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Denmark – An Impressive National Communication System

Denmark – An Impressive National Communication System. EPR in Danish Hospitals. 11/14 counties have an IT strategy for the health care sector. As of 2001, there were a total of 52 EPR projects in the country. The projects were in different phases and were controlled on different levels

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Denmark – An Impressive National Communication System

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  1. Denmark – An Impressive National Communication System Denis Protti - University of Victoria

  2. EPR in Danish Hospitals • 11/14 counties have an IT strategy for the health care sector. • As of 2001, there were a total of 52 EPR projects in the country. • The projects were in different phases and were controlled on different levels • Between 5% and 10% of all beds in Danish hospitals are covered by an EPR system. Denis Protti - University of Victoria

  3. What’s most interesting about Denmark is MedCom Denis Protti - University of Victoria

  4. Pre-MedCom • Late ’80s • A GP who also worked P/T in hospital biochemistry lab • Chief pathologist at the hospital • Head of IT in the county • Proposed a project for Funen County IT strategy • Electronically transmitting lab results Denis Protti - University of Victoria

  5. Medcom history • MedCom I: 1994 – 1996 • A two-year national project (MedCom) • Compile national EDIFACT standards for the most frequent text-based messages in Danish health system. • Develop communication standards for the most common communication flows between medical healthcare organisations and private companies • Establish a coherent Danish healthcare data network. • Goal: ensure regional healthcare data networks being developed make up a nationwide network. Denis Protti - University of Victoria

  6. Medcom history • MedCom II: 1997 – 2000 • Part of National IT Strategy • EDI standard following success of MedCom 1 • Target was 66% of all documents in health sector • Internet technology started to be used • Dentistry and telemedicine included Denis Protti - University of Victoria

  7. Medcom history MedCom IV: 2001 - 2005 • Project lines: • Internet strategy • Local Authority projects • EHR access and communication project • Funding: • 1/3 from Ministry of Health • 1/3 from County Association • 1/3 from Other Sources • Ministry of Social Services (recently) • Danish Doctors Association (early on only) • Dan NET • Danish Pharmacy Association Denis Protti - University of Victoria

  8. MedComNational health network • 30 different types of standardised EDI messages • Implemented in 40 different systems • 15 GP computer systems • 12 laboratory systems • 9 hospitals systems • 4 pharmacy systems Denis Protti - University of Victoria

  9. MedCom Facts • Used by ¾ of the healthcare sector • >2,500 different organisations • All hospitals, all pharmacies, all laboratories and ~1,800 general practices take part • ~Two million messages a month are exchanged (over 60% of the total communication in the primary sector) Denis Protti - University of Victoria

  10. Medcom status EDI has overtaken daily communication Denis Protti - University of Victoria

  11. Referrals Referrals Referrals Referrals 64845 = 45 % Reimbursement 15637 = 66 % Prescriptions Prescriptions 1139992 = 73% 1039105 = 73% Disch Disch . Letters . Letters 682923 = 85 % 826258 = 84 % Lab. Lab. reports reports 543040 = 82 % 653974 = 97 % Denis Protti - University of Victoria

  12. EDIFACT-prescriptions UNA:+.? ' UNB+UNOC:3+5790000120314:14+5790000172825:14+010430:1456+26++++1' UNH+15+MEDPRE:0:962:RT:SST012+Æskulap' BGM+PRS:SKL:SST++9' DTM+137:20010430145604:204' PNA+PO++291714:YNR:SFU+++US:Max Berggren+US:MedCom' ADR++1:Rugårdsvej 15++5000' COM+66133066:TE' EMP+4+PHY:SKL:SST' PNA+SE++5790000172825::9' DTM+97:20010430:102' RFF+CH:200118' ICD+DK:SKL:SST+NA:SKL:SST' GIS+ZZZ:SKL:SST' PNA+PAT+2512484916:CPR++++SCC:BERGGREN, NANCY ANN' ADR+1+1:PARK ALLE 48+Hillerød+3400++020:SKL:SST' LIN+1++385229:AK:NVN:LMS' IMD+A+DDP+:::creme' IMD+A+DNM+:::Diproderm' MEA+AAU+CT:::Tube a 60 g' MEA+DEN+S:::0,05%' PGI+10+NS:SKL:SST' QTY+189:1:NMB' PNA+GZ+++++AB:OR' CIN+9+222:LDD:LMS:mod eksem' EQN+2:ITE’ DTM+264:30:804' DSG+5+104:LDD:LMS:udvortes 2 gange daglig' TOD+2++OAD:SKL:SST'ADR+5+US:Vestergade 17++3400' PNA+AB+++++US:Knud Mosebryggersen' UNT+30+15' UNZ+1+26'

  13. Major Driving Forces • Communication benefits to physicians • Improves dialog with hospitals • Use to wait 5 days for results of tests (now almost as soon as it comes off the equipment) • Automatically notified when patient registered in an Emergency department • Discharge summaries now arrive within 1-3 days (use to be 4+ weeks) – standard set by Counties Denis Protti - University of Victoria

  14. Driving Forces (cont’d) • Out of Office Hours (OOH) system mandated • Started 1997 • >50% GPs using computers at the time • GP available from 1600 - 0800 hours (could be up to 3 GPs present) • ~30 sites across the country – some based at hospitals • Negotiated by PLO and County Association • GPs doctors had to use the OOH computer if they wanted to be paid Denis Protti - University of Victoria

  15. Driving Factors (cont’d) • Peer influence – collegial pressure • GPs go to see each others computers • PLO wrote conversion software to facilitate the transfer of patient data from one GP to another • Access to the Internet (2-3 times/day) • e.g. waiting times for x-rays for all clinics in Funen County • can see what procedures are done at each clinic • can decide with patient where they should go Denis Protti - University of Victoria

  16. Reasons for success • County Support • Training done by data consultant – visit all practices regularly • Practitioner coordinator for each specialty (psychiatry, general surgery, etc.) • Works minimum of 2 hours/month • Coordinates wishes of doctors to hospitals and vice-versa • IT agenda moved forward through them • Help desk • Provides GP with a diskette of all their patients when first starting Denis Protti - University of Victoria

  17. Reasons for success (cont’d) • Standards set by MedCom • Contract signed with Counties and PLO obliging everyone to use them • Clinicians and vendors involved! • MedCom tests and certifies vendor systems • Steering committee of paying agencies meets every 3 months to review compliance data - GOVERNANCE Denis Protti - University of Victoria

  18. New Zealand – Another Small Country Success Story Denis Protti - University of Victoria

  19. Denis Protti - University of Victoria

  20. New Zealand Facts • Over 95% of GP offices are using one of nine Practice Management Systems • 75% use their systems to electronically send and receive clinical messages such as laboratory results, radiology results, discharge letters, referrals, delivery of age-sex registers to their IPA/PHO, etc. • ~ 50% of GPs now use the Internet on a regular basis from their offices - including communicating with their patients. Denis Protti - University of Victoria

  21. New Zealand Facts (cont’d) • Specialists use of computers range from 30-90% depending on their region. The private specialist use of a full EMR is limited to 15-20%. • Like the Danes, GPs favor referring patients to specialists who are able to send information back to them electronically. Denis Protti - University of Victoria

  22. New Zealand Facts (cont’d) • Used by 75% of all healthcare sector organizations in New Zealand • All hospitals, radiology clinics, private laboratories • ~1,800 general practices. • > 600 specialists, physiotherapists, other allied health workers • Over 3 million messages a month are exchanged • 95% of the communication in the primary health care sector. Denis Protti - University of Victoria

  23. Driving Forces in New Zealand • Unlike the Danish success story, HealthLink received no government funding to initiate the service and its growth and success is based entirely on the market model of “supply and demand”. Denis Protti - University of Victoria

  24. Driving Forces (cont’d) • The development of IPA’s (Independent Practitioner Associations) encouraged the uptake of information technology in primary care in New Zealand. • IPAs paid the costs for their member GPs to access the HealthLink network as part of their membership services. • HealthLink facilitated change by offering an “electronic claiming only” service for claims submission free of charge for the first 6 months. Denis Protti - University of Victoria

  25. Driving Forces (cont’d) • The past decade has also seen the emergence of the new position of “Practice Manager” within a physician general practice. • The Practice Manager has become a pivotal person to assist with the installation, management and training for any physician office system. • The Practice Manager responsibilities include financial management, IT and the human resource function in larger practices. Denis Protti - University of Victoria

  26. As a result of these CDM applications of information technology in primary care: • Child immunization rates went from 75% to 95%. • Control of diabetes improved – for patients with HbA1c higher than 9, pre-enrolment was 34% and this was reduced to 7% post-enrolment • There was an 80% reduction in wait time for statins for diabetes patients. • Acute admissions were running at 9% per annum growth rate prior to HealthLink • By 2002, the growth rate was reduced to near 0%. Denis Protti - University of Victoria

  27. New Zealand’s critical success factors • A national health identifier NHI • Early adoption of HL7 • Development and acceptance of the 1993 Privacy Act and the 1994 Health Information Privacy Code along with “practical” implementation of these • Mandatory electronic claiming for GMS (government subsidies for GP care) • Collaboration with private and public organizations • Multi-vendor co-operation and understanding of the business opportunities Denis Protti - University of Victoria

  28. NZ critical success factors (cont’d) • Healthlink’s strategy has always been to work very closely with primary care physicians • to stay close to them and to support them. • HealthLink is intricately and comprehensively tied to the GPs • “like the parmesan in the spaghetti is how one observer described it”. Denis Protti - University of Victoria

  29. Other secrets to Kiwi successes • Primary care organisations are highly organised, they are fund holders on behalf of their members and thus take a fairly business-like approach to information strategy as well as which they have a clear understanding of their members' needs. • They compete with each other for members. • Healthlink has an informal user group whom they consult with frequently.  • Consists of 15-20 GPs around the country with whom they have worked with for most if not all of the ten years since starting. • They enjoy piloting new services etc. Denis Protti - University of Victoria

  30. Other secrets to Kiwi successes • Having strong technological skills for designing systems, interpreting standards and managing integration with other parties • It's key to get to a financial critical mass because only at that point can they concentrate on doing a good job (rather than just surviving). • They believe it is important that they survive on fees paid for value created, because if they relied on grants they would get fat and lazy and stop innovating. Denis Protti - University of Victoria

  31. United States – The Veteran’s Administration is leading the way Denis Protti - University of Victoria

  32. CALLS FOR ACTION • 1991 • Institute of Medicine (IOM) set forth a basic vision for use of information technologies in The Computer-based Patient Record: An Essential Technology for Health Care. • 1993 • General Accounting Office (GAO) urged the acceleration of message format and healthcare terminology standards development in Automated Medical Records: Leadership Needed to Expedite Standards Development. Denis Protti - University of Victoria

  33. The Formal Start to the EHR Journey • A Computer-based Patient Record (CPR) is an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids Institute of Medicine (IOM), 1991 http://www.nap.edu/books/0309044952/html/R11.html Denis Protti - University of Victoria

  34. To Err is Human: Building A Safer Health System First Report Committee on Quality of Health Care in America 2000 http://www.nap.edu Denis Protti - University of Victoria

  35. Crossing the Quality Chasm Second Report Committee on Quality of Health Care in America Released 2001 http://www.nap.edu Denis Protti - University of Victoria

  36. Errors occur because of system failures Preventing errors means designing safer systems of care Conclusion: A Chasm Exists Between Vision & Performance Compliments of Don Detmer, University of Cambridge

  37. CALLS FOR ACTION (cont’d) • November 2001 • INFORMATION FOR HEALTH: A STRATEGY FOR BUILDING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE • National Committee on Vital and Health Statistics Denis Protti - University of Victoria

  38. What is NHII? • Comprehensive knowledge-based network of interoperable systems (LHII) • Capable of providing information for sound decisions about health when and where needed • “Anywhere, anytime health care information and decision support” • NOT a central database of medical records Denis Protti - University of Victoria

  39. U.S. Hospital Record Records Returned Laboratory Results Specialist Record Requests for Records Temporary Aggregate Patient History Authorized Inquiry from LHII Index of where patients have records another LHII LHII system Patient data delivered to other LHII

  40. CALLS FOR ACTION (cont’d) • May 6, 2004 • HHS Secretary Tommy G. Thompson announced the appointment of David J. Brailer, MD, PhD as the first National Health Information Technology Coordinator. • The new position, will coordinate the nation's health information technology efforts. • Dr. Brailer is recognized as a leader in the strategy and financing of quality and efficiency in health care, with a particular emphasis on health information technology and health systems management. Denis Protti - University of Victoria

  41. CALLS FOR ACTION (cont’d) • June 2004 • Electronic health records for all Americans • Computer-assisted clinical decision support • Computerized provider order entry • Secure, private, interoperable, electronic health information exchange Denis Protti - University of Victoria

  42. July 2004 Strategic Framework Four major goals to be be pursued for improved health care. Each goal has a corresponding set of strategies and related specific actions that will advance and focus future efforts. CALLS FOR ACTION (cont’d) Denis Protti - University of Victoria

  43. Goal 1 - Inform Clinical Practice: • Bringing information tools to the point of care, especially by investing in EHR systems in physician offices and hospitals. • Goal 2 - Interconnect Clinicians: • Building an interoperable health information infrastructure, so that records follow the patient and clinicians have access to critical health care information when treatment decisions are being made. • Goal 3 - Personalize Care: • Using health information technology to give consumers more access and involvement in health decisions. • Goal 4 - Improve Population Health: • Expanding capacity for public health monitoring, quality of care measurement, and bringing research advances more quickly into medical practice. Denis Protti - University of Victoria

  44. The Leading American System:Veterans Health Administration Computerized Patient Record System (VistA) Denis Protti - University of Victoria

  45. VistA • Integrated computer-based medical record developed by Department of Veterans Affairs • Installed in all 172 VA medical centers • Includes clinician order entry, note entry, results review, imaging, decision support, remote data • Integrated with pharmacy, laboratory, dietetics, vital signs, nursing and bar code medication administration programs • User authentication with signature codes, business rules Denis Protti - University of Victoria

  46. Being adopted beyond the VA and outside the USA • US Federal Government – VHA, IHS • State Veterans Homes (WA, others) • DC Department of Health • States (West Virginia, Rhode Island) • Countries (Mexico, Jordan, others?) Denis Protti - University of Victoria

  47. Critical Success Factors • Top management support • Physician informaticist leading implementation • Committed clinical champions “in the trenches” • Well staffed knowledgeable clinical application coordinator (CAC) support team • Institutional commitment and culture • IRM, Clinical Services, HPM, QM • National networking, test site status, Clinical Application Coordinator “esprit de corps” • Excellent infrastructure and resources Denis Protti - University of Victoria

  48. VistA System Kudos • John Glaser, Ph.D. “The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the best in the world.” October, 2003 • Vice President & CIOPartners (Harvard) HealthCare System Denis Protti - University of Victoria

  49. VistA in the News • The Physician Executive – March-April 2004 “…frustration and disenchantment were widespread …. Several well-known technology vendors were subjects of biting criticism by name. Satisfaction with systems (in some cases from the same vendors) tended to be expressed in less than gushing terms.” “But there was one notable outlier from the nexus of negativity; the Veterans Administration. It received unwavering praise….” • Summary of results from almost 1600 respondents to a survey of American College of Physician Executives members regarding their organizations’ progress in implementing clinical information systems • Most indicated that problems and ordeals continue

  50. Impact of VistA? • Decreased length of stay • Reduced clinic visits per patient • Fewer adverse reactions, allergic responses • Decreased costs per patient • Improved formulary compliance Denis Protti - University of Victoria

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