Christian Nohr, Professor Department of Development and Planing. Aalborg University. Denmark

1. Experience from
implementing health
care informatics in
Denmark
Christian Nøhr
Aalborg University
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2. 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
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Healthcare in Denmark
57 public hospitals – 21000 beds
8 private hospitals - < 150 beds
3500 General practitioners
800 Practicing Specialists
11000 MDs employed by hospitals
331 Pharmacies
2700 Dentists
1700 Physiotherapists
250 Chiropractors
5 Regions – payors
• 98 Municipalities
• 1 private Health Insurance Company
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3. 5
Background
National 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
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4. Background
National 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
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Status of IT in the primary sector
18 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
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5. Medcom status
EDI has overtaken daily communication
Number %
GPs offices 2143 100 %
Specialists 697 86 %
Pharmacies 331 100 %
Hospitals 57 100 %
Local Authorities 127 48 %
December 2006
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MEDCOM communication
Number of documents pr. month
Prescriptions
1139992 79%
1039105 = 73%
Disch. Letters
826258 98
682923 = 85 %
Lab. reports
653974 98%
543040 = 82 %
Referrals
64845 = 78 %
Reimbursement
15637 = 96 %
Updated December 2006
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6. Practitioners
Discharge
% of all messages
Lab results
Prescription
Referral
Reimbursement
Lab order
Municipality
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Health Portal
Service for
Service for
citizens
health
providers
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7. 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
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Visions: Establish communications and
common information structure
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8. Visions: Establish communications and
common information structure
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Visions: Establish communications and
common information structure
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9. Further strategic goals
Provide (structured) data for:
• Clinic
• Administration - management
• staff
• work
• financing
• Quality assurance
• Research - epidemiology
• ……..
Avoid monopolies
Multi vendor
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Application
3 tier model with
interchangeable
layers
SOA architecture Integration
Technology
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10. Medi- Clinical
Booking Imaging
cation process
3 tier model with
interchangeable
components
(modules and
functionalities) Integration
Technology
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The basic EHR model
What is the
What is the Term: "Diagnose"? "Problem"? af handling
Resultat the
Was
Term: "Diagnose"? "Problem"? af handling
Resultat the
Was
situation???
situation??? outcome as
Def: En manifest eller potentiel meget
opfattes meget
outcome as
opfattes
Def: En manifest eller potentiel
intended?
bredt som:
intended?
bredt som:
sundhedsrelateret tilstand udtrykt på
sundhedsrelateret tilstand udtrykt på
Diagnostic grundlag af en faglig vurdering information
grundlag af en faglig vurdering information
conside Evaluation Def: ...
Def: ...
om en patients
om en patients
This is how I see
This is how I see ration tilstand ii forbindelse
tilstand forbindelse
Operationelt mål -
Operationelt mål -
the situation!
the situation! med ikkeudført
med en udført
dvs en hensigt
dvs ikke hensigt
handling
handling
eller formål!
eller formål!
Diagnosis Goal Def: Beskrivelse af
Def: Beskrivelse af
Result
en forventet eller
en forventet eller
ønsket værdi af en
ønsket værdi af en
What is my plan?
What is my plan? parameter it
This is how it
This is how
parameter
Term: "Plan"?
Term: "Plan"?
What is my
What is my went...
went...
formuleret ii
formuleret
"Ordination"?
"Ordination"?
intentions?
intentions? målbare termer
målbare termer
"Handlingsplan"?
"Handlingsplan"? Planning Execution
Def: Et program for
Def: Et program for
udførelse af en
udførelse af en Intervention And now I
And now I
bestemt type
bestemt type do it!!!
do it!!!
handling This is what I
This is what I This is what I
This is what I
handling
20 want to achieve!
want to achieve! am going to do!
am going to do!
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11. Terminology system
ICPC
ICD10
SKS
“Home made” codes
Snomed CT
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Terminology system
Translated into Danish.
Contains:
Concepts (364.400)
Terms (984.000)
Synonyms
Hierarchies
Relations (1,45 mill)
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12. Clinical Content ~ guidelines
Clinical Content provides:
• Documentation support
• Process support
• Decision support
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Clinical Content ~ guidelines
Standard plan
Standard activity
Standard result
Standard documentation
Describes how to configure an
EHR system
Operational goal
Decision point
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13. Terminology
system
Process Clinical
model content
A
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EHR-Observatory
A 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
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14. Nordjyllands Amt
Bruger- Bruger- Bruger- Bruger- Bruger- Fælles EPJ brugergrænseflade
grænse- grænse- grænse- grænse- grænse- (bliver en del af
flade flade flade flade flade klinisk procesmodul)
Klinisk
proces
Applikationsplatform
In- RIS/ LAB-
Blod Medicin
struks- PACS Booking syste-
bank system
system system mer
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KAS
Lab- GS
Portal
bruger- bruger-
Fælles brugergrænseflade
flade flade
Fælles- Rekvisi-
Medicin Klinisk komp. Booking tion
modul proces (print, log,
mail, etc.)
/svar
Applikationsplatform (J2EE Websphere)
Dataintegrationsplatform
Flexi- GS! Yder-
CPR Andre
Lab Åben register
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15. Bruger- Bruger- Bruger-
grænse- grænse- grænse-
flade flade flade
Fælles brugergrænseflade
Bruger- Bruger- (fælles rammesystem)
grænse- grænse-
flade flade
Rekvisition
Medicin- Booking- PAS Billed Notat-
og svar
modul modul modul modul modul
modul
Pato- Mikro- GEPJ-lag
Apotek
logi biologi
Integrationsplatform (EPJI)
Rønt- Klinisk
gen kemi
CPR CPR
opslag nyfødte
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H:S
Bruger- Bruger- Bruger- Bruger-
Portal
grænse- grænse- grænse- grænse-
Fælles brugergrænseflade
flade flade flade flade
Fælles-
Medicin- Klinisk komp. Booking,
modul Proces (print, log, rekv/svar
mail, etc.)
Applikationsplatform (J2EE)
LAB Dataintegrationsplatform
RIS/ Klinisk kemi Apotek PAS
PACS Patologi
Mikrobiologi
Data
Klassifi- Yder-
CPR
kationer register
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16. Background
National 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
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Background
National 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
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17. National EHR Diffusion
100
80
2001
60 2002
2003
40 2004
2005
2006
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0
2001 2002 2003 2004 2005 2006 2007 2008 2009
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Dissemination of EHR based on number of beds covered
100,0
90,0
80,0
70,0
60,0
%
50,0
40,0
30,0
20,0
10,0
0,0
01
03
05
07
09
11
13
15
17
19
21
20
20
20
20
20
20
20
20
20
20
20
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18. 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
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Latest news
The regions will still be in charge of the
development and implementation
The health ministry has formed an
office to coordinate the decentralized
development of the EHR
A Director for the office has not been
appointed yet
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19. Conclusion I
Harmonize political and health informatics
professional goals
Determine the adequate level for structure
and granularity
Involve the future users
Plan for an iterative development process
and
Evaluate every step
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Conclusion II
• 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
38 and stick to them!
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20. International conference on
Human Factors Engineering and Usability
June 7 and 8, 2007 in Aarhus, Denmark
http://www.HFEinHI.org
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