Status of the health information system in Ireland and its fitness to support health system performance assessment: A multimethod assessment based on stakeholder involvement

doi:10.21203/rs.3.rs-1426665/v1

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Research Article

Status of the health information system in Ireland and its fitness to support health system performance assessment: A multimethod assessment based on stakeholder involvement

https://doi.org/10.21203/rs.3.rs-1426665/v1

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Background

A major 10-year health reform, called Sláintecare, was launched in Ireland in 2017 with aims of improving health system performance, governance and accountability, while achieving universal health coverage. To support the implementation of the reform, the Irish Department of Health requested technical support from the European Union in developing a health system performance assessment (HSPA) framework. An external team of researchers was contracted to work in close collaboration with the Irish health authorities on the “Performance accountability for the Irish health system” project. Between September 2019 and March 2021, a pilot HSPA framework for Ireland was developed and officially launched in September 2021. Routinely collected health data are needed to populate indicators in the HSPA framework. Considering the pivotal role of data, in this scope, an assessment of the health information system (HIS) in Ireland and its fitness to support the implementation of an HSPA framework was conducted, involving a broad range of stakeholders.

Methods

Between May and November 2020, over 50 informants were engaged in key informant interviews and multi-stakeholder consultation workshops as part of the HIS assessment and the broader HSPA project. Descriptive themes and data availability heatmaps were derived from interview data using thematic analysis. Indicator “passports” for the HSPA framework were populated during stakeholder consultation workshops.

Results

The HIS in Ireland was able to provide administrative, survey and registry-based data for public sector acute care services, focusing on structure, process and output metrics. Significant data availability gaps, most notably from primary care, private hospitals and community care were reported, with little availability of electronic health record and people-reported data. Data on outcome metrics were mostly missing and so were data linkage possibilities. The COVID-19 pandemic emphasised the national HIS’s shortcomings but also capacity for rapid development and improvement.

Conclusions

Assessment of the HIS in Ireland contributed to the development of a national HSPA framework but also created a momentum to further strengthen data infrastructure and governance and work towards a more data-driven and person-centred health care system.

Health system performance assessment

Health information system

Assessment

Stakeholder involvement

COVID-19

Ireland

Data are crucial in knowing how a health system and its services perform [1]. Data collected on an ongoing basis that feed into the delivery of health and social care are referred to as the health information system (HIS) [2], one of the six main building blocks of any health system [3]. Without the data, turned into information and ultimately performance intelligence [4], it is difficult to manage and improve on the health system’s central role of providing accessible, quality and safe care and maintaining and enhancing individual and population health. Over the last two decades, health system performance assessment (HSPA) has emerged as a central method and tool for reporting and using performance intelligence needed to monitor, manage and improve national health systems, as well as to achieve alignment with strategic policy goals and aims [5, 6].

Following a historical cross-party political consensus in 2017 [7], a major 10-year health reform called Sláintecare was launched in Ireland. In line with their health system stewardship roles, the Department of Health (DoH) and the Health Service Executive (HSE) spearhead the reform process. By reforming the current two-tiered public-private health care system in Ireland [8], Sláintecare aims to improve the governance, performance and accountability of health services while achieving single-tiered, universal health coverage system. To measure the achievements against these reform objectives and their alignment with the broader policy cycle, the DoH and HSE prioritized participatory processes, including the development of an actionable [9] and reliable framework for assessing health system governance and performance. Historically, performance measurement and management approaches in the Irish health system mostly prioritised structure, process and output metrics [10]. To enable evaluation of the priority areas of the Sláintecare reform and to ensure that the Irish health system is optimally aligned to population’s needs, an outcome-oriented HSPA framework was to be developed. Following a request by the DoH, the development of the first Irish HSPA framework was supported through the European Union’s structural support reform programme [11], providing national health system stewards with technical support by liaising with experts in the field. To lead the technical development of the HSPA framework, health system researchers from the Amsterdam University Medical Centers of the University of Amsterdam were contracted to work in close collaboration with the Irish health authorities. The work took place in the scope of the “Performance accountability for the Irish health system” project, which ran from September 2019 until March 2021.

At the outset of the project, three main functions and users of the HSPA framework were agreed upon between the technical support team and national health system stewards: (i) to measure the overall performance of the system, in an outcome-oriented manner, and report to the general public; (ii) to monitor progress and impact of strategic system reforms by the DoH, evaluating whether the focus is on the right policies; and, (iii) to inform on components of the delivery system to the HSE, making sure that the intended services are delivered and managed accordingly. At the end of the project’s 18 months, an HSPA framework for Ireland was proposed [12], consisting of 5 main clusters (structures, processes, outputs, outcomes and cross-cutting), 16 domains and 36 subdomains, 49 features and 266 indicators (Fig. 1). The HSPA framework was officially launched by the Irish minister of Health at a conference held on September 10th, 2021.

Routinely collected data are used to populate indicators of an HSPA framework. A well performing national HIS provides quality data and successfully supports the development, implementation and use of an HSPA. Ideally, data infrastructure and governance mechanisms assure availability, timeliness, accuracy, completeness, usability and relevance of data [13], as well as linkage possibilities across datasets – for various types of services, from different data sources and across data types. Considering the crucial role of routinely collected health data sourced for HSPA indicators, an assessment of the status of the HIS in Ireland seemed warranted when developing a national HSPA framework. In a positive feedback loop, such an HSPA-tailored assessment helps improve national data infrastructure, also by underpinning better governance and evidence-informed decision-making [5].

With an aim of assessing a national HIS and its fitness to support ongoing HSPA efforts in Ireland, this paper presents a multimethod assessment of the HIS in Ireland in 2020, based on broad stakeholder involvement. To do so, it first explores the status of the HIS in Ireland, by summarising its main characteristics through stakeholder narratives and data availability mapping across services. Second, it investigates the fitness of the HIS to support the implementation of a national HSPA framework in Ireland, by specifically focusing on data availability for clusters and indicators in the proposed HSPA framework and by exploring data linkage possibilities and recent developments.

An iterative, multimethod assessment was conducted in 2020 to describe the status of the HIS in Ireland and assess its fitness to support the implementation of a national HSPA framework. Following a review of previous HIS assessments conducted in Ireland, this work used (i) semi-structured, individual and group, key informant interviews (N=16 interviews) and (ii) multi-stakeholder consultation workshops (N=6 workshops).

Figure 2 highlights the positioning of the HIS assessment work, described in this paper, in the scope of the abovementioned broader “Performance accountability for the Irish health system” project. In the HIS assessment but also throughout the project, broad stakeholder involvement was sought for, also by engaging citizens in the development of the HSPA framework [14].

The research team included healthcare performance intelligence researchers and practitioners with previous experience of working with health data and policy, designing HSPA frameworks and conducting HIS assessments in the European and global context. The research team worked closely with the Irish health authorities, namely the DoH and the HSE, while maintaining full scientific autonomy.

At the onset, to familiarise with general characteristics of the HIS in Ireland, a total of five HIS assessments, three publicly available [15 - 17] and two provided by the DoH, conducted between 2017 and 2019 were identified through the expert advice of the DOH and HSE, online search and the research team’s expertise on the topic. Most were specific assessments of the HIS in Ireland while some had a broader scope, for instance a more generalised review of the health system; none were performed for HSPA purposes. A summary overview of the included assessments was made in a spreadsheet and used internally to guide subsequent research steps. For each assessment, the overview included short descriptions of the context, assessment body and its mandate and assessment methods, as well as a comprehensive description of assessment findings in relevance to the HSPA project.

The status of the HIS in Ireland was assessed through thematic analysis of interview data and focused on describing its main characteristics and mapping data availability across health care services. The fitness of the HIS to support the implementation of a national HSPA framework was assessed by mapping data availability across the five main clusters and 266 indicators of the proposed HSPA framework, including identification of data sources and data custodians. It additionally assessed specific HSPA-related topics, such as linkages across datasets and collection of people-reported data. The data availability mapping framework categories were based on the HSE’s classification of health services in Ireland [18], indicator clusters for the proposed HSPA framework (Figure 1), Sláintecare reform priorities [7] and World Health Organization’s Health Metrics Network assessment tool for HISs [19].

Key informant interviews

Semi-structured, individual and group, key informant interviews were organised and aimed to elicit information from a range of relevant national stakeholders with regards to the HIS and performance measurement in the Irish health system. Potential informants (N=32) were suggested by the DoH and other informants, in a snowballing approach. Spanning different target stakeholder groups within the Irish health system, informants included employees of the HSE, DoH, regulatory and health professional bodies, research institutions, other governmental institutions, patient organisations as well as other custodians of health data. Between May 29th and October 27th, 2020, the study team (DI, TJ, EB, OBF) conducted 16 remote, one-hour interview sessions involving 18 key informants (10 female, 8 male), representing key stakeholder organisations (Additional file 1). The interviews discussed HIS in Ireland, specifically health data, indicators and data sources, as well as performance measurement, monitoring and management practices. Prior to each interview, informants were provided with preparatory materials and guiding interview questions (Additional file 2). Having received verbal agreement from the informants, interviews were recorded and transcribed. Thematic analysis was used to analyse interview data and populate data availability heatmaps [20, 21].

Stakeholder consultation workshops

To further complement and validate the findings from the interviews, six interactive online stakeholder consultation workshops were convened between October 15th and November 26th, 2020, involving over 40 stakeholders from different organisations across the Irish health care system, some of whom also previously participated in the interviews. Each workshop aimed to closely review a working list of potential indicators for the HSPA framework, developed in other streams of the project, paying special attention to the data availability and infrastructure in place. Following invitee suggestions by the DoH, stakeholders representing the three framework’s intended functions (overall performance, strategic reforms and services delivery) participated in each workshop. Each workshop lasted 2 hours and was attended by 11 to 16 participants. Workshops were organized around the five main clusters of the proposed HSPA framework (as shown in Figure 1), each focusing on a single cluster. An additional, sixth workshop was organised, following a suggestion by the DoH, focusing on indicators related to Sláintecare reform priority policies. In advance of each workshop, briefs on the status of the broader HSPA project, were shared with participants. Additionally, spreadsheets were shared, which listed the indicators identified through parallel research steps of the project and pertaining to the workshop’s cluster of focus (Additional file 3). Spreadsheets contained an “indicator passport” for each indicator. “Passport” categories included indicator’s fitness for the three HSPA framework’s purposes (overall performance for public reporting, strategic areas for reforms and short-term service delivery planning), indicator measurability and its methodological quality. Workshop participants were asked to fill in “passports” for all indicators they were familiar with. They were also asked to note comments, suggestions or modifications and propose additional sub-domains or indicators they thought merited discussion. An example of a brief and a spreadsheet containing “indicator passports” is shown in the Additional file 3. Spreadsheet data was analysed using descriptive statistics. To assess the fitness of the HIS in Ireland to support a national HSPA framework, we specifically looked at (i) what components of the framework were assessed as measurable or not and from which types of data sources; and (ii) which data custodians owned and managed the data.

The status of the HIS in Ireland

Based on key informant interviews, the HIS in Ireland was, in 2020, generally assessed to be able to provide data that was, when available, of good quality, accuracy, validity and timeliness, including demographic and geographic disaggregation possibilities. However, significant gaps were identified in the completeness of the data, with it mostly being available for publicly provided acute care services and by-large missing for services provided in the private sector, notably independent hospitals, general practice and community health centres. For a similar reason, respondents reported good data coverage for the lower income groups, but much less for the middle income groups, due to the latter using both public free-of-charge and paid private provider services. Registry data were reported to be readily available and of good quality. This was explained by population- and disease-registries having long histories and tradition in Ireland, which often meant dedicated and well-established operational and research teams, high levels of attention to data quality, extensive international collaboration and sustainable funding. In line with Sláintecare reform priorities, using HIS data to assess and address regional differences in the uptake of policies around Ireland were found crucial. However, informants concluded that the current HIS is not able to fully support these regionalisation efforts due to varying levels of data completeness across regions. Additionally, inadequate focus on case-mix and risk-adjusted indicator calculations, despite data being able to support both, hindered its use for benchmarking between regions. Finally, lack of high-level agreement on key priority indicators in the health system, a national oversight body, and consistent and standardised tracking of performance results over time were identified as hindering factors in working with health data in Ireland.

Analysis of information collected through stakeholder interviews also enabled mapping data availability, across health care system’s services. Figure 3 presents the heatmap of availability of certain categories of data for various health care services. Data were described as generally readily available for acute hospital care services across different types of data. Survey-sourced data, from the annual “Healthy Ireland” survey, were also obtainable across many services. Administrative data, especially those on health workforce and financing health services were available for the majority of acute, social and primary care services.

The fitness of the HIS to support implementation of a national HSPA framework

Based on interview data and using the same categories of health data as in the previous heatmap, the five main clusters of indicators, proposed for the Irish HSPA framework, were mapped for data availability (Figure 4). The most notable finding was generally lower availability of data pertaining to the health outcomes and cross-cutting indicator clusters of the HSPA framework. Due to its focus on structures, processes and outputs, at the time of the assessment, informants generally assessed HIS data in place as inadequate in supporting the framework’s focus on outcomes (and linking outcomes to inputs). The HIS was also assessed as suboptimally prepared to provide data on adaptability, resilience and up- and down-scaling capacity of the system, including its infrastructure, services and workforce.

When discussing the HIS in Ireland in relation to its ability to populate the proposed HSPA framework, key informants pointed to and elaborated on three topics of interest: (i) data linkage and the ability to analyse and manage care pathways and integration of care, (ii) collection, reporting and the use of people-reported data and (iii) recent developments, as a direct and indirect consequence of the ongoing (at the time of conducting this work) COVID-19 pandemic.

Pathways of care were not well captured in data and the data to measure care integration were mostly unavailable. Informants mainly attributed this to suboptimal data linkage efforts which, instead of enabling to patient follow-up through the system, mostly inferred care pathways and subsequent correlations. Slow implementation of the individual health identifier (IHI) and historical use of proprietary data standards hindered data linkage capabilities. Informants also attributed the limited data linkage capabilities to the lack of a dedicated national health data coordination body and a coherent strategic approach to health data. Proxies were used, such as bed days by people with primary care sensitive conditions, but it was pointed out by informants that it is impossible to have integrated care without fully integrated data. However, attitudes to data use and sharing, among stakeholders in the system, have recently changed, with a newly found appreciation for data use for policy, by policy- and decision-makers. Primary care was exemplified as an area in which an improved flow of data between general practitioners, hospitals and HSE would lead to better coordination and integration of care. Lack of clinical data flow between most community service providers and the HSE was also emphasised as a shortcoming. Other causes and examples of data linkage issues were presented, such as unaligned data standards and technical solutions among private hospitals with different systems for patient data collection and reporting and subsequently non-interoperable information systems.

According to informants, there seemed to be increasing interest and recognised need for the collection of people-reported data in the Irish health system. This included both patient-reported outcome and experience measures (PROMs and PREMs) as well as staff- and carer-reported data. However, apart from the annual “Healthy Ireland” survey for some services and a few smaller pilot projects, these kinds of data were not structurally collected, reported or used. Collecting people-reported data was seen as challenging and hence often done in small, research-focused ways rather than consistently by health care organisations as a way of gaining and learning from patients, staff and carers. Focusing these qualitative metrics on issues that matter to people, rather than on questions such as satisfaction with the cleanliness of the hospital was another theme, often repeated by informants. So was the lack of patient experience measures in primary care. Person-centeredness was recognised as key to patients and citizens, with suggestions by informants for Ireland to join on-going international initiatives, developing this area further.

With this assessment being conducted during the COVID-19 pandemic, issues of health data management in relation to the situation were also mentioned by informants. They agreed that it was difficult to say whether changes to the data landscape, catalysed by the pandemic situation, will persist, but that it was necessary to consider the potential of these developments. For instance, a temporary, emergency version of the IHI was rolled out to follow patients with COVID-19 through the system and for vaccination purposes [10, 22]. Also, a novel, emergency data hub for researchers to access data about COVID-19 was established, where data could be linked and accessed through the Central Statistics Office’s infrastructure [23]. According to informants, the views on how data is collected, accessed, reported and used have changed due to the pandemic. The crisis emphasised both the system’s shortcomings as well as its strengths. These improvements made data for acute care of COVID-19 readily available on a very granular level across organisations. However, the quality of non-COVID-19 care data had not improved and, some informants felt, it might have even worsened. Questions of data quality, with such rapid data infrastructure developments, were raised and informants noted that, due to the urgency, less attention was put to the minimum requirements of datasets. In general, informants were hopeful that the positive developments will sustain after the pandemic.

Following pre-workshop preparatory work by stakeholders on “indicator passports” and discussions during all six workshops, a total of 266 HSPA indicators were assessed as potentially useful for the first Irish HSPA framework. Data availability and potential data sources were assessed for each. Differing levels of data availability across the five indicator clusters were found, as shown in Figure 5. Data for the proposed framework was mostly available for indicators in the structures and outputs cluster and sourced from administrative, registry and survey data. Data sourced from electronic health records (EHRs) were able to populate only 0.5% of all proposed indicators (13/266).

Data for the 266 potential indicators of the proposed HSPA framework were available from various sources and managed by different data custodians within the Irish health system. Based on the results of stakeholder consultation workshops, two organisations were responsible for most of the indicator data. One quarter of all proposed indicators (72/266, 27%) could have been sourced from datasets held by the HSE, namely data collected and managed by the National Quality Improvement Team as well as the Hospital In-Patient Enquiry, National Patient Experience Study and the Healthy Ireland survey datasets. Another 18% of indicators could have been sourced from data managed by the Central Statistics Office, and its annual Survey on Income and Living Conditions dataset. Other relevant data custodians and datasets included Health Information and Quality Authority (14/266, 5%), Irish Cancer Society (12/266, 5%), Higher Education Authority (9/266, 3%), National Vaccine Information System (6/266, 2%) and the Health Research Board (5/266, 2%). Data to populate nearly a third of proposed indicators required further clarification of custodianship and sources (79/266, 30%).

This assessment also identified several specific data source type-related challenges. The coverage and timeliness of data collected primarily for administrative purposes was generally good, especially for acute care services, but its usefulness for monitoring population-level health and individual patient-level outcomes, which are important for an HSPA framework, remained limited. The use of population and patient survey data in Ireland has been increasing in prevalence and importance. At the time of the assessment, it covered many of the services, as well as clusters and domains conceptualised in the proposed HSPA framework. Predominantly ad-hoc PROMs and PREMs collection efforts could not fully support the envisioned framework and its focus on the use of indicators based on patient-reported data. Despite recent localised rollouts of new standardised EHRs among acute care services in Ireland, this modality of capturing health data was still very limited in its linkage and re-use capabilities. Legal requirements to adopt EHRs and adhere to standards were listed as some of the possible reasons. The increasingly important role of software solution vendors was also mentioned in both interview and workshop stages of this assessment.

This study explored the status of the HIS in Ireland and its fitness to support HSPA, providing a tailored- and purpose-driven snapshot of the national health data landscape in 2020. The work was conducted in the context of the development of the first HSPA framework for the Irish health system. Findings identified strengths, weaknesses and areas for improvement, while immediately providing input into the development of a first HSPA framework in Ireland.

High-level assessment findings revealed a national HIS capable of providing relevant data of perceived high quality for acute care services provided in the public sector, mostly sourced from administrative, survey and registry data and focusing on structure, process and output measures. Shortcomings and areas for improvement predominantly related to significant data availability gaps, most notably from primary care, private hospitals and community care. Availability of EHR and people-reported data were suboptimal, as were the data on outcome measures. At the time of this assessment, linking data across data custodians, data sources and types of data were limited. Therefore, inhibiting care pathway mapping and better integration of care, additionally enhancing the potential secondary use of data. COVID-19 pandemic further emphasised some of the identified shortcomings but also reveals system’s potential to rapidly innovate and improve.

The two-tiered nature of health care service provision and financing in Ireland significantly influences the current HIS and data landscape in Ireland. Localised rollouts of new, standardised EHR in the acute care services in Ireland [24], supported by recent strategic and technical [25, 26] initiatives on a national level, have been reported. However, this modality of capturing health data is still very limited in its pervasiveness as well as linkage and re-use capabilities, as the results of the assessment show. International experiences have pinpointed the relevance of legal requirements to adopt EHRs and adhere to data standards, supported by a national strategy and coordination, in helping accelerate these developments [27]. The increasingly important role of software-solution vendors should also be carefully considered and leveraged, as it influences data quality, performance of services and user experience [28, 29, 30]. Research has shown that the standards on interoperability of various EHR systems should be implemented broadly to enhance further digitalization of health care and facilitate broader data exchange [27, 10] but also that the single most important factor for successful implementation of a national EHR system is stakeholder involvement and buy-in [31].

The undertaken process of HSPA framework development and HIS assessment in Ireland emphasised broad and continuous stakeholder involvement, also including citizens. Other research activities in the broader HSPA project revealed substantial motivation of the Irish health system stewards in strengthening citizens’ voice through shared decision-making around its development [14].

Throughout the process of stakeholder involvement, informants agreed that this approach is a positive development and that it should continue in all future work on designing and implementing HIS and HSPA work in Ireland. This could also help tackle the recognised issue of the fragmented data custodianship in the Irish health care system [32]. Many of the phenomena, identified through this assessment, have also recently been reported in a study looking into common characteristics of European HISs [33]. These included fragmentation of data sources, secondary re-use of health data, issues in implementation of interoperable EHRs as well as governance, legal and data safety and security issues, among other.

The COVID-19 pandemic additionally emphasised national HIS shortcomings in Ireland but also its capacity for rapid development and improvement [34]. Examples included being able to link data across sources and services, secondary re-use for research purposes and generally strengthened use of health data for clinical and managerial decision- and policy-making.

Data privacy and security issues were rarely discussed during this assessment work on the Irish HIS landscape and its role in the HSPA process. This is an interesting finding for multiple reasons. Most data needed for an HSPA framework is, in fact, sourced from existing primary data sources, which provides unique opportunities for secondary data re-use but also presents a set of challenges related to data security and privacy. This finding is especially important in the light of the May 2021 ransomware cyberattack on the Irish health system, which caused both prolonged interruption of care provision in the Irish health system and affected majority of its data services [35, 36].

Strengths and limitations

To our knowledge, this is the first scientific report on an HSPA-tailored national HIS assessment. Its iterative and purpose-driven nature presents a strength, with findings being used real-time for the development of an HSPA framework. The broad, representative and continuous stakeholder involvement approach significantly added to capturing multiple perspectives and increasing the sense of ownership, increasing the likelihood of successful implementation [37]). The process was supported and sponsored by the highest-level national health authorities and linked to the on-going Sláintecare health system reform, which was recognised as a window of opportunity to address identified challenges. The study also carries with it several limitations. Despite making all reasonable efforts to maintain scientific autonomy, close involvement of the Irish health authorities in the process might have introduced bias to the selection of participating informants and their perceived freedom to express personal and professional opinions. The research period coincided with the COVID-19 pandemic, which meant that the stakeholders’ focus on the topic and their availability was somewhat limited and potentially skewed participation toward informants more interested and readily available. Also, the HSPA focus of this HIS assessment might hinder its applicability for other uses. As a primarily exploratory study, the data sources have not been directly accessed nor assessed for quality. This warrants further quantitative methods to assess the completeness and other components of data quality.

Strengths, shortcomings and areas for improvement of the Irish HIS, identified through a broad and continuous stakeholder involvement process, affirmed the usefulness of conducting a HIS assessment as part of the development of a national HSPA framework. Such efforts, especially in the disruptive, and potentially innovative, circumstances of the Sláintecare reform and the COVID-19 pandemic, present a window of opportunity for further advancements needed to effectively work towards a data-driven and person-centred health care system in Ireland.

HIS

Health Information System

HSPA

Health System Performance Assessment

DoH

Department of Health

HSE

Health Service Executive

EHR

Electronic Health Record

PROMs and PREMs

Patient reported outcome and experience measures

Ethics approval and consent to participate

All participants received verbal and written information, had the possibility to ask further questions and gave their informed consent for the interviews and workshops to be recorded, the recordings to be transcribed verbatim and the results of the analysis to be published anonymously. The research presented did not require ethical approval. In the Netherlands, research that does not involve subjecting participants to medical intervention or does not dictate particular codes of conduct for participants requires no approval. The autonomy of research subjects was respected, there was informed consent, no harm was possible for the subjects and confidentiality of the subjects, and research data was protected. All methods were carried out in accordance with the principles of the Declaration of Helsinki and the Research Code of the Amsterdam University Medical Centra.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was carried out by the Marie Skłodowska-Curie Innovative Training Network (HealthPros – Healthcare Performance Intelligence Professionals) that has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement Nr. 765141.

Authors' contributions

All authors contributed to the design and execution of the study. DI, TJ, EB and OBF collected and transcribed the interview data. All authors contributed to data collection through stakeholder workshops. DI and TJ analysed and interpreted the data. DI wrote the main manuscript. All authors made significant contributions to the manuscript. All authors approved the final version for submission and publication.

Acknowledgements

The authors would like to thank all the participants who voluntarily participated in the study, sharing their expertise during interviews and workshops. Their contribution was key to conducting this assessment and working on the broader HSPA project in Ireland. The authors would also like to thank colleagues at the Department of Health and Health Service Executive in Ireland. Their assistance and guidance were of utmost importance to facilitate this work.

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Additionalfile1.docx
Key informant interviews – Details on interviewed informants
Additionalfile2.docx
Key informant interviews - Brief
Additionalfile3.docx
Stakeholder consultation workshops – Stakeholder brief and the preparatory document (excerpt)
COREQchecklist.docx

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Status of the health information system in Ireland and its fitness to support health system performance assessment: A multimethod assessment based on stakeholder involvement

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