The Troubled History and Complex Landscape Of Information Management and Technology in The New Zealand Health Sector

• Abstract
• Introduction
• Information Management and Technology in Health Care
• Health System Restructuring and Policy Transition in New Zealand
• Information Policy and ICT through the Four Systems
  • The 1991 Ministerial Strategy
  • The 1996 Ministerial Strategy
  • The 1999 Health Funding Authority Strategy
  • The 2001 WAVE Report
  • The Extent of Information Management and ICT Problems
• Beyond the Wave Report
• Into the Future
• References

Abstract
In 2001, the New Zealand government launched an ambitious health care information management and technology strategy that sought to integrate the health sector and facilitate the adoption throughout the New Zealand health sector of electronic health records that enhance information portability and give patients greater access to their own information. This article looks at the prospects for that strategy, against a background of extensive public health system restructuring in the 1990s. It notes that, through this period, health purchasers and providers developed information systems in isolation from one another and with minimal central oversight. The result is a highly complex and firmly established architecture and an array of problems that need rectifying. These, together with the current decentralisation of health structures mean that government’s capacity to influence health sector activities is limited. The article concludes by reviewing current developments noting that progress by government towards it goals in this area is likely to be incremental, across a range of areas, sometimes driven by providers and sometimes by central agencies.

Introduction
In October 2001, the New Zealand government launched an ambitious health care information management and technology strategy.^{[ 1 ]} Driving the strategy is the "vision" that information and communications technology (ICT) will:

• integrate the disparate parts of the health sector
• facilitate portable electronic health records and bring together databases that will be accessible by multiple service providers
• give patients greater access to health information.

New Zealand is not alone in pursuing such goals. The governments of Australia, Canada and the UK, which, as in New Zealand, dominate health care provision in their countries, have issued comparable large-scale plans.^[2-4]

This article looks at the prospects for New Zealand’s health information strategy, against a background of extensive public health system restructuring in the 1990s, of moving from a competitive to collaborative environment and of an absence of developed information policy and policy co-ordination.

The article begins by reviewing the information management and technology requirements that must be in place to support the success of  New Zealand government’ sWAVE project. Secondly, it outlines the three health system changes through which New Zealand’s current information and technology systems emerged.

Thirdly, the article gives an overviews of health care information policy and ICT development through the period of restructuring and policy transition, and then discusses the 2001 WAVE strategy and the state of affairs at that time. Finally, developments since 2001 the strategy  are discussed, including the updated 2005 health information strategy, along with the prospects for achieving the WAVE objectives.

Information Management and Technology in Health Care
The New Zealand government’s vision for the health care sector, as outlined in its 2001 health care information management and technology strategy WAVE,  is that information technology will drive health care integration and information exchange. Where care is integrated, individual health information and funding would follow a patient, making the patient’s encounters with health care services "seamless" and reducing the need for tests and assessments to be repeated at different points within the system.^[5-6]  Where paper-based information and communication systems have been used, the capacity for integration has been limited. The emergence of ICT, facilitating the development of electronic patient records and the exchange of electronic information, has boosted the prospects for sector integration. In theory, ICT facilitates vertical integration through the various "levels" of health care: community to hospital to national agency; and horizontal integration between providers regardless of physical location.^{[ 3 ]}   However, to achieve integration, some basic ICT and related requirements must be in place. These include:

1. Full interoperability: fully-networked ICT systems that provide all relevant data at all points in the health system when needed.^{[ 7 ]} This requires that all parties involved in health care use computerised and interoperable systems. Protocols would be required to ensure that the right data is available to the right people at the right time. These would cover, eg, standards as to who can access "portable" electronic patient records, what information is included in these and how information is formatted, and agreements regarding information to be routinely "pushed" out to various parties, and information available only on a "pull", or request, basis.
2. A high level of data security to guard against third parties accessing networks, including systems for authentication and authorisation.
3. Protection and privacy of personal information. Policies regarding the collection of, access to and protection of personal information need to be developed, widely disseminated and strictly observed, to bolster professional and public trust in ICT systems and information sharing.^[8,9]
4. Co-ordination of data standards, including the type of data to be collected, the form it should be collected in and the way in which electronic information would be sent. In the health sector, common definitions are critical when information is shared. Complete compliance with standards such as ICD-10 (international classification of disease v10; promoted by the World Health Organization) and HL7 (health level v7; the agreed international standard for electronic data exchange) are critical for full interoperability.^[10]
5. Co-ordination of ICT system architecture. Without central oversight and co-ordination, health agencies make ICT purchases that are appropriate only  for their purposes or develop their own "in-house" systems with no thought to their ability to complement others across the health sector. Systems are often purchased or developed for specific purposes, such as patient record-keeping. Indeed, numerous competing hospital patient management systems exist, typically meaning many different systems of data collection, classification and coding which are not compatible and work against interoperability. Where system architecture standards are set, there is considerable reduction in the purchase and development of incompatible ICT.^[11,12]
6. Organisational reengineering. ^[13,14] Along with interoperability, strong relationships, trust, communication and co-operation among the various parties involved in a health care delivery system are critical to integration. Many health encounters cross professional and organisational (business) boundaries demanding that traditional barriers to information sharing and collaboration are overcome. This often begins with small projects related to a specific area, eg, diabetes management. Such projects require the involvement of personnel with knowledge of the technical, organisational and clinical implications of ICT. Additional challenges exist where, as has been the case with New Zealand and most other developed countries, a competitive culture stemming from internal market structures has preceded efforts for integration.

Health System Restructuring and Policy Transition in New Zealand
New Zealand presently faces a considerable number of obstacles to achieving interoperability because of successive prior health system restructuring, corresponding disruption to information strategies and a lack of central co-ordination or control over information management and ICT developments.

New Zealand had four different consecutive health care structures through the 1990s:

1. The Area Health Board (AHB) system, which replaced local hospital boards, was implemented from the mid-1980s and fully functional by 1989. It comprised 14 geographically-based AHBs, financed by government and responsible for planning and funding an integrated range of services based on the assessed needs of their respective populations.
2. The newly elected 1990 National Government (traditionally centre-right) unveiled a "competitive market system" for implementation by mid-1993. AHB functions were split with four new Regional Health Authorities (RHAs) responsible for needs assessment and purchasing and 23 hospital-based Crown Health Enterprises (CHEs) responsible for service provision. CHEs were required to "compete" for service contracts with one another and other private and non-government providers. Through this period, and inherent in the government’s  "market" ideals, there was little concern for national planning or co-ordination of the health system: purchasers and providers developed their own arrangements to deliver on the government’s health goals.
3. The competitive system was burdened with problems and a new National-led coalition government (1996) led to another restructuring. The four RHAs were combined into one nationalised Health Funding Authority (HFA). CHEs were renamed Hospital and Health Services. The new system’s  focus was public service, national consistency and patient equity. Through this period there was a noticeable shift in policy emphasis toward population-based planning, integrated and patient-centred care.
4. In 1999, a new Labour-led (traditionally centre-left) coalition government created a system resembling the earlier AHB system. HFA functions were split between the Ministry of Health and 21 semi-elected District Health Boards (DHBs). Within government allocated funding, DHBs are responsible for needs assessments, planning, prioritising and purchasing integrated services for their populations. The policy emphasis on collaborative, population-based strategies and integrated care was made explicit, and information collection and management highlighted as high priority.^[15]

It is notable that many initiatives and institutions survived the various restructures including: Pharmac, an agency established in 1992 by the RHAs to manage the pharmaceutical schedule; independent practitioner associations (IPAs), groups of publicly-subsidised general practitioners (family physicians) who clustered together for enhanced negotiating power vis-à-vis the RHAs; services operated by and for indigenous Maori; and use of formal contracts for service funding and accountability.

Information Policy and ICT through the Four Systems
Two reviews in the 1980s highlighted the poor state of health sector information systems.^[16,17] Information management was poor and data incomplete and unreliable. For example, there was no clarity about how many patients were being treated and where, the cost of services, or how efficient these were.

Through the 1990s, information came to policy prominence. However, progress through the restructuring period was variable, and many information and ICT problems identified at the start of that decade remained unresolved.

The 1991 Ministerial Strategy
The first Ministerial strategy for health information was issued in 1991,^[18] largely in response to the identified need for robust information in the pending competitive environment^[b] , but also to push the findings of earlier review work onto the policy agenda. It

noted that attempts to improve the value of health information "have had little success because of a lack of co-ordination and a lack of adequate funding" and that "until recently such initiatives were not part of an overall policy plan or strategy for the health sector".^[18]

The 1991 strategy cited problems with existing data and information services resulting from:

• poor data quality, lack of quality standards or of standard data definitions
• a focus on hospital data and gaps in primary care data
• data accessibility problems and lack of timeliness of access to data
• lack of agreed data interchange standards
• a multiplicity of unco-ordinated and overlapping data collections
• the high cost of national and AHB information systems
• a poorly maintained National Master Patient Index (NMPI).

The strategy suggested the need for new data systems, processing and organisational structures. A variety of recommendations included the need for:

• strong links between health sector goals and information systems
• one-time collation of data as close to the source as possible
• national health data to include only data used and validated at a local level
• a national health index (NHI) and a national minimum data set (NMDS) ^[c]
• a national data dictionary defining nationally required data and format rules
• electronic transfer of data to the NHI and NMDS
• open systems, open to facilitate movement of national applications across platforms
• standard protocols, including national standards and guidelines for data transfer and exchange, to facilitate communication over electronic networks
• private primary care providers to subscribe to national health information systems
• a single, national, data clearinghouse.

The strategy recommended the establishment of a "National Health Information Service" to address these issues and to manage health information services "as a business".^[18] The New Zealand Health Information Service (NZHIS),  was consequently established in 1992, to provide timely and accurate health and related information to a range of "customers", including the government, the new RHAs, CHEs and other health agencies. Projects included establishment of the NHI and NMDS, and the collection of national statistics.

Purchasers and providers working in this competitive setting rapidly sought to develop ICT capacity and a host of new information requirements and systems emerged. The NZHIS issued a set of broad guidelines for health information systems development,^[19] but responsibility for co-ordinating the collection and management of information and ICT across the health sector was left to the market. The competitive era saw the splitting of information collection and management across various agencies, and amplification of the problems highlighted in the 1991 strategy. Purchaser and provider agencies collected information for their own purposes and often, seeking competitive advantage, refused to share information.

The 1996 Ministerial Strategy
By 1996, a range of new agencies, data collections and information interchange systems straddled the different levels of care across public, private and non-government sectors. Information was collected in different forms and for different purposes with considerable overlaps in that collected by different parties. There was no co-ordination of advice on information policy and issues such as standards for data exchange. There were problems with fundamentals, such as development of the NHI. There had been no national campaign to educate the public about the aims of the NHI, no concerted effort to obtain provider compliance with NHI requirements, and providers often encountered difficulty obtaining NHI details for patients from the national database. Thus, it was not uncommon for patients to be assigned more than one NHI number and there were a host of "active" NHI numbers for deceased patients and foreign visitors. Such issues complicated processes such as tracking patients and administering service payments, and undermined data reliability.

ICT advancements, such as the advent of the web, and the policy direction changes meant that existing systems were becoming outmoded. Facing concern that the competitive system had resulted in confusion, complexity and high transaction costs, the revised government policy spelled out new directions for health , to which information was integral. These included that the health sector should focus on:

• measurable population-based health improvement and identification of groups with poor health status;
• placing people at the centre of health care delivery, requiring portable information and information sharing; and
• getting the greatest level of services for the dollar through measuring performances, service arrangements and disseminating best practice guidelines.^[20]

Following this, a second Ministerial strategy was issued.^[21] A stocktake performed as part of this highlighted:

• the fragmented nature of many initiatives and health information systems
• the lack of agreed standards and definitions in many areas
• the lack of agreement about access to information by other parties
• concern about the protection of privacy, particularly with increasingly sophisticated use of information technology.

Recommendations in the 1996 strategy aimed at resolving these problems included creation of a Health Information Council to provide leadership and oversee policy development related to standards and governance of health information and ICT. The new directives rested on an assumption that the web would bring the fragmented sector together at low cost.^[21]

The 1996 change of government and the HFA-led health sector configuration effectively sidelined development of the Health Information Council and its programme. Notably, during the amalgamation of the four RHAs into the HFA, little attention was given to information management issues.22 However, once the HFA had worked through the lengthy process of establishing itself and its relationships with the health sector, information management and ICT did become a key policy concern.

The 1999 Health Funding Authority Strategy
In 1999, the HFA issued a "strategic plan for information and technology management", reiterating the problems beleaguering health information and ICT which were seen largely to result from the former RHA structure and the difficulty of administering sector information in a consistent way.^[22]

Again, the HFA noted the need to: co-ordinate NHI use; formalise management of data collection and key health databases; create formal processes for co-ordinating information and ICT development within the sector; focus on  issues of quality; and develop security and privacy guidelines. Furthermore, new funding approaches promoting service integration, budget-holding and capitation required the collection and interchange of population data in addition to the basic claim data previously collected. The HFA asserted that, with growing dependence on basic data collections and reliance on a greater range of data, "it is with some urgency that the HFA must address data quality and collection".^[22] To do this, the HFA proposed to review and redevelop its own "business processes and information engines" including claims management and payment systems, reporting and monitoring systems and data collection systems. It also proposed developing a data dictionary, and enforcing sector data standards and delivery as a contractual requirement. An application strategy to support the HFA’s business processes and a structure for information management governance were outlined. The HFA strategy listed some 73 projects (see table 1) to further investigate a vast array of issues relating to the organisation and management of data and ICT internal to the HFA (such as that used for strategic planning and decision-making, and service contract management), and across the health sector.^[22] These were scheduled to commence during 1999.

Table 1: HFA Information Strategy Projects

Programme	Aim	Projects involved
Business process improvement	To redesign HFA’s business and information processes	3
Information management strategic planning	To ensure a consistent approach to information management issues (eg, NHI, patient databases, etc).	8
Health sector engagement	To develop consistent information management solutions and standards throughout the sector	3
Data collection and monitoring	To standardise and co-ordinate data and monitoring processes to improve quality of shared data in the sector	2
Data standards and quality	To provide key decision makers with better quality data shared throughout the sector	4
Access to information	To provide key HFA decision makers with access to relevant corporate and sector information	3
Transaction systems	To complete implementation of corporate systems, enhance their use and quality	4
Knowledge management and collaboration	To improve HFA’s corporate knowledge and methods of exchanging information	4
Business support systems development	To progress availability of adequate business support systems	3
IT infrastructure	To meet ICT requirements of the HFA	12
Implementation of organisational strategy	To implement recommended organisational structures and processes for information management in the HFA	4
Operating group information management projects	To develop plans and support systems for personal health, public health, Maori health, mental health, disability support services	23

Source: adapted from Health Funding Authority 1999^[22]

Progress was disrupted in late-1999 by another restructuring. The HFA’s focus shifted to redesignating its responsibilities to the Ministry of Health and DHBs. The shift in health structures demanded a new approach for information management and ICT. In May 2000, the HFA and Ministry collaborated to produce a series of recommendations for information management requirements in the new environment, and the strategies health agencies should adopt to ensure information management and ICT were co-ordinated, cost-effective and focused on improving decision-making.^[23] Key recommendations included the need to:

1. develop a set of national information systems based on individual anonymous patient data about health care events;
2. make these national systems accessible to all agencies involved in managing population health – the Ministry of Health, DHBs and other providers – via the Health Intranet; and
3. convert existing HFA contracting and payment systems into an application service provider model for use by DHBs and the Ministry.
   
   The report reiterated the now long-standing problems with health information and ICT: sorting out the NHI, developing a National Provider Index (an individual identifier for each service provider), and creating standards for data collection, interchange, security and privacy, and for ICT systems.^[23]

The 2001 WAVE Report
Acknowledging the need for careful planning and management of information and ICT issues throughout the transition to DHBs, the Ministry established a high status "Health Information Management and Technology Plan Advisory Board". This became the WAVE project, a concerted effort, with representation from across the health sector, to reflect on developments over the prior decade of restructuring, develop strategies to address problems, and plan for the future.

The findings and recommendations of the WAVE project reflected previous reviews and ongoing restructuring. The aims underpinning the recommendations were that:

• all health care providers could access full patient and service delivery information in electronic form via "open systems";
• health planners would have full and accurate population information and service quality data;
• the public would have information about issues including, appointment availability, safety of procedures, their rights and choices and the comparative performance of service providers; and
• that software vendors would have an opportunity to help shape national standards and a strong base for export.

With national planning and co-ordination, it was assumed that financial savings would result from a consolidated approach to ICT procurement, better service management through reduction of service duplication and overlaps, and improved quality for patients through delivery of more accurate information.^[24]

Of 79 recommendations in the WAVE report, new recommendations included the establishment of two independent central organisations: one to lead information management policy development related to the setting of data standards, systems integration, ICT capacity and a host of related issues; the other responsible for daily business transactions. The rationale for the new agencies was that none of the existing data processing and collection agencies had the capacity to move beyond their daily work to take on a leadership role; they had differing priorities, and there were considerable gaps  and overlaps between their work that needed rectifying.^[25] The dual agency approach was, however, a compromise. The WAVE report noted its preference for a single organisation.^[24] However, the NZHIS strongly opposed this as it believed its statistical information functions differed considerably from the "business" focus of transactions agencies, the "narrower" requirements of which could raise tolerance for missing or poor data and potentially compromise collection of statistics.^[25]

The Extent of Information Management and ICT Problems
The most insightful aspect of the WAVE project was the unpublished work of the WAVE board’s eight project teams. This revealed the impact of successive restructuring and the lack of attention through the 1990s to basic information management issues and ICT co-ordination, with issues as follows^[d] .

Messaging systems
Messaging systems were found to suffer from:

• An absence of agreed standards because of a lack of co-ordination and leadership across the sector. Thus, individual organisations were adopting incompatible messaging schemes.^[26]
• Gaps between accepted international standards and requirements. The lack of national agreement on the types of messages required and how they should be formatted had led to ad hoc implementation of the HL7 standard in various ways that were largely incompatible.^[26]
• A need for greater flexibility to handle both "push" and "pull" models of communication.
• Over-reliance on paper-based information interchanges, eg, many payments, invoicing and clinical information exchanges continued to be in paper form.^[26]

Electronic health networks
Electronic health networks (EHNs), that facilitate information exchange, had been developed in the absence of a sector-wide strategy. "Personalised" offerings from public and private organisations in the sector, developed without agreed sector-wide standards, meant that the ability to exchange information between or across networks "will continue to be as difficult to implement in the future, as it is now". ^[26]

Operational systems
Operational systems including the NHI and National Provider Index (NPI) were required to support integrated care, and administrative systems such as contract management systems and claims validation and processing systems. However, at least 12 different groups of agencies (such as DHBs and service providers) or individual agencies (such as the Ministry of Health, NZHIS and Pharmac) were maintaining several unique operational systems, as well as using the NHI or NPI. There were over 95 separate operational systems in existence (see table 2),^[24] notably with "multiple systems for the same function", a lack of links between systems and lack of a national view of data. The fragmentation of these systems across health agencies was attributed to the lack of a unified governance system overseeing common business processes.^[26]

Table 2: Health Sector Operational Systems

Group/agency	Number of unique systems managed
DHBs	13
Service providers	13
NZHIS	20
Shared Services Support Group	8
Health Benefits Limited	4
Statistics New Zealand	1
Environmental & Scientific Research	2
Pharmac	2
Department of Work and Income	1
Professional Bodies	4
Births, Deaths and Marriages	1
Ministry of Health	26
TOTAL	95

Source: Adapted from Systems Architecture Project Team 2001^[26]

Data security
Problems with data security, which relies on data encryption and associated policies, were resulting in inadequate and variable protection of health information. Issues included:

• Limited sector agency capability to measure the effectiveness of their data security measures;
• Limited use of 128-bit encryption, the highest available standard. The standard in most cases was 48- and 56-bit encryption, widely recognised as unsatisfactory, and in some cases there was no encryption;
• Poor standards and practices for authenticity (ie, password usage), eg, only two cases had password requirements that met the minimum of 8 alpha/numeric characters; and
• an absence of national security principles, standards and policy, resulting in an inconsistent approach across the sector to security.

Data warehousing
Extensive problems with existing data warehousing included the lack of:

• national datasets for outpatient visits, general practice or disability support services
• data collection, storage or access standards
• meta-data standards to help develop interoperability
• data comparability between sources
• governance arrangements. ^[26]

Beyond the Wave Report
It would be easy to conclude that the WAVE report produced the same findings as the preceding 1991 and 1996 Ministerial strategies, and 1999 HFA strategy. To recap, all found poor data quality, lack of standards, gaps in primary care data, accessibility and information exchange problems, a lack of co-ordination between data collections and systems, and problems with national data systems and governance. Following such findings, all made comparable recommendations. It seems evident that, at a strategic policy and development level, the successive restructuring did not assist improvemnet in  information management and ICT; neither did the health policy transition from competition to collaboration,  which required a shift in information management and ICT focus.

However, a step away from central government, at the provider and regional level, there were considerable, albeit variable, advancements. By at least the mid-1990s, some providers were focusing on ICT as an enabler of more effective service delivery. The Counties Manukau DHB is a prime example. Based in South Auckland, a community known for its low socio-economic status and ethnic and immigrant populations and related high-cost health problems that could be minimised if proactively managed at the community level, the DHB (at that stage a CHE) decided integrated care was the key to reducing hospital service demand. ICT was identified as the facilitator of this, with the DHB  hospital taking the developmental lead. Today, that hospital is closely linked with most GPs and community providers, with shared electronically accessible databases and messaging systems for a host of clinical and population-based services. Committing to ICT was crucial to this process; equally critical was developing strong working relationships with involved providers. The benefits of integration are now starting to emerge: there is evidence that hospital admissions for diabetes-related and other problems have reduced and that child immunisation has increased.^[27] Through the 1990s, IPAs were also increasingly employing ICT for patient management and profiling, enabling them to develop population-based health improvement strategies, although such activities have been limited.

Since the arrival of the DHB system and the WAVE report, there have been several developments that provide indications of the road ahead. There is a burgeoning number of sector-driven collaborative ICT projects, including inter-regional and integrated care initiatives. The information functions of the three Auckland-based DHBs are in the process of being merged, facilitating sharing of hospital and community data and extension of the Counties Manukau integrated care ICT initiative. Elsewhere, similar ICT mergers and interoperability projects are underway, but tend to be based around specific services. Examples include:

• An ICT enabled service integration developed by aWellington IPA which facilitates retinal screening of diabetics by community optometrists, circumventing the need for referral to a hospital-based ophthalmologist;
• A common price for access to full-text medical knowledge databases negotiated by the Ministry of Health and several DHB hospitals; the Southland DHB has provided practitioners outside the hospital with online access to these, while others have made them internally available;^[28]
• Progress with installation of web-enabled intranets for accessing clinical information at some hospitals;
• A focus by DHBs on reducing the number of software vendors they deal with to induce greater national consistency;
• The formation of the New Zealand Health IT Cluster by more than 20 software companies, which aims to align the work of its members more closely with health sector requirements and to co-ordinate international marketing efforts.^[f]

In 2002, the Ministry of Health established a Health Sector Information and Technology team dedicated to furthering WAVE recommendations. Much of this team’s work involves consulting the health sector over key issues such as security, standards and systems architecture, developing policy and supporting and reporting on provider-led developments. The Ministry has created a quarterly newsletter, Health e-News.^[g] that reports on developments, and the (limited) progress-to-date on WAVE’s "Top Ten" recommendations. The Ministry has also looked closely at its own information systems, many of which interface with the broader health sector, and has developed a strategic plan to consolidate these.

A survey of 17 DHB ICT systems conducted in late-2001 revealed the extent of the variation across the country, which might fairly be blamed on the lack of central oversight through the 1990s. The figure below portrays the number of different DHB software applications across core DHB information systems. Naturally, this situation presents a host of obstacles to interoperability and related issues that need to be worked through. The many systems beyond DHBs, such as those maintained by IPAs, add to the complexity. The Ministry team, thus, faces a protracted and challenging task. Its role may well be one of mediating between different players and directions and gently trying to influence behaviour and developments. However, its capacity to steer developments is limited in the present highly decentralised health sector. As noted, DHBs are funded on contract by central government but, in turn, are a step away from the many providers they purchase services from.

Figure: Numbers of DHB software applications across core DHB information systems in New Zealand^[h]

[Click to view the image in full size]

In 2002, a New Zealand Health Information Standards Organisation (HISO) was launched to take the "leadership" role recommended in the WAVE report, while the two existing "transaction" agencies (the Shared Services Support Group and Health Benefits Limited) were merged to form HealthPAC (Health Payments, Agreements and Compliance). HealthPAC work may eventually be conducted via a health web-based portal, while subscription to the Health Intranet, a portal precursor, continues to grow. The NZHIS remains an independent unit within the Ministry of Health dedicated to data collection and maintenance of national datasets. It has launched an "Infostructure Programme", which aims to establish ICT systems that provide the health sector with access to NZHIS databases. This programme also includes:

1. upgrading the NHI by removing the approximately 800,000 "duplicate" entries (for a population of four million);
2. extending NHI electronic access to primary care providers; and
3. establishing a Health Practitioner Index that identifies all registered health practitioners by a single number.

Beyond central agencies and largely outside of their influence, the chief information officers of the DHBs have been regularly meeting to discuss issues and strategy; a number of IPAs information managers have also agreed to work toward ensuring their ICT systems and standards are compatible and support interoperability. Such collaboration has been bolstered by the fact that DHB and independent practitioner association representatives were involved in the WAVE project.

Into the Future
In August, 2005, a fifth information strategy, building on the WAVE recommendations, was launched.^[29] Recognising how embedded and complex of ICT arrangements are, this largely reflects and formalises developments occurring in the health sector. It also provides a plan for improving interoperability and information sharing, and expanding the reach of ICT connectivity within a national framework. The 2005 strategy highlights the fact that the government is not in a position to lead this exercise because of preceding developments and health system structure; that New Zealand’s highly devolved health system means that "each organisation eeds to take responsibility for their own strategic information system plans to guide development of solutions to their unique business challenges".^[29]

In terms of the framework that will govern health information management and ICT in the foreseeable future, it could be suggested that there will be incremental advancement across various isolated, loosely or closely connected developments. Many developments will be driven by collaborative activity within the sector itself, which is the approach promoted in the 2005 strategy that provides a "birds-eye" view of the possible path ahead. The 2005 strategy is based on the idea that most information (for example, patient records) will be collected electronically and shared at the local level by Primary Health Organisations and DHBs; some population and planning information will be collected and held regionally, within DHBs; and some will be nationally maintained. Collaboration and interoperability are, again, the keys to this structure, as are yet to be created "stewardship" arrangements.^[29]

Developments across the sector will continue to be increasingly monitored, where relevant, supported and, in some cases, compelled by central agencies through contractual requirements. The newly-formed Health Information Strategy Action Committee (HISAC), which grew out of the 2005 strategy and sits above HISO, is likely to play a key role in advising on and steering these developments. The use of formal contracts between funder and provider, which has endured since the 1990s, potentially has the advantage of the ability to propel providers in centrally-driven contract-specified directions. With the increasing inclusion of information delivery requirements in contracts, and the application of centrally-derived ICT policy strategy, capacity for the centre to influence sector-wide ICT developments grows. However, for progress toward interoperability to continue, there needs to be  a highly developed and co-ordinated ICT strategy that is widely recognised and supported; the input of ICT system and policy experts will also be crucial in contract negotiations. As discussed, only the foundations of such a scenario have been laid. At best, it might be several years before New Zealand reaches a point where systems are fully integrated and there is national interoperability.

In the meantime, considerable work is required in three areas:

1. rectifying problems associated with the restructuring era and the shift from competition to co-ordination, including dealing with the many overlapping databases, data collection inconsistencies, and lack of information co-ordination across the health sector;
2. updating incompatible systems, particularly databases and systems used for financial and administrative transactions, patient management and clinical work; and
3. dealing with complex organisational, planning and policy issues such as the development of national systems architecture guidelines, the development of security and privacy policy, the creation of a coherent and functional institutional basis for the development of sound ICT policy and ICT co-ordination, and the consolidation of information strategy.

The continual advance of ICT complicates these tasks, as will further policy changes. New Zealand’s experience suggests that, in a highly politicised, disaggregated and transient environment, developing and implementing health sector ICT strategies is far from straightforward. Although New Zealand’s recent history of restructuring may be unique, its transition from a market oriented to collaborative health service environment matches that of other developed countries. For this reason, the difficulties with health care information management and ICT development witnessed in New Zealand might be expected elsewhere.

Footnotes

a.	Thanks to Ray Delany, Management Consultant, Auckland, New Zealand and former NZHIS, for comments on a previous draft of this article. Any errors and omissions remain the responsibility of the author
b.	Crucial to the competitive system was information that could be written into the myriad of service contracts (approximately 8,000 managed across the four RHAs). Purchasers and providers all required a reliable knowledge of how many services were in existence, who received them and what they cost, and progressively developed their own information systems.
c.	The NHI is a registration system used for identifying health service users. Each user is assigned a unique number to be used in encounters with the health system. The NMDS is gathers national data on public and private hospital discharges. All NMDS records are identified by the NHI.
d.	There is debate over the validity of the Systems Architecture team’s work in that its findings were an assessment of the present reality against an expectation of technically perfect information collection and ICT systems. The views forwarded showed no recognition of the well-documented need to mesh information systems needs with the reality that incremental progress in developing information systems in health care settings leads to greater clinical acceptance and long-term success. Refer: Gamm LD, Barsukiewicz CK, Dansky KH, Vasey JJ. Investigating changes in end-user satisfaction with installation of an electronic medical record in ambulatory care settings. Journal of Healthcare Information Management 1998; 12 (4) and Heeks R, Mundy D, Salazar A. Why Health Care Information Systems Succeed or Fail. Information Systems for Public Sector Management: Working Paper Series, paper no. 9. Institute for Development Policy and Management: Manchester University, 1999.
e.	The "collection of data from a disparate source and systems, that when combined into a formal structure offers more information to the user than the separate individual data elements". [26]
f.	See: http://www.healthit.org.nz.
g.	Available at: http://www.moh.govt.nz/publications.
h.	Thanks to NZHIS for supplying this figure. Numbers in the figure do not correspond with the number of DHBs (21) either because of missing data, or because electronic systems are not installed.

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