IT service

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MC-S000 December 2009

MedCom 15 years

Status report, MedCom 6

MC-S218 December 2009

cooperation

Internet

service

dialogue

efficiency

strategy

security

IT

VANS

15 years

development the patient

healthcare

communication

the citizen

information

digitisation

the future

cohesion

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Standardisation It began in a true pioneering spirit with the idea that electronic communication had the potential to become a good tool for the Danish Healthcare System. It ought to be possible to convert fixed forms such as prescriptions, referrals, etc., to standard electronic forms and then to send them directly from one IT system to another.

Find out more on pages 4 – 5

Consolidation Pilot projects became permanent arrange- ments. Dissemination gained pace, and the MedCom standards have long been part of everyday working life.

Perhaps not everywhere in the healthcare sector, but almost.

International issues International cooperation has more or less always been a special part of the development effort in the field of healthcare IT.

Standardisation, infra- structure and telemedicine have been some of the major areas of focus, and the EU has played – and continues to play – an important role.

sundhed.dk

Over the years, Health- care IT has become a very wide term. An important partner for MedCom is the eHealth portal sundhed.dk, which is the entry door to the Danish Health- care System for the citizens and also an important communication interface for healthcare professionals.

Find out more on pages 12 – 13

SDN

In time, a need arose to supplement the VANS- based message communication with a new network for telemedicine and other forms of communication in image and dialogue format. The idea arose to base a new national network on Internet technology, and the idea was then put into real life.

Find out more on pages 16 –17

M edCom is a cooperation between authorities, organisations and pri- vate companies involved in the Danish healthcare sector. The partnership was established as a temporary healthcare IT project in 1994, but was later made permanent through the 1999 financial agreement between the Government and the former counties.

MedCom’s purpose: MedCom will con- tribute to the development, testing, dissemination and quality assurance of electronic communication and informa- tion in the healthcare sector, with the aim of supporting good patient pro- gress.

The parties behind MedCom today are:

the Ministry of Healthcare and Preven- tion, the National Board of Health, Danish Regions, Local Government Den- mark, the Ministry of the Interior and Social Affairs and the Danish Pharma- ceutical Association.

Photograph: Helle Moos

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Foreword / Contents

H ealthcare IT is an absolutely vital tool in efforts to equip the Danish Healthcare System to face the challenges of the future.

Digitisation needs to be used in an efficient and targeted way in the efforts to create a Healthcare System that will deliver a high level of treatment and service. It is about supporting better communication with the citizens, and it is about a cohesive Healthcare System charac- terised by successful organisation of work procedures and routines.

Denmark is at the forefront in this area, not least by virtue of the efforts delivered by MedCom over the past 15 years, for example in terms of the standardisation, imple- mentation and dissemination of electronic messages between all parties within the Danish Health- care System. Today, this part of

communication has become routine in general practice, in local authori- ties, hospitals, pharmacies, labora- tories, etc.

Over the years, further measures have taken place towards exploit- ing to an even greater degree the latest information technology, thus strengthening the power of cohesion internally in the Danish Healthcare System and in respect of the population. Through the Health Data Network, system development and standardisation, the IT engine room of the Danish Healthcare System has been devel- oped and optimised, and this work is continuing all the time. At the same time, specific tools such as telemedicine are showing huge po- tential as a means both of making the Healthcare System more effi- cient and flexible and of improving

efficiency in the services to the population. For the population, a rapid development is taking place of access to information about themselves and the Danish Health- care System in general at the eHealth portal sundhed.dk.

Looking back, developments over the past few years have been impressive, not least thanks to the current MedCom projects and their predecessors. And they are poin- ting forwards. Towards dissemina- tion of the good solutions, for example the MedCom standards becoming fully utilised in all local authorities, regions and surgeries and telemedicine being implemen- ted to its full capacity in suitable areas so that healthcare staff can make efficient use of their time and energy for the benefit of patients.

Jakob Axel Nielsen

Minister of Health and Prevention

E-records

e-records is one of the many new functions.

The idea here is to provide healthcare professionals and citizens alike with direct access to patient records via sundhed.dk.

Local authorities The local authority reforms and creation of new, larger authorities and five regions to replace the counties provided completely new partnership relationships within the healthcare sector. The local authorities now came into the picture in earnest.

Telemedicine Telemedicine includes the expansion of healthcare IT to include images and sound. This provides the facility to involve citizens directly in their own treatment and the method in which specialised support is provided irrespective of geographical distances. The first steps were taken well before 2008, but now the new opportunities provided by IT have really had their breakthrough nationally.

Digital Health Much water flowed under the bridge in the years before healthcare IT. Organisations came into being based on specific tasks, and MedCom is just one of them. The task of SDSD, Digital Health, is to gather the threads together and set out the markers showing the path for the future.

Contents

Foreword 2

Articles 4

Projects 24

Toolkit 37

Statistics 42

Names 50

Digitisation – a core element in the development

of the healthcare sector

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“

In this department, we reduced the work processes from 18 to just 5 by switching to purely electronic communication.

Niels Jørgen Christensen

Anders Kristian Jørgensen

B ack in 1994, a group of professional IT experts got together with doctors and healthcare staff with an interest in IT to develop electronic commu- nication standards. One of the members of the group was Niels Jørgen Christensen, who today is IT Project Manager in the Central Jutland Region.

“We were six self-appointed nerds with masses of pioneering spirit and drive who said that we would be perfectly capable of developing some standards like this. We were all different and there were many disagreements, but we always managed to reach a decision that everyone would support,”

he recalls.

The standard electronic forms, EDIFACTs, were developed based on international standards and by examining the actual requirements of doctors and healthcare staff who would need to use the forms.

The technical challenge consisted of transferring a paper form into an electronic system.

“A computer, of course, cannot decide whether one thing is more relevant than another, or whether a date specified is a creation date or discharge date,” explains Anders Kristian Jørgensen, who was working at the time for Dan Net and who was res- ponsible for getting the systems to work in practice.

“We needed to ensure that the system could sort all the data in a meaningful way. And the EDIFACTs developed by the standardisation group in ‘96 are, at their core, the same as the ones used in the healthcare system today.”

nerds

and IT pioneers

1 5 years

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Standardisation, dissemination, consolidation

B efore the MedCom standards were implemented on a large scale in the country’s hospitals, local authorities and surgeries, they were pilot tested in real life at selected hospital departments and sur- geries throughout the country. What was then Vejle County worked together with MedCom to test a number of standards in radiology and pathology departments, several clinical departments and a number of GP surgeries, among other places.

“It was a positive and exciting process, even though getting the organisation of the projects approved and granted inter- nally was a challenge,” says Tove Charlotte Nielsen, who from 1997 until 2007 worked as a coordinator for the standardisation projects in the county.

“When MedCom were ready to launch a new project within their two-year pro- ject periods, it could easily be six months before the project was approved in our organisation and the resources found.

So we were already a little way behind,”

she recalls.

“However, the most important thing was that, in spite of everything, manage- ment backed the projects and could see the long-term benefits of developing some electronic standards for the whole healthcare sector.”

Tove Charlotte Nielsen Finn Mathiesen

Radiology Department, Vejle Hospital

Important for

management to be forward-looking Efficiency at

maximum and error rate at minimum

W e are almost 100% digital in this department, and that has changed our day-to-day work accordingly,”

explains Finn Mathiesen at the Radiology Department of Vejle Hospital, which is part of the Lillebælt Hospital.

“Previously – and, in fact, it wasn’t so very long ago – we would be standing there with paper records in our hands while we looked at X-rays in the light box and read out notes into the Dictaphone, which the secretary would then write up. Then, it wasn’t beyond the bounds of possibility for papers to get lost or mixed up. That situation doesn’t occur today, when all documents, notes and images are held on the patient’s electronic record. In this department, we re- duced the work processes from 18 to just 5 by switching to purely electronic communication. So, we have significantly improved efficiency and, at the same time, sealed off the chain of security, thus improving patient security.”

In practice, digitisation has released so many resources that today the department can offer drop-in examinations, which the patient can come to straight away. Another ad- vantage is that geography is no longer a barrier to coopera- tion.

“Everyone can see all the information everywhere in the hospital, and soon in the region, too. The plan is obviously to make it a national thing. I hope individual users in the future will be able to adapt the system to their own needs, and that everyone will be able to read the same formats.

I think it is important to stress that what is vital for com- munication are the common standards, not whether or not the record systems in the departments are the same,” Finn Mathiesen points out.

Photograph: Colourbox

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Things have gone well, but perhaps it is time

to take a step back?

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Standardisation, dissemination, consolidation

W e have come a really long way – further, indeed, than anyone dared dream of when we started the standardi- sation projects 15 years ago,”

says Jens Parker, a GP who has been actively involved in the MedCom work right from the pioneering years.

“Today, there isn’t a single agreement between various professional healthcare practi- tioners and the Danish Regions that doesn’t specify that Med- Com standards must be used.

That is great, I think, not least taking into account the fact that it succeeded despite there being so many GP and specialists’

systems. Try seeing how difficult it is to establish interdisciplinary communication in relation to the hospital systems! That brings the results from general practice into relief.”

At the time at which Jens Parker became involved in the MedCom projects it was done on the basis of a belief that communication could be orga- nised both more smartly and quickly by using the new infor- mation technology as a work tool. That conviction led him, over the years, to take an active part in project work and also as a type of ambassador to his colleagues for the new opportu- nities. Today, he acts as an observer for the Danish Medical Association in MedCom’s steering group, and he also sits on the project group for the Common Medication Card.

Must not drown in success

“The success has been secured, but I also think we must be mindful of the risk of drowning

in our own success,” he points out.

“In the long first period we in general practice have accep- ted the opportunities because we could see clear benefits to electronic communication.

Generally, it has been the reci- pients of the communication who have enjoyed the biggest benefits.”

Many of the more recent measures, however, are about delivering information which benefits others yet makes more demands on our time. There are several examples of measures where the GPs find that it was actually easier when they used paper. That sort of thing is hard to sell, although of course we do understand that we are not the only ones who should bene- fit from the communication.

Limited resources

“Another aspect pulling in the same direction is that the sup- pliers of GP and specialists’

systems must develop and im- plement the many new solu- tions. Resources are limited, and there is only one place to which to send the bills, but who will want to pay for solu- tions that require more time and work? In that way, you need to understand that GPs and their suppliers work under different conditions than the hospitals, local authorities and many of the other players.

There needs to be a sensible business model. This is often forgotten.”

So, even though the oppor- tunities are tempting, it may be necessary just to take a step back before we launch our- selves into too many large new projects.

Jens Parker

General practitioner

Photograph: Colourbox

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Leif Vestergaard Pedersen Vera Ibsen

Peter Behrendt Lau

With e-records I feel better prepared when I visit the doctor

W hen, like Benjamin Fugl- sang Breum from Tjele, you have been through a leng- thy illness involving hospital ad- missions and numerous exami- nations by various specialists, being able to follow the pro- cess via e-records is a great help. In 2004, Benjamin under- went an operation on his stomach, and the illness has now lasted for 3½ years.

“In particular, I used

e-records to keep myself up-to- date with my test results. In this way, I have been able to pre- pare myself better for my meetings with the doctors,” he explains, adding that the access to e-records will place greater requirements on the ability of doctors to communicate with their patients.

“I believe that it is a genuine- ly healthy thing all round for us as patients to have more op- portunity to get involved in our own course of treatment. How- ever, I also believe it will be a challenge to those doctors who have been used to patients simply listening and not asking so many questions.”

As far as the actual e-records system is concerned, he is happy about the information which the system allows him to access, but still feels there is room for improvement in terms of user-friendliness and design.

Photograph: Lars Holm

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e-records

P eople were enthusiastic about the possibility of be- ing able to look at the data in their own records, particularly as it offered them a better opportunity to arrive well pre- pared for their treatment and consultations, as Peter Beh- rendt Lau of Rambøll Manage- ment Consulting and Project Manager during the evaluation of e-records in 2008 explains:

“Hospital staff were also positive. Their main wish was simply for the system to be ex- tended nationwide as quickly as possible.

“The GPs were more reser- ved about it, mainly because the introduction of new IT sys- tems often proves a challenge for small practices and because some doctors had found that the information in e-records was not always up-to-date on the part of the hospital.”

Good start for e-records,

but room for improvement

I t quickly became apparent to us that we needed to develop a new standard, one that was able to extract the desired information from the various existing systems and present it in a clear and user- friendly way,” explains Vera Ibsen, who at the start of the e-records project was Chief of Section at Vejle County.

“One of the major challenges was to design and develop a user interface that would take into account the varying requirements of different target groups. This wasn’t exactly easy.”

When the first standard was de- veloped, MedCom was given the responsibility of commissioning the system, professionalising its main- tenance and keeping it up-to-date.

Vera Ibsen says of this cooperation:

“MedCom has the resources and skills to run and update systems of that size, and the cooperation works out fairly harmoniously.”

It is her opinion that e-records should be regarded as a forerunner of a more advanced system, which is also described in the Digital Health organisation’s strategy for a National Patient Index (NPI). All information – records, laboratory results and image data – from all sectors of the healthcare system will be available in this index.

A unique,

tailored format

T he need to exchange record data within the Danish Health- care System was obvious, and there were different solution models on the table, as Leif Vestergaard Pedersen, Healthcare Manager, Central Jutland Region, recalls.

“We had a good solution in Vejle and Viborg Counties. Gradu- ally, this spread to the whole of Western Denmark, and MedCom facilitated a number of the proces- ses in this regard. They did a good job of this, and showed their flair for developing simple solutions to complex tasks. In principle, every- thing is possible when it comes to IT. It’s just that sometimes solutions are so complex that the IT task it- self swallows up more resources than it frees up.

“So, you may of course be ask- ing yourself whether we gained just a temporary solution with e-records. We did indeed, but, then again, all IT solutions are tempo- rary!

“It could easily be the case that e-records will be developed further.

Perhaps, in the immediate term, there is room for improvement in terms of the patients’ access. My opinion is just that, while the pati- ents by all means can take a look, too, e-records is primarily a work tool for healthcare professionals.

“Speaking of professionals, GPs should by all means have easier access to e-records. It is also of decisive importance for the hospi- tals to be given equally easy access to the GP’s records. It needs to work both ways.”

Why make it harder than it is?

What is e-records?

The record retrieves data from

the existing electronic patient

records at the country’s hospi-

tals. Access is provided to clini-

cians at the hospitals and to all

general practitioners. Citizens in

most of the country also have

access to e-records via Digital

Signature at the eHealth portal

sundhed.dk.

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place to the structural reform

Vivienne Ottosen Peter Simonsen

C hristmas 2006 will not be easily forgotten by those working in the country’s largest IT company, KMD. The reason is that the new structural reform with its merging of local authorities and abolition of counties was due to take effect on 1 January 2007. Marianne Knudsen, Service Consultant at KMD, was res- ponsible at the time for getting the interfaces between the local autho- rities’ healthcare information sy- stems and the KMD Sygehusophold system to work. It may have been a hectic period, but today she looks back on it as a good experience:

“It was so fantastic to see how good cooperation can give ‘flow’ to a project. Everyone worked hard to ensure the system would work, and both the suppliers of healthcare in- formation systems and MedCom were really good players through- out the whole process,” says Mari- anne Knudsen.

The project advanced according

to plan, and she managed to cele-

brate a relatively peaceful Christ-

mas with her family. After the turn

of the year, a three month transi-

tion period followed, during which

communication between hospitals

and local authorities proceeded as

in the ‘old days’, i.e. by telephone

or fax. During that period, the new

KMD Sygehusophold system was

implemented in the local authori-

ties. According to Marianne Knud-

sen, this proceeded relatively free

of problems. She attributes this,

too, to good preparation and

teamwork.

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An indispens- able work tool

B y virtue of the structure re- form, the local authorities have gained a much more cen- tral role in the healthcare sec- tor than before. This applies not least in terms of rehabilita- tion, prevention, health promo- tion and measures for the chronically ill. It is, therefore, both natural and necessary for local authorities to be deeply involved in our efforts to en- sure there is communication between the other parties in the Danish Healthcare System – a communication that works flexibly, securely, efficiently and is free of errors. Here, health- care IT is an indispensable work tool, both in terms of messages about admissions, discharges, rehabilitation plans, etc., and with regard to the exchanging of information between the home care sector and general practice. New information tech- nology measures, too, will gain great importance – telemedi- cine, for example. As we see it, healthcare IT can both support successfully functioning proce- dures and, to a large degree, also enhance the quality of the service we provide to citizens.

Peter Kjærsgaard Petersen

Head of Division,

Social and Healthcare Policy, Local Government Denmark

The structure reform

Healthcare agree- ments are ‘born’

with IT support

R egion of Southern Denmark is the region that has come fur- thest in the implementation of the strategy for healthcare IT across local authorities, hospitals and general practice. And, according to the Head of Department for local authority collaboration, Peter Simonsen, there are numerous reasons for this:

“In the first instance, from the start we have ensured that our stra- tegy was supported and prioritised politically in all local authorities and in the region. This has meant that all parties have been willing to priori- tise and invest the necessary resour- ces in the project. Secondly, right from the start we have incorporated IT support as an integral part of the healthcare agreements between the local authorities and the region.

And, thirdly, we have been very aware that the implementation of new IT systems and standards across all sectors of the Danish Healthcare Service and the local authority sy- stem is a huge organisational task that requires a special unit to attend to coordination, training, technical support and communication. We therefore set up an IT secretariat, jointly financed by the region and local authorities, to act as ‘coordina- tor’,” explains Peter Simonsen.

The overall aim of the cross- sector healthcare IT strategy is to create an electronic link to the indi- vidual citizen/patient, so that health- care information can be exchanged from records at hospitals, in general practice, in the local authority home care sector and rehabilitation unit – in other words, all bodies with which the patient comes into contact during a course of treatment and throughout the whole of his or her life.

Three local

authorities - one common system

D uring the local authority mer- gers in 2007, what was then Svendborg Municipality merged with Gudme and Egebjerg Munici- palities. In terms of healthcare, they had three different systems.

Svendborg’s solution was entirely IT-based, Egebjerg’s partially so, while Gudme still communicated via paper forms and letters. With Svendborg the most advanced in this regard, it was quickly decided that the best solution would be for everyone in future to use the same system for healthcare infor- mation that they had good expe- riences of in Svendborg. Among the project managers for the mer- ger was Vivienne Ottosen, and she does not remember the process being particularly frustrating or problematic.

“We had a whole year in which to plan the merger, and because we got started right away and had set aside the necessary resour- ces, we were actually doing well against the timetable,” she recalls.

However, she admits there was pressure:

“We had additional people

sitting and entering information

from Egebjerg and Gudme into

our systems, and our administra-

tive staff also had to make use of

a few weekends. However, we

made it – both the purely techni-

cal part and also in terms of

getting all the new users of the

system trained before the merger

took effect on 1 January 2007.”

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W hen we started, the situation was more or less that we felt it was just the two of us, the eHealth portal sundhed.dk and MedCom, and no-one else. It was natural for us to cooperate, be- cause it was clear to everyone that we complemented each other:

sundhed.dk with its user interface to the whole of the Danish Health- care System and all the citizens, MedCom as coordinator of the standardisation work and Health Data Network.

“Then, it was a case of two small organisations, and there was a sort of ‘free play’ about our co- operation.

“There was a pioneering spirit, and the two or three people invol- ved on each side knew each other.

They could always talk their way through things and, to an extent, improvise their way forward.

It was just the two of us

“Since then, a fantastic amount has happened. Everything has be- come a lot more complicated, with a number of active players in the area of digitisation. Our two orga- nisations have grown, and the tasks have definitely done so, too.

“The cooperation has developed accordingly and has become more formalised and with more obliga- tions. There was also a need for greater professionalism. Naturally enough, this development must continue and lead to even more fixed frameworks of well-defined models and procedures for the co- operation. The aim for me is to see the apportionment of tasks so clearly defined and the cooperation between the two organisations run- ning so well that it may well appear to the outside world that MedCom and sundhed.dk are one organisa- tion, though with completely diffe-

rent sets of responsibilities.

Major tasks completed

“There are many good examples of how our two sister organisa- tions have completed even very large tasks along the way. Opera- tions, support, maintenance and the dissemination of e-records are good examples from the MedCom 6 period. Of course, there have been discussions among us, but that, too, has led to development and I think we have found reason- ably well-defined interfaces for the apportionment of work and skills between us.

“The expansion of e-records to 600,000 citizens in the Copen- hagen Capital Region in autumn 2008 was somewhat of a test piece in this regard. It was a huge challenge, and the project requi-

Photograph: Nils Lund Pedersen

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sundhed.dk

“

It may well appear to the outside world that MedCom and the eHealth portal sundhed.dk are one organisation, though with completely different sets of responsibilities.

red very close cooperation with the suppliers and MedCom. And it was a success!

“Now in 2009, sundhed.dk has been through a process which also included the reestablishment of the record system. Following this, we expanded to include the Central Jutland Region and Region of Southern Denmark.

These events have told me that the cooperation is getting better and better, and that is how it should be! If we look at what the future has to offer, there will be even more major projects on the programme, and we will need an even greater degree of professio- nalisation. But we will manage that, too!”

Morten Elbæk Petersen

Involved all the way

Some of the very first tentative attempts at electronic communication of messages with- in the Danish Healthcare System were con- cerned with the forwarding of prescriptions between GPs and pharmacies. A very great deal has happened since then, fortunately – and the pharmacies have naturally been deeply involved in the day-to-day use of the digital tools and in the development work.

GPs, the home care sector, hospitals, pharma- cies and others have a common interest in making use of the opportunities offered by digitisation. It creates the foundation for greater efficiency, minimising errors and pro- viding better service to our customers. Com- munication needs to be developed further so that it extends beyond the standard messa- ges – and this is happening. The correspon- dence messages are a good example of this.

The next target is an electronic dosage card as part of the common medication card, for use in the more secure and effi- cient transmission of information about dose dispensing, where we also expect MedCom to play an important role.

Niels Kristensen

Chairman, Danish Pharmaceutical Association

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Successfully managed

- so far!

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Digital Health

M edCom can take a lot of the credit for the fact that Den- mark has advanced as far as it has in terms of healthcare IT – no doubt about it,” states Otto Larsen, Direc- tor of Digital Health, which in the words of the organisation “forms the framework for the digitisation of the Danish Healthcare System.”

“It was done well by MedCom, and it is good that it has been done in a way whereby the players in the Danish Healthcare System have sig- nificant ownership of the solutions.

That is precisely the main explana- tion of how we have succeeded in disseminating and consolidating the solutions as extensively as we have.”

Various bases

“All the same, it is clear that our organisation, Digital Health, represents a different line to MedCom’s in developments with- in healthcare IT. That is only natural, as the two organisations were created on a different basis.

“When MedCom was founded in 1994, people said: ‘Here is a problem. How do we solve it?’ We talked to the users, developed a

number of standards and then gradually distributed them exten- sively. There are a lot of positive things to say about that process.

“The rather less positive angle on this is that it took a relatively long time, and that from time to time resources were used on pro- jects that did not succeed, and it was not always the most long- term, holistic solution that was sought.

“Digital Health came into be- ing three years ago from the de- sire to create greater cohesion in developments within healthcare IT. The structural reform with five regions and fewer, larger local authorities is pulling in the same direction, and the Danish Health Act has provided the minister with a firmer handle with which to drive developments in a more uniform direction.”

Need for new thinking

“Despite the centralisation trends, of which this is an expres-

sion, my opinion is that the whole area is still to a large extent mar- ked by budding. There are a large number of players in the game and organisations have come into being that live their own lives and have their own objectives.

The consequence of this is that there is some degree of uncer- tainty in terms of common strategies, skills and authorities.

MedCom, Digital Health and many organisations are operating in the wake of this, and the question is whether or not it is time for some new thinking. The tasks still need to be completed, but perhaps this can be done more simply and efficiently.

“I certainly do not wish to say by this that fewer resources will need to be used in the develop- ment of healthcare IT. On the contrary, it is my belief that there is a tendency to underestimate the task involved in developing a national IT architecture. The pro- blem lies partly in that there are not necessarily any direct rationa- lisation gains to be had. Health- care IT increases quality, produc- tivity and security, but we cannot use the argument that we save money. And so perhaps what if we change the problem around and think of the alternative? How would we manage to complete the healthcare tasks in future without the joint IT solution? It would be expensive, not just in terms of money but also abso- lutely in terms of quality and se- curity. Really, it is an impossible thought.”

Otto Larsen

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“I would like

to order a DIX, a healthcare DIX”

Important for someone to steer the vehicle

J an Kold, who on a day-to-day basis is the IT Manager for the Copenhagen Capital Region, anticipates that there will be technical challenges if the operation of all network connections on the common node in future is to be part of the central Health Data Network.

“Depending on how far the operational responsibility extends for the Health Data Network, there will be a

number of critical responsibility interfaces for the players’ operational organisations and these could cause very

major problems if they don’t work. However, it is quite natural for responsibility to be located in one place, and I

see no problem in principle for a central organisation like MedCom to take responsibility for the operation of such

a network,” says Jan Kold.

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tions just for fun. There was a need to connect the regional networks together, and for the facilities that Internet technology provides. The alternative would be chaos. Ima- gine if all the regional networks, each with perhaps ten different services, should be connected in pairs. It would be fairly unmanage- able.

“We explained this a great many times at innumerable meet- ings. We also asked the sceptics to tell us what requirements they would have of the new network in order for them to surrender some of their sovereignty.

“We built a pilot system on the basis of all the input received. Of course, it has been upgraded in every way since, but it has actually been in continuous operation since day one. And I really believe that everyone would agree that the so- called healthcare DIX has lived up to expectations. No-one’s scepticism has been confirmed – quite the re- verse, in fact.”

Much has been achieved, and the potential remains great

T he regions consider IT to be a vital requirement in order to equip the Danish Healthcare System for the challenges of the future, which among other things will be marked by more elderly and chronically ill pati- ents and less manpower. The regions are thus also actively in- volved in the development of healthcare IT. This includes colla- boration with MedCom. Much has been achieved over the past 15 years, while at the same time it is clear that there is consider- able potential for further strengthening both efficiency and quality using IT. There is al- most a queue of options waiting to be realised, including in terms of direct communication between the Danish Healthcare System and the patients. The healthcare agreements between the regions and the local autho- rities also bear witness to this, and from the regions’ point of view there is every possible reason to continue working determinedly in these areas.

Internet-based Health Data Network

I t cannot be done.” This was the reply when Lars Hulbæk from MedCom telephoned Martin Bech, Division Director at Uni-C, eight or nine years ago to order a health- care DIX. “There is only one DIX.”

“Nevertheless, the healthcare DIX today has become a reality, though to be absolutely correct this is a little bit disingenuous,”

explains Martin Bech.

“What we have is a central node for the Health Data Network, not a true DIX – an Internet exchange point, but does it matter? After all, all babies need a name.”

For Martin Bech, the telephone call from Lars Hulbæk was the start of an extensive and very unusual process to construct the Internet- based Health Data Network.

“At the time, I had already been working on communications in parts of the healthcare sector, but this took me right into the belly of the system,” he explains.

“The thing is, when people come to us to have a task comple- ted, they more or less always have the solution defined in advance. It is then a matter of putting it into real life. That wasn’t the case here!

You see, the starting point was that there were a number of regional networks, which many people had spent time and effort to build up.

One of their most important aims all the time had been to create se- curity, to keep strangers out. Now, in layman’s terms, we were coming up with a plan to keep strangers in.

Not just anyone, of course, but you see the point. Naturally enough, this generated a deal of scepticism.

Fortunately, we were able to argue that security would be intact, and that to cap it all the network would be able to deliver documentation of all transactions.

“And then, of course, we didn’t want to build the new construc-

“

There was a need to con- nect the regional networks together, and for the facilities that the Internet- technology provides

Bent Hansen

Chairman of the Danish Regions

Martin Bech

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Next generation will be ready

Photograph: Yilmaz Polat / Fyens Stiftstidende

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International

T here is a touch of ‘Brave New World’ about it when people need to use electronic equipment in the home, and they tend to get a little scared when we show them the possibilities, as home nurse Helle Holm explains:

“The drawback is precisely that many people in the target group of the over 65s are not used to using new technology. That situ- ation will most definitely change in time. The next generation will be ready. They will simply expect to have that sort of technology available.”

Active citizens

Helle Holm is employed by Lan- geland Municipality, where she is Project Manager for the munici- pality’s part in the international Dreaming project, which is about harvesting experiences of infor- mation technology in the service of healthcare.

“The project covers citizens aged over 65 who are relatively well and who are covered by the home care sector,” she explains.

“They have chronic illnesses such as diabetes, COPD and poor heart conditions, and they are given equipment in their homes so they can measure their blood sugar, blood pressure or lung capacity themselves. The results

of the readings are communica- ted directly to us, and if some- thing looks wrong we receive an alarm. The citizen can also con- tact us directly, and we can talk together at a miniature video conference using a webcam and their TV.

“As far as I see it, there are many benefits to the public. They become actively involved in their own treatment, and perhaps visit their doctor less frequently be- cause they gain more control of their illness. They feel a greater sense of security and are always in such good control that they will probably be admitted less frequently to hospital. At the same time, they are not so tied into having to be at home when we come.”

Six countries in the project

The pilot project is being carried out simultaneously in six coun- tries – Sweden, Italy, Spain, Ger- many, Estonia and Denmark.

Forty-four people will take part in Langeland Municipality. Half of them will have the equipment in their own home. The others will receive traditional treat- ment. The results will be exami- ned using questionnaires and interviews and experiences will be collated.

T he energy which international recognition gives in a cooperation situation provides strong motivation to continue the innovative work in this country and overcome possible resistance. The ‘H.C. Andersen effect’ – being better known abroad than in your own back yard – convinces people that it is worthwhile persevering and continuing the work.

Peder Jest

Director, OUH

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– major influence

K evin Dean, Director of Con- nected Health’s Internet Busi- ness Solution Group in the inter- national IT Group Cisco Systems Li- mited, sees a number of major chal- lenges to the European healthcare system in the coming years, with the rise in the proportion of elderly citizens. This places enormous pressure on resources, and it is therefore extremely important to increase productivity in the health- care sector. Better, more efficient IT communication and technological aids can help free up resources for those tasks that require people to carry them out.

At the same time, it is very im- portant to avoid a ‘brain drain’ of experts, especially from Eastern to Western Europe. The development of telemedicine may help avoid this, as experts can now be challen- ged, and rewarded, in a professio- nal way wherever they may be located geographically.

Good example

Since the start of the new millen- nium, Kevin Dean has worked with MedCom in a number of dif- ferent connections. He is impres- sed that such a small organisation has had – and still does have – such major influence on the de- velopment of IT healthcare com- munications at an international level.

“I often use MedCom as an example when I want to illustrate how a very practical, methodical approach can allow technology and communications to reach a higher level,” he says, and he continues:

“One of MedCom’s major strengths is that the organisation is based on the network mode of thinking, and therefore they have gradually created for themselves a gigantic network of internatio- nal specialists both in IT and the field of medical knowledge.

They manage to gather the best people for each project, and they create relationships for further development.”

You need to act quickly

MedCom is deeply involved in de- veloping solutions that will meet the challenges of the future in the European healthcare system, and Kevin Dean believes that MedCom is very modest conside- ring the amount of work and in- fluence that the organisation really has.

Where he does see the chal- lenges to MedCom in the future is in terms of the speed of devel- opment. Time requires, and tech- nology enables, people to act faster in future than they have so far been used to.

Kevin Dean

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International

Healthcare IT requires organisational changes

I nvesting in better IT technology in the healthcare sector is a sensi- ble prioritisation which in the long term will save resources, and it is something which all governments in the EU should be interested in carrying out. This is the opinion of Ilias Iakovidis, Chief Delegate for the Department of Healthcare IT at the EU Commission.

“What people, whether in ma- nagement or in national Govern- ment, need to be fully clear about is that the technology in itself is not the solution and cannot stand on its own. The investments have to be followed up by an extensive reorganisation of working proces- ses and functions. You need to en- sure that the users understand the technology and can see the act of becoming familiar with the new systems in perspective. Otherwise the new technology just leads to frustration and difficulties.”

No mandate on healthcare

But would having all healthcare IT systems in the EU based on the same standards not be the most sensible thing to do?

“Yes, definitely, but the EU does not have a mandate in the health-

care sector to impose requirements or orders on the systems of indivi- dual member countries, and there- fore developments in the area of healthcare IT within the EU become both slower and more unsystematic than you find, for example, in the environmental sector, where the EU has a mandate to impose require- ments on individual countries.”

MedCom is a shining example

Ilias Iakovidis has been involved for longer than most. He has worked on healthcare IT within the EU since 1993. At that time, he was involved in formulating and examining the principles of developing common standards for electronic healthcare com- munication in the EU, a project that led to the foundation of MedCom. MedCom has a special place in his heart because of the forward vision that the project then represented.

“For me, there is absolutely no doubt that MedCom is the exam- ple of how to develop and orga- nise a functionally competent IT system for healthcare IT.

MedCom’s working methods are based on the ‘trial and error’

principle, where testing and mo- difications are a continuous pro- cess. We are not as afraid to make mistakes, and the focus is on getting the users involved as early in the process as possible.

We are on the threshold of the next wave, where the break- through in technology and com- munication will be used in healthcare, for the benefit of all citizens of the EU. I hope the Danes will be just as forward- looking this time as they were then with MedCom.”

Ilias Iakovidis

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Hospital took the first steps

T he system was very simple, but it worked, as Ole Bergsten, Technical Manager at Medicotek- nik, explains about Copenhagen University Hospital’s first measures in telemedicine back in 1995–96. He remembers the attention surroun- ding its inauguration, including from the press.

“We worked on an ISDN2 connec- tion and used only standard systems.

It worked fine for echocardiography and X-rays, where all we did was to place a video camera on an overhead projector. We then also managed to convince the doctors that the image quality was acceptable. Otherwise, they were somewhat sceptical.”

The reason why Copenhagen Uni- versity Hospital took the first steps into the world of telemedicine was a degree of pressure from the Faroe Islands.

When it came down to it, they did not have a need for it. In- stead, a connection was set up to Greenland, which included echocardiography and X-ray imaging. The echocardiography works the same way today as then, while of course the tech- nique in the field of radiology is totally different.

From projects to routine

“Today, echocardiography is routinely communicated be- tween all hospitals in the region, and videoconferences have, for example, also become routine,” explains Ole Bergsten.

“Actually, I have never doubted the possibilities, but from a development point of view the many independent projects in the area have been a problem. They are initiated without people having taken the necessary organisational factors into account. These days, we start by getting the organisa- tion in place before we make a start on telemedicine pro- jects.

“At the same time, we have learned that the initiation into new work equipment is very important. For example, we got MedCom staff to run a training session before we embarked on a new collaborative effort in telemedicine with Bornholm. It gave us a really good start and showed the importance of making things easy for the users.”

W hen the doctors in the Cardiological De- partment at Roskilde Hospital need to de- cide whether a patient is suitable for an operation for a new heart valve, for example, they like to seek advice from heart surgeons in other hospi- tals. This is done at a weekly teleconference invol- ving doctors and surgeons from various hospitals in the country. At the teleconference, all partici- pants have the chance to see images and ultra- sound recordings, e.g. of patients’ coronary arteries, and a discussion is held as to whether an operation is appropriate, based on the images.

“The teleconferences have saved us a great

Telemedici

us better a

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Telemedicine

deal of time,” says departmental doc- tor Klaus Klausen.

“Now we no longer need to plan to meet in person, and we have the chance to give and receive professional support quickly and without any com- plications.”

However, in terms of the technical set-up of the telemedicine systems, Klaus Klausen believes there is still room for improvement.

“In some places, the systems are very ‘nerdy’, in the sense that you need

a degree of technical understanding to get the systems to perform to best effect. The user interface itself could benefit from being more intuitive and visually well thought out. And, of course, it is a ‘must’ that the connec- tion works. We probably would like a more stable, error-proof system, and here, too, technical improvements are continually being made. All in all, tele- medicine is a really major benefit to both patients and healthcare profes- sionals.”

ine makes and faster

Strategy for telemedicine

T he ABT Fund is a fund whose aim is to invest in innovative projects throughout the whole public sector. In overall terms, this means projects that increase efficiency and productivity in public sector service and care without this being at the ex- pense of quality. In this regard, telemedicine projects are right up its street. They can help en- sure that specialised functions last longer and that quality im- proves. At the same time, we consider the healthcare sector ready to make use of the new types of tools in IT.

The challenge to us is first and foremost to choose the right projects to support. The invest- ments made must match the re- sults, and from society’s perspec- tive the projects must point in the right direction. In other words, it is a matter of making a decision as to which strategic areas of effort within telemedi- cine we should invest in. Then, we need to establish some con- ditions which the projects need to meet. MedCom is helping us with this exercise, and they cer- tainly work quickly so we are ex- pecting to be in a position to have the basis of our decision in place by the spring.

We see great opportunities in telemedicine. We have reached the years of discretion. Now, the strategy needs to play its part in gathering together the forces for the action that provides the best result.

Ulrich Schmidt-Hansen

Secretariat Manager, The ABT Fund

Klaus Klausen

Photograph: Thierry Wieleman

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authorities that do not make use of all relevant communication solutions. For example, a number of MedCom standards have not been implemented in full.

At the same time, new solutions have been developed on a national scale with regards to the Common Medication Card (FMK) and Telemedicine. These are solutions that will be implemented at national level within the next few years.

The nature of MedCom 7 will, therefore, first and foremost be that of an overall dissemination project, with two main areas of effort:

G National implementation of central MedCom standards that have not yet been adopted by all regions and local authorities, including in particular:

– Communication of local authorities with hospitals and doctors.

– The use of the Common Medication Card in the surgery.

– The dissemination of e-records to citizens, hospitals and surgeries.

– Development and national implementation of package referral.

– Laboratory medicine communication.

G National implementation of tele-interpretation and ulcer assessment by telemedicine as part of Digital Health’s Tele- medicine programme.

Six project lines in MedCom 7

Specifically, this means that MedCom 7 includes implementation nationally within six project lines:

Surgeries and laboratories.Dissemination of laboratory medicine, the PLOXML format, of EDI/XML Partnership information and development and dissemination of package referrals.

Find out more on pages 25–27

Local authority projects.Dissemination of communication in the home care sector, rehabilitation, LÆ form and referral area.

The Common Medication Card in the primary sector.

Dissemination of the Common Medication Card in surgeries.

Find out more on page 30

e-records.Dissemination of citizens’ access to e-records and dissemination of e-records to GPs and hospitals.

Telemedicine.Dissemination of tele-interpretation and implementation of ulcer assessment by telemedicine.

International projects.Participation in EU projects, primarily in the areas of standards, telemedicine and welfare technology.

The MedCom 7 projects are all a direct extension of the activities in MedCom 6. The project descriptions on the following pages contain both a description of the develop- ment hitherto of the projects in MedCom 6 and the expecta- tions for MedCom 7.

7, 2010 -201 1

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Referrals from doctors and specialist practitioners for hospital treatment are stea- dily increasing, and the proportion is now around 50%.

With the ‘Cancer Packages’, there is a need for a revision of the electronic referral so that in future it reflects the need of the individual specia- lity for relevant information.

Next step

A dynamic referral is being REFHOST:A successful

MedCom 6 project, which allows all doctors to send referrals electronically to specialists, physiotherapists and psychologists.

The dissemination took place as a collaboration between the Danish Regions, the five regions’ practice units and data consultants, the Multi-

Dissemination of package referrals REFHOST – the

referral database

developed in MedCom 7, while solutions are being implemented that allow en- closures to be sent with referrals. In addition, MedCom’s lists of EDI recipients in hospitals are being resumed.

It is expected that a referral database solution will be established with REFPARC, where all referrals can be completed based on a dialogue, as in WebReq.

med supplier, the Danish Association of Medical Spe- cialists, Danish Physiothera- pists and the Danish Psycho- logical Association. MedCom project managed the implementation project.

The introduction of a univer- sal digital employee signature was a challenge, which was overcome in the course of just two months.

Next step

The project ends in 2009. The technical solution now opens up the possibility for other specialities to take part, such as podiatry and local authority preventive facilities.

Consolidation and dissemination

90000 80000 70000 60000 50000 40000 30000 20000 10000 0

01 02 03 04 05 06 07 08 09

Referrals to hospitals per month 2001–2009.

dual pharmacies and con- tacted all of the local authorities in the country in order to get them to use it.

The pharmacist began work on 1 February 2009. The graph on page 47 shows the results!

It is therefore expected that, in 2010, there will be much greater dissemination of the message facility, which is now both known and used by pharmacies.

Correspondence

message Pharmacies Consolidation and

dissemination

Consolidation and expansion projects in the MedCom 6 period has focused on dissemination of ‘old’ projects to such a degree that these electronic communication flows will be used ex- clusively in the future. Also, a number of new, smaller projects have been initiated to supplement the existing ones.

Henvisningshotellet REFHOST

Nu også til fysioterapeuter

og psykologer En brugervejledning til praktiserende læger, speciallæger, fysioterapeuter og psykologer

MC-S215 / JANUAR 2009

REFHOST referrals to

September Spe- Physio- Psycho- Pod-

2009 cialists therapy logists iatry

South Denmark 19575 6614 616 400

Central Jutland 19266 7533 449 0

North Jutland 8333 3871 374 0

Zealand 18100 5481 563 0

Copenhagen Capital 65200 11276 1408 0

Total 130484 34775 3410 400

The pharmacist systems previously developed a module for correspondence messages for communicating with doctors and local authorities regarding supplementary information for ordering medicines, etc.

The module has not been widely used, but thanks to a grant from the Danish Phar- macy Foundation to MedCom a project has been initiated:

Rollout of the correspondence message facility, where a pharmacist visited indivi-

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including support by sundhed.dk

The projects are coherent and form subcomponents of an overall, fully electronic communication internally between the labora- tories and between the laboratories and the users. The projects’

common title is Laboratory Medicine.

The topics are both laboratory results and requests between laboratories and support of laboratory functions which can be displayed using sundhed.dk. A total of 13 subprojects were ini- tiated in 2008–2009. The project was not fully disseminated in the MedCom 6 period due to time-consuming tasks with the implementation of new laboratory systems. The status of the projects is currently:

WebReq dissemination 93% of all laboratory tests from GPs can now be request- ed electronically. More than 3000 surgeries implemented the system over four years.

This must be considered a success.

Next step:

The last clinical immunological laboratories will join WebReq, and the use of the new func- tion, Web-Quality, will form part of the quality assurance process for laboratory tests in GP surgeries.

Electronic dispatch slip: New standard – REQ01 – R0131K The trilateral problem has been developed and implemented in a number of laboratory systems. The remaining systems have been delayed.

Implementation expected in 2010.

Next step:

In 2010 and 2011, it is expected that all laboratories will procure the dispatch note module and thus make the transi- tion from paper to electronic dispatch slips. MedCom will provide help with testing and

certification as well as with start-up meetings and monito- ring through statistics and workshops for users.

Request database

Requests from specialists and hospital outpatient departments can be saved to the request database. Patients are then able to go to their GP or a laboratory in order to have the tests carried out. The result is correct testing and a request that can be used irrespective of which laboratory the doctor uses.

Many specialists and some outpatient departments are now on the database. MedCom has developed a web service solution for direct, automatic access. It is ready on WebReq.

So far, no laboratory systems have managed to develop it.

Next step:

The laboratories will enter into agreements for the delivery of the module. Then, outpatient

departments can order tests and the individual laboratory retrieve requests automatically via the web service when the patient arrives. Dissemination is expected at the end of 2010 and in 2011.

Results between laboratories All laboratories send samples on for analysis by other laboratories. The results are normally on paper, but a large number are now sent electronically.

Results

23 laboratories send results to a total of 35 laboratories. When all laboratories are sending to all others, there will be around 40 laboratories sending results and around 60 laboratories able to receive results. In Sep- tember 2009, a total of 17,622 results were sent. This equates to around 25% of all results.

Not all laboratory systems are able yet to receive results. Mo- dules are under development.

The future

A natural consequence of the implementation of dispatch notes in subproject 2 will be that all results are sent electronically. MedCom provides assistance to the laboratories with start-up meetings, testing, certification and the staging of workshops for the users.

5. Manufacturer and manufac- turer code:The statutory requirement that it must be possible to see which laboratory carried out the analysis is now met by all major GP and specialists’ systems. Many laboratories also meet these requirements by including the manufacturer and manufacturer Subproject 1

Subproject 3

Subprojects 5, 6 and 7 Subproject 2

Subproject 4

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and discussed at a national laboratory seminar. Final establishment will take place in December 2009. The web service for the assignment of numbers and establishment of the numbers server was drawn up at the end of the year.

In 2010 and 2011, the systems will gradually be able to trans- fer to this numbers series, and from 2012 all laboratories are expected to use this solution, which will ensure that all tests have a unique national number. This will prevent mix-ups and renumbering. The numbe- ring system will last for more than 100 years and can be used in almost all existing analysis machines.

9. WebQualityfor quality assurance of the analyses per- ved the desired impact. All GP

and specialists’ systems have developed the functionality.

However, a number of laboratories have stopped publishing on sundhed.dk, as they need to be maintained both on regional systems and on sundhed.dk.

In MedCom 7, the solution is based on regional databases which can then be exported to sundhed.dk, or alternatively by using a direct link to the regional database.

8. A common national num- bering systemfor all laboratories based on 12 unique digits and assigned from a central server has now been described

Consolidation and dissemination

code in the dispatch. The rest are expected to join in 2010.

6. The short namesfor IUPAC or, now, NPU codes have been drawn up and sent to the clinical laboratory companies for consultation. These will be approved before the end of the year and published on the National Board of Health’s Labterm website.

The project has been delayed at MedCom. It is expected that all laboratories and sundhed.dk will use the short names in the course of the next few years.

7.The appearance of labora- tory guidelineson sundhed.dk by use of the manufacturer code (subproject 5) is obvious, but the project has not achie-

Subprojects 8 to 13

formed by doctors themselves.

Development of the solution is complete, so it is easy and ef- fective for GP surgeries to use.

It will come into use in selected laboratories at the turn of the year 2009/2010. The plan is that laboratories wishing to use this service will be able to do so immediately. MedCom provides assistance with the introduction, among other things, of start-up meetings at the laboratory and workshops.

10. Improved display of labora- tory results on sundhed.dk.In 2007, MedCom’s professional healthcare laboratory group drew up a proposal to improve the display of the results, targeted at the users. On this basis, a display module has been developed for all types of laboratory results. Develop- ment of the module is complete, but there has been a de- lay in putting it into use pen- ding clarification of the technical solution for presentation on the new sundhed.dk. It is expected that the system will become operational in April 2010.

11. Test tube receptionwas in- troduced at a number of hospitals in 2009. Following adapta- tion of laboratory systems and the introduction of changes to work procedures, it will gradually come into use at a number of laboratories over the next few years.

13. The Microbiology bankhas been established and will be fully operational in January 2010. It will not be possible to display microbiology results on sundhed.dk until the new display module (subproject 10) is complete.

Next step

Will be started during spring 2010, once a new display solution is ready on sundhed.dk.