SoTe- Tieran työpaja 29.11.2012 Madis Tiik
Miksi onnistui? Mikä on keskeistä terveydenhuollon järjestelmien uusimisessa? Mikä ei toimi/ onnistu?
Madis Tiik, MD Tartu University, Medical Doctor 1996 Nordic School of Public Health Diploma in Public Health 2003 Tallinn University of Technology, InsHtute of Clinical Medicine, lecturer, Phd student (defending on the 14th of December 2012) Chairman of The Estonian Society of Family doctors 2001-2008. CEO of Estonian ehealth FoundaHon 2007-2011 Current work Vormsi island, family doctor Finnish InnovaHon fund Sitra, senior adviser
e- Estonia PRECONDITIONS FOR SUCCESFUL IMPLEMENTATION OF EHEALTH
InformaOon Society By 2013 All public services are digitaly available Public infrastruture is service oriented (x road) Digital authorisaoon of users, based on the ID card, is the best available in the world Data is stored were it is collected and exchange of the data is available thous who need it
InformaOon society indicators 100% of schools and government organisaoons have broadband connecoon 71% of families have computer at home 68% of homes have broadband connecoon 99% of bank transfers are performed electronically 94% of income tax declaraoons made via the e- Tax Board Four operaoonal 3G and two 4G networks 1139 public WiFi areas for 45 227km² 24% of votes were cast over the internet on 2011 ( Parlament elecoons) E- census (jan2012) 815,467 persons have completed the quesoonnaire - 62%
ID- Card 2002 - introducoon of naoonal electronic ID- Card 1 163 917 acove ID- Cards Compulsory for all residents Contains: InformaOon shown on the card CerOficate for authenocaoon (along with e- mail address Forename.Surname@eesO.ee) CerOficate for digital signature Population: 1,340,415
X- Road was launched in 2001 Estonian Information System
Some achievements 2000: Launch of e- Tax Board 2000: Launch of m- Parking 2003: Launch of ID bus Ocket 2005: i- VoOng was introduced 2007: IntroducOon of m- ID 2007: Launch of e- Police system 2008: Launch of e- Health system 2010: Launch of e- PrescripOon
How we reached there? 1996: Tiger Leap FoundaOon to support ICT in schools 2001: Look@world starts to build 500 Public Internet Access Points 2002: Start of computer usage courses for 100 000 ciozens under Look@world project 2008: IT courses for healthcare professionals 15 000 doctors and nurses 2009/2010: Come Along, computer usage courses for 100 000 ciozens
Founders of the Estonian ehealth FoundaHon Ministry of Social Affars Society of Family Doctors Tartu University Clinic East Tallinn Central Hospital Union of Estonian Medical Emergency North Estonian Regional Hospital Estonian Hospital AssociaOon Estonian ehealth FoundaOon Board Management Board Strategy and Architecture Development EHR OperaOon MarkeOng and Channel Management Family doctors Hospitals Nursing Care PaOent Portal Health AuthoriOes Governance End users
Current situaoon ACTIVITI INDICATORS
More than 75% ciozens has digital documents in the EHR (989 338 persons) 555 Healthcare providers have send documents to the EHR 47 314 ciozenz have viuwed his/her data 768 have made expressions of will/ preferences
Most popular documents Ambulatory consultahon notes 2 311 506 Hospital discharge leyers 897 944 Image address links 1 139 790 ConsultaHon notes/image reports 1 508 306 ImmunizaHon notes 50 590 Altogheter 20 standardized medical documents
E- prescriboons 1 000 000 900 000 800 000 700 000 600 000 500 000 400 000 300 000 200 000 100 000-1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 issued sold
Paper prescripoons 16,0% 14,0% 12,0% 10,0% 8,0% 6,0% 4,0% 2,0% 0,0% july august sept oct nov dec jan feb march april may October 2012 4,6%
FUTURE
ICT and healthcare in Estonia PaOent empowerment Somware's for hospital and for GP in 1994 Digital claims since 1995 Equipping GP- s with PC- s 1998 Skipping paper claims 2002 Legally allowed to use only digital paoent record since 2002 Local EMRs Digital Claims & Reimbursement Time 1992 2010 2015 2020
ICT and healthcare in Estonia PaOent empowerment Secundary use of data Health seroficate 2010-2013 IntegraOon with social care 2011-2012 EbmDS decision support service 2011-2013 Integrated staococ 2010-2013 Clinical registries 2011-2013 InformaOon Exchange Central EHR 2005-2008 Health Portal 2009 Registries IntegraOon ( non clinical) 2008 StandardizaOon 2007-2012 IntegraOon of different user groups 2009-2013 Local EMRs Digital Claims & Reimbursement Time 1992 2010 2015 2020
Electronic medical records (EMRs) and IT. By 2020, health systems will move from predominantly paper records controlled by the industry to predominantly digital ones controlled by individuals. Ninety percent of health leaders surveyed said making EMRs available to clinicians and pa=ents would make their systems more efficient and effec=ve. But effec=ve implementa=on will be difficult and expensive. HealthCast 2020
Factors ContribuHng to Early Mortality Behavior 40 % Medical Care 10 % Environment 5 % Social 15 % Genetics 30 % McGinnis, et al., Health Affairs; 21(2), 2002
Health Care Costs Public Health and Preventive Measures 5% Curative Medicine 95 % McGinnis, et al., Health Affairs; 21(2), 2002
Empowering Citizens Focus PHR EHR systems PHR PrevenOve care Health care Amer care With the help of advanced ehealth services a ciozen can take control of his well- being before ailment. The variety of ehealth services enable the ciozen to have a holisoc view of his health. Healthcare professionals can use the rich background data that is stored in TalOoni. TalOoni enables a smooth informaoon flow between professionals and systems. Advanced ehealth services enable cost effecove and effecove amer treatment. Quick responses to changes in healing process and personal treatment foster faster recovery from ailment. TALTIONI
Finish populaoon (5.4M), based of the risk calculaoon Very high risk 60 000 High risk 200 000 Low risk 800 000 Self- care, prevenoon 4 340 000 Hospital care High specializaoon GP, outpaoent care Supported Self- care Walk in clinics Home monitoring PaOent centric team MoOvated, supported ciozen
ICT and healthcare in Estonia PaOent empowerment Value Added services Personal SimulaOon 2015 IntegraOon wth - Environment data 2015? - Behaviour data 2015? - GeneOc data 2013? Secundary use of data Health seroficate 2010-2013 IntegraOon with social care 2011-2012 EbmDS decision support service 2011-2013 Integrated staococ 2010-2013 Clinical registries 2011-2013 InformaOon Exchange Central EHR 2005-2008 Health Portal 2009 Registries IntegraOon ( non clinical) 2008 StandardizaOon 2007-2012 IntegraOon of different user groups 2009-2013 Local EMRs Digital Claims & Reimbursement Time 1992 2010 2015 2020
EHR SYSTEM
Analysis Follow- up Policy- making Treatment Campaigns Lifestyle Public Services Self- help Estonian EHR =EMR+PHR Tele- advice Appointment PHR Guidlines DiagnosOcs Workflow NoOficaOon PrescripOon
Access rights for EHR All healthcare providers must send data to EHR Regulated by the law Access only to licensed medical professionals The asending doctor concept ID card for authenocaoon and digital signature PaOent has the right to close his/her own data collected to the central database (opt out) CiOzen can access their own data CiOzen can declare their intenoons and preferences CiOzen can monitor visits to their EHR 29
Architecture of Estonian healthcare IT STATE AGENCY OF MEDICINES - Coding Centre - Handlers of medicines HEALTH CARE BOARD - Health care providers - Health professionals - Dispensing chemists POPULATION REGISTER BUSINESS REGISTER HOSPITAL ( HIS) integrahon 2009 FAMILY DOCTORS 2009 PHARMACIES 2010 january SCHOOL NURSES 2011 september EMERGENCY MEDICAL SERVICE 2012 X- Roads, ID- card, State IS Service Register PATIENT PORTAL 2009 HCP PORTAL 2011 XROADS GATEWAY SERVICE 2009 PHARMACIS AND FAMILY DOCTORS 2009 ehealth FoundaHon EHR SYSTEM 2009 Health Insurance INSURANCE REGISTER CLAIMS & REIMBURSMENT PRESCRIPTION CENTRE 2010 january
ApplicaOon Services of NaOonal EHR CiOzen Doctor Official StaOsOcan Register Health Portal Home Wearable Devices and Telemedicine services HCI Lab Registry PrescripOon Centre Systems Public IT Infrastructure Standards and Services WSDL XSD Processes and IntegraOon Health record Health status Booking Reports Ambulance 2012 Laboratory 2012 Document archive StaOsOcs Decision Support Demo- graphics Concent 2012 2012 2013 Long Ome archive
Lessons learned IMPACT STUDY PROCESSIS MISTAKES
DistribuOon of costs and benefits of Estonian e- Health plauorm (Digimpact study 2010) : Total cost of EHR system development (2005-2010) has been around 10M - it is 7.5 per ciozen hsp://eng.e- tervis.ee/digimpact- final.html
Vähemmän perusamasomia Oikea lääkitys oikeaan aikaan ajanvarauksia Vähemmän vaarallisia tai turhia tutkimuksia PoOlaan kirjaamat oma- hoidon seurantatulokset LääkärikäynOen korvaaminen hoitajakäynneillä Työajan käytön opomoino KomplikaaOoiden ehkäiseminen Omahoidon tehokkaampi tukeminen Lyhentyneet käynoajat Henkilökohtaisen poolasoedon laajempi hyödyntäminen Hoidon/lääkityksen tutkimukset ja seurannat henkilötasolla Vuorovaikutuksellinen ennaltaehkäisevä ote Hyödyt Kansalaiselle Palvelun tuosajalle Yhteiskunnalle Terveysjärjestelmän Jatkuva kehisäminen Laskutus Rekisterit Lääkemääräykset A PACS B Kroonisten sairauksien hallinta 15 Years of ehealth development Palvelut HIS C D DiagnosHikka Palveluprosessi E EHR Sairauskertomus F Hoitopolkujen toimivuus Reseptit G DokumentaaHo MääriYele käyyäjät Työprosessi EHR PoHlasHedot GP-s EMR InnovaaOot terveydenhuoltoon Palvelun käyyäjä Prosessi Tunnistautuminen X- väylä Haasteet Liiketoimintaprosessin kehisäminen Ydinprosessit Tukiprosessit Osapuolet, sidosryhmät Tiedot, materiaalit Yhteiset palvelut Mallit Sisältöjen määrisely ja standardoino Palvelutasot Omistajat Palvelujen käysäjät Palvelujen tuosajat Sovellusten integraaoot Tiedonkulku Käysöoikeudet Tiedon jakaminen Muutosten koordinoino MonitoroinO Ross&Tiik 2011
Success factors for NaOon- wide EHR system implementaoon Clear governance Establishing the Estonian E- Health FoundaOon Strategic decision making is done by the Supervisory Board of EEHF that is comprised of representaoves of main stakeholders in the healthcare. Access rights to the data, privacy and security of the data usage and using data for secondary purposes. The concept of asending physician Role asending doctor was taken also basic for the legislaove act and designing access rights to access in to the EHR system. StandardizaOon is one of the most criocal condioons for fluent data exchange
Were are the problems? Only 30% of GP- s sending agreed amound of documents regularly Signing the documents are not solved in convenient way Fear to show each notes to others and to paoents Not sufficient IT component in pricelist Schoolhealth, home nurses Conflict of interests
However If you ask me...... what could we done beser...and what have we learn Start with analyzing business processes in healthcare OpOmizaOon of the processes, before standardizaoon Pick- up a right technology to support the process Without knowing the process >do not start any projects Process- >StandardizaOon- Services/technology Support endusers with financial iniciaoves Clear governance Decide who is responsible for whole ehealth development Do not change it during the process Guarantee strong poliocal support Find enthusiasoc leaders Find best services start with Set realisoc Omeschale for projects Must have a vision, goal 37
Madis Tiik madis.tiik@eesti.ee THANK YOU!