Does anyone know if there is currently any group discussing the functioning of the National Medical Warning System at a national level? I’m wondering if this comes under either any new national Te Whatu Ora groups or HIRA. Perhaps @lara can advise if there is any active work here?
The reason for asking is that at Southern, we are about to replace our Patient Administration System, and our new PAS will have different alert functionality to our old PAS. As part of this change, we will need to look at how our systems interract with the National MWS. We may end up sending more data to the NMWS than we previously did, so would be interested to know if there is any planned developments to this so we can allighn with the future direction. In particular if there are any standards on what should and shouldn’t be on the NMWS. In terms of official advice this is what I’ve been able to find so far:
Interesting discussion.
From a community medical perspective when I send In a referral letter with medical alerts they do not automatically upload into the hospital based system. They only way they do is if I send a warning to CARM which seems like overkill for every adverse event. If there is going to be changes in the warning system please consider the integration with general practice and urgent care.
In primary care do you have the ability to add alerts to the National Medical Warning System? Some hospitals at least automatically pull information from the NMWS into their systems, so if you were able to add an alert to the NMWS then that may be a way of getting it into the hospital system.
I have raised this earlier in the year with the MoH’s Health Information Platform team, and understand that this MWS is planned to be lncluded as part of the NHI FHIR API, which will enable wide read and write access, as well as a single source of truth.
The battle will be getting wide clinical use of this and moving away from siloed PAS and other systems (we currently have 3 different sources in our clinical desktop, none of which are the MWS directly!) but going forward having API-based access to this information in the HIP is the right way to do it. Then GP, district PAS and other systems will all have up to date information.
Reconciliation of old systems is also a concern, but we have solved this for demographics more generally with the NHI system, and there is no reason it can’t be achieved for warnings also. If downstream systems have read and write access this can be done at the point of care (as we would be doing each time we engage the patients anyway).
Yep - @joel.brown has been doing some things. Mapping to Snomed and identifying categories.
@david.vink is also doing some work connected to it in the medicines space.
I have a bigger vision in terms of the service, I want to make sure these can be coded in terms of what they are (medication warning, allergy, social history) and not just severity.
But I want it to collect endorsements as well. Ie. the ability for clinicians and others to confirm the content in there. This should allow these to be ranked by agreement as well.
To be honest I think we have lacked investment in this so that is currently the big blocker. Keen to hear what else you might want it to do.
A further wild suggestion is that it could be used as the register of diagnoses… but we would need to figure out how that lines up with some of the other FHIR model resources.
Remember, approximately 50% of coded diagnoses are incorrect! Same goes for warnings and alerts.
But therein lies the great promise of tackling this - with a single (editable) ‘source of truth’ we can iterate a patient’s alerts (and maybe diagnoses) towards the actual truth. The benefits of this would be absolutely enormous, and it is rather scandalous that we haven’t even really tried. Then again, I’m not sure that many countries have!
I think we shouldn’t be deleting/editing we should be endorsing. Doing this, when assigned to a known person keeps previous differentials (in diagnosis context) and errors listed and these fall by the wayside as consensus is reached.
How about deleting / editing but with retention of history (much like the wiki functionality in the Forum)? This could likely be the best of both worlds.
We have a very strong tendency to copy / reinforce incorrect things again and again (appearing to endorse false information) unless questioning the quality of the information is build in by design.
I will tell you whether it is a good idea once we see how the maternity spine goes. Clinical users will be able to overwrite/update certain data features - eg. Gravida. I understand it can be quite contentious.
I think the question in that model is who has authority to delete/overwrite… A control we would implement is escalating lock out - eg. too many updates mean the next update can only be made at some sort of multiple of time (like your phone passcode lock out).
There’s a lot of research on the appropriateness of alerts, their design and application. A short cut to a good alert approach might be to read up on the research literature and set up a framework that helps you get it right first time without having to design and implement alerts by trial and error.
Our health IT in NZ is so backward it’s unbelievable. You should be able to generate your referral electronically, complete with alerts and relevant clinical information, to drive workflows in the receiving system. But none of our hospitals have the systems in place to do that. Pretty sure that MoH has responsibility for all health services, private and public, so it should be facilitating this level of integration across the whole service.
Totally agree. Some Districts are more advanced in this than others, some can send/receive electronic referrals whereas others have to print them out. It creates digital inequity in clinical care when an electronic referral can be triaged with electronic feedback to the referrer within 24 hours (subject to the person reading and advising) whereas the digital/manual hybrid can take days to weeks.
@joel.brown runs the national working group around MWS which meets a few times a year. We know we need to modernise this and extend it’s use and functionality and there’s some good thinking around Hira and other investments that potentially provide a path to do so. There’s a couple of pilots and investigations underway at the moment. Will take investment and prioritisation to make this happen.
A concern of late Inga is that a recent communication back to Community from hospital service even where this electronic closed loop is available was don’t send a e referral as we don’t have consultant capacity to even read the referrals. I’d need to send a patient for opinion please phone us ???
Bit of an update, have some plans which I will bring along to the connectathon and post some stuff here at the same time.
Have put together some business logic and a sample UI to describe how we could use this as a system. Have also had some help from @richard.medlicott in terms of understanding how Medtech stores problem lists for data mapping purposes. Hopefully you are coming for the chat?
Our work has also led on to thinking about reference ranges - will start a separate conversation about that.
Look forward to seeing this. The word I always wish to see more of of ‘reconciliation’, as is well described for medication lists, but applies also to all lists such as alerts and diagnoses. The word ‘reconciliation’ is helpful to remind all involved about the multiple providers involved, and the time it takes to curate/update lists, establish accountability and responsibility for which providers have the authority, and when, etc . . . all while ensuring patient portals are, ideally, at the core because patients have the most at stake and should be a part of reconciliation workflow. . .that’s the ultimate aim: a single source of reconciliation.
Any work on an a new NMWS should be predicated on a clear understanding of the following concerns…
a. What exactly constitutes a ‘Medical Warning’ - e.g., does it just include allergies, intolerances, hypersensitivities - or broader concerns relating to a patient’s functional status or behaviors that represent a risk to providers and care givers?
b. Supporting evidence & context - e.g. adverse reactions that point to an allergy or intolerance (was a drug administered as directed?)
c. The event and context-driven nature of this type of data and whether it’s feasible to maintain it at a national level with any degree of assurance as to its accuracy and provenance.
I have yet to see a Digital Health System used in NZ that represents allergy, intolerance and insensitivity information in a semantically interoperable format. For example, it’s probably the most poorly-designed and implemented clinical data class in the GP2GP Data Model.
@emily.gill - do you mean a single source of data that supports a reconciliation or a single place where that reconciliation takes place? Ideally, medicines reconciliation should occur whenever there is a transfer of care (e.g. community to hospital and vice versa) and be supported by a central source (NZ Medicines Data Repository- MDR).
Totally agree that, wherever possible, the patient or a nominated caregiver - should participate. Aside from in-patient settings, they are the only source of truth for actual usage. Hopefully, in time, MDR will include administration data - but at the moment it only contains prescribing and dispensing information.
Hopefully, MedChart’s NZePS implementation will go live next year which will provide in-patient and discharge prescribing and dispensing details to MDR. Once the pharmacy systems implement MDR access, community pharmacists will no longer struggle to reconcile meds on printed discharge summaries.
Providing accurate Medication Lists is challenging. Over the years, there have been various studies on the percentage of unfilled prescription. This is one of them which states that “20–30 percent of medication prescriptions are never filled and approximately 50 percent of medications for chronic disease are not taken as prescribed.”