1

1

Experience from implementing health care informatics in

Denmark

Christian NøhrAalborg University

2

2

3

Health care in Denmark• 5,302.876 inhabitants (February 21th 2007)• Free at point of delivery, (87 % tax paid)

• Covering both primary and secondary health care sector• Free medicine in hospitals, subsidised outside hospitals

• General practitioners 1 : 1200 people• Private, but > 99 % have contracts with public health

• Health is around 9 % of GNP • Mean duration of hospital stays is 5,3 days• Health care provided by Regions

• 5 with 500.000 – 1.200.000 inhabitants

4

Healthcare in Denmark

57 public hospitals – 21000 beds8 private hospitals - < 150 beds

3500 General practitioners800 Practicing Specialists

11000 MDs employed by hospitals331 Pharmacies

2700 Dentists1700 Physiotherapists

250 Chiropractors

5 Regions – payors• 98 Municipalities• 1 private Health Insurance Company

3

5

6

BackgroundNational IT strategy

2003-2007 for the health sector

• Initiatives must support health policy goals– High quality in health care delivery– Short waiting times and free choice of provider– High user satisfaction– Better information on service and quality– Efficient

4

7

BackgroundNational IT strategy

2003-2007 for the health sector

Strategy goals:• 100% coverage of EHR in hospitals by the end of 2005• …based on a Basic Model for EHR

• Large scale national XML communication between & inside hospitals by 2005

• Internet based secure health network by 2005• National health portal by 2004

8

Status of IT in the primary sector18 different GP systems (stand alone)

MedCom National health network

30 different types of messages standardised (EDI)Implemented in 40 different systems• 15 GP systems• 9 hospitals systems• 12 laboratory systems• 4 pharmacy systems

5

9

Medcom status

EDI has overtaken daily communication

48 %127Local Authorities100 %57Hospitals100 %331Pharmacies86 %697Specialists

100 %2143GPs offices%Number

December 2006

10

Prescriptions1039105 = 73%Prescriptions1139992 = 79%

Disch. Letters 682923 = 85 %Disch. Letters 826258 = 98 %

Lab. reports543040 = 82 %Lab. reports653974 = 98%

ReferralsReferrals64845 = 78 %ReferralsReferrals

Reimbursement15637 = 96 %

MEDCOM communicationNumber of documents pr. month

Updated December 2006

6

11

Discharge

Lab results

Prescription

Referral

Lab order

Reimbursement% of

all m

essa

ges

Municipality

Practitioners

12

Health Portal

Service forhealth

providers

Service forcitizens

7

13

Services for the citizen:

• Information about medicine• Buy medicine at the pharmacy on-line• Information about hospitals:

• location, staff, services• waiting lists• quality indicators

• Personal information: (require log in)• appointments• medication• diagnosis and procedures

14

Visions: Establish communications and common information structure

8

15

Visions: Establish communications and common information structure

16

Visions: Establish communications and common information structure

9

17

Further strategic goals

Provide (structured) data for:• Clinic• Administration - management

• staff• work• financing

• Quality assurance• Research - epidemiology• ……..

Avoid monopoliesMulti vendor

18

Technology

Integration

Application3 tier model with interchangeable layers

SOA architecture

10

19

Technology

Integration

Medi-cation

3 tier model with interchangeable components (modules and functionalities)

Booking Imaging Clinical process

20

ResultGoalDiagnosis

Intervention

ExecutionPlanning

EvaluationDiagnostic

consideration

What is thesituation???What is thesituation???

Term: "Diagnose"? "Problem"?

Def: En manifest eller potentiel sundhedsrelateret tilstand udtrykt pågrundlag af en faglig vurdering

Term: "Diagnose"? "Problem"?

Def: En manifest eller potentiel sundhedsrelateret tilstand udtrykt pågrundlag af en faglig vurdering

Operationelt mål -dvs ikke hensigt eller formål!

Def: Beskrivelse af en forventet eller ønsket værdi af en parameter formuleret i målbare termer

Operationelt mål -dvs ikke hensigt eller formål!

Def: Beskrivelse af en forventet eller ønsket værdi af en parameter formuleret i målbare termer

Resultat af handling opfattes meget bredt som:

Def: ... information om en patients tilstand i forbindelse med en udført handling

Resultat af handling opfattes meget bredt som:

Def: ... information om en patients tilstand i forbindelse med en udført handling

This is how I seethe situation!

This is how I seethe situation!

What is my plan? What is myintentions?

What is my plan? What is myintentions?

This is what I want to achieve!This is what I

want to achieve!This is what I

am going to do!This is what I

am going to do!

And now I do it!!!

And now I do it!!!

Term: "Plan"? "Ordination"? "Handlingsplan"?

Def: Et program for udførelse af en bestemt type handling

Term: "Plan"? "Ordination"? "Handlingsplan"?

Def: Et program for udførelse af en bestemt type handling

Was theoutcome as intended?

Was theoutcome as intended?

This is how itwent...

This is how itwent...

The basic EHR model

11

21

Terminology system

ICPCICD10SKS“Home made” codesSnomed CT

22

Terminology system

Translated into Danish.Contains:Concepts (364.400)Terms (984.000)

SynonymsHierarchiesRelations (1,45 mill)

12

23

Clinical Content provides:• Documentation support• Process support• Decision support

Clinical Content ~ guidelines

24

Standard activity

Standard result

Operational goal

Decision point

Standard plan

Standard documentationDescribes how to configure an EHR system

Clinical Content ~ guidelines

13

25

A

Terminologysystem

Processmodel

Clinical content

26

EHR-ObservatoryA project funded by the Ministry of Interior and Health, The Association of Danish Regions and The Copenhagen Hospital Corporation.

Monitoring the dissemination of EHR systems in Danish hospitals

14

27

Applikationsplatform

Fælles EPJ brugergrænseflade(bliver en del af

klinisk procesmodul)

Klinisk proces

Nordjyllands Amt

RIS/PACSsystem

BookingLAB-syste-mer

Medicinsystem

Blodbank

In-struks-system

Bruger-grænse-

flade

Bruger-grænse-

flade

Bruger-grænse-

flade

Bruger-grænse-

flade

Bruger-grænse-

flade

28

Applikationsplatform (J2EE Websphere)

PortalFælles brugergrænseflade

KAS

Dataintegrationsplatform

GS!Åben

Yder-register CPRFlexi-

Lab Andre

Medicinmodul

Klinisk proces

Fælles-komp.

(print, log,mail, etc.)

BookingRekvisi-

tion/svar

GS bruger-flade

Lab-bruger-flade

15

29

Notat-modul

Medicin-modul

Rekvisitionog svarmodul

Integrationsplatform (EPJI)

Kliniskkemi

Mikro-biologi

Pato-logi

Rønt-gen

Fælles brugergrænseflade(fælles rammesystem)

Bruger-grænse-

flade

Bruger-grænse-

flade

Bruger-grænse-

flade

Bruger-grænse-

flade

Booking-modul

PASmodul

Billedmodul

GEPJ-lag

CPRopslag

CPRnyfødte

Apotek

Bruger-grænse-

flade

30

Applikationsplatform (J2EE)

PortalFælles brugergrænseflade

H:S

DataintegrationsplatformLABKlinisk kemi

PatologiMikrobiologi

Yder-registerCPR Klassifi-

kationer

PAS

Medicin-modul

Klinisk Proces

Fælles-komp.

(print, log,mail, etc.)

Booking,rekv/svar

Bruger-grænse-

flade

Bruger-grænse-

flade

Apotek

Bruger-grænse-

flade

RIS/PACS

Bruger-grænse-

flade

Data

16

31

BackgroundNational IT strategy

2003-2007 for the health sector

Strategy goals:• 100% coverage of EHR in hospitals by the end of 2005• …based on a Basic Model for EHR

• Large scale national XML communication between & inside hospitals by 2005

• Internet based secure health network by 2005• National health portal by 2004

32

BackgroundNational IT strategy

2003-2007 for the health sector

Strategy goals:• 100% coverage of EHR in hospitals by the end of 2008• …based on a Basic Model for EHR

• Large scale national XML communication between & inside hospitals by 2005

• Internet based secure health network by 2005• National health portal by 2004

17

33

0

20

40

60

80

100

200120022003200420052006

2001 2002 2003 2004 2005 2006 2007 2008 2009

National EHR Diffusion

34

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

2001

2003

2005

2007

2009

2011

2013

2015

2017

2019

2021

%

Dissemination of EHR based on number of beds covered

18

35

What happened ?

The minister of health announced a centrally controlled action

• National on-line infrastructure • Systems based on a common integration platform• A few modules must be chosen – criteria: best practice

36

Latest news

The health ministry has formed an office to coordinate the decentralized development of the EHR

The regions will still be in charge of the development and implementation

A Director for the office has not been appointed yet

19

37

Conclusion I

Harmonize political and health informatics professional goals

Determine the adequate level for structure and granularity

Plan for an iterative development process and

Evaluate every step

Involve the future users

38

• Make sure to have a well described architecture• Open estimates for time and resources• Reserve 20% of the budget for unanticipated needs• Divide into many small projects• Buy standard software where possible –

development (home growing) is expensive and difficult• Be aware of intedependencies• Make sure that no single project can jeopadize the

whole project• Plan for iterations and in a way that enable you to stop

single projects• Make the core business your point of departure

and stick to them!

Conclusion II

20

39

International conference onHuman Factors Engineering and Usability

June 7 and 8, 2007 in Aarhus, Denmark

http://www.HFEinHI.org