The Health System of the Future

• Abstract
• Introduction
• How Strategies and Policies Point to the Health System of the Future
• A Framework for Collaboration
• Getting to the Health System of the Future - What is the Problem
• Crossing the New Zealand Quality Chasm - An Information Systems Road Map
• Evolution vs Revolution
• Conclusion
• References

Abstract
The current round of health reform in New Zealand is building a new way of delivering health care. Government strategies and Ministry of Health (MoH) policies describe at a high level the start of a journey to a "Health System of the Future", a system focused on wellness rather than illness, on promotion of collective responsibility for population health and on sensible co-ordination of individual patient’s treatment. This paper proposes practical models for making the health system of the future work, in terms of both structure and information systems. It proposes a guide through which all parties in the health sector might deploy information system tools that could enable, support and drive the new health strategies, and achieve the gains in population health status which those strategies are designed to provide. This guide is based on many years’ experience at Counties Manukau District Health Board (DHB), Auckland, New Zealand and carries the strong recommendation of broader uptake of proven, successful, practical methods and solutions Emphasis is placed on the need for a co-ordinated and common approach to information systems investment and to information sharing technology. Large and often unsuccessful IT investments have been made in the past in the health sector by organisations that took little notice of the experiences or requirements of other health care organisations. Experience in Counties Manukau DHB has demonstrated that collaboration and an incremental approach are the critical success factors to achieving the New Zealand Health Strategy. All organisations within the sector are urged to continue their efforts to fully embrace the principles of information sharing and trusted partnership to make the Health System of the Future a reality of today.

Introduction
The current round of health reform in New Zealand is building a new way of delivering health care. Government strategies and Ministry of Health (MoH) policies describe at a high level the start of a journey to the "Health System of the Future".

District Health Boards (DHBs) and their associates, Primary Health Organisations (PHOs), are the structures required by legislation to deliver health care under the new system. The new system is required to be focused on wellness rather than illness, on promotion of collective responsibility for population health and on sensible co-ordination of individual patient’s treatment. Radical, disruptive reform within the health sector carries huge risk of adversely impacting patient outcomes. Consequently, the current reform is being implemented progressively and incrementally, allowing time for adjustments and corrections at each stage.


In the health system of the future, all participants, including health care providers, patient, family/support groups, etc, will be required to work in a collaborative manner to provide a seamless continuum of health care, that makes sense to the patients, rather than in the manner represented by the traditional "silo structure", where the care and responsibility for patients is handed from one organisation to another.

The reform is now at the stage at which the pressure is on DHBs and PHOs to "make the new system work". Many of these organisations have limited practical experience in advanced systems implementation and more detailed practical guidance on how to apply the various strategies and policies laid down by the Government would be of value. One idea would be the creation of a "Dummies Guide" or road map providing step-by-step guidelines backed up by assistance from organisations with greater experience achieved through sector collaboration.

In order to achieve the goals of the new system, there is a need for a focus on increasing collaboration and increasing the consistency of approach towards adoption of solutions across the nation to avoid duplication and waste. In addition, we must increase our ability to achieve and sustain change.

This paper proposes practical models for making the health system of the future work - for both the structure and the information systems. It proposes a step-by-step guide through which all parties in the health sector might deploy information system tools that could enable, support and drive the new health strategies, and achieve the gains in population health status which those strategies are designed to provide. These models have been derived from many years’ experience at Counties Manukau DHB^{[ 1 ]} of what works and what does not, and strongly recommends the broader uptake of proven, successful, practical methods and solutions.


How Strategies and Policies Point to the Health System of the Future
The New Zealand Health Strategy^{[ 2 ]} describes how the Government is "reconfiguring the health and disability sector to improve the overall health status of New Zealanders" (page 3). It states that "services must be co-ordinated, and providers must collaborate to ensure institutional boundaries do not compromise quality of care" (page 9).

Information systems are clearly seen as critical to delivering the strategy: "the ability to exchange high quality information between partners in health care processes will be vital for a health system focused on achieving better health outcomes. Better access to timely and relevant clinical information can improve clinical decision-making and, therefore, health outcomes for individual patients" (page 29).

The Primary Health Care Strategy^{[ 3 ]}is a key first step in implementing the New Zealand Health Strategy. It presents "a new vision" which will lead to "a new direction for primary health care with a greater emphasis on population health" (page vii), which "will involve moving to a system where services are organised around the needs of a defined group of people" (page viii). The health system of the future is specifically contrasted with the old health system (page 6) as shown in table 1.

Table 1: Contrasting the health system of the future with the old health system

Counties Manukau DHB CEO Stephen McKernan contrasts the change from Hospital and Health Services (HHS) to DHBs as shown in table 2:

A later Ministry of Health paper, From Strategy to Reality: the WAVE Project ^{[ 4 ]}, lists 10 priorities for a national information strategy. This landmark document credibly reflects significant health sector input and includes the key recommendation made by all of the work streams making up the WAVE project. "Establishing a central body to exercise leadership, to drive the standards setting and governance functions (including design, implementation, promulgation) necessary to implement and order the future environment."^{[ a ]}

WAVE identified the following as the criteria indicating success:^{[ 4 ]}

Health sector representatives continued meeting after the completion of the WAVE report and collaborated on funding and policy documents for a leadership body. The sector representatives were clear that WAVE was to be an operational plan that was to be implemented immediately, and must not sit on the shelf like so many of its predecessors.

Some progress is now being made to address this, with a new standards committee, HISO (Health Information Standards Organisation), being established and having held its first meeting in June 2003. This body is seen to be taking the key leadership position prescribed in WAVE, and the sector is now looking forward to similar action towards completing the other WAVE recommendations.


A Framework for Collaboration
A factor critical to achieving "the health system of the future" is the ability of various of the parties involved in health care to collaborate. These parties must agree on their respective roles, responsibilities and strengths, with willingness and drive to genuinely partner with each other to achieve common goals.

The Operational Policy Framework ^{[ 5 ]} (OPF) one of a set of documents known as the "Policy Component of the District Health Board Planning Package", describes the Government’s expectations of DHBs. The 2003/04 edition describes the expectation for collaboration on information technology in Appendix A Section A.3.B (2):

Successful partnership between MoH and DHBs is also critical and there is growing project-based evidence of how it can work well. A good example is the joint MoH, Counties Manukau DHB and Waitemata DHB (Westkids) experience in developing and implementing the Kidslink Well Child system. It is vital that this successful model of such partnership be retained and the level of collaboration further developed, if strategic initiatives like the National Immunisation System and the Meningococcal Vaccination Programme are to be implemented successfully.

The health system of the future is a partnership between providers, PHOs, DHBs, the Minister of Health and MoH. PHOs provide team based co-ordination of care to their local communities, under agreement with their DHB, which is formally accountable to the Minister of Health for monitoring the needs of their population as well as developing and purchasing services to meet these needs. The Ministry provides: high level policy and strategic direction; standard toolkits and materials covering the most common health conditions; national service planning to avoid duplication and waste; and targeted funding to enable DHBs and PHOs to provide equitable distribution of resources. It also monitors the activities of all health care providers to minimise duplication of effort across the sector.

"The risk in not implementing a collaborative framework through which to work towards the desired health system is that staff across all DHBs and the Ministry continue to waste time establishing appropriate roles and responsibilities in implementing strategic work programmes, which at times would jeopardise the strategy itself." ^{[ 6 ]}

The Ministry also has a vital role in developing, implementing and operating national information systems such as the NHI, HPI, Health Information Network and national health databases, again to avoid duplication and waste. The new health system model positions the Ministry as a partner, resourcer and facilitator, working closely with, not in control of, DHBs. DHBs and MoH together will determine the priorities and actions required to bring about the desired future. This will include MoH working with DHBs experienced in the implementation and development of IT, as stated in the OPF, and leveraging proven successes as national demonstrations and templates for the sector as a whole. This new relationship will require a level of trust by MoH in those DHBs’ capabilities and expertise.

Different views of roles within the emerging health system can compound difficulties and tension associated with the adoption of any systemic change. Therefore, there is a need to ensure a common vision of the future, clarity of goals and agreement of purpose, and much good work already exists in the area. For example The Primary Health Care Strategy (February 2001) provides clear structure and role definition expected within the health system of the future (page 5). Speaking at HINZ, Annette King made the point that implementing this strategy was her top priority:

An issue that is my highest priority as Health Minister … is successfully implementing the Primary Health Care Strategy. The need for accurate information management will increase as we base funding on the needs of an enrolled population. ^{[ b ]}

Figure 1: The new primary health care sector

Similarly, there is a significant opportunity to ensure that structures within the DHBs and MoH match the new requirements of the new vision for the sector. Mismatch makes it hard to get effective communication between those creating and implementing policies, as multiple organisational units within DHBs and PHOs have to liaise with multiple organisational units within MoH.

At present three different Ministry departments work on child health: Child and Youth Health, which is responsible for the Child Health Information Strategy; the National Immunisation Register team; and the Meningococcal Vaccination team. By integrating the work undertaken by these teams on systems requirements, further improvements to the Well Child checks, which provide enormous health improvements for little investment, could be made. For example by including them as part of the National Immunisation Register System (NIRS).

Fundamental change is never easy and it will require all parties to compromise some level of local need in favour of a more standard investment in information systems, particularly the adoption of systems proven to be of value even if not developed locally. In the past, large and often unsuccessful IT investments have been made in the health sector by organisations that took little notice of the experiences or requirements of other health care organisations. In the future, New Zealand must develop a more co-ordinated and common approach to information systems investment and to information sharing technology.


Getting to the Health System of the Future - What is the Problem we are Trying to Solve?
Crossing the Quality Chasm, A New Health System for the 21st Century, published by the USA Institute of Medicine’s Committee on Quality Health Care in America in 2001, is a seminal description of the health system of the future. On page 67 it contrasts the features of new and the old health systems as shown in table 3.

Table 3: A contrast of the features of new and old health systems

The future health system will be patient focused and will integrate health care providers in order to deliver consistent, continuous, evidence-based care. Counties Manukau DHB is committed to delivering "the Right Care in the Right Place at the Right Time’. In this model, the patient is surrounded by a seamless continuum of care between primary, secondary and community carers. The activities of providers are integrated and their boundaries are not of concern to the patient. In our theoretical future system, the patient has a good understanding of the points at which they have access to care, is fully informed about their own health status and about the decisions that are being made for the delivery of their health care.

The need for Counties Manukau DHB to urgently address improvements in the delivery of care followed the tragic death of abused 4-year-old James Whakaruru. After investigating this case, the Children’s Commissioner Roger McClay stated, "Collectively the health sector had available a telling picture of James’ circumstances. This picture was never put together because of poor communication between practitioners".

While it would be oversimplistic to believe that information systems alone could solve this type of problem, Counties Manukau DHB recognised the major contribution it could make to tackling the type of communication problems identified by the Commissioner and included these in a wider initiative called "Integrated Care" using targeted funding from the MoH.^{[ c ]} The starting point of the Integrated Care strategic initiative was the transmission of electronic discharges and referral status messages from Counties Manukau DHB’s secondary provider South Auckland Health (SAH) to GPs in the district. Successful pilot projects testing this approach in the Kidslink system and a diabetes disease management system embracing primary and secondary providers followed. The improved information flowing from hospital to GPs now enables GPs to provide better management for their patients. The Kidslink system pilot was a collaboration between MoH (CHIS), Waikato DHB (Kidsnet), Westkids and Counties Manukau DHB, and it helped to improve reported immunisation rates in a high health need area from 40% to 94%. The diabetes system pilot helped to reduce the proportion of patients with HbA1c >9 from 47% to 16% and now effectively manages the health of over 2,000 patients.

IT has been found to be an integral component of an overall Integrated Care strategic initiative. Within this context, Integrated Care IT has helped to achieve significant improvements in care outcomes, has broken down barriers between health system silos, and has contributed to the establishment of a care continuum that is better for patients.

Having built some good (but not perfect) bridges across the primary-secondary gap, Counties Manukau DHB is now turning to the gaps between the community health care sector and the primary and secondary sectors. The problems are similar, although the community sector has had little IT investment made or actual capability in the past. The health system of the future will require community and PHO care co-ordination and case management systems which do not yet exist. Many of the access formula PHOs do not have the resources and infrastructure to invest in IT tools and MoH IT establishment funding is inadequate.

Why should DHBs care what PHOs need? The answer is because everyone interested in a better health system should be interested in helping PHOs to be successful, otherwise the overarching health strategies will fail and the health system of the future cannot be brought into being.


Crossing the New Zealand Quality Chasm - An Information Systems Road Map
Getting to the health system of the future will not be easy. To build on the analogy of Crossing the Quality Chasm, A New Health System for the 21st Century, it will be like crossing a gigantic chasm. In outline, the chasm has the same shape as the classic change curve (figure 2).

Figure 2: The New Zealand quality chasm I

The starting point for many health organisations is on the left-hand side of the chasm, with legacy patient administration and clinical support systems, and numerous little databases dotted around chaotically. From that viewpoint, the problem looks like a gaping hole which has to filled in to progress to the other side.

The first step must be to lay the foundation of an enterprise-wide patient administration system. In the case of Counties Manukau DHB and Waitemata DHB, that has happened and is known as the PiMS system. Hutt DHB have applied an additional layer of more modern technology on top of their legacy system so that it too can be delivered across the whole enterprise.

In Counties Manukau DHB, the next step was adding a system that replaced the time-consuming and error-prone paper reporting of laboratory and x-ray results with an electronic system (Web Éclair), which has now been adopted as a single instance regional system for Auckland DHB as well as Counties Manukau DHB and Waitemata DHB.

The next set of building blocks were the Concerto clinical workstation, with electronic discharge summaries, electronic notes, and extended message based integration, in support of one of the 10 rules of the future health system, "Knowledge is shared and information flows freely". Some of these Concerto systems have also been implemented in all three Auckland DHBs, as well as at Hutt Valley DHB.

At this point, two years ago, Counties Manukau DHB found itself on the other side of the chasm, and now the problem no longer looked like staring down into the abyss, but rather like looking up at a mountain. We called the integrated care challenge "the Everest of health". It had never been climbed before, but that is not the sort of thing to put Kiwis off! Rather, they relish a challenge, and Counties Manukau DHB had the unprecedented strength of a partnership of talents from our primary and secondary pioneer clinicians, our internal IT people and our software vendors.

The next stage in our road map was Kidslink, which provides basic workflow and Rhapsody basic message based integration. The software integrates directly with GP’s practice management systems (PMS) and messages are returned to the Kidslink system automatically from the GP’s PMS and other systems such as the National Plunket system. The software also allows for manual entry of data for those services no using a PMS.

Children are registered on the database and caregivers nominated by the parents are notified of their responsibilities for Well Child checks and immunisations and other requirements. Notifications are sent electronically for individual children from the provider systems or are entered manually by the Kidslink data administrators following faxed notification. Alerts are used when notification is not received for a scheduled check or immunisation within a designated timeframe.

So we carried on building on the blocks in the chasm. The next phase was developing clinical reasoning using clinical rules providing advice to clinicians, supporting another rule of the future state, "Care is customised according to patient needs and values". Then followed clinical assessment using the Predict pathway tool and evidence based practice, supporting "Decision making is evidence-based". In early 2002, we did the first New Zealand electronic prescribing as a proof of concept to support "Safety is a system property".

Counties Manukau DHB has reached a point quite high on the mountain, forging a path that it is happy to help others to follow wherever useful. However, there is still a way to go, and the hardest part.

The plan for the immediate future is to extend the results repository to a full clinical data repository, and to implement electronic referrals, to support "Waste is continuously decreased".

The big development, of a Community Care Coordination system, already under way, will be a critical component of this round of health reform and of the Primary Health Care Strategy - Community care co-ordination, which supports "Care is based on continuous healing relationships", "Care is customised according to patient needs and values", "Knowledge is shared and information flows freely" and "Co-operation among clinicians is a priority". This project demonstrates collaboration between DHBs by leveraging the pioneering work in this field undertaken and implemented at Auckland DHB as well as extending the CMDHB Integrated Care concepts to deliver a solution that will first be tested and implemented at Waitemata DHB, with the expectation that all three DHBs will gain significantly when the solution is extended to provide regional coverage.

Planned to be hard on its heels are enhancements to mental health care, to provide the capability for information sharing with NGOs and also confidentiality safeguards for this sensitive sector.

Finally, the plan is to add patient facing systems that allow patients to directly interact with information about their health and about the care processes and key performance reporting to providers and DHBs to better match the allocation of resources to needs, supporting "Transparency is necessary" and "The patient is the source of control".

Figure 2: The New Zealand quality chasm II

Evolution vs Revolution
Another Counties Manukau DHB mantra is "never let the perfect get in the way of the good". While it is absolutely critical that systems be easy to use at the coal face, making "the right thing the easiest thing to do", in order to achieve improvements in patient health, it is not appropriate to aim for perfection in all aspects of a system from day one. What is needed is a way of delivering a good system, backed up by a process for improvements to be added progressively and incrementally.

British researcher and academic David Feeny coined the expression "dolphins not whales" to describe how organisations around the world have successfully implemented large, complex IT projects by dividing them into smaller, simpler units. The Counties Manukau DHB IT success is founded on this incremental approach. While we have to a long-term plan with an ultimate goal of perfection, we are working through a continuous stream of advances and improvements that are resulting in immediate returns in terms of beneficial outcomes for patients.

There are some in the sector with an alternative philosophy of "do it once and do it right", an approach which carries the risks of "whale" projects, and which can tie up valuable, sometimes scarce, development resources of the software vendors and hamper further work on DHB integrated care initiatives.


Conclusion
Counties Manukau DHB learnt some lessons on its journey toward the future health system and believes that it and some of its many partners have found a path to the top of the mountain. In contrast with the foggy view from the bottom of the mountain, the picture of the health system of the future from half way up the mountain is much clearer. It is a picture which is alluded to in The Primary Health Care Strategy, and described in detail in Crossing the Quality Chasm. It depicts the population at the centre of an integrated health system which has a focus on wellbeing, is safe, shares relevant information, and provides a continuum of care.

Progress to date has been achieved, without exception, by working hard on integration, with significant efforts to engage clinicians, providers, vendors, other DHBs and, the MoH in various partnership models, using collaborative and iterative techniques. We have mapped a strategic systems path to achieving national and DHB-wide strategies, which can be implemented in low risk, affordable steps. This road map is available to anyone who may wish to adopt a similar approach. There are clearly benefits to the taxpayer and to the population generally if the various parties in the health sector work to a common goal and strategy.

We have demonstrated that collaboration and an incremental approach are the critical success factors to achieving the New Zealand Health Strategy. Despite the difficulties encountered, we urge all organisations within the sector to continue their efforts to fully embrace the principles of information sharing and trusted partnership, and to thus show true leadership so all within the health care sector can move to make the Health System of the Future a reality of today.


References