DHIS Workshop January 2012 1

HEALTH CARE ICT IN NORWAY

Margunn Aanestad, University of Oslo

Overview

Norwegian healthcare services ICT in the healthcare sector

Primary healthcare Hospital information systems

Experiences from digitization of hospitals (National level)

HMIS/Central registries

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Some facts about Norway…

Small and rich country Population 5 million (life exp. >78 m/>82f) 84 % public (2009), 16 % private 9,6 % of GNP (2009), 229 bn. NOK, (highest

OECD per capity exp. after USA)

http://www.oecd.org/dataoecd/21/3/46507296.pdf

http://www.helsedirektoratet.no/publikasjoner/nokkeltall-for-helsesektoren-2011/Publikasjoner/nokkeltall-for-helsesektoren-2011.pdf

(p. 22 ->)

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Specialist healthcare

Reform in 2001/2: - Transfer of hospital

ownership from county to state

- 5 (now 4) regional health enterprises (RHF)

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Helse Nord

Helse Midt-Norge

Helse Vest Helse Sør-Øst

Specialist healthcare

Somatic + psychiatric healthcare + ambulance services

2010: 866 000 admissions (somatic) Significant shift to oupatient/day

treatment (w/o admission) 4 mill (somatic)+ ~2 mill

(psychiatric)

100 000 ’man years’ (~110 000 employees) 6

Primary healthcare

Primary Health Service Act 1982: municipal responsibility (429 municipalites)

Financed by national government, local tax revenue and reimbursement

140 000 ’man years’, 265 000 service recipients (nursing homes/home based care)

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Primary healthcare

General Practitioners: Independent (contract w/municipality) or

employees of municipality Reimbursement for services Out-of-hours response teams (1,8 mill.

encounters) “Regular GP” (~ 4000) (24,5 mill

encounters) Gatekeepers for referrals to

hospitals/specialist care8

Primary healthcare

Primary healthcare in municipalities ”Health stations”: ANC, immunization,

school health Nursing homes, home-based care Rehabilitation (physiotherapists,

ergotherapists, speech therapists)

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The Coordination Reform

Reconfigure realtion between primary & secondary healthcare

Shift towards prevention

Continuity of care Financial, legal,

admin measures10

Healthcare ICT in Norway…

Early mover on Health ICTs: National ICT strategies since 1996 First to implement EPR (public hospitals

and GPs)

Widely digitized sector: Hospitals, general practitioners, nursing

homes, pharmacies, private sector specialists

… but weaker on linking them together11

Breadth/vision

Concretization/implementation

ICT

National level Ministry + directorate: shared solutions ePrescription, health portal, standards

etc. Specialist healthcare

RHF: hospitals’ IT systems Primary healthcare

Municipalities/GPs GP/nursing homes/home based care

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ICT in primary healthcare

EPR systems for GPs GPs first to implement EPRs, ~100 % coverage 4 products (other than hospitals); Profdoc Vision,

Profdoc Winmed, System X, Infodoc Plenario.

EPR systems in nursing homes/home based care No. of installations vs. pattern of use Mobile clients Other products (Gerica, Cosdoc etc)

Health stations: SYSVAK Admin. systems (IPLOS, KOSTRA reporting)

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Inter-organizational communication

Norwegian Health Network Secure, separate broadband network for

healthcare sector Established 2oo4 (RHFs), provider role State-owned since 2009: strategic role www.nhn.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

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Hospital Information Systems Patient Administrative System (PAS)

Patient demographic info, admission/discharge/transfer, waiting lists, scheduling, letters, reporting …

Laboratory Information Systems (LIS) Production support systems (automated analysis

machines) - (multiple) Electronic Patient Record system(s) (EPR)

Textual information (doctors’ notes, nursing plans, etc.) Radiological Information Systems and Picture

Archiving and Communication Systems (RIS/PACS) Textual information + digital images

Medical Chart systems Vital signs monitoring, medication etc.

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- Like PACS systemer (10 av 11 sykehus benytter AGFA PACS)

- Like EPJ/PAS system (DIPS)

- Felles blodbanksystem- Like mikrobiologisystem- Like patologi system- Like fødesystem- felles syketransportsystem- Like system knyttet til

klinisk kjemi (DIPS)- Etc.

Region North: standardized systems portfolio:

History

1980’s- 90’s: Development initiatives on a national scale Supported by research funds, aiming at

creating national standard & business opportunities

Resulted in three (Norwegian) products: Siemens Doculive DIPS ASA: DIPS Tieto Enator: IMX/Infomedix

Distributed decision making (counties) Regions seek standardization

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Helse Nord (DIPS)

Helse Midt-Norge(DocuLive)

Helse Vest (DIPS)

Helse Sør-Øst(DIPS. Doculive, IMX)

EPR systems in regions:

Main challenges:

To digitize hospitals To maintain control over growing no.

Of systems To achieve inter-organizational

collaboration (digital communication)

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Building EPR systems

Copied the structure of paper-based systems: A Core/critical information B Doctor’s notes C Results from laboratory tests D Results from other examinations of organs E Results from imaging examinations F Observation and treatment G Nursing documentation H Reports from other healthcare staff I External correspondence J Formal documents (sick leave forms, patient

consent forms etc)

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Building EPR systems

Partly digital: A Core/critical information B Doctor’s notes C Results from laboratory tests D Results from other examinations of organs E Results from imaging examinations F Observation and treatment G Nursing documentation H Reports from other healthcare staff I Exsternal correspondence J Formal documents (sick leave forms, patient

consent forms etc) 24

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”

EPRs25

Implementation of IT systems Henry Minzberg (org.theorist) about

hospitals:

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’the most complex type of organizations that humans have created’

Implementation of IT systems WHY COMPLEX?

Many professional groups Tightly interconnected work flows Unpredictable work Moment-to-moment management Many actors ’intervene’…

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complex x complex =

complex2

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Implementation of IT systems Change required at

Individual level Work group level Department level Hospital level

Paper-based information infrastructure is tightly interwoven with organization

Change is potentially disruptive The smaller the change, the easier the

process

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Digitization process

Unilab (medical biochemistry, immunology, microbiology)

Patient Record System

DocuLive Patology

2000 2005

Scanned

Electronic

Paper

Sectra RIS (Radiology)

Portal(svarrapporter)

DocuLive (tekstlige journaldokumenter)

Agfa RIS (Radiologi)

1995 2010

Miclis (microbiology)

DocuLive (andre journaldokumenter, skjema, svarrapporter fra ikke-integrerte systemer)

March 2006

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Original vision Later vision Current vision

PAS

LabSystem

LabSystem

...

LocalEPR

LocalSystem

LocalEPR

LocalSystem

DocuLive ”Umbrella” PAS

LabSystem

LabSystem

...

LocalEPR

LocalEPR

LocalSystem

LocalSystem

DocuLive ”Umbrella”

All systems integrated within DocuLive Some Systems integrated(loosely or tightly)

PAS

LabSystem

LabSystem

...

LocalEPR

LocalSystem

LocalEPR

New Portal ”Umbrella”

DocuLive

Variable levels of integrationunder the New Portal

From: Hanseth, Jacucci, Grison and Aanestad: Reflexive Standardization. Side-effects And Complexity In Standard-making. MIS Quarterly Vol. 30, Special Issue on Standardization Aug. 2006, pp. 563-581.

”Integration model” changed over time:

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Service layer

Presentation layer

Integration layer

Legacy systems

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… still a problem …

OK for the individual clinician/nurse, but a challenge for the IT department

> 1000 IT systems within the hospital

several hundred IT systems with clinical/patient-related information

Complexity as a core challenge35

The challenge of complexity Hospital merger: 4 Oslo hospitals

merged 1.1.2010 In total: more than 3000 IT systems

Aim: Standardize/reduce number Facilitate ”single sign-on”

Solution: ”Clinical work space” (a portal type

interface)36

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The challenge of complexity 2009: Tender process

2010: Tight deadlines (governed through

politics) Troubles … delays

May 2011: Termination (160 million NOK spent )

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Oslo Universitetssykehus

PAS

Klin.dok.

Kurve

RIS/PACS

LAB

PAT

Spes.

Aker UUS RH Radium

DIPS

(Meta-Vision)

Care-stream

Flexlab

Saphire, m.fl.

PasDoc

DocuLive

MetaVision

Siemens

Swisslab

DocuLive PAT

Prosang,Cardas,

Endus, m.fl.

DocuLive

MetaVision

Sectra

UniLab

DocuLive PAT

Well multimedia,

Nyrebase, Albert,

Vmax, m.fl

Agfa

DocuLive PAT

Oncentra, CytoDose, m.fl.

Status pr. 01.01.2011

DocuLive PAT

Learnings

Avoid or minimize complexity: prioritize hard and select wisely

Be aware of ”grand visions” Simpler technologies

Be aware of ambitious project set-ups Let processes take their time, let the local ’work

system’ have time to adapt

Evolution, not revolution Ongoing management of complexity

(IT not just an ’instrument’)41

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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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Hospitals’ reporting

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

Reports generated by the PAS system ICD codes (+ others) entered by clinicians ’Manual’ data validation processes

Individual (but anonynous) records

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

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Data in NPR record (example – old ’flat file’ format, now XML)

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.

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Publication of results:

Quality indicators: http://helsenorge.no/Helsetjenester/S

ider/Oversikt-over-nasjonale-kvalitetsindikatorer.aspx

Information for patients: www.helsenorge.no www.frittsykehusvalg.no

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National HMIS

Not integrated HMIS: 7 central health registries: Mortality registry, birth registry, cancer

registry, infectious diseases, tuberculosis, vaccination registry, prescription drug registry

Different data sources, flows and ’destinations’

Selective integration? Interoperable, rather than

integrated?49

Norwegian Institute of Public Health Promotion of better health and

prevention of disease Through research based:

Health surveillance Advice and various services

Employees and students: ~1000 Annual Budget: ~ 160 mill USD

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Main areas (equivalent to the Divisions of the Institute): Infectious diseases Environmental medicine Non-communicable diseases (Div. of

Epidemiology) Mental health Forensic medicine, toxicology and drug

abuse

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Personal ID no: Registries, cohorts, and biobanks:

valuable resource for medical research Strict privacy regulations

Ids: pseudonymized, encrypted ID, de-identified, anonymized

Physical and technical security measures QA systems, audits etc.

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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 NIPH

The 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-Ø

The Norwegian Patient Registry (NPR) 2007 Encrypted HDIR

The Information System for nursing and care services (IPLOS) 2005 Pseudonym HDIR

Central health registers From IdResponsible institution

The Norwegian Armed Forces registry 2005 Birth Id FD

National Database for Eectronic 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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Group assignment:

Examine a registry and prepare a presentation of what you find interesting: Cause of death registry Medical Birth registry (MFR) National immunization registry (SYSVAK) Norwegian Prescription database Surveillance system for communicalble

diseases (MSIS) Norwegian Patient Registry (NPR) Cancer Registry of Norway

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Or…

Biobanks Quality registers The HUNT study IPLOS

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