The Electronic Health Record in New Zealand - Part 2

• Primary Care
• Secure Networking
• Privacy and Security
• Evolving Health Sector Capability
• Research Questions
• Conclusion
• Bibliography

Click here for Part 1 of this paper

Primary Care
In international comparisons, New Zealand’s primary care information capability ranks highly. For example, approximately 70% of laboratory results are sent from community laboratories by electronic messaging to GPs. Practice management software is currently estimated to be in use by 80% of general practices for patient administration. Approximately 50% of GPs are using software for clinical purposes such as electronically generating prescriptions and electronically recording the details of patient encounters.

Further work is required to develop the standards within primary care that would enable consistent national coding of patient encounter information. There is also currently little data transferred between providers because most IT systems function only within the immediate work environment. This significantly restricts the ability to operate in a coordinated care environment which requires information to be shared among providers.

Secure Networking
A potential lever for the implementation of EHRs is the already established secure network for the transfer of health information. The Health Intranet has been developed as a "whole of health" network. It has been designed to assist the delivery of integrated health care by connecting, for example, general practice and secondary care clinicians, and enabling access to administrative systems such as the New Zealand Health Information Service’s NHI and for the transfer of claim data to a central collection.

The Ministry of Health and Standards New Zealand sponsored the development of a Code of Practice to support the Health Intranet and wider health information networking activities for a secure electronic environment within which users throughout the health system can transfer and exchange health information. A committee of health sector experts developed the Code.

The Code of Practice is an agreed set of rules outlining how information can be exchanged in the health sector. Among other things, the Code defines user and supplier criteria. The Code does not mandate a single delivery system (the Health Intranet is a delivery system that will comply with the Code and in the future will not necessarily be the only one) but does mandate the need for all delivery systems to have full interconnectivity. The Health Network Code of Practice assists health care providers and consumers who need to communicate securely and with confidence, by electronic means, through a chain of trust where the level of security is maintained across all the participants.

Individuals and organisations are accountable for considering how their business processes and health care provision could be made more effective by taking advantage of the opportunities provided by increased interoperability. There is a new programme of work underway to further develop connectivity through the promotion of the benefits of the health intranet.

The development of EHRs compatible with the Health Intranet would mean EHRs that are available to all via a secure network and would, in turn, increase the usability of the Health Intranet.

Privacy and Security
For some time, New Zealand has been working through the issues related to the privacy, security and confidentiality of health information at multiple levels. The legislative path is set out in the Privacy Act 1993 and the Health Information Privacy Code 1994. The Privacy Act is based on the notion that the collection, storage, use and disclosure of personal information should be carefully considered and that all activities in this area should be as transparent as possible. In the health sector, this has been interpreted at a policy level through the Health Networking Code of Practice and at an implementation level through formal assessments of impacts on privacy.

An example of the practical implementation of these codes of practice and the relevant legislation is the Health Intranet shown in Table 1.

Table 1: The Health Intranet security requirements

Any initiative to send health information via a network requires consideration of the above legislation and principles. The Health Intranet gives users the confidence they are meeting their regulatory and ethical obligations when sending out health information, without needing any technical knowledge.

Work is currently underway to enhance the Privacy, Authentication and Security (PAS) framework. This work will look at providing greater detail in the form of guidelines and suggested updates to the Health Network Code of Practice. The PAS framework can be used to further guide the development of EHRs in New Zealand, by providing a mechanism to manage the potential risks related to data sharing.

Evolving Health Sector Capability
Figure 2 illustrates New Zealand’s progress towards establishing the components required for a connected health care environment. New Zealand is progressing through the targeting process, well aware of the areas of improvement required. Change components may require more consideration and may present the most difficult barriers to overcome.

Figure 2: Progress towards a connected health care environment


Perhaps, as an indication of the enthusiasm of the sector for the implementation of EHRs, several grass roots initiatives are already taking place. As noted above, several hospitals are implementing e-prescribing systems and electronic discharge notices are being sent to primary care providers from several hospitals. Locally developed clinical decision support systems are also being implemented, with a disease management emphasis.

Now is the time to look at the high level strategy that will ensure a consistent approach to the development of EHRs across New Zealand. EHRs need to be suitable for the New Zealand health care environment, but compatible with international standards.

Research Questions
The areas of research which are most crucial to the development of New Zealand EHRs include the following:

• Remote access: EHRs need to be accessible from anywhere, including by mobile (network connected and disconnected) access. Research is required in the areas of networking, connectivity and infrastructure.
• Architecture: Research is required to develop a robust and scalable, yet open and platform independent architecture, capable of managing and integrating distributed, heterogeneous data repositories and application systems.
• Security and confidentiality: Authentication and security are major issues for such a distributed system, as is the appropriate level of detail of security. Additionally, research is needed on the support for various cultural aspects of heath care, such as the spiritual ownership of data or images in EHRs.
• Clinical workflow and clinical decision support: An adjunct to the establishment of comprehensive EHRs is their application in clinical practice. In particular, there is a need for definition and enactment of clinical workflow, supporting patient treatment across multiple specialties and providers.
• Presentation of medical information: An initial project must be the development of visual representations to support patient understanding of information contained in EHRs, for example, the clear explanation of clinical terms.
• Multiple media formats: Increasingly, medical data are being generated in multiple media formats, such as X-Ray, NMR and MRI images, laparoscope and motion analysis videos (eg, for performance athletes), and there is an increasing diversity of numerical and qualitative data from new types of instruments.
• Clinician training/education requirements: Research is required to guide the development of a sustainable education model that results in a high degree of computer literacy and clinician enthusiasm.
• Tools for population health analysis and decision support: Comprehensive national EHRs would require a national health research laboratory to attract local and international health researchers (both academic and industrial). Research is required into the tools to mine collected information effectively (all the while observing anonymity and cultural safeguards) for, eg, population health studies or identification of clinical best practice.
• Data quality: Research into the ability to build data quality into EHRs will further enhance effective decision making through nationally collected data derived from EHRs.
• Change management and implementation: A New Zealand methodology to support the adoption of new technology and to aid in the diffusion of innovation is required.
• Critical success factors, communication and marketing: Work is needed to identify critical success factors, communication and marketing, creating an information culture in the health and disability sector and addressing work practices.

Initial research must concentrate on the development of electronic prescribing, covering the electronic management of drug, patient and decision support information from procurement through to administration, integrating all the steps of the medication cycle from supply chain management and inventory control (hospital pharmacy and ward), to prescribing (hospital and primary care), dispensing (hospital and community) and administration.

The Commonwealth Fund 2000 International Health Policy Survey of Physicians found that provision of quality information on electronic prescribing of drugs was viewed by physicians as "the most useful thing to do".^[12]

Conclusion
It is now feasible, in the current New Zealand health care environment, to propose the further development and implementation of more comprehensive EHRs. Considerable work is already underway at the grass roots level and guidance and leadership are now required to ensure that this does not result in disparate systems being built that stifle connectivity and integrated care efforts.

The foundations are in place and further developments are underway, such as the implementation of the HISO, the Health Intranet and PAS frameworks, to provide improved communication between health care providers in New Zealand.

Iterative and evolving comprehensive EHRs that deliver benefit to the sector will require strategy development, infrastructure improvements and research.

Bibliography

1. Benson, T. Why general practitioners use computers and hospital doctors do not – Part 1: incentives. BMJ 2002; 325:1086–1089.
2. Swain, P. Breaking through the barriers: ITC Taskforce Draft Report. Wellington: New Zealand Government; 2002. p.38. 
3. Care, ADoHaA. A Health Information Network for Australia: National Electronic Health Records Taskforce Report. Canberra: Australian Department of Health and Aged Care; 2000. 
4. Key Capabilities of an Electronic Health Record System. US National Institute of Medicine; 2001.
5. Group, EW. NSW Strategy for the Electronic Health Record. NSW Health Department: Sydney, Australia; 2002. p.20.
6. Mitchell, E and Sullivan F. A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980–97. BMJ 2001; 322: p.279–282.
7. Bates, DW and Gawande, A A. Improving Safety with Information Technology. N EnglJ Med 2003; 348(25): 2526–2534.
8. Electronic Record Development and Implementation Programme. UK: NHS Information Authority; 2003.
9. Brailer, DJ and Terasawa EL. Use and Adoption of Computer-based Patient Records. California Health Care Foundation; 2003.
10. Wagemann, CP. Medical Records Institute; 2002.
11. From Strategy to Reality. The WAVE (Working to add value through e-information) Report. Wellington: Ministry of Health; 2001.
12. Davis, K et al. The Commonwealth Fund International Health Policy Survey. The Commonwealth Fund/Harris Interactive/Harvard School of Public Health; 2000.
13. Ministry of Health. Health and Independence Report. New Zealand Government; 2003.

Click here for Part 1 of this paper