The Electronic Health Record in New Zealand - Part 1

• Abstract
• Introduction
• What is an Electronic Health Record?
• Essential Components of Electronic Health Records
• The Impact of the Electronic Health Record
• International Trends
• Barriers to Implementation
• The New Zealand Health Care Environment and its Ability to Support EHRs
• The Health Information Standards Organisation
• The District Health Board Perspective

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Disclaimer
Opinions expressed in this paper are those of the author and do not necessarily reflect the view of the Ministry of Health. The Ministry of Health accepts no liability for the actions or decisions based on the contents of this paper.

Keywords:
Electronic Health Record(s), New Zealand health care system, Software research and development, Technology implementation, Information technology, IT, Connectivity, Change management.

Abstract
Considerable work is now underway in many countries to develop the components of effective and comprehensive Electronic Health Records (EHRs). EHRs consist of components that enable health care providers to access a patient’s health information regardless of geographical location. Other components refer patients to various providers and enable providers to access clinical decision support, including electronic prescribing, with the overall goal of assisting providers to give better quality of health care. New Zealand has many of the infrastructure components needed to support the development of comprehensive EHRs, such as secure health information networking through the Health Intranet, a unique patient identifier, well-developed privacy and security legislation and a national standards organisation, the Health Information Standards Organisation (HISO). Several countries have attempted to implement EHRs without success, noting that change management often described as organisational and business / clinical process redesign is a significant aspect of the research work required to support implementation.

Introduction
This paper provides an outline of New Zealand’s current capability to develop comprehensive EHRs and relates them to the current international position. Work is underway internationally and within New Zealand on developing the components of feasible, effective and comprehensive EHRs. As a result of New Zealand’s new focus on seamless delivery of health care between primary and secondary providers, and increasing pressure for individuals to take responsibility for their own health status, both clinicians and consumers need access to up-to-date patient information and the latest health research. Health care sectors in many Western countries are now becoming more computer literate and networked, enabling improved communication between providers and greater access to information for consumers. All Western countries acknowledge the need for clinicians to have access, from disparate locations, to the information held in EHRs in order for EHRs to reach their full potential.

Comprehensive, accessible EHRs have long been the "holy grail" of health information technology (IT) development ^{[ 1 ]}. The New Zealand health sector is ranked highly in the level of penetration of computers and is second only to the UK in terms of primary care use of EHRs (52% of New Zealand GPs versus 59%), double that achieved to date in Australia (25%) and triple that of the US (17%). It is interesting to note that in addition to, data relating to the raw penetration of IT infrastructure shows that New Zealand EHRs are also becoming increasingly more technologically advanced, making use of decision support algorithms, public key infrastructure (PKI), digital certificates and a high level of HL7 (Health Level 7) standards implementation.^{[ 2 ]}

What is an Electronic Health Record?
EHRs could simply be software applications that provide integrated, longitudinal views of patient data, eg, demographics and health records, as a minimum. EHRs would provide several software applications in a networked environment, including clinical decision support, physician order entry, integrated communication with laboratories, imaging centres, colleagues and patient; and would include population health management. The Australian Health Online project provides a definition of EHRs that includes all the components of comprehensive EHRs model:

An electronic longitudinal collection of personal health information, usually based on the individual, entered or accepted by health care providers, which can be distributed over a number of sites or aggregated at a particular source. The information is organised primarily to support continuing, efficient and quality health care. The record is under the control of the consumer and is to be stored and transmitted securely. ^{[ 3 ]}

Essential Components of Electronic Health Records
The US Institute of Management ^{[ 4 ]} notes that the development if EHRs should strive to improve patient safety, support the delivery of effective patient care, facilitate management of chronic conditions, improve efficiency and be feasible to implement. Critical components of and the key building blocks to be researched and implemented to support EHRs include:

Standards
• Privacy and security
• Messaging and coding

Infrastructure
• Unique patient and provider identifiers (where not currently available)
• Telecommunications infrastructure

Information
• Health event summaries contents

Change Management
• A skilled health sector and industry information management (IM) and IT workforce
• Acceptability to clinicians and consumers. ^{[ 5 ]}

The content, including both information and new functionality within EHRs, can be added to incrementally following the implementation of the supporting infrastructure and can be dependent on local requirements.

Figure 1 shows possible EHRs capabilities structure that highlights seven core requirements that must be addressed prior to a EHRs implementation. These include:

1. Consumer
2. Regional systems required by the DHBs and hospitals
3. Community and local systems
4. National connectivity and access
5. Core national systems such as the National Health Index, Practitioner Index, National Minimum Dataset (Inpatient), etc

Figure 1: A possible structure for New Zealand Electronic Health Records Capabilities Architecture.

The Impact of the Electronic Health Record
The widespread use of EHRs, accessible to all those seeing and treating a patient, would substantially improve the co-ordination and quality of health care^{[ 6 ]}. EHRs would provide clinical decision making support functions, particularly the capacity to promote adherence to guidelines in diagnosis, treatment and prescribing. Many studies now demonstrate that computer-based decision making support can improve physicians’ performance, and in some instances, patient outcomes.^{[ 7 ]} Access to the latest research enhances a clinician’s ability to provide evidence-based care.

EHRs would contribute to health care efficiency by improving providers’ access to clinical data, providing aggregated, regional and national data, and improving co-operation among clinicians, as it could be possible for multiple physicians to access the same patient’s records for purposes of consultation or cross-coverage.

Improved patient safety has been noted by the sector as a benefit of the implementation of electronic prescribing and access to patient information. This was supported by the recent e-prescribing pilots at Counties Manukau and Otago District Health Boards. Computer use in primary care, where reminder systems are used, has been found to reduce prescription costs, through encouraging generic prescribing, to reduce costs of test ordering and to improve health promotion interventions. This has been evidenced in New Zealand with the use of pharmacy and laboratory utilisation information that has reduced the volume of prescribing and tests ordered within Independent Practitioner Organisations following facilitated utilisation reviews [New Zealand Ministry of Health data].

EHRs would provide the capability to collect unit level information about patients that can be aggregated at local, regional and national levels as required. The benefits of such granular clinical information are extensive and include the ability to undertake health outcomes research, targeted regional and national health promotion programmes, clinician performance assessment and national policy development. Data at the national level is likely to be stored in a summarised form.

The implementation of EHRs is likely to enable a shift of focus, particularly in primary care, towards a more holistic, proactive, disease management style of practice. There is a cultural shift, worldwide and in New Zealand, towards enabling patient self-care. Electronic access to generic information about health care topics is primarily accomplished through the Internet; sources include public institutions and private companies. Increasingly, this information is rated by international agencies to improve its integrity and is becoming a more reliable information source. This information, intelligently combined with personalised health information that is formatted to patients needs, such as patient orientated EHRs, would assist patients to make informed decisions about their care. Educated and empowered patients would increasingly demand a health care system that is high performing, consistent, safe and dependable.

Concerns voiced about the use of comprehensive EHRs include the privacy of information held (once electronic it can be rapidly shared with many parties) and the doctor-patient relationship which is now supported by many information sources rather than discrete written notes. In addition the cost, time involved, and training needs for clinicians and administrators is another concern.^{[ 7 ]} Further, very clear guidelines and a strong national data governance framework would be required for EHRs to be successful.

International Trends
Europe has developed an Electronic Healthcare Record Architecture Standard through the Open European Health Record Project, providing considerable input into the development of EHRs internationally. The UK is currently developing and implementing EHRs in regional areas and piloting different aspects of development. Summaries of the lessons learned from these exercises have added to the body of knowledge about practical implementation problems and possible responses to these.^{[ 7 ]}

The Australian Health Online Taskforce is working towards the development of national EHRs. The taskforce is charged with creating a national framework for the collecting, storing and sharing of information that will also remain flexible, able to be added to over time and useful to all the major stakeholders. ^{[ 3 ]}

Extensive research has been undertaken in Canada on a framework for EHRs, which can operate by connecting many parts (interoperable), providing several options for technical requirements for implementation. Canada has also noted that a national system is required and proposes a framework that would allow for Provinces to use their own existing EHRs, where they exist, and would enable the ongoing use of older existing systems, through the development of messaging standards. As is common with many proposals for EHRs, little has been said about clinician uptake and change management issues.

Barriers to Implementation
The California Healthcare Foundation has noted the most significant barriers to adoption of EHRs as being lack of funding and resistance by physicians.^{[ 9 ]}

Challenges to implementation as noted by the Australian Health Online Taskforce include:

• The need for standardised clinical terminology
• Concerns about data privacy, confidentiality and security
• Challenges associated with data entry into EHR’s by health providers
• The difficulties of integrating EHRs with other sources of information in health care settings.^{[ 3 ]}.

All developers have noted the need for a nationally interoperable EHRs that are accessible to all relevant clinicians. A national approach, however, has inherent difficulties due to the current disparate nature of health sector information systems in many countries and the lack of international standards. A national system would, at a minimum, require a national unique identifier for patients. Wagemann^{[ 10 ]} highlights major causes of implementation problems as the complexity of a data model encompassing multiple health specialities, a failure to encompass process as well as data, an inability to provide a master health index and political considerations. Wagemann also indicates that there are many research problems that need solving before robust and comprehensive national EHRs can be arrived at.^{[ 10 ]}

Barriers within New Zealand may include:

• Leadership of the development and governance of EHRs
• Divergent stakeholders
• Agreements on design with no consensus on priorities or design approach
• Consideration of legacy systems
• Privacy and security issues
• Lack of acceptance by customers and clinicians
• Inadequate funding for implementation and ongoing support
• Appropriate use of standards to support interoperability.

The New Zealand Health Care Environment and its Ability to Support EHRs
The cornerstone of New Zealand’s health system is public finance through taxes with access to health services based upon need. In New Zealand in 2000/01 $9.884 billion, including private funding, was spent on health and disability support services (NZ$2601 per capita). Of this, $2.3 billion (23.3 percent) was privately funded and $7.584 billion (76.7 percent) publicly funded.^{[ 13 ]} For the past eight years, the New Zealand Government has been moving away from market-based structures, in the health sector by combining the health care purchaser and provider functions into community-focused District Health Boards (DHBs).

In 2001, the New Zealand Ministry of Health prepared a five-year, broad, strategic directive for information and technology developments, referred to as "The WAVE Report".^{[ 11 ]} The report was produced by means of collaboration among health sector participants, including system vendors, clinicians, government representatives and health care managers. It identified New Zealand’s most pressing health information technology (IT) needs and the significant issues that will continue to form barriers to improved health outcomes and the reduction of health care delivery costs over the next five years. The WAVE Report ^{[ 11 ]} recommends the development of the building blocks required to enable integrated care.

Historically, there has been no sector-wide approach to developing health information systems in New Zealand. Over the past three years, however, the DHBs have been replacing isolated departmental and clinical systems with more integrated and dynamic web-based technologies that support a more connected information delivery network. All of the 21 DHBs have entered into some form of shared service arrangements for information systems (eg, finance and/or patient management systems), corporate support (eg, health provider contract management) and contracting or clinical data analysis. Such arrangements have reduced duplication and contributed to more effective and efficient management of infrastructure with greater interoperability. IT has been essential for implementing the population health care initiatives in New Zealand [These "e-health Building Blocks" are also recognised in the Asia pacific region as leading developments in health IM. For instance, the Australian National Electronic Health Records Taskforce report states "the decision by the New Zealand to invest in and promote key items of health IM infrastructure has positioned it as a world leader in the field, particularly in the primary care sector." ]

Several of the components required to support EHRs are already being tackled within New Zealand in response in part to the WAVE Report ^{[ 11 ]} recommendations and from local initiatives to fill gaps in need. New Zealand has had a National Health Index (NHI) since 1977, providing a national unique patient identifier.

The Health Information Standards Organisation
The newly formed Health Information Standards Organisation (HISO) will take on a key co-ordination role in leading the development and implementation of IM and IT standards for the New Zealand health sector. The HISO is to ensure that relevant standards are identified for development and that, once defined, are implemented effectively for the overall benefit of the sector. Standards development in all areas of EHRs still requires considerable work in New Zealand and internationally.

The 2000 National Electronic Health Records Taskforce Report of the Health Information Network for Australia states:

Without agreed national standards, health information would break down into smaller networks, isolating some jurisdictions, individual organisations such as hospitals, or even individual health care providers (including general practitioners). Widely accepted and implemented standards are needed to underpin the operation of key elements of information activities in the health care sector, including electronic business transactions (e-commerce) and the development of a national system of electronic health records.^{[ 3 ]}

Standards enable the interoperability of health information. Standards such at HL7 enable information originating in a variety of formats and from distributed and varying clinical systems to be sent to and understood by another health care provider. Disease states and procedure classifications systems such as ICD-10 allow clinical items to fit into categories for data collection. The SNOMED-CT (SNOMED Clinical Terms); a universal health care terminology, provides the ability to code primary and acute care data in a consistent manner, internationally. The incorporation of READ codes and nursing terminology into SNOMED CT enhance its suitability for primary care and nursing concepts coding.

The District Health Board Perspective
In New Zealand, new projects on the transfer of electronic discharge summaries from secondary to primary care are providing valuable information on the feasibility of electronic messaging between secondary and primary providers. Studies are also taking place into electronic prescribing in hospitals, with considerable success. Implementation of e-prescribing software is already taking place in at least two hospitals.

The key issues, as noted by DHBs in New Zealand, are similar to those identified overseas:

• Fragmented health care delivery services
• Difficulty in allocating best use of resources
• Patient is not a reliable transport mechanism for their own health information
• Reliance on paper based medical records
• "Sensitivity" of health information
• Monitoring health outcomes is required.

The DHBs also note the considerable opportunities offered by the implementation of EHRs, such as a paperless records and the ability to more readily measure outcomes and resources. Allowing providers to talk to each other securely with legible, timely, accurate and complete information that follows a patient to different providers would prove invaluable in improving decision making in patient care.

Considerable work on training and change management would be required by DHBs during the implementation phase. Recent experience with the implementation of e-prescribing in New Zealand indicates that younger, junior doctors are computer literate and have received health informatics training throughout their medical education. Many are convinced of the benefits of information and communication technology (ICT) and readily take up new applications provided they fit well into workflow processes. They also move around to different hospital departments, taking with them the knowledge of the new application and are often able to convince new departments of the benefits. More senior doctors in hospitals appear reticent about utilising new technologies. There have been similar findings overseas, for example, a UK study also notes that by May 2002, 76% of consultants had access to NHSnet for email and browsing, although few actually used computer-based patient records.^{[ 1 ]}

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