Can I ask a provocative, but genuine question here please - happy to take personal messages on this one
As background - been involved for quite a few years now in looking at these - and we have flirted/played with this a few times - truth is we have always come back to what we already know
it’s comfortable
we enjoy making our own stuff
the “counter factual” from the USA don’t actually look good /are not good enough to get the business case over the line / enough other areas standing together with one voice
Which means we have actually come a long way in supplying functional IT at the coal face with what we already have.
New to NZ clinicians remark on how nice it is when they first start
NZ clinicians are not singing “let doctors be doctors!” - some even stop me to say they like what they have and thank me and the team for what we do!
Don’t get me wrong, there is still lots of room to improve - and maybe it’s more the slow change than we have something that is acceptable and not had the “negative publicity” of the USA
but given all that - what are we looking for from the USA eHR market that we all want to go and see various clinical systems outside of NZ?
What are we actually looking for
What would it take for us to - standing together - say - “actually we have to move to this!”
Would be very keen to hear what others are hoping to find that would convince them that moving away from what we have would leave us overall, better off
Because if any of us really do want to move towards something we don’t already have in NZ - it’s going to take a lot of us standing together, with a unified voice, explaining just what it is that is so super special that would sell the need to move.
Hi Lara, I take your point. I think there are various lessons we can learn from the tech in Oz (I’m interested in how well resident guide works for example and we imported PFM from Oz and possibly an anaesthetic EHR ). However some of the things I really want to look at is how do the clinicians feel about what’s on offer, change management issues, organisational structures that work and also forging relationships across the ditch to widen our community. I think you raise a very good question though and one that would be good to explore in ChCh…
Hey Lara,
I agree with you that one of the things we haven’t done (yet) in NZ is make the IT system so cumbersome and demanding that people can’t do their job, and that’s a real strength.
I think that implicit in this and going to look overseas at what has been done is seeking out non-IT evangelist clinicians and asking them what works and what drives them nuts. i.e. what you discover that doesnt’ work or has unintended consequences is sometimes just as important as the clever functions which do work.
One of the realities of the somewhat piece-meal NZ DHB IT structure is the ability to pick and choose, so we might as well play to that as a strength.
To avoid the usual NZ trick of ignoring our home grown competence, primary care has considerable experience in using integrated Health IT systems to provide increasingly complex multi-disciplinary care. With various vendors around the country they are now moving to a cloud based through a variety of highly competitive tender processes. There is much we could learn. For any primary care folks reading, hospitals are using a mid-1990s version of Medtech32, without all the health system integration or practice financial management systems added.
I am involved in the MidCentral & Southern DHB HIMSS pilots. One of the comments made is that there are non-US providers of monolithic systems that we may wish to consider. Equally, regardless of model adoption is more about how you use whatever system model you choose, once it is beyond a base level of core functionality .
I am looking forward to catching up in Christchurch.
I have been thinking along similar lines for a while … thanks to a certain test question once upon a time @KarenDay
A few key themes come to my mind:
Does the system actually do what it says on the tin? - that links in with @Mat’s point re: seeking out non-evangelist experiences, privately, preferably unbound by non-disclosure agreements. There have also been too many collective experiences here of developer over-promise and under-delivery of system functionality.
How much does the “full functionality” version of the system really cost and would the MoH be prepared to fund it if there is a compelling case of benefit to be made? - including the set up and all the required ongoing maintenance and support costs? - this comes from discussions with Australian colleagues where the system bought into is often the cheapest, most watered down version with NONE of its actual functionality either available to clinicians and/or supported enough to be truly useable. The decision to get the cheapest is entirely managerial and clinicians are either not consulted at all or, if they are, it’s lip service only. When they try to protest, their clinical (!) jobs get threatened.
How likely is it that if the system enjoys excellent development and support at the moment, that this will still be the case in 10-20 years? - of course nobody has a crystal ball, but certain personality-driven successes have been known to wilt when the leader departs. What I am saying is what would epic be like when Judith Faulkner is no longer at the helm? … Just like once we were asking what would apple be like without Steve Jobs?
What’s in it for NZ? NZ is a country of 4.5million - that’s less than Kaiser Permanente population, the US Veterans group, and any other typical enterprise of any of the big players. It’s not only that there are less of us, but we also come with far lower per capita health funding - to put it into perspective, the US Veterans Health Administration annual operating budget is 65billion USD! For us to (maybe) derive an actual benefit from anything single platform is to put the whole country on it. Of course we would need to define what “benefits” we are actually after, but realistically it will be $ as far as any funder is concerned. So, bearing in mind that so far actual net financial benefits have been far more modest than predicted in the US, I am assuming similar for Australia and the UK, why would we be any different? In any case, with our limitations as above, the temptation for the vendor is to then treat NZ as a small market that can’t afford to walk away from the deal. Legal action, while it can certainly be threatened if the contract is drawn up correctly, would be protracted and costly. Overall, our position would be unpalatable to any government making a funding decision, but more importantly, a misstep here would be disastrous for engagement from the actual system users. This thought was unfortunately strengthened by the French experience of trying to introduce an electronic prescribing platform into its paediatric hospitals [personal communication].
Yes, agree with @Ruth_Large that we can and should learn lessons from other jurisdictions, but we can apply them to our own stuff that we already know works here. And where we do not have a solution that works, we need strategies to find the “between the lines” of what really goes on elsewhere.
I would love to hear a different take on this and I would be open to changing my mind if there are benefits that I am overlooking or under-appreciating, and, yes, I’m contributing a counter view to what you were actually asking for @lara, sorry! … so I do look forward to more discussion on this in ChCh
I don’t disagree with you @eras I think there is stuff out there we simply don’t do and small developers are often riskier (especially one man bands) plus add in the costs of integration . However if we were to harness our developer and financial power across all DHBs… but then we can’t even agree on regional things in midland so… It will be great discussion in ChCh, can’t wait
I am uncertain as yet what the role of this forum is – hopefully this comes up in the discussion later this month.
It seems to be a strange mix of socializing, very specific discussions of a wide range of digital health, and a small thread of overarching
questions re: planning and governance at local and national levels.
I think this thread is a useful thread for a Clinical Informatics leadership network to further elucidate. An awful lot of digital
health adoptions are the tail wagging the dog – where proactive determination of needs, strategies, and business requirements fall second to a vendor engaging in selling a product a healthcare delivery service may or may not need.
Fundamentally, the rewards of digital health in general have been missed by most jurisdictions for a variety of reasons, but interoperability
and silo-ing of data in stand-alone systems has been cited as a major cause.
As Era points out, NZ is quite small, and it well down a path due to lack of national or even regional thinking, that while there have
been substantive investment by DHBs in digital solutions for a number of issues, the rewards of population level data aggregation and analysis are as unachievable at present as they are across the United States, the UK, and other large jurisdictions. NZ has
become a microcosm of the dysfunction of this larger systems, as opposed to using our size as an advantage to emphasize monolithic data storage and access. I hope that this group can help form a vision, make recommendations, and help to implement regional
and national solutions – it would be great if we could look at systems that work, like Kaiser Permanente, the VA, or Estonia.
@matthew.strother did you just call us strange?
… to clarify the uncertainty, the forum is a work in progress (started in Nov 2018 by @NathanK ) for us to find our feet, and then voice, as a community of clinicians who share similar broad goals of what we’d like to see in NZ health IT landscape. The ChCh meeting is the next step in this, so glad that you’re joining us then!
Hi Lara,
I think you just hijacked a thread! OTOH, I’ve yet to meet someone who can stop Ruth in flight… waiting to see the thread stolen back.
You’re absolutely correct, with the proviso that we are still sacrificing trees to our patients so we haven’t reached where we need to get to yet.
Part of the issue is how easy it is to get clinicians doing their own coding, billing, and miscellaneous administration when you move to an electronic system, and the US systems have been designed by the people who have a focus on this, so they add tasks to the clinicians that traditionally weren’t part of the job. One of the easiest way to get disgruntled employees is to hire them for one job (seeing patients) and make them do another(medical billing). I get the distinct impression that the US systems are very close to “the click that broke the users’ back” so to speak, and we haven’t gone down that track here - Yet.
Hi Lara
Thanks for your post. Here is what I am looking for outside of NZ, and hoping to look at in the upcoming trip to the UK:
Examples of how health data can be stored in vendor neutral systems, that allow the data to be efficiently extracted and used by a variety of clinical systems, including systems built in-house by public hospitals, and systems built by other private companies.
We have a new hospital build planned in Dunedin, and what we need to achieve within 4 years for the first stage of the move to meet our paperless ambitions, hasn’t been achieved yet anywhere in NZ as far as I can tell. I’m hoping to see from the UK trip how we might achieve this outside of the USA eHR approach.
It seems that the UK is closer to our system than the US, so in looking outside NZ, it may be a good place to start.
I’m obviously much newer to Health Informatics than you are Lara, so I’m interested in your perspective on this.
Great meeting today at CHCH. After a dinner with my 20 yo son studying here and him asking me multiple questions about todays meeting I have a few musings of my own born through his bemusements of how far behind we are in this world of integrating patient care delivery with the digital world.
Why do we not collaborate on a national level of lessons learned?
What has been holding us back? Vendors? Egos? Nepotism? Lack of knowledge?
How can we be getting away with current budget blowouts without accountability to the above questions?
We probably need to consider adding very young minds to this group. I know of a particular young RMO who is very tech savvy and would blow us all away. He developed an app to look up any ACC code with snomed that you then enter into your ED/admission paperwork. . Our young doctors are coming out with dual talents and we need to tap them.
). However some of the things I really want to look at is how do the clinicians feel about what’s on offer, change management issues, organisational structures that work and also forging relationships across the ditch to widen our community. I think you raise a very good question though and one that would be good to explore in ChCh…
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