Twenty years experience by implementing ehealth in the Danish Health Care Services Morten BRUUN-RASMUSSEN mbr@mediq.dk HIQA. Dublin. 7 th April, 2011
AGENDA 1. The Danish Health Care Sector 2. Analysis of the ITC strategies 3. The Health Care Data Network 4. The ehealth Portal 5. Shared Medication Record 6. National Tele Interpretation Service 7. Chronic diseases management 8. Recommendations
The Danish Health Care Sector
Denmark Parliamentary democracy and constitutional monarchy 5,5 mill. inhabitants 90,1% Danish 9,9 % other 5 Regions 98 Municipalities Equal and free access to healthcare
Health Care System: Administrative levels National Ministry of Interior and Health Regional 5 Regions Local 98 Municipalities
Health Care Providers 3 sectors Primary Care Responsible for: General health problems including prevention and chronic diseases Hospitals Responsible for: Specialised treatment and intensive care Municipalitie s Responsible for: Prevention, rehabilitation and social care
Primary Care GP s are self employed and are gate-keepers GP s are paid a basic fee (30%) and a fee for services Most patients are linked to a specific GP (family doctor) 90% of all patient contacts and services are kept in Primary Care 3.500 GP s in 2.100 clinics 1.000 Private specialists 250 Pharmacies 2.700 Dentists 1.829 Physiotherapists 224 Chiropractors 726 Psychologists
Hospitals Hospitals are operated by the 5 Regions Somatic and psychiatric 63 Public Hospitals 60 Private Hospitals/Clinics 16% of the cost
Municipalities Prevention Monitoring and information Children's health Home nurses Home care Treatment of drug and alcohol abuse Rehabilitation Dental care
ehealth organisation (Jan. 2011) National Board of ehealth Ministry of Interior and Health National Board of Health MedCom Danish Regions Danish Regions ehealth org. Sundhed.dk Local Government Denmark Danish Institute for Quality and Accreditation in Healthcare Danish Quality Unit of General Practice
Analyses of the ICT strategies
IT in health care The vision is to have access to the individual patient data across organisations Denmark has a history of e-health strategies 1995: It political action plan 2000: It in the hospital system 2003: It for the health services 2008: Digitalisation of the health sector The objective of the strategies have been different and have been analysed
Analysis: Scoring of the content The content of the four strategies have been analyzed and scored (0-100%) in five groups: Business support Infrastructure, technical Infrastructure, clinical Governance Stakeholder involvement Low score is given for: A general description and lack of specific actions High score is given for: A detailed description with specific actions
Analysis: Spider diagram
Strategy #1 - Objective IT political action plan 1995 Establishment of a health care data network, for the systematic exchange of information between doctors, hospitals, pharmacies, municipalities and health authorities before the end of year 2000 Development of a national standard for Electronic Health Record (EHR) for hospitals and general practitioners.
Score:1995-1996
Strategy #1 - Outcome IT political action plan 1995 A new organisation (MedCom) was established The first version of the Danish Health Care network was established. The health care network was a closed network based on interconnecting agreement by private Value Added Network Operators (VANS) No standards for EHR was identified and/or developed.
Strategy #2 - Objective National strategy for it in the Hospital system 2000-2002 To point out the necessary initiatives for the Hospitals it systems, in order to support the work and realisation of the political healthcare goals High health professional quality Clear information and short waiting times High user acceptance Better information regarding service and quality Efficient use of resources
Score: 2000-2002
Strategy #2 - Outcome National strategy for it in the Hospital system 2000-2002 Implementation of messages in the health care sector. Today (January 2011) more than 5,5 million messages are exchanged every month between primary care, secondary care and pharmacies No standards for EHR was identified and/or developed.
Strategy #3 - Objective National IT strategy for the health services 2003-2007 Ambitious with 29 initiatives in three areas Clinical workplaces in the health services National registries and databases Coherent access to information Focus on EHR in all Danish Hospitals by 2005
Score: 2003-2007
Strategy #3 Outcome (1/3) National IT strategy for the health services 2003-2007 Establishment of a Danish public health portal (www.sundhed.dk). The portal includes access to clinical and patient information as well as a number of services Start translation of SNOMED CT (side effect -> establishment of IHTSDO in Copenhagen) EHR coverage (beds) in Hospital increased to 50% (not all systems are full EHR) National medication profile on Sundhed.dk Internet based Health Care Network Messages between Hospitals and Municipalities
Strategy #3 Outcome (2/3) National IT strategy for the health services 2003-2007 Extract from HIS/EHR systems to a national repository A lot of debates regarding EHR model, terminology and clinical content The development/implementation of a Danish standard for EHR failed No standards for EHR on national level by the end of 2007 A lot of negative publication in the news.
Strategy #3 Outcome (3/3) National IT strategy for the health services 2003-2007 Political discussion regarding the lack of EHR in the Danish Hospitals (eq. one system for whole Denmark) A strategy check-up is needed! Minister of Health Lars Løkke Rasmussen March 2006
Strategy #4 Digitalisation of the health service 2008-2012 New IT strategy keep the high ambition A tool for the employee to create quality and productivity Better service for involvement of patients and citizens Stronger collaboration to create coherence Strategy and action plans are separated
Score: 2008-2012
Score: 1995-2012
Score: 1995-2012
The Health Care Data Network
National Registries National Patient Registry (1977 ) National Cancer Registry (1942 ) Pathology Registry (1997 ) Death Registry Quality Databases (more than 80) Patient Safety Database and many more
Cross sector communication National health network (1992 ) Frequent messages in large volumes Discharge letters, prescriptions, lab. request and results, referrals, consultation notes... More than 100 profiles (Jan. 2011) Vendor systems are tested by MedCom www.medcom.dk
Test results are published
5.5 mill. messages per month
The ehealth Portal
The ehealth portal Was launched in 2003 Was relaunched on a new platform 2009 Target audience = Citizens (incl. Patients) as well as Health Professionals across sectors Integrates data from 85 (existing) sources
Citizens/patient access Directory of names and addresses Medical information (eg. information about treatments) Waiting list information from hospitals Preventive medicine Health laws and regulations Patient to patient dialogue in online patient networks Online Electronic Health Record from hospitals Personal Electronic Medicine profile Overview of personal medical history since 1977 (list of contacts with hospitals) Online Organ Donor Registration Online Living Will My log (lets the patient see which health professionals have accessed their personal data)..and more
The ehealth Portal Features: Citizens Directory of names and addresses Medical information (drug, procedures..) Waiting list information from hospitals Preventive medicine Health laws and regulations Patient to patient dialogue in online patient networks Online Electronic Health Record from hospitals Personal Electronic Medicine profile Overview of personal medical history since 1977 (list of contacts with hospitals) Online Organ Donor Registration Online Living Will My log (lets the patient see which health professionals have accessed their personal data)..and more
The ehealth Portal Features: Health Professionals Information for GP s Online Medical Handbook ICPC search of diagnoses from GP s electronic health Record System Complete cross-sectoral list of health and prevention programs offered by municipalities or hospitals. Waiting list information from hospitals Encyclopedias (Cochrane etc.) Access to edit information on the clinic s presentation on the portal. Regional data Contact information (authorities, departments, health personnel) Visitation information from hospitals/regions Preventive medicine Health laws and regulations Laboratories and consultants Patient data Online Electronic Health Record from hospitals Cross-sectorial personal electronic medicine profile Web access to laboratory data Treatment feedback and benchmarking data regarding current patients with diabetes etc.
Shared Medication Record (SMR)
SMR: Paradigm shift FROM sending TO sharing
What is SMR? Central SMR service A Serviceprovider of online medication data to share and update Secure Healthcare network Serviceplatform Local EMR/EHR - Transport -Security, - Connection Local serviceconsumer that uses online data via a distributed serviceplatform
SMR and EHR in Hospitals
SMR on mobile devices
Home Care access from ipad
National Tele Interpretion
Interpreting in the Health Sector Demographic changes 340.000 immigrants and descendants from non-western countries Approximately 75.000 interpreting sessions a year in hospitals Approximately 130.000 interpreting sessions a year in GP clinics Unmet needs GPs 75% have patients requiring interpreters each week 59% use interpreters each week Hospital doctors 41% have patients requiring interpreters each week 21% use interpreters each week Ethnic minority health profile Over-representation of Type 2 Diabetes, muscular disorders, post-traumatic stress syndrome and other lifestyle diseases.
Work process
Video interpreter service pilot scheme at Odense University Hospital Five-month pilot scheme 85 interpretation sessions, 2 languages Significant time savings compared to using traditional interpreting services Regional solution being implemented Outline solution for national interpreting service
National tele-interpreting project Nationwide expansion of tele-interpreting in health services, with the main emphasis on regional hospital services: 90% of relevant hospital wards by the end of 2012 Pilot projects in general practice and municipalities Establishment of national hub for secure video conferencing for tele-interpreting use and for re-use in subsequent national expansion projects within the framework of the Digital Health programme of tele-medicine and home monitoring, including tele-psychiatry Budget: DKK 41 million for nationwide expansion from the ABT Fund in the years 2009-2012
Chronic Disease Management
Chronic diseases Extent (estimate for Denmark) 1,7 mill. lives with one or more chronic diseases 0,5 mill. with intense reduced functionality Public expenditures are 20 billion EUR per. year 80% of the health care cost Special attention to Diabetes (220.000) Cancer Cardio vascular diseases (320.000) Osteoporosis Asthma COPD Psychological diseases
Interoperability (ALT model) Organisational level Continuity and quality Application level presentation functionality Clinical Interoperability presentation functionality Logical level clinical content terminology Semantic interoperability clinical content terminology model model Technical level format & storage transmission Technical interoperability format & storage transmission Communication
Shared Care Platform Data capture module General Practitioner Hospital Shared Care Platform Municipality Patients at home
Home monitoring
Recommendations Use a participatory approach Include the end-users from the beginning Build on the top of existing knowledge and existing projects Copy as much as you can from other projects Divide the work a winning project or a role to everybody Start small and scale up Keep it simple the complexity will come by itself during the realisation Be realistic regarding resources and timescales
Thank you.. Morten BRUUN-RASMUSSEN mbr@mediq.dk Acknowledgement MedCom: Ib Johansen (ijo@medcom.dk) MedCom: Lars Hulbæk Fog (lhf@medcom.dk) National Board of ehealth: Ivan Lund Pedersen (ilp@nsi.dk) Sundhed.dk: Morten Elbæk Pedersen (mep@sundhed.dk) South Region Denmark: Tove Lehrmann (Tove.Lehrmann@regionsyddanmark.dk)