New Zealand goes for gold in medications management
This article first appeared in the October 2012 edition of Pulse+IT Magazine.
Dunedin Hospital in NZ’s South Island has been trialling an electronic medications management system since 2010. Using MedChart, from the vendor formerly known as iSOFT and now part of CSC, the system has now been installed beyond the two wards it was trialled in and an extension throughout the remainder of the district is underway
And it is no longer being called a trial, according to Andrew Bowers, an internal medicine specialist who is also the medical director of information technology at Southern District Health Board (DHB) and who has been leading the project from the outset.
The trial is now a staged roll out, Dr Bowers says, and is an integral part of NZ’s ambitious target to have an eMM system in place in every hospital in the country by 2014, part of the Ministry of Health’s Go for Gold strategy.
This strategy has meant huge changes to the way things are done in New Zealand, which has for many years been split into 22, now 20, disparate district health boards, many using different systems and different ways of doing things.
Several barriers have had to be overcome to enable widespread adoption, not the least of which was a complete rewrite of the main piece of legislation covering medicines, the Medicines Act 1981.
The new legislation, which passed the lower house of Parliament in February but has not progressed much since then, will change the wording of the 1981 Act to enable electronic signatures.
The 1981 Act required a hand-written signature on all prescriptions – a huge step forward in patient safety in those days but one that has had the unintended effect of stymieing the progress of electronic systems.
As the new legislation is not yet law, the team running the eMM system in Dunedin has been working under a special dispensation allowing electronic signatures to be used.
According to Dr Bowers, the dispensation application process was supposed to have been streamlined, but says it remains a significant barrier to a timely rollout.
It was also a barrier that affected the last time NZ tried to introduce an eMM, back in 2004 when MedChart was brand new.
“We actually implemented MedChart in 2004 but it didn’t go well, for several reasons,” Dr Bowers says. “The biggest reason was that legislation didn’t support electronic signatures and it still doesn’t.”
“Back in 2004, we had to have a hybrid solution in place with paper and electronic charts, and that was inherently dangerous. Also, nobody had electronic prescribing in place anywhere in the southern hemisphere and we didn’t really know how to roll it out very well.
“But we’ve learned from our mistakes, from the other places that have put it in since that time, and we have now developed a national process to achieve it. We understand how to engage better and on this occasion, we did a much better job of it.”
The Ministry of Health’s plan to have the system in place in every hospital in country is ambitious, but unapologetically so, Dr Bowers says. “The Ministry has said they do appreciate that we may not achieve 100 per cent of that, but if we ask for a longer timeline we won’t achieve that either. So this is really pushing it and stimulating development.”
Broad vision for eHealth
Another barrier to overcome is the way district health boards function and are funded. New Zealand has now decided to split the country into four alliances for the purpose of streamlining the several elements of the National Health IT Board’s broader vision for eHealth in NZ.
This includes the Connected Health program, a standards-based, commercial model for the delivery of universal connectivity across the New Zealand health sector. There is also a Health Identity program, which aims to deliver a single integrated system that will lay the foundation for a secure and transferable electronic shared care record.
The National e-Medication Programme (NeMP) is also part of the vision, and it has been given priority status. A huge part of it is the eMedicines program that Dr Bowers is helping to lead in his district. He is now taking part in the South Island Information Systems (SI IS) Alliance, one of the four new alliances created to allow the programs to be streamlined.
“I chair the SI IS Alliance, but I am also the medical director of IT for the South Island Alliance, covering every South Island public hospital,” Dr Bowers says. “This role is collectively funded by every SI DHB, which indicates the strength of resolve for the Alliance, I believe. This role has gone full time when combined with my MD of IT role for the Southern DHB. I expect that I have more that 10 years of work ahead of me.
“What it means is that in NZ we have broken our health service down into four health regions. The South Island is its own health region – we’ve got roughly equivalent numbers of people in each of the regions. The aim of that of that is not to fragment but actually to align our processes alongside a vision that has come out of the National Health IT Board and various other advisory groups.
“One is called the National Information Clinical Leadership Group (NICLG). The South Island Alliance has a very large number of work streams but one of those is medicines management, and we are implementing the Ministry’s “Go for Gold” program.”
MedChart has been live in two acute internal medicine wards at Dunedin Hospital since October 2010, and the reason they were chosen is they were the “hardest nut to crack”, he says. “The patients that are there are the most complex and the most unstable, using the most medications and with the highest turnover. If we could do it well there, we felt that the rest of the hospital would be relatively simple.”
The system is now being rolled out throughout the 388-bed hospital, and the plan next is to roll it out to the other hospitals in Southern DHB, and in parallel with the rest of the South Island. “We are now aiming to have the whole of the South Island on electronic prescribing and administration by the end of 2014, and we are likely on track to achieve most of this,” he says.
“We have achieved board support and funding for the whole Southern DHB. We have also achieved SI IS Alliance support for this, making it a major regional workstream. Canterbury DHB has advanced plans, hopefully going live early next year, and we are in the process of forming governance groups across the whole South Island to ensure regional alignment of process.”
Single clinical desktop
Work is also in hand to redesign all patient management systems in every South Island public hospital to ensure there is a single system across all hospitals, enabling improved patient journeys between hospitals, fully aligned business processes, reduced cost and the ability to develop shared business intelligence and planning across the whole region.
“Expressions of interest for a partnership in this are soon going to be published,” Dr Bowers says. “We have been supported in this by the National Institute of Health Innovation (NIHI), which is based in Auckland, and by the National Health IT Board. Other health regions are also taking interest in the outcome of this process and of course we aim to share our activities with them.”
The team has also started rolling out a single clinical desktop across every hospital in the South Island. Based on Orion Health’s clinical portal package, formerly known as Concerto, this has been rebranded as Health Connect South. “We are in partnership with Orion Health to develop this and other innovative additions to clinical support via this interface. Doing so will enable identical access to shared complete patient records in every DHB, via a standardised desktop with a single login, and reduces the risk we know exists when clinicians move between hospitals in shared services who have to learn new systems or lose track of patients.”
Beyond that, the plan is to have electronic medications management installed in every hospital in the country. It is a requirement that everything this team does is shared, right down to the business case, he says. “We will be developing people as train the trainers and through the National e-Medication Programme that is part of the National Health IT Board, and the Health Quality and Safety Commission, we’ll be developing guidelines that can be mirrored in every hospital.”
It will also be spread out into the community. Dr Bowers is very keen to see eMM systems used more in the community, particularly in nursing homes but also for community mental health provision. “We want to develop it further regionally so that we have what we call a My List of Medicines, which is a single list that rules them all, which is reconciled so that all of our electronic systems both in the general practices and in the hospitals read and write from the same source of truth and it is reconciled.
“We do have great interest in moving MedChart into the community, not only to rest homes but into the general practices themselves and we do want to keep that enthusiasm boiling. Our primary aim at this stage though is to keep focus on the activities within the hospital and to stay within our limited resources. Once we have this consolidated in every public hospital we will extend the scope to close the loop with all community prescribers, and with hopefully additional funding by then.”
New Zealand has very much got the jump on Australia with the development of its Universal List of Medicines (NZULM), which is already up and running. “We know there are different ways of prescribing medication that vary according to which hospital and which company you are purchasing from, so part of this is to have a single list of descriptions of medicines and a single type of barcode that describes a medication right across the country.”
Mandate for support
Another thing Australia could learn from our cousins is the formation of the four alliances and a mandate from the Ministry of Health that they all support each other, he says. All information must be open as well, so Australia is free to pinch any ideas if we see fit, he said.
While Dr Bowers can’t speak for the other IS regions, there is an expectation that they will progress along this path also, he says. “Taranaki Hospital went live with MedChart in a Care of the Elderly area [recently], and also has plans to keep the momentum up for rollout. Counties Manukau DHB is in the final stages of preparation and intends to go live early next year with a rapid rollout beyond that.
“We all struggle with issues of funding. Not every DHB has the advantage of a clinician-directed IS service, but hopefully, based on our success in the South Island, this will become standard practice. I believe that we are on the cusp of great change in IS in terms of refocussing activity towards improving patient outcomes through clinical partnerships with IS.
“We are far too small to have 20 district health boards in a country of only 4.5 million. It’s silly. Each hospital was working on parallel processes with different ways. It also wasn’t good for the software vendors because they have very small markets, each of which is going in a different direction so they had to configure things differently for each hospital – it was inefficient.
“The other change that has happened is that we now have a mobile workforce – people are moving constantly between district health boards and hospitals within the region and having to learn completely different ways of doing things. So we now are going to align all of our clinical processes, all of our software systems, so that doctors and nurses and patients can move very easily between different parts of New Zealand and have a complete health record that they can rely upon being safe.”
Posted in New Zealand eHealth