Attendees at last week’s Digital Health Association parliamentary reception were disappointed to find themselves contemplating the news that $330 million of funding for Hira and associated projects had been withdrawn.

Given this ‘sea-change’ I believe that it is time for our health IT leadership to adjust the direction of Hira and focus on building systems and services tailored to New Zealand’s unique requirements, rather than trying to emulate the large national shared electronic health record systems (SEHRs) that have been attempted, and have mostly failed, in a number of overseas jurisdictions.

Figures from a 2024 Australian Productivity Commission report indicate that New Zealand could gain $1 billion in annual savings and provide vastly improved patient outcomes. The important question is how we go about building an SEHR.

Delays in automating the sharing of a patient’s past medical history (PMH) are hampering efficient provision of emergency department care and other unscheduled healthcare services. We need the best possible shared electronic health records system (SEHR) in place and we need it now.

I believe that it is time for a rethink about Hira. Further calls for an additional multi-billion dollar investment in new health IT systems are unlikely to be heeded, in this decade anyway. Under our present circumstances we are unable to fund much more care, demand is growing year on year and the cost of healthcare provision continues to grow apace.

Our only chance of improvement is to streamline our delivery of care and the most effective option available for doing that is better use of information technology.

Something I have been pondering, is why we should focus our efforts on delivering a centrally managed patient record system that operates in parallel with the very able patient portals that are used by more than 70 per cent of practices and more than two million patients.

During the decade 2010-2020, the Ministry of Health made significant efforts to promote patient portals as the principal point of access to patient records. In 2020 that effort was discontinued in favour of establishing Hira as a centrally managed SEHR.

Instead of creating a parallel SEHR system alongside of our primary care and hospital systems, why don’t we consider opening up existing sources of patient information and utilising the records created via enabled primary care and patient enrolment. I believe that we no longer have a choice.

Putting in place a large expensive SEHR system is no longer an option in the present economic environment.

Perhaps it is time we drew inspiration from Sir Ernest Rutherford, one of New Zealand’s most famous early scientists who said; “We don’t have much money therefore we must think.”

Principal Patient Record

New Zealand’s healthcare system has three distinct advantages: Firstly, more than 95 per cent of Kiwis are registered with a primary care provider who is responsible for oversight of each patient’s care.

Secondly, New Zealanders have pioneered use of the international HL7 (Health Level Seven) communications inherent standards framework and most, if not all, of our primary care-related systems can and do exchange large volumes of patient data on a daily basis (approximately 200 million pieces of patient information are exchanged annually).

Thirdly, we have a number of robust, accessible well designed and implemented national databases, including for immunisations, pathology results and prescribed medicines.

Bearing in mind the above factors, I favour an alternative approach that is vastly different from existing SEHR models. I propose instead that we extend the electronic medical record (EMR) held by each general practice or primary care organisation that the patient is enrolled with, to create a shareable Principal Patient Record (PPR).

A PPR strategy would especially be suited to New Zealand because almost all (95%+) of our patients are enrolled with a primary-care provider where much of a patient’s health related information is currently held.

In my view, instead of effort going into building or procuring a big new additional system, we should be improving the quality of the data currently being exchanged between primary care and other parts of the health system and stored within each enrolled patient’s individual primary care-held record.

As Peter Jordan, secretary and past chair of HL7 New Zealand recently stated: “The key to sharing clinical records is the conformant and consistent implementation of international standards – nothing less.”

In my view, we in New Zealand have put insufficient effort into keeping our data communications standards up to date – and we have been even worse at implementing the standards that we have available to us.

Vendor competition

In addition to fully supporting greater effort to develop and implement communications standards, I suggest that creating competition amongst IT systems and service providers is the by far the best way in which to accelerate progress.

No IT vendor worth his or her salt will allow a competitor to arrive at a solution faster or do a better job than they can. By harnessing competitive forces throughout the 1990s and early 2000s a great deal of progress was made, world-leading systems were built and rolled out. It is time for us to make that happen again.

From an IT standpoint, the very worst situation arises when the sector (clinicians and IT providers) are made to wait around for a solitary system provider to deliver an end to end solution. We need a strategy that gets everyone to work. I firmly believe that if we were able to rely upon standards conformance at all levels it would be possible to seamlessly share and exchange data without the need to purchase large and expensive proprietary systems.

Cutting to the chase, I believe it is inevitable that we scale back our immediate ambitions and settle on a more down to earth approach to electronic record sharing. History has shown us that if our strategy holds water and we build a firmly standards based information exchange foundation we can create an extremely useful SEHR system.

Trial PPR systems have already been rolled out in several New Zealand regions including at the Hawkes Bay DHB emergency department, as well as one in Northland and another in Nelson, which enabled after-hours clinicians to look at local GP-held records. They have achieved very encouraging results.

Big and expensive systems are now off the table but we urgently need an agreed method of sharing patient data. Being unable to access a patient’s past medical history is costing us dearly. Let’s work together now to address this challenging situation.

Tom Bowden has recently completed a PhD with the Australian National Institute for Health Innovation at Macquarie University, Sydney on improving emergency department clinician access to patients’ past medical history. He has no shareholding or financial interest in any health IT-related commercial organisation.

References are available upon request.