% response
rate.6 In the 2 years since that study, Medtech
has strengthened its hold on the PMS market in New Zealand.
Of the practices that use a PMS
system, almost three-quarters (71.8%) used it for storing full clinical notes
(electronic medical records). This figure is an improvement on a previous small
geographical subset of GPs in New Zealand in 1999, of whom 61.8% were recording
patient notes using a PMS system.7
Most practices that have a PMS
use it for several other clinical functions such as electronic request and
receipt of lab (pathology) results (81.3%), prescriptions (89.7%), and recording
screening parameters (94.6%). This can be compared to the Canadian study
conducted in 2000, which found that approximately 75% of practices have a PMS
system, however just over 12% are using it for storing full clinical notes, 10%
are using it for lab results and 5% for
prescriptions.2 These are much lower figures
than New Zealand, however the Canadian study occurred over 3 years ago, and
utilisation may have since increased. In the USA in 2002, 17% of US primary care
physicians used a PMS system for storage of full clinical
notes,5 once again, a very low percentage.
In Australian general practices, there are no exact figures
for the use of a PMS to store full clinical notes, however 71% use computers for
writing scripts and 54% use them for receiving or storing pathology
results.3 The UK has comparable figures to New
Zealand—with the claim that most practices are paper-less in relation to
patient registrations, claims, prescribing and some pathology results. Latest UK
statistics (in May 2002) showed that 89% of prescriptions were computer
generated.1 There are several other countries
such as Sweden that are likely to have similar high rates of computerisation,
based on previous figures.5
Almost two-thirds of practices (64.7%) claimed to use a
coding system for clinical diagnoses, and of these, almost all used the Read
Code system. As indicated by several respondents, it is likely that only a small
proportion of the practices are consistently coding each consultation, and it is
more likely that codes are only used for claiming purposes or for a specific
range of conditions. For research purposes and national/international
collaborations, it would be of great benefit to have a standardised and
consistently used coding system. As part of the UK strategy, it is planned to
standardise clinical terminology using SNOMED
CT.1
The high rate of use of the Internet and Healthlink in New
Zealand, indicates that most practices are equipped for electronic transfer of
health information between providers. To use these functions, almost half have a
permanent high-speed link (mostly ADSL), which is a relatively high
figure—latest figures showed that only 0.02% of general practices in the
UK had a broadband internet connection.1 Email
is used in more than three-quarters of New Zealand practices compared to the
Canadian study in which only half were using an email
address.2
A main disadvantage seen in email communication are the
security issues involved with the transfer of confidential information and the
question of whether patients would actually desire to communicate in this way. A
recent New Zealand study found that a sample of patients accessing
Internet-based laboratory results were satisfied with the service, and accepted
it as a favourable progress in communication. Not surprisingly, the older
participants (over 60 years) did not find the system as user-friendly as the
younger age groups, and this is a reflection on technological
awareness.8 This is an important point to
consider as general practice populations are often made up of a larger
proportion of elderly patients as their high users.
Other negative issues related to adopting new technologies
include the fact that electronic communication with patients may not attract a
patient fee and would not be presently covered by ACC, insurance companies, or
government levies. Information technology is also very expensive in terms of
initial outlay, and ongoing software development and upgrading costs.
Many practices feel that their IT is adequate for their own
needs—but they also feel that they are forced into expensive systems to
satisfy requirements of PMS vendors (eg, requiring certain hardware to support
their software packages) and the Ministry of Health (with requests for national
data registries and other information). In the proposed new UK GP contract
(February 2003), primary care trusts will be responsible for funding the
purchase, maintenance, and upgrade of IT systems, telecommunications, and other
National Health Service infrastructure and
services.1 It is possible that many Primary
Health Organisations in New Zealand will follow this example.
Using electronic technology can often be very
time-consuming, and (with constant pressures on a GP’s time) the use of IT
may actually detract from their time spent with a patient. In a 1996 study
involving GPs in New Zealand, significant concerns were reported by respondents
regarding the perceived interference of computers with the doctor/patient
relationship and privacy issues.4
In a 1995 review of findings from international studies on
the influence of desktop computers on general practitioner consultations, it was
concluded that although using a computer during the consultation may help
improve clinician performance it may also increase the length of time of the
consultation.9 Hence, there must be great
caution in not adopting technology at a level which compromises the face-to-face
nature of the patient/doctor relationship.
A possible limitation of the present study is the accuracy
of data collected by postal survey, which is often called into question. A
recent study performed among diabetologists in Germany found that 10% of
responses in a postal survey were found to be
inaccurate.10 Another major problem in such
surveys is the low response rate (which leads to
bias),10 however the response rate in the
present survey was very high (80%), thus reducing this source of bias
considerably. Other such sources of bias include the tendency towards socially
desired responses,10 which in this case would
actually be more likely to skew responses towards a negative perception of
information technology, and this was not seen.
Interestingly, a recent study in the US compared the
paediatrician response to a survey presented by three different communication
modes—email, fax, and postal survey.11 It
found that email surveys generated the most satisfactory, complete, and timely
response;11 therefore, email surveys should be
used more with studies (such as the present one) in the future. There are also
considerations that should be taken into account with questionnaire design and
how this affects responses.
Questions with a ‘yes’ or ‘no’
answer are likely to be more accurately answered than questions which require a
perceived answer; for example, indicating whether a practice uses a certain
process, as compared to estimating how often that process is used. These factors
were taken into account when designing the questionnaire used in this study,
however improvements can always be made.
Technologies are constantly advancing as new ways are found
for attempting to make tasks more efficient. There are many areas of future
development—including issues such as reliability of connection to
electronic services, and costs involved in adopting technology. For example, a
solo rural GP might gain the most benefit from linkage to computerised services,
however these providers are the least able to meet the initial and ongoing costs
involved with adopting a PMS system.
Other future technology advances may include online
patient/doctor groups, emailing lab test results directly to patients, online
consultations, patients booking own appointments, and reviewing own notes and
direct links between primary and secondary care, pharmacies (although an
electronic prescription is not currently legally valid in New Zealand), and
related healthcare providers. Some of these functions are likely to be already
in place in practices around the country that have taken these initiatives in
technology.
In summary, New Zealand general practices can be proud of
the fact that they rank amongst the best in the world in terms of the adoption
and use of IT.
Appendix 1. Questionnaire (sent to general practices in
New Zealand)
Author information:
Rebecca Didham, Assistant Research Fellow/Senior Data Analyst; Isobel Martin,
Senior Lecturer/Director; Richelle Wood, Administrator; Ken Harrison, Database
Administrator, Royal New Zealand College of General Practitioners (RNZCGP)
Research Unit, Department of General Practice, Dunedin School of Medicine,
University of Otago, Dunedin
Acknowledgements: We
thank the practice managers and general practitioners (that contributed
information for this study), Mr Kaine Elston (for his initial work on
questionnaire development), Mr Ray Delany, NZHIS (for his input into
questionnaire content), and Jason Hall and Andy Tomlin, RNZCGP Research Unit
(for their support and assistance).
Correspondence:
Rebecca Didham, RNZCGP Research Unit, Department of General Practice, Dunedin
School of Medicine, University of Otago, PO Box 913, Dunedin. Fax: (03) 477
2056; email: rebecca.didham@stonebow.otago.ac.nz
References:
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