News from the Coal Face: There’s light at the end of the tunnel. Presented by Dr Andrew Miller, General Practitioner, at HINZ 2014, 11 November 2014, 4.30pm, Marlborough Room

1. There’s light at the end of the tunnel

2. North Island by Deprivation Index
NZ Census 2006

3. North Island by Deprivation Index
NZ Census 2006

4. Northland by Deprivation Index
NZ Census 2006

5. Northland by Deprivation Index
NZ Census 2006

6. Whangarei City by Deprivation Index
NZ Census 2006

11.  One DHB and 2 PHOs who are not in
competition- in fact share most “back office”
functions
 Good alliancing relationships with Maori
Providers
 Highly functioning PHOs with good
population health data, full time data analyst,
highly effective IT team & practice facilitators
 Makes implementation and provider change
management relatively simple

12.  Northland Primary Information Governance
Group
 Established December 2007
 Chaired by Ken Leech
 Wide representation-both planning and
funding so decisions made in one forum
 Driver behind most primary IT developments
in Northland

14. Pronounce things like:
 Acute glomerulonephritis
 Necrotising fasciitis
 Phenoxymethyl penicillin
And calculate the dose of multiple drugs from
mg/kg/day and convert this into tablets and
liquid forms

15. Patient DashBoard

17.  Auckland PHO
 Central PHO
 Compass/WIPA
 East Health
 Hauraki PHO
 Health Hawkes Bay
 Manaia PHO
 Nelson Bays PHO
 Pegasus
 ProCare
 South Canterbury DHB
 Southern PHO
 Te Tai Tokerau PHO
 Waitemata PHO
 Well Health
 [West Coast PHO - soon]
 Whanganui Regional Health Network
 a number of individual practices and A&Ms

23. • Alan Davis
• Northland District Health Board
• Northern Regional Alliance

24. • Northland
• Primary Care/DHB initiative
• Driver = security/primary access
• 9 month development phase
• Roll-out initiated March 2009
• 100% electronic from 1st June 2013
• Auckland
• Negotiation/Product development 2009
• Driver = security
• Heavy secondary care involvement
• Roll-out initiated 2012

25. E-transmission
E-triage

26. Service Median time to triage completed
(June 2013)
Cardiology 0.21 days
Respiratory 0.5 days
Ophthalmology 0.96 days
Paediatrics 1.67 days
Renal 0.25 days
Gynaecology 0.67 days
Orthopaedics 9.15 days

28. Clinic type % referrals managed with non contact
outcomes
Haematology 53%
Oncology 69%
Renal 59%
Paediatrics 24%
General Medicine 59%
Neurology 41%
Respiratory 29%
Liver 32%

31. •People move their mindset at a certain speed
• Be modular and iterative
• Reflect on changes at each step
• Be prepared for unintended consequences
• Involve everyone in the pathway

32. • Phase 1 – referral generation and transmission
• All about primary care
• Goal is security of the message
• Keep it simple
• Keep secondary care out of the room
• Phase 2 – triage and response
• Mainly about secondary care
• Volumes will increase
• e-Triage takes longer

34. 1. Increase access to specialist services
2. Provide Specialist Services within Primary care
3. Provide chronic disease management within a
patient’s home
4. Facilitate communication for health
administration and education

35. To provide a seamless and reliable
telehealth service which looks and feels like
clinical care

36. Telehealth as a key enabler:
•Increase availability of and access to
services in primary and community
settings
•Improve primary care access to
specialist advice to support community-based
care

37.  30 VSL end points at NDHB
 15 of these are Telehealth
◦ Kaitaia Outpatients (2 clinic rooms)
◦ Bay of Islands Hospital
◦ Dargaville Hospital
◦ Child Health Centre (2 clinic rooms)
◦ Orthopaedics
◦ Whangarei Outpatients (2 clinic rooms)
◦ Renal (3 locations)
◦ Kamo, Kaikohe CMH
◦ ICU
◦ Te Roopu Kimiora (2 mobile locations)

39.  Engagement with Primary Care
 Outpatient Clinics
 ICU -> District Hospital ED
 Dargaville Mobile Telehealth
 Regional Cancer MDM
 Mental Health – Kimiora
 Standards and Guidelines

41. 6 of the major specialities are now doing
telehealth clinics on a regular basis

42.  Overwhelmingly positive
 Before and after impressions
Consensus: Great if it means don’t have
to travel, take time off work etc

43.  Increased specialist presence and reduced patient and
clinician travel
 Can reduce patient waiting lists
 Increase access to education and support
 Provide access to multi disciplinary teams
 Improve cross team communications and management
capability
 Knowledge gain for remote location

44.  Health Link Tool- used to make e-referrals to
private specialists and NGOs.
 NGOs will include- Green Prescriptions,
Alzheimer’s Society, Arthritis NZ etc
 Doesn’t require the recipient provider to have
a PMS
 Will allow provider to send back an inbox
message to our PMS

46.  • Sport Northland
 • Hospice
 • Arthritis Foundation
 • Alzheimer’s society
 • Cancer Society
 • Northable
 • Epilepsy Northland
 • Stroke Foundation
 • Parkinson’s Society
 • Plunket
 • Maori Providers
 • Manaia PHO

47.  Gives a view of classifications, medications,
allergies, immunisations to external providers
 Currently being accessed by ED, WhiteCross,
Mid/Far North afterhours GPs and the
hospital pharmacists
 Most used by hospital pharmacists

48.  Largest Practice in Kerikeri has given access
to district nurses to become users of their
version of MedTech
 Kaipara Care- Dargaville is also sharing
MedTech via Manage My Health with Te Ha
(local Maori Provider), district nurses and the
pharmacists.

49.  A component of the Care Connect Tool
 Trial started in the Hokianga and Bush Road
Medical Centre to allow 2 way messaging
between general practice and hospital
specialists
 Possibly a more elegant solution than e-referral
simple advice
 Message can be initiated by secondary
services
 May lead to more comprehensive shared EHR

50.  MedTech Manage My Health and My Practice
Health 365.
 Access if via a secure website- same level of
security as internet banking
 Patients can be enrolled at whatever rate
practices feel comfortable with

52.  Patient Portal have an option to allow patients
to read their notes from the time they enrol
onto the portal
 Evidence strongly suggests that having Open
Notes
 Improves health literacy
 Improves compliance
 Strengthen doctor/patient relationships
 Is well liked and accepted by doctors and patients
 Does not increase patient complaints or doctors workload

53. 53
13,564 the majority of patients who viewed at least one visit note
reported;
77-85% understood their health conditions better
76-83% remembered their plan of care better
70-72% thought able to take better care of themselves
69-80% better prepared for visits
60-78% would take medications better
Ann Int Med 2012;157(7):461-470

54. and what we tend to do in Northland
“…start very simple and then just begin with it. And let
things happen organically and let it expand as the
organization and the patients are ready for it. …There is
no perfect system, everything’s gonna have flaws.
….You can think about it in a room for twelve months and
not learn as much as you could in one week of actually
doing it.”

57. Kenealy et al. Diabetes Care
2010

60.  Changes will be evolutionary not
revolutionary
 Pace of change will be dictated by what
providers can cope with and wish to do
 Underlying philosophy is to make care more
patient centred and coordinated
 However changes should also make our work
more enjoyable and allow us to work to the
top of our scopes
 Using IT in “Stealth Mode”

61.  His proposed definition of “patient-centred care” is this:
The experience of transparency, individualisation,
recognition, respect, dignity, and choice in all matters,
without exception, related to one’s person, circumstances,
and relationships in health care.
 “ There needs to be a radical redesign to move the focus of
health from a quality improvement health focus to a
courageous pursuit of wellbeing
 (1) “The needs of the patient come first.”(2) “Nothing about
me without me.”(3) “Every patient is the only patient.”

62. “I can plan my care with people who work together to
understand me and my carer(s), allow me control, and
bring together services to achieve the outcomes
important to me”.
“We are sick of falling through gaps. We are tired of
organisational barriers and boundaries that delay or
prevent our access to care. We do not accept being
discharged from a service into a void. We want services
to be seamless and care to be continuous”.
National Voices UK

63. “The patient is always a person.
The person is sometimes a
patient.
The person is more than an
individual.
The person is part of a context.
The person exists because of
their context”

64.  Maori Providers
 Whanau Ora Providers
 Other Health Providers: pharmacists, dental,
Plunket, DHB community services etc
 Whanau members
 Government agencies: MSD, Housing NZ
 NGOs
 All these providers have the ability (and
responsibility) to work in a collaborative
model.

65.  Providers involved for 5 hours per year,
patients for the other 8755 hours
 Patients, families and communities have
assets that should be used
 Partnership of Equals- with patients not to
patients
 Informed and empowered patients are more
likely to make healthy lifestyle choices.
 On-line self help tools reduced consultation
rates by ~20%.

66. “ All changes and new concepts that we initiate
in order to make the healthcare sector more
person- centred must include all stakeholders.
We must make sure that everybody is on board
or we are not likely to succeed”
Jacqueline Bowman-Busato European
Platform for Patients’ Organisations

68.  Who is your customer?
 What do you want for yourself if you’re
needing a health IT system that best manages
your care in an integrated, person centred
way
 Make NZ’s health IT system the model the
rest of the world aspires to.
 Strive to make systems interoperable and
share standards
 “Above all else do no harm”- Hippocrates

69. “Good will is easy. It gets complicated when
it’s about money and income.”

70. He aha te mea nui o te
ao?
He tangata! He tangata!
He tangata!