Interview: Policy needs to support choice: National Health IT Board
- 18 November, 2013 08:16
On the sidelines of a conference on health that took place recently, Graeme Osborne, director of the National Health IT Board and Director of the Information Group, National Health Board, Ministry of Health talks to ComputerWorldNZ on the progress of the plan, the efforts to standadise systems and processes, and how the Ministry is working to change the nature of healthcare in the country with ICT.
Q. What is the status of the National Health IT plan?
A lot of what today is about what we are going to do with all the information that is coming out of those IT systems and how are we going to organise that information so that appropriate access can be provided from it.
My challenge is to create a policy framework to ensure that all of that works well and balances the strife between personal care and information and people’s interest in research and progress.
The National Health IT plan is going very well. However, I would be very clear in saying that there are number of stakeholders and leaders who would have to deliver for me in order for the whole plan to come together. This is not one system that is being rolled out across the country, this is an ecosystem of IT systems that know about each other and interoperate very well together, and reflects on what we call the beneficial owner. We know that IT systems work their best when there is a beneficial owner, who sees the quality of the data collected and the value from that data in the first instance. If you like, the primary owner. We need that beneficial user to understand their role in the wider health system.
So it will take a little while and I am happy to run through a couple of key areas.
There are probably five or six key groups of people who would all have to deliver for me in the next few months to deliver on the outcome that we are trying to achieve by the end of 2014.
Let me give you an idea of the ones that I think about the most.
The first one is primary care. So we have made a decision in New Zealand that citizens will address their core primary care information as an additional service that GPs will offer. So that means, depending on the GP you are enrolled with or depending on the software that they offer you to loginto and use. You don’t just want to log into and look at your information, you actually want to interact with the service provider. So in NZ today we have around 4000 New Zealanders accessing their information through that model – where the GP is offering that service. We have three very good products in use.
We have probably a thousand or more GP practices who haven’t yet got to that point. They all know they need to. They are all starting to share more information more readily with the emergency department, and between themselves and the pharmacies. But the next step of getting them to share it with the consumer is the real barrier that I have to work very hard on at the moment.
It is a little bit more mindset and the way primary care operates. I will give you an example. Many GPs will see between 25 and 30 patients in a day. It might be a 10 or fifteen minutes slot and its very busy for them. And in fact they are sitting in front of their own computer putting down notes and organising lab results and other things.
The worry is that when they get to an online consultation model of working, how do they fit it in into a busy day of 30 patients already. And so this isn’t just about IT. This is about changing the way they operate. We need them to use more nurse triage, more phone triage. We need to make sure that the GPs are only seeing the patients they absolutely need to see face-to-face. We need to get lab results presented to the GP prior to the arrival, so that they have thought about the patient.
We really love the way some GP practices are now seeing 15 to 20 patients a day, and now have the time to consult online, and basically treat people at their home or at their workplace.
So that’s a real challenge – the challenge is how we create an adoption model by getting consumers to demand it, because the technology is there. It is not about the technology. It is fundamentally about a change of operating models for our GP practices.
The other one that I like to think about is everyone involved in prescribing medicines and dispensing them. So that’s both in the GP community, not a big change for them. But during the next 12 months we are rolling out a common national e-prescribing system for the country.
For pharmacies this would mean that they don’t need to type in the details. They can just scan it off a bar-code. And there are 950 pharmacies, and we currently have around 200 operating. There are 1300 or 1400 GP practices, and we currently have about 25 per cent of them operating.
So we are pushing that very hard. It is all about the roll out and integration – the technology is proven, we know it works very well.
Similarly in the hospitals we have a common e-prescribing system going into all our hospitals. By the end of next year we want to have six operating with that common system and we currently have three, so we have three more to get in place over the next 12 months.
We have had huge enthusiasm for this from care facilities who really see the value of this for everyone.
There are some other clinical areas. You have heard today that there will be a common cardiac registry for the whole of New Zealand that covers both interventionists – who don’t have open heart surgery, who might have catheters in their veins – as well as surgery. So what we are going to have is a common database of all interventions, including surgery. That’s one going on really well.
Oncology we are slightly early on in the cycle but we are very close to confirming a common approach to that, wherein there will be a common system and a common reporting outcome to the database.
The cardiac registry is progressing. It’s in two parts. Certainly the interventionists will be on a database in 2014. On the surgery side, I think we will have three out of five, there are only five centres in New Zealand, by the end of 2014.
The oncology one is more challenging, but I would like to think that by the middle of next year they would have confirmed a common approach and system, and it will be rolled out regionally across the four regions. I know we have already one region going very well, so hopefully we will have a second region by the end of 2014.
Oncology is more challenging because these models have to be clinically led. So therefore if there is a really mature relationship between leading clinicians around a subject area, like cardiology, and many years of experience, when we come along and help with the IT aspects of it, try to help them procure a common approach to IT and reporting frameworks. If maturity is there, we can progress quite quickly, and the clinicians stay with the program, because they have got to make it work. They have to commit with colleagues to get the program working, and get the data quality high, and cardiology has done that.
With oncology individually they know how each system is and the data quality, but they have not quite committed as a national consistency. And until they do that the national IT board steps back a little. Because unless we see that in clinical leadership, we know we cannot be effective in trying to implement a common IT framework.
Phase two of the IT plan is about providing access to New Zealanders who want to have access to their information being given access. As I mentioned, our main strategy is through primary healthcare. I think we are on track for that.
What we have learnt from overseas and the UK is a great example. They spent a lot of money and failed. Not only do clinicians and primary care need to be committed to and that the data has got to be really high quality. If you went home and logged into your health information and it was incorrect or did not have medications that you expected to see, you would lose confidence very quickly. And you probably wouldn’t want to go back. So we needed to do that first step, to make sure that the data could be coherently shared and presented – a trusted set of data.
We feel we are well down that path, and that’s why we are pushing very hard for primary care to open up that access. We had to go through it in two steps. Otherwise, there was the risk of poorly-formed data being made available to consumers.
Q. The 4000 New Zealanders who are currently accessing their information online – how are they geographically spread?
They are related to the practice they are part of. Hamilton has that operating, Island Bay in Wellington, Wairepa – there is some work happening there, and I believe in Auckland there are two different software tools that are being tried.
Q. Why three different products to provider consumer information?
Primarily because the GP practice management system is where the core of the data is sitting, and it is that which is offering the portal solutions. So I am happy to share with you that it is
MangeMyHealth from MedTech is one of those products. Now about 80 per cent of GPs use MedTech software to run their business. ManageMyHealth is a separate tool for the portals, but there is tight linkage, and the security is tight as well.
So from the GP’s point of view they are going to trust that.
MyPractice is an Auckland-based tool that about 10 per cent of GPs use, and they are rolling out a MyPractice portal.
And Orion also has a product that they are looking to use in the Canterbury region. They are doing a lot of good work around sharing information between GPs and other clinicians in the community of health.
Portals can talk to other practice management systems. So GPs will have the option of using other tools.
So those are the three providers at the moment. There might be many more in the future.
Q. Doesn’t having different front-ends take away any potential standardisation for the consumer receiving the information?
They are slightly different in the front-end. But I think that is part of the innovation that we need to allow in the market. There is no standard view of what a portal should look like, and I would rather not indicate. But we are very mindful of what each of them can offer.
In a mobile world, it doesn’t matter – you don’t want a detailed portal many time. What you want is to know you lab results and you want to press a button and out comes those results. The fact that it might be delivered by one of those three products does not matter. You won’t know that. Only the data or the content is key.
We want to be able to be certify them. We worked very closely with those three providers but in the future, as the potential for many apps rises, I would expect that in 2015 or 2016, we would be looking to a certification model. At the moment we are working very closely with the three, but we are happy with the standards but as we open up we need to work on a certification model that allows a wider range. Clearly we can’t have people have access to their core health information without having that.
Q. As part of these steps, have you made sure that they have sufficient integration and commonality in the entire IT chain – from infrastructure and apps – at all levels and layers in the healthcare chain?
The way to answer that is we have done enough. I think it would be true to say that anyone who is in an IT leadership role, can always imagine other things that they would like to also put in place, to continue the strength of it.
But we have done enough in the area of privacy, security and interoperability. One of the areas that I would talk about is Connected Health – that is our brand for the IT infrastructure. It is secure, and only organisations that are registered with the Ministry of Health can have a Connected Health domain name. It is a private network just for health information. So there are those key components that we now have in place.
We have replaced the NHI system with a very modern one now. We have done enough. There is always more to do, but we are very happy with the foundations.
Q. What more do you think can be done?
There are two or three areas.
We have got the foundations right now. What we know is that not all New Zealanders are not well, and those who are not well require a more of team approach to care. So they might have a cardiologist, a physiologist, private care nurse, a GP or a pharmacist – and so we need a shared record that allows co-ordination of care in a complex case. There are some very good studies and trial programs we have done and we will progressively drive more of that. We think that is where the real value-add is.
The other aspect that I have not touched on is some of the things we have asked hospitals to do under the DHBs. We had committed in the plan that DHBs will get common capabilities across five areas across the regions. That has not progressed as fast as we would like. So we certainly, each region has some common capabilities, but we don’t have all five in place. The other aspect that I think about in the future we would have to address those issues and make sure it gets done.
It has not progressed as fast, because, firstly, the 20 DHBs are crown entities. That means they are independent government agencies. And therefore, the IT board and the plan is important for them but not mandated. Secondly, they run well over 400 apps in each of those 20 sites, so they have a long legacy of some very good systems, but equally a lot of systems that they struggle to maintain and keep good.
So when we came along with our national and regional approaches, they all started from different starting points. Some of them have found it easier to come on board than others. And some of them have worked as regions better than others. So the reality is we have been very much supporting them to this point.
I am happy to signal in this conversation that we will be setting a much higher hurdle for them to improve to, and that will be done on a CMM maturity-capability model basis because there is only so much pushing that you can do to get people to be better. At the end of the day you have got to set a standard.
We want the Ministry and the four regions to be at CMM level 3, as a minimum, by the end of 2014.
So we will be putting a huge amount of pressure on each of those regions and their capabilities towards that end-point.
We don’t like to use the word mandated. It is still about influencing them towards an outcome. But it will be much firmer that it has been today.
The other aspect is the Health Benefits Ltd. They are a partner in the work that we do in health, driving with us a move to IaaS (infrastructure-as-a-service), which is in line with the AoG (all-of-government) programme. And that is happening over the same two year period.
So what you will see is the DHBs IT teams will need to resolve their regional leadership models. They will lose their engineering role, because the IaaS will take that over, and focus on the value-add with the CMM model’s approach. So we rolled everyone to a much clearer place, but we are moving forward to a more professional model.
Q. What will the CMM level cover – both processes and systems? How will your IT teams change?
It has got to be both. If I can add to that, I am very interested in the IT professionals themselves who work within those regional IT capabilities. We need to be very clear that we need the same level of IT professionals that a bank has or an insurance company has. And equally, those people will have wonderful roles, because they will have health value-add roles. I think it is one of the most exciting roles in IT in the next ten years.
We have around a 1000 people who work on health IT. I do think some of the roles are going to change. The pure engineering and network roles, I would expect to see over the next few years to transfer to professional IaaS type providers IT and general third party organisations. However, I don’t think the total number would disappear, because the value-added opportunities are so large.
So I would see a change to roles where we need to get the balance between clinical knowledge, workflow, process improvement and IT connecting together.
We are focusing on clinicians to see how many we get interested in a CMIO (clinical medical information officer) role. We are starting to talk to the universities. But it is an interesting area. You can develop this area but we would like to have a pull model. We are really excited about making e-health a good place to come and work, both private sector IT firms – there are over a 100 IT firms in health – as well as working for the four regions with the Ministry of Health.
Q. As you work to push more information to the consumer, there are also more technologies coming out around tapping into patient-generated data. How do you see that being integrated into the plan?
We have had that in mind from the start of our work years ago. If you see our vision talks about a core set of health information. So our job in the IT group is to create a core set of health information that other data can be added to. And the consumer makes that choice.
We want to be open to the innovation that is possible, because we can’t imagine what kind of mobile devices and apps that will turn up over the next 10 years. But we do know that unless we have a common view of who the person is, who their clinician is, what the facilities are being provided by, and running on a private network that is only for health information, then we won’t be able to make some new and innovative ideas really work well.
If Vodafone did not have a customer database, they could not offer all the new services that they offer. So the roll of the ministry and the IT board is to ensure that the consumer database, and the provider database is of high quality. And some of the other layers that I have talked about, but then we want lots of information that grows and adds to that core set of information.
Q. How will you be pulling data into that highly secure network and in the light of privacy concerns?
The policy answer is that New Zealanders will need to consent for that information to be made available. The public health system is very clear. We will make sure that there is a core set of information that is trusted by consumers. How they then choose to interact with other service providers and make links with that data and other data sources will be their choice.
In the same way that Apple or Google has app platforms, arguably we are trying to create a core-enabled app platform to be operationalised for New Zealanders to use. And it must be their choice.
I am sure the Privacy Commissioner would agree that there should be nothing about us, without us. Consumers have got their own choice. And not all of them will opt in. But there is a generation of consumers who probably will be more open to these opportunities – the digital natives.
We have got to think that through. We need to create a policy framework for people who might be more conservative as well as those who are more open and want to be networked.