IT and Health - Vision to Reality

Mike Rillstone, Chief Advisor, Health Sector Information & Technology, Ministry of Health, co-presented with two colleagues Ray Delany, Group Manager, New Zealand Health Information Service (NZHIS), Ministry of Health and Paul Cressey, Managing Director East Health, various health sector boards, Deputy Chairman CMDHB, HIGB.

Rillstone opened by highlighting that there is now clarity about the need for change in the health sector with respect to IT, highlighting that the WAVE report has pointed to significant priorities for information and IT. The next stage involves picking up these recommendations and looking at their implementation.

He noted the good foundations for IT that exist in New Zealand, for example the National Health Index (NHI), but highlighted the need to move forward on the issue of connectivity.

The value of IT in New Zealand’s emerging knowledge economy is about innovation across organisational boundaries even though they may have conflicting or non-aligned goals. The health sector is a good example of the development of the knowledge economy. IT must support efficient and effective health care capability at the point of care while co-ordinating activity across the continuum of care, ie, support both a single patient and a population approach to health issues and solutions. The role of the IT manager has shifted from one based in technology to one focused on relationships.

Across the continuum of care, the output of one component in the system is often the input to another in a reciprocal arrangement. There is a strong degree of interdependence. There is a need for co-ordination of reciprocal interdependence that demands a systems view.

Unlocking the potential of IT requires alignment of three critical success factors:
   1. Context -why we are doing it and what is to be achieved, with a focus on vision and strategy
   2. Capability -sometimes present at provider level but not within the Ministry of Health.
   3. Content -which often exist in both locations

It is important to get all three things working correctly.

Discussing the shift from strategy to reality, Rillstone noted the need for an emphasis on carer relationships and on simple datasets collected nationally (NHI, carer identification, referral, procedure, contractual terms, date, outcome, reason for visit).

He described the new structure for the Ministry of Health, which comprises four groups with defined areas of operation: HPAC (operational delivery), CA HSIT (strategy and sector linkages), IMAT (technology development, support and knowledge management) and NZHIS (information gathering and dissemination). He emphasised the importance of strong linkages between the groups.

Rillstone then set out the top priorities derived from the WAVE report:
   1. Set up an independent organisation to lead IM/IT capability.
   2. Collect reliable ethnicity data.
   3. Implement the National Provider Index (NPI).
   4. Fix up the NHI - allow primary provider access, improve ethnicity data.
   5. Gather primary care information.
   6. Fix up pharmacy and laboratory data and provide primary care with access.
   7. Clean up messaging standards.
   8. Sort out health event summaries - with data dictionaries, electronic discharges and referrals.
   9. Launch health portal.
   10. Make integrated care work by developing standards for data exchange, security and network infrastructure.
And …involve patients!

With respect to the role of the Ministry of Health in making these things happen, Rillstone highlighted in particular the need to work on tidying messaging standards and on security policy for electronic transactions in the health sector, which he regards as critical for making progress in an electronic environment.

Rillstone noted that IT is mostly about people and process. There have been successes in implementing new technologies, in particular in the primary care and integrated care areas, and it is important to create such success consistently. However, there will always be difficulties, such as the conflict between local and national priorities despite a degree of overlap.

The concepts of privacy and security are now well established, for example, information issues in relation to content are well understood but this understanding must be embedded into business and into standard practices, not treated as a separate issue.

Rillstone concluded by emphasising the importance of making and measuring progress, ie, setting goals and how they will be measured and periodically determining if there has been real progress made.

Ray Delany noted that the three priorities for NZHIS of the 10 WAVE priorities were to implement the NPI (priority 3), fix the NHI (Priority 4) and to gather primary care information (priority 5). From these have developed five key projects to be run over the next 12-18 months:

  â€¢ NHI upgrade.
  â€¢ Health Practitioner Index.
  â€¢ National Immunisation Register.
  â€¢ Primary care data warehouses.
  â€¢ Electronic reporting of cancer pathology.

With respect to the NHI upgrade, he noted that the key requirement is for a secure network, be it intranet or otherwise, that will allow information to flow securely across information networks (refer slide 15).

There is also a need to clean up NHI data. Despite problems with data quality, it is still the best information available. There are approximately 800,000 duplicates that have been worked on slowly to date. However, this process will now be accelerated and the aim is to delete all duplicates within 12 months.

Discussing the Health Practitioners Index, previously the National Provider Index, Delany highlighted two considerations for a secure information system: "who am I?" (authentication) and "what can I access?" (authorisation). He noted the need for a system able to authenticate practitioners. Consultation on this project is underway and it has a planned development timeframe of 9-12 months. The project will focus on doctors initially, as the best information available is about this group, and it will then be rolled out to other health practitioners. With respect to authentication, Delany noted that organisations will need to set their own rules for authorisation.

With respect to the National Immunisation Register, the Kidslink software (implemented in Counties Manukau DHB and via Westkids) will be expanded into three tiers: national register level (information collection), regional co-ordination and local immunisation delivery. He emphasised that the Register is a national system that is regionally employed. A proof of concept was due by July 2002, first pilots will run in September 2002 and national rollout will occur in early 2003. The aim has been to create a business-enabling model that is repeatable, eg, into the diabetes management area.

The GMS data warehouse will be built for GMS claims within NZHIS and will feed data back to HealthPac (previously Health Benefits Limited) rather than be built in HealthPac, in keeping with an approach that focuses on what the different groups within the Ministry of Health do well (refer slide 18). The project has a project manager and is currently being scoped.

The effort invested in sorting out the internal issues in NZHIS has identified the need for a value chain approach, which Delany presented diagrammatically (refer slide 19). There has been a shift of focus from building data to disseminating required information. Researchers, policy analysts, DHBs, the primary care sector and the general public are just some examples of the relevant clients.

Paul Cressey acknowledged the new approach to health information in New Zealand and improved communication between different interested groups in Wellington, such as Pharmac, Ministry of Health, etc.

Health professionals are focused on delivering care to patients and making a difference for them. Primary care provides the proverbial fence at the top of the cliff rather than an ambulance at the bottom and there is a challenge in shifting the DHB focus in this way.

In his view, there are still significant issues related to health information. He describes the current reality as an "upside down" pyramid that is in place because of the emphasis to date at the policy making level (refer slide 21). Providers have had limited say in relation to health information and patients have had even less input.

However, he acknowledged some "wins", which he reviewed:
  â€¢ WAVE.
  â€¢ Immunisation.
  â€¢ Resource Management.
  â€¢ Practice Management Systems.
  â€¢ Practice registers.
  â€¢ Disease coding.
  â€¢ Integrated care.
  â€¢ Health Intranet.

He described WAVE as a very positive project but noted that the project is possibly "45% Ministry of Health and 45% District Health Boards/secondary care" and has not engaged the "coal face", ie, primary care.

Cressey noted that the successes with immunisation are mostly the result of improved relationships and passing on of information. Increases in immunisation rates have resulted from improved counts and information management, not changes in technology.

He raised the possibility of having standards for practice management systems. He noted that a lot of health providers, such as Plunket nurses, operate without systems and this produces difficulties when such groups need to be linked into something like the immunisation register system. As practice management systems are often run by external groups, there can be problems when changes are required. Cressey noted that primary care needs to be the driver for technological change and must tell the vendors what is required.

Cressey describes the way forward as a shift from the current pyramid model to a rectangular one (refer slide 24), one in which all concerned groups look at issues collectively. However, Cressey’s vision is a "right side up" pyramid with a firm focus on patient and provider (refer slide 25).
[View Mike Rillstone, Ray Delany and Paul Cressey’s presentation IT and Health - Vision to Reality]