Insider report: Establishing public health e-services in Croatia

1. Insider report:Establishing public health e-services in Croatia Damir KalpićFaculty of Electrical Engineering and ComputingUniversity of ZagrebUnska 3, 10000 Zagreb, Croatia http://www.fer.hr/Damir.Kalpic/ damir.kalpic@fer.hr

2. History PRESENTATION BASED ON RELATED OCCASIONAL PERSONAL/INSTITUTIONAL ENGAGEMENT Topics: • Sporadic computerisation efforts / Islands of computerisation • Croatian Health Insurance – WB Loan in ’90-ties • WB Loan for health computerisation in a Croatian county • Study of computerisation for the largest Croatian hospital complex in 2002 (KBC Zagreb - FER) • Public tender for software in 2002: • Primary health care (Cap Gemini, E&Y) • Central Server of Primary health care (Cap Gemini, E&Y) • Hospital information system • Evaluation of the procurement status in 2004 (FER) • Telemedicine

3. Sporadic computerisation efforts / Islands of computerisation • Developments: • based on occasional donations • based on occasional injections of money • based on local enthusiasm & incentives • by own modest computing staff • Partly functionally satisfactory • Not integrated • Not maintained

4. Croatian Health Insurance – WB Loan in ’90-ties • Alphanumeric application (Informix, Unix) • Whole country covered • Functionally adequate • Never fully completed • Improperly maintained • Due to (unnecessary?) dispute with the developer • New version currently under development

5. WB Loan for health computerisation in a Croatian county • Bidding announced (only) in Financial Times of London • International references required • BIS Healthcare Group, UK had them: • Macedonia • Bosnia & Herzegovina • Did not have even a Web site • Project in Croatia: Copy & Paste from Macedonia

6. WB Loan for health computerisation in a Croatian county (cont.) • Findings after a few million £: • Unfortunately, there is no computing expertise in Croatia • If patient’s data are stored in a database, they can be retrieved later • If patients visits are scheduled via Internet, they do not have to wait so much, etc. • Results: • WB forbade to BIS Healthcare Group to apply for WB financed projects for a number of years • The responsible person in Croatia moved to a better paid position

7. Study for computerisation of the largest Croatian hospital complex (KBC Zagreb) in 2002 • Large, complex, heterogeneous • Different levels of computerisation • Weak in-house IT Department • Large savings possible, especially on medication • Tendency to buy an ERP after a WB loan • Advice: • Instead of paying back the loan, finance the gradual improvement by local contractors • If WB loan & ERP: • Payment according to achieved and user-accepted functionality, not on consultant*hour base • Licence prices according to per capita GDP • What happened?

8. ERP Maturity testCampbell R. B., “ERP: Show me the Money! Axilogic Consulting Inc. http://www.axislogic.com/erpstory.htm (2002) • You have a company strategy. • Your employees (management at least) know the details of this strategy. • The strategy includes an action plan so that it will be met. • You see IT as an enabler and do what is required to keep it up. • Your IT management is close to your business organization. • Management is aggressive and is willing to take risks. • Management is good at communicating goals and measuring progress. • The organization is structured in a comprehensive fashion. • Employees have a taste for change and innovation. • Your organization has successfully completed 'large' projects in the last five years.

9. Primary health care(G2) Public tender for software in 1998: Bidding published in a local (Čakovec) newspaper Oracle based application for nurse & doctor CASE produced and unpolished Developers ignored feedback from doctors & nurses Failed! Public tender for software in 2003: 5 solutions for general practitioners accepted and regionally assigned Smart ID cards for medical staff temporarily introduced Pilot project with connection to the central health server Delayed deployment – allegedly until the end of 2005

10. Central Server of Primary health care(G1) • Cap Gemini Ernst & Young tender: • Central Server of Primary health care • Developer Ericsson Nikola Tesla • Central Health Server

11. Role of G1 as seen by developer

12. G1 Architecture

13. National Information System on Health Infrastructure based on G1 • System architecture: • Multi-tiered communications, • Component based design, • Asynchronous point-to-point communication, • Usage of open systems norms and recommendations. • Main components of NISHI are: • HCSI (HealthCare System Integrator), • EPRS (Electronic Population Register System), • HRRS (Health Resource Register System), • EHCRS (Electronic Healthcare Record System), • HCP (Health Care Portal).

14. Hospital information system • About 3000 required functionalities in the tender(Dr. Dragan Schwarz’s tender) • A year period to establish representative functionality • All activities regarded as part of the bidding procedure • No financial compensation for developers • Tough conditions – only the strongest could afford it • Very favourable for the purchaser • In April 2003 4 suppliers were chosen and assigned to 4 hospitals • In February 2004 Ministry of finance cancelled the bidding!

15. Hospital information system (cont.) In July 2004: • b4b – a Croatian SAP based developer • After cancellation continued with developments • High integration and functionality • Working with historical data • Ready for a (risky?) Big Bang deployment • Ericsson Nikola Tesla Consortium including smaller developers with relevant experience • After cancellation continued with developments • Partly integrated and modest functionality • Developed components in full use • IBMCroatia • Allegedly the world’s best hospital SW • Did absolutely nothing! • AME, Austria • After cancellation went home

16. Evaluation of the procurement status in 2004 • Recommendations after evaluation: • G1 • Good concept as central health server, not primary health alone • To continue with developments • G2 • Pay to developers and deploy their solutions • Hospitals • Restore the legal status of the bidding • Continue with both systems • Acceptance test on real data • Let them both survive if they deserve

17. Telemedicine • In 2005 Kovač & Kalpić in the Procurement Committee for TM equipment • Meticulous considerations which bidder is better • No organisational efforts by the Ministry for TM deployment • Result • TM equipment purchased for the Adriatic islands but mostly unpacked?

18. Further developments (1) • Suggested Coordination Board for the Health IS: • Ministry of Health • Croatian Health Insurance Institute • Representatives of hospitals • Representatives of primary health care • Public Health Institute • Representatives of developers • FER? • Why?Coordination problems: • Health Insurance Institute does not accept reports on CD but rather on printed A3 • Glue on recipes to be printed disables printers • Hiding of citizens’ unique identification number • Unilateral decisions, regardless on other stakeholders, etc. • Supported by (most) stakeholders • Never constituted!

19. Further developments (2) • Report accepted but the Ministry did not do anything for a year • Popular TV contact show (Otvoreno, Hloverka Srzić Novak) in 2005: • Primary health care software developers • Actual and former Minister of health • FER (Kalpić) • Result: • (New) Minister obviously misinformed • The person in charge in the Ministry of health was selling his SW product instead • Fired after the TV show

20. Current status • FER (Kovač & Kalpić) nominated to the Committee for procurement of the Integrated hospital information system • New tender for 7 hospitals announced for February 2006 • Consider saving the existent solutions • Too many at a time! • Do not forget the role of G1, the hospitals cannot communicate among themselves • Primary health care allegedly deployed? • Smart ID cards to be introduced in the future with resumed Unique Citizen’s Identifier

21. Speculation about conclusion • Significant rationalisations possible through IT • Romania (Info World): 30% savings • Insufficient care regarding computing expertise within the Ministry of health • Not enough legal security for SW suppliers • Same pattern of behaviour as 35 years ago! • Public biddings time & place: • End of July • Between Christmas and New Year • A village newspaper XOR Financial Times • MOTIVATION FOR SUCCESS?

22. Related published papers • D. Kalpić, K. Fertalj, V. Mornar, M. Kos: A Proposal for Information System Development for Clinical and Hospital Centre Zagreb, 1st Croatian Congress on Telemedicine with International Participation, Abstract, Ivica Klapan (ed.), Makarska 16-18.05.2002. • D. Kalpić, V. Mornar, M. Kovač: Personal authentication and privacy protection on Internet, TELEMED 2004, 2nd Croatian Congress on Telemedicine with International Participation, Zagreb, 19.05.2004. • D.Kalpić, Damir; Mornar, Vedran; Kovač, Mario; Fertalj, Krešimir; Kos, Mladen: An insight into efforts to establish computerization and e-services for public health in Croatia // Proceedings of the 2005 Networking and Electronic Commerce Research Conference (NAEC2005) / Gavish, Bezalel (ed.). Dallas : Southern Methodist University, Dallas, USA, 2005. 75-91 • D. Kalpić, V. Mornar, M. Kovač, K. Fertalj, M. Kos: Establishment of computerization and e-services for public health in Croatia, Abstract, 3rd Croatian & International Congress onTelemedicine and e-Health, Hvar, 2006