4.3 Case Study #09: National ehealth network in Denmark

Transcription

1 4.3 Case Study #09: National ehealth network in Denmark Author of case study within the estandards project: Morten Bruun-Rasmussen Project name: National ehealth network in Denmark Project type: Large-scale deployment for sustained routine use Project status (in 10/2015): Deployed for sustained routine use Countries / Regions: Denmark Project partners: Ministry of Finance, Ministry of Health, Regions, Municipalities, Hospitals, GPs, Health specialist, Vendor of ehealth systems, Consultants Scale of deployment: National, cross-sector Project Overview The vision for the health care system in Denmark is to provide coherent clinical pathways through the various parts of the health care system, focusing on the needs of patients and the provision of high quality treatment. One of the main prerequisites for a coherent integrated health care system is to ensure that all health care professionals have easy access to relevant patient information where and when it is needed. Since 1995, IT strategies have been an important instrument in Denmark to agree about which systems and services were going to be developed and implemented on a large scale, on a national basis. Below is a list with years and titles of the strategies: : IT political action plan : IT for the hospitals : IT for the health services : Digitizing the health sector : Digitize with effect The use of those strategies has been important for the rather satisfactory results achieved for citizens, patients, and professionals in Denmark. Because of the specialisation and division of labour, there is a need for extensive communication between the participants involved in the health care sector, i. e. communication of everyday routine messages such as prescriptions, referrals, discharge letters and laboratory results. The communication, sharing, and access to data has been a general topic in all the strategies. Today, ehealth is very commonly used throughout the whole Danish health care system and supports many work processes, including processes that reach across organisations and sectors, which is also a major result of the national strategies. The IT landscape (October 2015) is shown below: D4.1: Solutions for a Coexistence of ehealth Standards Page 124

2 4.3.2 Approach Figure 46: ehealth IT landscape, October 2015 It is important to mention that, as the development has been use-case driven, there have not been a lot of efforts as regards the coordination and selection of the standards used. The development and use of national standards is a history of approximatively 20 years of work. Throughout this time, the technology has changed and the solutions can be grouped into the following three technologies: Messaging Repositories Indexing Each of the technologies and the standards used are described below Messaging Messaging is peer to peer communication which includes a sender and a receiver. In some cases a copy can be sent to additional receivers. MedCom ( was established in 1994 with the purpose of developing nationwide communication standards for the most common messages between public hospitals and general practitioners as well as private companies linked to the health care sector, e. g. pharmacies. The messages cover the most frequent clinical messages in the Danish health care system, e. g. discharge letters, referrals, lab test orders, e-prescriptions and reimbursement from public health insurance. In the past years, focus has been placed on new messages between hospitals and nursing homes in municipalities, including discharge letters and nursing homes plans. In 2015, more than 6 million messages were sent every month. D4.1: Solutions for a Coexistence of ehealth Standards Page 125

3 Figure 47: More than 6 million messages are sent each month ( The primary users of messaging are hospitals, municipalities, specialists, general practitioners. The messages are also used for internal communication within the hospitals. The messages are based on EU EDIFACT standards. For each message, MedCom has developed a Danish profile, which only includes the core and needed content for the implementation. All the profiles are also found in an XML-version and it is up to the vendor to use the EDIFACT or XML-version. Today, more than 100 profiles are used and new profiles are still developed. The timeframe for a new profile, including implementation in the vendor and end-user system can be as low as 6 month. MedCom is doing testing and certification of all vendor systems. The result of the test and certification is published at MedCom s web-page for each profile and vendor system. This information has been very useful for the adoption of the standards as all end-users can easily follow what systems have implemented the national agreed standards. To support the vendor implementation of the profiles, MedCom organises annual test-camps, where the vendor can get advice, talk to colleagues and get its systems tested Repositories Repositories are national databases, which can be physically placed and maintained by a health care organisation, e. g. a hospital. A quite large number of repositories (>100) are clinical databases, which are used for monitoring and improving the quality of care for selected diseases (cancer, cardiovascular, diabetes etc.). Some repositories are an improvement and add-on to the messaging communication, where the messaging data are stored in a central database and can be accessed by all health care organisations and the patients. For example, all laboratory results are communicated to the ordering system as a message and a copy of the result is stored in a central database. The advantage is that all other health care professionals and the patients can access all the laboratory results, which have been per- D4.1: Solutions for a Coexistence of ehealth Standards Page 126

4 formed. Figure 48: A copy of all laboratory messages is stored in a national repository The shared medication card is another example of national repository. The shared medication card holds the current active medication for all patients. It is mandatory (by law) that all systems have integration to the shared medication card and that all health care professionals update the information. A last group of repositories is called Hotels for example Hotels for eprescriptions and ereferrals. The first generation of eprescription was implemented as messages, where the patients had to choose the pharmacy where the drug was to be delivered. The eprescription Hotel makes it possible for the patients to travel around in the whole country and select a pharmacy on his route and buy the prescribed drug. Based on the patient s personal identification number, the pharmacy can retrieve information an all the patients prescriptions and handout the drug to the patient. The ereferrals are useful as the patient is able to freely choose the location for the treatment. The patient s GP can store the referral in the national referral Hotel and the patient can then select a Hospital based on the distance and published quality of the treatment offered. The typical main users of the repositories are the health professionals. Some repositories (lab-results, shared medication card) can also be viewed by the patients via the public health portal ( The exchange of data with the repositories is based on proprietary formats. Repositories which are add-on to messaging are based on messaging standards extended to access via web-services. The test and certification of systems is only mandatory for few of the national repositories Indexing Indexing is a technology where data are stored by the owner and a central index (pointers to data) is maintained and can be used to search for specific information by using filters to focus and limit the data to be retrieved. Indexing is under development in Denmark for the exchange of radiology imag- D4.1: Solutions for a Coexistence of ehealth Standards Page 127

5 es and for the establishment of a national infrastructure for Telemedicine services. The indexing standard is based on IHE XDS and the content information to be used for the Telemedicine infrastructure is HL7 CDA. Until now 3 Danish CDA profiles have been developed (in English): Personal Health Monitoring Record (DK CDA PHMR) Questionnaire Form Definition Document (DK CDA QFDD) Questionnaire Response Document (DK CDA QRD) The infrastructure and the CDA profiles have been validated in A new project to mature the use is planned Concurrent Use of Standards and Specifications (De-facto Standards) As described above the implementation has been use case oriented and includes only one standard (e. g. exchange of discharge letters, lab-results). However, an exception is the use-case for Homemonitoring, which are based on Continua Health Alliance and involves several content and infrastructure standards (XDS, HL7 v2 and HL7 CDA). The National Board of Health maintain a national coding system Sundhedsvæsenets Klassifikations System (SKS = Health Care Classification System). SKS is based on ICD10 and includes diagnosis and procedures which are used in all hospitals and the related ehealth systems. All laboratories in Denmark are using national codes from the Committee on Nomenclature, Properties and Units in Laboratory Medicine (C-NPU). General Practitioner (GP) is using International Classification for Primary Care (ICPC) codes. A mapping table is used to translate ICPC codes to ICD10 diagnoses, when a GP sends a referral to a hospital. The mapping table is also used when a GP receive a discharge letter. The municipalities are using the International Classification of Functioning (ICF) codes, but only internal in the care systems and not for cross sector communication. The above mentioned codes are the most important and are probably the glue for ensuring that clinical content in the many different standards can be exchanged and used for other purposes than for the specific use case. However, this has not been analysed in depth. The National Board of Health developed a common reference model in The objective was that clinical data should only be entered once for a patient and all data should be structured. The model was very similar to the OpenEHR model and was tested in a number of full scale pilot projects. Several years of testing and assessment lead to political discussions on governmental level and the model was closed down Governance The National ehealth Authority is a government authority, responsible for setting national standards for ehealth with powers stipulated in legislation. The National ehealth Authority has established an online catalogue containing a list of the standards applying to each individual area as well as how strongly these are recommended. As part of its work of setting standards for the healthcare services, D4.1: Solutions for a Coexistence of ehealth Standards Page 128

6 the National ehealth Authority also draw up reference architectures which together create a coherent data and ICT architecture for the Danish healthcare sector. The National ehealth Authority is also responsible for the National Service Platform (NSP), which is a central communication platform making it possible to cost-effectively and uniformly couple a large number of local/decentral health applications with national health services, registers and reporting solutions. The National Service Platform has been in operation since 2010 and it is regularly developed in step with digitalisation of the healthcare system and consolidation of government ICT systems. The NSP does not store any clinical data for the individual patient. MedCom was established in 1994 as a public funded, non-profit cooperation. MedCom facilitates the cooperation between authorities, organisations and private firms linked to the Danish healthcare sector. In the 1999 financial agreement between the counties and central government, it was decided that MedCom would be made permanent, with the following objective: "MedCom will contribute to the development, testing, dissemination and quality assurance of electronic communication and information in the healthcare sector with a view to supporting good patient progression". MedCom s profile was intensified further in connection with the financial agreement between the regions and the government for 2011 which states that MedCom is continued based on the politically established goals and milestones concerning cross-sectorial communication and with a precise role as operating organisation. MedCom solves problems with a focus to support efficient performance and a gradual expansion of the national ehealth infrastructure, which is necessary for a safe and coherent access to relevant data and communication across regions, municipalities, and general practitioners. MedCom is financed and owned by: The Ministry of Health Danish Regions Local Government Denmark MedCom s steering committee is furthermore composed by the partners in MedCom. MedCom has, since its establishment, worked in time-constricted project periods of 2 4 years. MedCom9 takes place in Based on the national ehealth strategy, three project lines will be implemented during the MedCom9 period: Realisation of the national telemedicine action plan, where MedCom is responsible for Clinically Integrated Home Monitoring, deployment of telepsychiatry and the deployment of telemedical ulcer assessment Full dissemination and implementation of the Shared Medication Record (FMK), with Med- Com involved in adoption by general practitioners and municipalities Full dissemination and implementation of message-based communication in regions and municipalities, in addition to an ongoing focus on full dissemination and implementation of MedCom standards between hospitals, municipalities and general practitioners. Initiatives are also set in motion in the fields of psychiatry and social services. Furthermore MedCom is responsible for permanent basic tasks within four main areas: Cross-sectoral dissemination and expertise D4.1: Solutions for a Coexistence of ehealth Standards Page 129

7 Standards, testing and certification Operation and further development of the Danish Healthcare Data Network and national data sources International activities Lessons learned, successes and pitfalls This case study is a very short summary of the ehealth development during the last 20 years. More than 100 projects have been launched and contributed to a high level of digitalization of the Danish Health care sector in an international perspective. Lessons learned, successes and pitfalls in all these projects seems not to be related to concurrent use of standards but more to traditional project management. This is also because the national implementation was based on use case and took place within separated isolated projects, each of them with its own objectives and financing. D4.1: Solutions for a Coexistence of ehealth Standards Page 130