20 March 2008

The Power of Bureaucracy

One of the first initiatives of the new Williams administration, back in 2004, was to turn the Newfoundland and Labrador Centre for Health Information (NLCHI) into a Crown corporation.  Not surprisingly, it was a hold-over from the previous administration.

That capped a decade of evolution for the organization in fine bureaucratic fashion.

Now people who know might think NLCHI started in 1996 under the Tobin administration and they'd be partly right.  Tobin's cabinet put a new name on an offshoot of an earlier task force established originally to look at developing a way of sharing and consolidating health information among health care providers across the province. 

Before that - if memory serves - there had also been a technical committee of the computer guys that looked at computerizing records and creating a common set of records for the hospitals in the St. John's area.  Some may recall that in the early 1990s, hospitals in the province were run as individual sites.  Records from one weren't readily available at another and there was no common way of sharing records simply and easily using the marvels of what was then a new technology - the Internet.

If you take a look at the recommendations of NLCHI's immediate predecessor (follow the Tobin link above) and the ideas will sound very familiar. Aside from making fuzzy recommendations on how everyone needed to work together happily, the Health System Information Task Force recommended a raft of ideas from the creation of a new "unique identifier", or health card number, for residents of the province to development a provincial information technology plan.

It's that last one that's particularly interesting in light of revelations on Thursday about Eastern Health's woefully inadequate information management system. CBC's Here and Now obtained a copy of a briefing note prepared for the current health minister last November.  The briefing note detailed, among other things, the inadequate computer systems at Eastern Health that forced officials to review patient files one by one, by hand, to try and determine  how many patients had been affected by the breast cancer scandal.  They couldn't even use an electronic search function, apparently.

Look at the NLCHI site and you'll see a pile of buzzwords, chief among them the stuff that comes in the "vision" paragraph.  Heaven knows that in the "strategic" planning craze of the late 1990s  - it is still with us today - every organization had to have a vision statement and a mission statement:

The Centre's vision is the improved health and well-being of the people of Newfoundland and Labrador by making quality health information available to the public, health professionals, government, regional integrated health authorities, and other people and organizations. Working closely with these stakeholders, the Centre is responsible for the development and management of a province-wide Health Information Network (HIN). This is a tool to help achieve the best possible health for every person in the province. The HIN will help improve health by allowing health professionals to electronically share information with other health professionals. The Centre will support decision-making, planning, and research with reliable statistics and applied health research.

There have been plenty of studies and conferences but, as one may infer from the Eastern Health briefing note, there has been plenty of planning and visioning but not a heck of a lot of concrete action. There's a hefty-sized board overseeing CHI and there is a staff which now comprises about 60 people. There are a bunch of projects that are in various stages of development but aside from the diagnostic imaging project for radiology, most seem to be conceptual or otherwise not focused on the most straightforward and pragmatic approach to delivering service needed at the front-end of acute health care.

In short, the original technical committee looking to figuring out how to wire together computers and find common software standards has morphed into a bureaucracy that continues to grow apace. Participants in the ongoing CHI project will no doubt disagree strongly, but the evidence speaks pretty clearly for itself.

After discussing a unique health identifier to replace the medical care commission number, that idea was scrapped in favour of keeping the MCP number in place.  If memory serves, that study alone took three years before winding up back where it started.

The other major project which is well underway is a $15 million program to replace the existing computer systems in private sector pharmacies with a single, publicly owned one.  Doctors  - the people who actually write prescriptions and the people with primary responsibility for co-ordinating patient care - will only get access to the system in the third phase:

Phase I of the project will include the integration of the province's approximately 180 retail pharmacies and provide a viewer into the emergency departments of acute care facilities; Phase II will include integration with hospital pharmacy systems; and Phase III will provide electronic prescribing capabilities to physicians and other prescribers.

One of the issues identified in the 1995 Strategic Social Plan (approved for release in December 1995 but killed by the Tobin administration in 1996) centred on the implications of growing health care spending driven by, among other things the demographic changes taking place in the province.  Initiatives like health care re-organization in the early 1990s were intended to deliver needed health care as efficiently and effectively as possible.  It was about doing the most possible with a given amount of money, recognizing that the inertia of bureaucracy the doing the same things over and over simply couldn't be sustained.

Look at it this way:  within a decade, the change identified as necessary in 1995 hadn't taken place. In fact, the goal had been abandoned, by degrees.  In 1994 health care consumed about 25% of the provincial budget annually. Even allowing for the re-organization of health and community services, health still consumed 25% of the annual budget five years later. By 2003, that figure was up to 30% and in 2007, health care consumed 32% of the budget. 

One of the reasons for that growth has been the steady retreat from simple, pragmatic approaches toward ones that are demonstrably bureaucratic in nature.  The empire built in CHI is one example.  The 2004/2005 re-organization of health care administration is another. 

Sure the treasury has grown fat over the past five years compared to the leaner times of the 1990s and so some will justify the increased spending on that basis.  People with a vested interest in the system as it has grown will be the first to tell you of all the wonders they've achieved for all the extra money. They'll also tell you that there isn't enough money to meet all the needs, but more must be added, perhaps for more officials to plan and co-ordinate and produce vision statements.

But ask the people flipping through files - electronic or paper - by hand and you might get a different response.

We don't need to ask patients if "the system" works. 

We've been hearing from some of them this week.

Such is the power of bureaucracy.