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The pulse of IT (roundtable)

The pulse of IT (roundtable)

During a recent roundtable conference sponsored by BMC, seven chief information officers from the country's district health boards reveal how they manage a raft of challenges ranging from rationalising different systems to working with a range of users.

MIS finds they have a distinct advantage – they formed the DHB CIO forum to focus on issues critical to IT and beyond. Phil Brimacombe, Counties Manukau and Waitemata District Health Boards: I’m currently the chair of the DHB CIO forum. We meet every quarter to share our experiences and potentially to help each other; and also try and achieve some kind of rationalisation in the systems that we use.

We’re not like a group of companies in a particular sector where we’re all competing with each other and trying to get one over each other. The issue we saw was that 21 district health boards (DHBs) on 21 different systems wasn’t really the best thing for the patients and for public health.

An issue that came up in one forum was the fact that a lot of us feel captured by Microsoft and we pay a lot of money in the whole sector on Microsoft licensing fees.

So we thought, should we be thinking about alternatives? We had a workshop on open source software, and that discussion is continuing.

Tony Cooke, Hutt Valley DHB: There’s a similar CEO forum across all the different district health boards. At the end of each forum we try to give four or five key burning questions and issues with CIOs, that we can escalate to CEOs as a group.

Convergence

Phil Brimacombe: Six months ago, we met with the Health IT Cluster, which is the association of the health vendors. Initially, the vendors were probably a bit suspicious of us, expecting a customer pressure group. But it was much more to say to them, ‘Look guys we’re actually all in health. Our purpose is to collaborate as a sector. We share information. We’re all funded from the same source – the taxpayer.’

We haven’t formed purchasing conglomerates, but what’s happened is that over the time we’ve been meeting in CIO forums, there’s definitely been a significant rationalisation in the key systems, particularly patient clinical systems.

We’re structured into four regions – Northern, Midland, Central and Southern – and the convergence has happened around the regions. In metro Auckland, we’re converging on common systems and Midland is converging on a particular set of vendors, common systems, and it’s starting to happen in Central as well.

Tony Cooke: We call it ‘convergence’ because what we’re doing is we’re not throwing out our old systems. We’re converging on systems that are well established, have good support structures in New Zealand, and have a good reputation.

Gary Ireland, Wairarapa DHB: We decided last year to go with a particular clinical information system and the decision was partly based on the fact that it was becoming a standard choice amongst the other DHBs (in the Central region).

We could have easily gone for a system from another vendor which had a closer tie with some of our existing systems, but we chose to go the other route. We’re at the very early stages of implementing the system yet we’re already getting positive feedback from clinicians who have used it previously (at other DHBs) and they can’t wait to get their hands on it.

Alan Grainer, Waikato DHB: We’re currently engaged in a replacement patient management system and four of the five of the DHBs in the Midland region are already signed up at the CEO level. The selection we make will set the default standard for all the other DHBs, and the contract that will be negotiated will be a bulk contract.

Andre Snoxall, Capital and Coast DHB: The doctors are really lucky because they can move from hospital to hospital and they’re accessing a very similar system or a very similar version of a system that they’re used to. That wasn’t the case say, five years ago. So I think there’s a lot of good thinking around convergence.

The next step, of course, after we had some similar infrastructures or even the same shared infrastructure, what business benefits can we get on top of that? Should we actually share our patient information between the two district health boards? Of course that’s not a CIO call. That’s a DHB call but until recently, because it wasn’t easy to do, it wasn’t on the radar.

Privacy issues

Alan Grainer: One of the big policy questions is the trade-off between information sharing and privacy. Most of the policy and legislation is couched in terms of privacy but the direct implication of all the administrative driven initiatives and the local initiatives is around degrees of information sharing.

Tony Cooke: The Health Practitioner Competency Assurance Bill has come out to clarify that and says health professionals are allowed to share information with each other. Privacy is more about informing patients what you’re going to do with that information.

What we’re working on is a more generic statement around information sharing which will comply with the Privacy Act legislation. We’re trying to come up with a standard set of principles which the GPs can put in their waiting room, we can put in our emergency department, and can be hung up all over the place and we know that we’ve covered all of our obligations in terms of being able to use that information down the line for the patient’s care.

Chris Dever, Canterbury DHB: We’re not very good at going out and saying what are the positive things about sharing information, why does your GP want to share your personal information with another health professional and benefits this would have for you. There is a potential for us to be able to turn it around and highlight the reasons why it makes perfect sense for your health professionals to share your information with other health professionals, and that the reason we hold this information is because potentially we might need to do it in the future.

Andre Snoxall: The people who have custodianship of that information are not facing any different issues than what they were facing five years ago. For instance, we’re putting in systems for the Capital and Coast DHB where they can share electronic health records with health care providers in Australia.

Now under the information privacy code, you can’t hold someone in Australia accountable for their behaviour, right? So we get the question, ‘Well, what are we going to do? We’re going to be sharing this information electronically within Australia.’ Well what did you do before? ‘Oh, we sent the paper medical record over there.’ Did you always get it back? ‘No.’ When it did come back, how long did it take? Were you able to operate under that record while it was over there? Did you have any control? Did you hold them accountable? ‘Well no, not really.’ The same issues apply. It’s just that the likelihood of you having a problem because someone does something silly like sharing it around the world on the internet, is higher.

Setting priorities

Steve Mayo-Smith, Auckland DHB: You can’t change your business processes and improve your quality without IT these days. So there’s a lot of pressure on us to really do a lot in that area.

Chris Dever: It’s all very well to say, ‘We need a database’ in the last paragraph of a business case. But they forget the fact that this database needs $20,000 worth of hardware and a whole bunch of bits and pieces. They also forget this isn’t a commitment to buy a server and implement now. It’s a decision to purchase something now and replace the server every four years and maintain the application for a long time. They’re actually paying for past decisions.

Phil Brimacombe: Another huge challenge on top of all this is that the more we put in patient and clinical systems, and the more clinicians use and become dependent upon the clinical systems, then the more demanding they become.

The other challenge is, once you’ve given them a taste of clinical systems, they want to be continuously improving, enhancing and building on them. Now suddenly you get a huge ratcheting up of the demand and the expectations on IS and it is hugely resource intensive to respond adequately to that demand and expectation from clinicians.

Our challenge is that our organisations do not have the budget to invest in us to provide that level of expertise and resourcing and responsiveness, and so you get a situation where they’ll say ‘We’ve got a problem with IS. Our systems aren’t reliable and resilient and IS aren’t providing the service levels that we need.

They’re a problem.’ We’re a problem because there isn’t the budget to fund us adequately ... You can’t say I’m going to give attention to service over the desktop instead of to radiology or instead of to the pharmacy. In health we have to deliver it all and that’s where we get squeezed.

Steve Mayo-Smith: I can give you an example of how important information technology is and this is a situation we had a couple of months ago. A patient comes up from Tauranga. He has been scheduled a while in advance and is seeing a specialist at Auckland Hospital. Unfortunately, the radiology system is down.

The patient has travelled from Tauranga and it’s a fairly serious case. Can the consultant see the person? No. The IT system is down. It’s up two hours later. That two hours made a huge difference to that one person. You have to make sure that the systems are up 100 per cent of the time. You have to operate and be sure that you have really good disaster recovery and really good back-up for when things go down because the impact on an individual is significant.

Managing emergencies

Steve Mayo-Smith: Clearly when something goes down, you have a whole set of procedures that you follow and so on, because a critical thing is to make sure the systems are up. But what is your plan B, which is when the systems go down? Then your plan C is of course your disaster recovery. That’s critical and that’s why it’s a huge focus not only from an IT perspective. It’s a DHB board focus.

Alan Grainer: There is quite a strong emergency response capability because the health sector needs it. These are people who think about a crash at the airport or responding to SARS, things which are well beyond IT. A regular part of our process is that if we have an outage which lasts longer than X period of time, there has to be this emergency response team and they mobilise the rest of the organisation. They actually take that out of IT’s hands, which is quite novel.

Phil Brimacombe: We are good at emergency response but the disaster recovery is getting tougher the more systems become critical in a clinical setting. We had a fire in a power distribution board at North Shore Hospital recently which took out not only the mains power but generator power as well and a large part of the hospital lost power. There were people waiting for operations and some potentially serious situations.

Luckily there was no patient harm, but normally hospitals put in massive generators to have essential power going, and we lost essential power as well ... One of the most serious things was the loss of all the computer systems because users are completely dependent upon the clinical workstation, and on electronic lab and radiology results. Emergency care department is completely computerised, life becomes very difficult without the computer. Luckily we got power back in four hours.

Needless to say, we’ve got an intense project now around a disaster recovery plan. The DR planning is important because it tells you what your risks are. We discovered at Middlemore Hospital recently when we had a power outage that the generator came up. Except the one thing the generator wasn’t supplying power to was the air conditioner in the computer room. So now what’s going in the DR plan is, get generator power through to the air conditioner in the computer room.

On dealing with myriad users

Chris Dever: There are three things I look for [in staff]. Knowledge – that’s what they’ve learnt and their background. Skills – that’s what they can do with that knowledge. And the third one really is attitude.

I can educate people and I can train them with skills but I can’t change their attitude. So those people in any organisation that don’t have a positive attitude to the job and aren’t able to actually give that customer service focus, are either going to have to get them fast or move on.

Alan Grainer: You’re an IS department within a large organisation, but there’s quite a large IT industry out behind you on the street that’s different from some of the other services that are provided within that environment. My predecessor described them under the heading of ‘sharks lurking’ – the vendors who would like to be the outsourcing provider ... I’ve been trying to get this through to my department [that] these [outsourcing staff] are not actually your colleagues [though] you might all work for the same organisation and get paid out of the same payroll.

The point I am making is that they need to think about their organisational colleagues as their customers, provide them with good customer service, and be as sharp in their performance and attitude as an out-sourcing company. Otherwise it will be that company who has the rest of Waikato DHB staff as their customers, not the internal IS department.

Tony Cooke: Another issue we face as CIOs is, when the district health board does its planning and it sets up a new service or a new initiative, IT generally comes as a little bit of an afterthought. It’s sort of in the small print at the bottom of the proposal, ‘Oh, we need a database for this.’ No costing or anything like that and then it lands on your desk.

So they kind of forget about the whole infrastructure component around IT. So you’re wondering where the hell you are going to put this new system and whether you are going to attach it to some other database or some other system, or whether you are going to make a brand new one or buy something from a vendor. How you are going to integrate it with all your other systems.

Phil Brimacombe: One of our disasters lately was a problem with the payroll, when we had the fire and the power outage and the main payroll server is based at

North Shore. Finance was saying buy a back-up box, we’ll find the capex. Here’s $10,000, just go and buy a back-up box and stick it in the payroll office which is off at a remote site.

When I found out about it, I said no, stop, you’re not doing that. It’s not as simple as that. One of my technical guys has now done an assessment of what we need to do. There’s a lot of complicated data replication across to a back-up server and you can’t just bung it in any old office. You need to put it in a proper computer room that’s got air conditioning and security and a generator.

Mobile applications

Phil Brimacombe: There’s a whole bewildering array of devices. That’s the trouble. Every vendor and his dog is producing a phone or a smart phone or a PDA or a tablet or a laptop. The ideal is for an always on, real-time online device, but of course the cellular networks are not reliable enough.

I’ve seen a Linux tablet recently that looks really good. It’s small and it’s cheap but it’s still got a decent size screen and you can bring up a normal size keyboard or you can use a stylus. But when you come back to the office it sits in a docking station to which you can attach a normal keyboard and mouse and it’s connected to the LAN. It’s also an open source device. Now I’ve just got to get around not paying Microsoft licences and then that device becomes an attractive proposition.

In the panel:

Phil Brimacombe, Counties Manukau District Health Board (DHB) and Waitemata DHB

Tony Cooke, Hutt Valley DHB

Chris Dever, Canterbury DHB

Alan Grainer, Waikato DHB

Gary Ireland, Wairarapa DHB

Steve Mayo-Smith, Auckland DHB

Andre Snoxall, Capital & Coast DHB

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