1. DHIS Workshop January 2012 1 Margunn Aanestad, University of Oslo

2. Overview  Norwegian healthcare services  ICT in the healthcare sector  Primary healthcare  Hospital information systems  Experiences from digitization of hospitals  (National level)  HMIS/Central registries 2

3. Some facts about Norway…  Small and rich country  Population 5 million (life exp. >78 m/>82f)  84 % public (2009), 16 % private  9,6 % of GNP (2009), 229 bn. NOK, (highest OECD per capity exp. after USA) http://www.oecd.org/dataoecd/21/3/46507296.pdf http://www.helsedirektoratet.no/publikasjoner/nok keltall-for-helsesektoren- 2011/Publikasjoner/nokkeltall-for-helsesektoren- 2011.pdfhttp://www.helsedirektoratet.no/publikasjoner/nok keltall-for-helsesektoren- 2011/Publikasjoner/nokkeltall-for-helsesektoren- 2011.pdf (p. 22 ->) 3

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5. Specialist healthcare Reform in 2001/2: - Transfer of hospital ownership from county to state - 5 (now 4) regional health enterprises (RHF) 5 Helse Nord Helse Midt-Norge Helse Vest Helse Sør-Øst

6. Specialist healthcare  Somatic + psychiatric healthcare + ambulance services  2010: 866 000 admissions (somatic)  Significant shift to oupatient/day treatment (w/o admission)  4 mill (somatic)+ ~2 mill (psychiatric)  100 000 ’man years’ (~110 000 employees) 6

7. Primary healthcare  Primary Health Service Act 1982:  municipal responsibility (429 municipalites)  Financed by national government, local tax revenue and reimbursement  140 000 ’man years’, 265 000 service recipients (nursing homes/home based care) 7

8. Primary healthcare  General Practitioners:  Independent (contract w/municipality) or employees of municipality  Reimbursement for services  Out-of-hours response teams (1,8 mill. encounters)  “Regular GP” (~ 4000) (24,5 mill encounters)  Gatekeepers for referrals to hospitals/specialist care 8

9. Primary healthcare  Primary healthcare in municipalities  ”Health stations”: ANC, immunization, school health  Nursing homes, home-based care  Rehabilitation (physiotherapists, ergotherapists, speech therapists) 9

10. The Coordination Reform  Reconfigure realtion between primary & secondary healthcare  Shift towards prevention  Continuity of care  Financial, legal, admin measures 10

11. Healthcare ICT in Norway…  Early mover on Health ICTs:  National ICT strategies since 1996  First to implement EPR (public hospitals and GPs)  Widely digitized sector:  Hospitals, general practitioners, nursing homes, pharmacies, private sector specialists  … but weaker on linking them together 11

12. Breadth/vision Concretization /implementation

13. ICT  National level  Ministry + directorate: shared solutions  ePrescription, health portal, standards etc.  Specialist healthcare  RHF: hospitals’ IT systems  Primary healthcare  Municipalities/GPs  GP/nursing homes/home based care 13

14. ICT in primary healthcare  EPR systems for GPs  GPs first to implement EPRs, ~100 % coverage  4 products (other than hospitals); Profdoc Vision, Profdoc Winmed, System X, Infodoc Plenario.  EPR systems in nursing homes/home based care  No. of installations vs. pattern of use  Mobile clients  Other products (Gerica, Cosdoc etc)  Health stations: SYSVAK  Admin. systems (IPLOS, KOSTRA reporting) 14

15. Inter-organizational communication  Norwegian Health Network  Secure, separate broadband network for healthcare sector  Established 2oo4 (RHFs), provider role  State-owned since 2009: strategic role  www.nhn.no www.nhn.no 15

16. Security/privacy policies  Data protection and information security principles:  EU Directive 95/46/EC (the Data Protection Directive)  National laws  National ”Code of Conduct” defined (incl. practical guidelines)  www.normen.no (also in English) www.normen.no  Norwegian Health Network requires implementation of CoC 16

17. Hospital Information Systems  Patient Administrative System (PAS)  Patient demographic info, admission/discharge/transfer, waiting lists, scheduling, letters, reporting …  Laboratory Information Systems (LIS)  Production support systems (automated analysis machines) - (multiple)  Electronic Patient Record system(s) (EPR)  Textual information (doctors’ notes, nursing plans, etc.)  Radiological Information Systems and Picture Archiving and Communication Systems (RIS/PACS)  Textual information + digital images  Medical Chart systems  Vital signs monitoring, medication etc. 17

19.  Like PACS systemer (10 av 11 sykehus benytter AGFA PACS)  Like EPJ/PAS system (DIPS)  Felles blodbanksystem  Like mikrobiologisystem  Like patologi system  Like fødesystem  felles syketransportsystem  Like system knyttet til klinisk kjemi (DIPS)  Etc. Region North: standardized systems portfolio:

20. History  1980’s- 90’s: Development initiatives on a national scale  Supported by research funds, aiming at creating national standard & business opportunities  Resulted in three (Norwegian) products:  Siemens Doculive  DIPS ASA: DIPS  Tieto Enator: IMX/Infomedix  Distributed decision making (counties)  Regions seek standardization

21. 21 Helse Nord (DIPS) Helse Midt-Norge (DocuLive) Helse Vest (DIPS) Helse Sør-Øst (DIPS. Doculive, IMX) EPR systems in regions:

22. Main challenges:  To digitize hospitals  To maintain control over growing no. Of systems  To achieve inter-organizational collaboration (digital communication) 22

23. Building EPR systems  Copied the structure of paper-based systems:  A Core/critical information  B Doctor’s notes  C Results from laboratory tests  D Results from other examinations of organs  E Results from imaging examinations  F Observation and treatment  G Nursing documentation  H Reports from other healthcare staff  I External correspondence  J Formal documents (sick leave forms, patient consent forms etc) 23

24. Building EPR systems  Partly digital:  A Core/critical information  B Doctor’s notes  C Results from laboratory tests  D Results from other examinations of organs  E Results from imaging examinations  F Observation and treatment  G Nursing documentation  H Reports from other healthcare staff  I Exsternal correspondence  J Formal documents (sick leave forms, patient consent forms etc) 24

25. Electronic Patient Record System (EPR)  Simple:  Text-based, no graphics/images  Free text, not structured text (some templates)  Chronological structure (not problem-centered)  No decisions support/expert system functionality  Some integration with Patient Administrative System (patient demographic data)  Few standards defined  So:  Limited value in comparison with grand visions  Far easier to implement than ”grand vision” EPRs 25

26. Implementation of IT systems  Henry Minzberg (org.theorist) about hospitals: 26 ’the most complex type of organizations that humans have created’

27. Implementation of IT systems  WHY COMPLEX?  Many professional groups  Tightly interconnected work flows  Unpredictable work  Moment-to-moment management  Many actors ’intervene’… 27

28. complex x complex = complex 2 28

29. Implementation of IT systems  Change required at  Individual level  Work group level  Department level  Hospital level  Paper-based information infrastructure is tightly interwoven with organization  Change is potentially disruptive  The smaller the change, the easier the process 29

30. Digitization process Unilab (medical biochemistry, immunology, microbiology) Patient Record System DocuLive Patology 20002005 Scanned Electronic Paper Sectra RIS (Radiology) Portal (svarrapporter) DocuLive (tekstlige journaldokumenter) Agfa RIS (Radiologi) 1995 2010 Miclis (microbiology) DocuLive (andre journaldokumenter, skjema, svarrapporter fra ikke-integrerte systemer) March 2006

31.  31 From: Hanseth, Jacucci, Grison and Aanestad: Reflexive Standardization. Side-effects And Complexity In Standard-making. MIS Quarterly Vol. 30, Special Issue on Standardization Aug. 2006, pp. 563-581. ”Integration model” changed over time:

32. 32 Service layer Presentation layer Integration layer Legacy systems

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35. … still a problem …  OK for the individual clinician/nurse, but a challenge for the IT department  > 1000 IT systems within the hospital  several hundred IT systems with clinical/patient-related information  Complexity as a core challenge 35

36. The challenge of complexity  Hospital merger: 4 Oslo hospitals merged 1.1.2010  In total: more than 3000 IT systems  Aim:  Standardize/reduce number  Facilitate ”single sign-on”  Solution:  ”Clinical work space” (a portal type interface) 36

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39. The challenge of complexity  2009: Tender process  2010:  Tight deadlines (governed through politics)  Troubles … delays  May 2011: Termination  (160 million NOK spent ) 39

40. Oslo Universitetssykehus PAS Klin.dok. Kurve RIS/ PACS LAB PAT Spes. AkerUUSRHRadium DIPS (Meta- Vision) Care- stream Flexlab Saphire, m.fl. PasDoc DocuLive MetaVision Siemens Swisslab DocuLive PAT Prosang, Cardas, Endus, m.fl. DocuLive MetaVision Sectra UniLab DocuLive PAT Well multimedia, Nyrebase, Albert, Vmax, m.fl Agfa DocuLive PAT Oncentra, CytoDose, m.fl. Status pr. 01.01.2011 DocuLive PAT

41. Learnings  Avoid or minimize complexity:  prioritize hard and select wisely  Be aware of ”grand visions”  Simpler technologies  Be aware of ambitious project set-ups  Let processes take their time, let the local ’work system’ have time to adapt  Evolution, not revolution  Ongoing management of complexity  (IT not just an ’instrument’) 41

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43. Inter-hospital communication  Privacy law prohibits sharing of complete EPR files when a patient goes to another hospital  Discharge letters are automatically sent, and the other hospitals can ask for other reports from the EPR (not automatic)  Sharing of images and examination results  Electronic (NHN) and paper (mail, fax) 43

44. Hospitals’ reporting  Hospitals report activities – get their income  Activity-based cost (DRG system)  Reports generated by the PAS system  ICD codes (+ others) entered by clinicians  ’Manual’ data validation processes  Individual (but anonynous) records  The recipient (Norw. Patient registry) forwards to health authorities and provides data also for other uses (research etc) 44

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

46. Reporting: quality monitoring  Quality/performance/efficiency:  Handled locally by Dept/Hospital management  Publication of data relating to: Patient satisfaction, Waiting times, Complications etc.  Quality of treatment:  Professional groups (e.g. urological surgeons) have initiated voluntary reporting systems  Manual data entry (not pulling from EPR)  Exist for >60 areas  Varying coverage, quality, security – a national harmonization initiative. 46

47. Publication of results:  Quality indicators:  http://helsenorge.no/Helsetjenester/Sider/Ov ersikt-over-nasjonale- kvalitetsindikatorer.aspx http://helsenorge.no/Helsetjenester/Sider/Ov ersikt-over-nasjonale- kvalitetsindikatorer.aspx  Information for patients:  www.helsenorge.no www.helsenorge.no  www.frittsykehusvalg.no www.frittsykehusvalg.no 47

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49. National HMIS  Not integrated HMIS:  7 central health registries:  Mortality registry, birth registry, cancer registry, infectious diseases, tuberculosis, vaccination registry, prescription drug registry  Different data sources, flows and ’destinations’  Selective integration?  Interoperable, rather than integrated? 49

50. Norwegian Institute of Public Health  Promotion of better health and prevention of disease  Through research based:  Health surveillance  Advice and various services  Employees and students: ~1000  Annual Budget: ~ 160 mill USD 50

51.  Main areas (equivalent to the Divisions of the Institute):  Infectious diseases  Environmental medicine  Non-communicable diseases (Div. of Epidemiology)  Mental health  Forensic medicine, toxicology and drug abuse 51

52.  Personal ID no:  Registries, cohorts, and biobanks: valuable resource for medical research  Strict privacy regulations  Ids: pseudonymized, encrypted ID, de-identified, anonymized  Physical and technical security measures  QA systems, audits etc. 52

53. 14 Central Health Registries  The Norwegian Cause of Death Register  The Medical Birth Registry of Norway  Register for Induced Abortion  The Norwegian Surveillance System for Communicable Diseases and The Tuberculosis Registry  The Vaccination Register  The Norwegian Surveillance System for Resistance Against Antibiotics in Microbes  The Norwegian Surveillance System for Infections in Hospitals  The Norwegian Prescription Database  The Norwegian Cardiovascular Disease Registry  The Cancer Registry of Norway  The Norwegian Patient Registry  The Norwegian Information System for The Nursing and Care Sector  ePrescription  The Registry of the Norwegian Armed Forces Medical Services 53

54. Central health registers FromId Responsible institution The Cause of Death Register1925/51 Birth Id NIPH The Medical Birth Registry of Norway (MFR)1967 Birth Id NIPH The Abortion Registry 1979/ 2007 Avid NIPH The Norwegian Surveillance system for Communical Diseases (MSIS)1977 Birth Id NIPH The Childhood Vaccination Register (SYSVAK)1998 Birth Id NIPH The Norwegian Surveillance System for Antibiotic Resistance in Microbes (NORM)2003 Avid NIPH The Norwegian Surveillance System for Infections in Hospitals (NOIS)2005 Avid NIPH The Norwegian Prescription Database (NorPD)2004 Pseudonym NIPH The Cancer Registry of Norway1952 Birth Id H S-Ø The Norwegian Patient Registry (NPR)2007 Encrypted HDIR The Information System for nursing and care services (IPLOS)2005 Pseudonym HDIR

55. Central health registers FromId Responsible institution The Norwegian Armed Forces registry2005 Birth Id FD National Database for Eectronic Prescriptions (eResept)2007 Birth Id HDIR

56. 19 national medical quality registries  Regional Health authorities:  South-Eastern Norway  Child and youth diabetes + Neonatal medicine + Cerebral palsy + Trauma + Colorectal cancer + Prostate cancer  Central Norway  Myocardial infarction + Cerebral stroke + Vascular diseases/vascular surgery  Western Norway  Intensive care + Diabetes in adults + Cleft lip and palate + COPD (KOLS) + Arthroplasties + Hip fractures + Cruciate ligaments + Multiple sclerosis (register and biobank)  Northern Norway  Back surgery + Hereditary and congenital + neuromuscular diseases 56

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58. Group assignment:  Examine a registry and prepare a presentation of what you find interesting:  Cause of death registry  Medical Birth registry (MFR)  National immunization registry (SYSVAK)  Norwegian Prescription database  Surveillance system for communicalble diseases (MSIS)  Norwegian Patient Registry (NPR)  Cancer Registry of Norway 58

59. Or…  Biobanks  Quality registers  The HUNT study  IPLOS 59