NZ live and kicking with health RM

NZ live and kicking with health RM

New Zealand's medical industry is showing the world how a national records management system can be built.

By Paul Montgomery

The health sector in many Western countries has been slow to catch on to the benefits of information management. Australia is struggling with a national policy. Britain is twiddling its thumbs. The gigantic US system has isolated pockets of innovation.

New Zealand, on the other hand, has a much more healthy prognosis. It is constructing what may be the first national integrated system for medical records management in the world.

The NZ Health Information Service, a group within the Ministry of Health, has been collecting and disseminating health-related information in a system which started in July 1999, with antecedents which stretch back twenty years. The records management strategy of the NZ health system is based around the National Health Index, which is a register of all citizens, be they residents of NZ or not, who have used any part of the country's health care system. The NHI includes a unique identifier which is assigned on a random basis. The Index is also connected to supplementary databases like the Medical Warnings System, which includes patient histories, allergies, sensitivities, and other information which may be vital to correctly treating a patient.

The records management system which supports the NHI was purpose-built by the Government in 1993. The NZHIS has built, maintains, and is constantly upgrading a communications network which delivers this data to the health industry system. This system, which has to be available around the clock, now serves around 100 hospitals across New Zealand, in addition to thousands of what are known as "primary care" providers, which include general practitioners (GPs), chemists and other professionals whom patients visit before they are referred to specialist doctors, clinics or hospitals.

"Our required service level is that 97 per cent of all transactions must be delivered to the originator within three seconds," said Paul Cohen, group manager of the NZHIS. "If a person walks into a hospital in Auckland and goes to the submissions desk, [the hospital] looks for the NHI number. If they can't find it on their local network, then they submit a search [to the NZHIS server] over an X.25 network."

Access to the system has only recently been extended to primary care providers, and there are now in excess of two million hits per month on the NZHIS servers.

"This system has been in place for 20 years, in one form or another. In the last five years, it has been clinical and administrative [reasons] that have been pushing GPs and health facilities to get access to the numbers," said Mr Cohen.

"Here, we do it on the smell of oily rag, but we get much more buy-in because of it."

The data set attached to the NHI numbers is not restricted to name and contact details. As with every project of this type, privacy issues had to be addressed in the design of the database, but the result is an integrated data warehouse which contains the details of all interactions a citizen makes with the health system - and that includes foreign citizens.

"Every month, hospitals report to us using encrypted NHI numbers on who went in, what was done, when they came out, and how they were discharged," said Mr Cohen. "There are a couple of hundred million rows in the data warehouse, with an entry for every prescription given out to a patient."

As part of the database, there are registries for cancer and mental health, and there is also a mortality registry which cross-references with the clinical discharge records.

This system is based on a network which uses electronic data interchange (EDI) as its communication language, not just for the NHI-based system but also for commerce-related transactions like sending and receiving laboratory test orders and results. Mr Cohen said one of the next phases of the rollout of the full NZHIS system was a changeover to a virtual private network (VPN) - substituting EDI for a secure version of the Internet Protocol called IPSEC, and swapping the existing X.25 network of leased lines for the open Internet. Plans have also been drawn up to use digital certificates, compliant with the X.509 standard, to authenticate parties and transactions over the VPN.

"We're seeing the Internet changing the way quite a number of industries do business," said Mr Cohen. "We're bringing the Internet into health care. The problem with the Internet is that it is not secure and not reliable. The NZHIS has got to make sure of that 97 per cent return at three seconds. We can't guarantee that over the Internet, but we can over a managed network."

VPNs were very exotic back in early 1998 when the network was planned. The NZHIS spent NZ$1 million on a pilot process involving 20 GPs and two hospitals later that year. The construction of the full network was contracted out to Telecom NZ. Although the network cost NZ$3 million to build, only a third of that was covered by the Government, as Telecom NZ was expected to be repaid by collecting monthly charges from health organisations in a hybrid "user pays" model. Hospitals can now connect to the NZHIS network for "close to local Internet service provider rates" with a minimum charge of NZ$40 per month, said Mr Cohen. This is not much more than the equivalent rates for the old X.25 network.

The combination of private and public funding was an "interesting mix", said Mr Cohen. "We were part of government, but we did this on the cheap," he said. "Australia tends to put up a large amount of money for projects, but they go belly up. Here, we do it on the smell of oily rag, but we get much more buy-in because of it."