At some time in our lives, we all end up there. The after hours clinic following a medical event that just won’t wait until morning. On entering the consultation room, you’re faced with a barrage of questions.
The first ones relate to your current episode, and are followed by the more generic inquisition. Any allergies? Vaccinations up to date? On any medications? Generally in good health?
You sit there and diligently give the answers, hoping that you haven’t forgotten some vital fact.
Serial visitors to the A&E or those with long standing medical issues start to have a feeling of déjà vu. Have I not told you this before, and why do I need to tell you again? And what if you are unconscious? Who answers the questions then?
Imagine another scenario. You walk into the consultation room, give some identifying facts, and there on your healthcare professional’s computer screen, is your medical record in its entirety – allergies, medications, test results, the works.
Ian McCrae, Orion Health's CEO, says he can imagine a time, probably in the next five to ten years, where a patient will be able to access everything they need to know about their own and their family's health from a mobile device.
"A mother is going to be able to log on, and there she'll have her records, and the records of her children. The medical record she owns will be in the cloud, and there will be contributions being made to that record all the time from different devices. The cloud will know about the patient's genetic profile, and the cloud will be smart enough to make suggestions to the patient about their health."
To some, what is amazing is not that this could happen in the future, but that it isn’t happening already. The same mother can track her bank account, her phone records, her transactions with government – all through the cloud. So why can’t she track her health?
McCrae says health often lags behind other sectors in its adoption of technology. Some of it is around privacy, some around under-investment in health IT; but also healthcare is just so damned complicated, with a myriad of different organisations – GPs (most of whom are individual businesses), A&E, physio, hospital, ACC, specialists, midwives, social workers, health ministries etc – all needing to be on board to make initiatives work.
Some parts of the country are already benefiting from smart technology. Patients undergoing dialysis in Kaitaia and Kawakawa are visiting satellite units where video conferencing links them in real time to a renal specialist at Whangarei Hospital for monitoring and consultations.
In the Waikato, waiting times for specialists and unnecessary clinic visits are being reduced for patients with suspicious skin lesions using the virtual lesion clinics, with images being sent on to dermatologists rather than the whole person booking a visit.
Central Otago children with Type One diabetes are replacing long car rides into Dunedin every three months with half an hour video consultations from Clyde’s Dunstan Hospital to their specialist in Dunedin city.
The race to innovate
The irony is, New Zealand started out being ahead of the game. The backbone of any health IT system is having a unique identifier for each patient, and New Zealand’s national health index (NHI) number system was introduced way back in 1993, before most other countries in the world.
And for a few years we continued to be early adopters of health IT, says Jodi Mitchell, CEO of health technology company SimplHealth.
“New Zealand was unbelievably innovative in IT. We had GPs with desktops, pharmacies with software and computers running, and the NHI number to uniquely identify each individual. Unfortunately, for a variety of reasons, there has been a lack of strategic investment over time.”
Some of those reasons are political, in terms of our three-year election cycle, and others are due to how the health system works here, with GPs running their own private businesses, and how IT vendors behave.
“It was hard 15 years ago to say what health technology was going to look like – we simply didn’t know. When people have purchased something and are running it, to then change it to a product that is new and cool two years later is just unrealistic from a business perspective. Systemic elements have created what is now a challenging environment.”
While innovation slowed for some years, the February 2011 Canterbury earthquakes were also a catalyst for health IT in that region. Suddenly many people couldn’t be seen by their usual doctor, and patient records were stuck inside inaccessible buildings. An existing plan for an electronic shared record was fast-tracked, and within six months a basic system, HealthOne, was up and running. A pilot for GPs began in November 2011, with the full rollout in August 2012; HealthOne was rolled out to Canterbury community pharmacies in February 2012 and Canterbury community nursing organisation Nurse Maude came on board in December the same year. By 2013, clinicians in the emergency department were able to see all relevant medical information about patients, including medications, allergies, immunisations, recent or chronic illnesses, test results, hospital discharge summaries and previous operations. HealthOne is now a regional system and is used in three DHBs, with the remaining two on track to implement in 2016.
Dr Nigel Millar, chief medical office of the Canterbury DHB, says within days of linking emergency departments into the system, doctors were telling him the information had already revolutionised the way they worked – and the outcomes for patients.
Take the case of a man who arrived at the 24-Hour Surgery with fluid in his lungs. Previously, doctors would have sent him straight to hospital, but now they could see in his records that he’d recently been admitted with the same condition – and what the successful treatment had been. Using the notes, staff were able to keep him out of hospital – and the risks that involves.
“Within a very short timeframe, the shared care records became ‘can’t do without’ information for emergency doctors,” Millar says.
Canterbury was fortunate in that it had just the one main primary healthcare organisation, Pegasus, and the majority of GPs were already using MedTech software.
It’s better living everybody
Another South Island initiative will see the five district health boards setting up a single, shared, patient administration system, called SI PICS (South Island Patient Information Care System).
SI PICS will connect health workers with coordinated, consistent access to a single region-wide solution, with improved quality and safety systems. And patients will have a more streamlined patient journey, with the flow between facilities and services a lot smoother. For example, a patient could visit a clinic in Christchurch, and have a follow-up appointment in Blenheim, without the loss of information.
SI PICS will roll out first in Canterbury, in 2016. It’s set to be in use at every South Island DHB by the end of 2020, when it will manage the continuity of care for the whole South Island population of over one million. It’s expected the system will save the South Island DHBs around $40m over the next 15 years and provide significant improvements in the consistency of services and efficiency of referrals.
There is also a new partnership between Orion Health, Auckland health software company Medtech and US information technology company CSC involving a integrated precision medicine solution for New Zealand that will join hospital level clinical data with primary care data and personal health data.
The initiative quickly gained momentum following the initial announcement in December last year, with the partnership growing to more than 12 leading vendors within two weeks. Vendors Sysmex, SimplHealth, Hewlett Packard Enterprise, IBM, and Microsoft are among those expressing an interest in working together. These companies aim to create a strong national health IT grouping and NZ Inc. brand to improve the health of New Zealanders.
Expressions of interest have also come from Atlantis Healthcare Limited, Callaghan Innovation, Green Cross Health, Healthpoint Limited, Incisive Software, Konnect NET, MKM Health, NZ Trade and Enterprise, Pathway Navigator Limited.
A new self-help
Customer need and the delivering of health outcomes for consumers will define the level and extent of the partnership agreements and how they are to be structured. Collaboration is already underway, with Orion Health, Medtech, and CSC kicking off working sessions last December, with potential project areas including the collective intent to work together to resolve delays across existing projects, a better connected community and secondary care, and the enriching of patient portals for the ultimate healthcare experience.
Compass Health, a primary health provider in the Wellington, Porirua, Kapiti and Wairarapa area already has a patient portal platform – ManageMyHealth – in operation. Developed by Kiwi company MedTech Global, patients can view their medical records, request repeat prescriptions, book appointments, view test results, send messages to their GP, receive notifications and update their personal details. With the mobile app patients can remain connected to their patient portal on their mobile device – Apple or Android – allowing for added flexibility, convenience and efficiency.
In the Capital and Coast DHB and Wairarapa DHB there are almost 8,500 patients registered for a patient portal via ManageMyHealth, with numbers increasing at a steady rate. As of September 2015, nationwide more than 93,000 people from 271 practices could use a patient portal.
Think of patient portals as “internet banking for your health”, says Wellington GP Richard Medlicott, an early adopter of ManageMyHealth portal and medical director of telehealth provider Medibank Health Solutions.
Medlicott says that for many years New Zealand was decades ahead of other countries in the IT game due to our early computerisation. Medlicott’s own father, a GP, was an early adopter of electronic health records in the 1980s. But we have fallen behind, he says.
"A lot of the computerisation was built around individual practices with individual databases, and hospital systems that were all different. We've never had that one big bang, one-stop solution. Yet we have delivered a hell of a lot off the smell of an oily rag, and we are still doing that."
There's a lot of complacency in medicine, says Medlicott, with some in the sector not prepared for the changes that are about to arrive. Healthcare technology is being dragged into 2001, he says, with celebrations around the simplest of tasks, such as being able to email your GP directly.
"It's an opportunity for medicine. I think that doctors who can't see that change is coming probably need a bit of a reality check, because it's coming faster than you think."
Medlicott says technology has the potential to radically change healthcare delivery.
“If the cloud knows that you have diabetes, knows what your blood pressure is, knows what your cholesterol levels are, knows your smoking status and knows what your blood sugar levels are, then technology is going to be able to adjust your insulin for you. Or if you're feeding it regular blood pressure recordings, it will be able to use algorithms to adjust your blood pressure medication. This sort of technology will allow GPs to get on and do some more of the complex stuff, around diagnosis and patient management.”
But he admits that there is a fair way to go in the adoption of shared care records and patient portals, and also in changing the mindset of GPs.
“There is a lot to sort out, but as consumers become more aware that there are more possibilities they will start asking for them. We might find there’s going to be more consumer pressure coming on. Some doctors don’t see patient portals as a competitive advantage yet. But portals enhance my relationship with my patients. It doesn’t replace the relationship, it makes it stronger.”
It’s about empowering the patient, Medlicott says, and he finds that the patients appreciate that.
The advent of the internet – and ‘Dr Google’ – has shifted the power of knowledge from the GP into the hands of the patient. So it would seem a natural progression that patients, who have a world of medical knowledge—even if plenty of it is of dubious quality—at their fingertips, would want to play a bigger part in accessing their own health data.
“It’s inherently a good idea to have an empowered patient who has greater knowledge,” Medlicott says. “To some extent, I think that we should be saying to GPs on the one hand patient portals will improve the efficiency of your practice, and on the other hand, appeal to these GPs’ sense of ethics, by enabling them to empower their patients.”
Another example of technology empowering people is a partnership between health technology company SimplHealth and primary provider Green Cross Health to set up an online information and consent system for vaccines like flu, whooping cough, shingles and meningococcal disease. In 2014, over 14,000 consumers chose to have their flu vaccine at a pharmacy.
The process is simple. Consumers fill out an online pre-vaccination checklist to confirm their eligibility, and complete the electronic consent form. They then visit the pharmacy – without the need for an appointment — where the pharmacist conducts the final consent process and vaccine administration. Everyone wins, with consumers having the convenience of getting their injection at a local pharmacy, and pharmacists reducing the time spent on documentation.
SimplHealth has also worked with the Ministry of Health to develop the New Zealand ePrescription Service (NZePS), where a barcode on each printed script retrieves prescribing information from a central repository without the need for duplicate typing.
The NZePS is not only eliminating errors, it's also generating a goldmine of potentially useful data, says SimplHealth CEO Jodi Mitchell. With e-prescribing expected to generate 20 million prescriptions annually for 60 million different medications, there’s the opportunity to find out more about patients who don’t stay on their medication, for example, and put into place programmes to support them.
Take Murray for example, a fictitious teenager with Crohn’s disease, who needs to take his medication every two weeks by injection but often forgets to pick up his drugs. Mitchell says it wouldn’t be hard for a prescription monitoring tool to see that Murray has forgotten to have his script filled, prompting a nurse to send a reminder text.
So why can’t Murray get his hands on the technology he needs right now?
To begin with, the health sector in New Zealand is complex and fragmented, says Mitchell.
"Making any shift in that complex environment takes a long time… It's more about the change management rather than the technology itself. Technology is the enabler."
Mitchell says the development of the National Health IT plan means things are starting to happen in a national sense. However, the current environment is not set up for the 'big bang' approach, she says.
“What has happened is that over many years we now have systems that we would call legacy, and the reason is that they haven't been invested in. There are no big bang answers to replace them, and we are left in a quasi world of we all know we need a new system, but we can't afford the change."
It is important that industry – and importantly consumers – start pushing change, Mitchell says.
"We can create a demand for new healthcare innovation by talking to the sector and consumers directly, saying to them 'imagine if you had this product or service, wouldn't it be fantastic!' It's about getting everyone excited, and then the pressure is on for something to happen."
Mitchell says that doing things differently requires transformation. She says there could be the ‘uberisation’ of healthcare, where clinicians are called and arrive to give their service in a workplace consultation room. Or every Kiwi could be given a health and fitness tracker from the Ministry of Health to record and deliver health information back to their own digital heathcare record.
In Australia, the National Home Doctor Service brings back one of the conveniences of yesteryear – the home visit. Transformed by technology and the adoption of mobile phones, the after hours service uses an app to deliver patients with important but not urgent issues an on-call doctor who will visit their home to provide on-the-spot healthcare. So it’s not too much of a stretch to see this kind of service offered to the workplace environs.
A key part of the health IT picture is keeping conversations going between significant players in the industry, says Kate Reid, who recently moved from patient support company Atlantis Healthcare (where she was New Zealand managing director) to being the director of strategy and partnerships at Orion Health. Reid says getting different healthcare organisations working together is critical, but it’s not easy in a fragmented and competitive environment.
“Even within the competitive space there is a lot of room for collaborative solutions. What I find interesting is that we are all willing to work together, but often when we put those solutions forward to funders, they aren't interested in having a multi-solution, big vision project. They tend to chop it up and put it back into the silo funding bucket that they use for procuring."
Reid says she has seen a lot of pilot trials being funded that do not have much of a vision for the longer term.
“People need to ask ‘if we're successful, what are we going to do? How are we going to roll it out? What does the infrastructure look like? Who are the partners involved? How would it be bought if it was going to be rolled out nationally?’ We find that quite often there is a huge opportunity to do something much bigger than what is being procured, and which would have a far greater impact on overall New Zealand's people's health. Often the projects going through the procurement process are just a slither of what's possible.”
Reid says the tender system, which can at times involve months of negotiation and dozens of meetings, isn’t conducive to a big-picture, collaborative approach.
“The competition is fierce, the procurement processes are slow, and the prize is often a pilot that never has a long term vision of how it would ever be scaled to a national solution, should it be successful. We [the vendors] understand that the size of the prize is much bigger for these projects, but if you don’t get it – and usually two of the three companies won’t – then as a small New Zealand organisation it can be crippling.”
The magic number
One of the areas where health IT could really deliver benefits to New Zealanders (and save money for Government) is in disease prevention and early intervention, Reid says. But different organisations have to work together.
“There are so many funded contracts for different things, like vaccinations, before school checks, dental hygiene, and then screening and diagnostic funding, but none of them are co-ordinated or connected, and none of the data is shared. Each interaction with a health professional is a touch point and an opportunity for intervention.
She says the NHI number is a hugely valuable thing to leverage to track a person’s health through their lifetime and target interventions or support when a person needs it.
“But we don’t do that yet. We put all the money into the pointy end of health, when people are already quite sick. What some of us are saying is ‘hang on – where’s the funding in prevention? We’ve got innovations and technology that could be reaching at-risk people right now. But we don’t have the infrastructure that allows us to shift the funding from picking up the patient at the bottom of the cliff, to treating them early.’”
Innovation vs continuous improvement
Scott Arrol is CEO of New Zealand Health IT, the national industry body. He says advances in the health IT sector are coming – they’re just not arriving as fast as everybody would like. Arrol wants to see New Zealand recognised as an international leader in the provision of smart technology-based solutions for better health. He says innovation won’t happen overnight – but as consumers start to demand change and health practitioners get more comfortable with new systems, it will happen.
The implementation of patient portals, for example, was initially hindered as both practitioners and systems adapted to a new approach.
“It’s also about the business model. How do you fund the doctor that is now answering emails for an hour, instead of seeing patients?
“GPs are like any sole business operator. There will be early adopters who are willing to push the boundaries and take the risks, and there will be others who will ask if they are in the position to try it yet, and may want to see how it works for everyone else first."
But as GPs get more confident, as consumers demand better solutions, and with so much at stake, both individually and, with the amount of money being spent on healthcare, collectively, he and many others believe the pace of change will increase.