A collaboration model for co-production and implementation of technology-driven services in public health care

A collaboration model for co-production and implementation of technology-driven services in public health care INVOLVING THE COMMUNITY TO CO-PRODUCE PUBLIC SERVICES Good practice document

1 Contents 2 Executive Summary... 3 3 Introduction... 5 4 Good Practice background... 5 4.1 Existing Transferring Authority... 5 4.2 Context specifically related to the Good Practice and its development... 6 4.3 Rationale for the Good Practice... 7 5 Good Practice general description... 8 5.1 Name and acronym... 8 5.2 High level description... 8 5.3 Main objectives... 9 5.4 Stakeholders/who benefits?... 9 5.5 Distinguishing characteristics and features... 10 5.6 Main achievements and results... 10 5.7 Critical success factors... 10 6 Good practice implementation... 11 6.1 Planning... 11 6.2 Development... 11 6.3 Deployment... 11 6.4 Acceptance... 11 7 Good practice evaluation... 12 7.1 Evaluation mechanisms and methodologies... 12 7.2 Recognition... 12 7.3 Opportunities and areas of improvement... 12 8 Sustainability... 12 9 Transferability... 12 9.1 Lessons learned... 12 9.2 Recommendations... 13 10 Further information... 13 10.1 Contact details:... 13 10.2 Additional info... 13 Pag. 2

2 Executive Summary The project "Meldingsløftet Sogn & Fjordane" worked to introduce electronic messaging between local health services, general practitioners (GPs) and specialist care in the county of Sogn and Fjordane. Sogn and Fjordane, 1 one of Norway's 19 counties, is a challenging region for public services, owing to the great distances and demanding topography, including long fjords and high mountains dividing the landscape. Despite the regional characteristics constantly putting local infrastructure and communication to the test for the 26 municipalities in the county, the region has shown remarkable results in the field of e-health and new technology in health care. S&Fj was one of the first counties to complete the process of establishing electronic messaging between local health services, general practitioners and specialist care in 2014. Figure 1 Sogn and Fjordane County Only two years earlier, when the first stage of electronic interaction in health services between GPs and hospitals in Sogn and Fjordane was evaluated, it was "the long and winding road" that dominated: years of challenges and delays (Larsen & Skogseid, 2012). The evaluation of the final stage in 2014 however, tells about a project that fulfilled its goal in time with motivated and proud participants in short, it is told as a "success story" (Corneliussen, 2014a, 2014b). 1 The county of Sogn & Fjordane covers 18 623 km2 of mountains and fjords, with approximately 109 000 inhabitants. The municipalities has populations between 800 and 12 800 (Statistics Norway, 2015, http://bit.ly/20nd61t). Pag. 3

The project was organised with IT-Forum Sogn & Fjordane, a multi-stakeholder network, as a central organiser of the project. The system for electronic messaging was new for the local health services and they had little knowledge about the system when they started. All the 26 municipalities enrolled in the project in the first phase. Each municipality established a local project group involving health services as well as IT, and the project developed a checklist for the municipalities to follow. Figure 2 E-health for 26 municipalities in S&Fj One of the recognised success factors in the project was two municipalities acting as pilots in this project as well as in the larger project Vestlandsløftet, covering a larger region of Western Norway. The pilots were dealing with technical issues and contributing with knowledge, experience, user manuals and routines, as well as being motivators. In the evaluation process we found that once the initial technical challenges were solved, it was all running smoothly for most of the municipalities. The process had, however, required a willingness to enter a state of "learning by doing" for the municipalities to establish competence in a new method for communication. This meant that local "super users" and "enthusiasts" were of high importance. The project evaluation documented that the new system was perceived as increasing the quality of health care, mainly by turning previous oral messages into written communication, but also by improving contact between local health care, GPs and specialist health care. Pag. 4

The project "Meldingsløftet Sogn & Fjordane" completed its mission, making S&Fj among the first counties to complete the triangle of electronic messaging between local health services, GPs and specialist health care. The project organisation based on the multi-stakeholder network of IT- Forum was reported as important for the municipalities ability to comply with the national expectations to start using electronic messaging. IT-Forum Sogn & Fjordane is a multi-stakeholder network, involving a cross-sectoral group and with representatives from a selection of municipalities, the Health Trust, practitioners, county governor, research and industry. There was more than one driving force behind the process of establishing electronic messaging in the county, however, the cooperation across municipalities proved to be one of the most important single factors, and the multi-stakeholder network IT-Forum has been vital in initiating, planning, organizing and running the innovation projects for the public health care services in the region. The coordinated efforts, and particularly the tight coordination with the regional Health Trust is unique also in a national setting. 3 Introduction This guide highlights the key aspects of the Sogn and Fjordane model for e-health innovation in public services. The model is described based on the electronic messaging project described above. As part of the IMPROVE project, WNRI is working along the model described here with the municipalities and relevant stakeholders in the county of Sogn and Fjordane to promote innovation of health care services with the help of welfare technology. 4 Good Practice background 4.1 Existing Transferring Authority Type of authority (regional, municipal etc.) Municipalities and Helse Førde regional health trust. IT-Forum Sogn and Fjordane, a network of stakeholders from private and public sector. General Practitioners. Scale and size All 26 municipalities in the county of Sogn and Fjordane participated. Range of functions Pag. 5

Helse Førde is a regional health trust responsible for specialist health care services in the county of Sogn and Fjordane, with about 2300 employees. The municipalities' health care service is organized in each of the 26 municipalities, responsible for a range of tasks, from elderly care and people with special needs, institutions and home care services. In the process of moving patients between specialist health care and municipality health care services, these two levels are required to communicate and cooperate. General Practitioners are localised in the municipalities, some are private and some are employed by the municipalities. 4.2 Context specifically related to the Good Practice and its development National context The Coordination reform, starting in 2012 (HOD, 2008-2009), aims to improve efficiency in the health care sector, in particular by moving patients quickly from hospitals and specialist health care to municipalities, aiming to deliver health care as close to the patients' home as possible. A tool for achieving this was to fine municipalities if they were unable to receive patients as soon as they were considered ready to leave the specialist health care unit. The requirements in the reform increased the need for good communication between specialist health care, municipalities and GPs. The national goal set for electronic messaging in the health care sector was that it should be "the norm for exchange of patient information" between all involved parties by the end of 2015, supporting an increase in "information safety and accessibility." 2 Challenges around 2010-2012 The region experienced problems and delays in introducing ehealth projects. National ehealth infrastructure (=broadband net) was in place from 2007, but several competing ehealth systems in use in the municipalities represented a challenge for introducing new information and communication technology. There was some activity on creating national standardisation, however, the field remained to be not fully standardised resulting in huge interoperability problems. Local pilots were developed and worked for a while, but then stopped because of uncoordinated upgrades of technology. All of these challenges and frustrations resulted in lack of activity for almost 2 years. Regional and socio-economical context The municipalities in Sogn and Fjordane range between 800 and 13.000 inhabitants, and in many issues they experience that their size becomes a barrier to take on major projects to innovate their services, either voluntary, or like the electronic messaging, a required innovation. IT-Forum has 2 https://www.nhn.no/english/pages/electronic-messaging.aspx. Pag. 6

previously proved to be a successful network for working on behalf of the many small units. The purpose of IT-Forum is to initiate and coordinate "activities that promote efficient and developmentoriented use of information and communication technology in the private and public sectors", and to work "to strengthen and develop cooperation and coordination between agencies, organizations and businesses in Sogn & Fjordane." 3 Despite its informal structure and voluntary participation, IT-Forum has, with its goal-oriented and long-term visions, contributed to moving public positions from cities to rural locations in S&Fj, and it has secured an infrastructure investment of 300 million NOK in broadband in the county. Regional commitment At the annual ICT conference in the region autumn 2012, the main stakeholders of IT-forum participated in a session on ehealth. At this time the nation Coordination reform was about to start. The regional stakeholders in IT-forum made an agreement that ehealth should now be the highest priority in the regional collaboration as it was seen as fundamental and critical to a successful implementation of the national Coordination reform. This was the start of the revitalisation of the ehealth activities in Sogn and Fjordane. 4.3 Rationale for the Good Practice Introducing new technology and communication protocols requires modification and innovation in the services. Each municipality had a responsibility for innovating their communication methods according to the national requirements, however, the size and resources of the municipalities in Sogn and Fjordane made this a challenging task. By working together with IT-Forum as a host for a central project group, the municipalities did not have to "reinvent the wheel", and instead the central project group could establish necessary information and guidelines and make this available for all municipalities. 3 http://www.it-forum.no/. Pag. 7

5 Good Practice general description 5.1 Name and acronym Meldingsløftet Sogn & Fjordane (emessaging) A collaboration model for co-production and implementation of technology-driven services in public health care 5.2 High level description Meldingsløftet provides a collaboration model for co-production and implementation of technologydriven services in public health care. In this model for innovation of public services, each of the municipalities remain independent units, while the central project management is organised through a voluntary multi-stakeholder network. This way of organising an innovation processe ensures that different stakeholders necessary to achieve the goals are involved and co-production is acheived. The many small units become united and achieve a strength that each of the units alone will be unable to reach. This united strength makes the network, instead of each municipality, responsible for establishing knowledge, guidelines, and structures for cooperation and support. The network also becomes a candidate for winning in national and regional competitions for project funding, which is important for innovation processes in municipalities where scarce resources make "innovation" appear as an extra economic burden. The main driving factor in this model is therefore the collaborative network. Most of the development of knowledge, guidelines and routines is done in, or in close cooperation with the central working group of the network. Figure 3 IT-Forum Sogn & Fjordane: a collaborative network Pag. 8

5.3 Main objectives The aim of the project Meldingsløftet was to establish electronic messaging as the norm for communication between local health services, general practitioners (GPs) and specialist care. Electronic messaging improves and secures communication in the health care sector, bringing great benefits to all involved parts, as well as patients and relatives. The process of introducing technology requires change and innovation in routines, guidelines, practices as well as the technological equipment to support the new practices. The good practice described here is the model used to establish this new technology-driven service through the collaborative network of IT-Forum. This network served as a multi-stakeholder collaborative tool for the process, securing close involvement from all relevant stakeholders, and thus also a higher degree of co-production. 5.4 Stakeholders/who benefits? Managers, planners and IT in county and municipalities receive vital support through the network. National authorities benefit from the region being able to work in an independent way and from knowledge developed in the region. Relevant stakeholders in the region benefit from the openness of the collaborative network, in this case: service development (healthcare) The regional health trust needs to relate to each of the 26 municipalities, and the network becomes a communication channel to reach all of them. Local industry, in particular IT business, and educational institutions benefit from the open and inviting planning processes. Figure 4 IT-forum Sogn & Fjordane Conference 2013 The multi-stakeholder working group gathers actors from different sectors and various disciplines. In order to make a multi-stakeholder collaborative network work, it is necessary to facilitate and create Pag. 9

structures for dialogue across the actors, boundaries and disciplines. Thus, in an ehealth project like this, it is vital to establish connections between local experts working with infrastructure development (broadband) and service development (health care). 5.5 Distinguishing characteristics and features A typical structure for a project following this model could be described in four phases: a) Collect information about the status in the municipalities: what is their situation, and what do they need to achieve the goal of the innovation process. b) Establish a central working group to develop guidelines and checklists. c) Guidelines and checklists are spread to the municipalities, who will establish their own project group and work their way through the process of innovating their services according to the guidelines. d) Evaluate the project and report to share information across municipalities, as well as national, to health authorities and other regions. 5.6 Main achievements and results Through this collaborative model, all 26 municipalities in the county of Sogn and Fjordane managed to establish electronic messaging as a standard in the health care services nearly a year before the final deadline from the health authorities. Evaluation of the project revealed that the collaborative and management model was a major part of the success factor for the project. Presently a similar model is used to work with implementation of welfare technology in the municipalities in the county. 5.7 Critical success factors (Suggested format is bullet points) Organisational commitment The combination of a voluntary network and the municipalities commitment to the process, motivated by national e-health policy, as well as project funding that was possible to achieve because of the collective effort. Political commitment Political commitment was important for all involved organisations, both at regional and local level. Resources (incl. people, expertise, consultancy, hardware, software etc.) Project working group, pilot municipalities and enthusiasts were important resources for the project. Process Improvement and/or Change Management Pag. 10

Clear guidelines and checklists developed through the project were of vital importance for each municipalities' ability to start the implementation process. Technical factors Technical expertise, suitable equipment and good communication with technology providers is of high importance in a technology-driven project like this. Some of the major barriers and delays were caused by technical faults. 6 Good practice implementation 6.1 Planning IT-Forum, working group for e-health, was responsible for planning the project. A project proposal requesting funding was sent to the County Governor of Sogn and Fjordane. The project received funding, which secured financial support for establishing and carrying out the project, as well as evaluation at the end of the project. 6.2 Development The IT-Forum working group established contact with all municipalities, appointed the pilot municipalities responsible for testing equipment as well as for designing guidelines, routines and practices for implementation of the technology-driven service. A checklist was developed and distributed to all the other municipalities. A local working group was established in each municipality, including health care workers/leaders and IT expertise, as well as GPs. 6.3 Deployment Each municipality was responsible for their own process and for establishing a local working group with necessary level of expertise. All municipalities enrolled in the project, motivated by gaining access to knowledge and guidelines for the process, and by funding that could be requested after the project goal had been achieved in the municipality. 6.4 Acceptance The project was promoted through direct contact with each of the involved partners. Existing networks for communication and collaboration between municipalities were relevant contexts for encouraging participation. The check list as a tool for aggregation and dissemination of knowledge was important to create motivation for starting innovation in the local organisation. Pag. 11

7 Good practice evaluation 7.1 Evaluation mechanisms and methodologies The municipalities were encouraged to do measurements of cost benefit. The central project evaluated the project through interviews with a selection of project groups from the municipalities (Corneliussen, 2014a, 2014b). 7.2 Recognition The project and in particular the management and collaborative project structure have been well received by local and regional authorities. This was documented in the evaluation of Meldingsløftet, as well as by the ongoing project on welfare technology (Corneliussen et al., 2016), which is based on the same model. 7.3 Opportunities and areas of improvement As stated above, the same good practice has been the main model for working with implementation of welfare technology in the municipalities in Sogn and Fjordane, since 2014. 8 Sustainability What is needed to guarantee the sustainability of this GP Financial Resources: to secure activity in the multi-stakeholder voluntary network, and to motivate municipalities to engage in the process of establishing new practices. Human resources: enthusiasts and experts (champions) are vital for making this action model work. Network: The multi-stakeholder network with a high degree of trust, acting on behalf of all the municipalities, however without threatening the municipalities' authority or sovereignty. Connected to real benefits: Activities and goals need to be perceived as meeting real needs and be connected to real benefits. 9 Transferability 9.1 Lessons learned Collaboration makes small units strong together. Establish and nurture local and regional networks involving all key-stakeholders. Invite a broad spectre of stakeholders, but identify and nurture the champions. Pag. 12

Enthusiasts are important to drive the process. But enthusiasts cannot run a project alone! Knowledge transfer in the network supports the innovation process. Introducing technology in health care services requires expertise to deal with technological questions. 9.2 Recommendations In order to transfer this GP to another sector or region: Start with existing networks for communication and collaboration. Aim for a multi-stakeholder group at regional/local level. Develop and provide knowledge, guidelines etc. for participants. This will motivate their participation. 10 Further information 10.1 Contact details: Name of the contact person responsible of the BP Hilde G. Corneliussen Email address: hgc@vestforsk.no Telephone number: +47 4790 0814 Others (website, Facebook, Linkedin, Twitter, etc) of the organization/contact person http://www.vestforsk.no/en/employees/hilde-g.-corneliussen http://www.vestforsk.no 10.2 Additional info Links to additional info: Include here the links where additional information about the GP can be found (it can be a website, social media channels related to the GP, etc). http://www.it-forum.no/ http://it-forum.no/aktuelt/meldingslftet-i-kommunane-fase-ii Pag. 13

http://www.vestforsk.no/prosjekt/meldingsloftet-i-kommunane-fase-ii http://www.ushtsognogfjordane.no/velferdsteknologi/ Glossary Meldingsløftet (emessaging) a project aimed at implementing electronic messaging in the health care sector. Electronic messaging information about patients sent through a designated electronic system. Sogn and Fjordane one of 19 counties in Norway. IT-Forum Sogn og Fjordane a cross-sectoral action group working on a voluntary basis to "promote efficient and development-oriented use of information and communication technology in the private and public sectors". GP General Practitioner References Corneliussen, H. G. (2014a). Meldingsløftet Sogn og Fjordane - Små og tett på! Vestlandsforskingrapport nr. 8/2014. Corneliussen, H. G. (2014b). A Success Story about a Communication Reform in the County of Sogn & Fjordane'. In C. E. Moe & M. Fossum (Eds.), Proceedings from Scandinavian Conference on Health Informatics. August 21-22, 2014, Grimstad, University of Agder, Norway. Corneliussen, H. G., Strandos, M., & Grøtte, I. P. (2016). Evaluering av piloter i prosjektet velferdsteknologi i kommunene i Sogn og Fjordane: et prosjekt for å etablere lokal erfaring med velferdsteknologi. Vestlandsforsking-rapport. HOD. (2008-2009). Helse- og omsorgsdepartementet (2008 2009) St.meld. nr. 47: Samhandlingsreformen. Rett behandling på rett sted til rett tid. Larsen, Ø. H., & Skogseid, I. (2012). Electronic Interaction in Health Services and Organizational Change - Lessons from the Norwegian County of Sogn & Fjordane. IADIS International Journal on WWW/Internet, 10(1), 65-78. Pag. 14