Health record standards

HISO 10038.0.2017 Preface to the Cancer Data Standards

HISO 10038.1:2011 Interim National Cancer Core Data Business Process Standard

HISO 10038.3:2011 Interim National Cancer Core Data Definitions Standard

Please note that the preface and interim standards have been withdrawn. New cancer related standards can be found on Te Aho o Te Kahu’s website.

The New Zealand Cancer Action Plan | Te Mahere mō te Mate Pukupuku o Aotearoa  2019-2029 provides a pathway to improve cancer outcomes for all New Zealanders with the objectives of building a system that delivers consistent and modern cancer care, equitable cancer outcomes, fewer cancers and better cancer survival, supportive care and end of life care.

Te Aho o Te Kahu, the Cancer Control Agency is an independent departmental agency that was established to lead and unite efforts to deliver better cancer outcomes for Aotearoa. Te Aho o Te Kahu is responsible for developing cancer-specific data standards.

• HISO 10039.1:2011 National Specialist Palliative Care Data Business Process Standard ensures that minimum agreed palliative care data is collected and stored in a consistent manner wherever it is collected and stored. In June 2013, the status of these standards was changed from ‘interim’ to 'full'.
  
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• HISO 10039.2:2011 National Specialist Palliative Care Data Definitions Standard ensures that minimum agreed specialist palliative care data is collected and stored in a consistent manner wherever it is collected and stored. The Standard encompasses and defines essential elements of service delivery.
  
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HISO 10047:2013 Clinical Document Architecture Templates for Comprehensive Clinical Assessments

Published 31 October 2013

This standard provides an electronic format for sharing comprehensive clinical assessment reports created using the interRAI methodology.

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HISO 10048 Emergency Care Data Standard

The Ministry of Health has set standards for improved recording by district health boards of emergency department visits. For every Emergency Department (ED) patient, a record of the chief presenting complaint, any diagnosis and any procedures or investigations needs to be kept. Each of these data elements must be recorded using SNOMED CT, our standard for clinical terminology. This requirement became mandatory for all DHBs from 1 July 2021.

Reference sets

To enable this process we have introduced SNOMED reference sets for chief presenting complaint, diagnosis and procedure concepts in emergency care.To enable this process we have introduced SNOMED reference sets for chief presenting complaint, diagnosis and procedure concepts in emergency care. The three refsets can be downloaded either 

1. as Excel spreadsheets - ED chief presenting complaint reference set (xlsx, 19 KB), ED diagnosis reference set (xlsx, 101 KB), ED procedure/investigation reference set (xlsx, 13 KB)
2. as part of the SNOMED NZ Edition from our SNOMED Member Licensing and Distribution Service or
3. using our SNOMED CT terminology service. The files can then be loaded into any compatible ED information system or terminology server.

While the SNOMED NZ Edition is our standard product, we will continue to maintain the spreadsheets as long as there is demand.

Terminology service

The most direct way to access the refsets is to integrate the hospital ED information system with a terminology service that is called in real-time as the ED visit record is created. In line with our Interoperability Roadmap, we have introduced a FHIR(R) terminology service to support this method of integration. This API for development and production purposes is available on the internet at https://snomednz.digital.health.nz/fhir.

Here are examples of using the API to query each of the three refsets (in the above order):

• snomednz.digital.health.nz/fhir/ValueSet/$expand?url=http://snomed.info/sct/21000210109?fhir_vs=refset/61000210102&count=10
• snomednz.digital.health.nz/fhir/ValueSet/$expand?url=http://snomed.info/sct/21000210109?fhir_vs=refset/71000210108&count=10
• snomednz.digital.health.nz/fhir/ValueSet/$expand?url=http://snomed.info/sct/21000210109?fhir_vs=refset/321000210102&count=10

SNOMED International's Snowstorm terminology server is the software used. See the Snowstorm GitHub repository for more about how to use the API.

We ask that software suppliers who are not already SNOMED affiliate users to register with us to use the API.

The refsets can also be browsed online using the SNOMED refset management tool:

• NZ emergency care chief presenting complaint reference set
• NZ emergency care diagnosis reference set
• NZ emergency care procedure reference set

Adoption roadmap

The National Collections Annual Maintenance Project (NCAMP) set the requirement for DHBs to implement SNOMED in their ED information systems and submit SNOMED-coded ED visit data to the National Non-Admitted Patient Collection (NNPAC).

• NCAMP 2019 introduced the change for voluntary early adopters Nelson-Marlborough DHB, Auckland DHB, Canterbury DHB and Bay of Plenty DHB. The Annual Plan Guidelines for 2019/20 asked all other DHBs to plan for adoption.
• NCAMP 2020 set the mandatory implementation date of 1 July 2021 for all DHBs.
• NCAMP 2021 affirmed the mandatory implementation date of 1 July 2021.

The Ministry is developing and making available new reports from NNPAC using the SNOMED-coded visit data. 

A clinical leadership group meets with the SNOMED National Release Centre ahead of each six-monthly release of the SNOMED NZ Edition to determine updates to the three SNOMED refsets. 

We acknowledge the work by emergency medicine specialists at Nelson-Marlborough DHB to develop the presenting complaint and diagnosis reference sets, which have been used at Nelson and Wairau hospitals since 2013. The procedure reference set was also developed by New Zealand emergency care specialists.

The introduction of SNOMED in EDs is endorsed by the Australasian College of Emergency Medicine.

HISO 10052:2015 Ambulance Care Summary Standard

HISO 10058.1 Infection Surveillance Data Standard

This standard defines the format and structure for capturing the information used to undertake surveillance of health care-associated infections.

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Summary of public comment

The Ministry of Health sought public comment on the draft HISO 10058.1 Infection Surveillance Data Standard from 2 October 2020 through to 13 November 2020. This document summarises the responses received and provides an overview of the decisions made by the subject matter experts.

• Summary of the Review of Public Comment Feedback on the Draft HISO 10058.1 Infection Surveillance Data Standard (Word, 300 KB)
• Summary of the Review of Public Comment Feedback on the Draft HISO 10058.1 Infection Surveillance Data Standard (PDF, 193 KB)

Contact

Email: standards@health.govt.nz.

HISO 10059:2021 Oral Health Data Standard

Published 02 March 2021

The Oral Health Data Standard has been developed by TAS in consultation with sector experts and with support from HISO. Sector experts included key members of DHB provided COHS’, HDS’ and IS staff responsible for reporting oral health information.

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HISO 10065:2018 Allied Health Data Standard

Published 01 March 2018

HISO 10067:2021 COVID-19 Contact Tracing QR Code and NFC Tag Specification

HISO 10094:2022 Māori Descent and Iwi Affiliation Data Protocols

HISO 10094:2022 Māori Descent and Iwi Affiliation Data Protocols – Public Comment Outcomes

Cardiovascular Disease Risk Assessment Data Standard

This standard supports the implementation of cardiovascular disease risk assessment using the agreed primary prevention equations.

Improving the accuracy and consistency of cardiovascular disease (CVD) risk assessment and management is an opportunity for significantly improving equity in health outcomes for New Zealanders. We want to see CVD risk being assessed, understood and managed to ensure that morbidity and mortality for key New Zealand population groups continue to improve over time.

HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard supports the frontline implementation of two new sex-specific CVD risk equations for primary prevention; for the general population and for patients who have diabetes. It provides a data set specification for the inputs to the calculation, and the algorithms used.

The clinical aspects of CVD risk assessment are covered by the following publication: Cardiovascular Disease Risk Assessment and Management for Primary Care.

Risk calculators will need to provide a good user experience for both the patient and the clinician. This includes integration with patient management systems, and consideration being given to health literacy, risk communication and consumer interfaces.

Test cases and worked examples 

We have posted a set of test cases and updated the main document to include worked examples to support implementation of the new sex-specific CVD risk equations for primary prevention. The test cases and worked examples have been developed to assist software suppliers to check the behaviour of their calculators. The set of test cases, although not exhaustive, represents a reasonable clinical range of patient profiles.

Acknowledgements to the HRC-VIEW Research Team, School of Population Health, University of Auckland for preparing the test cases, worked examples and accompanying guidance.

• Test cases (Excel, 112 KB)

See also:

• CVD risk assessment tool
• CVD risk assessment tool on the API marketplace