Margunn Aanestad, University of Oslo
HEALTH CARE ICT IN NORWAY
DHIS Workshop January 2012
1
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
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-helsesektoren2011/Publikasjoner/nokkeltall-for-helsesektoren2011.pdf (p. 22 ->)
3
4
Specialist healthcare
Reform in 2001/2:
- Transfer of hospital
ownership from county
to state
- 5 (now 4) regional Helse Midt-Norge
health enterprises
(RHF)
Helse Vest
Helse Nord
Helse Sør-Øst
5
Specialist healthcare
 Somatic + psychiatric healthcare +
ambulance services
 2010: 866 000 admissions (somatic)
 Significant shift to oupatient/day treatment
(w/o admission)

4 mill (somatic)+ ~2 mill (psychiatric)
 100 000 ’man years’ (~110 000 employees)
6
Primary healthcare
 Primary Health Service Act 1982:
 municipal responsibility (429 municipalites)
 Financed by national government, local tax
revenue and reimbursement
 140 000 ’man years’, 265 000 service recipients
(nursing homes/home based care)
7
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
Primary healthcare
 Primary healthcare in municipalities
 ”Health stations”: ANC, immunization, school
health
 Nursing homes, home-based care
 Rehabilitation (physiotherapists, ergotherapists,
speech therapists)
9
The Coordination Reform
 Reconfigure realtion
between primary &
secondary healthcare
 Shift towards
prevention
 Continuity of care
 Financial, legal, admin
measures
10
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
Breadth/vision
Concretization
/implementation
ICT
 National level
 Ministry + directorate: shared solutions
 ePrescription, health portal, standards etc.
 Specialist healthcare
 RHF: hospitals’ IT systems
 Primary healthcare
 Municipalities/GPs
 GP/nursing homes/home based care
13
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
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
15
Security/privacy policies
 Data protection and information security
principles:
 EU Directive 95/46/EC (the Data Protection
Directive)
 National laws
 National ”Code of Conduct” defined (incl.
practical guidelines)
 www.normen.no (also in English)
 Norwegian Health Network requires
implementation of CoC
16
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
Region North: standardized systems portfolio:
 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.
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
EPR systems in regions:
Helse Nord
(DIPS)
Helse Midt-Norge
(DocuLive)
Helse Vest
(DIPS)
Helse Sør-Øst
(DIPS. Doculive, IMX)
21
Main challenges:
 To digitize hospitals
 To maintain control over growing no. Of
systems
 To achieve inter-organizational collaboration
(digital communication)
22
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
Building EPR systems
 Partly digital:
 A Core/critical information
 B Doctor’s notes




C Results from laboratory tests
D Results from other examinations of organs
E Results from imaging examinations
F Observation and treatment
 G Nursing documentation
 H Reports from other healthcare staff
 I Exsternal correspondence
 J Formal documents (sick leave forms, patient consent
forms etc)
24
Electronic Patient Record System (EPR)
 Simple:





Text-based, no graphics/images
Free text, not structured text (some templates)
Chronological structure (not problem-centered)
No decisions support/expert system functionality
Some integration with Patient Administrative System
(patient demographic data)
 Few standards defined
 So:
 Limited value in comparison with grand visions
 Far easier to implement than ”grand vision” EPRs
25
Implementation of IT systems
 Henry Minzberg (org.theorist) about
hospitals:
’the most complex type
of organizations that
humans have created’
26
Implementation of IT systems
 WHY COMPLEX?
 Many professional groups
 Tightly interconnected work flows
 Unpredictable work
 Moment-to-moment management
 Many actors ’intervene’…
27
2
complex x complex = complex
28
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
Electronic
Digitization process
2000
1995
2005
Scanned
Paper
March
2006
2010
DocuLive (tekstlige journaldokumenter)
DocuLive
(andre journaldokumenter,
skjema, svarrapporter fra
ikke-integrerte systemer)
Patient Record System
Portal
(svarrapporter)
Unilab (medical biochemistry, immunology, microbiology)
DocuLive Patology
Sectra RIS (Radiology)
Agfa RIS (Radiologi)
Miclis (microbiology)
”Integration model” changed over time:
Original vision
Later vision
DocuLive ”Umbrella”
PAS

PAS
Local
EPR
Local
EPR
Current vision
New Portal ”Umbrella”
Local
EPR
Local
System
Local
System
Local
EPR
PAS
Local
EPR
DocuLive
Local
EPR
DocuLive ”Umbrella”
Local
System
Lab
System
Local
System
Lab
System
Lab
System
Local
System
Lab
System
...
Lab
System
All systems integrated within DocuLive
Lab
System
...
...
Some Systems integrated
(loosely or tightly)
Variable levels of integration
under the New Portal
From: Hanseth, Jacucci, Grison and Aanestad:
Reflexive Standardization. Side-effects And Complexity In Standard-making.
MIS Quarterly Vol. 30, Special Issue on Standardization Aug. 2006, pp. 563-581.
31
Presentation layer
Service layer
Integration layer
Legacy systems
32
33
34
… 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
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
37
38
The challenge of complexity
 2009: Tender process
 2010:
 Tight deadlines (governed through politics)
 Troubles … delays
 May 2011: Termination
 (160 million NOK spent )
39
Status pr. 01.01.2011
Oslo Universitetssykehus
Aker
PAS
UUS
DIPS
Klin.dok.
DocuLive
DocuLive
MetaVision
(MetaVision)
MetaVision
RIS/
PACS
Carestream
Siemens
LAB
Flexlab
Swisslab
Spes.
DocuLive DocuLive PAT
PAT
Saphire,
m.fl.
Radium
PasDoc
Kurve
PAT
RH
Prosang,
Cardas,
Endus, m.fl.
Sectra
Agfa
UniLab
DocuLive
PAT
DocuLive
PAT
Well multimedia,
Nyrebase,
Albert,
Vmax, m.fl
Oncentra,
CytoDose, m.fl.
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
42
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
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
Data in NPR record
(example – old ’flat file’ format, now XML)
Reporting: quality monitoring
 Quality/performance/efficiency:
 Handled locally by Dept/Hospital management
 Publication of data relating to: Patient satisfaction,
Waiting times, Complications etc.
 Quality of treatment:
 Professional groups (e.g. urological surgeons) have
initiated voluntary reporting systems
 Manual data entry (not pulling from EPR)
 Exist for >60 areas
 Varying coverage, quality, security – a national
harmonization initiative.
46
Publication of results:
 Quality indicators:
 http://helsenorge.no/Helsetjenester/Sider/Ov
ersikt-over-nasjonalekvalitetsindikatorer.aspx
 Information for patients:
 www.helsenorge.no
 www.frittsykehusvalg.no
47
48
National HMIS
 Not integrated HMIS:
 7 central health registries:
 Mortality registry, birth registry, cancer registry,
infectious diseases, tuberculosis, vaccination
registry, prescription drug registry
 Different data sources, flows and ’destinations’
 Selective integration?
 Interoperable, rather than integrated?
49
Norwegian Institute of
Public Health
 Promotion of better health and prevention of
disease
 Through research based:
 Health surveillance
 Advice and various services
 Employees and students: ~1000
 Annual Budget: ~ 160 mill USD
50
 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
 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
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
Central health registers
From
Id
Responsible
institution
1925/51 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 Norway
1952 Birth Id
H S-Ø
The Norwegian Patient Registry (NPR)
2007 Encrypted
HDIR
The Information System for nursing and care
services (IPLOS)
2005 Pseudonym HDIR
The Cause of Death Register
Central health registers
From
Id
Responsible
institution
The Norwegian Armed Forces registry
2005 Birth Id
FD
National Database for Eectronic Prescriptions
(eResept)
2007 Birth Id
HDIR
19 national medical quality
registries


Regional Health authorities:
South-Eastern Norway


Central Norway


Myocardial infarction + Cerebral stroke + Vascular diseases/vascular surgery
Western Norway


Child and youth diabetes + Neonatal medicine + Cerebral palsy + Trauma +
Colorectal cancer + Prostate cancer
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
57
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
Or…
 Biobanks
 Quality registers
 The HUNT study
 IPLOS
59