The Nordic level of co-operation is important for the development of health care services. The countries have many features in common, which build a ground for beneficial co-operation and exchange of experiences.
One important initiative is The Nordic Healthcare Network. Today, Denmark, Norway, and Sweden each have national health care networks.
The challenge is to create a solution, which would make Internet technol-ogy available to health care professionals across different networks, while making it safe to transmit person-sensitive data. The networks connect secure local or regional networks into a large single network, reusing as much of the existing equipment and infrastructure as possible.
During 2003, the three network administrators have been involved in the technical network group to develop a technical solution that can con-nect the three networks and thereby create one large Nordic Healthcare Network (NHN). An important step was taken in May 2004 when a test connection between the Danish and the Swedish networks was estab-lished. Later in the summer and autumn of 2004 Norway will also be connected.
This technical idea is basically the same as in the national networks, i.e. there must be a central point at the core of the network to handle con-nections among the different networks. The administrators responsible for security are given the necessary tools to handle the traffic and ensure that national regulations on data security and protection are met.
The work to establish the final technical solution for a central Nordic connection point has started and is expected to be finished around 2005.
The central connection point will be established based on the results from the test connection between Denmark and Sweden, but at least the fol-lowing principles will be applied:
All interested parties in the health sector can be connected to the NHN, thus enabling exchange of information between network systems, providing health care personnel with access to the network services, and enabling them to use the network in connection with web references etc.
Patient information, administrative, pedagogical, and technical sup-port systems as well as essential collaborators with special association to the health sector can be connected upon specific approval.
The security will be built on three levels:
• The networks will be connected over the open Internet with encrypted VPN tunnels (Virtual Private Network) to a central connection point (a HUB or router complex).
• Connection to the central point gives no access to other networks before an agreement between the responsible network owners has been signed. At the central connection point, a web-based agreement system will be established handling the opening and closing of connections.
• Access to any application or web-service in the network will be built on User-ID and Password or PKI solutions.
The technical connection of the networks are:
• The NHN will give official RIPE IP addresses to the participants. The local IP structure can thereby be maintained.
• The central connection point will adjust to the local network, which allows the reuse of existing firewalls and router equipment.
The network will be able to handle the following kinds of communica-tion:
• Web-references, e.g. to radiology service reports and laboratory entries
• EDI mail
• WEB services based on SOAP and other standard Internet protocols
• Telemedicine collaboration services
• Videoconference
The financial, legal, and organisational challenges of establishing and running the NHN will initially be handled within the framework of the Nordic eHealth project. During the project period the three national net-works owners will jointly form a non-profit organisation (a Management Agency) that will own and run the central connection point of the NHN.
After the project period it will be necessary to establish a permanent organisation that can run, maintain, and develop the Nordic Healthcare Network. This organisation must have the resources, legal foundation, and technical capacity needed to maintain the network. It will also be necessary to create a legal entity that can handle the requests for
connec-tion from other partners and set-up rules, standards, and guidelines for the network. This organisation will be the owner of the network and hold the contract with the vendor that runs the network.
There are also several other examples of Nordic co-operation:
The Nordic Centre for Classifications in Health Care was established by the Nordic Council of Ministers, and is responsible for collaboration between the Nordic countries and international representation of these countries in the field of health care classifications. The Centre is an offi-cial collaborating centre in the WHO-FIC network (World Health Or-ganization Family of International Classifications), and plays an active role in the development and maintenance of the WHO-FIC classifica-tions, notably ICD-10 (The International Statistical Classification of Dis-eases and Related Health Problems, 10th Revision) and the recently re-leased ICF (International Classification of Functioning, Disability and Health). In addition, the Centre is responsible to maintain and update the NOMESCO Classification of Surgical Procedures (NCSP), developed by the Nordic Medico-Statistical Committee, and the Nordic Classification of External Causes of Injury (NCECI). The Centre is also responsible for the maintenance and development of the NordDRG-system, which is a case-mix system used by the Nordic countries to assess activity and form a basis for reimbursement in the national hospital systems. The Univer-sity of Uppsala in Sweden hosts the Nordic Centre. The national actors in Centre activities are: the National Board of Health (DK), STAKES (SF), Landlæknisæmbettiđ (Isl), KITH (Norway), and the National Board of Health and Welfare (S)
Harmonisation of EHR architecture (HC Interest). The project was executed in 2001/2002 and supported by Nordic Council of Ministers and national authorities with participation from KITH (N), MedCom (DK), Aaalborg University (DK), and Sahlgrenska University Hospital (S). This project has created a first basis for interoperable Electronic Health Care Records in the Nordic countries. The long-term aim is that the informa-tion in different EHR systems can be communicated and re-used. HC Interest has proposed key components of a Nordic EHR architecture and analysed Nordic terminology needs. This has enabled the development of operational EHR messages that have been tried in a pilot project. EHR plays a central role in the IT strategies in the Nordic countries, and HC Interest provides input to these strategies. It is widely accepted that ex-change of experiences and standardisation must extend beyond the na-tional level. There is also a common interest in making the Nordic market for EHR less fragmented and thus more attractive for the software indus-try.
University summer course in Health Informatics (SUMIT) were held 2000–2002, organised by the universities of Aalborg (DK) and Trond-heim (N), KITH(N), and Carelink(S).
Collaborative Network of Nordic eHealth Competence Centres with participation from Carelink (S), MedCom (DK), KITH (N), STAKES (SF), and Ministry of Health/University Hospital of Reykjavik (ISL). The network aims at exchanging views and experiences regarding national developments for IT in health and social care. Special subgroups are ac-tive regarding health nets and PKI, and initiaac-tives for common projects are taken. The network has been active since 2001.
Nordic Telemedicine Association (NTA). The organisation has existed informally for some years, but was formally established in 2003. The goal of the Nordic Telemedicine Association is to facilitate Nordic co-operation and co-co-operation between Nordic countries and internationally in the field of telemedicine and telecare. The association has an official journal, Journal of Telemedicine and Telecare. A main task has been organising a bi-annual Nordic telemedicine conference in Copenhagen (2002), Tromsø (2002), and Uppsala (2004). NTA is supported by the Nordic Council of Ministers.
Another conference, The Scandinavian eHealth conference, has been organised in Arendal (N) in 2003 and 2004, by Agder Regional college (N), University of Asalborg (DK), and associated partners.
Nordic Medico-statistical Committee and the Nordic Social Statistics Committee are both permanent committees financed by the Nordic Coun-cil of Ministers. However, information and knowledge regarding the use and development of IT in the social and health sector is insufficient in the Nordic countries. The existing national information regarding these sub-jects is sporadic. Most of the data is regional, and suitable indicators have not been developed. Developing IT indicators in the social and health sector would improve the possibilities for benchmarking progress in this field.
In addition there are two relatively large projects, one of which has re-ceived Interreg funding and the other is evaluated by EU eTen pro-gramme.
The project Baltic eHealth (2004–2007) is a result of above co-operation and has achieved Interreg support. The project will connect national and regional health nets in the Baltic Sea Region and demon-strate clinical electronic co-operation in radiology and ultrasound ser-vices. Participating countries are Denmark, Sweden, Norway, Estonia, and Lithuania, and the project is run by the Danish Centre for Health Telematics, Carelink, KITH, Norwegian Centre for Telemedicine, Danish Centre for Rural Research and Development, and one clinical partner in each of the five participating countries. The project period is September 2004–August 2007, and co-funding comes from the Baltic Sea Region Interreg IIIB Programme.
The background to this project is that most rural areas in the Baltic Sea Region suffer from a lack of specialised health care professionals.
This problem is expected to grow in the future and, if unattended, will
lead to a situation where citizens in rural areas will receive a lower stan-dard of health care than people living in cities. Baltic eHealth addresses this problem by promoting eHealth as a tool to provide access to highly specialised health care services for the rural citizen. The aim is to con-vince political decision makers that eHealth is an effective and easily implemented solution to the above-described problem, and to promote and facilitate the large scale and daily use of many different eHealth ser-vices in all rural areas.
By establishing the Nordic Healthcare Network, most technical obsta-cles for previous eHealth initiatives have been eliminated. The eHealth services in two clinical pilots are intended to demonstrate to decision makers that eHealth has a positive effect on the accessibility of health care for citizens in rural areas. A goal is that by the end of the project period, the infrastructure, tools, guidelines, and business plan presented in Baltic eHealth will be used in at least five new eHealth services not al-ready included in Baltic eHealth, and that this number will increase in the long term.
Another project involving co-operation between the Nordic countries is the NorMa project. The vision of this project is to create a Nordic (and later European) market for eHealth services supported by the Nordic Healthcare Network (NHN). By creating a Nordic market, the Nordic model for applying eHealth services could be disseminated in other Eu-ropean countries. The Nordic region is at the forefront in this area. The development of a trans-national eHealth market is under way in Den-mark, Norway, and Sweden, based on the nation-wide health care net-works currently being connected to the NHN. The first step in developing such a market is to conduct a market validation of eHealth services in the Nordic countries, and this is the objective of NorMa. A market analysis will be undertaken to analyse the shortages and surplus of health care services and needs of potential buyers. Furthermore, guidelines on re-moving legal and financial barriers for eHealth services will be presented, and two eHealth service pilots building on the NHN will be implemented and evaluated. The existence of NHN brings opportunities for other coun-tries to learn from the experience in the Nordic councoun-tries.
Participating countries are Denmark, Sweden, and Norway. The part-ners involved are the Danish Centre for Health Telematics, Carelink, KITH, Norwegian Centre for Telemedicine, University of Southern Denmark (Dept. of Marketing), University of Aalborg (Dept. of Devel-opment and Planning), and seven clinical partners.
Conclusions
The development of services on a Nordic Health net has major potential benefits, one being the benefit of a larger market. The national markets for these services are small, and a larger Nordic market could increase
efficiency. A vigorous supplier industry is a prerequisite for further pro-gress in the efficient application of IT in the health and social care sec-tors. EHR or PACS represent complex systems coping with complex environments, hence dependent on a market of sufficient size to be able to meet all customer needs.
Since most health and social care services in the Nordic countries are publicly financed and organised, buying power is in relatively few hands.
This creates a certain risk for impairing the market dynamics.
Culture, legislation, and the organisation of services in the Nordic countries have more similarities than differences. This, together with the two considerations mentioned above, would favour opening the Nordic market by increasing co-operation in standardisation, concept develop-ment, and related issues. In many respects, the Nordic nations are front runners in health informatics. A functioning Nordic market can also form a home market for an export-oriented Nordic health informatics systems industry.