Healthcare ICT and HMIS in Norway

Miria Grisot

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Overview

• Norwegian healthcare system• Organization and services• National IT strategy for healthcare• Current Reform

• ICT in the healthcare sector• Primary healthcare + Hospital information systems• National initiatives

• HMIS/Central registries• Current reform• Quality indicators• Hospital reporting

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Some facts• Total population 4953000 (2011)• Life expectancy at birth 81.2 (2010) (1st Japan, 2nd Switzerland)• Total health spending accounted for 9.4% of GDP in Norway in 2010 (1st US,

then Netherlands, France, Germany, Norway...)• In terms of health spending per capita, Norway is ranked the second highest

among OECD countries in 2010 (after the United States)• In Norway, 85.5% of health spending was funded by public sources in 2010

(well above the OECD average of 72.2%)• Norway employs more human resources in the health sector than most OECD

countries (more doctors (4.7 per 1000 in 2010), more nurses (14.4 per 1000))• The number of hospital beds for curative care in Norway stood at 2.4 per

1000 population in 2010 (below the OECD average of 3.4): • as in most OECD countries, the number of beds per capita in Norway has fallen over

time, coinciding with a reduction of average length of stays in hospitals.

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Healthcare sector• Norway has a predominantly public health care sector.

• The Norwegian health system is characterized by universal coverage: the health system is built on the principle that all legal residents have equal access regardless of socioeconomic status, country of origin, and area of residence.

• It is financed mainly through taxation and only to a small extent by out-of-pocket payments (see Frikort).

• Unique personal number

• Health care services are provided at two governmental levels: • primary care is at municipal level, • and specialized care is at regional level.

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Municipal Health services: primary care• 430 municipalities• consists of 

• general practitioners services, • emergency room services, • physiotherapy, • nursing homes, • midwife services • and nursing services, (including health visitor services and home-based

services). • The health services are performed by personnel employed by the municipality

or private personnel with a reimbursement agreement with the municipality.  • The municipality also runs preventative health services + Health 'Stations' and

school-based health services• (Except for a few institutions with advanced rehabilitation services) long-term

care does not exist within the hospital sector but it is integrated in primary health care.

• Primary health care and social care services also care for patients recovering after a hospital stay.

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Municipal health services (some numbers)

• On average a municipality has 10,000 inhabitants (range from 250 to 500,000 people)

• The larger cities are subdivided into boroughs (city districts) covering services for about 30,000 inhabitants each.

• A municipality with 10,000 inhabitants will have about 10 GPs, 90 nursing home beds and 150 nurses, nurses aids and home helpers working in home care for elderly and disabled people.

• In 2010, there were 0.83 GPs per 1 000 population.7

Municipal health services• Primary health care services are financed by the municipalities,

which receive their income from taxes and a block grant from the central government.

• The funding of the primary health care services is supplemented by user-payments.

• The general practitioner scheme was introduced in 2001, states that:

• Every inhabitant is entitled to be listed with a general practitioner (GP) of his or her choice, (almost all residents (99.6%) are registered in the scheme).

• Every GP is now responsible for a list of individual patients• GPs’ role as gatekeepers: patients need to see their GPs before they

can be referred (referral letter) to the hospital (except in emergencies). 8

Regional Health Authorities - 2002• hospitals and institutions: organised in enterprises/ trusts under four

Regional Health Authorities: • Helse Nord (covers the counties of Nordland, Troms and Finnmark) • Helse Midt-Norge (Nord-Trøndelag, Sør-Trøndelag and Møre og  Romsdal) • Helse Vest (Rogaland, Hordaland and Sogn og Fjordane) • Helse Sør-Øst  (Vest-Agder, Aust-Agder, Telemark, Vestfold, Østfold,

Buskerud, Oppland, Hedmark, Akershus, Oslo) • The RHAs have structured the hospitals around 25 health enterprises

(65 hospitals)• (Before 2002 the hospitals have been owned and run by the counties

for over 30 years).

• In 2010, the private hospitals (both not-for-profit and for-profit privately owned hospitals) accounted for 1 601 beds, approximately 10% of the total of 16 117 beds.

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4 Regional Health Authorities - 2002

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Helse Nord

Helse Midt-Norge

Helse Vest Helse Sør-Øst

Regional Health Authorities (specialised care)

• There is a system of referral to specialist care, with primary care physicians as gate keepers.

• Patients may choose the hospital. • (They are not, however, allowed to choose a hospital that is more specialised,

e.g. a university hospital, than the one they have been referred to.)• Free choice of hospital for elective treatment was introduced from 1

January 2001 (Fritt sykehusvalg, www.frittsykehusvalg.no)• to strengthen patients’ positions as decision-makers (informed choice) • to even out differences in waiting times for treatment.

• Some studies indicate that relatively few patients seem to have opted for the possibility of receiving treatment outside of the hospitals’ natural catchment areas. 

• Patients are willing to wait a considerable length of time to avoid travelling. The reluctance to travel increases with age and decreases with level of education.

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Specialsed care• Emergency or elective patients via GP

• Waiting lists are primarily relevant for the specialist health care sector (which includes both specialist visits and surgical/medical treatment)

• Specialist health care is financed through a combination of a basic allocation and (since 1997) activity-based financing using diagnosis-related groups (DRGs).

• In 2007, somatic patient treatment was funded 60 % by the basic allocation and 40 % by the activity-based allocation

• The state has responsibility for specialist services such as public hospitals and psychiatric institutions, ambulance and emergency call services, hospital pharmacies, laboratories and some of the drug rehabilitation institutions.

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The Coordination Reform

• Reconfigure relation between primary & secondary healthcare

• Shift towards prevention

• Continuity of care• Financial, legal, admin

measures

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The Coordination reform – premises

• interaction between primary care and specialized care lacks mediating structures.

• each care sector belongs to separate levels of public administration: local and national.

• different systems of funding and different administrative, political and professional cultures.

• Specialist health care sector: high competence, highly medical and diagnostic intensive. 

• Municipality health services are characterized by lower skills, where as much as 29% of the labor force is performed by personnel without appropriate formal health professional education, mostly in long-term care.

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The Coordination Reform 1st Jan 2012

• addresses a serious lack of coordination between hospitals and primary health care

• how: increase the quality of information transfer between the levels, establish arenas where physicians at the different levels can interact and establish grounds for mutual learning.

• Means: (heavily) on economic incentives• targets the administrative level

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The Coordination reform

1) more patients should be taken care of in primary health and long-term care instead of being referred to hospital treatment

2) discharge from acute hospitals should take place earlier.

• establishment of pre-hospital low threshold wards in primary health care 

• municipalities are gradually obliged to establish primary emergency 24-hour care for patients who do not need specialized hospitalization

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Breadth/vision

Concretization/implementation

IT strategy in health sector

IT strategy in health sector• S@mspill 2.0• Specific vision/aims e.g.:

• Relevant and good quality information on health , lifestyle, services, treatments is available on internet.

• The patient has access to his own health information, own medical record, overview of prescriptions and medications, discharge letters, freecard and more.

• Via an interactive services is possible to (for instance) change appointments at the GPs or other providers.

• New services on internet support self care possibilities.• Patients and users experience that health personnel has a

good overview on their health status and health history when they come in contact with health care services.

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One resident – One record• improved quality, improved

patient safety, more efficiency and better use of resources

• quick, easy and secure access to all necessary information.

• regardless of where in the country the patient is receiving treatment

• Citizens should have quick access to simple and secure digital services.

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Main actors• Ministry of Health and Care Services• Health Directorate• Regional Health Authorities

• Hospital trusts• Municipalities

• Nasjonal IKT (RHAs) www.nasjonalikt.no• KITH (Kompetansesenter for IT i helsevesenet) www.kith.no• Norsk Helsenett SF www.nhn.no • NSEP (Norsk Senter for Elektronisk Pasientjournal) www.nsep.no• NST (Nasjonalt Senter for Telemedisin) www.telemed.no• ..

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Healthcare ICT in Norway…

• Early mover on Health ICTs:• National ICT strategies since 1996• First to implement EPR (public hospitals and GPs)• 1980’s- 90’s: Development initiatives on a national

scale

• Widely digitized sector:• Hospitals, general practitioners, nursing homes,

pharmacies, private sector specialists• … but weaker on linking them together• GPs first to implement EPRs, ~100 % coverage

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National Information infrastructure• all GPs use electronic patient records, and most receive discharge

letters electronically from hospitals, but uptake by municipality home care and nursing homes has been slower owing to more complex and integrated information system requirements.

• GPs often communicate electronically with laboratories outside their unit, and many can send prescriptions electronically to the pharmacy.

• Many GPs can also order X-rays and outpatient specialist services directly through the electronic network.

• All hospitals use electronic health records.• The lack of structured patient records in both primary and

secondary care precludes automatic data extraction.

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Electronic Patient Record System (EPR)

• Simple: • Text-based, no graphics/images • Free text, not structured text (some templates)• Chronological structure (not problem-centered)• No decisions support/expert system functionality• Some integration with Patient Administrative System

(patient demographic data)• Few standards defined

• So: • Limited value in comparison with grand visions• Far easier to implement than ”grand vision” EPRs

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Norwegian Health Network

• Norwegian Health Network• Secure, separate broadband network for healthcare

sector• Established 2004 (RHFs), provider role• State-owned since 2009: strategic role• www.nhn.no • Every day 250.000 electronic messages are sent

through the health network (2011) (before e-prescription)

• includes a high-quality video conference network (30.000 meetings in 2011)

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Inter-hospital communication

• Privacy law prohibits sharing of complete EPR files when a patient goes to another hospital

• Discharge letters are automatically sent, and the other hospitals can ask for other reports from the EPR (not automatic)

• Sharing of images and examination results• Electronic (NHN) and paper (mail, fax)

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Region North: standardized systems portfolio:

Same EPR system, same PACS system, shared bloodbank system, same microbiology system…

Main challenges:

• To digitize hospitals• To maintain control over growing no. of systems• To achieve inter-organizational collaboration

(digital communication)

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Directorate of Helath

• Helsedirektoratet.no• IT og helse

• E-resept• Kjernejournal

• Helsenorge.no• Fritt sykehusvalg• Min fastlege• Mine Resepter• Frikort• (…)

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Health Information Management

• Norwegian Institute of Public Health

• Quality Indicators/Quality registers

• Reporting from hospitals

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Norwegian Institute of Public Health• fhi.no

• Health registers• responsible for ten out of 14 mandatory national health registries

• A project has been established to modernise the mandatory national health registries: Gode helseregistre – bedre helse

• The goal is that the national health registries shall provide current, reliable and secure information about

• the population's health • and the quality of healthcare. • This includes information about disease incidence, unexpected changes in

incidence patterns such as during an epidemic, and knowledge about risk factors and causes of disease. 

• Goal is having real time data and a simpler linkage between the different registries.

• All registries should have electronic solutions for collecting and handling data.

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Registries• The Central Health registries

• nationwide • Reporting • In some cases, data are personally identifiable,• Strict regulation for their access/use.• The core registers are used primarily for health monitoring, research, quality of

healthcare, managementand management.

• None of them are based on the consent of the data subject.

• Medical Quality registries• To ensure quality of treatment• Few are national• There are about 200 medical quality registers,

of which 12 have official status as a national• most

of current medical quality registers are based onconsent.

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Gode helseregistre – bedre helse 2010-20

• Strategy for modernizing the central health registers, and the medical quality registers

• Should be able to answer to e.g.• How many people have diabetes in Norway today?• And which other health porblem do they have?• How do pregnant women respond to influenza?• How many children are overweight and which health

problems do they have?• Now, they do not provide answers…

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Strategy – concrete and visionary• Introduction of electronic

reporting to all registries• • Use of structured and

specific patient record system as basis for developing a new reporting solution to the national registries using Norsk Helse Nett

• …34

National registres• Helsedirektoratet

• Kvalitet og planlegging• Quality Indicators

• E.g. fritt sykehusvalg

• Norsk pasientregister (NPR)• When patients receive referral or treatment in a hospital, a clinic or a contract

specialist - what we call the specialist health - a series of data are recorded at the treatment site. 

• A selection of these details sent to the Norwegian Patient Register (NPR).• For current patients, it collected information on year of birth, sex and residence. • From 1 March 2007 it is also registered the personal number in encrypted form. (it can

be decrypted if necessary, such as when the information is to be connected with other registers).

• Data from the register used regularly for waiting list statistics, National quality indicators for specialist health, Statistics of activity in the specialist health, Research, Activity-based funding, …

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14 Central Health Registries• The Norwegian Cause of Death Register• The Medical Birth Registry of Norway• Register for Induced Abortion• The Norwegian Surveillance System for Communicable Diseases and The

Tuberculosis Registry• The Vaccination Register• The Norwegian Surveillance System for Resistance Against Antibiotics in

Microbes• The Norwegian Surveillance System for Infections in Hospitals• The Norwegian Prescription Database• The Norwegian Cardiovascular Disease Registry• The Cancer Registry of Norway• The Norwegian Patient Registry• The Norwegian Information System for The Nursing and Care Sector• ePrescription• The Registry of the Norwegian Armed Forces Medical Services

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Central health registers From IdResponsible institution

The Cause of Death Register 1925/51 Birth Id NIPHThe Medical Birth Registry of Norway (MFR) 1967 Birth Id NIPH

The Abortion Registry1979/ 2007 Avid NIPH

The Norwegian Surveillance system for Communical Diseases (MSIS) 1977 Birth Id NIPH

The Childhood Vaccination Register (SYSVAK) 1998 Birth Id NIPH

The Norwegian Surveillance System for Antibiotic Resistance in Microbes (NORM) 2003 Avid NIPH

The Norwegian Surveillance System for Infections in Hospitals (NOIS) 2005 Avid NIPH

The Norwegian Prescription Database (NorPD) 2004

Pseudonym NIPH

The Cancer Registry of Norway 1952 Birth Id H S-ØThe Norwegian Patient Registry (NPR) 2007 Encrypted HDIRThe Information System for nursing and

care services (IPLOS) 2005Pseudony

m HDIR

Central health registers From IdResponsible institution

The Norwegian Armed Forces registry 2005 Birth Id FDNational Database for Electronic Prescriptions (eResept) 2007 Birth Id HDIR

19 national medical quality registries

• Regional Health authorities:• South-Eastern Norway

• Child and youth diabetes + Neonatal medicine + Cerebral palsy + Trauma + Colorectal cancer + Prostate cancer

• Central Norway• Myocardial infarction + Cerebral stroke + Vascular diseases/vascular surgery

• Western Norway• Intensive care + Diabetes in adults + Cleft lip and palate + COPD (KOLS) +

Arthroplasties + Hip fractures + Cruciate ligaments + Multiple sclerosis (register and biobank)

• Northern Norway• Back surgery + Hereditary and congenital + neuromuscular diseases

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Hospital reporting

• Main system is PAS (not the EPR)• ICD codes (+others) entered by clinicians

• Hospitals report activities – get their income• Activity-based cost (DRG system)

• The recipient (Norw. Patient registry) forwards to health authorities, and provides data also for other uses (research etc)

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Activity-based fundings - DRG system• (in Norwegian: the ISF scheme)• DRG (Diagnosis Related Groups) is a patient classification

system that yields a simplified description of hospitals activity and patient mix, and is used as the basis for funding.

• Each individual DRG represents both medical and financial information. Patients that are classified together in the same DRG are medically very similar and require roughly equal resources to treat.

• Each year, around one million stays are classified, and the results are used to monitor activity and productivity

• At present, the system lacks adequate standardisation in coding practices across hospitals and regions.

• Assessment available at helsedirektoratet.no41

Reporting from PAS systems

PAS Patient administration system

On patients: Record patient personal information Summary of contacts Waiting lists Time booking and notifications to patients Register of arrivals/discharges Patient Hotel stays/movements within the hospital

On hospital personnel and resources: Register of employees and roles Scheduling of work shifts Economy and resource use Register of services delivered Various reports

PAS patient administration system It is used to keep track of the patient logistics on site and the formal interaction with other healthcare

providers. Key Features

Patient search and registration previous patient history uniqueness in the identification of the patient

Referral management Referral management is the process from when the service requester sends a request to a service provider until the service provider

either rejects the request, or accepts the request to provide healthcare to the patient. Encounter management

keep track of where the patient is/shall be, the reason for the stay (diagnosis), what treatment is given (procedures), evaluate further examination or treatment after planned treatment is given, and to enable collection of any vital information necessary to create a correct patient bill/invoice pr hospital stay.

Inpatients: managing room and bed capacity and utilization Outpatients: utilization of personnel (physician, nurse, etc.) rooms and other medical equipment

Booking search capabilities to find available time slots for different types of services and resources Clinical administration work lists: finding which patients are currently in different scenarios

Billing and finance integration grouping/calculation engine to identify a Health care resource Group (HRG) or Diagnosis related group (DRG) code that is used as the

basis for the calculation of the cost of services given. Reports, Exports, Analysis

reports, for  example ad-hoc reports supporting the work process of the users, reports for activities performed by the hospital which is to be reported to the owners and the government.

export of data which has to be sent to the finance applications used by the hospital to ensure comprehensive follow-up of the billing process to all parties that retrieve bills

Letter module functionality for creating and printing letters to patients, as well as letters to next of kin and health personnel

ICD 10 and NCSP code help

Reporting: quality monitoring • Quality/performance/efficiency:

• Handled locally by Dept/Hospital management• Publication of data relating to: Patient satisfaction, Waiting

times, Complications etc.

• Quality of treatment:• Professional groups (e.g. urological surgeons) have

initiated voluntary reporting systems• Manual data entry (not pulling from EPR)• Exist for >60 areas• Varying coverage, quality, security – a national

harmonization initiative.46

Publication of results:

• Quality indicators:• http://helsenorge.no/Helsetjenester/Sider/Oversik

t-over-nasjonale-kvalitetsindikatorer.aspx• Information for patients:• www.helsenorge.no • www.frittsykehusvalg.no

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Security/privacy policies

• Data protection and information security principles:

• EU Directive 95/46/EC (the Data Protection Directive)• National laws

• National ”Code of Conduct” defined (incl. practical guidelines)

• www.normen.no (also in English)• Norwegian Health Network requires

implementation of CoC• Datatilsynet

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The code of Conduct• the Code specifies which measures are deemed necessary to

achieve satisfactory information security for such processing of health and personal data.

• The Code regulates organizations’ manual and electronic processing of health and personal data, but is particularly relevant for the electronic processing.

• E.g.: Message distribution and e-mail containing sensitive personal data

• Clearly defined areas of responsibility must be established between the sender, recipient, and any message distributor, and the responsibilities shall be stated in the agreements between the organizations and the message distributor.

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• Helsedirektoratet.no• Tall og analyse

• Quality indicators

• Rapport generator• Om aktivitet data

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