IT brings the Danish health sector together

Danish Healthcare and IT

Danish Health Sector

5.5 Mn. inhabitants95% Citizens with access to

the Internet5.8 Mn. mobile phones

60 Public hospitals with21000 beds

>10 Small private hospitals

3500 GPs in 2100 clinics811 Private Specialists

+ 205 part time250 Pharmacies

2700 Dentists in 1650 clinics1829 Psychotherapists in

580 clinics224 Chiropractors726 Psychologists

5 Regions98 Municipalities

1 Private Health Insurance

Aalborg

Viborg■

■

■

■

■

Vejle

Hillerød

■Rønne

Sorø

Regionerne:

Nordjylland

Midtjylland

Syddanmark

Sjælland

Hovedstaden

Bornholms Regionskommune

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Denmark, with 5.5 million inhabitantsand divided into five administrative regions, has a predominantly publichealthcare provision with 60 publicand several small, private hospitals,3500 primary care physicians, GPs,and 250 pharmacies, not to mentiondentists, physiotherapists etc.

In addition to this, the Danish health-care sector is characterised by a

■ North Jutland Region ■ Mid Jutland Region■ Region of Southern Denmark■ Sealand Region ■ Capital Region of Denmark■ Regional Municipality of Bornholm

number of aspects that closely linkIT to the provision of health and social care:

■ Homecare, nursing homes, rehabilitation etc. are municipaltasks that integrate with the health-care system, meaning patients can be discharged early from thehospital. ■ Broadband penetration is thehighest in Europe and more than 95% of the population have accessto the Internet. ■ All healthcare institutions andGPs have access to both the openand the secured Danish Health DataNetwork. All GPs have an electronicpatient record system and use electronic communication and trans-actions extensively. ■ About 15 different electronic patient record systems are inter-operable in the GP sector and fourdifferent homecare records are usedin the municipalities. Through a consensus process with vendors ofalmost 100 systems, all patient management systems for hospitals,GPs, homecare and pharmacies haveincorporated the messaging systemafter special certification.■ A unique personal identifier isissued to all Danish citizens at birth,and a software-based PKI digital signature is widely used, instead ofthe hardware-based chip card.

■ eHealth including telemedicine isimplemented in municipal, regionaland national collaboration.

It couldn’t work without IT

Over the last 20 years, IT communi-cation has become indispensible tothe Danish healthcare services. Datais stored digitally and the communi-cation of text, images and sound viathe Danish Health Data Network hasbecome an integrated part of thecooperation between all groups inthe health sector. It is impossible toimagine daily life without it.

The fundamental requirement is thatinformation must be available whereand when it is needed. It must becommunicated without error andwith a high level of data securitythat ensures the confidentiality ofpersonal data.

On this basis, IT solutions are devel-oped and distributed to the entirehealth sector and always with thecitizen as the primary focus in termsof the communication approach. Theobjective is for properly functioningcommunication to ensure that therefor citizens is access to the bestpossible diagnosis, treatment andcare using the most effective method and in a form that is aseasy and accessible as possible. In practice, this means that thoseinvolved in the individual patient’scourse of treatment must have access to all the relevant informa-tion. They must also be able to ob-tain a second opinion from specia-lists as required. Another basic

In addition, videoconferences takeplace and X-ray images, as well assound and moving pictures, are exchanged and these underpin thecooperation between the specialistsinvolved. Citizens have access toboth information and communica-tion with the entire healthcare ser-vice via the web portal, sundhed.dk,and telemedicine solutions increa-singly enable patients to have directaccess to treatment and monitoringin their own homes.

There are still many IT solutionsawaiting development, implementa-tion and distribution. The develop-ment process never stops. We dofeel, however, that we are on theright track and this view is con-stantly supported by the everydayexperiences of eHealth in the Danish healthcare sector.

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principle in the overall communi-cation approach is that, as far aspossible, information must followthe patient and not the other wayaround.

The Danish healthcare services havecome a long way with this develop-ment. Overall, there has been signi-ficant computerisation of the worktools used for record-keeping in hospitals and at GPs’ surgeries, forexample. Millions of messages –prescriptions, referrals, requisitions,laboratory reports, etc. – are com-municated via the Danish HealthData Network every month. One ofthe biggest current projects con-cerns the Shared Medical Card,which gives all members of the Danish healthcare services on-lineaccess to an individual patient's status in terms of their medication.

Jakob Axel NielsenDanish Minister of Health and Prevention

Bent HansenChairman of the Association of DanishRegions

Focus on the citizen

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The citizen is at the centre of theorganisation of eHealth in Denmark.The aim is to make it easy for him orher to communicate with the Danish healthcare services and to obtain information about health and ill-nesses. At the same time, it is astated goal that the communicationbetween the parties involved in the Danish healthcare services mustbe organised in such a way as to ensure that the citizen always

receives the best possible treatmentfrom the health services. It is there-fore entirely appropriate to use the term “welfare technology andservices” to refer to eHealth.

The two most important access routes to the Danish healthcare ser-vices for citizens are their GP andthe web portal, sundhed.dk. Theemergency department is of coursea third option, in the case of suddenillness or accident.

The patient's GPEvery citizen has their own doctor,or GP as they are known. He or shehandles common health problemsand assesses on a case-by-casebasis whether they need to involvespecialists in the treatment or torefer the patient to a hospital. Alarge proportion of GPs have theirown website, where the citizen canmake consultation appointmentsand renew prescriptions, amongother things.

Web-based information and communicationThe web portal, sundhed.dk, is theaccess route to a great deal ofinformation on health, illness andthe areas of the Danish healthcareservices. Here, citizens can find information on classifications, treat-ments, waiting lists, and muchmore. It is also possible to commu-

The Danish Health Data Network

sundhed.dk

Hospital

GP

Citizen

LaboratoryPharmacy

Physio-therapist

Municipality

X-ray

Chiropractor

Dentist

Psychologist

nicate directly with the Danish healthcare services to a certain extent via sundhed.dk.

The citizen is in the pictureThe internal communication of theDanish healthcare services is basedon the needs of citizens. For exam-ple, a citizen can collect his or hermedicine from the pharmacy imme-diately after the GP has sent anelectronic prescription. Other exam-ples are notifications of admission,discharge letters and rehabilitationprogrammes which the hospitalsends to the municipal authorities.This ensures that the citizen receives the correct follow-uppromptly after hospital treatment.Another example is patients, notleast those who have chronic illness,who are in direct contact with theirGP or hospital department via tele-medicine solutions.

The Danish Health Data Network

sundhed.dk

sundhed.dk is the official DanisheHealth Portal for the public Danishhealthcare services – the word‘sundhed’ means health in Danish.

The Danish healthcare services arethe joint public services of all theDanish health authorities and provi-ders and they are brought togethervirtually at sundhed.dk. This makesit possible for patients, their fami-lies and healthcare professionalsalike to access general and individual

health information and to communi-cate with each other.

Two purposes and two profilessundhed.dk has two purposes – thefirst is to support the national goalsof the Danish healthcare servicesand the second is to communicatethe current activities of the Danishhealthcare services.

The portal features on-line servicesfor the general public, who can find

general health information, bookappointments with their GP andrenew prescriptions, as well as gainaccess to their own medicationdata, for instance. For the health-care professionals, sundhed.dk features include on-line services foraccess to laboratory test results andto data stored in electronic patientrecords.

Citizens and healthcare professionalsboth searching for information via sundhed.dk

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Flow of electronic messages in the health sector

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GeneralPractitioner

�

On-line booking ofconsultation appointments.On-line consultations.Prescription renewal

Transfer of patient record

�

Booking report. Discharge letters

�

Billing

Messagesfrom and to...

Citizen

sundhed.dk

GeneralPractitioner

Hospital

All parties

Public HealthInsurance

sundhed.dk

��

Information and communicationbetween the citizen and theDanish health-care services

Hospital

�

Referrals. Bookings

Municipality

�

Request for prescription renewal

�

Notification of admission and discharge. Notification of completion of treatment. Healthcare report. Rehabilitation programme.�

Admission response. Homecare status.

�� Information and communication between healthcare professionals

�� Letters of correspondence

Read the flowchart as follows,for example:

Once the patient has been examined, the doctor sends an � X-ray referral to the Imaging Diagnostic Department and receivesan � X-ray report in return.

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Laboratory

�

Requisitions�

Lab reports

�

Requisitions

�

Billing

Imaging DiagnosticDepartment

�

X-ray referrals�

X-ray reports

�

X-ray referrals. X-ray dischargereports

Pharmacy

�

Prescriptions

�

Prescriptions

�

Billing

Physio-therapist

�

Referrals�

Discharge letters

�

Billing

Psycholo-gist

�

Referrals�

Discharge letters

�

Billing

Chiro-practor

�

Referrals�

Discharge letters

�

Billing

On-call GP

�

Discharge letters

�

Billing

Medical specialist

�

Referrals�

Discharge letters

�

Billing

Health Visitor

�

Notification of birth

Citizens,patients and eHealth

1. Bruno Elmer Berggreenmakes an appointment withhis GP because of the painin his right hip. The appointment is madevia the eHealth portal sundhed.dk.

2. Bruno goes to the appointment with his doctorand is examined for thecause of his pain. The doctor takes blood testswhich are sent to the laboratory and orders an X-ray examination.

3. The doctor receives thereport for the requested examinations and on thatbasis decides that Brunoshould be referred to theHip Arthroplasty departmentat the hospital.

4. Bruno is referred to thehospital, where the doctorhas access to the X-ray andlab-reports that the GP ordered. The hospital sendsa request for Bruno to beadmitted for treatment.

This description is very simpli-fied in order to provide a clearoverview of the electroniccommunication in relation tothe patient’s course of treat-ment.

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Bruno Elmer Berggreen is an elderly citizen, who is a widowerand lives alone. Chronic bronchi-tis and diabetes have weakenedBruno to such an extent that hereceives direct help with cleaningand other chores in his homefrom municipal homecare. Recently, Bruno has had seriousproblems with pain in his hip.

Citizen Citizen

GP sundhed.dk

GP GP Hospital

Laboratory X-rayX-ray

Laboratory

HospitalLaboratory X-ray

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5. Bruno is admitted to thehospital. The hospital sendsan automatic notification to the municipality so thatmunicipal homecare isaware that he has been admitted.

6. Bruno is discharged fromhospital and comes home.Municipal homecare receivesa notification in advancewhen he is discharged fromthe hospital.

7. The homecare nurse orders pain relief medicineand a prescription renewalfrom the GP.

8. The GP receives the discharge letter and a copyof the rehabilitationpr0gramme from the hospi-tal. The GP also receives therequest for prescription renewal from municipal homecare and sends it tothe pharmacist.

9. The municipality receivesthe rehabilitation pro-gramme and starts the rehabilitation process.

Hospital Municipality

Citizen CitizenCitizen

MunicipalityHospital GP

Municipality

Pharmacy Municipality MunicipalityPharmacy

GP Hospital

Millions of messages every month

It all started as a pioneer project,when one GP decided on his owninitiative to develop a solution thatwould enable him to send electronicprescriptions to the pharmacist. Thatwas at the beginning of the 1990’s,and that was the start of the DanishHealth Data Network.

More accurate and effectiveSince then, the Danish Health DataNetwork has been expanded to

computer system – for example, theelectronic patient records at the GPclinic as well as at the hospital andthe citizen care record at municipalhomecare.

At the same time, the simple trans-mission of messages from sender torecipient has now been supplemen-ted by forms of communicationwhere the recipients retrieve the in-formation themselves, such as look-ing up the laboratory test report.

Putting the idea into practiceA communication standard is speci-fied for each individual message,which is tested and then implemen-ted and distributed for general useby MedCom. An important experi-ence is that implementation anddistribution require detailed infor-mation, and to a certain extent organisational adjustment, if elec-tronic communication is to workmost effectively.

It is characteristic of this develop-ment that it is user-led to a largedegree and that a number of publicofficials act as coordinators in theprocess. They have, to a great extent, specified the framework andguidelines, which have subsequentlyprovided the conditions for privatesuppliers to be able to develop andmarket communication solutionsunder market conditions.

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include the transmission of all stan-dard messages for healthcare com-munication and between almost allinvolved parties. Electronic messa-ges have replaced paper ones,which in many cases used to besent by post. Sending messageselectronically is much faster andmore accurate, as data only has tobe written down once. It is alsomore effective, as data is automati-cally integrated into the recipient’s

Million messages per year.

The vision of the paperless hospital

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These days, many Danish hospitalsare carrying out extensive develop-ment work in relation to electronicpatient records (EPR). At some hospitals even, EPR has been im-plemented and is already in use, although not in its fully developedform. The vision is that these recordswill replace paper records in the nottoo distant future and will in fact become the definitive main sourcefor all relevant patient information.

The individual patient’s course of treatment typically involves severalhealth professionals, partly becausetreatment and care take up manyhours of the day and partly becauseholistic treatment can easily involvea number of specialists, each with a different area of expertise. Previously, many of the specialistsinvolved each had their own paperrecord, which made the coordinationand organisation of a flexible courseof treatment more difficult.

In the future, all relevant informationwill be gathered in one place and willbe accessible anytime from any-where. Initially, the idea is to have ashared EPR for each individual hospi-tal, but this is also a natural basisfor providing an interconnected EPRsystem for the entire hospital net-work and in the longer term for theDanish healthcare services as awhole.

Telemedicine

■ that diabetics are able to havetheir blood sugar levels monitoredfrom their own home.■ that patients with chronic bron-chitis can measure their lung func-tionality from home and they canalso have electronic consultationswith their doctor. ■ that the time spent in hospitalcan be reduced for COPD patients,thus radically improving their qualityof life.■ that a visiting homecare nursecan obtain specialist advice on-linewhen treating sores in the patient'sown home (teledermatology).

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The ultimate purpose of developingand implementing telemedicine solutions in Denmark is to providepatients with the best informationand the best treatment as close tothem as possible. Telemedicine isideal for patients living in remoteareas, such as islands, but is alsoparticularly important for patientswho need contact with the healthservice because of long-term orchronic illness and telemedicine canalso be used as a collaborate plat-form for health professionals andspecialists.

In cases of chronic illnesses, tele-medicine solutions can mean, for instance:

In providing services to patients over distances, the Danish healthsector can use telemedicine solu-tions to monitor diabetics and heartpatients, but also to conduct con-sultations with alcoholics under-going treatment, for example.

New forms of telemedicine solutionsare continually being developed forcommunication between healthcareprofessionals. These include videoconferences and specialist consulta-tion during the video transmissionof operations. Telemedicine is alsoused to transfer duties between hospitals, such as X-ray and mammogram screening diagnosis.

SwedenNorway

Denmark

Lithuania

Estonia

Mid-Norway

Västerbotten

BHN

Tallinn

VilniusFunen

International projects

In large parts of the developmentprocess, the parties behind the Danish Health Data Network havestressed the importance of inter-national cooperation. A number ofspecific projects have been carriedout over the years and the resultsare reflected in the achievements inhealthcare communication, both forDenmark and for the collaborativepartners and countries.

Alongside actual cooperation onprojects, there is also significantcross-border networking takingplace. In this respect, the Danishhealthcare sector is particularly in-volved in the Nordic and Europeannetworks.

It is only natural that some institu-tions and countries are furtheralong with their development workin certain areas than others. The po-sitions of strength change, however,as the individual countries typically

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place emphasis on different areas ofeHealth. As a result, internationalcooperation is a kind of give andtake situation for all concerned –no-one takes part solely to learn orto teach but rather to do both.

A good example of an internationalcooperation project is the transferof tasks from resource-weak areasto resource-strong ones. Specifically,this relates to X-ray diagnosis,where X-ray images are taken inDenmark, for example, and trans-mitted to Estonia, where the reportsare made. The results are trans-mitted back to the Danish hospital,

where they are used to diagnoseand determine further treatment. Similar cooperation has been established between Denmark andSweden for diagnosis based onmammogram screening.

This cooperation is possible becausethe Danish Health Data Network isconnected not only to the Norwe-gian and Swedish national HealthData Networks, but also to regionalnetworks in Estonia and Lithuania,so that data and images can betransmitted via a closed and securenetwork called the Baltic HealthNetwork (BNH).

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There are many behind the successes

It is a feature of the Danish Health Data Network that many different groups – large and small, public andprivate, users and suppliers – have worked closely together to develop the communications solutions intowhat they are today. The requirements have mainly been specified by the users, in the form of healthcareprofessionals. A number of public groups have worked together with the healthcare professionals to definethe standards, framework and guidelines, while private suppliers have provided the solutions under marketconditions.

Three public institutions operate at national level:

Digital Health “Connected DigitalHealth in Denmark” provides theframework for the computerisationof the Danish healthcare sector andthe goal is to create a coordinatedhealth service, where doctors, practitioners and citizens have access to all necessary health data.The Shared Medical Card, for exam-ple, is a project running under SDSD,which will give all members of theDanish healthcare services on-lineaccess to an individual patient’s status in terms of their medication.

The organisation creates the chan-nels of communication throughwhich the health data must flow aswell as the language in which thesystems should communicate.Through cooperation with regions,municipalities and hospitals SDSDworks on making the many, local,well-functioning systems communi-cate with one another.

The eHealth Portal is the officialDanish eHealth portal for the publichealthcare services. The portal canbe accessed with a digital signature– different for citizens and pro-fessionals. Citizens can gain accessto general and personal informationand professionals have access to anumber of services including readingelectronic records etc. under the ruling of the Danish Data Protectionauthorities.

MedCom was established in 1994,primarily to serve the needs of GPs. It currently manages the secure Danish Health Data Network andintersectoral communication formore than 50 MedCom standardisedand certified message of varioustypes. Today more than four millionmessages are transmitted per month.

MedCom also focuses their efforts on telemedicine at a national and international level, and is closely in-volved in many European projects.

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of IT in the Danish health sector

Private suppliers:

Suppliers of X-ray systems

AgfaLogica Danmark A/SEDB GruppenFormatexIT-driftscenter OdenseSectra A/SMedosMedical InsightGE Healthcare TechnologiesFirst Impression MyClinic A/SCSC ScandihealthCarestream Health (Kodak)

Suppliers of laboratory systems

CSC Datalab ApS, LABKALogica Danmark A/SSkejby SygehusIT-driftscenter OdenseADBaktCapio Diagnostik a.s.NordTeamGruppen ApSTietoEnator A/SSafirlisMisys Healthcare Systems –International Databyrån för informationsbehandling AB

Suppliers of pharmacy systems

Cito Data A/SApoteksdata I/SNNIT-PharmaNet

Suppliers of healthcare systems

Rambøll Informatik A/SCSC Scandihealth A/SLyngsoe Systems A/SKMD A/SAvaleo ApSZealand Care A/S

Suppliers of hospital systems

Logica Danmark A/SEDB GruppenFormatexEM-data A/SIT-driftscenter OdenseACURE – an IBM DivisionCSC ScandihealthFirst Impression MyClinic A/SFICS Danmark A/STM SoftwareSystematic Software Engineering A/SSkejby SygehusGamma-Soft

Suppliers of medicine systems

CSC ScandihealthACURE – an IBM DivisionLogica Danmark A/SFICS Danmark A/STM SoftwareSystematic Software Engineering A/S

Suppliers of doctor’s systems

Nordteamgruppen ApSPC-Idé/PC-PraxisEG Data Inform MedwinA-Data ApSDatagruppen Vejle MultiMed ApSProfdoc A/SFormatexAver & Lauritzen ApSEM-data A/SDocbase A/SLægernes edb-centralDan-Med-SoftStructura IT ApSFirst Impression MyClinic A/SMedol ApSProfdocLinet

Danish RegionsAssociation of Danish Regions.www.regioner.dk

sundhed.dkThe Danish eHealth Portal.www.sundhed.dk

MedComA national public project organisa-tion involved in cooperative ventures with authorities, organisations and private firms.www.medcom.dk

Digital HealthConnected Digital Health in Denmark.www.sdsd.dk

Local Government DenmarkAssociation of Danish Municipalities.www.kl.dk

Text: arki•tekst kommunikationPhotos: Nils Lund Pedersen (pages 5, 6, 8, 9, 11 right),Alex Tran (page 4), Colourbox (pages 11 left, 12 right),Grafik & Klinisk Foto, OUH (page 14), Regionshospitalet Viborg, Skive, Kjellerup (page 15) Graphic Design: Christen ToftePrinted in Denmark 2008 by one2one, Odense