“There’s this concept in computer science and security where you’ve got white-hat hackers who will break into systems and . . . then help them fix the security, whereas the black-hat hackers just break in and take what they can get.”
A registered nurse (RN) and midwife, and a senior lecturer in health informatics at the University of Auckland, Day spoke to Kaitiaki after what appeared to be an attack by a black hat — a name derived from headwear worn by western baddies — on the MediMap platform.
Aotearoa needed to prepare for more hacks, she said, but when it came to a digital future, “there’s no going back now”.
Instead, nurses needed to understand the “analogue” component of their mahi: This was the work that “needed to be valued and cannot be let go of”.
Digital information systems could be used to support and enable that work — but could never replace it, said Day.
“Because we’ll never ever be without nurses. We never have been without nurses — we never will be without nurses.”
Meanwhile, as the country consolidated its digital health-care systems, primarily the work of Te Whatu Ora — Health NZ (HNZ), it could expect more outages, “and more opportunities that the black-hat hackers find, to break in”.
At a glance
- MediMap is a digital medication and prescription system used in aged residential care, hospices and disability services.
- The system was in a “phased restoration” process from Monday after a data-altering hack was discovered on February 22. Some patient names were replaced by that of US far-right activist Charlie Kirk; other patients were marked as dead when they were alive.
- Nurses were forced to go back to paper systems for medications and prescriptions — rebuilding patient charts from scratch.
- It closely followed the hack of primary health portal Manage My Health where the personal information of 120,000 patients was stolen by ransomware group Kazu.
Number-crunching Nightingale
Health informatics covered the theory and practice of health information systems (processing, storing and sharing data): all with the goal of boosting health outcomes.
Day said informatics has become more of a tech-based science in the age of digitisation, however the first nursing informatician was Florence Nightingale herself — a mathematician and statistician.”She used the information that she could glean in the Crimean War and applied public health principles like ‘please don’t do your patient’s wound care right next to the free-flowing sewage outside the building’.”
New Zealand’s health system needed to be more vigilant with its cyber security — and that meant creating a better infrastructure for its workers, Day said.
Wander around hospitals and in primary care, however, and you’d see nurses using systems designed for doctors, she said. Nurses were left out of decision-making on software over the past 30 years, something that stuck in Day’s craw. She was an advocate for nurses to “get in there” when it came to IT decision-making — after all, there was a limit to how much doctors can speak for nurses, “and I think the bar is pretty low”.
“We’ll never ever be without nurses. We never have been without nurses — we never will be without nurses.”
Meanwhile, as part of the collective responsibility for the health system, nurses should also boost their personal skills in a fraught new digital world.
“We have to remember all the time: hackers run businesses, very successful businesses. They use the same theories and research and experience that anybody who has a business will use. And they’re very scary people in an organised way.”
The same health privacy considerations that existed in the analogue world existed in the digital world, she said. “That means you have build skills in your digital competency. And if your employer’s not offering to give you digital literacy training, then you should ask for it.”
Training or otherwise, the software situation in hospitals was still looking patchy.
‘Twenty iterations of itself’
New Zealand hospitals had a compatibility problem, and it started about 25 years ago, Day said.
In 2001 the health system was decentralised via district health boards (DHBs) and primary health organisations (PHOs). This was the start of a “legacy of mismatched systems” in hospitals.
Thanks to customisations, the major software used by hospitals had “20 iterations of itself ” across the country. “So if you’re working in hospital A and you need to see a patient from hospital B, you can’t see their record because the software, although it’s got the same name and upgrade, works very differently.”
It had created a gridlock problem, she said: Legacy software was woven in with a bunch of other software products — updating it meant updating everything. “And that gets very expensive.”
Compounding the problem was the fact half of the vacancies and occupied positions in HNZ’s digital team disappeared after the Government cut non-clinical staff numbers, she said. “That’s a very strong message about the Government undervaluing the work that goes into keeping the lights on.”‘
Nursing, and digitisation, are the future
So if nurses could never be replaced, but digital systems could help them work better, how does that work?
Day pointed to digital prescribing as an example of how — despite the risks — the software could shorten time needed by nurses and improve safety.
Digital prescribing had eliminated a lot of transcription errors, and ambiguity. Many digital platforms had decision-support tools — providing pop-up guidelines such as queries about dosage if patient weight has changed significantly. This kept users “within the straight and narrow of good care”.
Prescribing had always been a “contentious space” between doctors and nurses, but with registered nurse specialists with certain prescribing rights, and nurse practitioners, “we can now move the doctors on to do their expensive work elsewhere”, Day said with a chuckle.
“Nurses do prescribe differently from docs. Of course you’ve got match the drug to the problem, the same way the docs do it, but they have a different approach and I think nurses should be involved in that kind of decision-making.”
“That’s a very strong message about the Government undervaluing the work that goes into keeping the lights on.”‘
Day said she wouldn’t recommend going “back to analogue” for prescriptions.
“But I would recommend that . . . nurses who are doing the administration and management of medicines sit down and say ‘what’s our business continuity plan if that system goes down again?’.”
Managing the risks was important — but Day kept a positive outlook when it came to the ongoing showdown between white hats and black hats.
“There are lots of really good people in the world, and in my hopefulness I think they outnumber the bad guys.”
Karen Day, RN, RM, PhD, FHiNZ, FIASHI, is a senior lecturer in health systems in the School of Population Health, at the University of Auckland.