ISSUE 1

Recent Initiatives in the Management of Health Information in New Zealand

Fundamental changes to the organisation of health services in New Zealand were announced in the 1991 Health Information Strategy document. A significant component of this strategy is a framework for the development of health information services to meet the national requirements for health information. This report essentially describes recent developments in health information management in New Zealand initiated by the proposals in the 1991 Health Information Strategy. It discusses the role of the New Zealand Health Information Service (NZHIS) in the development of a national health register. At the heart of this development are three national databases. These applications and their functions are presented. Also discussed are a number of other health information management initiatives currently being explored. The report concludes with some comments about the issue of individual privacy and medical ethics.

Set up in 1993 to implement the country's health information strategy, the New Zealand Health Information Service (NZHIS) has recently established a national health register which may be the envy of many larger, wealthier countries. The NZHIS is a group within the Ministry of Health responsible for the collection and dissemination of health-related information. Its primary goal is to make accurate information readily available and accessible in a timely manner throughout the health sector. The vision of NZHIS is to support the health sector's ongoing effort to improve health information management in New Zealand.

The national health register consists of several core applications implemented on the Sun Microsystems platform with multi-CPU servers. Running over public electronic highways, these applications contain information for secondary and tertiary health events from Crown Health Enterprises (CHEs). At the heart of this development are three national databases: the National Health Index (NHI), the Medical Warnings System (MWS) and the National Minimum Data Set (NMDS).

The National Health Index is a population-based register of all healthcare users (patients) in New Zealand. Assigned to each patient is a unique identifier allocated on a random basis. The NHI holds details such as names, alternate names, addresses, date of birth, gender and ethnicity. This enables an individual to be positively and uniquely identified for the purposes of healthcare services and records.

The Medical Warnings System is designed to "warn" healthcare providers of the presence of any known risk factors that may be important in making clinical decisions about individual patient care (eg. allergies, sensitivities, past significant history, etc). The MWS provides information on medical warnings and alerts, healthcare event summaries and donor information. These data are held nationally because of the clinical importance of quick access to the clinical information, and the relative geographic mobility of the New Zealand population. The responsibility for making sure that the content of the MWS is up to date will rest primarily with its users, the healthcare providers.

The National Minimum Dataset is a single integrated collection of health data required at a national level for policy formulation and performance monitoring and evaluation. The NMDS provides a reliable, validated and comprehensive but selected set of information on (i) the health status of the New Zealand population; (ii) the factors which influence health status; (iii) health resources and their utilisation; (iv) the outputs, outcomes and impact of health services for national policy making; and (iv) the performance of the health sector.

The NHI, MWS and NMDS are central to effective national health information management. There are now systems for use by primary and secondary care providers that incorporate the facilities to communicate with these databases, and which can thereby contribute to making interactions with these systems easy and "transparent".

Plans are now in place to expand the existing information base to include primary care information. Considerable progress in this direction has been achieved, and various sites in primary care are operating with information systems that break new ground and offer significant advantages to patients, providers and purchasers. The use of electronic data interchange - for example, sending and receiving laboratory test orders and results or exchanging patient details for admission and discharge - is growing fast. Health Intranet pilot projects are well underway to explore the possibility of improving the exchange of information between healthcare providers through a wider use of the National Health Index (NHI). When fully implemented, this initiative will provide a secure means of communications nationwide, with access to all health information systems for all healthcare providers registered to use the intranet. In a recent report, the health intranet pilots are nearing completion and the NZHIS plans to roll out the application nationally in early 1999.

Although the core function of the NZHIS is the management of health information for the Ministry of Health, it has also established a business centre, offering its services on the open commercial market. The NZHIS has the flexibility to leverage its expertise to tender and bid for outside projects to generate additional revenue. An example of such external projects is the recent implementation of a pharmaceutical data warehouse. Funded by two commercial enterprises and in coordination with another agency responsible for managing pharmaceutical expenditure policy, the NZHIS was contracted to establish and store a data warehouse for all pharmaceutical information from across New Zealand.

Most health information is collected in a situation of confidence and trust for the purposes of care and treatment. Assurances as to confidentiality and protection of privacy are vital components of the relationship between patient and health professional. It is therefore not surprising that the modern privacy rules overlap substantially with a much older law of confidentiality and the medical ethics of the profession. Against this backdrop it is strange that there has been to date very little public outcry over the development of a centralised health register in this country. This can be explained by two possible reasons.

Firstly, there appears to be a lack of public awareness of the implications of these developments. It seems that the issue of health information has bypassed public scrutiny. There are still many details to be addressed and debated. The lack of discussion involving all parties concerned has resulted in many doctors and even more patients being unaware of the type of patient details which are going to be collated and kept by health authorities. The health sector's lack of openness about the various developments and plans in the collection of individual health information is somewhat disquieting. As this program moves forward, it seems appropriate that more attention should be given to consultation with the public and debate within parliament.

Secondly, it might be thought that there is a high level of acceptance and trust amongst New Zealanders that the information collected will be used appropriately. For instance, information can be used to catch people defrauding the system by matching data from various agencies like inland revenue, accident compensation and social welfare. Data matching is now a practice since the middle of 1998. According to a senior health official interviewed by the author, the general population appears to be comfortable with the concept of a health number for tracking hospital admission and discharge; the use of a universal number by general practitioners; and the recording of allergies and health history on a national database. For example, Community Service Cards were first issued in early 1990s and today around 50% of the population carry them. These cards entitle cardholders to discounted consultations with general practitioners, but they do not contain the NHI number or any medical information. It appears that people are often surprised that these cards are not linked to their medical details and do not give their NHI number when swiped. An 'improvement' to this card is currently underway in the form of a medical smart card pilot. The smart cards combine Community Service Card details, NHI number and medical warnings of the cardholder. New Zealanders have a strong history in accepting the use of electronic systems, with the highest penetration of EFTPOS terminals in the world. This may explain the high level of acceptance of the development of a centralised health information system and the use of electronic health cards in this country.

In summary, this article briefly outlines recent developments in health information management in New Zealand. A centralised national health register is now in place with a few thousand PCs linked to a central IT client/server platform. This system now services around 30 hospitals and other medical services providing health care to New Zealand's 3.6 million population. The resolution of a number of issues pertaining to individual privacy and medical ethics are the current challenges facing the nation.

Felix B Tan teaches at The University of Auckland,New Zealand. He is editor of the Journal of Global Information Management which is one of the IRMA Journals. His email contact is f.tan@auckland.ac.nz