Better Information for Better Care New Zealand s. Healthcare

Transcription

1 Better Information for Better Care New Zealand s Approach to Efficient and Affordable Healthcare White Paper APRIL 212 Prepared by Malcolm Pollock, Director of New Zealand s National Institute for Health Innovation

2 europe Health White Paper, APRIL Foreword This White Paper covers a topic that is relevant to all interested in managing a sustainable health system. Whether you are a health professional, manager, funder, policy maker or academic, the paper will be of interest. The role that information technology (IT) plays in achieving a sustainable high quality health system cannot be ignored. The explosion and fast changing pace of IT applications affects our everyday life. Malcolm Pollock paints a picture of New Zealand s journey and progress in the use of IT in healthcare. He also includes a comparison with OECD nations and makes observations of European countries use of IT in healthcare. Reading the many exemplars that Malcolm has made in the paper, I recall some of the complex debates, challenging discussions, and at times, heated disagreements amongst very passionate participants in New Zealand. We managed to make progressand continue to do so although at times it felt like we were taking two steps forward and one step back. However, reflecting back on those periods when we were pausing, I am of the view that they were necessary to allow stakeholders affected by the change to come to the party. Not everyone did of course and in an open and democratic system that choice must always be available. The paper discusses some of the factors that have allowed New Zealand to make progress, such as a single tier of government, clinical leadership, collaboration amongst stakeholders and the role played by national leadership groups like the National Health IT Board. Whilst all these factors played an important part in our progress, they played their part within the context of changes that were happening in the overall New Zealand health system. I often get asked whether what happens in New Zealand is transferable to larger health systems or to those that are funded by insurance rather than taxation. The answer I think lies in understanding why New Zealand has chosen these initiatives and how these factors complemented other changes that were happening in the New Zealand health system. Over the years, New Zealand has looked and continues to look at what is happening in other countries and has customised much to suit the New Zealand health system and the culture of our country. Therefore, as you read of our exemplars, I would encourage readers to think about how these can be customised to your health system and your country s culture. I hope that this paper provides the catalyst and opportunity for debate and discourse amongst our colleagues in Europe and beyond. My colleagues and I in New Zealand look forward to joining you in the discussions to follow. We can learn from each other. The current global financial crisis provides greater impetus for most, if not all, developed countries to look at how to run a sustainable high quality health system. There can be no doubt that IT is playing and will continue to play an essential role. The key to getting the best value from IT investment in health is ensuring that it is integrated with and part of a broader package of changes. Changes in models of care, workforce, funding mechanisms and business models are part of the broader package. In addition, incentives need to be carefully developed to lubricate these changes. Finally, there needs to be investment in the development of capacity and capability of the consumer, families and communities not only of paid participants in healthcare. I wish you well in your on-going endeavours to improve your health system and trust that this paper will provide you and your colleagues with a platform for your deliberations. In closing, let me share with you the Chinese word for crisis. It comprises two characters Wei and Chi which stand for danger and opportunities. As you, and your colleagues, wrestle with solutions for a sustainable quality health system in the midst of the current global financial crisis, may you see more opportunities than dangers. Chai Chuah National Director National Health Board Business Unit Ministry of Health Wellington, New Zealand April 212

3 europe Health White Paper, APRIL Table of Contents Foreword 2 1. Executive summary 4 2. New Zealand's healthcare sector New Zealand in context The New Zealand health sector 7 3. Health IT in New Zealand and Europe: Denmark, France, Germany and the UK Key indicators and indices Health expenditure across European and OECD nations Health system performance The health IT context Health IT Strategy The environment The infrastructural elements Standards Leadership IT at work in New Zealand health Integration across the continuum of care IT in hospitals Research Case studies Introduction Connecting organisations for better healthcare Hospital bed management Co-ordination of care plans and funding Integrated care for patients with long term conditions the National Shared Care Plan Project Electronic referrals Mental Health Services The Canterbury Initiative Conclusion Appendix one 38

4 europe Health White Paper, APRIL Executive Summary Information technology (IT) that supports the sharing of clinical medical information is proving to be a valuable means of ensuring continuity where it matters most: human healthcare. According to the OECD, evidence is growing that, if left unchanged, Europe s current healthcare systems will become unsustainable within the next 15 years. 1 As budgetary pressures take hold, finding efficiencies has become central to the preservation of high-quality care. This combined with ageing populations suffering from chronic conditions, and lower proportions of individuals providing the tax revenue on which healthcare funding depends, is creating the perfect storm. New Zealand, a relatively small and young country, is well placed to offer a new perspective to Europe, not least drawn from its innovative technological approaches to healthcare challenges, while containing costs. This focus on innovation has resulted in New Zealand s health sector being recognised internationally as a provider of high quality and cost effective services, as can be gauged by these independent rankings: First in overall quality care delivery, including first in coordinated care and patient centred care delivery 2 First in practices routinely sending patients reminders for preventive or follow-up care (97 percent same as the UK) Highest ratio of using a computerised system for patient reminders for follow up care (92 percent) rather than manual procedures (76 percent in UK 3 ) First in practices with advanced electronic health information capacity (92 percent), followed by UK (89 percent 4 ) New Zealand, together with Norway displays the highest physician satisfaction rate (over 75 percent) with practicing medicine 5 Second in doctors use of electronic patient medical records (97 percent), following the Netherlands (99 percent 6 ). At the same time, the per capita cost of healthcare in New Zealand is less than in many other developed countries. According to the OECD, in 29 New Zealand per capita health expenditure was US$2,983 versus US$4,348 in Denmark, US$4,218 in Germany, US$3,978 in France, US$3,487 in the United Kingdom and US$7,96 in the United States. 7 Throughout the country, innovative technology is enabling clinical excellence. New Zealand s use of IT in healthcare is among the highest in the world. 99 percent of the country s pharmacies are computerised 8 and there is a rapid uptake across the sector of electronic medical records. 9 As noted by the Commonwealth Fund 1, New Zealand s record in primary healthcare is a notable area of strength, particularly in the effective coordination of care, taking a patientcentred focus and the use of innovative IT as an enabler that drives success. 1 N Denjoy, 21, Health and IT showing the way forward, Organization for Economic Cooperation and Development, The OECD Observer, Paris Oct 21 (281): 2 2 Mirror, Mirror on the wall: how the performance of the U.S. healthcare system compares internationally, 21 update, The Commonwealth Fund, retrieved from: International health policy survey of primary care physicians in eleven countries, the Commonwealth Fund, retrieved from: commonwealthfund.org/~/media/files/publications/in%2the%2literature/29/nov/pdf_schoen_29_commonwealth_fund_11country_intl_ survey_chartpack_white_bkgd_pf.pdf 4 Electronic medical record adoption in New Zealand primary care physician offices, August 21, The Commonwealth Fund, retrieved from: commonwealthfund.org/~/media/files/publications/issue%2brief/21/aug/1434_protti_electronic_med_record_adoption_new_zealand_intl_brief.pdf 5 See Footnote 3 6 See Footnote 3 7 OECD Health Data 21, Country notes and press release Canada, retrieved from: 8 New Zealand health technology excellence Delivered to the world, 21, New Zealand Trade and Enterprise, retrieved from: eu/images/stories/pdf/nz_health_technology_brochure.pdf 9 See Footnote International health policy survey of primary care physicians in eleven countries, the Commonwealth Fund, retrieved from: commonwealthfund.org/~/media/files/publications/in%2the%2literature/29/nov/pdf_schoen_29_commonwealth_fund_11country_intl_ survey_chartpack_white_bkgd_pf.pdf

5 europe Health White Paper, APRIL New Zealand has achieved these advances through far-sighted strategies, the leadership provided by the National Health IT Board, by the long term investment over more than 2 years in health IT and the country s single tier of governance. Healthcare is viewed as operating along a continuum: from patient, to primary medicine, to community and ancillary care, to the secondary and tertiary sectors; from public to private; from strategy to operation. New Zealand was among the first countries in the world to establish an electronic Population Health Index, a secure system that features nearly 2 years of health encounters. It is now supplemented by an equally comprehensive Health Practitioner Index. Beyond informing public policy decisions, these indices have enabled development of rich datasets, which in turn have sparked the growth of an internationally respected health research capability. At a policy level, New Zealand is committed to protecting and improving its health system on a sustainable basis. It is accepted that new approaches are required to increase quality while containing spending. New Zealand is focusing on clinically-led innovative models of care; greater involvement of patients and consumers in designing future health services; and greater integration of investment in IT, workforce and infrastructure. There is a broad consensus across Europe that a focus on prevention is the key to achieving a healthy ageing population. New Zealand is in the vanguard of this and other developments in healthcare delivery, including: the prevalent use of clinical IT systems in primary care integrated care across primary, secondary and community settings shared care planning across the continuum of care patient centric health, patient selfmanagement and patient-doctor collaboration the use of national indices hospital resource utilisation management. New Zealand s innovative character has been roused by pressing challenges in healthcare. Clinicians, policy makers, researchers and technicians have risen to the challenge with the active support and participation of New Zealand s home-grown, yet internationally recognised, health technology companies. The collaborations have changed clinical practice and other aspects of the health system for the better, particularly over the last decade. Together, innovators, entrepreneurs and clinicians on the front line have spurred rapid growth in New Zealand s health technology sector. Granted, being a small country of 4.5 people with a single tier of government simplifies streamlining, but New Zealand has confronted many territorial and proprietary barriers that stand as obstacles to developing a truly integrated care service.

6 europe Health White Paper, APRIL The approach has required health system stakeholders to: involve clinical leadership in strategy development develop vision and a strategy for socialising it throughout the sector gain community buy-in and support, as far as possible put in place key infrastructural elements: technologies, consent frameworks, architectures, integration approaches, process changes etc. create partner-style engagements between the healthcare sector and the supplier and research communities initiate a series of trials and evaluate them, with the clear commitment to move from trial to large-scale deployments align the reward frameworks with the new structures and processes (still a work in progress). There is much to learn from the approaches taken by different funders and providers in New Zealand and their significant use of IT to enable change. This White Paper provides evidence that New Zealand s attainment of objectively measurable clinical excellence in its healthcare system arises from new, IT-enabled approaches to the delivery of healthcare. In many cases, success has been fuelled by the innovative nature of local culture, and by technologies and products this culture has spawned. Case studies illustrate how IT contributes to the quality of New Zealand s clinical care now recognised as among the best in the world. The White Paper also summarises, for comparative purposes, the IT strategies and progress in a number of European countries. Every European nation has a vested interest in protecting and improving the health of its citizens, and many are seeking and finding ways to leverage IT for this purpose despite the complexity and scale of the various healthcare systems. New Zealand is inviting European health policy makers, clinical leaders, and executives from the healthcare and IT sectors to consider opportunities for collaboration, exchange and mutual learning. By sharing some of its experiences and innovations, New Zealand can offer a new perspective and highlight alternative pathways to success.

7 europe Health White Paper, APRIL New Zealand's healthcare sector 2.1 New Zealand in context New Zealand is a small island nation in the south-west Pacific with a population of 4.5 million people. According to the most recent census, the main ethnic groups are European (8 percent), Māori (14.7 percent), Asian (6.6 percent) and Pacific peoples (6.5 percent), with ethnicity understood in terms of cultural affiliation, rather than necessarily by descent. Some people claim more than one ethnicity, which is why these figures add up to over 1 percent. Approximately 86 percent of the population inhabit urban areas (towns larger than 1 inhabitants), and 69 percent inhabit main urban areas (places with more than 3, residents). According to the OECD, in 29 New Zealand per capita health expenditure was US$2,983. This compares to US$4,348 in Denmark, US$4,218 in Germany, US$3,978 in France, US$3,487 in the United Kingdom and US$7,96 in the United States. 2.2 The New Zealand health sector New Zealand s healthcare system shares characteristics of many European countries, including: A publicly funded system in which the majority of healthcare expenditures are made by the public sector. Approximately 77 percent of healthcare in New Zealand is funded through taxation. Devolved healthcare delivery responsibility, with regional health organisations of some form taking responsibility for funding and, in many cases, delivering healthcare services across the continuum of care in a geographic area. A mix of urban, rural and remote healthcare delivery challenges driven by low population densities. A fundamental philosophy that healthcare should be delivered to those who need it, when they need it. The principal players in the New Zealand healthcare sector include: The Ministry of Health: responsible for policy advice to the Government, the implementation of policy, development of national strategies in such areas as public health, workforce development, quality and IT, the provision of funding, audit services and, directly, the operation of a small number of national programmes. Twenty District Health Boards: the recipient of the bulk of public funding, developing regional strategies, operating hospitals and overseeing the provision of primary health. Sixty Primary Health Organisations: supporting groups of primary health practices, which are private organisations funded through a mix of capitation and fee-for-service models. Accident Compensation Corporation: a no-fault, compulsory national accident insurance scheme funded through employer and employee contributions. Pharmac: the Government-funded purchaser of pharmaceuticals for the health sector. Private Healthcare Sector: providing health insurance and healthcare services, primarily in the area of elective surgery, to about 2 percent of New Zealanders. A more detailed description of the New Zealand health sector is set out in Appendix One of this White Paper. 11 OECD Health Data 21, Country notes and press release Canada, retrieved from:

8 europe Health White Paper, APRIL Health IT in New Zealand and Europe: Denmark, France, Germany and the UK 3.1 Key indicators and indices It should be noted that in this analysis, the UK is treated as a single country, whereas in practice the healthcare systems are run independently in each of the English, Welsh, Scottish and Northern Irish jurisdictions. Table 1: Key indicators of New Zealand and four European nations population and health status 12 Demographic statistics Mortality Information and communication technology usage ehealth foundation actions INDICATORS New Zealand Denmark France Germany UK Population (s) 4,23 5,47 62,343 82,167 61,565 Population in urban areas (% of population) Population in rural areas (% of population) GDP per capita (PPP Int $) 29,352 55,992 41,51 4,67 35,165 Life expectancy at birth (years) National mortality rate (per 1 live births) ICT development index Mobile cellular subscription (per 1 population) Internet users (per 1 population) National ehealth policy and implementation year ehealth policy implemented status National ICT procurement policy for health sector Yes 25 Revised in 21 Yes 28 Yes 22 Yes 23 Yes 22 Partly Partly Partly Partly Partly Yes, 25 Revised 21 No No Yes, Before 2 Yes, Figures are retrieved from the following sources: - World Health Statistics 211, - Atlas ehealth country profiles, - GDP per capita (current US$) Table, The World Bank, - The Global Information Technology Report , World Economic Forum,

9 Density of health workforce and infrastructure 5 per 1, population Figure 41: GDP per capita (USD) ranking 14 based on 29 data Physician density Germany Germany France France Germany France Germany Denmark France United Denmark Kingdom United Kingdom Denmark United Kingdom New Zealand New Zealand United Kingdom New Zealand Denmark New Zealand Denmark United Denmark Kingdom 1 Germany Germany France Denmark Germany Denmark europe Health White Paper, APRIL France New Zealand Germany Germany New Zealand Germany Denmark United Kingdom United Kingdom France New Zealand 12 Nursing and midwifery personnel density New Zealand France United Kingdom United Kingdom New Zealand United Kingdom France New Zealand Denmark France Denmark United Kingdom Germany Denmark United Kingdom New Zealand Dentistry personnel density France Denmark France Germany France United Germany Kingdom Germany Hospital bed density 9 9 France Germany United Kingdom Denmark New Zealand United Denmark Kingdom New Zealand New United Zealand Kingdom United Kingdom New Zealand Denmark Germany France New Zealand Denmark Pharmaceutical personnel density United Kingdom Denmark 1 France United Denmark Kingdom Denmark France United Kingdom Germany Denmark Germany Germany Denmark New Zealand Germany United France Kingdom GDP per capita (USD), 29 6 New United Zealand Kingdom France New Zealand New Zealand Germany New France Zealand Denmark France New Zealand Denmark France United Kingdom France France United Kingdom Denmark United Germany Kingdom Denmark Germany United Kingdom Denmark New Zealand France New Zealand New Zealand Germany New Zealand Denmark Germany Denmark United Kingdom Denmark France Denmark France Germany Germany Germany United Kingdom United France Kingdom New Zealand New Zealand New Zealand

10 europe Health White Paper, APRIL Health expenditure across European 13 and OECD nations 14 Total health expenditure as percentage of GDP Figure 2: Total Health expenditure (% of GDP) across EU nations, Public expenditure on health Private expenditure on health % GDP Figure 3: Total Health expenditure (% of GDP) among OECD countries, Public expenditure on health Private expenditure on health United States France Switzerland Austria Germany Canada Belgium 1 Netherlands Portugal New Zealand 1 Denmark Greece Sweden Iceland Italy Spain OECD Ireland United Kingdom Australia Norway Finland Japan Slovak Republic Hungary Luxembourg Czech Republic Poland Chile Korea Turkey Mexico France Switzerland (27) Austria Germany Belgium 1 Portuga (26) Denmark (27) Greece (27) Sweden Iceland Italy Netherlands 1 Spain Ireland United Kingdom Norway Finland EU Slovenia Slovak Republic Hungary Bulgaria (27) Luxembourg (26) 2 Czech Republic Poland Latvia (27) Lithuania Estonia Turkey (27) Cyprus (27) Romania % GDP 1. Current expenditure Source: OECD Health Data 21, June Figures and tables are retrieved from: Health at a Glance Europe 21, OECD ilibrary 14 Health at a glance 29: OECD indicators, retrieved from: OECD ilibrary 15 Growing health spending puts pressure on government according to OECD Health Data 21, OECD Newsroom, 46,en_ _ _ _1_1_1_1,.html

11 europe Health White Paper, APRIL Total health expenditure per capita Figure 4: Total health expenditure per capita (Euros) across EU nations, Public expenditure on health Private expenditure on health EUR PPPs Figure 5: Total health expenditure per capita (usd) among OECDE nations, United States Norway Switzerland Luxembourg (26) 1 Canada Netherlands Austria France Belgium Germany Denmark Ireland Sweden Iceland Australia (26/7) United Kingdom OECD Finland Greece Italy Spain Japan (26) New Zealand 2 Portugal (26) Korea Czech Republic Slovak Republic Hungary Poland Mexico Turkey (25) Norway Switzerland Luxembourg (26) 1 Austria Ireland Germany Netherlands 2 France Belgium 2 Denmark (27) Sweden Iceland United Kingdom Finland Spain Italy Greece (27) EU Slovenia Portugal (26) Czech Republic Slovak Republic Cyprus Hungary Estonia Lithuania Poland Latvia (27) Bulgaria (27) Romania Turkey (27) USD PPPs Public expenditure on health Private expenditure on health

12 europe Health White Paper, APRIL Health system performance According to the OECD, evidence is growing that if left unchanged, Europe s current healthcare systems will become unsustainable over the next 15 years. 16 Aging populations, an increase in chronic disease and health conditions and lifestyle changes are worsening the current situation in the healthcare sector. Europe s policy makers and governments are seeking solutions to resolve these long term sustainability issues. The World Health Organisation in its Year 21 Health Report asserts: At a time when money is tight, before looking for places to cut spending on healthcare, look first for opportunities to improve efficiency. 17 The healthcare system is a comprehensive network that interconnects all the stakeholders and evolves alongside a country s financial, economic, political and social aspects. This means that there is no single magic spell that can be casted universally to solve the sector s long term sustainability issues. In contrast, it requires each country to take into account its own resources, capabilities and capacities in order to design and adopt a strategy with multi-dimensional approaches. Boosting system efficiency can be achieved via better allocation of resources, better procurement practices, broader use of generic products, better incentives for providers and/or streamlined financing and administrative procedures. The adoption of Information and Communication Technology (ICT) in the healthcare system is an all-encompassing and sustainable movement towards shaping the health system into including new services, more efficient operations and with better informed decision making. In terms of healthcare financing, there is a trend that countries with a higher GDP tend to spend a greater proportion on healthcare. Figure 3 shows that, compared to Denmark, Germany, France and the United Kingdom, New Zealand s health expenditure as a percentage of GDP is the third highest at 9.8 percent of GDP, above the OECD average of 9. percent. At 11.2 percent and 1.5 percent respectively, France and Germany are in the high end tier of health expenditure as a percentage of GDP, both among OECD nations and the European Union (EU). They are also the high spenders in health expenditure in terms of spending per capita. Comparing across the OECD nations, in 28 the United Kingdom was the sole country whose health expenditure as a percentage of GDP is below the OECD average, albeit only slightly below at 8.7 percent. In terms of health expenditure per capita in 29, New Zealand has the lowest figure (US$2,983) among the five countries and is below the OECD average of US$3, However GDP is not the sole factor that influences the level of health expenditure. From the population and health indicators shown in Table 1, we can see that compared to the selected four European nations, New Zealand barely shows a difference in population mortality index in terms of life expectancy (approximately around 8 years) and mortality rate at birth (2-3 out of 1 new-borns). In terms of health workforce and infrastructure, New Zealand figures sit at a relatively low level compared to the European countries. New Zealand physician density and hospital bed intensity are both the lowest among the five nations. The density for nurses, midwives and dentists in New Zealand are the second lowest among all the listed countries. 16 N Denjoy, 21, Health and IT showing the way forward, Organization for Economic Cooperation and Development, The OECD Observer, Paris Oct 21 (281): 2 17 World Health Report Health systems financing: the pathway to universal coverage, World Health Organization, retrieved from: whr/21/1_summary_en.pdf 18 OECD Health Data 21, Country notes and press release Canada, retrieved from:

13 europe Health White Paper, APRIL Figure 6, taken from a 29 Commonwealth Fund study, provides some quick comparisons and insights into each nation s healthcare sector. New Zealand scored three top positions for quality care, patient centred care and coordinated care. The United Kingdom scored top in delivering effective care, healthcare efficiency with low cost-related problems, which indicates an easier access to mechanisms in the healthcare service. The United Kingdom was also positioned well in terms of overall care ranking (second position following the Netherlands), safe care, access to care and healthcare equity. Germany s overall healthcare ranking compares less favourably with New Zealand and the UK. Figure 6: Seven OECD countries health sector overall ranking 19 AUS CAN GER NETH NZ UK US OVERALL RANKING (21) Quality care Effective care Safe care Coordinated care Patient-centred care Access Cost-related problem Timeliness of care Efficiency Equity Long, healthy, productive lives Health expenditures/capita, 27 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,29 country RANKING Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 27 International Health Policy Survey; 28 International Health Policy Survey of Sicker Adults; 29 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development OECD Health Data, 29 (Paris: OECD, Nov. 29). 19 Mirror, Mirror on the wall: how the performance of the U.S. healthcare system compares internationally, 21 update, The Commonwealth Fund, retrieved from:

14 europe Health White Paper, APRIL In a 29 Commonwealth Fund study that compares health policy of primary care physicians in eleven countries 2, it is shown that New Zealand and the United Kingdom are both at a leading position in terms of health information practice capacity. New Zealand has the second highest rate of doctors using electronic patient medical records of 97 percent (following the Netherlands at 99 percent). In the United Kingdom, 96 percent of doctors use electronic patient medical records, which is well ahead of Germany and France where the comparative figures are 72 percent and 68 percent respectively. New Zealand and the United Kingdom also have the highest ratio of carrying out practices utilising advanced electronic health information capacity. 92 percent of New Zealand and 89 percent of United Kingdom practices are carried out using advanced electronic health information capacity, compared to below 5 percent in France and Germany. In areas where New Zealand is less well ranked, there has been considerable focus on raising the standards. The Government has established national bodies for the improvement in health quality and safety and the development of the healthcare workforce. Waiting lists for elective surgery have shrunk in the last two years and the government has established a series of key indicators by which it and the general public can measure the performance of the sector. 2 C Schoen and R Osborn, 29, The Commonwealth Fund 29 International Health Policy Survey of primary care physicians in eleven countries, retrieved from: Commonwealth_Fund_11country_intl_survey_chartpack_white_bkgd_PF.pdf

15 europe Health White Paper, APRIL The health IT context 4.1 Health IT Strategy New Zealand s approach to deploying health IT can best be characterised as bottom up, with support (but not necessarily direction) from the national level and an intense focus on deploying IT solutions at the point of care. As a result, New Zealand s use of IT in healthcare has become among the highest in the world, especially by primary care providers. 21 Together, policy makers, health providers, innovators, entrepreneurs and clinicians on the front line have spurred rapid growth in New Zealand s health technology sector. Rather than major investment programmes, one of the foundations of the country s progress has been the encouragement of innovation at a local level with emphasis on evaluation and dissemination of successful pilots. In New Zealand, strategy and purchasing decisions have largely been taken at local levels and the focus of Government has been on the development of standards for syntactical and system interoperability. The Government, through its National Health IT Board, has set a clear direction and vision for the sector and sought to rationalise the architecture and vendor choices made at local levels. The policy is to allow for competition, but from a relatively limited menu of supplier options. In practice, the uptake of IT systems in New Zealand has been strong, in both the hospital and primary sectors. The Government s strategy is to emphasise the need for a high level of integration across the sector, taking a comprehensive approach to ehealth. Universal patient access for all New Zealanders to their summary care record is planned for 214. How does this compare with Europe? Set out below is a brief description of the key elements of each country s strategy and achievements. A more detailed overview can be downloaded from England England embarked on an ambitious plan for ehealth in 22, but progress has been at best mixed and the National Programme for IT (NPfIT) is now in the process of being terminated. The approach was based on a top down contracting model with a small number of very large suppliers. England has now reverted to a standards based interoperability based model. Key points to note include: multi-billion pound ehealth programme achieved variable success national appointments system high penetration of EMR usage in primary care variable use of eprescribing new commitment to patient access to, and updating of, personal EHR. Scotland An ehealth strategy for Scotland was announced in 28, which focuses on integrated care, patient summaries, EHR, eprescribing and telehealth. Good progress is being made and there is a high penetration of EMR systems in primary practice. Key points to note include: decentralised approach to EHR clinical portal being planned wide use of Emergency Care summary eprescribing routine for a number of years, with 9 percent uptake Scottish Centre for Telehealth provides research and implementation leadership no integrated healthcare plan systems implemented. 21 Electronic medical record adoption in New Zealand primary care physician offices, August 21, The Commonwealth Fund, retrieved from: commonwealthfund.org/~/media/files/publications/issue%2brief/21/aug/1434_protti_electronic_med_record_adoption_new_zealand_intl_brief.pdf

16 europe Health White Paper, APRIL Wales In 23, Wales published its paper Informing Healthcare Strategy. A clinical portal is being rolled out across the country and initiatives around bar-coding prescriptions are underway. Primary use of EMR is widespread. Key points to note include: individual health record to provide primary health data to other settings single electronic health record available in secondary care some regional projects for telemedicine lack of integrated care initiatives no integrated healthcare plan systems yet implemented. Northern Ireland Northern Ireland published its Information and Communications Technology Strategy in 28. Its focus is on patient summaries, EHR, eprescribing and telehealth. Key points to note include: pilot for Emergency Care Record electronic prescribing implemented in 28 several telehealth pilots target of 5, telemonitoring patients by 211 no integrated healthcare plan systems yet implemented to date. France The use of an electronic card and the 24 legislation for EHR deployment has seen France take a leadership role in ehealth. Barriers to progress include poor data capture at primary level and the recent reorganisation of the sector into regional providers (Regional Health Authorities or Agences Régionales de Santé). Key points to note include: very low usage of EMR in primary care EHR development a strong focus of Government policy challenge now to integrate a national approach to EHR with regional initiatives eprescribing system in use for about 1 percent of the population rising telehealth usage little progress on integrated care plans. Germany Germany has made relatively slow progress in the domain of ehealth. It has faced security issues with respect to electronic patient cards and very low usage of EMR in primary care. Key points to note include: EHR planned from 23 based on electronic health cards for patients federal/state governance issues have hindered progress 29 data protection review doctor to doctor and other ehealth initiatives planned eprescribing on hold telehealth initiative planned for 211 Denmark Denmark is seen as very much an international leader in the adoption of ehealth. It has implemented a secure, integrated system across the continuum of care and enjoys an excellent uptake of EMR in primary care. However, uptake of the patient portal for clinical purposes is less advanced. Key points to note include: standard approach of one patient one EHR five hospital regions long term interconnection goal national Patient Index eprescription widely adopted personal health portal pharmacy Health Portal widespread use of standards national programme for telemedicine.

17 europe Health White Paper, APRIL The environment What factors have enabled New Zealand to recognise the significance of innovation in both public policy and practical reform within its healthcare system? As a small country, governance is relatively simple. There is only one tier of government and healthcare is funded nationally, planned regionally and delivered locally. New Zealand has an excellent education system, which ranks highly internationally, and has top class medical schools. Perhaps of even more importance, its geographic isolation tends to drive independent thinking and innovation. Other factors have also played their part. A Government committed to providing a universal healthcare system to its citizens acknowledged that it also needed to rationalise investment in that system. The decision to support the free market as a means of encouraging innovation for the benefit of all has delivered results the nation s healthcare system is today recognised by international surveys (OECD, Commonwealth Fund) as being among the best and most costeffective in the world. Moreover, many of the skills and systems that have made it so are available to help other countries and entities struggling to solve their own, similar problems. It is clear that certain policies have helped New Zealand achieve its success. Competition among technology suppliers is encouraged, but the National Health IT Board oversees adherence to the national strategy and vision. Adoption of standards is encouraged and increasingly mandated to facilitate interoperability of technologies. Some of the other foundations supporting New Zealand s success include infrastructural investment, adoption of standards and national leadership. 4.3 The infrastructural elements National Health Index The National Health Index number (NHI) is a unique identifier that is assigned to every person who uses health and disability support services in New Zealand. A person s NHI number is stored on the National Health Index (NHI) along with that person s demographic details. The NHI and associated NHI numbers are used to help with the planning, co-ordination and provision of health and disability support services across New Zealand. The National Health Index (NHI) number is a unique number assigned to a person to help identify them when they use health and disability services. All New Zealand-born children receive their own NHI number at birth. About 95 percent of New Zealand citizens now have their own NHI number. The NHI number is not a health record, nor does it contain clinical information. The New Zealand Health Information Service (NZHIS), which is part of the Ministry of Health, ensures that information is secure and that procedures are in place to prevent unauthorised access. Access to NHI numbers is restricted to health workers authorised by NZHIS and District Health Boards. These include family doctors, nurses, midwives, and hospital specialists. The NHI number identifies individual patients and makes sure they are correctly matched with their health record. Where regional services exist, such as a laboratory service, the family doctor may receive results electronically. An NHI number is included when the results are sent to the patient s doctor. The doctor uses the NHI number to ensure results are associated with the correct patient and are placed on their medical file. Case studies of innovations in New Zealand s healthcare delivery system, and the companies that helped drive them, are set out in Section 6 of this paper.

18 europe Health White Paper, APRIL Health Practitioner Index The Health Practitioner Index (HPI) was introduced in 25. Its principal purpose is to uniquely identify health practitioners and to hold that information in a central, national database for use by the New Zealand health and disability sector. The HPI is a national database holding information to identify health practitioners. The HPI comprises three separate indexes for: practitioner HPI-CPN (Common Person Number, eg 12ABCD) organisation HPI-ORG (eg GA1234) facility HPI-FAC (e.g. FB132) The HPI marks a significant advance for the New Zealand health sector, because: It has established a sound basis for identifying sector participants when communicating electronically with sector agencies Trusted identity and qualification information is made available and can be used by sector agencies to conform to established health information security and privacy guidelines Conformance with the wider New Zealand egovernment guidelines is achieved as HPI technologies will be integrated over the next few years into applications across the sector. The HPI uniquely identifies health practitioners, practitioner organisations (employers) and facilities (the physical address where the healthcare takes place) in three separate indexes. The Ministry of Health provides the computer system and the administration function for the HPI. The Ministry enters into a Data Provision Agreement with each Data Source (Responsible Authority) and Data Access Deed with each Data Consumer. The HPI contains information about practitioners such as identifier, name, contact details, practising status, qualifications, scope of practice and conditions of practice Medical Warnings System Where patients have a significant medical condition such as diabetes, or an allergy to certain medicines, such as an antibiotic, this information may be stored in another system managed by NZHIS, called the Medical Warnings System (MWS). A flag attached to the NHI number points health workers to this information on the MWS. The MWS may speak for patients when they cannot, such as when they are unconscious. The NHI is associated with the Medical Warnings System (MWS), which is designed to warn healthcare providers of any known risk factors that may be important when making clinical decisions about individual patient care. 4.4 Standards The New Zealand Ministry of Health has for many years facilitated and funded the Health Information Standards Organisation (HISO) which supports and promotes the development, understanding and use of fit-for-purpose health information standards. HISO seeks to develop and promulgate health IT standards to enable application and syntactical interoperability. Most New Zealand standards are based on internationally agreed standards, such as HL7 and Snomed, but some local developments have greatly facilitated the uptake of initiatives such as e-referrals, e-discharge summaries and e-lab orders. Standards are developed or adapted through partnerships with clinicians, technology company representatives and policy makers. Increasingly adherence to standards is a key criterion in sourcing software, and a certification process is currently under discussion for key applications.

19 europe Health White Paper, APRIL Leadership The approach taken by New Zealand to IT strategy in the health sector has been to harness the best aspects of the free market by delegating responsibility to health providers while at the same time providing leadership and incentives to ensure an orderly and cohesive uptake of technology investment. This leadership comes primarily from the National Health IT Board (NHITB) and the National Health IT Plan it has authored. In addition, the Board s sponsorship of standards and investment in broadband networks enable and encourage the interconnectivity that is at the core of the national approach. Beyond sponsoring standards, the NHITB selectively invests in and evaluates innovation projects, to flesh out and inform the National Plan. The core of this national strategy is illustrated in the diagram below: FIGURE 7: core elements of New Zealand s national strategy Phase 2 (5 years) Shared care Patient Vitals E-events Care Plans Decision Support Phase 1 (2 years) Clinical Data Repository Medicine Reconciliation GP2GP PRIMARY COMMUNITY Referral Continuum of care Discharge SECONDARY TERTIARY National Specialty Systems E-Prescribing New Zealand s national strategy can be downloaded at Most of the initiatives set out in section 5 are supporting elements to this strategy. Some of them, such as the Shared Care planning, are pilot programmes led and partially funded by the National Health IT Board.

20 europe Health White Paper, APRIL IT at work in New Zealand health 5.1 Introduction There are many examples illustrating how IT has been effectively deployed within the New Zealand health sector. Section 6 of this report contains a number of case studies. This section summarises some key areas of innovation across the sector; it is not comprehensive but rather spotlights big picture components. 5.2 IT in primary practice All primary physicians in New Zealand make extensive use of computer systems. IT helps with administrative tasks such as appointment scheduling, billing, and financial administration, and doctors especially appreciate the ways that IT can support clinical excellence. Most doctors keep their patients medical records on their computer. A consultation will commence with the medical record in front of the doctor and often in view of the patient. The electronic medical record not only simplifies record-keeping, but actively engages patients in their own healthcare and thus boosts treatment success. Doctors access the latest drug information, medication history and test results; they use electronic decision support systems and clinical pathways; they order laboratory tests and prescriptions, make referrals to specialists and receive discharge summaries; they use drawing tools for anatomical references, geocoding for demographic information; they access immunisation records, and link to other relevant files (e.g. digital photos) all via one system. Perhaps nowhere else in the world are clinical systems as much a part of primary care practice as in New Zealand, and this ubiquity is providing a platform for real breakthroughs. If the rate at which clinical data is collected electronically continues apace, the prime objective of New Zealand s national plan will be achieved on schedule in 214. Namely, health IT will ensure that the right clinical data is delivered safely and securely to the right care providers at the right time, across the whole continuum of care. In New Zealand, special incentives have not been necessary to drive the uptake of healthcare IT systems. Other factors have sufficed: The need for practitioners to claim from the Government for part payments for consultations, which requires the supporting evidence (NHI number etc.) and can only be received electronically The availability of integration software, enabling the passing of messages and documents across all parts of the sector A strongly held view by the majority of clinicians that they are able to provide more effective and safer service to patients by using Electronic Medical Records and run their businesses more effectively, thanks to electronic Practice Management Systems. The New Zealand government is now funding a process that will specify requirements for key application areas, starting with Practice Management Systems in primary health. Although the relatively small scale of the New Zealand market suggests that certification (as per the HITECH Act) may not be compulsory in the short term, suppliers are being encouraged to meet the standards that have been set and purchasers are increasingly aware of their power to improve the quality of product offerings.

21 europe Health White Paper, APRIL Integration across the continuum of care The computerisation of primary care practices in New Zealand prompted certain immediate changes: hand-written prescriptions, laboratory orders and secondary referrals were swiftly replaced with computer-generated versions. In the next wave of change, electronic transmission of these and other documents started to become possible. There has been variable progress in each area but it is planned that within the next 2-3 years almost all laboratory orders, prescriptions, referrals and discharge summaries will be transacted electronically across the whole sector. Almost all New Zealand hospitals provide clinical workstations for clinicians to receive patient information from external sources (such as e-referrals) as well as the means to electronically order and receive laboratory tests and review radiology results. There is currently a national programme on eprescribing and dispensing of medications. These clinical systems are also integrated to the hospital administration and financial systems. Already this process of e-enablement is speeding up patient workflow and improving the accuracy and availability of data needed at the point of care. A secondary, but crucial result is the development of regionally-based clinical data repositories (CDRs). These CDRs contain all of the laboratory, imaging and medication records of the patients. Although these do not constitute a full longitudinal Electronic Health Record, they provide most or all of the information needed during a clinical consultation. A simple and pragmatic consent model has been put in place to guard patients confidentiality rights. This seems to be working well, but there is still some debate about full patient and data usage. The most recent development shaping New Zealand s approach to integrated care comes in the form of technology-enabled Shared Care Plans. 5.4 Shared care planning The first trials for Shared Care Plans are now underway in Auckland, New Zealand s largest city. The concept behind Shared Care Planning is to provide support for people, particularly those with chronic conditions, to achieve their best possible health outcomes, by enabling the sharing of goal-orientated care plans agreed upon by the individual, their primary care provider and the multidisciplinary team that interacts with the patient across the continuum of care. The objective is for the care team to be better supported to provide effective communication, collaboration and coordination of services to individual patients. This IT system allows all participants, including the patient and authorised members of their family network, to access an application that develops a personalised care plan from a series of standardised templates. The plan is informed by an associated summary care record which is automatically updated both directly by care team members and indirectly by two way connections with other related systems, such as the patient s GP s Practice Management System. A primary physician develops an initial personalised plan in conjunction with the patient, including such aspects as medication, diet, laboratory test and exercise regimes, from a standard care template related to the patient s condition type(s). Patients may subsequently update this with information from their daily lives, potentially including automatic updates from any tele-monitoring equipment they may be using. Other participants, such as medical specialists or physiotherapists, can also update the plan and data asynchronously. This creates a virtual, real-time team care environment that is focused on an agreed plan and enjoys proactive patient participation. The expectation, currently being investigated during these early trials, is that this change in clinical practice will improve patient outcomes, reducing visits to Accident and Emergency Departments as well as unplanned hospital admissions.