S. Teng Liaw
These are some observations from a recent work-in-progress presentation of the above project in August 1993. I attended as an interested proponent of patient-centred computing and as the SA member of the Information Management Committee of Council, RACGP.
The SA Health Info 2000 project is part of the Information Resource Management Strategic Plan for the SA Health Commission which began in the early 1980s. With a 'BETTER HEALTH THROUGH BETTER INFORMATION' theme, the objectives were to provide a framework and guidelines for health units to integrate information technology into the SA health system. The dimensions of the framework were clinical, service delivery, resource management and information technology. A pyramidal model for the heirarchy of information needs was adopted: the patient/client at the apex and descending through service delivery, resource manage-ment, performance management, and 'whole-of-health' to environmental information needs.
A fairly comprehensive summary of past mistakes and information needs had been gathered, some 'critical success factors' identified and some 'guiding principles' for information system proposals outlined. There were no surprises in what was a fairly slick presentation by a local consultancy firm with the appropriate rhetoric on paradigm shifts e.g. service delivery must be patient-centred and community-based, management be flexible and outcome-oriented, and systems be open, interoperable and multimedia.
Despite the patient-centred rhetoric, the thrust of the project appeared to be management-oriented. There was certainly abundant management jargon and theorising about fairly obvious concepts. The demonstration of the HCN pilot asthma project and 'costs-modelling' at the 2nd open forum on 11 August 1993 which purported to be patient-oriented was merely a graphic representation of the 2 dimensional spreadsheet modelling of existing data. The idea of an asthma (or chronic disease) register was excellent and the provisions for data security adequate. However, neither the project nor the demonstration came to grips with data quality (validity and reliability), clinical care or patient centredness at all.
The strategic options were based on cost, benefits, risk, and constraint criteria and a client-server processing model. A common open multivendor architecture system for applications, minimum data sets, reporting criteria, information exchange and profiling was the preferred option. It is preferable to buy rather than build. Funding should be increased to upgrade existing infrastructure and benefit realisation should be the joint responsibility of the implementation team and the local management. Human and technical resources should be developed and expanded. Standards and policies should be coordinated. The final strategy, business case and investment profile is expected to be ready for appraisal by September 1993. After that the SAHC Executive is expected to endorse it and submit it for Cabinet approval. The strategy will then be launched and the implementation phase will begin.
In summary, Info 2000 had summarized the needs quite comprehensively and some useful guidelines were developed. The rhetoric on patient-centredness was not matched by the strategic work up to date. The top-down approach adopted partially explains the obvious lack of emphasis on data quality and, to a lesser extent, data security. There is increasing support for the view that information management standards should be determined at the primary care level. The 1990 UK National Health Service GP 'performance-related contract' demonstrated that IT can support primary care clinical, administrative and financial activities and placed primary health care at the centre of the development of health care information management and services as a whole. While the reliability and quality of some of the information may be suspect, it is a step forward to complement and enhance the existing incomplete and fragmented statistics and provide a more meaningful picture and guide to real population health needs.
