Nursing Informatics in Pacific Rim,Asia and South america

Pacific rim

The evolution of NI has varied in each of the pacific Rim countries.The adoption of informatics usually began as a vision by one or more individual.Such people used any number of opportunities plus their leadership skills to promote and disseminate the use of information technology  to support nurses  in all areas of nursing practice .This occurred in healthcare ,education, and government organizations, as well as within the IT industry and via any number of new and existing professional organization . Events external to the nursing  profession frequently became the catalyst stimulating some type of activity by nurses towards the adoption of informatics.International and multidisciplinary links have assisted theses beginning and its progression. Australia, New Zealand , and Hong Kong have made considerable progress since the early 1980s,South Korea since the 1990s in this regard, although much remains to be done.Nurses in a number  of other countries  in this region have only just begun or have yet to learn about NI although introduction and use of these technologies in the industry is progressing  rapidly especially in Malaysia and Japan.

The Asia pacific Medical

Informatics Association was formed in 1993 as regional group of the international Medical Informatics Association . APAMI has helped launch national healthcare informatics association in Malaysia,Indonesia, and the Philippines and has generated  awareness about the field in India, Pakistan,Sri Lanka, and Fiji.Other member nations are Australia, Hong Kong , japan, Korea,New Zealand, the Peoples Republic of china, Singapore,Taiwan, and Thailand. Nurses who are interested  in promoting informatics to their profession need to link up  with this network.Evidenced  suggests that many nurses continue to have some difficulty in embracing these technologies to support their practice ( Ho and Hovenga,1999,2003). Furthermore it continues to be a challenge for many nurses to obtain appropriate education in informatics both  during their initial nurse education and as a component of post- nurse registration specialist courses.Notwithstanding these conditions,an increase in computer use by practicing nurses in Australia, New Zealand ,and other Asia Pacific countries is creating an awareness of the opportunities and gains to healthcare resulting from an increase in the use of computers ,information,and telecommunication technologies.Thus, the nurses in all health environments are becoming more dependent on electronic information.

Health and Nursing Informatics in New Zealand

• New Zealand’s total population is just over 4 million. These people are predominantly found in the urban areas,with the greater Auckland  area having over a third of the total population.
•  In 2003 ,there were 32,687 active registered nurses and midwives working in nursing and midwifery in New Zealand. With most of the nurses and midwives practicing  in Auckland ,this city by default becomes the focus of the drive for greater health informatics awareness.
  
• Notable changes have occurred  within New Zealand nursing legislation that impact on the roles and future                           of nurses. 
• Firstly , in line with international trends  in nursing workforce development , the Nursing Council of New Zealand established the new role of nurse practitioner. Then in 2003 , legislation was passed permitting nurse prescribing.
•  At this early stage there are only  a few of Nurse practitioners and fewer nurses prescribing ,but there is clearly a move toward further  postgraduate education to attain these new nursing roles. 
• The impact of globalization  has seen an increase  in the movement of nurses in and out  of New Zealand , which increases the challenges for the  Nursing Council  in terms of ensuring  safety practice  at the level expected in New Zealand  while not providing necessary barriers for overseas nurses.

 As part of ensuring standards of practice the government passed the Health  Practitioners Competence  Assurance  (HPCA) Act (2003). This Act came into force  in 2004 and replaced the Nurses Act of 1977. The HPCA Act 2003 requires each  health practitioner group to describe its profession  in terms of scopes of practice and to ensure the safety of the public by defining  the health services that health practitioners can perform.

 Changes  are continuous in the informatics arena and there are many sources and pressure for these.

The hub labeled “ informatics influences “ represents information  collection, since  this is seen as central  to nursing, informatics , and healthcare. The other entities  identified are significant  player’s in  New Zealand’s healthcare system, which  influences NI  and it’s development.

Health and Nursing Informatics  in Australia

• Australia is a federation of eight states and territories. It has a population of just fewer than 20 million .
• Approximately 71% of all it’s households are located in inner and outer urban and provincial areas, mostly near cities on the coast.
•  In 2001 ,the national census indicated that there were 1,259 nursing workers per 100,000 population where 51%  worked less than 35 hours per week ( AIH &W,2004a,p.229)

• Around 225,000 registered (80%)  and enrolled (20%) nurses  are employed in acute care hospitals (65%), aged and community care (35%) in Australia. Of these 89% are employed as clinical nurses mostly within the following specialities : medical surgical(30%), geriatrics and gerontology (17%),operating  theather  and related nursing (7%) , midwifery, obstetrics and gynecology(7%),and mental health (7%).(Karmel and Li,2002). 
• The trend suggest we increasingly need a greater proportion of nurses in the aged and community care sectors as a result of projected population demographic changes. 
• As a consequence of the globalization of the profession, Australia's  contribution to international education,the resultant  workforce mobility, economic growth, and changes in the healthcare industry  resulting  from technology  and in informatics advances, changes are being witnessed in the nursing workforce.
• Credentialing and accreditation  of  nursing specialties is now  being promoted.Nursing  specialty and other organization have developed and adopted practice standards, competencies,guidance for curricula development , and various professional  development program. 
  
• Australia has more than 50 specialty nursing organizations, where the health care informatics spacial interest group(HISA NI sig) is  one of these.
• Most have developed a set of specialty competencies and they provide credentialing service. Following the November 2003 Australia Health ministers conference it was announced that a national nursing taskforce  would be established to drive major nursing education and workforce reforms as recommended by a previously  undertaken national review of nursing education. 
• Consequently the HISA NI Sig has been funded to develop a strategic NI capacity building, and a plan for nursing professions engagement with the Australian government and its informatics agenda .

Healthcare funding framework

The government ,through  the ministry of health chiefly funds healthcare in New Zealand. Overall ,the funding healthcare in New Zealand is driven by business requirements,where information is used as the basis for cost-effective quality care, given limited resources.

Healthcare is available for all resident New Zealanders via  a National System. The cost of every consultation with the general practitioner is subsidized by the government. Tertiary care is almost totally publicly funded . There  remains in New Zealand an impression that if  you have an accident or are acutely sick, then good quality public hospital care will be available. There is, however,competition between private and public healthcare in the primary and secondary arena. Elective surgery is more often provided in the private sector , although it may be funded by the public sector ,as the public hospitals struggle to cope with long waiting lists and beds full of acutely ill and injured people. The role of the private sector has increased significantly. In 1999,private insurance funded about 6% of healthcare compared with just 2% ten years ago, and given the aging population, improved options of health treatment, an increasing demands yet limited public budgets. The cost of private insurance is rising with premiums predicted to increase faster than the general cost of living. This means health insurance cost the individual more and there is a widening gap between those who need and those who can afford private healthcare.

The government also controls healthcare provision and funding through agencies such as the Accident Compensation Corporation ( ACC). The ACC provides a rage of health benefits and subsidized  to assess individuals in the event of accident. The establishment of the ACC as virtually eliminated suing for compensation in the event of an accident covered by the ACC. Information is colliated about the nature and costs associated with accidents. ACC funding is provided through levy on employers and employees. That more recently ACC has targeted accident prevention as an incentive  ,charging more to those companies and organizations that has employees/member accidents.

All prescription-related medicines are regulated the government thought Pharmac. Subsidized are available on a rage of medicines, although only a few options of each drug classification maybe subsidized by Pharmac. The public can purchase an increasing number of over the country remedies and increasing need for drug  information for medical practitioners,nurses and  the public.

In Australia work began in collaboration with Professor Fetter from Yale University during the 1980’s to develop the patient classification systems to describe the care mix services by healthcare organizations.

Since 1992 ,the Australian Refined  Diagnosis Related Group(AR-DRG) has been in use first for  the purpose of monitoring and comparison of hospital activity and later for costing and funding purposes. This Australian Hospital Information, Performance Information Program relies on data obtained from individual patient records, including the ICD-10-AM codes. A number of case- mix  systems are used in to suit a variety of patient populations. Service weights to reflect the cost of providing various hospital-based services including nursing were developed and currently in the process of being updated.  These are included in various funding formulas adopted . This case-mix system has been adopted by Germany and is being considered for adoption by other countries.

Health spending continues increase, By 2001-2002 this amounted to 9.3 % of the gross domestic product (GDP) compared with 8.9% in 1992-2000. In 2001 -2002 , the Australian

government spent 46.3% primarily on health research ,aged care,and medical services.All taxpayers contribute a 1.5% Medicare levy and high income earners who do not  have private health insurance,pay an additional 1%. States,territory and local governments spent 22.3% mainly on community and public health  services. The cost of public hospitals is shared by all governments  in accordance with specifically negotiated healthcare agreements. Nongovernmental sources such as third party payers and individual contributions amount of 31.4%. This funds is all private hospital care. The Australian  government manages Pharmaceutical Benefits Scheme (PBS) which is jointly funded by them and non-government sources(AIH&W,2004a,pp.242-247).

Professional Organization and Government Advisory Groups

Both New Zealand and Australia have many health informatics and related professional organizations and groups advising various government departments and specific projects. There tends to be a considerable over-lap of members between these.

New Zealand Health Informatics Groups

There are number of informatics interests groups in New Zealand ,each with slightly different focus.   Health informatics New Zealand (HINZ) is a national ,not-for-profit organization whose focus is to facilitate improvements in business process and patient care in  the health sector through the application of  appropriate information technologies. HINZ ,a new organization ,emerged in September 2000 from two health informatics organizations: Nursing Informatics New Zealand (NINZ) and New Zealand Health Informatics Foundation (NZHiF). NI was originally formed in 1990 and NZHiF was originally formed in 1994.HINZ does not compete with existing organizations or activities.,but assists network key and influencial partners to improve the effectiveness of health informatics business in New Zealand .HINZ act as a single portal for the collection and dissemination of information about the New Zealand Health Informatics Industry. Membership is for anyone who has an interests in health and informatics and wants to be a part of an organization


that can provide relevant up-to date information about health informatics. HINZ holds an annual conference in collaboration with other main health IT organizations.

HINZ ,in conjunction with other professional health-related groups such as New Zealand Health Information Technology Cluster,New Zealand Institute of Management ,and New Zealand Health Level 7(NZHL7) Users Group (NZHUG), jointly organizes an annual national conference as well as seminars. 

 New Zealand Health Informatics Groups

• HINZ -Health Informatics New Zealand (HINZ) as a national ,not- for-profit organization whose focus is to facilitate improvements in business processes and patient care in the health sector through the application of appropriate information technologies.HINZ has established working groups to mirror those within the International Medical  Informatics Association Special Interest Group in Nursing Information( IMIA-NI). The HINZ Nursing Informatics Working Group  is most active of HINZ group.

• NZHUG-New Zealand  Health Level 7 User Group (NZHUG) is the New Zealand arm of international Health Level of 7(HL7) organization,which has a proven  and widely used methodology for standards development. The organization is comprised of  technical committess are directly responsible for  to the organizationthe technical committees are directly responsible for the content of standards. Sigs serves as a test bed for exploring new areas  that may need coverage in Hl 7’spublised standards.
• NZHITC- The NZ Health Cluster Inc. is a consortium of 37 organizations with a common interestin improving health care delivery. The cluster was formed as part of industry New Zealand’s cluster development program and has been formally working together to provide mutual support for local and international business development.
• MoH – the Ministry of Health plays an important role for the formal intra- and intergovernment liaison work it understakes,its influence on sector policy and strategy,and its funding capability.
• DHB’s – District Health Board New Zealand is a national organization that has been set up by 21 DHB’s to assist with representation,help coordinate jointDHB processes  and activities,and undertake work that can be done more effectively  and efficiently on national basis.
• DHB forums- the NZ CIO/CEO/CFO forums comprise members who are chief information officers (CIO’s) chief executive officers( CEO’s) , and chief financial officers (CFO’s) from DHB’s, through sharing information , the forum members aim to advance respective strategies( business and technical).
• HIGB- the health intranet governance  is responsible for the governance of the Health  Intranet,the New Zealand  national health  information network, and has been responsible for the development of the health netwoek code of practice.
• IPAC- Independent Practitioners  Association Council  has a group of key technical people “GEEK” who work within the IPAc and who have established a regular forum to discuss issues and share information. This groups includes some vendors representative.
• HISO – A proactive ministerial committee with responsibility for direction setting together with the  overall governance of the New Zealand health  and disability sector standards agenda.
• Standards NZ- standards NZ are heavily involved in the development and application of national,regional, and international standards many of which are developed in partnership with Australia.
• NZCA-  the New Zealand Coding Authority exists to promote excellence and coding consiensistency in clinical coding through advice and support for the New Zealand  clinical coder workforce and related organization.
• Statistics New Zealand  -( Stats NZ) administers the statistics Act(1975) producing the official  statistics for the nation.
• ACC – The Accident Compensation Corporation  administers New Zealand’s accident compensation Scheme,which provide accident insurance for all New Zealand citizens ,preventing injury ,buying health and disability support services to treat  care for ,and rehabilitate injured people.
• NDPG –  The National Data Policy  Group ,originally the data Definitions Working Group ,was formed to ensure consultation  with the health sector on the data elements that are collected in the national minimum dataset( NMDS) and their definitions. The NDPG in its present form has been existence since 1997 and has been claired by NZHIS staff during that period.
• ILG – Information Liaison Group provides input to the ministry’s current short- term  information projects that are designed to provide DHB’s with access to information from the systems managed by the business units. The ILG has an impact on the decision -making  process of all DHB’s and MoH , in that it is a forum where these parties can be represented when changes to business rules and reporting requirements from the business units can be discussed  and prioritized.
• CLANZ – Clinical Leaders Association  of New Zealand manages issues critical to health  such as clinical safety ,quality of care ,and resource management demands also embracing competent and effective clinical leadership .CLANZ seeks to grasp opportunities evident within  the New Zealand health system for clinicians willing to take responsibility and to show leadership , by building strategic partnerships and alliances with other health organizations and agencies.
• CHECKMATE- Collaboration for Health and Clinical Knowledge Management and Technology  is somewhere unique in being academically led but  having a multisectoral membership including academics ,software developers ,and end users. This group is primarily focused on knowledge  systems rather than technology and the main objective is bring together people from throughout the health IT sector who have interests in research and training.
• HIANZ -  Health Information Association of New Zealand  is involved with medical records and medical libraries.

Health Informatics Groups in Australia

• 

  The history of the formation of medical ,health and NI groupa reflects the difficulties experienced as a consequence of a federal system government and vast distances between population centers.
  Australia has had a representative  to IMIA’s Working  Groups 8 (WG8) now (NI sig) since 1984. Nurses were the second group of health professional to organize themeselves to promote  health informatics in Australia. The general Practitioners were first, beginning in the late 1970’s although the Health Information Managers Association(HIMAA) has been in existence since 1949 but the integration of informatics is more recent. NI is now a Sig of HISA, which came into existence in 1993. It has  been long  and tortourous path to reach this position.
  NI in Australia  began with the Royal Australian Nursing Federation (now ANF) in 1984. A Year later  a small group of midwives in Victoria ,including Joan Edgecumbe,who is now the executive officer of the HISA decide to call a general meeting of nurses in  interested in computer use. About 70 nurses  agreed to establish  the Nursing Computer Group  Victoria( NCGV). This group continued to flourish and hosted the Fourth International Symposium on Nursing use of Computers and Information Science  in Melbourne in 1991. The profits of this conference enabled the formation of the HISA.It has been tortuous path towards the recognition and professionalization of health  (and nursing) informatics as discipline . We have not managed to achieve a unity or consensus regarding how best to operate  as one national professional organization to date although increasingly joint activities are being  organized.

 Historical Development

• NI in Australia  began with the Royal Australian Nursing Federation (now ANF) in 1984. A Year later  a small group of midwives in Victoria ,including Joan Edgecumbe,who is now the executive officer of the HISA decide to call a general meeting of nurses in  interested in computer use. About 70 nurses  agreed to establish  the Nursing Computer Group  Victoria( NCGV). This group continued to flourish and hosted the Fourth International Symposium on Nursing use of Computers and Information Science  in Melbourne in 1991. The profits of this conference enabled the formation of the HISA(Health Informatics Society of Australia).

  

   

Nursing Informatics in Hong Kong

Hong kong nurses established NURSINFO (HK) Ltd. In 1991 ,and this organization has enjoyed a consistent increase in membership. They have as their motto “ Nursing Infomatics for Excellence in  Patient Care” .They  organize regular educational activities,use a communication network,produce a regular newsletter, and are activity involved with the Hong Kong  Society of  Medical Informatics and  the Hong Kong Computer  Society. Together they participate  in the organization of  trade exhibits  and regular conferences. The Hong Kong Hospital  Authority is responsible for over 40 hospitals  and over 50 specialist clinics that are part of a large multisite ,multiprotocol intelligent  data network to provide seamless data communications  . Implementation began in 1993. It includes a clinical management system focusing on patient-oriented data sharing.

This provides longitudinal medical profile for patients and can be accessed  by healthcare  professional 

on a need to know basis. Telemedicine and video conferencing are in use and multimedia enhancement in the clinical setting with voice recording and imaging now helps to speed up the work process and strengthens services in the clinical areas.

Nursing Informatics in South Korea

A  Korea Society of Medical Informatics , the premier organization in Korea dedicated to the development and application of  medical and health  informatics in the support of patient care, education,research and administration of healthcare arena in general. The Society was established in October 1989. KOSMI is hosting the next International Nursing Informatics Symposium to be held in Seoul, August 2006, under the auspices of IMIA NI (http://www.ni.2006.org/).Technology trends The healthcare environment is changing at an ever increasing pace due to the proliferation of new and emerging technologies. Embracing the advances and technology enables us to to deliver healthcare in new and innovative ways. Basic hardware has advanced into multiple components of input and output devices. Development of infrastructures enabled this technology to be networked and internet to provide medium to transmit information nationally and internationally. The physical constraints and boundaries are now so blurred that healthcare delivery can occur at any time or place. New Zealand has been embracing these changes in technology and has particularly benefited from the development of infrastructure. No longer is information restricted to individuals and organization. Higher speed networks including wireless and broadband are enabling information in   a variety of formats to be shared.

Digital images are becoming the norm and picture archiving and communication system(PACS) abound. Eploration into telehealth has occurred in a number of fields  including teledermatology,teleradiology, telepyschiatry, and telepediatrics(Oakley 2001). Improves

transmission in both speed and quality. Improvements in portability are now allowing the use of techonology in a greater range of setting. Both personal digital assistants(PADs) and tablets are being used or trailed in the clinical setting by students and healthcare professionals. One of the nursing schools has issued PADs to its students and the success of this has been evidence by the reluctance of the students to relinquish  them . some Australian nurses are using  PADs for point-of-care information and clinical documentation  for community and acute hospital nursing, hospital based infection control and wound management.

Funding for the use of the  technologies is probably one of the biggest limitations imposed in embracing new technologies to enhance care delivery. Unfortunately for New Zealand ,its size does not allow economies of scale but this does  not prevent efficient use of the available resources. Although the cost for individual items of technology decreases ,our demands for this technology, and therefore our overall spending increases. Nurses need to be prepared to work alongside and use technology to best care for clients. Healthcare organization are now looking to implement clinical information systems and electronic  patient records.

Current National Initiatives 

• The New Zealand Ministry  of Health, in 2001,prepared a 5 –year broad strategic directive for information and technology developments, referred to us  “  The WAVE Report “ that was largely driven and developed by the key stakeholders. 
• The report was produced by means of the collaboration among industry,clinicins,government, and healthcare managers. It identified New Zealand’s most pressing health IT needs and significant issues that will continue to form barriers to improved health outcomes and reducing delivery cost over the next 5 years.
•  The reports has been the cornerstone of formed the foundations for long-term issues such as EHRs. While it is not necessarily unique in its content or conclusions, the collaborative approach to developing the report heralded a new way of getting whole of sector  buy in for a range of national initiatives, changing the focus from debating direction to unifying action. 
• Following WAVE report, the drive for collaboration from the bottom-up has consolidated as the district  health boards(DHBs) replace their isolated departmental systems with more intergraded and dynamics Web-based technologies that support a more connected delivery network.
•  It has also made the development more of a reality. The development of national technology infrastructure has proved useful; however, securing appropriate access to relevant clinical and administrative information throughout the health sector remains the greatest challenge. 
• Early progress has been made in the areas of claims systems and laboratory results. New Zealand government’s health policies have been driving toward a population health management approach.  The national health information agreements and the establishment of the National Health Data Dictionary in 1993 laid the foundation strategic information action plan.
•  Health online was initiated. This was followed by a number of projects initiated by the Australian government: Healthconnect, Mediconnect, the provision of quality health information for consumers known along with more than 360 projects such as the integration of primary health  and hospital care projects, and the establishment of health call centers.

 Standards  Development and Adoption

• Following the 2001 WAVE Report, the minister of health directed that a WAVE working group, the Ministerial Committee on a Health Information Standards Organization (HISO), be established to investigate  the implications of establishing of non statutory organization to manage health information standards.
•  Organizations ,2002. HISO drew together hitherto disperate  health –related groups with specific interest in producing IT standards for New Zealand .
•  HISO’s role includes identifying ,developing,publishing,and monitoring New Zealand’s health information standards( Cressey ,2003). The scope of development activities that HISO will be involved with includes standards associated within the following categorization scheme.

Records structure and content-data formats. 

Vocabulary –codes for medical and other healthcare terms.

Messaging- standards used for the interchange of data.

Security and privacy- how access to information and managed.

• HISO governed by the Health Information Standards Committee-HISC), and supported by the ministry of health produced the New Zealand Draft National Health Standards Information Plan (NZHSP) to assist in its role of developing health information standards for the health  and disability sector. 
• HISO enhances the New Zealand  e- Government Interoperability Framework(e GIF) direction.
• The NZHSP recognizes there is an urgent need to progress work on national standards . It analysis the key sector drivers,requirements,and issues and sets a foundation to  rapidly advance the sector information standards agenda. It proposes a framework for describing the sector priorities,standards development processes,governance and leadership , and presents a clear  statement of the proposed plan for the development and adoption of national health information standards. 
• NZHSP anticipates HISO undertaking the constituent parts of that framework.
• A key driver for HISO’s role- consistent use of standards –is aim at the acceptance throughout the health and health-related industries of such standards. This requires enabling real-time access to information about the standards( i.e., what standards are agreed , what are being developed or proposed ,what initiatives are taking place ,and what are the downstream implications) including where the information may be freely accessed.
•  The availability of detailed  and clinically relevant data is essential for clinical care decisions and for oversight groups making decisions  related to the quality of that care. 
•  Standardized terminology systems are essential to permit the use and exchange of clinical data across applications and IT systems. Given point –of-care documentation ,technology is now available to  build  electronic health information system that will efficiently meet a variety needs. 
• This includes providing immediate feedback to care provides by ,for example,issueing alerts related to relevant best practice guidelines,generating data needed for internal and external  quality monitoring,exchanging critical patient information in a timely manner across the healthcare continuum, and reducing provider burden associated with current documentation requirements.
• Currently one of the most significant challenges to implementing electronic health information system is the current lack of standards for electronic patient medical record information, especially standards around the terminology that expresses clinical documentation.
• Standards New Zealand and HISO,working partnership with standards Australia (SA),were persuaded to establish a health informatics committee in 1992. The SA IT-14 committee now has several active technical subcommittees and works closely with other similar groups such as HL7 Australia, the ISO technical committee 215(TC215) and the committee European de Normalization(CEN) TC251,Nurses are represented via the Royal College of Nursing and Central Queensland University. The focus in Australia has been in the area of standards development to facilitate data interchanged to first of all support all types of ecommerce and now to support the interchange of clinical data. This is putting greater emphasis on the need for a standard architectural structure for patient’s records and terminologies. And number of Australian IT-14 committee and subcommittee as well as Health Level Seven(HL7) Australian members have been instrumental in influencing many international standards to ensure that they meet Australian and New Zealand needs. Particularly the development of new ISO standads for requirements for an EHR architecture  ISO/TS 18308) and the EHR definition,scope and context ISO/DTR 20514(, plus the HL7 EHR System Functional  Model  EHR-S) and the revision of of the four -part CEN/TC 251 EHRcom standard ENV 13606). the latter will now include an additional part detailing the archetype interchange format. archetypes are constraint-based models of domain  entities and were first defined by the Australian-based open EHR group , an international not-for-profit foundation working toward interoperable lifelong EHR's.Two  IT-14 members represent that committee at the national  ICT Standards Committee who report to the NHIG and the AHIC who currently make up the Australian goverment governance model.In July 2004,NHIG endorsed HL7 as the standards for healthcare messaging in Australia.This represents a small step toward the implementation and an increase in the adoption of available standards.