The quest for interoperability in health IT needs to accelerate, says Zoran Bolevich, group manager information strategy and architecture group at the Ministry of Health.
But this is at a time when New Zealand’s gross domestic product is under pressure and the key challenge is to live within our means, he told a recent Health Informatics New Zealand (HINZ) seminar in Auckland.
The seminar was the final in a series focused on the sharing of electronic patient records.
“We’ve enjoyed $750 million a year growth [in health] for some years. That’s about to decrease,” Bolevich says.
His comments may be an indicator of what is to come. Former Treasury secretary Murray Horn is leading a ministerial group charged in January with advising on the quality and performance of the public health system. Part of its mandate is to give doctors and nurses more say.
His report was imminent as this article was being written.
The issues in health are myriad. The sector is bedevilled by interest groups with their own agendas.
“There is too much going on,” claims one consultant to the sector. “People up high have their own pet projects and those at the coalface can’t absorb it all.
“It is good to have a vision, but too many people want to get there in one bound.
“The Ministry of Health is a classic example of constantly rewriting strategies. They want to own it all.”
The ministry refutes that. Alan Hesketh, the deputy director general of the ministry’s information directorate, says the ministry is working with organisations across the health sector to implement the HISNZ 2005 strategy.
“This has not changed. Together with DHB CEOs, the ministry is working on a joint work plan to continue the implementation of the deliverables from this strategy,” he says.
The consultant claims there are too many people in the ministry looking for something to do. “They’re misguided, but they have enough money to throw at it. They’re too removed from the coalface, introducing too many slogans like ‘clinical leadership’, but doing little about it.
“The sector is so disorganised, it’s almost impossible for the vendors to provide them with what they need. This is where the ministry could help, but they’re not about solving the problem,” the consultant claims.
Hesketh says vendors have a critical role to play. He says the ministry has recently made a number of changes to improve the way in which it facilitates vendors working with the health system.
“Specifically, this includes the appointment of a person to lead the work with vendors and strengthen our relationship with the industry body that represents health IT vendors, the Health IT Cluster,” he says.
However, a range of people in the sector spoken to by Computerworld are similarly critical of the ministry — including some who work there.
For example… “The major issue facing the sector is an absence of coherent health policy upon which to base strategy”… “Because recent government policy has been somewhat vague, individual District Health Boards have taken to developing their own policy”… “The ministry has taken leadership in other areas, but its interest in ICT has died and it has forgotten about enabling the sector”… “No one wants to get on with it and do something – they all want to talk and write white papers.”
Computerworld inquiries suggest that, excluding telecommunications costs, the sector spends around $200 million a year on ICT. However, nobody really knows.
A majority view among people spoken to is that health should be clinically owned and led, with IT as an enabler.
There is a caveat. Unfortunately many clinical people don’t understand the IT processes and what should be the appropriate clinical model. For example, there are five different ways drugs can be managed in a hospital.
Who owns the patient data? Does it belong to the patient or to the general practitioner? There is no legal definition. It has been suggested the Privacy Commissioner should facilitate an ownership debate that leads to binding legislation.
Chronic care management is a major issue. It is estimated that 20 percent of the population uses 80 percent of the resources. Some say that rather than one big IT system, the focus should be on patient vitals and what needs to be shared, probably at a regional level.
“Connected Health” has long been a ministry mantra but, in its proposed form, the idea seems to be dying it is claimed.
“A lot of money has been spent on documentation, but nothing is happening,” one source claims. “There wouldn’t be one CIO at the 21 district health boards who knows what it’s supposed to mean.”
Hesketh responds that the ministry is actively continuing the Connected Health programme and it is being adopted within several ministry-facilitated and DHB projects.
He cites Waikato DHB using the Connected Health architecture and standards to support the design of its new network and Midland region DHBs using the Connected Health standards to design a regional network.
“The new online pharmacy claiming service uses the Connected Health standards. This service is deployed in the majority of pharmacies in the Auckland metro area and will be rolled out nationally,” he says.
The recently announced One.Govt shared network services are using Connected Health developed standards in their designs, Hesketh says. Similarly, the GP2GP project will enable the safe transfer of patient information from one general practitioner to another, he adds.
The 21 DHBs have themselves been under fire for duplication of systems. There’s a strong view that one single system isn’t the answer, but should at least apply to core back-office applications. Why have multiple financial systems, for example?
Standards remain a major issue those attending the HINZ seminar were told. There is an over-arching standard, HL7 v2.4, which would fit most things.
“That’s something the ministry needs to drive, but they go ‘it’s too hard’ so let’s use something else’,” the consultant claims.
Hesketh says inter-operability and open standards are vital to creating an environment that supports the safe sharing of information in a person-centred health system.
“Wherever appropriate, we are adopting internationally recognised standards such as HL7 and SNOMED CT. It is not the ministry’s policy to support the use of non-compliant messaging standards,” he says.
New Zealand is not alone in dealing with the complex issues that surround health, particularly with electronic communications. The use of IT within healthcare is significantly lower than in other sectors of most western economies.
New Zealand has, comparatively, done well in implementing a high level of information exchange, particularly through automation of routine processes such as hospital discharge summaries, pathology reports and specialist letters.
At the HINZ seminar there was general agreement that, going forward, a system must be devised to make patient information more accessible, creating an electronic health record whether centrally held or virtual.
That could, for example, mean expansion of the DHBs’ patient management systems to include shared record functionality.
There is no general agreement on how a shared electronic health record should work.
The technology is available today. What is needed if it is to happen, is a detailed plan and a sector-wide effort to put it into place.
Yet, as Canterbury DHB chief medical officer Nigel Millar told the HINZ seminar: “With anything in health, people have lead in their boots and process is glacial.”
A shared record is not a simple decision about health system efficiency. There has never been a successful large-scale shared medical records implementation. Attempts such as the British National Health Services’ Summary Care Records system have encountered major difficulties and have failed to launch on any scale.
If New Zealand decides not to go ahead with a shared record, it must move swiftly to underpin day-to-day delivery of care with better IT, says a long-term industry participant.
“The keys are a good standards-setting process and putting in place worthwhile financial incentives that will encourage swift implementation and uptake.
“It is essential that we work together as a sector to develop standards, using the Health Information Standards Organisation as the coordinating body.”
— Jackson was flown to Auckland courtesy of HINZ
Reconciliation of drug scripts a major challenge
At the recent Health Information New Zealand seminar, Canterbury DHB chief medical officer Nigel Millar said 15 percent of frail, elderly people had to be admitted to hospital because something in their medicine had harmed them. “We’re in so much difficulty with the risk,” he says. “The problems we have are substantial, mammoth and harmful.
“We need to design a system, then do something to make it work. This will lead to e-prescribing in hospitals, which we can’t do yet.”
He adds that reconciliation of medications is “a complete nightmare”.
There is currently an on-going Safe Medications Management Project at the 21 DHBs.