Pacific Rim Perspectives: A Deep Dive into Nursing Informatics Evolution, Infrastructure, and Future Trends

Evolution of Nursing Informatics in the Pacific Rim

The evolution of nursing informatics (NI) has varied across Pacific Rim countries, typically starting with the vision of one or more individuals.
These individuals utilized various opportunities and leadership skills to promote the use of information technologies in all areas of nursing practice.
This promotion occurred in healthcare, educational, and government organizations, as well as within the IT industry and professional organizations.
Events external to nursing often acted as catalysts, stimulating nurses to adopt informatics.
International and multidisciplinary collaborations have aided the advancement of NI.
Australia, New Zealand, Korea, and Hong Kong have made significant progress since the early 1980s, followed by Japan, Singapore, Thailand, Taiwan, and China more recently.
Some Pacific region countries are only beginning to explore NI.
The Asia Pacific Medical Informatics Association (APAMI), formed in 1993, has been instrumental in launching national healthcare informatics associations and raising awareness in several countries.
Nurses interested in promoting informatics in countries with developing NI sectors are encouraged to connect with the APAMI network.
Obtaining appropriate informatics education remains a challenge for many nurses in the region.
Increased computer use by nurses in countries like Australia and New Zealand is raising awareness of the benefits of IT in healthcare.

National Health System Infrastructures

New Zealand has a population of nearly 4.5 million, with approximately 75% residing in urban areas.
Auckland, the largest city, accounts for over a third of the total population.
20% of the population is under 15, and 14% is over 65, with the older population projected to increase.
The majority of New Zealanders are of European descent (69%), with Maori, the indigenous people, comprising 15% of the population.
Australia is a federation with a population exceeding 22 million.
Approximately 9.4% of Australia's GDP is allocated to health services.
71% of Australian households are located in urban and provincial areas, mostly near coastal cities.
Australia has a low population density outside major cities.
In 2009, there were approximately 1105 full-time equivalent registered nurses and midwives per 100,000 population, with 20% aged 55 or over.
Government health policies must address:
- An aging population
- Increased complexity of healthcare needs
- A higher incidence of long-term conditions
- Growing consumer demand for choice
- Changing lifestyle factors
- Technological developments
- Increased consumer-provider partnerships
Judicious use of health IT investments is essential for the long-term sustainability of national healthcare and improved health outcomes.

National Health System Funding Frameworks

Australia began developing a patient classification system in collaboration with Professor Fetter from Yale University in the 1980s.
The Australian Refined Diagnosis Related Group (AR-DRG) standard is nationally used for costing and funding purposes.
This system relies on data from individual patient records, including ICD-10-AM codes.
Service weights that reflects the cost of providing various hospital-based services including nursing are updated periodically.
A 2009 review of Australia’s case-mix system estimated annual savings of 4 billion (for bed days) against an annual cost of 10 million.
Australian taxpayers contribute a 1.5\% Medicare levy, with high-income earners paying an additional 1\%, which contributes 15\% to the government’s total health funding.
Taxpayer contributions to Medicare are projected to increase to cover disability services.
Spending on cardiovascular diseases was the highest at 7.9 billion.
The Australian government also manages the Pharmaceutical Benefits Scheme (PBS), jointly funded by government and non-government sources, accounting for 14\% of recurrent health expenditures.
New Zealand has a publicly funded healthcare system, providing free or heavily subsidized healthcare to consumers.
The Ministry of Health allocates funds to 20 district health boards (DHBs) based on population.
DHBs purchase and provide healthcare services for their region, working together to ensure cost-effective and efficient service delivery.
The New Zealand Accident Compensation Corporation (ACC) provides comprehensive, no-fault personal injury cover for all residents, funded through levies on employers, employees, and vehicle registration.
Private insurance-funded healthcare is increasing due to an aging population, improved treatment options, limited public budgets, and increased waiting times for elective surgery, now accounting for nearly 20\% of healthcare.
Rising private health insurance premiums are widening the gap between those who can afford private healthcare and those who cannot, affecting the older population particularly.
All prescription medicines are regulated by Pharmac, with subsidies available on a range of medicines.
Pharmac has recently taken responsibility for medical device management, increasing the need for drug information for medical practitioners, nurses, and consumers.

Technology and Healthcare Trends

The past decade has seen major technological advancements including cloud services, systems integration, device proliferation, mobile access, and enhanced data collection and analysis.
Healthcare providers have become more adept with ICT development and change management.
Technology advancements have enabled innovative healthcare delivery methods, with blurred physical constraints and boundaries allowing remote supervision and expertise.
Some Australian nurses use personal digital assistants (PDAs) for point-of-care information and clinical documentation.
New monitoring devices are being connected to information systems for automated data entry, and portability improvements enable technology use in diverse settings.
Both PDAs and tablets are being used or trialled by students and healthcare professionals.
Integrating care is now a priority in New Zealand, supported by technology-enabled information flow.
Electronic health event summaries, laboratory, and radiology data are transmitted between providers and across primary and secondary sectors.
Data on prescriptions dispensed are also available electronically.
The Internet and intranets provide extensive information to both health providers and consumers, supported by sophisticated national broadband infrastructures.
New Zealand has a high proportion of Internet users (88%), with government initiatives in place to improve broadband services.
A survey of New Zealand consumers found that 67.9\% used a computer to access health information, with the Internet being the third most popular source after doctors/health centers and nurses.
Consumers are not always aware of existing New Zealand health information websites and resources.
National strategies identify consumer information, patient portals, and shared health records as important for the future.
Web environments and integration engines offer contextual data views through browser-based portals, providing a single patient-centric view for clinicians.
Online technologies enhance patient care and improve clinical outcomes through evidence-based information and decision support systems.
Mobile computing, especially the use of smartphones, is increasing, and tablets are being used more in healthcare settings.
Social media is increasingly used in healthcare for promotion, communication, and community development.
Examples include Facebook support groups for teen parents and online forums for families with mental health problems.
New Zealand has high social media usage, but the Nursing Council of New Zealand addresses its use in the nurses' code of conduct.
New Zealand has a thriving health IT sector, with information technology being its third-largest export.
The government supports innovation in ICT through research and development funding.

Standards Development and Adoption

Detailed and clinically relevant data are essential for clinical decisions and quality monitoring.
Health information systems should meet various demands for data to support:
- Feedback via automated alerts
- Decision support
- Quality monitoring
- Information exchange
- Reducing provider burden
- Payment policy
- Outcomes research
Health data and information standards support the secure exchange of patient information between healthcare providers and IT systems.
National adoption of technology is a prerequisite for optimized IT use, ensuring interoperable clinical systems.
Standards Australia (SA) established a health informatics committee in 1992, which collaborates with other groups like HL7 International and ISO Technical Committee 215.
The focus in Australia has been on developing standards to facilitate data interchange, with SNOMED-CT adopted as the national terminology standard.
Australia contributes to international standards development to meet local needs.
All Australian standards are freely available on the SA’s eHealth website, funded by the government.
Australia's National eHealth Transition Authority (NEHTA) works with the SA IT-14 Committee to align standards development with business priorities.
NEHTA aims to enhance healthcare by enabling access to the right information at the right time and place, publishing resources for stakeholders.
In 2001, New Zealand established the Health Information Standards Organisation (HISO) to manage health information standards.
HISO’s role includes identifying, developing, publishing, and monitoring New Zealand’s health information standards.
HISO aims to endorse existing standards and only develop new standards specific to New Zealand.
Consistent standards use will require enablement of real-time access to information about the standards.

eHealth Policy, Governance, and Funding Initiatives

Singapore’s Integrated Health Information Systems (IHiS) organization began in 2008, aiming to drive synergies and strengthen IT workforce.
IHiS provides IT services for public hospitals, national specialty centers, and polyclinics, standardizing IT resources.
This collaboration aggregates demand, fosters interoperable EMRs, and builds IT skills.
SingHealth hospitals in Singapore include Nursing Informatics Heads who works with IHiS staff.
Australia initiated Health Online in 1999, followed by projects like HealthConnect and MediConnect.
Numerous reports have emphasized the need for widespread eHealth adoption, which was also made reference to in the NSW Health Garling Report on Acute Services.
The term eHealth came into widespread usage only a few years ago and still lacks a universally consistent definition.
The World Health Organization (WHO) defines eHealth as the transfer of health resources and healthcare by electronic means.
Australia’s 2008 National eHealth Strategy aims to reinforce collaboration and support health reform, providing flexibility for states, territories, and the public and private sectors.
The 2010 federal budget funded personally held and controlled EHRs (PCEHR).
Electronic prescribing was introduced in 2011, and the eHealth record system launched in 2012 is under review.
The National eHealth Transition Authority (NEHTA) facilitates the transition to a connected system.
The new Australian government is expected to develop new health policies based on the view that we need a closer working relationship between GPs and hospitals, better ehealth solutions, and improved coordination of care for people with chronic and complex conditions including cancer.
Pressures influencing eHealth policy and funding include:
- An aging population
- An aging workforce
- Health inequalities
New Zealand desires more informed consumers and continues to expect free healthcare and evidence-based best practice.
Nurses are recognized as having enormous potential to advance health and disability outcomes.
The Victorian HealthSMART program, now 10 years old, has faced issues such as poor planning, inadequate understanding of complex requirements of the clinical ICT system, and that some clinical ICT systems have issues that potentially affect patient safety.
New Zealand’s healthcare is guided by a national health strategy to improve health and well-being, which recognizes the importance of good information management.
Following a Ministerial Review in 2009 that sought "better, sooner, more convenient health services,” the National Health IT Board was formed to support the delivery of high-quality healthcare and provide strategic leadership on health information investments and solutions.
Electronic medication management, national clinical solutions, regional information platforms, and community-based integrated care initiatives are four priorities being identified for 2014 and beyond.
The need for shared and accessible records from multiple sites was reinforced following the Christchurch earthquakes in 2010 and 2011.
Telehealth Forums have been established to promote the use and maximize the benefits of government broadband programs.
Telehealth is challenging traditional care delivery and participant roles.
Planning is underway for a national telehealth service using a multi-channel approach to improve public access to advice, counseling, and referrals.
Changes to the health sector following a Ministerial Review in 2009 included organizational changes, implementation of review recommendations, and legislative amendments.
The National Health IT Board aims to drive innovation, partnership, and respect the context of the whole sector; and work towards the eHealth vision: “To achieve high quality healthcare and improve patient safety.”
Primary care is moving toward integrated healthcare, however, significant gaps remain on the brick and mortar.

Information Governance

The national health information agreements and the National Health Data Dictionary in 1993 laid the foundation for consistent health data sets in Australia and provided the national infrastructure needed to provide high-quality health data.
It includes Australia’s repository for national metadata standards for health, METeOR, providing online access to a wide range of nationally endorsed data definitions and tools for creating new definitions based on existing already-endorsed components.
An Australian Community Nursing Minimum Data Set was developed during the early 1990s and has been adopted and extended by the Department of Veteran Affairs (DVA), which has also adopted a Community Nursing Classification System.
Australia’s health sector governance is constantly changing, with distributed governance over many jurisdictions considered a significant impediment to better healthcare outcomes.
The National Health Information Standards and Statistics Committee (NHISSC) continues to provide a national health data governance service despite changes in governments.
Historically, primary care in New Zealand made use of the READ codes, which is continued by the Accident Compensation Corporation (ACC).
Secondary care used the ICD-10 classification system, originating from the World Health Organization as a means of classifying and coding diseases and signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
Both Australia and New Zealand have invested in Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT®), and HISO has endorsed the use of SNOMED-CT as the clinical terminology to be used in New Zealand.
The New Zealand Ministry of Health is responsible for national collections and surveys of health and disability information, hosting 14 national collections.
Core systems supporting healthcare include the National Health Index (NHI) and the Health Practitioner Index, with each person assigned a unique identifier.
National data collections provide valuable health information to support performance monitoring, decision-making, policy formulation, funding, evaluation, and research.
All information collection, storage, access, and retrieval in New Zealand are governed by the Privacy Act (1993), the Health Information Code (1994), and the New Zealand Law Commission Privacy Commissioner.
The University of Hong Kong utilizes interRAI minimum datasets for nursing home, home care, and mental health assessment, now available in Chinese, with the coordinating center based at the University of Queensland in Brisbane.

Nursing Workforce

A total of 50,060 nurses practicing in New Zealand provide care to its population, with The nursing workforce in New Zealand being the single largest health professional group.
Changes such as nurse practitioner roles and nurse prescribing have occurred; where there were 110 Nurse Practitioners in 2013.
As part of ensuring standards of practice the Health Practitioners Competence Assurance Act (2003) requires each health practitioner group to describe its profession in terms of scopes of practice to ensure the safety of the public.

Regional Developments

Health and Nursing informatics developments are highly dependent upon Government and associated industry initiatives and available ICT infrastructures.
The Asia eHealth Information Network (AeHIN) was launched in Bangkok in August 2012 to promote better use of information and communication technology (ICT) to achieve better health. The organization enhances leadership and governance, capacity building, peer assistance, and promoting standards and interoperability.

HI and NI Professional Organizations

Both New Zealand and Australia have many health informatics and related professional organizations and groups advising various government departments and specific projects.
Health Informatics New Zealand (HINZ) is working closely with the Australasian College of Health Informatics, with both organizations having many nurses as members and fellows.
New Zealand participates in the international health informatics arena through representation in the International Medical Informatics Association (IMIA), International Medical Informatics Association Nursing Informatics group (IMIA-NI), various working groups of IMIA, and the Health Information Management System Society Asia-Pacific (HIMSS Asia-Pac).
Nursing informatics in Australia began with the Royal Australian Nursing Federation (now ANF) in 1984 which later grew to a Health Informatics Society of Australia (HISA) in 1993.
In 2003, the HISA NI Sig (NIA) was funded to develop a strategic plan for nursing informatics capacity building, and a plan for the nursing profession’s engagement with the Australian government and its informatics agenda.
Since then NI’s contributions have been ad hoc mainly by individual experts or via the Royal College of Nursing. e Coalition of National Nursing Organisations (CoNNO) did develop a Position Statement on Nursing and eHealth under the leadership of its NIA member (CoNNO, 2008).

HI and NI Research

There’s a growing awareness of the need for timely and accurate data for research.
Clinical pathways, evidence-based practice, and nursing service architecture are gaining more attention with the Internet and workplace intranets providing ready access to evidence.
Research in health informatics is supported through funding, and master’s and doctorate programs.
The main avenues for sharing health informatics research is through internationally indexed conference proceedings and journal publications, plus local professional conferences and workshops such as the Health Informatics New Zealand (HINZ) annual conference and quarterly seminars, workshops, and meetings held by AeHIN, APAMI, and HIMMS-AsiaPac.

HI and NI Education

The first Australian textbook on health informatics was published in 1996 (Hovenga, Kidd, & Cesnik 1996), a second edition was published by IOS Press in 2010 followed by a text on Health Data Governance in 2013 (Hovenga, Kidd, Garde, Hullin, 2010; Hovenga & Grain, 2013).
Informatics education for nurses in Australia varies considerably from one university to another.
A study of 10,000 nurses in Australia (44% response rate) on their use of information technology has clearly identified that nurses recognize benefits of adopting more information technology in the workplace.
Nurses registering for practice in New Zealand complete a three-year under-graduate degree, where much of nursing informatics is integrated into under- graduate curriculum under the guise of other subjects.
The new nursing student enters with greater computer skills compared to earlier cohorts.
Learning that utilizes the benefits of technology is becoming increasingly common for post-graduate nursing education.

Competencies and Credentialing

Australia has more than 50 specialty national nursing organizations (NNOs).
A general HI skills Internet/Web-based survey based on IMIA’s educational guidelines and the use of Benner’s competency levels, from which nurses’ responses were separately identified and analyzed showed:
- Self-assessed levels of competent (35%)
- Proficient (33%)
- Expert (4%)
With a that combined 72%.
A local survey of 1465 nurses showed:
- A quarter of the nurses rated themselves as below competent with enrolled nurses showing the lowest levels of competency.
- That a study found that a quarter of the nurses rated themselves as below competent with enrolled nurses showing the lowest levels of competency.
The only statement that the majority of nurses disagreed with was “computer and technology in health will reduce my workload”, which was viewed as being caused by, negative past experiences, common misconception or inadequate education leading to inefficient use.
ACHI established an education committee in late 2008, which obtained Government funding in 2009 to establish what is now known as the Australian Health Informatics Education Council (AHIEC).
Competencies identified that are needed in HI include:
- What is HI ?
- Ethics
- Basic Computer science
- Consumer health informatics
- Research

Impacts on NI Discipline Development

Professional health, medical, and nursing organizations, along with educational providers and research centers, play a major role in the awareness raising, education, and dissemination of knowledge in the Pacific Rim.
It is complex with the proliferation of government initiatives spanning multiple government departments.
Nurses, as the largest group of health professionals, have a major role to play.
Nurses need to make better use of available technologies and that all applications need to have a strong nursing focus to enable the realization of that is now established as well as there is an urgency to develop a critical mass of nurse informaticians.