Nanna Skovgaard, Head of Division Center for Health Economics. 24 th of June 2015

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1 Health Presentation Care in Denmark Title Goes Here Nanna Skovgaard, Head of Division Center for Health Economics 24 th of June 2015

2 Agenda The Danish Health Care System Hospital Investments ehealth and Telemedicine Continua: Motivation and experience

3 The Danish Health Care System Basic Features Universal Coverage Free & Equal Access Financed by general taxes A high degree of decentralization

4 Organization of the Health Care System National Level Regional Level Local Level Ministry of Health 5 Regions 98 Municipalities

5 Where to go to if you get ill? Specialist Private Hospitals Patient General Practitioner Hospitals Emergency ward Dentist

6 Financing Health Care Central Government Organization Municipalities of the State Collect direct taxes Co-financing (20%) Collect direct taxes Regions

2012 (OECD) 39 15 Organization of the State 10 6 15 74 5 0 Regions - hospitals

7 Financing Health Care Breakdown of costs in the health care system, 2014 (billion DKK) Total: 153 billion DKK 20 Total expenditure on health as a share of GDP, 2012 (OECD) Organization of the State Regions - hospitals Regions - out-of hospital medicines Regions - family doctors Municipal health services

Some results and challenges The average length of stay in hospitals is low But average

Organization of the State and patient satisfaction is very high 98 96 94 92 90 88 86 2009

percentage positive and the number of citizens with a chronic condition is rising 250 225

8 Some results and challenges The average length of stay in hospitals is low But average life expectancy not as high as in similar countries Organization of the State and patient satisfaction is very high Outpatient treatment - percentage positive Inpatient treatment - percentage positive and the number of citizens with a chronic condition is rising No of citizens with chronic condition, pr inhabitants

9 Unique patients vs. bed days (2009 = index 100) Cancer Cardiovascular diseases Unique patients Patients Bed days Unique patients Patients Bed days Year Year COPD Type II diabetes Unique patients Patients Bed days Unique patients Patients Bed days Year Year

Hospital Investments 16 new hospital projects A total investment of 5,5 billion Euros - The Government: 3,3 billion Euros - The Regions finance the rest New structure for

10 Hospital Investments 16 new hospital projects A total investment of 5,5 billion Euros - The Government: 3,3 billion Euros - The Regions finance the rest New structure for emergency departments (From 40 20) Approx. 20 pct. reserved for investments in ICT and medico-technical devices. Demands for efficiency gains of 4-8 pct. on future activity

Hospital Investments - Why build new hospitals?

in fewer and larger units in order to: - increase

care - secure faster diagnosis - create better

11 Hospital Investments - Why build new hospitals? The overall aim is to merge specialized functions in fewer and larger units in order to: - increase the quality of care through better continuity of care - secure faster diagnosis - create better learning environments - secure the optimal use of resources

Hospital Investments Aims toward year 2020 The dimensions of the new hospitals aims at: Outpatient treatment up with 50% Number of beds down with 20% Bed days down to approx.

12 Hospital Investments Aims toward year 2020 The dimensions of the new hospitals aims at: Outpatient treatment up with 50% Number of beds down with 20% Bed days down to approx. 3 days New patterns and possibilities for cooperation and task sharing Hospitalization does not cure you, treatment does! Large scale adoption of new technology Within the buildings: Logistics, tracking systems Outside the buildings: Telemedicine, personal devices, home monitoring etc. A unique chance for a coordinated boost of patient treatment and technology in the health care sector

13 Background expectations vs. actual developments Number of beds 7,500 7,000 6,500 6,000 5,500 5,000 4,500 4,000 Number of beds, Outpatient treatment, no. of cases Outpatient treatment, ,000,000 10,000,000 9,000,000 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 Year Actual development, Linear extrapolation of actual development Initial expected development (-20% ) Year Actual development, Linear extrapolation of actual development Intial expected development (+50%, )

14 Reshaping the healthcare landscape - From castles to lighthouses

15 ehealth and Telemedicine Electronic messages have to a large extent replaced handwritten messages, telefax or phone calls: Type of message Referrals from GPs to specialized treatment Discharge letters from hospitals to GPs Lab test orders and reports between GPs and labs E-presciptions from GPs to pharmacies % digital 81 pct. 99 pct. 99 pct. 99 pct.

ehealth and Telemedicine The Shared Medication Record One national database containing updated information about prescription medicine for all patients in Denmark Access for all doctors, nurses,

16 ehealth and Telemedicine The Shared Medication Record One national database containing updated information about prescription medicine for all patients in Denmark Access for all doctors, nurses, dentists, pharmacists at hospitals. Viewing access for citizens (own data) Fully implemented in all hospitals and GPs during 2014, municipalities in 2015 Background: Reducing number of medication errors Better communication regarding medicine between all involved parties Improving the quality of the treatment

Citizens have access to personal health data such as: Selected information from Electronic

17 ehealth and Telemedicine Communicating with citizens Sundhed.dk - the official Danish ehealth Portal for public healthcare services. Citizens have access to personal health data such as: Selected information from Electronic Health Records from hospitals Life will, Lab reports, Home monitoring data, GP and specialist encounters Info on prescription medicine Organ Donor Registration

Telemedicine an example Telemedical ulcer assessment: The method - The nurse photographs the ulcer with her cell phone and mails the image to the doctor.

18 Telemedicine an example Telemedical ulcer assessment: The method - The nurse photographs the ulcer with her cell phone and mails the image to the doctor. - The doctor prescribes new treatment or new medication. - Communication between nurse and doctor is based on a shared web based patient record. - Positive Business case: - 30 per cent reduction of healing time - fewer visits by the municipal nurse - fewer outpatient visits to the hospital - 50 per cent reduction in number of amputations

Improved ulcer care skills from the direct communication with the experts in hospital Doctors and

19 Telemedicine an example Telemedical ulcer assessment: The pay-offs Patients: - High satisfaction - Less travelling - Can log on to shared web record, monitor own treatment Nurses - High satisfaction - Improved ulcer care skills from the direct communication with the experts in hospital Doctors and specialists in hospitals - Only see the most complicated ulcers - More exciting jobs, better use of public resources

Business case on national implementation of telemedicine for citizens with COPD Strong qualitative benefits for patients Compared to patients receiving traditional treatment, COPD-patients using

improvements in self-perceived ability to navigate through the health care system, including increased security in the cooperation with health professionals 3.

20 Business case on national implementation of telemedicine for citizens with COPD Strong qualitative benefits for patients Compared to patients receiving traditional treatment, COPD-patients using telemedicine experience: 1. Increased insight into own health, increased self-care and perceived competence on how to act when needed 2. improvements in self-perceived ability to navigate through the health care system, including increased security in the cooperation with health professionals 3. Positive effects on security, perceived health condition and overall quality of life Source: Anne Lee og Marianne Sandvei, Center for Anvendt Sundhedstjenesteforskning ved Syddansk Universitet, Tina Hosbond fra Socialstyrelsen, Jan Petersen og Kirsten Ravn Christiansen fra MedCom, Klinisk Integreret Hjemmemonitorering (KIH): Slutrapportering til Fonden for Velfærdsteknologi

21 Business case on national implementation of telemedicine for citizens with COPD Economic results, 5-year period (mio. Euro): Reduction in hospital admissions 64.3 Reduction in munici pal home care 0.9 Investments, mainly home monitoring equipment Operating costs, mainly health professionals' follow-up on data Other costs Total

22 ehealth and Telemedicine PRO Patient reported outcome (PRO) - better use of patients own knowledge on disease and treatment - a measurement of any aspect of a patient s health status that comes directly from the patient Food and Drug Administration (FDA) 2009 Individuel (patient) level: Individualization of patient care - "Needs rather than routine Streamlining of patient contacts - patient gives informs in advance Group level: Quality monitoring for quality improvement, management, etc. Clinical quality databases to assess the clinic's efforts

PRO the case of patients with epilepsy PRO the case of epilepsy: Patients with epilepsy are often a part of long-termed outpatient treatment Through regular questionnaires PRO is used to: Avoid

23 PRO the case of patients with epilepsy PRO the case of epilepsy: Patients with epilepsy are often a part of long-termed outpatient treatment Through regular questionnaires PRO is used to: Avoid unnecessary consultations and create a more flexible continuity of care Increase patient involvement Increase supervision and quality Based on the patient answers the system decides whether the patient needs to go to the hospital.

24 PRO the case of patients with epilepsy The patient answers the system decides: First question: Do you want do go to the hospital? Yes the patient will always go to the hospital No the patient will go to the hospital if needed based on the rest of the answers No need or wish for a consultation. The patient will receive an automatic answer and another questionnaire after xx months The patient could need a consultation. A clinician will decide based on PROM and other patient records(epr). The patient needs a consultation immediately

25 ehealth and Telemedicine Patient involvement and - empowerment Treatment as portfolio management and stratification Better health through better use of data Patient reported vs. citizen reported More health for the Money PRO A question of referrals an opening for big data

ehealth and Telemedicine The way forward Better use of ehealth systems already in place Better access for patients to own records and More advanced ict-support for communication and

26 ehealth and Telemedicine The way forward Better use of ehealth systems already in place Better access for patients to own records and More advanced ict-support for communication and cooperation between sectors Better use of health data Nationwide telemedicine initiatives where sound business cases nationwide dissemination of telemedicine for COPD-patients from 2016

27 Motivation for choosing Continua Motivation: Equipment reliability: We need to make sure the equipment is reliable and measures sufficiently to secure patient safety and procurement ex PROM in the case of patients with epilepsy. We found ourselves looking for an international metric-system Our Hospitals use different nomenclature: We have to use common denominators - to be absolutely sure how the data is defined and understood when we communicate across sectors from GPs to specialists from citizens to nurses. We need classifications both technical and linguistic A standardized system User and market perspective: Technicians and clinicians argued that standards was a good idea Our industry small and medium sized companies argued that it would be easier to develop new solutions if based on international standards. Producers argued that from a long term perspective solutions would be cheaper and more flexible based on standards.

28 Continua - some experiences Experiences: Procurers have made tenders based on Continua and are content. Two things are though still missing: 1) Consumer products still needs to be refined (ex batteries), 2) A broader range of products to choose from: To become a truly big contender on the market, Continua has to keep pace when it comes to new products and technologies We plan to move forward on telemedicine and patient reported data in the coming years and the continua standards are essential for multiple reasons: Patient safety Procurement Growth and innovation We see Continua as a variant of a new metric system part of our systeme internationale We want an open telemedicine infrastructure based on open international standards and profiles avoiding black boxes and data silos

29 Thank you for your attention

30 Building telemedicine on Continua Bjørn Astad Continua Open House Programme Paris, 24 June 2015

31 Presentation overview Health and care sector in Norway Empowering patients Personal connected health Continua 31

32 32 The Health and care sector in Norway

33 Healthcare systems facing challenges Public health expenditure Ageing population More chronic ailments Demands Workforce

34 Empowering patients 34 Patient at the center Use technology in a way that involves the patients in a different way

35 The National health portal 35 National Health Portal, Helsenorge.no helsenorge.no helsenorge.no din veiviser og hjelpende hånd til helse Self enablement Manage my health Renewal of prescriptions, Book an appointment Self-services My prescriptions, reimbursement status etc econsultation GPs and other healthcare professionals mhealth Self assessment, trackers, patient communities etc Health and illness information Better health in different phases of life Symptoms, diseases and treatment Access to health data Summary care record Access to information Log who and when? Register My vaccines, Birth history My care record I.e tests, discharge summaries, referrals Check your own data Navigate to the healthcare services Locate healthcare and care providers Feedback to the healthcare service Contact helsenorge.no Rights Established in 2011 Health and illness information My health (log in) E-consultation ( ) My health record (hospitals) My summary care record My e-prescriptions M-health Universell utforming og tilgjengelighet Én løsning tilpasset alle funksjonsbehov, tilgjengelighet for spesielle grupper

36 Personal connected health

NORWEGIAN FOCUS 2014-2020 Enable people to manage their own life and health longer National initiative to use new telecare services in the municipality health care National large scale project

37 NORWEGIAN FOCUS Enable people to manage their own life and health longer National initiative to use new telecare services in the municipality health care National large scale project using new telehealth services for people with chronic diseases National project using mhealth for reducing development of noncommunicable diseases (part of the WHO/ITU program Be Be Mobile)

38 Moving from pilot to scale "The plauge of pilots" Lock-in-situation Lack of standards Unique products from different suppliers (non interoperable)

39 Norway goes for Continua December 2014: Decision by the Norwegian Government Norway signs up as a promoter partner in the Continua alliance (PCHA) The national ICT architecture for PCH&C will follow the Continua framework Stimulate the Norwegian market to adopt Continua Nordic cooperation

Continua 40 Standardisation of personal connected health with Continua Products from different suppliers shall work together Easy information exchange

40 Continua 40 Standardisation of personal connected health with Continua Products from different suppliers shall work together Easy information exchange between different players Work for a common Nordic approach to achieve a common Nordic market Picture: Continua. PCHA: Personal Connected Health Alliance

41 Summary Empowering patients Large scale projects in Norway Moving telehealth from pilot to scale Standardization Continua

42 Thank you! Bjørn Astad

43 Transforming Healthcare through Personal Connected Health solutions in Sweden Per Mosseby CIO and Head of division

Swedish Local Self Government - Role of municipalities and county

planning, health and environmental protection, reuse collection

voluntary basis - Recreation activities, culture, housing,

services 21% of GDP Employs 30% of the workforce 80% of the

44 Swedish Local Self Government - Role of municipalities and county councils Municipalities Compulsory - Social services, schools, planning, health and environmental protection, reuse collection and waste disposal, rescue services, water and sewage On voluntary basis - Recreation activities, culture, housing, energy, industrial facilities, public transport 75% of public services 21% of GDP Employs 30% of the workforce 80% of the workforce are women County Councils Compulsory - Health and medical care, regional development

The Swedish Association of Local Authorities

45 The Swedish Association of Local Authorities and Regions (SALAR) A politically run organisation that defends and promote the interests of our members. SALAR represents Sweden s: municipalities - 20 county councils/regions Local democracy is the foundation of all our work

46 The mission of SALAR Monitor and safeguard the interests of the municipalities and the county councils/regions Act as an employers organisation Offer services and support for operational development Provide an arena for dialogue between members The composition of the Congress and the Board corresponds to the political situation in the municipalities, county councils and regions

47 Where do 9.6m Swedes live?

48 Some of our challenges The demographics an ageing population Increase of chronic diseases Increased cost for health care Challenge to deliver equal care Continuity of care gets harder with increased fragmentation Difficult to meet healthcare professionals' expectations of IT support with today's equipment and software Unclear division of responsibilities for e-health in Sweden government / county councils 48

49 How to meet these challenges? Cooperation and ehealth

50 Inera National e-health Inera is a company owned by the 20 county councils and regional common e-health and develop services for the benefit of citizens, patients, healthcare professionals and decision makers. The goal is to support care, strengthen the patient's position and create good access to health care. Yearly turnover 60m+ SALAR is in a process of acquiring Inera

51 1177.se National Health Care Portal Thousands of articles about health care, diseases, symptoms, medicines and treatments 7 millon visits per month

52 1177 Vårdguiden on phone First-line care Nurses on call centers across the country National phone number 1177 Shared medical decision support system calls per month

53 National Patient Overview

54 E-services Book an appointment See and renew prescriptions Order self-tests Follow your referrals and much more 2 million user accounts

55 Medical records online Patients can see the care records from clinic s EHR system

National e-health IT Infrastructure Patient Data

transfer within and between counties and regions,

56 National e-health IT Infrastructure Patient Data Act and the National e-health Strategy requires nationwide IT-components Ensures a safe, accessible and cost-effective information transfer within and between counties and regions, municipalities, government agencies, private providers and citizens

57 Many services with ONE joint infrastructure?! Common services

Good foundation Our national open architecture show how to build and integrate systems in a secure and cost-efficient manner Our new financial model (utilization-based) enables continuous evolution

58 Good foundation Our national open architecture show how to build and integrate systems in a secure and cost-efficient manner Our new financial model (utilization-based) enables continuous evolution of ehealth without the constraints of a limited national budget The open architecture and the financial model together enables us to invite the industry to utilize the IT and stimulate business development Stimulate innovations

59 Opportunities and new demands We must give citizens better tools to manage their own health and manage their own care We need a common framework for personal connected healthbased on international standards to create an interoperable ecosystem of connected health devices and systems.

60 Pilot projects spring 2015 Children with heart failure ECG measurement at home Surgical division heart failure weight and blood pressure Community Care weight and blood pressure

61 Strategy for Personal Connected Health and TeleCare Since 2014 SALAR and Inera has worked with a strategy for Personal Connected Health and TeleCare Following Continua design guidelines gives the possibility to start up in a small scale and thereafter grow Ongoing pilot projects will be evaluated during 2015 Nordic collaboration Plan for a political decision to join Continua in Sept 2015

62 Thank you!

Swedish e-health strategies and national e-services. 16 th November 2017

Swedish e-health strategies and national e-services 16 th November 2017 tomas.lithner@inera.se The Swedish health care landscape National level Regional level Local level (State) (Regions) (Municipals)