NZ goes for gold in medication management

New Zealand has taken on the ambitious target of rolling out an electronic medications management (eMM) system in every hospital in the country by 2014. With only one hospital using it at the moment this might seem a tall order, but under the national eMM program, all work is being shared and guidelines prepared so all hospitals are working off the same system.

Dunedin Hospital in New Zealand'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, funding was recently released to allow the system to be installed beyond the two wards it is being used in currently and extended throughout the hospital.

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 systems in place 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 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, 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. It was a barrier that also affected the last time New Zealand 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 said. “The biggest reason was that legislation didn't support electronic signatures and it still doesn't. What we have now is a dispensation process to enable us to carry on outside the boundaries of the current law, which is being rewritten.

“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 I believe that we have rolled it out 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 said. “The Ministry has said they do appreciate that we will 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.”

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 Medication Safety Programme 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. He is now taking part in the South Island Information Systems Alliance, one of the four new alliances created to allow the programs to be streamlined.

“I've been the medical director of information technology at Southern DHB for quite some time and I'm involved in the South Island Information Systems Alliance, which is a new thing,” he says. “What it means is that in New Zealand 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, on several of which I also sit.

“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 since October 2010. “The reason we did that is because it was the hardest nut to crack,” he said. “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.”

Funding has come through for the rest of the 388-bed hospital, and the plan next is to roll it out to the other hospitals in Southern DHB, and then the rest of the South Island. “The South Island IS Alliance is working functionally as a single board, so the alliance is making plans that will take it right across the South Island. It's really quite exciting.”

Beyond that, the plan is to have the system 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 said. “We will be developing people as train the trainers and through the electronic medicines management group 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 high-care 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.”

New Zealand has very much got the jump on Australia with the development of its New Zealand 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. We believe that is the first time it has been done.”

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.

“We are far too small to have 22 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 were having 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

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