2014 and beyond: New Zealand’s eHealth agenda
This article first appeared in the October 2012 edition of Pulse+IT Magazine.
In 2009, New Zealand’s new National Health IT Board was tasked by the government with developing a national plan to improve patient care and information sharing through health IT. In 2010, the board released its plan, which took as its main goal the enabling of person-centred integrated care.
From an Australian perspective, one of the most crucial elements of New Zealand’s plan was its pragmatism. It is not a wishy-washy collection of vision and mission statements, but a detailed strategy aimed at setting actual implementation goals and deadlines for real change and investment. And at the heart of the plan was the realisation that while setting national targets was important, a regional approach would be faster and would build on already proven successes.
Having led the establishment of the National Health IT Board and then the development and introduction of the plan, Graeme Osborne is now charged with its implementation. At the HINZ conference this week, he will outline the progress so far, but will also detail a revision of the plan that will see it refocus on priority programs towards 2014 and beyond.
The spark for the plan came from the change of government in 2008, when the new Health Minister, Tony Ryall, expressed his frustration that not enough was being done to improve healthcare through the use of information technology. For a small population with limited resources, it made sense to harness eHealth initiatives to improve the quality of care.
“What the minister did was set up the National Health IT Board as a sector group and charged us with creating a national plan for the first time,” Mr Osborne says. “The real difference was that it would be an implementation plan, not a strategy plan. From there, working with the board we came up with a goal, and the goal was we wanted to enable person-centred integrated care. We thought that if we enabled person-centred integrated care wherever the health sector moved, that would be a common theme.”
In 2010, the board introduced a four-year plan that set out a number of priority programs to begin implementation in 2011/2012, aiming to achieve real goals by 2014. It would build on eHealth initiatives already established, such as the Safe Medication Management program and the eReferral solution implemented in 2008 at Hutt Valley District Health Board (DHB), but would also set some foundational goals to bring the whole country up to a similar level.
“We didn’t just try to make the argument for why [innovation] was important – we were in fact really looking for where successes had already been proven,” Mr Osborne says. “The plan was based on the idea of lifting everybody up to the current good practice as a base standard, while not wanting to slow down innovation as well.
“In many cases the plan was based around quite careful consideration of what was achievable, by looking at what had already been achieved, pretty much in isolated parts. Throughout New Zealand there were some strengths but a lot of weaknesses as well so we were trying to lift everyone up to the strengths.
“We did adopt a few things (that were already happening) although not many. The medications and eReferrals were probably the two that we picked up. We talk a lot about what we call the beneficial owner – we like to leave the accountability for building and delivering and operating an IT solution with the beneficial owner. It was pretty clear therefore that we had to work with those people who were taking the lead, rather than try to compete.”
There are three main issues the plan sought to solve. The first was to get the DHBs to make investments in health IT for their regions, which was a big step forward, he says. The second was to get some key capabilities working across the regions and nationally. And the third was to target those areas where a national and controlled system was more likely to work.
For 2011/2012, four priority programs were identified, under each of which lay a number of initiatives. The four priority programs are regional information platforms, integrated care initiatives, national solutions, and eMedicines.
Regional information platforms
The regional information platforms program encompasses a number of different aspects, the most interesting from an Australian perspective being the creation of regionally based clinical data repositories underlying a common clinical workstation for hospital clinicians. It also involves bringing the acute care sector up to scratch in terms of patient administration systems (PAS), radiology information and picture archiving communication systems (RIS/PACS), and clinical support for laboratories and pharmacies, as well as improvements in the continuum of care out to the primary care sector, involving eReferrals and eDischarges.
While the plan stated that these platforms would be implemented through DHBs, it made sense to group the DHBs into four different geographical regions – Northern, Midland, Central (in the North Island) and Southern (the whole of the South Island) – all of which are developing regional implementation plans. The plans call for all DHBs to have a single PAS for each region, common systems for laboratory information systems, up-to-date pharmacy systems and improved RIS/PACS.
It also calls for one common system, implemented regionally, for the clinical workstation throughout the country, with four underlying sets of clinical data repositories. While many aspects of the plan allow DHBs or the four regions to choose their own vendor, the National Health IT Board has insisted on one vendor for the clinical workstation based on a patient safety and productivity argument. That vendor is Orion Health with its Concerto platform, which is being implemented as part of the PCEHR project in Australia.
“We call it a clinical workstation but the underlying technology is web-based,” Mr Osborne says. “That means it is able to more easily integrate, collect data and represent data. Hospitals have multiple systems – most hospitals have around 70 to 100 systems – and we’ve had some very smart hospitals that are using the Orion web-based clinical workstation and have really progressed very quickly on being able to present integrated information.
“It was on the back of that best practice that we actually went out to the four regions and said we believe it would be very smart if our clinicians had a common clinical workstation throughout the country, and they’ve come to that conclusion as well. So each of the regions is moving towards the single regional instance of the latest version of Orion’s Concerto and that means that the ones that haven’t used it in the past will come on board. They’ll turn off their local version to enable a regional version.”
The Central region has chosen to use Orion Health to build its clinical data repository (CDR) as well as the workstation, while the Northern and Southern regions have chosen Sysmex's Eclair Testsafe product for the CDR. The Midland region has yet to choose a preferred vendor.
The plan also calls for common PAS, RIS/PACS, ePharmacy, eReferrals and eDischarge summaries, Mr Osborne says. Each region will be allowed to choose which one it uses, but all will be tied together with the common view provided by Concerto.
“We believe that the combination of the three things – the clinical workstation, the CDR and the PAS – are the fundamental systems that we want to have consistently throughout the regions. And we want to have a national view across that as patients move from one region to another. Allied to that is we want to have common RIS/PACS, common ePharmacy, common eReferrals and discharge summaries.
“Once you put all of that into place, you take a lot of the 70 systems out and you can rationalise how many other systems you need in your hospital. That is our philosophy. We don’t talk about hospital systems, we call them regional information platforms, so ultimately this is our strategy about how to rationalise the investment in IT strategy within hospitals.”
While each region can choose its preferred vendor, the National Health IT Board uses a “guided market model”, in which the board sets minimum standards. “We haven’t gone through what I would call a formal certification process yet, although we are building towards that,” he says.
Using the hospital ePrescribing program being pioneered by Dunedin Hospital in the Southern region as an example, Mr Osborne says the board has endorsed a single solution – CSC’s MedChart system – as the national standard.
“Does that mean that product is going to be rolled out across New Zealand? The answer is that unless there is another product that is endorsed, then yes. The DHBs like that because they just want to know what has been endorsed. What we are trying to do is reduce the amount of solutions that are in any one segment of the sector, but we are also needing to show that we are following good procurement practices. There is a balance there.
“We don’t want to have many [different solutions] and in things like medications we would be very happy if there was only one solution. We have to endorse it and it has to be researched – Johanna Westbrook showed that MedChart was as good as Cerner and clearly better than nothing at all. There are a couple of other vendors with products but they don’t have the independent research behind them. That has been what has made us confident around MedChart.”
While the regional information platforms are what they say on the tin, it was decided that there should also be some national solutions that must be implemented. These include systems for different specialities, such as oncology or cardiac and renal health, along with a national assessment system for aged care. Underlying this is a national system of healthcare identifiers.
New Zealand has had a National Health Index (NHI) for its population for 17 years, and this has not changed under the plan. What has changed is new technology to support the NHI along with the Health Practitioner Index and an index of what facilities those practitioners are working from.
“We need to know who is providing care to whom and what facility are they working at, and the Health Identity Programme picks up that – it’s the national index number for the patient and a national number for the provider and the facility they working out of,” Mr Osborne says. “The first one, the National Health Index, we’ve had running for 17 years. Now we are replacing all three into one really smart system. We believe that to have an integrated system we have to have commonalities.”
For the specialty areas, Mr Osborne says the board is setting standards for software solutions specific to those areas. “We prioritise areas where there is commonality and agreement and also where there is value. When you look at oncology or cardiology in New Zealand, we are only talking about 20 or 30,000 patients that are diagnosed each year, so that is very readily manageable on a national system.
“We would expect that when we complete this work, that there will be common systems used throughout the country, although it is interesting that as we go into these areas in more detail, to say there will be a single system is probably a bit simplistic. A system that might be used in say, cardiology, around risk assessment in the community is likely to be one version, and then the system that manages patient flow, that follows people through the tertiary sector may be another system, but at the end of the day we have a national approach working to a common outcomes data collection.”
A national approach to aged care has also been decided, based on the work of the interRAI standard, a collaborative network of researchers devised in Canada and now in use in over 30 countries. interRAI has developed a structured interview protocol to provide a consistent view of individual needs, whether they are as simple as helping older people shower to more complex medication and clinical needs.
interRAI is now known as the Comprehensive Clinical Assessment (CCA) tool in New Zealand. This tool is being used to assess the needs of anyone over 65 who needs access to publicly funded services, with the assessment information stored in a national repository. The wider benefits of a national system were brought into stark relief during the Christchurch earthquake last year, when it was able to be used to find and assist more than 600 elderly people living at home who might have needed assistance and to assess their needs almost immediately.
“We have accepted in New Zealand that we see value in having that common assessment process for aged people whether they are getting that care in the home or in an aged care facility,” Mr Osborne says. “What we did was create a national solution that DHBs and the aged care facilities will utilise but it will be one national system and process.”
Integrated care initiatives
Another benefit of the CCA system for aged care is its integration into other parts of the national health IT system, including the plans for a national shared care record. Much different in its structure and outlook than Australia’s PCEHR, it is the most innovative part of the national plan, Mr Osborne says.
“We are very clear that a group of New Zealanders, people who have co-morbidities or are recovering from a major accident and they need lots of care, will benefit from having a way of logging into a system that has all of their care team members and they can see the action plan to get them well again.
“We are trialling that at the moment. We have a long-term conditions project in Auckland and we have the work going on in Canterbury. It is looking positive but when you are in an innovative area of health IT, it is about the clinicians learning to work differently supported by the software tool, and it’s about them having confidence to engage the consumer in that new approach.”
The integrated care initiatives program includes the development of a shared maternity record of care, a shared care plan for long-term conditions (commonly called chronic disease management in Australia) that is being piloted in Auckland, and a shared care record view, which is developing technology to enable emergency access to patient records and was developed and implemented in Christchurch after the earthquake.
Other projects in this program include the Patients First initiative, which is overseeing the implementation of the primary care sections of the national plan. It includes the GP2GP project, which is developing technology to enable the transfer of patient files electronically from one general practice system to another, along with the practice management systems (PMS) certification program. This is defining and prioritising the clinical, functional and non-functional requirements of GP practice management systems, together with the interoperability needs of a PMS within the broader healthcare eco-system.
While it more generally falls under the regional information platforms program, the eReferrals system that is up and running in Auckland is also providing foundation technology to better enable person-centric integrated care at the community level. NZ secure messaging company HealthLink has been a driving force behind this project, which is being used in three metropolitan DHBs in Auckland, covering a million people.
The four regions are being allowed to choose their own vendor for eReferrals, with the Northern and Central regions choosing HealthLink while the Midland and Southern regions are understood to have chosen a different vendor. Mr Osborne says this will create competition to drive further innovation over time.
The eMedicines program has five parts to it: the introduction of electronic prescribing and administration in hospitals; electronic systems for medicine reconciliation to allow clinicians to view the most accurate list of patient medications, allergies and adverse drug reactions; the New Zealand Electronic Prescription Service (NZePS), to allow GPs to send prescriptions to community pharmacies electronically; the NZ Universal List of Medicines, a master list of all medicines used in the country under a common terminology; and the NZ Medicines Formulary, a point of care reference addressing the day-to-day needs of those prescribing, dispensing and administering medicines in NZ.
The eMedicines program has already achieved a number of goals, Mr Osborne says, with the Universal List of Medicines up and running for 12 months and the formulary going live in July. A deadline of 2014 was initially set for all hospitals to use a common ePrescribing system, but that has been adjusted slightly, with a more pronounced focus on the medicines reconciliation and GP-pharmacy prescription service to be rolled out nationally.
“With medications we’ve decided to get the GP-to-community pharmacy right and getting the medicines reconciliation in and out of hospitals right. The hospital ePrescribing program is an important program to address but we expect it to take a year or two longer to get it fully rolled out around the country.”
The Health IT plan will not come to a halt in 2014 – the idea is to build on its momentum past that date. At the HINZ conference, Mr Osborne will provide the audience with an update on achievements to date, but will also be releasing both a revised 2012 plan and some consumer feedback. “We are going to provide a tree diagram that we’ll share publicly to answer the question of ‘2014 and beyond, how does all of my information fit together?’
“This will be in our revised 2012 IT plan – we launched it in 2010 and we are going to have a revised version in 2012. I’ll be sharing feedback from our consumers, because they are saying it all sounds really good but what does it mean for us? Who is going to hold it, what is it going to look like? There are still quite a lot of New Zealanders who ask us is there one big database that is going to be sitting in Wellington.”
Asked if New Zealand had considered going down the path of a PCEHR, Mr Osborne says it did, but the idea was quickly discounted. “I go back to that concept of the beneficial owner,” he says. “As soon as you create a national electronic health record, you get into two problems. One is that the people who are the beneficial owners of the information, being the consumer and the clinician at the point of care, feel disconnected from it.
"And the second one is how do you maintain the quality of information that ends up in the national system without having a moderation function to ensure the information is coherent? We think the best moderators are the consumer and the clinician together, not individually.
"There is one other reason – we think electronic health records are pretty boring. We think the shared care plans are more interesting in terms of setting out what the person needs to address in their language and how the health workforce is going to work together to address their objectives. We believe it’s a hybrid activity centred around the person and we’ve got to enable the whole sector to work well together.”
The HINZ conference begins in Rotorua on Wednesday. See www.hinz.org.nz for more information.
Posted in New Zealand eHealth