In the third of a series of articles looking at the recently released Australian Digital Health Strategy, NZHIT investigates what lessons can be learned for New Zealand as it develops its own national strategy and Electronic Health Record.
New Zealand’s Ministry of Health is in the midst of creating a national Digital Health Strategy to guide investment in health technology over the next four years.
Key to this strategy will be nurturing an environment in which industry can innovate and work with healthcare providers to develop digital services that improve patient care.
But while encouraging innovation is a laudable goal, how can government go about actually achieving it?
The importance of industry
Tom Bowden is director-industry relationships at health system integrator, HealthLink Ltd. With 11,500 client sites across the country, Australia is the company’s biggest market and Bowden is also deputy president of Australia’s Medical Software Industry Association.
He says the key good thing about the Australian Digital Health Agency strategy is that it recognises the importance of partnering with industry.
“We do have a lot to do with them and direct link-ups with (the ADHA) all the time. It’s quite a dynamic environment and industry is valued,” he tells NZHIT.
He says the key area where governments should provide leadership is on the development of standards.
“If you want innovation and transformation you need to set clear guidelines and rules,” says Bowden. “But a dynamic well-funded industry will only occur if the government takes its sticky beak out of it.”
Margie Peat is managing director at HealthSoft, developer of pharmacy dispensing software RxOne to pharmacies across New Zealand and Australia.
She also argues that the key to encouraging innovation is to treat industry as a partner.
“We have been involved in a lot of projects with the New Zealand government over the years and where it’s worked best is where it’s a true partnership,” says Peat.
“Governments by their nature can be very cumbersome. Industry is agile and can move much faster, so it’s a delicate balance,” she adds.
“You don’t want to be tied down too much with hard specifications for something that’s a big project, because then you won’t get innovation. Rather government should describe the ideal outcome and industry can say how they might make that happen.”
She says there are pockets of great innovation in New Zealand and these should be expanded upon.
“An issue here is that government has tried to compete with industry and it’s just not their place to do that,” says Peat.
“They shouldn’t be doing things already being done or that could be done better by industry.”
A distorted market?
Lorraine Pyefinch, chief relationship officer at GP clinical management software supplier Best Practice Software, agrees that government competition in the Kiwi health IT market stifles innovation.
“We want to be a partner and achieve the goals the government and the country want, but the government needs to ‘get out of the kitchen’,” she says.
“By all means set the standards, frameworks and goals, but as a vendor I want freedom to innovate in a really healthy competitive market-driven environment, not manipulated by government.”
A common complaint from industry in New Zealand is that the government ends up creating new competitors and Bowden believes that this is creating a distorted marketplace.
“I’m largely disillusioned by how it’s going in New Zealand, largely because for whatever reason lots of government agencies are getting into IT services and competing with local companies,” he says.
“I have heard people in New Zealand say they wouldn’t set up IT in healthcare because government funding can be used to compete with it and copy it.”
Some history on EHRs
Alongside its work to develop a Digital Health Strategy, the Ministry of Health is also working on an Electronic Health Record business case.
An indicative business case for this programme is going through the Treasury Better Business Case Process. Once this is approved, the MoH will produce a Detailed Business Case, then go through a procurement process and contract award.
The Ministry recently released a Request for Information for the EHR business case project and received 53 responses. These are being reviewed and a summary report will be released soon.
The Australian version of the EHR project is called My Health Record and the ADHA strategy promises the delivery of an MHR to every Australian by 2018 unless they choose not to have one. The Australian government has also committed more than $300Million to its national expansion.
Pyefinch explains how My Health Record started life as the Personally Controlled Electronic Health Record, which “took everyone down a very expensive road, but didn’t achieve much at all.”
She says in its initial incarnation, it was “poorly designed and badly implemented: many mistakes were made, resources wasted and opportunities wasted because it got to the point where people didn’t understand what it was supposed to be doing.”
Ultimately the PCEHR was implemented, but barely used.
The ‘Royle’ review of the implementation identified challenges with the registration process linked to the opt-in nature of the system, the limited amount of clinically usable information, inadequate governance arrangements and the usability of the system.
Given that it has cost more than $1Billion to develop, “they are under a considerable amount of pressure to deliver value from the investment made in Australia so far,” adds Pyefinch.
A central point of truth?
Pyefinch believes a centralised health record could be become a piece of key infrastructure that the government can use to measure and report and plan services, as well as providing secondary opportunities such as using data for research.
However, the fact that the information in MHR is curated by the patient themselves could be problematic, as it may not give the whole picture of a patient’s care.
“It will only contain items that the patient wishes to share with others, so from a clinician’s point of view there’s a criticism about the value of that.”
She gave the example of a psychiatric patient who chooses not to share any of their mental health information.
“The government – and in New Zealand too - has to be upfront about what they want it for and why they want it as to assume it’s a central point of truth about a person’s healthcare is not correct,” she says.
Bowden agrees that an ongoing issue in Australia is a lack of clarity about what MHR actually is.
“Some people say it’s the answer to everything and some say it’s the answer to nothing, even within the ADHA there’s a total lack of clarity about what it is,” he says.
“The EHR in NZ could be a good thing, but if we don’t learn the lessons from history in the UK and elsewhere it could be a real distraction.
“In Australia, it’s been a massive distraction. From when it first started until now, we are only just coming out of a time when almost nothing else occurred and the health record project has gone badly.”
Lessons for New Zealand
HealthSoft has just integrated with My Health Record, which Peat describes as a “bit of a process.
“One of the issues has been that while there’s a lot of documentation, it’s very hard to see at a glance what process you need to go through to become accredited for it,” she explains.
She says clear simple documentation for companies wanting to integrate with national systems such as MHR is essential to encourage industry to get involved.
“In New Zealand, it would be great to have a flowchart of how you go about becoming accredited (to the new Electronic Health Record) if that’s what we will need to do,” Peat says.
Peat believes New Zealand should strive to keep things simple and work closely with industry as it develops its approach to an EHR.
“The main thing in Australia is that it’s taken a long time to get to this point with MHR and the biggest mistake with them is they tried to make it a one-size-fits-all and they tried to do the whole thing themselves,” she says.
The push also needs to come from customers, as if they are not interested in using a national electronic health record, then integration will not be a priority.
In Australia, pharmacy partners such as HealthSoft were offered financial incentives to connect with MHR within a certain timeframe.
“It does motivate partners to get involved as otherwise something like that could easily be pushed out. We would have left MHR a lot longer had we not had incentives to get going,” she says.
Pyefinch says the Australian method of incentivising GPs to create MHRs for their patients could also be duplicated in New Zealand, as the Royle review identified the lack of financial assistance as a possible reason for uptake being slow.
She was also pleased to see the ADHA strategy make the MHR an opt-out care record, meaning people will automatically have one unless they choose not to.
“New Zealand should do an opt-out as a good starting point, that way everyone has one,” she says.
An NZ industry take on things
Scott Arrol, chief executive of NZ Health IT, says the key words the public sector and health IT industry should be focused on as they plan for the future are; interoperability, collaboration and engagement.
He says it is good to see the Ministry of Health’s digital technology team reaching out to industry and acknowledging that what industry has to say is of value, particularly in the development of the Digital Health Strategy and EHR business case.
However, he agrees with Bowden, Peat and Pyefinch that there are ongoing issues created by government agencies that are stifling investment and innovation across the country.
“The complexities and structures and policies and regulations in New Zealand definitely are stymying investment in innovation, particularly in the private sector because why invest in an environment where you are competing with the funder, with tax-payer money and in some cases where governance of that spend is lacking?” Arrol asks.