Executive Summary
This report evaluates the current implementation level of HIS, PACS, EHRs, and HIEs in the UK and Australia. The health information system (HIS) provides a promise of improved clinical outcomes and efficiency in these countries. An overview of the country profiles reveals that the UK spends more on health care than Australia (9.6% vs. 9.4%). Further, the UK’s healthcare resources are better than those of Australia are.
The UK physician and hospital bed population are 8.2 and 2.8 per 1000 people compared to 3.39 and 3.36 in Australia. Each country uses a different model to deploy the HIS and PACS systems. While the UK’s deployment has used regional clusters, the Australian system has employed a state-level Enterprise Imaging Repository (EIR). With regard to EHRs, although the UK leads in the physician use of EMRs, its Care Record has limited information exchange capacity compared to Australia’s PCEHR due to interoperability issues. The two countries use a centralized data repository to facilitate a secure exchange of patient health data between providers.
Introduction
The purpose of this report is to evaluate national implementations of health information systems (HIS) in the UK and Australia. The two countries have implemented large-scale health information systems to improve clinical work processes and support health care policy formulation and implementation. Such systems provide data on the prevailing health determinants, value of investments, performance indicators, health outcomes, and health inequalities within a country (OECD par. 2).
The two countries’ HIS and PACS performance and deployment approach, EHR status, and HIE status fall within the scope of this evaluation. The approach adopted involves a systematic search and analysis of country-specific data related to the implementation of HIS in the two countries, as reported in literature. This report will be limited to the contexts, deployments, and status of the healthcare technologies in the two countries.
Country Profiles
UK
The demographic data of the UK, according to the World Health Organization [WHO] (2015) report, show that the country has a total population of 64.1 million, a median age of 39.8 years, a life expectancy of 82.8 (female) and 78.8 (male) years, and a GDP of US$36,327 (par. 6). The percentage of the UK’s GDP that goes into health is 9.6%. The country has an open economy with adequate investment in science and technology. The unemployment rate dropped to 5% in 2016 (OECD par. 5). However, the Brexit referendum outcome has had an impact on productivity growth. The new strategies implemented focus on university-industry collaborations to boost competitiveness.
Australia
The 2015 WHO estimates show that Australia has a total population of about 24 million (par. 12). Its gross national income per capita (purchasing power parity) is $42. The life expectancy at birth stands at 81/85 years with the probability of death or mortality rate (15-60 years) being 74/44 per 1000 people (OECD par. 11). The country’s per capita healthcare expenditure is $4,357, while the proportion of GDP spent on health is 9.4%. Over the past decade, the growth in the Australia’s labor productivity has been the highest among the OECD countries (OECD par. 15). The economy is reliant on coal and iron exports. Current government strategies/policies aim at promoting business innovation and entrepreneurship.
Country Health System Overview
The Department of Health (DOH) manages the entire UK healthcare system. The national health services (NHS), a separate entity, controls the local clinical commissioning group (CCG) initiatives to attain the set health goals and efficiency. In Australia, the local governments receive federal funds to coordinate local services through regional health boards. Public health financing involves the NHS, which provides universal coverage to residents.
It receives its funding from taxes, copayments, and payments from private patients. In the UK, 84% of health care expenditure comes from taxes. Further, the number of physicians and nurses per 1000 population is 2.8 and 8.2, respectively. The number of hospital beds per 1000 population is 2.8, a ranking of 28 out of 34 OECD countries. The WHO report puts the UK’s morbidity rate, as indicated by disability-adjusted life years (DALYs), at 8,949 per 100,000 persons (par. 4). The main indicators accounting for the high disease burden include ischemic conditions (25.4%), COPD (4.0%), and stroke (9.1%).
The Australian healthcare system comprises both public and private providers involved in primary and secondary care. Local health networks (LHNs) provide coordinated services to reduce disparities across the country. Other models of care include clinics and tele-health services. Healthcare funding mainly involves the Medicare program, a universal coverage plan that caters for medical treatment and pharmaceuticals. The Australian physician population stands at 3.39 per 1000 people. Further, the number of beds in acute care facilities is 3.36 per 1000 population, while the average LOS is estimated to be 4.8 days. Australia’s disease burden (DALYs) is attributed to cancer (19%) and heart disease (15%).
HIS and PACS Deployments
The UK (England, Scotland, N. Ireland, and Wales) has made considerable progress in the deployment of the Health Information System (HIS) and Picture Archiving and Communication Systems (PACS) through the NHS-led National Program for IT (NPfIT) initiated in 2002. The HIS and PACS were deployed to secondary and tertiary (specialist) hospital clusters in the different regions. The hospital-wide PACS facilitates access to data (images) by practitioners within the radiology department as well as those in other wards and clinics (Sutton 244).
The purpose of the NPfIT program was to “develop and implement an integrated IT infrastructure and systems” for all hospitals in the UK (Sutton 246). To realize its full benefits, the national PACS program was launched across the country beginning in 2007. Within three years, PACS was deployed to 127 hospital trusts in the country. The model used in PACS deployment divides the UK into regional clusters that are individually run by a local service provider (LSP) (Mossialos and Wenzl par. 6). The LSP’s role entails contracting the PACS provider and, in certain regions, a Radiology Information System (RIS) supplier (Mossialos and Wenzl par. 9). The key characteristics of each cluster relate to the online storage archives provided to hospitals by PACS providers in each cluster.
In this model, England has five regional clusters, including London and North East. Presently, there are three PACS providers in England due to the unification of the five clusters into three areas. Providers of other HIS components, e.g., RIS, have also been merged. In contrast, in Scotland, a centralized PACS provider offers cluster data archives to facilities in forty sites and a central unit that supports “long-term data storage and sharing” across all sites (Sutton 249).
For Wales, current efforts aim at integrating various PACS and RIS solutions to avoid the need for PACS contract renewal. The distributed PACS architecture facilitates information sharing through the XDS-1. Finally, for N. Ireland, a unified PACS/RIS product (NIPACS) has been deployed in five healthcare authorities (Sutton 249). The model involves a local archive and a virtual central RIS that serves 20 connecting sites for improved data storage and sharing.
In contrast, the Australian PACS model entails a state-level Enterprise Imaging Repository (EIR). The EIR serves as a central archive of images and reports that is accessible to practitioners in all hospitals (Unwin and Sanzogni 4). The EIR connects more than 100 healthcare centers across Australia. Accessing the archived data involves the use of patient identifiers through three HIS components, namely, EHR, RIS, and PACS systems. It provides practitioners with an immediate access to past patient reports and images for fast and accurate diagnoses and interventions.
The EIR system archives data obtained using PACS-RIS that are deployed in all states. The first step of the deployment involved the provision of PACS-RIS systems to hospitals. The aim was to offer a universal access to patient data across each state. The pilot project covered eight health centers that together did 400,000 radiological procedures yearly in W. Sydney, Nepean Blue Mountains, and Westmead (Unwin and Sanzogni 7). The statewide EIR system allowed clinicians to track patients across different care facilities. Later, the system was launched in 15 local health districts (LHDs) in the New South Wales State. All clinicians within NSW can access the EIR system for an in-depth review of the patient’s status based on archived data and imaging reports across the state.
In the other states, the multimodal HIS systems implemented in hospitals have a reduced interoperability, which hampers data sharing. In addition, the data outputs are largely incompatible with EHRs and must first be converted to the correct format. Protection protocols also limit data exchange across platforms to support clinical decisions and diagnoses. Most hospitals use multi-modality systems, which limits data sharing because the information is stored in a local workstation (Unwin and Sanzogni 9). Further, most of the multi-modality systems cannot process 2D/3D images that would allow the clinician to make an accurate diagnosis.
The Current EHR Status
The UK NPfIT program aimed for regional deployments of EHRs with an “interoperability spine” that would link all NHS trusts through applications such as e-prescription (Payne 91). However, the EHR adoption has been slow. Under the NPfIT program, it was envisioned that the implementation of the NHS Care Record across the UK would be completed in four years. However, while most providers adopted EHR systems, there was no central information exchange to facilitate data exchange. The national Care Record project failed due to the problem of interoperability. The national government had invested over $24bn in trying to complete the project.
Currently, the NHS uses the GP2GP system to allow the exchange of patient health records between general practitioners (GPs). The system enables the practitioner to send a patient’s record electronically to the GP treating the patient. In the UK, electronic medical records (EMRs) in general practices have been in existence for a long time. The UK adoption rate of EMRs stands at 97%, which is the third highest globally (OECD par. 16). EMRs are used in most practices and hospitals. However, the GP health record is not interoperable with the NHS Care Record (OECD par. 16). Further, the UK legal system bars GPs from sharing patient data, except in special cases. Thus, the legal and political factors hamper patient data sharing across practices in the UK.
The GP2GP program seeks to achieve greater interoperability of patient records. It will enable practitioners and healthcare centers to share complete medical records between themselves. The GP2GP systems currently deployed to support patient record exchange in primary care settings include the “EMIS Health, SystmOne, iSOFT, and INPS Vision” (OECD par. 19). The Scottish NHS deployed the GPASS system in 2013 to support EHR exchange. Since 2014, various hospitals have implemented these systems to enable the online patient scheduling, e-prescriptions, and online retrieval of patient data and record.
In Australia, the EHR currently in use is the personally controlled electronic health record (PCEHR), also called ‘My Health Record’. This EHR program was first deployed at the territorial, state, and national levels in 2012. From a technological perspective, Australia has the requisite national assets for supporting an EHR system. First, a large majority of the country’s GPs and medical specialists use computer systems in their respective practices, including for online billing, patient scheduling, and accessing radiology images (Xu et al. 93). It is estimated that the internet is available to over 96% of GPs, while another 95% of GPs use EMRs in their practice (Xu et al. 93).
Second, all public healthcare centers have computerized their clinical processes, providing adequate infrastructure for EHR deployment. Nationally, 85% of the citizens use the internet (Xu et al. 94). The widespread use of the internet in Australia provides a basis for rolling out EHRs in the country.
The process of developing EHRs for the Australian healthcare system began in 2004 with the piloting of MediConnect, a repository for medication information. MediConnect success as an integrated system was the impetus for the nationwide deployment of HealthConnect that brought together different EHRs implemented in various states in 2009. Between 2010 and 2012, federal investment in health IT saw the launch of the national PCEHR that integrated all the functions and elements of the other systems (Xu et al. 93). Besides the national IT infrastructure, the government has enacted important legislations for EHR project development and implementation.
The status of EHRs in Australia is characterized by high utilization rates by patients and GPs. It is estimated that a patient interacts with providers at least 22 times annually, including GP visits and prescriptions (Xu et al. 96). With the deployment of PCEHR, patient health information, including lab results, drugs received, Medicare data, and demographics, are captured through this EHR system. Further, the PCEHR allows for real-time access to critical data.
However, while Australia and the UK have a high EHR utilization rate (>90%), fewer than 10% of the hospitals have adopted these systems. Australia has invested heavily in the PCEHR system. In the 2012-2014 periods, $233.7m was invested in improving the PCEHR system (Xu et al. 99). The heavy investment in this EHR system aims at improving patient outcomes and clinical efficiency.
The Current HIE Status
The UK achieved a robust health information exchange (HIE) through favorable policy options, acquisition of computing resources, and utilization of financial/clinical incentives (Payne 91). Therefore, the main national assets contributing to improved HIE in the UK include established legal and ethical models, incentives, and applications. The UK policy initiatives aim to protect patient health information by providing a framework for secure information exchange.
Additional national assets for supporting HIE include the institutional Caldicott Guardians (‘conscience’ individuals), an independent National Information Governance Board, secure NHS Net, unique patient and clinician identifiers, and national standards (Payne 93). All these efforts are meant to address legal and ethical issues related to patient confidentiality and information disclosure.
The UK health information exchange also involves incentives. The NHS uses financial and clinical incentives to promote secure electronic exchange of patient’s data by GPs and other staff. In particular, the GPs or Trusts receive reimbursements for “software, hardware, and maintenance” (Payne 96). However, only certified EMRs that meet the NHS standards as prescribed under the Common Assurance Program are eligible for compensation. The standards prescribe the procedure of sending patient data via the ‘Spine’ to make it accessible to other GPs.
The British Medical Association also supports electronic HIE through financial penalties to GPs (salary cuts) and hospitals failing to submit a discharge summary within 48 hours (Menachemi and Singh 11). The incentives/disincentives aim to foster compliance with the use of deployed applications. The NHS requires GPs and hospitals to use the ‘Spine’, a program that integrates several applications, such as “Choose and Book, Patient Demographic Service, GP2GP, and EPS1” (Menachemi and Singh 15).
The GPs use smartcards to access the applications and data via the ‘Spine’. The GP2GP allows a GP to share a patient record with a provider based in a community healthcare center. In contrast, the ‘Choose and Book’ application facilitates patient scheduling and clinical visit management. The Electronic Prescription Service 1 (EPS1) helps the pharmacist to retrieve a patient’s e-prescription records from the Spine during pharmacy visits.
In Australia, the National E-Health Transition Authority (NEHTA) coordinates health information exchange through various measures. The organization prescribes the “national data standards, exchange standards, and security frameworks” for the national PCEHR (Xu et al. 93). However, vendors collaborating with state and territorial authorities have facilitated the development of the country’s IT infrastructure (Mettler 106). The NEHTA implements the Healthcare Identifier Service.
This unique national identifier helps address the problem of limited interoperability that was seen in earlier EHRs in Australia. NEHTA also controls the PCEHR platform, which is a central data archive populated with data from multiple sources. Therefore, the PCEHR system provides an avenue for health information exchange between practitioners (Xu et al. 95). Practitioners can access patient data in the PCEHR using the unique identifiers. Therefore, the key national assets for HIE in the Australian context include the PCEHR system, established exchange standards, and national identifiers.
In NSW, a central data repository has been deployed to support health information exchange between providers. Public healthcare facilities with ER department populate this repository with records of ER visits through an area HIE system (Hughes 15). NSW hospitals are required to submit emergency room data either weekly or monthly. Subsequently, data quality checks are performed at all levels to remove redundancies and errors. Currently, the central repository is populated with data from 87 ER departments across NSW. Data on three ER measures are submitted to the NWS repository, namely, “off-stretcher time, ER admissions, and triage until treatment performance” (Hughes 17). The data are periodically uploaded to the HIE reference platform of the Department of Health.
The unique identifiers are the digital certificates created based on pre-approved Australian standards. The digital certificates are given to providers and facilities that have been approved by the Health Identifiers Service (Xu et al. 98). An organization called NASH authenticates the providers accessing the PCEHR system through the Public Key Infrastructure (PKI). In addition, patient health information is exchanged in an encrypted format. Therefore, the PKI supports user authentication, data integrity, non-repudiation, and confidentiality (Xu et al. 98). Patient confidentiality is achieved through data encryption, which ensures that only the intended recipient can read the contents of the record sent.
Works Cited
Hughes, James. “NSW Public Hospitals Accessing Digital Radiology Images.” Cardiovascular Diagnosis Therapy, vol. 2, no. 4, 2012, pp. 14-19.
Menachemi, Nir, and Sanjay Singh. Health Information Technology in the International Context. Emerald Group Publishing, 2012.
Mettler, Tobias. “Anticipating Mismatches of HIT Investments: Developing a Viability-fit Model for E-health Services.” International Journal of Medical Informatics, vol. 85, no. 1, pp. 104–115.
Mossialos, Elias, and Martin Wenzl. International Profiles of Health Care Systems. World Commonwealth Fund, 2015. Web.
OECD: OECD Reviews of Health Care Quality: United Kingdom 2016. OECD. Web.
Payne, Thomas, et al. “National-scale Clinical Information Exchange in the United Kingdom: Lessons for the United States.” Journal of American Medical Informatics Association, vol. 18, no. 1, 2016, pp. 91-98.
Sutton, Laurence. “PACS and Diagnostic Imaging Service Delivery: A UK Perspective.” European Journal of Radiology, vol. 78, no. 4, 2011, pp. 243–249.
Unwin, Duncan, and Louis Sanzogni. HIT in Australian Hospitals – Evidence of Benefits in a Systematic Review. Melbourne: 24th Australasian Conference on Information Systems, 2013.
World Health Organization: Health Information Systems. World Health Organization, 2015. Web.
Xu, Jun, et al. “Implementation of E-health Record Systems in Australia.” The International Technology Management Review, vol. 3, no. 2, 2013, pp. 92-104.