Adaptive Networked Governance of e- health Standards

1. Adaptive NetworkedGovernanceof e-health Standards IN5430 10.04.2019 Kristoffer Fossum

2. Theme – Governing standards in complexorganizations • Goals for thelecture • Present a case from the Norwegian healthcaresector (specificallythe South East Health Region) aboutchange from a top-down to a networked regime for e-health standards governance. • Show howthischangeenablesthe region to handle complexity in standards governancebetterthanbefore • Learning outcome: • Insight in standardizationchallenges in complexorganizations • How onehealth region in Norway tries to dealwithitscomplexity

3. Agenda • Introduction to the • Norwegian healthcaresector • The South East Health Region • The complexityof hospitals • The consequencesoflocalautonomy in relation to complexity • Regional programs to improve IT portfolios • Top-down • New governancestructures and processes • Networked

4. So, what is an e-health standard? • “Syntactic, semantic and functional standards, implemented in healthcare IT solutions. These allow healthcare personnel to capture, store, process and share information based on clinical practice needs.” • or • Standards in IT systems thataredirectlyrelated to clinicalpractice in healthcare service provision.

5. The Norwegian healthcaresector • Around17 000 autonomousenterprises in the Norwegian healthcaresector • Eachenterprise is responsible for quality and safetyofcare • Eachenterprise has theirownresponsibility to establishtheirownpatient journal systems according to Norwegian law (pasientjournallovens §8). • Procurementof IT systems is theenterprise’sresponsibility • Adoptionof e-health standards is up to eachenterprise • Eachenterprise is responsible for informationsecurity

6. National governancestructure

7. The South East Health Region • Responsible for hospital healthcare for approx. 2.9 million ofthe Norwegian population • 100% state-owned • 80 000 employees • Annualbudget: 80 billion NOK • 11 health trusts Ministryof H and C. Regional health trust Hospitals Hospitals Sykehuspartner Hospitals Hospitals

8. The South East Health Region • Each hospital trust is an autonomousenterprise • Information security • Quality and safetyofcare • Ownpatient journal systems -> Consensus-basedagreementsacrossenterprises • Decadesofimplementationof IT systems has led to a plethora of systems thatare not wellintegratedwitheachother • High variation in e-health standards in the systems

9. Traditionalgovernanceprocesses, local and regional projects

10. Support patienttreatment and flow

11. IT systems support manyfunctions

12. Many IT systems to support hospital operations • Approx. 5700 IT applications • More than 1200 directlyinvolved in clinicalwork • Administrative systems • Etc. • Unknownnumberoflocal «under the radar» systems

13. Many different IT systems for the same functions

14. Information in the DIPS application

15. Flowofone type ofinformation in theinformation systems in one hospital

16. DIPS integrationoverview for one hospital

17. From 2012: New regional strategy – cleaning the IT “mess” • Large investment programs to standardize and consolidate the largest IT systems 2012 2024

18. From 2012: Governance Styret i Helse Sør-Øst AD Helse Sør-Øst RHF Programkontor REGIONAL PROGRAMS Regional IKT for forskning Regional klinisk løsning Virksomhets-styring Prosjekter Prosjekter Prosjekter

19. From 2012: Governance

20. Challenges • Typicallyone IT system per project • Decisionmakingstructures for eachproject • Standardizationlookedupon from an IT perspective • Project tries to decideupon standards – far away from clinicalpractice • Assistance from clinicalexperts, butuncleardecisionmakingpower • Manydependencies - projects - IT systems - clinicalpractice • For instance 91 IT systems involved in medication management • No defined line management that has owership to standards • Outcome • Relativelypooranchoringof standards locally at hospitals • Unrealized plans for standardization and consolidation

21. New governancestructures – Regional Centre Other health regions Configuration requests Regional Centre Representatives (coordination) Experience/ knowledge Hospital Partner Implementing changes Regional projects Experience/knowledge training Feedback/ suggestions Hospital reception projects/line org National functions Regional network groups

22. New governancestructures – regional networkgroups

23. New governanceprocesses • Three waysofinitiating a process • Locallyoriginatedsuggestions for change/improvement • Regional projects in need for standards assessment and development • Regional governancecoordinatorsinitiatingonowninitiative • Dailymeetings in the regional centre • Weeklymeetingslocally in hospitals • Bi-weeklymeetings in the regional networkgroups • Continuousaccess to information and participation in discussions via thegovernanceplatform

24. New governanceplatform • Web-basedplatformthat all relevant actorsacross hospitals and projectsmayread, discuss, and follow up suggestions for change, and trace actualchanges. • Creatingtransparency in processesbeforedecisions • Creatingtransparency in madedecisions.

25. New governanceplatform

26. Challenges and opportunitieswithnewgovernancemodel Advantages: • Systematic case handling • Fast disseminationofknowledge and information • Transparency in decisionprocessesamong all involved parts • Decisionsbecomelocallyanchored • Decisionsarealreadyanchoredwhen IT systems change • Systematic training and sharingofexperience • Streamlined handling ofchangerequests and exceptions Potentialchallenges: • Still a consensus-basedpowerstructure – hospitals maysayno to a suggested standard • Live withdeviations and variations • The networkstructureitselfbecomes a heavybureaucracy • slower to move • Can it handle major changes?

27. A combination enableschange Network orchestration, Adaptive co-management Goal-directednetwork Governanceplatform

28. Contributions • The analytical lens contribute to understandinggovernance standards • Top-downvsbottom-up governance • Both at the same time, but in different parts ofthegovernancenetwork • Beingexplicitongovernanceof standards in complexinformationinfrastructures