Nursing Informatics in South Africa

Introduction to South Africa

  • South Africa has undergone dramatic changes, marked by historical conflicts.
  • 1652: Dutch settlers arrived to establish a refreshment post for ships traveling from Europe to the East.
  • British also arrived, leading to the Boer War.
  • 1910: The Union of South Africa was established under joint rule.
  • 1961: South Africa became a republic.
  • 1948: Apartheid implemented by the National Party, leading to protests.
  • 1994: First multi-racial election, resulting in the African National Congress coming into power (CIA, 2010).
  • Post-apartheid, imbalances in healthcare provision needed correction.

Healthcare in South Africa

  • Consists of a large public sector and a smaller private sector (SouthAfrica.info, 2010a).
  • Public sector caters to those with insufficient funds or without medical insurance (Medical Aid), about 72% of the population (SouthAfrica.info, 2010b).
  • Nearly half of state expenditures are spent on health, catering to almost 80% of the population.
  • Public sector is under-staffed and over-utilized.
  • 2012/2013 budget year: Health budget was R121 billion.
  • 2011: 8.3% of the GDP was spent on health, totaling R248.6 billion (approximately $23 billion).
    • 48.5% spent in the private sector (16% of the population).
    • 49.2% spent in the public sector (84% of the population) (SouthAfrica.Info, 2014).

Objectives

  1. Introduce the history of nursing informatics in South Africa.
  2. Identify the problems of implementing computerization in a resource-constrained environment.
  3. Describe the barriers to establishing a nursing informatics speciality.
  4. Describe nursing informatics from a South African perspective.

Keywords

  • Nursing informatics
  • South Africa
  • Computers
  • History
  • Barriers

History of Nursing Informatics

  • 1978: International Medical Informatics Association (IMIA) working conference in Cape Town, led by Dr. Marion J. Ball (Safran, 2003).
  • 1988: First nursing informatics workshop in Rustenburg.
  • Western Cape province was the focus area for health informatics; an informatics department was established at Groote Schuur Hospital.
  • MEDINFO 95: A paper emphasized separating nursing informatics from medical informatics (Babst & Isaacs, 1995).
  • Little progress in the South African nursing informatics environment since then.
  • Nursing informatics combines healthcare, information science, and computer science (Lanciault, 2014).
  • Emphasis is on finding enough nursing and medical staff to provide basic healthcare.
  • Hospital information systems exist in certain hospitals, but staff implementing them may not necessarily be nursing or medical staff.
  • The South African Health Informatics Association (SAHIA) aims to start a chapter for nursing informatics.

Nursing Education

  • The National Strategic Plan for Nursing Education, Training, and Practice was launched in February 2013.
  • Specifies requirements for various categories of nurses (South African Government News Agency, 2013).
  • Current programs:
    • Four-year nursing degree
    • Four-year nursing diploma
    • Two-year enrolled nurse’s course
    • Auxiliary nurses (practical nurses)
  • Emphasis on degree nurses, to be implemented in 2015.
  • New curriculum includes basic computer usage training.
  • Aims to assist with computer technology use in nurses’ work (hospital information systems, rural clinic databases).
  • Government encourages computer training but there is often a lack of computers available at workplaces (Asah, 2013).
  • South Africa lags behind first-world countries in the number of personal computers available.
  • Basic computer courses should be compulsory in nursing education programs.
  • Nursing informatics is not mentioned in nursing specialities, with no specific qualifications available.
  • Post-graduate qualifications in medical (or health) informatics and telemedicine are offered at universities, but do not focus on nursing.
  • No career path in nursing informatics; nurses working in informatics departments are self-taught.
  • Nursing informatics not regarded as a speciality is demoralizing.

eHealth Strategy in South Africa

  • 2012: Government released the “National eHealth Strategy, South Africa 2012/2013-2016/2017” (Department of Health, 2012).
  • Aims to enable a long and healthy life for all South Africans (Department of Health, 2012, p. 8).
  • Objectives:
    • Support medium-term priorities of the public health sector.
    • Pave the way for future public sector eHealth requirements.
    • Lay the requisite foundations for future integration and coordination of all eHealth initiatives (Department of Health, 2012, p. 8).
  • First eHealth strategy published, detailing aspects needing correction and implementation.
  • Need for a common identifier for patients due to a lack of interoperability between hospital information systems.
  • Standardization of systems is a long-term goal.
  • Successful rollout of a national health plan requires well-coordinated IT aspects and competent staff.
  • Emphasis is at the provincial level, not so much at the hospital or clinic level.
  • South Africa is placed at Stage 3: “migration of traditional district health information systems to electronic and storage” (Department of Health, 2012, p. 13).
  • Aims to move to stages 4 and 5, with stage 5 being a fully comprehensive and integrated national health information system.
  • Focus on:
    • Pharmaceutical coding
    • Diagnostic Coding Schema
    • Procedural Coding Schema
    • Diagnostic Related Grouping
    • Standards for Clinical Content (Department of Health, 2012, p. 16)
  • South African Bureau of Standards (SABS) is working on standards:
    • ISO/TS 18308:2004 (SANS 18308 Health Informatics—Requirement for an EHR Architecture)
    • ISO/TR 20514:2005 (SANS 20514 Health Informatics—EHR—Definition, scope, and context) (Department of Health, 2013, p. 16)
  • Road of standardization needs to be taken further.

Hospital Information Systems in South Africa

  • Healthcare is in a major state of flux with the National Health Insurance scheme being set up.
  • February 26, 2014: Budget Speech by the Minister of Finance addressed the National Health Insurance.
  • Improvements are being made in public sector health delivery, and the high cost of private health care has to be reduced.
  • National Health Insurance (NHI) pilot districts have been established in every province, supported by funding for NHI as a conditional grant.
  • R1.2 billion has been allocated for piloting general practitioners’ contracts.
  • An Office of Health Standards Compliance has been established.
  • A new funding framework for the National Health Laboratory Services has been agreed to.
  • Rising life expectancy, reduction in infant, child and maternal mortality are seen.
  • 2.5 million people now have access to anti-retrovirals.
  • Enrollment in the HIV treatment program will expand by about 500,000 a year (Gordhan, 2014, p. 13).
  • Main objective is to align Public and Private Healthcare situations.
  • Public: services delivered by the Government.
  • Private: healthcare provided to persons who have Healthcare Insurance (Medical Aids).
  • Implementation of the National Health Insurance is underway.
  • Main aim is to improve access to and improvement of the quality of healthcare for all South Africans (Matsoso & Fryatt, 2013).
  • Pilot sites have been identified and set up in all of the nine provinces.
  • Increased medical student places, Cuban medical specialists recruits, and contracting of private doctors to provide services in under-serviced communities (Matsoso & Fryatt, 2013).
  • Technology will be used to ensure improved health outcomes and service delivery.
  • Cost-effectiveness of such technology is still to be investigated (Matsoso & Fryatt, 2013).
  • Major challenge in rural areas where computer expertise is minimal.
  • Provision of stable electricity is problematic in some rural areas.
  • The National Health Insurance plan will be looking to an effective information system for standardization across private and public sector systems.
  • About a third of the public hospitals have a functional EMR system (Department of Health 2012, p. 14).
  • Many tasks will fall on the shoulders of the nurses, especially in the rural areas.
  • Ratio of population to nurses varies from province to province, from a ratio of 165:1 to 303:1 (SANC, 2013).
  • Additional burden of AIDS and tuberculosis.
  • Brain drain of healthcare workers (mainly nurses) to countries such as Australia, Canada, the United Kingdom, and even countries in the Middle East.
  • Reasons include crime, fear of degradation of the public health and education systems, general feelings of insecurity, as well as the lure of a better income in first-world countries.
  • South Africa needs to determine how to better facilitate the remaining nurses’ work by providing tools that can access information in the form of electronic patient data.

Standards

  • Establishment of the Board of the Office of Health Standards Compliance.
  • Assist to facilitate the implementation of the National Core Standards.
  • State of Public Health in South Africa has been placed under tremendous strain.
  • Dealing with the increased patient loads; the high costs of professional salaries; the increased costs of materials for maintaining an institution in good functional order.
  • Current Minister of Health stated that “the importance of providing quality health services is non-negotiable.
  • Better quality of care is fundamental in improving South Africa’s current poor health outcomes and in restoring patient and staff confidence in the public and private health care system.
  • The National Core Standards set out how best to achieve this.” (Department of Health, 2011, p. 5)
  • The National Core Standards fits in with the National Department of Health’s 10 Point Plan (2009–2014) which is to try and bring about “a long and healthy life for all South Africans”.
  • Key aspects:
    • Improve life expectancy.
    • Improve mother and child health and survival.
    • Reduce the impact of HIV/Aids and TB.
    • Improve health systems effectiveness (Department of Health, 2011, p. 8).
  • Levels or requirements for each health facility to attain.
  • Minimum acceptable level of care that must address vital areas of care delivery, especially those patients who are at high risk or are extremely vulnerable.
  • Essential areas of care delivery, which carries a medium risk with the goal of optimum care, where the levels become developmental and carry a lower risk of susceptibility.
  • Seven Domains of the National Core Standards:
    • Domain 1: Patient Rights
    • Domain 2: Patient Safety—Clinical Governance and Clinical Care
    • Domain 3: Clinical Support Services
    • Domain 4: Public Health
    • Domain 5: Leadership and Corporate Governance
    • Domain 6: Operational Management
    • Domain 7: Facilities and Infrastructure (Department of Health, 2011, p. 10)
  • Six Priority Areas:
  1. Values and attitudes of staff
  2. Cleanliness
  3. Waiting times
  4. Patient safety and security
  5. Infection prevention and control
  6. Availability of basic medicines and supplies (Department of Health, 2011, p. 15.)

Other important notes

  • Implementation of baseline requirements are independent of the Health System.
  • Only a handful of institutions have computerized information systems.
  • Even fewer have fully-integrated computer systems.
  • The need and demand for effective healthcare supersede the computerization of the clinical workplace.
  • The merging of the paper environment to the computer environment in the health sector is a major challenge.
  • The new Nursing Curriculum that was introduced this year for the first time addresses the need for computer education for nursing professionals.
  • Keep motivating clinical staff to see that IT in Healthcare is a very powerful tool at their disposal, and also how to use it effectively.
  • It is always about the patient.
  • Improvements over the past five years are reflected in a rising life expectancy and there is a decrease in mortality rates for infants and mothers.
  • Millions of patients affected and infected with HIV/AIDS now having access to appropriate treatment.
  • Accurate records, up-to-date patient information, and the appropriate coding of patients according to the International Classification of Diseases (ICD-10).
  • Application of Early Warning Scoring Systems for vulnerable patients, and if documented, provides the necessary alerts to occur.
  • The abuse of current manual systems seen with the increasing trend to “sell” HIV medication can also be closely monitored by the application of a fully integrated computerized information system that provides for medication dispensing and stock management.
  • Closing the gap electronically keeps everyone honest and more importantly, the patient is protected with all the allergy checks, drug interactions, and dosing.
  • With the implementation of the National Core Standards, the need for monitoring and evaluation is a prime requirement.

Conclusion

  • A concerted effort is required by the informatics community to bring nursing informatics to the attention of educators and to the nursing community at large.
  • More information needs to be disseminated so that the importance of nursing informatics, especially concerning the use of systems for information and patient management, is directed to the right sectors.
  • Without skilled and trained nurses who are able to use the tools available to provide optimum patient care, the benefit of having such first-class technology may be lost.