Could health information systems enhance the quality of Aboriginal health promotion? A retrospective audit of Aboriginal health programs in the Northern Territory of Australia

It is widely known that improving the quality of healthcare is one of the most direct ways to address the significant health disparities between Aboriginal and Torres Strait Islander peoples and Australians of other descent. In 2008, the Council of Australian Governments (COAG) committed to ‘work together to achieve equality in health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by the year 2023′ [1] (Hereafter, we use “Aboriginal” as a collective term, acknowledging the diversity of language and culture of Aboriginal and Torres Strait Islander peoples, as the First People and custodians of Australia). A core component of COAG’s ‘Closing the Gap’ strategy were measurable targets to monitor improvements in the health and wellbeing of the Aboriginal population. In response, there has been a rapidly expanding quest for information, reflected in a proliferation of quality improvement programs and introduction of key performance indicator (KPI) reporting [2]. In the Northern Territory, for example, gaps in quality of Aboriginal primary health care were identified following the introduction of Aboriginal Health Key Performance Indicators and performance reporting systems. These findings informed the Northern Territory’s continuous quality improvement strategy, which has been credited not only for its sustained use, but for the value of its data in strengthening health systems and improving quality of health care for Aboriginal peoples [3].

Reports on health care quality and health system performance, however, repeatedly lack information about Aboriginal health promotion programs. For example, health promotion—described as ‘activities designed to improve or protect health within social, physical, economic and political contexts’- is one of 68 performance measures included in the Australian Government’s Aboriginal and Torres Strait Islander Health Performance Framework [4]. Reporting on this measure is based on the number of health promotion interventions provided by clinicians and other health professionals. Information that could be used to monitor quality of Aboriginal health promotion is lacking. Cited reasons for this include suitability of indicators to measure and monitor quality, and limitations in data availability and quality [4].

In addition to improving reporting of the contribution that Aboriginal health promotion makes to ‘closing the gap’, there are calls for Aboriginal people and communities to become active partners in their health care delivery [5, 6]. COAG’s most recent Closing the Gap report makes stronger assertions to increase meaningful partnerships between all levels of governments and communities, in recognition that work to date is insufficient for meeting 2023 targets [7]. Studies evaluating Aboriginal people’s participation in health promotion have consistently concluded that community involvement enhances delivery and uptake of health programs [8‐11]. However, the value of health promotion has yet to be fully realized because there remains insufficient evidence to confidently determine the impact on Aboriginal health and wellbeing [10, 11]. It has been suggested that by improving documentation of community participation strategies and processes, more successful strategies could be identified and replicated, thus strengthen the evidence base [10, 11].

Health information systems (HIS) have the potential to capture and share data that could improve quality and reporting of Aboriginal health promotion, including details of community participation. Firstly, by facilitating collection, documentation and organization of a vast array of information about health promotion in a structured and systematic way. Secondly, as a source of data to be analyzed and communicated in real-time for quality improvement and performance indicator reporting purposes. A HIS commonly used in hospitals and medical services is the Electronic Medical Record (EMR). EMRs, digital versions of the patient chart, contain information about patient medical and treatment history collected by and for clinicians, usually within a single healthcare institution. EMRs are valuable sources of data that providers can use in making decisions about health care delivery. Indeed, health services have sought innovative ways to utilize these data to report on and improve the quality health care and health system performance for Aboriginal Australians [12, 13]. EMRs and many other health information systems, however, are rarely designed or developed to capture, store or retrieve data about population-level services and activities. Currently, there is some evidence to suggest that health promotion and prevention could similarly benefit from health information systems [14, 15]. Yet, to our knowledge, there is no research on the potential use of these systems in the context of Aboriginal health promotion. Research into such technologies is challenging because HIS for recording and monitoring health promotion efforts are often created for individual organization’s internal purposes, without any public record of how it was designed, used or lessons learned [16].

Within this broader context, we report a study of Australia’s first investigation of a HIS designed for recording and storing information about Aboriginal health promotion. The Quality Improvement Program Planning System (QIPPS) was an innovative and unique online, project planning and evaluation system for health promotion and community development projects. From 2008 until 2019, when QIPPS was decommissioned and no longer available on the market, it was the centralized online system for recording information about health promotion programs delivered by Northern Territory Health (NT Health). We were interested in the feasibility of utilizing this information to report on the quality of Aboriginal health promotion. Specifically, our aims were to extract data stored in QIPPS to describe: (1) the scope of Aboriginal health promotion programs; (2) the quality of Aboriginal health promotion program planning, delivery and evaluation; and (3) community participation strategies and processes used in Aboriginal health promotion, using chronic disease prevention activities as exemplars programs. Thereby, we identify the benefits and limitations of HIS’ for health promotion and potential for secondary uses of stored data for quality improvement purposes.

The Northern Territory (NT) is arguably Australia’s most challenging health service delivery environment. The NT has the highest proportion of Aboriginal Australian residents compared to other states in Australia. Approximately 30% of the total NT population identify as being Aboriginal peoples compared to 3% of the total Australian population [17], making NT Health the single largest provider of health services to Aboriginal peoples in Australia. About 90% of the NT Aboriginal population live in discrete, remote communities, where the delivery of health care is logistically challenging, hence more expensive, than in urban settings [18]. The gap in life expectancy between Aboriginal peoples and Australians of other descent is greater in the NT (14.4yrs for both males and females compared to 10.6 years for males and 9.5 years for females, nationally), and is increasing over time [1]. The cost of the Aboriginal health gap in the NT has been estimated at $16.7 billion [20].

The NT Aboriginal population experience a disproportionate burden of chronic disease linked to inactivity, diet, socio-economic disadvantage and access to primary health care services [19]. NT Health—the public healthcare system responsible for delivering clinical, primary health care and public health services to all Territorians – recognizes the critical role of health promotion and prevention in addressing these inequities and improving Aboriginal health outcomes. Health promotion is an ongoing strategic priority of NT Health [18, 22] and a core function in models of comprehensive primary health care [21]. However, in reality, a range of challenges influence health promotion delivery and its success in the NT, including the burden of acute care in Aboriginal communities, high workforce turnover, low stability and acute-oriented, temporary staffing [19, 23] together with the availability of information about, and capacity to report on, health promotion quality and effectiveness [10, 23, 24].

To overcome some of these challenges, NT Health has introduced over the past 10 years a range of initiatives. These have included: (i) a Health Promotion Strategic Framework [25]; (ii) introduction of the Quality Improvement Program Planning System (QIPPS); and (iii) participation in continuous quality improvement initiatives [26], including in health promotion specifically [27]. These initiatives have proved useful in guiding planning and implementation of health promotion programs across the NT’s diverse context, and there is some evidence of impact on health promotion quality [10, 24]. Previous assessments, however, have mainly been conducted at a community-level. There remains limited knowledge on the extent to which these initiatives are meeting Territory-wide strategic health promotion goals.

This retrospective audit of health promotion projects demonstrates the potential of a purpose-built, health information system to capture and share data that could be used to report, and improve, the quality of Aboriginal health promotion. At NT Health, QIPPS was used to record and store information about diverse health promotion programs. Encouragingly, details about planning aspects of health promotion, like community consultations, were recorded such that the information could be used for secondary analysis. However, documentation of information for implementation and evaluation phases was missing or described insufficiently. QIPPS provided a valuable source of information about Aboriginal health promotion in the NT, but data availability and quality were limiting factors for reporting on health promotion quality. To realize the systems’ full potential more needs to be done to support and encourage accurate records of practice – not only health promotion plans or intentions—but also what practitioners actually do. In particular, more details and improved documentation about ways of engaging community would allow for successful strategies to be identified and replicated in future work. This would enhance program success, strengthen the evidence base and contribution of health promotion to closing the gap in Aboriginal health inequities.

Australian reports on health care quality and system performance do not always capture and track health promotion performance measures. Moreover, current indicators of Aboriginal health care quality do not monitor and report on Aboriginal participation in health care delivery [3]. Few research studies of Aboriginal health promotion have assessed quality against indicators of best practice; for those that have done this, it is generally reported at a community-, and not health system level [10, 24]. Using a structured data extraction tool designed for health promotion quality improvement purposes, this study provided insight into the scope of health promotion and identified gaps in quality which could be used to target system level changes and improve Aboriginal health promotion efforts. The inclusion of a range of indicators to assess community participation in health promotion enabled a nuanced exploration of the different ways community are engaged as active partners throughout each phase of the health promotion cycle. For example, we identified that the most common strategy of community participation occurred during the planning phase, using consultation processes. Yet, information about strategies and processes of community engagement during implementation and evaluation phases were not documented or not of sufficient detail. Our previous research demonstrated that using indicators of Aboriginal health promotion quality within a continuous quality improvement framework enhances health system capacity for recording health promotion, and subsequently the availability and quality of data [10]. With further support for uptake and implementation of quality improvement in health promotion, demonstrable and sustained improvements in Aboriginal health promotion are feasible [30, 31].

As for information systems more generally [12, 13, 32, 33], a significant constraint in realizing the potential of QIPPS was data quality. Information about some elements of health promotion, particularly related to project planning, were more readily available, and reliably collected, such as stating project goals and objectives, identifying the target group and health issues to be addressed. Meanwhile, information about aspects of project implementation and evaluation, such as strategies for community participation, evaluation methods and reporting findings, were missing or inconsistently reported and therefore, less reliably collected for secondary analysis.

From a quality improvement standpoint, data standardization is critical for monitoring indicators and tracking performance over time. Records about health promotion practice predominately constitute prose-like narratives, or free text, invariably resulting in inconsistency in documented information. However, important insights about the quality of Aboriginal health promotion, such as community participation processes and strategies, will likely remain invisible if information is recorded in pre-specified formats or by applying strict documentation practices. Herein lies one of many challenges in designing information systems to support recording, collection, analysis and reporting of health promotion data for quality improvement and performance reporting, alongside health professionals’ planning and evaluation needs [14‐16].

The extent of generalizability of our study findings should take into account: (i) data were based on recorded health promotion practice, which may underestimate breadth and depth of actual health promotion efforts; (ii) given the long-standing use of QIPPS in NT Health, the quality of data reported is likely to be better than for other Aboriginal health services and state/territory government health departments more generally in Australia. Furthermore, NT Health provided support and training for QIPPS users –Aboriginal and non-Aboriginal dedicated health promotion practitioners and non-dedicated health promotion staff including nutritionists and public health staff in hearing, oral and environmental health—thus, staff have a better understanding of the information system which is likely to influence quality of information entered in QIPPS; and (iii) several biases can arise auditing records of health service delivery, including experience and skills of the auditor/s; and the type of data extracted, influencing the reproducibility of quality indicator/s. A strength of the study was the iterative and team-based approach of Aboriginal and non-Aboriginal researchers, policy staff and health promotion practitioners working together.

Since completing this study, QIPPS was decommissioned by Infoxchange and is no longer available on the market. NT Health is currently transitioning from using QIPPS to an internal record management system. Study findings will inform the development of customized templates for documenting planning and evaluation of health promotion, and tailored workforce development initiatives to improve quality and accuracy of data entry and recording.

We hope this study will also inform future discussions and design of health promotion information systems and promote the potential for secondary uses of stored data for performance reporting and quality improvement purposes. To reap the full potential of health promotion information systems, we recommend continuous use of quality improvement approaches, such as tracking quality indicators using an audit and feedback technique. A continuous quality improvement approach could encourage, monitor, and reward accurate reporting of indicators. This would enhance health information system functionality, the capability of practitioners to use these systems effectively for planning and evaluation, and for monitoring improvements in quality of health promotion.

This first Australian study of a purpose-built, health promotion information system demonstrates the potential for utilizing stored data to report on quality of Aboriginal health promotion. More should be done to encourage accurate recording of information about health promotion practice, particularly findings of evaluations and how community are engaged throughout the health promotion project cycle. This would allow the more successful strategies to be identified and replicated to enhance health promotion success, and ultimately improve the health and life expectancy of Aboriginal peoples. Testing and improving the validity and reliability of indicators of Aboriginal health promotion quality is an important area for future research. More specific attention to the development and use of information systems in health promotion should contribute to a more comprehensive understanding of the quality of health services and programs for Aboriginal Australians.