Danish health care – overview and template



Danish healthcare – overview and template

The Danish Healthcare sector - overview

Working with the healthcare sector has two perspectives; the existing systems, and the future. Today the counties run most hospitals in Denmark, but there is a tendency towards both greater competition and cooperation among hospitals and counties and e.g. in the Copenhagen region seven hospitals have joined up in one organization. There are also state-owned and municipal hospitals plus a few private hospitals. The counties are also responsible for a number of institutions e.g. for the disabled, and the municipalities are responsible for e.g. care of the elderly and home-care of patients. GP’s, specialist clinics and pharmacies are private.

The healthcare sector is developing into a new age where the communication between the involved parties is continuously increasing, both internally in the different hospitals and externally.

This desire to increase the efficiency of the communication is driven by the economical benefits, and in Denmark a “National IT strategy for the healthcare sector” has been formed. This strategy has a goal of going beyond only focusing on the economical aspect, but also increase the service level to the citizens.

The National Board of Health is responsible for the development and the applications of the Healthcare Sector’s classification System, healthcare sector terminology and definitions, electronic case file standards, EDIFACT standards and healthcare data network and databases on clinical quality.

In Denmark the authorities have, as a part of the National IT Strategy, launched an ambitious plan to create a public health portal in two years. The vision is to embrace all electronic communication between patients and the healthcare sector and to be a communication tool for the healthcare professionals. Furthermore the portal will provide information to the healthcare professionals and information for the patients/citizens enabling greater responsibility for wellness, healthcare and self-care.

Today the management of the healthcare sector is already a heavy user of IT, and there are many initiatives on standardizing the healthcare area. In Denmark MedCom – The Danish Centre for Health Telematics - has already (in 1996-96) defined an EDIFACT standard for the most frequently exchanged messages between GPs and the other health care sector, i.e. discharge letters, laboratory reports and prescriptions , which today is widely used in the Danish healthcare system (2.4 mil. messages pr. month).

Within the medication area, which is one of the most complex activity areas in the health sector, a cross-governmental project has recently been established. The project investigates the total flow of information and data between the many involved parties, and has been commissioned to put forward a conceptual model for the whole area and pinpoint activities needed to avoid critical redundancy issues and other ineffective processes.

As a part of the national IT strategy the National Board of Health has defined the basic EHR (G-EPJ); a model for documenting the clinical work process. One of the characteristics of Electronic Healthcare Records (EHR) is the continuous flow of information on the same patient.

MedCom is currently moving from EDIFACT to XML, which is the recommendation from the G-EHR project and in this process coordinating this work to conform to G-EPJ.

A recent bill in the Parliament has commissioned the Danish Medicines Agency to establish a so-called Electronic Medicine Profile, which is now under construction. The Electronic Medicine Profile will be a central service where all citizens’ medicine data will be stored and made available to GPs and the citizens themselves.

The security aspect of communicating health information is eminent. This area is under Danish legislation. The possibilities to enforce this, changes when moving from a paper based solution. Controlling when and by who access to the given information is allowed gets easier when working with electronic information. The Danish Board of Health has in 2002 developed a security guide, which aims to guide hospitals on how to comply with the Danish law.

It is also prudent to focus on the international projects on the area. Some of which is defined below.

The existing national work in Denmark

• MedCom (medcom.dk in Danish – some information available in english)

Is a cooperation between government authorities, organisations and private firms connected with the Danish healthcare system.

Are currently working on transforming existing EDIFACT messages to XML.

• G-EPJ ( in Danish)

Is an effort to make an coherent model of the essential areas around the EHR.

The existing international work with Danish participation:

• CEN/TC251 ()

Standardization in the field of Health Information and Communications Technology (ICT) to achieve compatibility and interoperability between independent systems and to enable modularity. This includes requirements on health information structure to support clinical and administrative procedures, technical methods to support interoperable systems as well as requirements regarding safety, security and quality.

• PICNIC ()

PICNIC is initiated by regional health care providers, who are planning to develop the next generation regional health care networks to support their new ways of providing health and social care. PICNIC was scheduled to run from January 2000 until March 2003. (Funded by EU)

The existing work without Danish participation:

Descriptions are obtained from their websites.

• HL7 ()

Health Level Seven is one of several ANSI-accredited Standards Developing Organizations (SDOs) operating in the healthcare arena.

Health Level Seven’s domain is clinical and administrative data.

• OpenEHR ()

The openEHR Foundation is a non-profit organisation bringing together an international community of people working towards the realisation of clinically comprehensive, ethico-legally sound and interoperable electronic health records to support seamless and high quality patient care.

OpenEHR work closely with standardisation bodies, including ISO, CEN and HL7

• OpenECG (Digital Electrocardiography )()

the OpenECG project is to promote the consistent use of format and communications standards for computerised ECGs and to pave the way towards developing similar standards for stress ECG, Holter ECG, and real-time monitoring.

Patient record

(Government to citizen, government to government)

Background

The patient record is the central document concerning the individual citizen’s medical history. Whenever a patient is to be treated in the healthcare system the patient journal has two purposes; supplying data on the patient’s medical history, and registering the current treatment.

The individual citizen will get the possibility to check his or hers medical record. Furthermore it is possible for the citizen to interact with the healthcare system. This possibility is already today being used where patients with chronic diseases can report their physical state. This form for interaction can assist the medical personal in evaluating and counselling of the patient. Another advantage is that the patient only has to describe his condition once.

By having the patient journal available the mobility of the patient will increase. When the patient is moved within the healthcare system the patient’s journal will always be available – internally and externally. This is imperative to insure a correct treatment – for instance avoiding medicating the patient with drugs which he/she is allergic to. This means that the patient isn’t exposed to unnecessary tests and medical procedures.

The patient record can be seen as a collective of all medical data related to the individual citizen – hence the patient record is a structured way of presenting other documents. The complexity of the patient record is therefore very extensive. This means that introducing the patient record in practise should be done smaller steps – which is also recommended in the Danish National IT strategy for the healthcare sector. It has been agreed that the Danish hospitals shall have implemented electronic patient records based on a shared standard before exciting 2005.

In Denmark a large initiative has been initiated by the Ministry of Health to create a model on the EHR (G-EPJ).

This model is then being supplied with elements by practical projects:

• MedCom is currently transforming EDIFACT messages to XML. This project is currently working on defining 26 messages involving 36 different IT suppliers.

• “The Danish Health Portal” is currently running a pilot project to enable the medical professional to access medical records (running in 2 regions/counties). This project is running against legacy systems, and clearly indicates the need for standards in the area of EHR.

Service (eGov)

The patient record has two main areas of interest.

• For the citizen it is possible, if his/hers record is available, to check ones own medical record. This can also lead to a more active and knowledgeable patient.

• Within the healthcare system itself it is possible to have an efficient way of communicating the patient records, and insuring that the record at hand is always up to date.

Service Interaction

The patient can have a personalized web-page where the patient record is available.

If this is implemented globally the patient can get treatment at all medical institutions without risk of mistreatment due to lack of information of his/hers medical history. This will also minimize the need for initial examination before the actual treatment.

Within the medical system the communication of patient records can be done by accessing a central server.

Doctors, nurses etc. can access the patient record on demand by a portable device (Tablet PC, PDA etc.)

In case of an accident rescuers can access the injured person’s patient record to insure the best treatment. The injured could be allergic to specific types of medication, have a pacemaker etc.

Subjects(actors)

Patient

GP

Specialist

Hospital

Portal

Pharmacy

Locations

Internet access for citizens/professionals.

Integration in the healthcare ERP systems

Access trough portable devise (On the spot treatment)

Identifiers

CPR number – person identification number.

CVR - Central registry for companies.

Evidence

For citizen access:

• Digital signature.

• Smartcard.

• Biometrics.

Within the healthcare sector it is necessary that only authorised persons can get access.

Outcome

It is possible to get increased access to clinical data that can be analysed and used to improve the quality of the medical sector.

Giving the citizen better insight in their medical history, and essentially giving the patient the possibility to be better informed about his/hers treatment.

Minimizing cost for the citizen when in need of acute help by avoiding initial examination.

Creating the possibilities to make the healthcare system more efficient; both economically and with regards to treatment.

Rules

The information is person sensitive and is regulated under Danish law. There are requirements to the security of the system.

E-healthcare appointments

(Government to citizen, Government to Government)

Background

Healthcare appointments comply with all cases where the patient physically has to meet with one of the actors in the healthcare system. The wish is to create a transparent way the patient can interact with the entire healthcare system.

Introducing IT it is possible for the citizen to make appointments with the healthcare sector, and even get electronic consulting (e.g. by email).

First steps toward providing this service are now being taken in Denmark. The Danish National Health Portal will provide a single point of communication between citizen and health service. This includes the possibility for booking appointments with GPs and, in time, for scheduling hospital visits and procedures. This work is an extension of facilities already in place at the privately operated sundhed.dk which currently offers appointment scheduling with GPs and online consultation by email among other things.

Another point of focus is the possibility for the professionals to utilise the system. When needing to refer a patient to a hospital, specialist etc. this can be done efficiently though a common system. Currently it is possible to check waiting list for the Danish hospitals on the web (venteinfo.dk/ventelister/visventetider.asp).

Service (eGov)

Most citizen-interactions to the healthcare system starts and ends at the GP. Through the course of the treatment can involve several other instances, such ad labs, hospitals, specialists etc.

This communication should be transparent to the patient creating the feeling of one system.

The professionals will be able to make an appointment for the patient while the patient is present, thereby identifying the optimal choice regarding to time (possible waiting lists) and distance. This can also help limiting bottle necks in healthcare system.

Service Interaction

This can be divided into two different scenarios which has different possibilities, but also equally different scopes of development.

The basic scenario is “powering up” the existing paths of communication.

[pic]

Figure 1 : the basic form

This approach can help making the communication between the involved actors more efficient, but will not be transparent to the patient.

Another approach is somewhat more complex as this requires that all the parties’ agree on a common standard to interact.

[pic]

Figure 2 : a central solution

The idea in figure 2 is to facilitate the patient with one instance (portal) where all communication with the healthcare system can take place. The grey arrows in the illustration indicate the possibility for having direct lines of communications between the actors in the healthcare system.

This approach presents the possibility to make an efficient platform for communication between all the actors, and will provide the patient with a transparent interaction with the system.

There is however a part of making an appointment that’s difficult to computerize. Estimating the time needed to the individual appointment require assessing what is wrong with the patient, and treatment needed.

Subjects (actors)

Citizen

GP

Specialist

Hospital

Home care

Portal

Booking system

Locations

The citizen will contact the portal witch could be a web-site.

The role of the portal is to provide the logic that provides the transparency. This could be achieved by having the data providers facilitate their data with a web-service.

Integration in the healthcare ERP systems

Identifiers

CPR number – person identification number.

Appointment-identifier is required. This is must be coordinated in a way so that all the systems have a common key.

CVR – Central registry for companies.

GEO-data / BBR – to provide geographical information.

Evidence

Use of digital signature.

Alternatively only providing the users with username and password.

A number of registers are needed.

• Booking register. What is registered, by whom, when, etc.

• Waiting list to operations etc.

Outcome

When making an appointment with an actor in the system, the patient will get a simple way of communicating with the entire healthcare sector.

Rules

The information sent is person sensitive and is regulated under Danish law. There are requirements to the security of the system.

The Danish legislation enables the patient to a free choice of hospital and GP.

E-prescription

(government to citizen, Government to business)

Background

Medication that needs a prescription requires that an authorised person (PG, dentist etc.) fills out a prescription which is then processed by a pharmacy, hospital or similar. This process is done by paper and registered in the patient’s health journal.

The possibility to renew a prescription electronically is already available to the Danish citizens via the sundhed.dk web page (which also is a portal with general health information). Currently there are only a limited number of PG’s available on the service.

This initiative is currently being incorporated under “the Danish Health Portal” to create one place to communicate with the healthcare system.

Service (eGov)

Issuing prescriptions to a citizen can be issued directly to the delivering party (pharmacy etc.)

Service Interaction

The e-prescription can only be issued by authorised personal to an authorized supplier.

Integration in the healthcare ERP systems

Subjects (actors)

Patient

GP

Specialist

Hospital

Dentist

Pharmacy

Health insurance (public and private)

Emergency service

Locations

The different actors existing systems

Distributed or central Web-service

Identifiers

CPR number – person identification number.

CVR Central registry for companies.

CTR – Central Registry of Reimbursments

Evidence

Use of digital signature.

Outcome

Efficiency in the processing of prescriptions – the data will only be needed to be registered once.

Better insight for the user.

Possible to compare chosen medicine with to potential cheaper alternatives

It is possible to make extensive analysis of the national use of medicine.

Rules

Person-sensitive information is under legislation control.

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