State of EHR in New Zealand

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This is the prezo I used for the EMBC workshop

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  • I was trained as a medical doctor with PhD in Information Systems and a Fellow of the Australasian College of Health Informatics. My main research interests are clinical information modelling, interoperability standards and software maintainability. I lead the openEHR Localisation Program, sit in HL7 New Zealand Board and Executive Committee of Health Informatics Association (HINZ).Based at the University of Auckland, I am using openEHR Archetypes to create computable clinical information models. I have co-authored the national Interoperability Reference Architecture (HISO 10040) underpinned by openEHR I lead the technical evaluation and procurement of major health IT projects and advise the government and industry.
  • I was trained as a medical doctor with PhD in Information Systems and a Fellow of the Australasian College of Health Informatics. My main research interests are clinical information modelling, interoperability standards and software maintainability. I lead the openEHR Localisation Program, sit in HL7 New Zealand Board and Executive Committee of Health Informatics Association (HINZ).Based at the University of Auckland, I am using openEHR Archetypes to create computable clinical information models. I have co-authored the national Interoperability Reference Architecture (HISO 10040) underpinned by openEHR I lead the technical evaluation and procurement of major health IT projects and advise the government and industry.
  • New Zealand is a small nation but with very good profile in healthcare. Health IT has been an important enabler, and key factors for success are: a single tier of government; strongclinical leadership and collaboration amongst stakeholders; and the role played by national leadership groups like the National Health IT Board. New Zealand was among the first countries in the world to establish an unique health identifier for all citizens which gives us the ability to link our health information easily and safely.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 – all supported by health IT.
  • New Zealand, together with Netherlands and Norway displays the highest physician satisfaction rate with practicing medicine
  • This single diagram has been influential in communicating the vision and components of health IT strategy to the Sector.We even have a PhD student who is studying the impact of this single diagram on our progress.It consists of two phases, where we are 2 years into the second phase now.The ultimate aim is to establish “Shared Care” which is effectively a minimally functional longitudinal EHR, not only having static but also care plans. The technical enabler is the Clinical Data Repository, in 5 regions in the country, that stores data from numerous local provider systems.Interoperability among different systems is a necessity and has been recognised adequately in the Plan and during implementation.The link between primary and secondary/tertiary care has been and still is the major goal. We have more success in the primary care in the past but not secondary/tertiary care is picking up.
  • Four groups, all progressing at the same time.Will give details in upcoming slides
  • This is how the Ministry’s e-health programme sees the sector’s information landscapeThere is certain core health information, held nationally for every person – this naturally centres on the NHI as the master for patient demographic informationWhere individuals have special needs, they might have a care plan with input from a multi-disciplinary care team – the sector is working on maternity shared care, Well Child (Plunket etc), and long term conditions shared care records, as prioritiesR-CDRs store objective clinical records such as test results, transfer of care documents, and perhaps also medications listsThese information resources are available to the many types of system used at point-of-service
  • This has been the single most important enabler for New Zealand’s success in health information integration.A person’s NHI number is stored on the National Health Index (NHI) along with that person’s demographic details. NHI is used to help with the planning, coordination and provision of health and disability support services across New Zealand.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.
  • New Zealand is among the first in the use of comprehensive EHR - Practice Management Systems (PMS).These not only help with administration and billing but GPs and nurses actively use PMS during patient encounter.While the adoption of computers is a great challenge elsewhere in NZ most of GPs prefer to give a break if there is any temporary problem with the system. They use it for lab orders and prescription and enter goals and milestones. System can automatically recall patients if necessary. Lab results and discharge summaries come automatically to GPs secure inbox.GP2GP Record Transfer:Currently about 4000 medical records transfers per monthAbout 50% of GPs in the country are using it!
  • These are various screenshots from the most commonly used PMS – MedTech32.It is technologically old and is being replaced by new generation or competitors’ systems
  • One important feature of PMS is that there are standard interfaces so that add-on applications can be added.This is the most commonly used CVD risk assessment and management tool – PREDICT housed at the University of Auckland/NIHI.If the patient meets inclusion criteria, PREDICT is invoked at the end of the GP encounter which prepopulates data from PMS and allows for GP to enter additional data. Using the Framingham based algorithm 5 year risk of CVD events are calculated together with clinician and patient advice. A management plan is printed and given to the patient.Underlying data is aggregated at NIHI and used for research. We can link this rich cohort to national collections, pharmacy dispensing and lab tests.
  • EHR systems in NZ hospitals are not as advanced as the US and other developed countries.Systems are used mainly to manage patient journey and billing. There are also specialist systems and research databases.However the Orion Health’s Concerto clinical portal allows for a single view of all patient data – creating a virtual EHR.Reaching high in the HIMMS EMR adoption scale is now a priority and hospitals have started to procure HIS.
  • Various screens from Orion’s Concerto Clinical Portal (Clinical Workstation)
  • Technically the system works now!Care plan can be shared by team membersConnects primary, secondary and allied healthIntegrated with common health IT systems (e.g. Medtech32, Concerto, SAP)Full shared care functionality available now
  • Screenshot-1: Overview page Recent Activities, Allergies, Prescriptions, Care team, Admissions & Assessments, Current Diagnosis and Tasks; visible/use dependent on user’s roleScreenshot-2: Current Encounter Clinical notes, Measurements, Diagnosis, Prescription (further details down), Assessment, TasksScreenshot-3: Medication List
  • It is important to have a single definition of medicines related information.NZULM is a service providing consistent terminology and linkage to other medicines related services.NZ Medicines Terminology underpins NZULM service and based on the Australian Medicines Terminology. Both are SNOMED derived.Finally the NZ Formulary brings it together and provides crucial knowledge for decision support.All nationally, all free of charge to vendors and users
  • New Zealand ePrescription Service (NZePS): also known as the Community ePrescribing Project, allows GPs to send prescriptions electronically to community. The service comprises an information broker, which can store and forward prescriptions asynchronously using tight security. Although clinical information is not stored on the broker except while the transaction is occurring, it is designed to feed this data to a clinical data repository. NZePS has been trialled and will be progressively rolled-out
  • What standards do we need to reach the 2014 goal?Of these, HISO 10040 is an interim standard (awaiting trial implementation)NIHI is currently reviewing 10041 suite of main clinical information types based on the content model
  • These are the three building blocks – or pillars – of the HISO 10040 series that embodies the central ideas of the Reference Architecture for Interoperability10040.1 is about regional CDRs and transport10040.2 is about a content model for information exchange, shaped by the generic information model provided by CCR, with SNOMED as the default terminology, and openEHR archetypes as the chief means of representation10040.3 is about CDA structured documents as the common currency of exchange – not every single transaction type, but the patient information-laden ones
  • Published by HISO (2012); Part of the Reference Architecture for Interoperability“To create a uniform model of health information to be reused by different eHealth Projects involving HIE”Consistent, Extensible, Interoperable and Future-Proof DataWe will work with Australia and share their Archetype repository as health systems and culture is very similar.
  • Definition of health information in each use case (different CDA documents or using Web services based exchange) comes from the same library.With Archetype specialisation all data collected using definitions of different granularities are semantically compatible.For example a query retrieving all Lab Tests (not specifically HbA1c) will also fetch all specialised versions of Lab Tests.
  • CDA definitions for messaging is not a starting point but an end point.The source of truth for health information definition is with the Content ModelIt is possible to create CDA definitions based on specific use cases using automatic or semi-automatic XSL transforms.
  • Archetypes support multiple languages and terminology bindings
  • R-CDRs – provide the registry and certain XDS-enabled repositoriesLIS, RIS, national systems – load content intoR-CDRsEHR/PHR systems – register content with R-CDRsClinical portals – populate results tree from the registryPMSs, shared care systems – architected as consumers of data services
  • A significant opportunity arises for secondary use in this scheme by the use of a data repository that can natively persist and query standardised datasets. Since all health information in transit in various formats (e.g. HL7) within a standard message (payload) conforms to the Content Model, all data persisted in this repository can safely be linked, aggregated and analysed.
  • NIHI’s big data initiative in healthcare.It is an information infrastructure (or infostructure) to enable collection, validation, storage, querying, linking, reporting of health data from multiple sources in a secure manner. It will enable secondary use of healthcare data and foster public health, health research and educationProof of Concept in progress
  • State of EHR in New Zealand

    1. 1. State of EHR in New Zealand Koray Atalag MD, PhD, FACHI k.atalag@auckland.ac.nz
    2. 2. About National Institute for Health Innovation (NIHI) The University of Auckland Private Bag 92019, Auckland New Zealand Koray Atalag, MD, PhD, FACHI Medical Doctor, PhD Information Systems Fellow of Australasian College of Health Informatics Chair openEHR New Zealand openEHR Localisation Program Leader HL7 New Zealand Board Member Health Informatics New Zealand Executive Member ISO TC215 Working Group Member
    3. 3. New Zealand Quick Facts • Population: 4.5million – (~20% Maori & Pacific) – <30 million sheep >60 million cattle! • GDP (PPP) per Capita: USD 28,800 • Good healthcare, low cost • High IT adoption, good integration • Single health identifier ~20 years • National eHealth strategy and plan – National Health IT Board
    4. 4. NZ Health System • Publicly funded (~77% from taxation) • Ministry of Health and National Health Board • 20 District Health Boards (DHB) – receive public funding, develop regional strategies, operate hospitals and oversee primary care • 60 Primary Health Organisations – groups of practices funded by capitation & fee-for-service • Accident Compensation Corporation – national accident insurance (employer + employee contributions) • Pharmac – Government-funded purchaser of pharmaceuticals • Private Healthcare Sector – providing health insurance and healthcare services, primarily in the area of elective surgery, to about 20% of New Zealanders.
    5. 5. 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 1980 1984 1988 1992 1996 2000 2004 2008 US ($8,233) NOR ($5,388) SWIZ ($5,270) NETH ($5,056) DEN ($4,464) CAN ($4,445) GER ($4,338) FR ($3,974) SWE ($3,758) AUS ($3,670)* UK ($3,433) JPN ($3,035)* NZ ($3,022) Source: OECD Health Data 2012. Average Health Care Spending per Capita, 1980–2010 Adjusted for Differences in Cost of Living 5 Dollars ($US) THE COMMONWEALTH FUND* 2009
    6. 6. Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 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, 2009 (Paris: OECD, Nov. 2009). AUS CAN GER NETH NZ UK US OVERALL RANKING (2010) 3 6 4 1 5 2 7 Quality Care 4 7 5 2 1 3 6 Effective Care 2 7 6 3 5 1 4 Safe Care 6 5 3 1 4 2 7 Coordinated Care 4 5 7 2 1 3 6 Patient-Centered Care 2 5 3 6 1 7 4 Access 6.5 5 3 1 4 2 6.5 Cost-Related Problem 6 3.5 3.5 2 5 1 7 Timeliness of Care 6 7 2 1 3 4 5 Efficiency 2 6 5 3 4 1 7 Equity 4 5 3 1 6 2 7 Long, Healthy, Productive Lives 1 2 3 4 5 6 7 Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290 Country Rankings 1.00–2.33 2.34–4.66 4.67–7.00 Exhibit ES-1. Overall Ranking
    7. 7. 7Pharmaceutical Spending per Capita, 2010 Adjusted for Differences in Cost of Living 983 741 640 634 630 541 510 508 481 474 395 369 331 285 0 100 200 300 400 500 600 700 800 900 1,000 US CAN GER FR JPN* AUS* SWIZ OECD Median NETH SWE NOR UK** DEN NZ * 2009. ** 2008. Source: OECD Health Data 2012. THE COMMONWEALTH FUND Dollars ($US)
    8. 8. 9 99 97 97 96 95 94 72 46 68 37 98 98 97 97 92 88 82 69 67 56 41 0 20 40 60 80 100 NETH NOR NZ UK AUS SWE GER US FR CAN SWIZ 2009 2012 Source: 2009 and 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Percent Doctors’ Use of Electronic Medical Records in Their Practice, 2009 and 2012
    9. 9. 11 55 52 49 49 45 39 38 31 27 22 14 0 20 40 60 80 100 NZ SWE NET SWIZ NOR FRA UK US AUS GER CAN Percent Doctor Can Electronically Exchange Patient Summaries and Test Results with Doctors Outside their Practice Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
    10. 10. eHealth Vision To achieve high quality health care and improve patient safety, by 2014 New Zealanders will have a core set of personal health information available electronically to them and their treatment providers regardless of the setting as they access health services.  Information will be recorded electronically  Personal health information will be available, with appropriate access, across providers  People will be more involved in the collection and use of their personal health information  Providers will have clearly defined roles when collecting, using and sharing health information  Optimise resources (time, facilities and equipment) and focus on the quality healthcare.
    11. 11. National Health IT Plan Enabling an Integrated Healthcare Model
    12. 12. National Health IT Board Programmes eMedications Programme 1. Community E-prescribing Service 2. Inpatient e-prescribing 3. Medicines reconciliation, medication management and administration 4. Universal List of Medicines 5. NZ Formulary National Systems 1. Health Identity (new NHI) 2. Connected Health Network 3. InterRAI for Aged Care 4. Oncology 5. Cardiology Regional Information Platform (DHBs) 1. Clinical Data Repositories/ Workstation 2. Patient Administration Systems 3. Imaging/PACS 4. Clinical support – Labs/Pharms 5. Continuum of care: eReferrals/eDischarges Integrated Care Initiatives 1. Shared Care - Maternity 2. Shared Care - Long-Term Conditions 3. Care/Clinical Pathways 4. Primary Care 5. Well child
    13. 13. National Health Index (NHI) • Unique health identifier used >20 years • All NZ-born children receive NHI at birth • Information stored centrally: • name and address • date of birth • sex & ethnicity • Statistical search algorithms, adaptive • NZ has strict privacy and security laws • System also includes: – Medical Warning System – Health Provider Index (Organisation, person, facility)
    14. 14. (GP) Practice Management Systems • 4 major vendors; one >90% market • Very comprehensive EHR, all GPs really use it • Integrated w/ Labs, ePrescribing, Discharges, secure messaging • Warnings & Reminders, patient recalls • Advanced decision support modules – PREDICT CVD risk prediction tool ~400,000 pts. – Also provides clinician advice & patient guides
    15. 15. MedTech PMS Screenshots
    16. 16. PREDICT CVD Decision Support System
    17. 17. Hospitals • Patient Admin Systems; ADT, billing etc. • LIS, RIS, PACS + clinical systems • Clinical Workstation – integrated view – Orion Health’s Concerto Product – Rhapsody integration engine (Orion) • Orion is rolling out integrated Hospital Information System in most of NZ – (Orion bought Microsoft’s Amalga HIS)
    18. 18. Clinical Workstation
    19. 19. Shared Care Shared care is about caring for patients with high needs in collaboration with other healthcare professionals. Central to shared care is the patient care plan. All team members can access and contribute to the care plan and communicate with each other to provide the best care for the patient. 23
    20. 20. 24 Shared Care System (HSA Global CCMS) Community Pharmacy Emergency DepartmentsOutpatients Inpatients HOME-BASED SERVICES Patient’s home General Practice HML St John COMMUNITY SERVICES Community-based Secondary Services - Falls prevention District nursing Private/ public Allied Health FAMILY MEMBERS CENTRAL SERVICES DHB Planning and Funding LTC Meds Contract Mgrs Aged Care Providers Hospice Palliative care
    21. 21. 11 July 2013 25
    22. 22. CCMS Care Planning 26
    23. 23. Seismic Innovation!
    24. 24. • NZULM includes: – approval status and restrictions for use in NZ – subsidy info and any conditions that apply. • SNOMED based terminology • NZ Formulary – clinically validated medicines information and guidance on best practice – Used for decision support New Zealand Universal List of Medicines (NZULM) and Formulary
    25. 25. NZ ePrescription Service
    26. 26. HISO standards development
    27. 27. HISO 10040 Health Information Exchange 10040.1 R-CDRs XDS 10040.2 CCR SNOMED CT Archetypes 10040.3 Documents CDA
    28. 28. Usage of the Content Model
    29. 29. Creating CDA Payload
    30. 30. Localisation Content definition is language independent
    31. 31. Exploiting Content Model for Secondary Use Single Content Model CDA FHIR HL7 v2/3 EHR Extract UML XSD/XMI PDF Mindmap PAYLOAD System A Data Source A Map To Content Model System B Data Source B Native openEHR Repository Secondary Use Map To Content Model Automated Transforms No Mapping
    32. 32. Shared Health Information Platform (SHIP)
    33. 33. Questions? k.atalag@auckland.ac.nz

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