What the doctor orders

IMPROVING connectivity to hospitals and health clinics is one of the primary objectives for the government’s ultra-fast broadband network. But how can ICT and better broadband enable a healthier nation? Sarah Putt seeks a diagnosis. DR Emma Parry is one of only five Maternal Fetal Medicine specialists in the country – a discipline thatrequires 18 years of training. She is the clinical director of National Women’s Maternal Fetal Medicine Service and the New Zealand Maternal Fetal Medicine Network. The latter is an electronic network set up to provide information via a website on threelevels: patients, doctors  and specialists. It aims to provide all pregnant women whose own health, or the health of their unborn children, is in danger,  with information abouttheir condition, and to ensure they receive the right care regardless of where in the country they live.While she takes care of populating the site, another Dr Parry – her husband – manages the ICT infrastructure.  Dave Parry is a senior lecturer in the AUT School of Computing andMathematical Sciences.The electronic platform they’ve created enables the secure sharing of word documents, but the plan is to  include 4D scans onto which diagnostic information can be tagged and automatic bookings made to a clinic.  Not only will this ensure mother and baby are treated as quickly as possible – delays can be fatal – it will  create a body of knowledge that can be used to educate health practitioners around the country and relievethe  burden on those four specialists. The Parrys are excited about the network – it’s one of the first websites to be registered under the new  domain .health.nz and as broadband infrastructure improves, the ability to transfer large files to cities and  towns around the country will help more women carry babies to term. The Electronic National Maternal Fetal Medicine Network shows what can happen when clinicians and ICT  practitioners work together to create a national solution in a specific medical discipline. But is it an isolated example or is it indicative of the kind of inter-regional cooperation that might one day see  the creation of a national system that stores every citizen’s health record electronically? The creation of a national ICT solution has been the topic of hot debate throughout the health sector, with the  government moving to address the issue through the fomation of an IT board that govern across all 21 District  Health Boards. At the time of going to print, Minister of Health Tony Ryall announced that the Health Information Strategic  Advisory Committee (HISAC), which was set up in 2005 to advise the Ministry of Health, will be transformed  into the national health IT board. Its first tasks will be the management and support of payment systems and the national health information  collection, the national immunisation register and the cancer register. There are 120 million payment  transactions, handling $6.5 billion each year. The change to HISAC was one of the key recommendations in the recent Ministerial Review Group’s Report  ‘Meeting the Challenge’. HISAC chair is Graeme Osborne, who until recently was CIO at the Accident Compensation Corporation. At  the Health Informatics New Zealand (HINZ) conference in October he told the audience that a national health  information portal could be established by 2014. That is, any New Zealander could access their health record  via a secure login from anywhere in the country. According to Hutt Valley CIO Tony Cooke, who also spoke at the HINZ conference and whose presentation  was entitled ‘The Infrastructure Behind eHealth’, there is broad consensus that better cooperation on ICT  among the 21 DHBs is required. He says the debate as to how that can be achieved is often framed as a debate between those who favour  interoperability within local DHBs and regions and those looking for a ‘one system approach’. “The two sides are artifi cially polarised,” Cooke says. “There is actually quite a lot of agreement about what  the world should look like and what the enterprise people are saying. There isn’t an enterprise system that  would do it anyway, so we have to have interoperability.” The discussion has shifted to how to achieve convergence and execute a plan that would enable systems to talk to each other.  “I would say the waythings are heading at the moment is towards regional solutions,” Cooke says. “The  reason is that it’s so much easier to work collaboratively regionally – you’ve got five or six DHBs, not 21.“The national stuff is being determined from the centre without understanding the business environment that  DHBs are in. There’s a recognition that some things need to be done nationally, some regionally and some  locally. And a general recognition that more of the local stuff needs to become regional – that’s where the  direction of travel is.” While a regional solution appears more manageable, to get a sense of how complicated it is to achieve, Cooke  highlights the complexity in the six DHBs in the central region that Hutt Valley is part of – here’s how many  DHBs have the same solutions for the following three Health IT systems:  Picture Archiving Communication System (PACS) – four out of six DHBs have the same system.Electronic Health System – four out of six have the same system, another DHB has one component the same  and one DHB is planning to implement. Patient Management System – three out of six DHBs have the same system.“We can’t keep doing what  we’re doing because it’s too complicated and it’s too costly to maintain so we  need to have a direction, even if it’s a regional direction,” Cooke says. “The Ministry of Health is very focused on their internal things and they expect the DHBs to sort this out  anyway. It’s between the hospital and the GPs.” There are an estimated 12,500 health providers in New Zealand, and the primary health provider most of us  see is our GP – what are their systems like? Earlier this year the Ministry of Health surveyed 7000 clinicians and ICT decision makers from more than  5000 health provider organisations and received a 32% response rate. Ross McKenna, the portfolio manager for health system infrastructure at the Ministry, presented the findings at the HINZ conference and found the  following: • More than half (51%) of non-DHB clinicians and three-quarters (72%) of DHB clinicians reported that at  least once a day they could not find the patient electronic information they required to optimally treat their  patients. • Nine out of 10 (93%) New Zealand clinicians have Internet access and use email. • Both DHB clinicians (84%) and non- DHB clinicians (71%) identified that lack of compatible patient  management systems was the most significant barrier to electronically accessing medical or health care  information from other organisations.Interoperability may be the main issue, but it isn’t the only one that needs addressing in order to achieve better  use of ICT in the health sector. The survey showed that only a small number (16%) of health ICT  decisionmakersreported ‘excellent’ value from their ICT investment. “This response implies that a health user’s experience of what capability ICT typically provides does not  translate well to their perception of value (cost/benefit),” writes McKenna.Many are relying on email for their electronic communication – despite its lack of security and the issues  around sharing private patient information. Fax is also a favoured form of communication, but this relates more to regulations which state that  prescriptions must be signed, meaning that paper records are considered more secure and authoritative.The Ministry’s survey also found that while doctors recognise the need for better ICT systems to improve the  communication between health care providers, they’d prefer to access new information, rather than share their  own patient records. “In reality the barriers to sharing information are not just technical, but depend on clinical relationships and  inter-organisational business processes being established,” writes McKenna. The paper concludes by suggesting the way to achieve the greatest gains is “the implementation of a national  architecture framework and standards, a series of process change activities, increased sharing of ICT services  and joint clinical governance arrangements.”Cooke says the sector is hopeful that a national Health IT Board will be given the funding to encourage  change. Also that there will be a requirement for DHBs within regions to adopt the same standards for their  core systems, even if they don’t all agree.A possible model is the Canadian Info Way, where regional health providers can approach a national board,  and providing they decide on one of the preferred systems, the board will fund half its implementation. The Ministry’s survey showed that the top four clinical priorities for electronic access and sharing are:  diagnostic test results, referrals, discharge summaries and medication information. But Cooke points out that  even if all of the information about every person in the country existed securely  online, it would still need to be  accessed sensibly. It might only make a difference for 15-20% of patients seen.“You’ve got to put it in context. If you turn up with broken glass in your hand you don’t actually need a lot of  your medical history, except if you’ve got a condition like diabetes,” he says. On the other hand he says that not knowing critical information, such as what drugs a patient has been  prescribed because clinicaians have poor access to this information, is currently injuring about five percent of  people admitted to hospitals. For Cooke the ideal would be that a patient’s detailed health records were accessible at a regional level, but  that vital information could be accessed nationally. “If you have an electronic medical history that takes the doctor 15 minutes to read through, they’re not going  to do that,” he says. “High value stuff should be available nationally –everything you need to know in a  nutshell about that patient.”