Factors influencing Health IT Policy in New Zealand: Evidence, Pragmatism, Money and the Policy Process
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This document summarizes a study examining factors that influence health IT policy in New Zealand. It finds that scientific evidence plays a small role in policy development and four main factors have more influence: foundations of evidence definitions; leadership priorities; funding availability; and the rapid pace of the policy process. The study concludes that incorporating different evidence sources could improve policy quality by better addressing stakeholders' needs within time constraints.
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Factors influencing Health IT Policy in New Zealand: Evidence, Pragmatism, Money and the Policy Process
- 1. 2011 FACTORS INFLUENCING HEALTH IT POLICY IN NEW ZEALAND: Evidence, Pragmatism, Money and the Policy Process 24 November 2011 Nouran Ragaban, MPH (PhD Student) With: Drs. Karen Day & Martin Orr
- 2. Overview • Objectives • Background • Methods • Findings • Examining the Influencing Factors • Future Direction 2011
- 3. Objectives • Explore the role of research evidence in health information strategy in New Zealand • Examine any compounding factors affecting the use of that evidence 2011
- 4. Background Willing is not enough. We must do. - Johann Wolfgang von Goethe • There are rapid and extensive changes occurring within the healthcare sector: – populations with longer life spans – higher demand for healthcare services – shortages within the healthcare profession – health system facing concerns around quality of care, medical errors, and waste of resources • The use of information technology has become necessary to manage these demands on global healthcare 2011
- 5. Background • New Zealand has undergone a substantial shift from paper-based records to an electronic form of keeping patient and medical data • Policy was an essential facilitator in the adoption of those health IT systems • Support can be lent to policymakers in using various forms of evidence to aid in priority setting 2010 “National 2005 Health IT “Health Plan” 2001 Information “Working to Strategy for Add Value to New Zealand E-Information (HIS-NZ)” 1996 (WAVE “Health Report)” Information Strategy for 2011 the year 2000”
- 6. Terminology Evidence • „Evidence‟ in the health context refers to the characteristics of the scientific knowledge that exists • Contention on how to categorize the different types of evidence, opinion, knowledge, etc. • Different categories and levels of evidence • The scope of evidence was expanded • What is the evidence and what role is it playing? 2011
- 7. Context The NHITP was up for discussion 2011
- 8. Methods 6 Domains of Knowledge 1. Innovation: Refers to the health information strategies (and health IT systems utilized). 2. Innovator: One who invents the Innovation but can also be further identified as innovators of improvement. a. Creator b. Improvement 2. Implementer: Those who facilitate the implementation and adaption of the Innovation. 3. Individual: Individuals are people who use the Innovation within the „Invironment‟. 4. Investor: Invests money, time or clinical expertise a. Financial b. Resources c. Clinical Knowledge 6. ‘Invironment’: The larger landscape within which the Innovation is developed and implemented.
- 9. Methods One-on-One Interviews 9 HEALTH SYSTEM EXPERTS INTERVIEW SCHEDULE Question 1. Discuss in general the New Zealand Health Information Strategy and the role of evidence in developing these strategies. Question 2. What are considered sources of evidence (scientific versus other sources)? Question 3. Is the policy process open to taking in evidence? 2011
- 10. Findings • Indication that research evidence does not play a large role in developing strategy • The industry is looking for evidence to change decision-making • Role evidence should play vs. role evidence plays • Four main factors emerged: foundational, leadership, funding variables and the policy process itself. 2011
- 11. Findings Factor: Foundational …So it comes down to your definition of evidence. If your definition of evidence is • „How do you define evidence?‟ that there have been rigorous double blind clinical trials that say this way is better than – discussed it in research-oriented that way, then there are only a small number terms of areas within information systems where you have that amount of rigor to be able to rely on. (Expert F) • Only a few areas within health IT where that amount of detailed and validated information is available • International evidence but an absence of a specific health IT So, they can’t wait for the evidence and it’s no particular one nation’s problem to evidence base generate the evidence… But policy certainly has a lot of things to consider. And the evidence is not in a format such • Scientific evidence is currently that it’s going to be everything. It’s going playing only a small role. to say okay, this was effective in this context, in this situation. But does that mean that you can run to an emulation of it? (Expert D) 2011
- 12. Findings Factor: Leadership So, obviously the scientific paradigm says that evidence is key, yet I think one has to be very careful in how they integrate • Role of clinical as well as evidence as compared to taking clinical political leadership judgment in this broad way, particularly clinical judgment of their work flows. (Expert D) • The pragmatic convenience in using government leaders‟ judgments and clinical With the vast majority of every day, it comes leadership either in lieu of or in down to individual clinicians best judgment, of the people who are clinically leading the combination with scientific project, as to what is or is not appropriate. evidence (Expert F) • Clinical input in fact became I think it is generally based on the information source (the consensus… the consensus approach to source of evidence) strategy development is probably more pragmatic and more sensible. (Expert B) 2011
- 13. Findings Factor: Funding Variables • Scarcity of financial resources There are other things that come in to the leading to policies being mix. Things like funding opportunities, if someone is prepared to fund something to be informed by economic done. Then it’s funny how that gets a higher imperatives priority than perhaps a more worthwhile piece of work from an evidence perspective, but which has no funding behind it. (Expert F) • The issues around funding and resource availability centred around three discussion topics: 1. financial availability as a source of evidence in lieu of scientific evidence 2. financial availability used in combination with scientific evidence 3. financial availability used to trump So, evidence works as far as it can and then scientific evidence even when it is when money becomes an obstacle you just have available. to go, pity but we’re just not going to go there. (Expert H) 2011
- 14. Findings Factor: Policy Process … That’s standard procedure for governments. That there are so many pressures and realities driving these things. • The policy process occurs at a (Expert D) rapid pace, a pace much faster than the research cycle There’s always an urgency to act. You have • The time constraints and to have a plan. You have to have a policy. It looks really bad if you don’t have any of it. variation between the two (Expert D) cycles inhibiting the degree to which policies are informed • Urgency to act and develop … My understanding of the approach is that health IT policies in this country effectively, projects that would be undertaken would be piloted or there would be a test implementation at a particular location and then • Often there is not enough time we would move to developing an evidence base to wait for or generate the based on that experience which would then inform subsequent implementation. (Expert B) evidence base relevant to the health issue being addressed 2011
- 15. Summary & Key Points • Different modes of evidence exist in informing policy • Good quality policy making depends on high quality information from a variety of sources • The scale of the availability of scientific evidence varies, indicating the need to consider all the best available sources • Greater incorporation of the various evidence sources will help improve policy formulation 2011
- 16. It is clear that there are deficits in how Government obtains and uses knowledge and evidence and this must affect the quality of policy formation. 2011
- 17. Future Direction • Policy process involves many • Differences between what stakeholders with their own organizations need and what priorities they have; appropriate tools are needed to reduce those • Policy can get in way of differences successful health IT implementation at other times • Identify the necessary political it works - want to see where tools to facilitate that these meet and how to use this to inform policy 2011
- 18. Contact Nouran Ragaban n.ragaban@auckland.ac.nz THANK YOU! 2011
Notes de l'éditeur
- So, for this research, we wanted to explore the role of research evidence in health information strategy in New Zealand and examine whether any compounding factors affected the use of that evidence.So, why did we think it was important to begin looking into this? {Leads to background}
- As you are aware, there are rapid and extensive changes occurring within the healthcare sector. Although the way healthcare is provided varies globally, there are common factors that are present among all countries that are influencing healthcare delivery. These challenges within the healthcare sector include: the rise of the ageing population, the advent of new technologies and knowledge, and healthcare systems facing concerns around quality of care and waste of resources, among other things. And so health information systems, like electronic health records, have been receiving attention as systems to answer crucial healthcare sector issues. At the heart of the development and implementation of these systems is the political drive for change. {Lead into Background}
- These political forces in New Zealand have permitted the country to set standards, funding and communication within the health sector.Over the past decade and beyond, NZ has undergone a substantial shift from paper-based records to an electronic form of keeping patient and medical data. As you can see from the figure:In 1996 there was the Health Information Strategy for the year 2000, followed by the WAVE report, and more recently, the national health IT plan. This shift with the aid of these policies has had a significant effect on the health system in New Zealand, allowing the country to become a frontrunner in its use of computerized health technology.Of particular interest for us was to examine what role scientific evidence plays in developing New Zealand health IT strategies. So, what do we mean when we refer to scientific or research evidence? {Lead into terminology}
- The past two decades have seen a growing emphasis on basing healthcare decisions on the best available evidence. This evidence encompasses all facets of healthcare, and includes decisions related to the care of an individual, an organization or at the policy level.‘Evidence’ in the health context refers to the characteristics of the scientific knowledge that exists, for example reporting through methods such as randomized control trials, meta-analysis or systematic reviews (as you can see from the figure). However, there is contention on how to categorize the different types of evidence, opinion, knowledge, etc. There is no single, universally-accepted hierarchy of evidence.The variety of hierarchies are widely discussed in the literature but what happens in practice is influenced by a range of factors. Our research sets out to identify and explore those factors. {Leads into Context}
- At the time that this research was starting (early in 2010), the National Health IT Plan draft was up for discussion. This was very useful for us because it meant that we would be able to hear about how the process has worked before when strategies were created and consolidated and how things occurring now.It also meant that we had a wide range of individuals that we could talk to during this consultation phase. So, we needed a way to choose a good amount of people with a diverse background. {Leads into the 6 Domains of Knowledge}
- To ensure that participants came from varied backgrounds, Day and Orr’s characteristics of the six domains of knowledge were used, and adapted for this research. We recruited participants who have experience in one or more of the knowledge domains to lend sufficient scope for conclusions to be drawn. The six domains are: Innovation, Innovator, Implementer, Individual, Investor and ‘Invironment’. The characteristics and sub-characteristics of the six domains are shown here.These knowledge domains encapsulate all aspects of experience from creating and improving health information strategies and health IT systems to investing time, money or clinical expertise in decision-making.So, we used these to select our participants, and this is how they fit in {Leads into the participant table and interview schedule}
- The table here shows how the nine participants fit under those six domains. And you can see the diversity of the participantsBelow that is a condensed version of the interview schedule. The questions were generally open-ended (with probes to help focus the discussion) about the role of evidence in developing policy and specifically health IT strategies. This meant that participants could draw on their experiences while putting their responses within the New Zealand context. {Leads into findings}
- So, what did we find?All of the participants indicated that evidence (in the stricter definition)generally does not play a large role in developing strategy. However, they did indicate that the industry is looking for evidence to change decision-making. This was expressed in different ways by the participants but one expert summarized it well saying:You can find evidence for and against certain arguments. It’s not the end-all be-all but it’s certainly helpful to have a look around... Certainly, doing research before you start changing things to understand what the problem is... As that shows, there is a realization ofthe importance of using evidence to drive strategy. The point of contention then becamewhat role evidence should play versus what role evidence actually plays.Theoretically, we want evidence to play a substantial role in informing policy. However, that is not always the case. In conducting the interviews it became apparent that although many of them wanted evidence to play a larger role, there were certain factors that affected the use of evidence.The four main factors that will be discussed are: foundational, leadership, funding variables and the policy process itself. {Lead into foundational}
- It was clear that when explaining the role of evidence, all participants automatically discussed it in research-oriented terms. One expert summed it up nicely by saying:…So it comes down to your definition of evidence. If your definition of evidence is that there have been rigorous double blind clinical trials that say this way is better than that way, then there are only a small number of areas within information systems where you have that amount of rigor to be able to rely on.Evidence availability is another issue that was consistently brought up in most of the interviews. It was believed that the scientific evidence needed is not always available. In lieu of of that, it was mentioned that sometimes white papers were used. There was also agreement that because the country is leading the way in using health IT solutions, it is sometimes difficult to know exactly what evidence should be used to build it up. Although not always directly transferable, seeing what another nation has done lends more credence as evidence as well. It can help identify what can and cannot be done and further indicate areas where changes can be made.As discussions around the evidence itself went on, it was stressed that these challenges point out the need to define a range of sources to support the development of policy.What it does indicate is that the type of evidence and what is deemed evidence that can inform policy needs to be expanded to be drawn from different locales. {Lead into Leadership}
- And so, one of these factors is leadership. As each participant’s dialogue shifted away from scientific evidence to other sources, the role of leadership started to enter the discussion. The shift went primarily onto the role of clinical as well as political leadership.This factor refers to the pragmatic convenience in using government leaders’ judgments and clinical leadership either in lieu of or in combination with scientific evidence. It’s the consensus approach that plays a role in driving policy.As one expert stated: With the vast majority of every day, it comes down to individual clinicians best judgment, of the people who are clinically leading the project, as to what is or is not appropriate.This raised the point that due to practicality and the lack of availability or validity of some of the scientific evidence, clinical experience and leadership plays a larger role. They deemed this important because clinical judgment incorporates training and frontline experience. Again, the degree to which they should have input was contested between the experts and lent even more support to the view that there should be a combination of evidential sources to aid decision-making. Nonetheless, the consolidation process by the National Health IT Board was praised for recognizing the importance of integrating evidence that goes beyond scientific research and clinical knowledge alone. {Lead into Financial}
- Throughout each interview, the point was raised that resource availability also has a big impact on what role evidence plays in developing policy decisions. Resource availability refers to scarcity of financial resources leading to policies being informed by economic imperatives.The issues around funding and resource availability centred around three discussion topics: financial availability as a source of evidence, financial resources used in combination with scientific evidence and financial resourcesused to trump scientific evidence even when it is available.Each participant clearly identified interplay between the consensus opinion of the leadership with financial availability in driving health IT policy. They all indicated that the public health system has limited resources to achieve a multitude of national priorities. As a result, they have seen that the limited time and resources drive the disincentive to always source and attain scientific evidence. It is easier to do what has been decided based on the knowledge and feedback from leadership, with the financing that is available sometimes as the lead driver. {leads into Policy Process}
- Lastly, all this all leads to the fact that they wanted the policy process to work with evidence. However, the policy process occurs at a rapid pace, a pace they all indicated as being paced faster than the research cycle. This factor refers to the time constraints and variation between the two cycles which can inhibit the degree to which policies are informed by scientific research. What all the participants emphasized was that there is an urgency to act and develop health policies in this country. Often there is not enough time to wait for or generate the evidence base relevant to the issue being addressed.One expert stated it very well by saying:There’s always an urgency to act. You have to have a plan. You have to have a policy. It looks really bad if you don’t have any of it.If the requirement is to have a strong scientific evidence base to inform strategy, then some of them believed that a lot of time will be spent on that process.However, there were indications that this was changing. Some spoke of instances within the country where literature reviews have been commissioned and that information was fed back to the Ministry of Health to aid in policy development. A mixture of examples was given by the interviewees with some even recollecting cases where evidence from pilot projects within the country was incorporated into the policy process. So, evidence was generated post-policy implementation and fed back in. {Lead into Summary}
- Through a series of interviews our research indicates that different modes of evidence exist in informing policy (not just research alone). The findings indicate that although scientific evidence currently plays a small role in decision-making, a multitude of factors impact how evidence is utilized.The scale of the availability of evidence varies, and there is a need to consider all the best available evidence and options to inform better policy decisions. The combination of different sources of evidence can enhance the evidence base and help lessen uncertainties in decision-making. The implications for the future of policymaking in terms of using evidence as a foundation is heightened by the fact that the health IT system infrastructure needs to line up with the nation’s health priorities. Over time, greater incorporation of the various evidence sources will help improve policy formulation.
- I wanted to point out that when this research was completed, so was the Chief Science Advisor to the Prime Minister’s discussion paper ‘Towards better use of evidence in policy formation’ which was published earlier this year.They looked at health policy in general and stated that ‘It was clear that there are deficits in how Government obtains and uses knowledge and evidence and this must affect the quality of policy formation.’So, this got me further interested in health IT policy and has lead to my current work {leads into Future Direction}
- I realized that with policy, there is no singular entity making all the caveats of what is necessary to insure implementation and adoption.The policy process involves many stakeholders establishing and enforcing their priorities. The decision-making process involves all levels of government with input from citizens, interest groups, the media and so on.The research objective is to identify issues of importance to health IT implementation and systematically identify where current policy is inadequate (from an international viewpoint}. Successful health IT implementation may not result from simple adoption but rather from accompanying changes and pertinent infrastructure. There are differences between what organizations need and what they have. Thus, appropriate tools are needed to reduce those differences. The aim is to identify the necessary political tools to facilitate that. And that’s where my work is going currently. {Leads into final slide}
- Thank you again for your time today, this is my contact information and please feel free to contact me. Thank you very much!