A coherent future: aligning health service and ICT trends HINZ Seminar April 2009

Presentation outline Why the health system needs to re-orient Long Term System Framework and emerging models of care Role of ICT in re-orienting the health system Ministry of Health’s priority areas in health ICT Critical enablers for faster progress Work currently under way

Why the health system needs to re-orient

Long Term System Framework and emerging models of care

Role of ICT in re-orienting the health system

Ministry of Health’s priority areas in health ICT

Critical enablers for faster progress

Work currently under way

The New Zealand health system is experiencing a number of pressures, which will intensify Current pressures Workforce shortages at all levels Service failures Cost growth Safety and quality Health Targets Inequity of access Decisions in the national interest Pressures will intensify in the future: Population growth, redistribution and ageing; Increasing risk and prevalence of long term conditions; Health inequalities; Managing within an affordable funding path; Effective utilisation of the available workforce; Effective application of technological advances; and Rising consumer expectations Other drivers: Not a system: evaluation of the health reforms Develop system leadership, innovation spread and strategic planning: Ministry review Lack of collaboration across DHB boundaries: Health & Disability Commissioner reports Productivity imperative Safety & quality agenda

Current pressures

Workforce shortages at all levels

Service failures

Cost growth

Safety and quality

Health Targets

Inequity of access

Decisions in the national interest

Pressures will intensify in the future:

Population growth, redistribution and ageing;

Increasing risk and prevalence of long term conditions;

Health inequalities;

Managing within an affordable funding path;

Effective utilisation of the available workforce;

Effective application of technological advances; and

Rising consumer expectations

Other drivers:

Not a system: evaluation of the health reforms

Develop system leadership, innovation spread and strategic planning: Ministry review

Lack of collaboration across DHB boundaries: Health & Disability Commissioner reports

Productivity imperative

Safety & quality agenda

Long Term System Framework as the system response The challenges - and the solutions - are complex and inter-linked LTSF is a Ministry-led response Focus on system performance, responsiveness and sustainability A structured, co-ordinated, multi-year work programme The new Minister is supportive, with adjustments to reflect the new Government’s policy priorities Areas of close linkage with Ministerial Review Group

The challenges - and the solutions - are complex and inter-linked

LTSF is a Ministry-led response

Focus on system performance, responsiveness and sustainability

A structured, co-ordinated, multi-year work programme

The new Minister is supportive, with adjustments to reflect the new Government’s policy priorities

Areas of close linkage with Ministerial Review Group

Current LTSF focus Vulnerable services assessment and mitigation of service failure risks focus on next 18 months while longer term service planning develops Clinical networks a structure to support clinical engagement and leadership, performance and quality government policy priority networks at regional and national levels build on NZ experience with cancer and mental health immediate national priorities: cardiac surgery, genetics, maternal fetal medicine, paediatric subspecialties draft policy framework being developed for discussion with Ministerial Group

Vulnerable services

assessment and mitigation of service failure risks

focus on next 18 months while longer term service planning develops

Clinical networks

a structure to support clinical engagement and leadership, performance and quality

government policy priority

networks at regional and national levels

build on NZ experience with cancer and mental health

immediate national priorities: cardiac surgery, genetics, maternal fetal medicine, paediatric subspecialties

draft policy framework being developed for discussion with Ministerial Group

Current LTSF focus cont’d Service planning defining district, regional and national level responsibilities developing planning methodologies, tools and capabilities strong fit with networks and decision making supporting emerging DHB regional service planning, and existing national tertiary planning Decision making what key decisions will need to be made in the system over the next 5-10 years? equity of access, affordability, vulnerability, quality & safety, new technologies and services, workforce, ICT accountability and decision structures currently decentralised to individual DHBs most of the key future decisions will need to be made across DHB boundaries likely rebalancing of decisions towards regions, and to the centre important role for clinical leadership at regional and national levels linkage with shared services for backroom functions, and aggregation of P & F options being explored with the Ministerial Group

Service planning

defining district, regional and national level responsibilities

developing planning methodologies, tools and capabilities

strong fit with networks and decision making

supporting emerging DHB regional service planning, and existing national tertiary planning

Decision making

what key decisions will need to be made in the system over the next 5-10 years?

equity of access, affordability, vulnerability, quality & safety, new technologies and services, workforce, ICT

accountability and decision structures currently decentralised to individual DHBs

most of the key future decisions will need to be made across DHB boundaries

likely rebalancing of decisions towards regions, and to the centre

important role for clinical leadership at regional and national levels

linkage with shared services for backroom functions, and aggregation of P & F

options being explored with the Ministerial Group

Current focus cont’d Engaging the community and health professionals communications strategy to build awareness of challenges and trends provide context for specific change proposals provide opportunity to shape the future system being scoped in discussion with National Health Committee

Engaging the community and health professionals

communications strategy to build awareness of challenges and trends

provide context for specific change proposals

provide opportunity to shape the future system

being scoped in discussion with National Health Committee

Longer term work programme Seven response areas identified for co-ordinated response through the LTSF : long term service planning quality, safety and innovation new models of care performance leadership and decision making workforce information systems Key elements of the LTSF work programme from 09/10 will be defined through Ministry SOI process and with DHB CEOs

Seven response areas identified for co-ordinated response through the LTSF :

long term service planning

quality, safety and innovation

new models of care

performance

leadership and decision making

workforce

information systems

Key elements of the LTSF work programme from 09/10 will be defined through Ministry SOI process and with DHB CEOs

New models of care Review of trends in models of care and service configuration: Acute secondary and tertiary inpatient services will consolidate into a smaller number of centres Smaller district hospitals will use clustering, regional services and networks to expand their critical mass Services will shift between professional groups Services will shift between settings: from tertiary to secondary, from there to primary and community, and into the home Primary care will have greater role in prevention, delivery of traditionally secondary services, and improved access to specialist diagnostic testing Increase in integration and self management will be enabled by information technology What will the cost impacts be? How will change be managed? What does this mean for ICT development?

Review of trends in models of care and service configuration:

Acute secondary and tertiary inpatient services will consolidate into a smaller number of centres

Smaller district hospitals will use clustering, regional services and networks to expand their critical mass

Services will shift between professional groups

Services will shift between settings: from tertiary to secondary, from there to primary and community, and into the home

Primary care will have greater role in prevention, delivery of traditionally secondary services, and improved access to specialist diagnostic testing

Increase in integration and self management will be enabled by information technology

What will the cost impacts be?

How will change be managed?

What does this mean for ICT development?

Direction from the new Government “ It will be critical to re-orient the health service in a way that fosters quality, is patient-centred and provider-friendly.” Hon Tony Ryall Minister of Health February 2009

“ It will be critical to re-orient the health service in a way that fosters quality, is patient-centred and provider-friendly.”

Hon Tony Ryall

Minister of Health

February 2009

Goal of a nationwide Health ICT effort Develop a sustainable and effective information management and technology environment… that stimulates, enables and supports… re-orienting the health system in a way that fosters quality is person-centred is provider-friendly increases productivity of the system as a whole

Develop a sustainable and effective information management and technology environment…

that stimulates, enables and supports…

re-orienting the health system in a way that

fosters quality

is person-centred

is provider-friendly

increases productivity of the system as a whole

Person-centred Services organised around the needs of each person and family/whānau Information systems and processes centred on the person The right care can be provided by the right professional/provider at the right place and the right time Person/citizen is a participant (‘co-producer’) in the health care process

Services organised around the needs of each person and family/whānau

Information systems and processes centred on the person

The right care can be provided by the right professional/provider at the right place and the right time

Person/citizen is a participant (‘co-producer’) in the health care process

Provider friendly Simple, automated processes, where ‘compliance costs’ for providers are minimised Providers only required to collect and report information that really matters Clinical delivery tasks are made easier and safer through the use of supportive technologies (such as clinical decision support systems) Clinical networking is made easy

Simple, automated processes, where ‘compliance costs’ for providers are minimised

Providers only required to collect and report information that really matters

Clinical delivery tasks are made easier and safer through the use of supportive technologies (such as clinical decision support systems)

Clinical networking is made easy

Information Management Principles (NIHI, 2008) Health information should be recorded in a form that allows all relevant actors to be able to trust that information where appropriate Health information must always identify source and method of derivation Health information should be encoded to international standards wherever practical Primacy of patient safety All individual health information will be made available to all clinicians engaged in care of a patient (subject to audit trails)

Health information should be recorded in a form that allows all relevant actors to be able to trust that information where appropriate

Health information must always identify source and method of derivation

Health information should be encoded to international standards wherever practical

Primacy of patient safety

All individual health information will be made available to all clinicians engaged in care of a patient (subject to audit trails)

Information Management Principles cont’d Health information of all individuals will be shared in privacy-protected form to support healthcare quality improvement Statutory adherence People can access their own health information People can contribute to their own health record People can define additional access rights on their health information for other people (e.g. family members) People can review who has accessed their health information and have a clear and effective means of directing queries concerning such access

Health information of all individuals will be shared in privacy-protected form to support healthcare quality improvement

Statutory adherence

People can access their own health information

People can contribute to their own health record

People can define additional access rights on their health information for other people (e.g. family members)

People can review who has accessed their health information and have a clear and effective means of directing queries concerning such access

Current state evidence (NZ) ‘ Connected Health’ quantitative survey (2008, to be published) found: 79% of surveyed clinicians agreed that better access to electronic healthcare information held by other organisations could improve the way they provide health services 48% of surveyed clinicians were unable to find the electronic information they needed from other organisations at least once a day Among DHB employed clinicians, this number rises to 75% nearly 15% report they are unable to find this information more than 10 times every day

‘ Connected Health’ quantitative survey (2008, to be published) found:

79% of surveyed clinicians agreed that better access to electronic healthcare information held by other organisations could improve the way they provide health services

48% of surveyed clinicians were unable to find the electronic information they needed from other organisations at least once a day

Among DHB employed clinicians, this number rises to 75%

nearly 15% report they are unable to find this information more than 10 times every day

Current state evidence (NZ) cont’d ‘ Connected Health’ quantitative survey also found: Surveyed clinicians wanted electronic access to: Patient medication information 68% Diagnostic test results 66% Discharge summaries 61% Clinical guidelines 57% Wanted day-to-day tasks handled electronically: Diagnostic test results 47% Discharge summaries 44% Patient medication information 42% Patient referrals 34% 85% of clinicians strongly agreed that having improved e-access to health information would Improve coordination of care between practitioners Help achieve better outcomes for health organisations

‘ Connected Health’ quantitative survey also found:

Surveyed clinicians wanted electronic access to:

Patient medication information 68%

Diagnostic test results 66%

Discharge summaries 61%

Clinical guidelines 57%

Wanted day-to-day tasks handled electronically:

Diagnostic test results 47%

Discharge summaries 44%

Patient medication information 42%

Patient referrals 34%

85% of clinicians strongly agreed that having improved e-access to health information would

Improve coordination of care between practitioners

Help achieve better outcomes for health organisations

Emerging evidence in favour of EHR outcomes Amarasigham, R. et al. (2009). Clinical information technologies and inpatient outcomes. Archives of Internal Medicine, 169, 2: In hospitals where more doctors used computerised data, there were 16% fewer medical complications than in hospitals where less computerised data was used More computerised hospitals also tended to have lower costs because medical complications can add dramatically to the cost of hospitalisation The Commonwealth Fund (In-the–Literature, January 2009): 31% of primary care physicians with high IT capability and 28% of those with medium IT capacity reported their ability to provide quality medical care had improved over the past five years By contrast, just 22% of those with low IT capability reported similar views

Amarasigham, R. et al. (2009). Clinical information technologies and inpatient outcomes. Archives of Internal Medicine, 169, 2:

In hospitals where more doctors used computerised data, there were 16% fewer medical complications than in hospitals where less computerised data was used

More computerised hospitals also tended to have lower costs because medical complications can add dramatically to the cost of hospitalisation

The Commonwealth Fund (In-the–Literature, January 2009):

31% of primary care physicians with high IT capability and 28% of those with medium IT capacity reported their ability to provide quality medical care had improved over the past five years

By contrast, just 22% of those with low IT capability reported similar views

Ministry of Health priority areas Provide better information for the public Provide on-line directories of providers and guidance on service options Improve the use of national data collections Foster development of personal health ‘portals’ Ensure smarter investment in information technology Provide a national ‘blueprint’ for health information systems Develop a common decision-making process Accelerate progress through collaboration and sharing Strengthen the national health information infrastructure Strengthen identity management (NHI, HPI) Provide a ‘core clinical record’ capability for safety and continuity of care Provide facilities for finding and sharing information nationally Simplify agreement, payment and reporting systems Rationalise service agreements Automate administrative and payment processes Make performance monitoring and reporting meaningful

Provide better information for the public

Provide on-line directories of providers and guidance on service options

Improve the use of national data collections

Foster development of personal health ‘portals’

Ensure smarter investment in information technology

Provide a national ‘blueprint’ for health information systems

Develop a common decision-making process

Accelerate progress through collaboration and sharing

Strengthen the national health information infrastructure

Strengthen identity management (NHI, HPI)

Provide a ‘core clinical record’ capability for safety and continuity of care

Provide facilities for finding and sharing information nationally

Simplify agreement, payment and reporting systems

Rationalise service agreements

Automate administrative and payment processes

Make performance monitoring and reporting meaningful

Accelerating progress - critical enablers National health information architecture National health information infrastructure Shared services Spreading innovations Community dialogue on safe sharing of health information Common decision making framework

National health information architecture

National health information infrastructure

Shared services

Spreading innovations

Community dialogue on safe sharing of health information

Common decision making framework

National health information architecture An overarching architecture for the New Zealand health system – developed jointly with DHBs, PHOs, NGOs, private providers Describes how business processes, systems, information components and technical standards will combine and work together Provides a context for the development of enterprise architectures at organisational levels Ensures alignment and re-usability of artefacts Enables smarter IT investment decisions It is supported by: A set of collaborative tools A common repository A joint governance mechanism

An overarching architecture for the New Zealand health system – developed jointly with DHBs, PHOs, NGOs, private providers

Describes how business processes, systems, information components and technical standards will combine and work together

Provides a context for the development of enterprise architectures at organisational levels

Ensures alignment and re-usability of artefacts

Enables smarter IT investment decisions

It is supported by:

A set of collaborative tools

A common repository

A joint governance mechanism

Health System Architecture

National health information infrastructure Provide a nationwide coverage Provide a platform for regional and local developments Provide better information to the public Support collaboration and clinical networking Examples: National directories (NHI, HPI) ‘ Core clinical record’ (replacing the Medical Warning System)  clinicians to define ‘core clinical data set’ first Data warehousing, analysis and reporting (focus on quality improvement) - includes public reporting of provider performance ‘ Secure portal’ – collaborative on-line environment supporting communities of interest (eg, clinical networks)

Provide a nationwide coverage

Provide a platform for regional and local developments

Provide better information to the public

Support collaboration and clinical networking

Examples:

National directories (NHI, HPI)

‘ Core clinical record’ (replacing the Medical Warning System)  clinicians to define ‘core clinical data set’ first

Data warehousing, analysis and reporting (focus on quality improvement)

- includes public reporting of provider performance

‘ Secure portal’ – collaborative on-line environment supporting communities of interest (eg, clinical networks)

Safe sharing of health information A comprehensive stakeholder and community dialogue programme which will: inform / educate the community and the policy makers (two-way communication) canvass a vision of a person-centred health information environment enable the identification and debate of key issues discuss approaches to difficult balancing decisions (eg, safety vs privacy; individual vs common good) clarify the roles, rights and responsibilities of people and their health providers in respect of health information “ What should I as a New Zealander expect the health system to know about me in order to provide me the health services I need, safely?” Appropriate community and clinical representation and leadership will be critical

A comprehensive stakeholder and community dialogue programme which will:

inform / educate the community and the policy makers (two-way communication)

canvass a vision of a person-centred health information environment

enable the identification and debate of key issues

discuss approaches to difficult balancing decisions (eg, safety vs privacy; individual vs common good)

clarify the roles, rights and responsibilities of people and their health providers in respect of health information

“ What should I as a New Zealander expect the health system to know about me in order to provide me the health services I need, safely?”

Appropriate community and clinical representation and leadership will be critical

Work in progress Directional content July 2009 and ongoing In conjunction with regional planning processes Collaborative on-line space National fora and sector-wide engagement Architecture July 2009 and ongoing In conjunction with DHB, PHO, IPA, NGO, clinical and governance experts Shared on-line repository Infrastructure 2009-2011 Building on previous NSDP work Refocusing and clinical leadership Initial focus on eEvents (GP-to-GP, eReferrals, MWS) Working with the Ministry of Economic Development on maximising benefits to health of the Government’s broadband investment strategy Safe sharing June - Dec 2009 Subject to Minister’s sign-off

Directional content July 2009 and ongoing

In conjunction with regional planning processes

Collaborative on-line space

National fora and sector-wide engagement

Architecture July 2009 and ongoing

In conjunction with DHB, PHO, IPA, NGO, clinical and governance experts

Shared on-line repository

Infrastructure 2009-2011

Building on previous NSDP work

Refocusing and clinical leadership

Initial focus on eEvents (GP-to-GP, eReferrals, MWS)

Working with the Ministry of Economic Development on maximising benefits to health of the Government’s broadband investment strategy

Safe sharing June - Dec 2009

Subject to Minister’s sign-off