Medcom IV Status, Plans and Projects

Home , Aarhus County, Frederiksborg County, Funen County, South Jutland County, Vejle County, West Zealand County

MedCom – the Danish Healthcare Data Network / Dec. 2003 / MC-S177 MedComMedCom IV IV Status,Status, plans plans andand projectsprojects

Healthcare Healthcare portal DIX

Local County authority

Internet Pharmacy Dan Net network

Doctors’ KMD systems network

KPLL

Primary sector Medical Nursing Home Specia- practice homes care lists c. 13%

Other hospitals c. 10%

Clinical service Clinical Other c. 40% treatment clinical treatment unit units EPR c. 23% Other service c. 13% HOSPITAL

Administration c. 4%

● Internet strategy ● Local authorities and healthcare communication ● Hospitals and healthcare communication ● International activities 2 MedCom IV – status, plans and projects

Contents

Aims of MedCom 2 The local authorities and healthcare communication 20 Introduction 3 The Hospital-Local Authority XML project 20 Healthcare on the move 3 The Hospital-Local Authority project and Common Language 22 History 4 Commentary: The Minister of Social Affairs, Henriette Kjær 22 The MedCom steering group 6 The LÆ form project 23 Commentary: The Minister of the Interior and Commentary: The Chairman of the National Health, Lars Løkke Rasmussen 7 Association of Local Authorities, Perspective: MedCom certifies communication 8 Ejgil W. Rasmussen 24 Perspective: The IT Lighthouse’s local authority- The Internet strategy 9 medical practice communication 24 The infrastructure project 9 The hospitals and Commentary: The Chairman of the Association of healthcare communication 25 County Councils, Kristian Ebbensgaard 12 Perspective: The Internet strategy and the From hospital to hospital 25 Healthcare Portal 12 The XML EPR project 27 Web lookup of laboratory data 12 Perspective: XML EPR 27 Web requesting of tests for clinical biochemistry Commentary: Head of Department in the Ministry and clinical immunology 14 of the Interior and Health, Vagn Nielsen, Web lookup of X-rays images and descriptions 16 chairman of the MedCom steering group 32 Teledermatology network 17 Perspective: The XML EPR communication EDI via the Internet 19 project and G-EPR 32 MedCom’s SUP project 33 International activities 36

International interaction 37 International projects 1996-1999 37 Aims of Commentary: Ilias Iakovidis, Ph.D. Deputy Head of Unit-eHealth, European Commission, DG Information Society 38 MedCom International projects 2000-2002 38 International projects 2002-2004 39 MedCom aims to contribute Nordic co-operation 39 to the development, testing, Perspective: Nordic Health care Network group 40 dissemination and quality assurance of electronic com- Statistical material 41 munication and information Good EDI letters 41 in the healthcare sector What can the counties do now? 42 with a view to supporting coherent treatment, nursing Danish Centre for Health and care. Telematics 43 Introduction 3

Introduction

cation across the regions. The around a million messages a Healthcare idea was to develop joint month. The figure is now twice national communication stan- that level. communica- dards for the most important Alongside all this develop- forms of messages and to make ment, there has been intensive tion on the the regional healthcare data network on the consolidation and works building-blocks in a quality assurance of communica- move national healthcare data network. tion. There has also been consid- Coordination, development and erable positive experience of the exchange of experience became significant work involved in car- Communication is a key word in important tasks for MedCom in rying out organisational changes a healthcare sector, which reflects the efforts made to promote IT under the impact of the new specialisation and division of communication in the healthcare informational technology. Only labour between a large number sector. if organisational changes are of specialists and specialist A particular dimension of the made can the improved commu- groups across sectors. Quality development work throughout nication really prove effective. and efficiency in patient treat- the period has been interaction ment are entirely dependent on with private business. At first the New perspectives rapid, reliable and error-free market for the IT solution in this exchange of information between area was virtually non-existent. The dentists, physiotherapists all parties concerned with the A market of this kind has been and occupational therapists are patient. built up alongside the develop- relatively new users of the health- It was therefore natural for ment of the healthcare data net- care data network. Promising the healthcare sector at the end work under close and construc- trials are underway with tele- of the eighties to start examining tive co-operation between users, medicine, and the Internet has the options for using data com- suppliers and MedCom. come into the picture. The ex- munication. It started with a few pansion and development of the enthusiasts, who could see the From the doctor Internet has made it appropriate sense in transferring standard to the whole health- to look at the opportunities to messages electronically. The idea care sector use Internet technology to meet quickly caught on, and the use of some of the communication electronic communication devel- In the first phase of develop- needs of the healthcare sector. oped in both breadth and depth ment, the general practitioner And this is where one of the – more and more users joined in, was the pivotal point in commu- principal focal areas of MedCom and the potential applications nication, which primarily passed IV has been. The Internet opens were extended to include new between medical practices, hospi- up completely new opportunities types of messages. tals, laboratories and pharmacies. both in relation to the patient Then the local authorities also and in dialogue with healthcare One healthcare data joined in and became an impor- professionals. It is important to network, several tant partner in cooperation, in gather experience with this com- regional networks home care and other areas. munication through a large Messages in the form of pre- number of practical projects. At The small, dispersed projects scriptions, laboratory results, X- the same time, MedCom IV has were soon brought together in ray results, discharge letters etc. been concerned with the expan- actual regional healthcare data were exchanged in steadily in- sion and quality assurance of networks, the project organisa- creasing numbers between more EDI communication, as well as tion MedCom was founded back and more users. By the end of the development and implemen- in 1994, both to control devel- the nineties, the healthcare data tation of communication to and opment and to ensure communi- network was already forwarding from electronic patient records. 4 MedCom IV – status, plans and projects

al involving communication between 10 pharmacies and 11 History ●● medical practices was held on ●● Amager in 1989-90. The trial It started in the was pioneering in EDI communication in Denmark, and the eighties ●● same technological platform has ● ●● The history of the healthcare been used for communication ● ●● data network goes back to the right up to the present day. ●● ●● ●● ●● ● ●● end of the 1980s, when interest ●● ● ●● in electronic communication The first regional ● between the various parties in projects ●● the healthcare sector grew. Local ●● projects were launched on the Three large regional EDI pro- Pilot projects in initiative of the Association of jects started in 1992: Medcom I County Councils, at the hospitals in Vejle and Silkeborg and ● FynCom in Funen County MedCom I: elsewhere. The projects, together ● The Odder project in Århus 1994-1996 with the DSI report EDB over County (sektor) grænser (Computing Across ● KPLL in Copenhagen To counteract the tendency for (Sector) Boundaries) helped to the counties each to “re-invent draw attention to the need for All three projects were based on the wheel”, Funen County in cross-sector communication from the technology used in the 1992 submitted a proposal to 1991 on. “Amager trial”. organise a joint nation-wide pro- Alongside these projects, a tri- ject bringing together national government, the counties, private Millions of messages companies and healthcare 25 organisations under the name of: 24 “MedCom – The Danish 23 22 Healthcare Data Network”. 21 The purpose of MedCom was 20 to develop nation-wide standards 19 for the most common communi- 18 cation flows between medical 17 16 practices, hospitals and pharma- 15 cies: referrals and discharge let- 14 ters, laboratory results, X-ray let- 13 ters, prescriptions and hospital 12 billing, totalling over 30 million 11 10 messages a year. 9 The development projects ran 8 from 1994 to 1996 as 25 pilot 7 projects spread across the whole 6 country, which together involved 5 4 the majority of the suppliers of 3 IT to hospitals and medical prac- 2 tices. However, the dissemination 1 of the standards went slowly. A 0 decision was therefore made to 92 93 94 95 96 97 98 99 00 01 02 carry out a second project – The spread and use of the healthcare data network has developed MedCom II. appreciably over the last ten years. Today, 2.3 million messages a month are communicated. History 5

MedCom II: the standards were used differ- 1997-2000 ently by the various suppliers. At the same time, a decision The primary purpose of Med- was taken to launch four smaller Com II was to ensure rapid and project lines: the Hospital Area, large-scale dissemination of the Telemedicine/Internet, Local- standards developed under the Authority Communication and MedCom I project. The local- International Projects. authority healthcare sector was brought into the project together Consolidation MedCom today with the area of dentistry and telemedicine. Internet technolo- Electronic EDI communication gy also started to be used. has now overtaken daily, paper- Following the implementation based communication in the of MedCom II, EDI communi- primary healthcare sector. By far cation between hospitals, medi- the majority of doctors, hospi- cal practices and pharmacies tals, laboratories and pharmacies became everyday reality in all use electronic communication Danish counties, and 1.3 million instead of writing letters – and messages a month were Hospitals this is the most common form of exchanged. Altogether more than communication in the major 2000 medical practices, pharma- areas of the primary healthcare cies, hospitals and laboratories sector. were connected to the healthcare data network at the end of 1999, Spread Number % and between a third and a half of all standardised communication General practitioners 1939 88% between the parties in the Specialists 444 57% healthcare sector was exchanged Pharmacies 331 100% Hospitals 64 100% electronically. Local authority Local authorities 24 26%

Gains Saving

Medical practice 50 min./day II: Telephone follow-up MedCom to hospitals 66% ination projects Per message DKK 25 193 dissem Total electronic communication: 12 local-authority projects 2.3 million messages a month. 8 dentist projects 70% of all communication in the Telemedicine/ edicine projects primary healthcare sector. 10 telem Internet

MedCom III: MedCom III reflected a consolida- 2000-2001 tion of the healthcare data network throughout the country and As communication in MedCom four project lines – Hospital, Local II came into use on a large scale, Authority, Telemedicine/Internet it became clear that fundamental International and International Projects – which quality assurance of the EDI projects each separately covered a group of communication was necessary, as regions. 6 MedCom IV – status, plans and projects

MedCom status MedCom IV: Percentage of possible messages 2002-2005 0 100 A substantial part of the work in MedCom III consisted in estab- 80 0 lishing the basis for the subsequent MedCom projects in two important areas, the introduction 60 0 of Internet-based communication in the healthcare sector and 40 0 re-use of MedCom’s standards in the hospital area.

20 0 The MedCom 0 0 steering group 1998 1999 2000 2001 2002 2003 ● Vagn Nielsen, Head of Doctors site no. Discharge Lab res. Prescriptions Department, Ministry of the Referral Billing Lab req. Local auth. Interior and Health (Chairman) ● Leif Vestergaard Pedersen, The “Doctors site number” curve shows the proportion of doctors who use County Health Director, Århus EDI communication, while the “Local authorities” curve shows the pro- County (Deputy Chairman) portion of local authorities connected to the healthcare data network. The ● Karin Meinicke Andersen, other curves show how large a proportion of discharge letters, laboratory Head of IT, Danish Pharma- requests, laboratory results, prescriptions, referrals and bills from general ceutical Association practice to the National Health Insurance Scheme proceed electronically. ● Lene Bilslev-Jensen, Head of Only in laboratory requesting and communication with the local- Section, Ministry of Finance, authority health visiting service is there still a need for further develop- The Digital Taskforce ment and dissemination projects. ● Steen Christophersen, Vice President IT, H:S Informatik ● Leif Hagerup, Chief of Medical practices, 1 April 2003 Section, Association of Percentage of all GPs County Councils ● Morten Hein, Head of Sec- 100 Having EDI tion, Ministry of Social Affairs Having computers ● Henrik Bjerregaard Jensen, Centre Manager, MedCom 90 ● Ralf Klitgaard Jensen, Chief of Section, National Associa- tion of Local Authorities 80 ● Anders Kristian Jørgensen, Vice President, Dan Net A/S ● Arne Kverneland, Chief of 70 Section, Nat. Board of Health ● Peder Larsen, Deputy Director, Funen County, 60 Healthcare Secretariat N.Jut. Vib. Årh. Ring. Ribe Vejle S.Jut. Fun. W.Z. St.str. Rosk. Fr.b. CHC Cop. Born. Total ● Jørn Jan Nielsen, Deputy The columns show for each county how high a proportion of medical Chief of Section, Copenhagen practices have computers and EDI. It can be seen that most GPs have Local Authority, Healthcare both, but there is a small group who do not have either computers or EDI. Directorate A small group have computers, but do not use EDI communication. History 7

The MedCom IV project is Commentary therefore building on previous MedCom projects and consists of four project lines: An important driving force 1. The Internet Strategy, the The Minister of the Interior and purpose of which is to intro- Health, Lars Løkke Rasmussen duce a nation-wide, Internet- based healthcare data network “The Danish Government and achieve large-scale use of actively supports the MedCom web lookup, telemedicine and co-operation, because it con- other Internet-based forms of tinues to constitute an important communication in the health- driving force in the development care sector. and expansion of electronic 2. The Local-Authority pro- communication across the health jects, the purpose of which is service,” says Lars Løkke to achieve large-scale use of Rasmussen, the Minister of the MedCom’s standards for com- Interior and Health. munication between hospitals “In a specialised health service, ensuring that staff have rapid and and local-authority home care secure access to all relevant clinical information on patients is a great covering 75% of all Danish challenge. It is essential that healthcare staff are able to communicate local authorities. effectively across the boundaries of institutions, units and sectors. 3. The XML-EPR Communi- The projects underway in MedCom IV focus in particular on com- cation project, the purpose of munication in the hospital sector and communication between local which is to achieve large-scale authorities and hospitals, as well as GPs. In addition, the establish- nation-wide use of all relevant ment of the new Internet-based healthcare data network is opening MedCom messages for com- the door for new nationwide forms of communication, including munication internally in hos- secure web-mail, videoconferencing and lookup, for example in X-ray pitals and between hospitals. systems. 4. MedCom’s SUP project, the I anticipate that the communication projects will lead to increased purpose of which is to achieve quality and coherence in patient progressions and provide the basis Internet access to PAS and for improved information and service to patients. I also anticipate EPR patient records both that the projects will act as catalysts for changes in old routines and within a county and across procedures in the health service, so that the resources can be used in county boundaries. the best possible way.” All general medical practices are now joining October 2002. They must follow laboratory results in their com- the standards for prescriptions, munication, and – to the extent A number of new IT opportuni- billing, discharge summaries and that it is safe and practical to do ties for general practitioners were so – referrals and laboratory introduced in the new agreement requests as well. between the Association of All doctors who did not County Councils and the GPs, receive a computer billing fee in which came into effect on 1 January 2003 must join by 1 April 2003. January 2005. In addition, pro- By 1 January 2004 all doctors vision is made to offer patients who have received a computer e-mail consultation and give billing fee in January 2003 must results to patients by e-mail, as be able to communicate accord- well as appointments and pre- ing to all the MedCom approved scription renewal on the Inter- standards as they existed in net. 8 MedCom IV – status, plans and projects

Specialists join in EDI healthcare data network and on 1 January 2003, and in the that he or she uses all relevant first few months of the year The new agreement between messages in the communica- alone 86 new specialist prac- the Association of County tion that currently takes place tices started using EDI, three Councils and the Danish Asso- in the county concerned. times as many as in the whole ciation of Medical Specialists The grant scheme started of 2002. makes it possible to offer grants enabling specialists in Dissemination private practice to acquire IT Proportion of GPs and specialists in the healthcare data network and establish facilities for EDI 100% communication and Internet access. 90 The grant is DKK 15,000 80 for full-time practitioners, 70 DKK 20,000 for part-time practitioners, and a grant of 60 DKK 5,000 is paid for the 50 establishment of EDI commu- 40

nication alone. To qualify for a 30 grant, it is necessary to pur- chase a doctors’ system capable 20 of handling all MedCom 10 messages with the exception of 0 MEDREQ. It is also a require- 1997 1998 1999 2000 2001 2002 2003 ment that the specialist’s practice is connected to the Doctors site no. Full-time specialists Part-time specialists

Perspective

MedCom certifies communication

Error-free communication of EDI messages in the healthcare data network is entirely dependent on both the sender and the recipient using standards and syntax correctly. This makes demands on the computer systems at both ends of the communication. Previously the standards for the individual messages were tried out in pilot projects county by county and supplier by supplier, and the systems were gradually adapted. It was a process that was time-consuming and demanded considerable resources for all parties involved. As part of the quality assurance of communication, users and technical staff have developed and introduced “Good EDI Letters”, with MedCom as the intermediary. Thus the documentation of the standards has been made very precise, and it is to a large extent possible to carry out the adaptation of sender and recipient systems before the EDI message is put to use. MedCom offers all systems houses and counties testing and certification of the sending and receiving of each individual EDI type. If the systems house or county complies with the standard for the type of letter concerned, MedCom issues a certificate of approval. The approval is published on the MedCom website. Only systems that have undergone testing and approval may use the MedCom stamp of approval. Counties, Copenhagen Hospital Corporation (CHC) and national laboratories have undertaken only to use and communicate with systems and messages approved by MedCom. Internet strategy 9

The Internet strategy

Within the health service, the Internet today is used for lookup The Primary Group in referral information and clinical guidelines. Use of the Inter- The purpose of the Primary Group ● Jan Stokkebro Hansen, net is, however, limited by the is to monitor and carry out Med- Copenhagen County lack of security in the open Com projects under the Internet ● Niels Hornum, KPLL Internet. If the Internet is to strategy and in the area of local ● Rose-Marie Jensen, supplement or be an alternative authorities. In addition, it fulfils Bornholm County to the VANS-based healthcare tasks in relation to problem- ● Lisbeth Jørgensen, data network, it will need to be solving and enhancement in con- Funen County possible to pass on the structured junction with the EDI communi- ● Tine Korsholm, EDI messages via Internet tech- cation already in existence. The Ringkjøbing County nology, and for the messages to Group consists of project leaders ● Tove Lehrmann, Funen County be integrated into the computer and other key individuals from ● Søren Lorentzen, systems that take part in the counties, CHC, local authorities Frederiksborg County communication. Expanded use and other organisations in the ● Niels Munk-Jensen, FAPS of Internet technology makes healthcare sector. ● Birgit Nielsen, Storstrøm fundamental demands with County regard to security, infrastructure, ● Birte Elgaard Andersen, ● Claus Nielsen, National Associa- certification, user administration Copenhagen County tion of Local Authorities and so on. ● Karin Meinicke Andersen, ● Lisbeth Nielsen, Association Danish Pharmaceutical of County Councils Association ● Tove Charlotte Nielsen, The Infrastruc- ● Karin Argir, Capio Diagnostik Vejle County ● Lone Behnfeld, ● Helle Stockfleth Olsen, ture project South Jutland County Statens Serum Institut ● Karin Bisgaard, ● Jens Parker, PLO West Zealand County, ● Peter Pedersen, CHC The aim of this project is to ● Bente Christensen, Vejle ● Susanne Duedal Pedersen, establish a nation-wide secure IP- County National Board of Health based network for communica- ● Ib Thyge Christensen, ● Jens Henning Rasmussen, tion between the parties in the Frederiksborg County Roskilde County health service. The basic idea is ● Anne Danborg, ● Henning Voss, Centre for to build up the network by link- Skovbo Local Authority Healthcare Telematics ing together existing secure intra- ● Kjeld Erbs, Århus County ● Kim L. Østerbye, Ribe County nets in counties, local authorities ● Ronnie Eriksson, Association and other organisations. of County Councils ● Karin Demkjær, MedCom The first phase in establish- ● Anne-Marie Falch, ● Lars Hulbæk, MedCom ment is to carry out a pilot pro- North Jutland County ● Gitte Henriksen, MedCom ject involving the construction of ● Lene Meyer Grosen, ● Henrik Bjerregaard Jensen, a prototype, by which the rele- Frederiksborg County MedCom vant forms of communication ● Jens Grønlund, Viborg County ● Ib Johansen, MedCom can be tested in daily operation ● Susanne Larsen Grøntoft, CHC ● Dorthe Skou Lassen, MedCom between the participants in the ● Merete Halkjær, ● Jens Rahbek Nørgaard, project. Copenhagen Local Authority MedCom With a healthcare internet, ● Finn Roth Hansen, ● Claus Duedal Pedersen, the way is cleared for communi- West Zealand County MedCom cation options that were not ● Iben Søgaard, MedCom available in the traditional 10 MedCom IV – status, plans and projects

Healthcare Healthcare portal DIX

Local County authority

Pharmacy Internet Local authority Pharmacy Pharmacy Doctors’ system Dan Net Pharmacy network Pharmacy system Pharmacy County

Medical practice Local authority Medical practice Doctors’ KMD Doctors’ system Medical practice system network Pharmacy system Medical practice County KPLL

VANS-based network. It will be Timetable for technical pilot project possible, for example, to put the pull principle into practice, so 2002 2003 that it is the recipient of informa- 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 tion who actively retrieves the Infrastructure project information he needs from the VPN connections information supplier’s system. EDI via MIME (mail) At the same time, images, sound, Web lookup Evaluation of phase 1 graphics etc. become part of the Web-mail forms of information that are Videoconferencing easily accessible. Communication project Finally, Internet technology 4 working groups opens the door to the circle of System development users in the healthcare internet Spearhead dissemination being expanded to include all parties involved, not least the Use of the new infrastructure is ensured through spearhead projects in patients. 2003, with subsequent dissemination projects in 2004 and 2005. Internet strategy 11

The Infrastructure Group

The purpose of the Infrastructure ● Flemming Engstrøm, ● Peter Pedersen, CHC Group is to ensure that MedCom’s Copenhagen Local Authority ● Morten Pedersen, infrastructure projects are imple- ● Jørgen Granborg, A-Data ApS Association of County Councils mented. The Group is temporary ● Jens Grønlund, Viborg County ● Palle Runer, DataPharm A/S and consists of project leaders and ● Jan Stokkebro Hansen, ● Ole Sprøgel, Dan Net network managers from organisa- Copenhagen County ● Jan Staack, CHC tions that have decided to estab- ● Peter Illum Hansen, Funen ● Lise Wormstrup, KMD A/S lish VPN connections to the County ● Kim Østerbye, Ribe County healthcare data network under ● Lars Hillerup, Vejle County the pilot project. The temporary ● Niels Hornum, KPLL ● Lars Hulbæk, MedCom Infrastructure Group will be ● Erik Jacobsen, ● Henrik Bjerregaard Jensen, replaced by a permanent group Datagruppen MultiMed ApS MedCom when the project is ready for daily ● Henrik Thuren Jensen, ● Jens Rahbek Nørgaard, operation. Profdoc A/S, Darwin MedCom ● Lisbeth Jørgensen, FynCom ● Claus Duedal Pedersen, ● Karin Meinicke Andersen, ● Børge Knudsen, Ribe County MedCom Danish Pharmaceutical ● Ib Lucht, UNI-C Association ● Bo Nielsen, bo soft A/S ● Orla Antonsen, Viborg ● Tove Charlotte Nielsen, Hospital Vejle County ● Allan Bech, Copenhagen ● Jens Parker, Lægehuset County ● Morten Pedersen, ● Martin Bech, UNI-C Datapharm A/S

VPN contacts

● Karin Meinicke Andersen, ● Lars Hillerup, Vejle County ● Hans Birger Olsen, Danish Pharmaceutical ● Niels Hornum, KPLL Bornholm County Association ● Erik Jacobsen, ● Allan Pedersen, Viborg ● Hans Elmquist, DataGruppen MultiMed ApS County West Zealand County ● Niels Kinnerup, ● Jens Henning Rasmussen, ● Susanne Enevoldsen, West Zealand County Roskilde County Ringkjøbing County ● Jan Kold-Larsen, ● Palle Runer, DataPharm A/S ● Flemming Engstrøm, Copenhagen County ● Lennart Sorth, UNI-C Copenhagen Local Authority ● Carsten Lind, ● Ole Sprøgel, Dan Net A/S ● Jørgen Granborg, A-Data ApS Frederiksborg County ● Jan Staack, CHC ● Jens Grønlund, Viborg County ● Claus Lohfeld, Århus County ● Aksel Worm, Copenhagen ● Helge Hansen, ● Kenneth Mogensen, Local Authority South Jutland County Storstrøm County ● Lise Wormstrup, KMD A/S ● Peter Illum Hansen, Funen ● Bo Nielsen, bo soft A/S ● Kim L. Østerbye, Ribe County ● John Møller Nielsen, County ● Lone Hassingboe, Eterra Danmark A/S North Jutland County ● Tove Charlotte Nielsen, ● Søren Herget, West Zealand Vejle County County 12 MedCom IV – status, plans and projects

Commentary

MedCom and the Healthcare Portal Kristian Ebbensgaard, Chairman of the Association of County Councils

“MedCom plays a key role in the communication between hospitals and GPs. The counties have taken an active part in the co-operation, which has nurtured electronic communication without equal in the rest of Europe,” says Kristian Ebbensgaard, county chief executive and chairman of the Association of County Councils. "The Association of County Councils has taken the initiative for the joint public healthcare portal. We owe our ability to implement such an ambitious project partly to the standardisation and infrastructure created within MedCom. With MedCom IV, MedCom is now moving into the hospitals and seriously making a start on Internet technology. The primary local authorities are also on the way to becoming active participants in MedCom. A proper foundation for effective communication throughout the Danish health service has been created.”

Perspective Web lookup The Internet strategy and of laboratory the Healthcare Portal data The MedCom standards, which are used at present in the healthcare data network, can be directly re-used for data exchange via the Public Healthcare Portal, which is being developed on the initiative of the The idea in the “Lookup of Lab- Association of County Councils. oratory Data via the Web” pro- Today, more than 40 types of letter based on MedCom standards ject is to give healthcare profes- have been established. The MedCom standards are based on con- sionals Internet access to patient sensus among healthcare professionals on content and application. data stored in another county, On this basis, documentation and test messages have been prepared, hospital or laboratory database. sender systems have been approved in the testing of content and It will typically be relevant in syntax, and in a similar way recipient systems have been approved situations where the healthcare through the testing of reception and presentation. professional has to treat a patient By linking together existing secure intranets, MedCom has estab- without having any knowledge lished the healthcare internet, known as HealthcareDIX (Sundheds- of the patient’s data, for example DIX), via VPN connections to VPN nodes. Operation is user-financed, in the case of emergency hospital and 13 counties, CHC, Copenhagen Local Authority, two doctors’ admissions. Quick and easy systems, KPLL and Dan Net are currently taking part in the network. access to relevant patient data in The work on the healthcare internet consists here and now in the those cases will boost both development of a series of Web-based services, which are made avail- quality and efficiency in patient able to the parties connected to the network. treatment. HealthcareDIX is therefore ideally suited to fulfilling the com- Provision for Web lookup will munication needs the Public Healthcare Portal has to meet. generally be useful where it was not “known” that patient data would be needed. This applies for example in the treatment of free-choice patients and patients Internet strategy 13

who are being treated in another ● to minimise the number of county, because they need a duplicate investigations and Project Group national or regional function. in that way prevent the Previous projects have shown patient being subjected to ● Anni Christensen, that great gains can be made for unnecessary investigations Department of Clinical both the patient and the health ● to establish a supplement to Biochemistry, Esbjerg Varde service by ensuring access to the existing EDI communica- Central Hospital laboratory results and ECGs. tion and create the possibility ● Marianne Ebbell, The reasons why this solution of improving diagnoses and Central Laboratory, Næstved has not been put into practice the planning of treatment Central Hospital already are both technological ● Lone Espensen, Department and organisational in nature. It is The objective of the project is of Clinical Immunology, not until the closed healthcare that the counties and laboratories Odense University Hospital internet is established that there taking part have Internet-based ● Niels Hornum, KPLL is a genuinely realistic prospect of access to relevant data for exter- ● Michael Johansen, B-DATA carrying out a project aimed at nal users developed and imple- ● Lisbeth Jørgensen, massive dissemination of lookup mented and to provide access to Funen County in laboratory data via the Web. the service via the closed health- ● Kate Kusk, Viborg County care internet. ● Dorthe Skou Lassen, The establishment of lookup Funen County provision in laboratory systems is ● lse Mortensen, Clinical to be seen in the context of the Biochemistry Section, forthcoming Public Healthcare Hillerød Hospital (observer) Portal. If the Healthcare Portal is ● Lisbeth Ramsvatn, Institute seriously to be the Web entry of Pathology, Hillerød port to the health service, it is Hospital (observer) essential that services are devel- ● Maja Stephansen, oped that make it appropriate Storstrøm County and attractive for healthcare ● Kim Østerbye, Ribe County professionals to use the portal. A huge expansion of lookup ● Lars Hulbæk, MedCom The overall aims of the project solutions to laboratory data, ● Claus Duedal Pedersen, are: which can be made available via MedCom ● to assure the patient that all the portal, will contribute to ● Iben Søgaard, MedCom relevant information can making the portal a natural tool always be accessed in connec- for healthcare parties to employ. tion with treatment and in- In relation to the national IT vestigation strategy, Web access to laboratory ● to make sure that relevant data will support the develop- results are always available to ment of various telemedicine the attending healthcare pro- services. fessional, across county and organisational boundaries

Timetable for Web lookup of laboratory data

2002 2003 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 Communication project Project preparation Co-operation agreements System development Spearhead dissemination 14 MedCom IV – status, plans and projects

Web requesting of tests for clinical biochemistry and clinical immunology

The project on the requesting of chemistry and Immunology. ● No further investments in analyses in departments of clini- WebReq enables the connected comparison with EDI cal biochemistry and immunolo- doctors’ systems to have labora- requesting gy will mean saying goodbye to tory-specific information stored ● Same interface regardless of pre-printed request forms. The in a central place, so that they laboratory departments will be able to are free to record and maintain ● Freedom of choice between receive electronic requests which this information in the local EDI and Web requesting the doctors have filled in via a doctors’ system. This provides a ● Not dependent on choice of standard Web browser. number of benefits: laboratory and laboratory With the WebReq program, system all doctors can send an electronic ● Same procedure in the labora- ● Can easily be used by all request in MEDREQ format as a tory for both EDI and Web doctors’ systems without normal EDI file to Clinical Bio- requesting major programming effort ● Provision for changes in laboratory systems and doctors’ systems without Project Group involving all users ● Easy access for doctors to set All departments of clinical bio- ● Kate Kusk, Viborg County up their own profiles and chemistry and laboratories as ● Birgit Juhl Madsen, their own tests well as all suppliers of doctors’ Vejle Hospital ● Provision for easy re-ordering systems are invited to take part ● Tove Charlotte Nielsen, of previous tests in the project. A WebReq project Vejle County ● Provision for printing out group with the following ● Dora Simonsen, Viborg Hospital PTB (sampling forms) participants has been set up to ● Tom Valbjørn, KPLL monitor and implement the ● Kim Østerbye, Ribe County The doctor obtains access to the project: system using a normal Web ● Karin Demkjær, MedCom browser via VPN/SSL and later ● Dorthe Black, KPLL ● Gitte Henriksen, MedCom via the healthcare internet. Users ● Niels Jørgensen Christensen, ● Ib Johansen, MedCom have to log onto the system with Aarhus County Hospital ● Claus Duedal Pedersen, an access code (external number) ● Kjeld Erbs, Århus County MedCom and a password. In WebReq, the ● Lotte Estrup, KPLL ● Iben Søgaard, MedCom doctor can parameter-transfer ● Finn Roth Hansen, West necessary patient data and rele- Zealand County (observer) vant practice information, inclu- ● Rita Henriksen, ding default laboratory choices, Esbjerg Central Hospital so that a WebReq call can be ● Niels Hornum, KPLL built into the individual doctors’ ● Bodil Jacobsen, Vejle Hospital system as a fixed routine and ● Erik Jacobsen, consequently minimise the num- Datagruppen Multimed ber of manual registrations. ● Lisbeth Jørgensen, Funen The procedure for requesting County (observer) using WebReq is quite straight- ● Margit Kisbye, Funen forward. When a request is filled Svendborg Hospital (observer) in, it is approved, and a standard PTB form is completed. Alterna- tively, one of the laboratory’s Internet strategy 15

Instruction film of new procedures into medi- dures and the associated taking on laboratory cal practices. To show how an and labelling of samples. efficient and practical proce- The videos can be down- request dure in relation to electronic loaded from the MedCom requesting proceeds, MedCom website, www.medcom.dk. The introduction of electronic has prepared a number of They have also been issued on laboratory requesting necessi- instruction videos that review a CD, available free of charge tates incorporating a number the various requesting proce- from MedCom.

pre-printed forms is used. The Timetable for Web requesting samples are taken, and the request is sent off in normal 2003 MEDREQ-EDI format to the 01 02 03 04 05 06 07 08 09 10 11 12 recipient laboratory. Project description The doctor receives a report Co-operation agreements back from the laboratory as WebReq module ready Meetings with suppliers MEDRPT in the traditional way, Testing of systems but the request can also be sent Pilot operation as a copy to the requester with Pilot operation completed the aim of being able to read the Fine-tuning of software, if necessary requested analyses into the local Dissemination doctors’ system. 16 MedCom IV – status, plans and projects

among both GPs and specialists. Web lookup The reasons why this solution Project Group does not already exist are both of X-rays technological and organisational ● Dan Gedebjerg, Esbjerg Varde in nature. It is only with the Central Hospital (observer) images and establishment of the closed ● Finn Roth Hansen, healthcare internet that it is West Zealand County descriptions genuinely realistic to carry out a ● Bjarne Hjorth, Odense project that disseminates a University Hospital The “Lookup of X-ray Images lookup solution of both X-ray ● Lisbeth Jørgensen, Funen and Descriptions via the Inter- descriptions and various types of County net” project aims to provide images stored in digital form. ● John Kiil, West Zealand healthcare professionals with The overall aims of the pro- Hospital direct access to central patient ject are: ● Lillian Kofoed, information stored in the X-ray Kalundborg Hospital system of another county or ● to assure patients that all rele- ● Tove Charlotte Nielsen, hospital. It is very relevant in vant information can always Vejle County (observer) connection with emergency ad- be accessed for treatment and ● Marianne Richelsen, missions, treatment of free-choice investigation Hillerød Hospital patients and national and region- ● to make sure that relevant X- ● Kim Østerbye, Ribe County al patients or in the preparation ray descriptions and images (observer) of the treatment of a new patient. are always available to the The healthcare professional can attending healthcare profes- ● Lars Hulbæk, MedCom obtain the information quickly sional, across county and ● Claus Duedal Pedersen, via Web lookup, so that the organisational boundaries MedCom patient’s treatment is efficient ● to minimise the number of ● Iben Søgaard, MedCom and of the highest quality. duplicate investigations and Web lookup also makes it in that way prevent the possible to establish different tele- patient being subjected to medicine services, such as asking unnecessary investigations an expert for a second opinion. ● to establish a supplement to As the shortage of experts in the the existing EDI communica- area of radiology increases, tele- tion and create the possibility medicine solutions of this type of improving diagnoses and will steadily gain ground. the planning of treatment Finally the lookup solution will be useful for GPs when they The objective of the project is have to inform patients about that the counties and laboratories their illness and treatment, as X- taking part have Internet-based rays often encourage dialogue access to relevant data for exter- with the patient. Access for nal users developed and imple- doctors to X-rays additionally mented and to provide access to care internet. The establishment supports the upgrading of skills the service via the closed health- of lookup provision in laboratory systems is to be seen in the con- Timetable for Web lookup of X-ray data text of the forthcoming Public Healthcare Portal. Massive dis-

2002 2003 semination of lookup solutions 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 to image diagnostic data, which can be made available via the Communication project Project preparation portal, will contribute to giving Co-operation agreements the portal the healthcare content System development that makes it a natural tool for Spearhead dissemination healthcare parties to employ. Internet strategy 17

Teledermatology network Project Group

● Birte Elgaard Andersen, This project, which is concerned ● Replace/supplement general Copenhagen County with establishing a nation-wide referrals to skin specialists ● Kjeld Erbs, Århus County “teledermatology network”, is with telemedicine consulta- ● Jens Grønlund, Viborg County based on MedCom’s TeleMed tions ● Bo Gundtofte, Roskilde project from 1999. During the ● Ensure patients have of equal County (observer) course of three months of and quick access to specialist ● Finn Roth Hansen, operation, MedCom tested the assessments of skin images West Zealand County sending of digital skin images to through their own doctor ● Lisbeth Jørgensen, Funen supplement the traditional co- ● Support continuing training County operation and pattern of referral of GPs through communica- ● Tonny Karlsmark, between medical practices and tion with skin specialists Bispebjerg Hospital dermatology specialists. ● Establish nation-wide pro- ● Finn Klamer, Øster Jølby, Mors Experience from this project vision for telemedicine skin ● Tine Korsholm, Ringkjøbing showed that it is possible to image consultation County make gains in the form of: ● Ove Kristensen, West Zealand In relation to the future national ● Søren Lorentzen, Frederiks- ● Easily available specialist IT strategy for the health service, borg County (observer) support the establishment of a telederma- ● Peter Pedersen, CHC ● Improved patient service, tology network will be the first ● Bjørn Perrild, Kongens fewer visits to doctors, no step towards putting into effect Lyngby extra transport, waiting time the recommendations made in ● Hanne Boje Rasmussen, and absence for the patient the Ministry of Health’s tele- Odense ● Improvement in the quality of medicine report from 2001. ● Peter Wendelboe, Grenaa treatment The establishment of tele- ● Regular continuing training dermatology is to be viewed in ● Lars Hulbæk, MedCom of the doctor the context of the future Public ● Claus Duedal Pedersen, ● Simpler check-up/follow-up Healthcare Portal. Via the MedCom treatment in general practice Healthcare Portal, GPs can ● Iben Søgaard, MedCom ● Support of the patient’s free obtain an overview of providers choice of specialist of teledermatology consultation, and guidance and recommenda- The overall objectives of the tele- tions in connection with teledermatology project are to: dermatology should also be available here. In the longer term, a

teledermatology network can be supplemented by a national skin image database of particularly interesting and/or typical skin ailments, as known from Erlangen University in Germany. 18 MedCom IV – status, plans and projects

Initial dissemination of tele- Timetable for teledermatlogy dermatology can additionally form the basis for increased 2002 2003 interdisciplinary co-operation 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 between the home care service, Communication project medical practices and dermatolo- Project preparation gists in the area of wounds. Co-operation agreements Finally teledermatology can pre- Healthcare recommend. System devel. (MedBin) pare the way for other tele- Spearhead dissemination medicine solutions in relation to general practice in the future, for example in cardiology.

MEDBIN – images by EDIFACT Edifact – with MEDBIN elements PNA+PAT+PatCPR:::CPR:IM+++SU:PatEnavn+ In conjunction with imple- FO:PatFnavn' mentation of the consolidation RFF+XPI:PatErstatCPR' project and with inspiration Binary elements S11+11' from the EU CoCo project, UNO+Objektlbnr+AID:Objektrefnr+OBJ: the idea arose of employing OBJEKTTYPE:OBJEKTEXTENSION:91+ existing EDI solutions to Objektstoerrelse:14:1:A' transfer items other than The object file SelveObjektet smaller text-based documents. UNP+Objektstoerrelse+Objektlbnr' These may, for example, be Number of repetitions UNO/UNP can be repeated up to 10 times. images and text documents of The max. size of the ActualObject significant size. Mention can (SelveObjektet) is 20 Mbyte be made here of X-ray images and pathology images as well as a common basis of data for from the Institute of Patholo- Danish guidance for this EDI medication and patient listing gy at Vejle Hospital to medical message, known as MEDBIN. for general practice. practices and the exchange of MEDBIN is used today for In co-operation with Data- skin images between GPs in the transfer of skin images and gruppen MultiMed, KMD, Vejle County and specialists in is employed in MedCom’s Vejle County, B-Data and skin diseases in Århus County. dermatology project and for Århus County, in the spring of The trial was an unconditional the transfer of medication up- 2002 MedCom carried out a success. MedCom has there- dating files and electrocardio- trial on the exchange of images fore decided to draw up joint grams.

Eye fundus image X-ray image ECG Internet strategy 19

EDI via Project Group

Internet ● Jørgen Granborg, ● Palle Runer, DataPharm A/S A-Data ApS, PLC ● Ole Sprøgel, Dan Net A/S ● Carsten Jacobsen, KMD A/S ● Lise Wormstrup, KMD A/S In connection with the testing of ● Erik Jacobsen, DataGruppen the technical infrastructure, co- MultiMed ApS ● Lars Hulbæk, MedCom operation agreements with the ● Bo Nielsen, bo soft A/S ● Claus Duedal Pedersen, VANS suppliers in the present- ● Morten Pedersen, MedCom day healthcare data network Datapharm A/S ● Martin Bech, UNI-C ensure that the suppliers together ● Michael Rasmussen, ● Ib Lucht, UNI-C with any other future network Dan Net A/S providers in the Internet-based healthcare data network are able to handle EDI mail via the Inter- net over the HealthcareDIX (SundhedsDIX). The purpose of this is to ensure coherence between the MX MX existing healthcare data network and the future healthcare data network in the area of EDI. It requires all parties in the Inter- Healthcare net-based healthcare data net- DIX work to apply the same envelope standard. Only a change in envelope wrapping is concerned, as the EDI standards are applied MX MX in the same way as today. To support the dissemination of EDI mail via the Internet, there is a need for MedCom to ensure uniform envelope wrapping by offering supplier testing in the MX period 2003-2005, in accordance with the EDI mail standard. The dissemination of EDI mail can accordingly be based on the free Pharmacy market. Network The trial, which was completed in September 2003, involved KMD, Dan Net, Data- Gruppen MultiMed, A-Data, Apotekernettet, DataPharm and CitoData (bo soft A/S).

EDI exchange via the Healthcare DIX is based on decentralised mail-exchange servers (MX). 20 MedCom IV – status, plans and projects

The local authorities and healthcare communication

sending and receiving technical ● for the project to support Hospital-Local and clinical messages and all other key initiatives in rela- ECR systems in the local tion to the healthcare sector, Authority authorities and all PAS systems including in particular: in the hospitals. – Building-up of the XML XML project At the same time, the project database of the Ministry of is aimed at expanding the use of Science correspondence messages and – The work of the National The reason for the Hospital- warning of completion of treat- Board of Health with Local Authority XML project is ment. The correspondence mes- G-EPR to expand the use of a number of sage can fulfil a large number of – Further development by the electronic messages – the elec- communication needs for which National Association of tronic admission message, ad- there is a demand in the hospi- Local Authorities/Ministry mission report and discharge tals and local authorities. The of Social Affairs of Com- message. All three messages free-text field of the message can mon Language strengthen communication be- be filled in for instance by re- – Build-up of the Public tween hospital and local authori- using existing recordings from Healthcare Portal ty, where there has traditional ECRs, including information on – The work of the Digital been problems in ensuring com- medication and services provided Taskforce on legal barriers munication on admission to and and functional assessment. From to digital administration. discharge from hospital. the hospital, action and retrain- As of September 2002, only ing plans can be written directly The Hospital-Local Authority 17% of the Danish population into the correspondence module XML project is to be seen in the were covered by messages of this of the PAS system. context of the general work on type, despite the opportunities The aim of the Hospital- EDI-XML translation. This work that exist in facilitating the pro- Local Authority XML project is is necessary with a view to cedure and ensuring better therefore: preparing the Public Healthcare patient treatment by virtue of Portal. electronic communication. ● to ensure that the use of The EDIFACT standards for The target group for the pro- advice of admission, admis- advices and admission results are ject is primarily those hospitals sion result and advice of dis- technically the simplest of all and local authorities that do not charge is extended to hospitals MedCom standards. It is there- use these electronic messages. At and local authorities that fore logical to use these standards the same time, those hospitals cover 75% of the Danish for a first testing of options in and local authorities that already population at the end of 2004 EDI-XML translation. exchange advices and admission ● to ensure the necessary tech- The project is to ensure that results have long wanted to ex- nical conditions for a sharp coherence is created between the pand electronic communication. increase in the use of the cor- development of the healthcare There is a need to make possible respondence message and data network and the overall a regular exchange of informa- warning of completion of XML work in the Ministry of tion before, during and after an treatment, so that counties Science. At the same time, a admission. representing 75% of the framework was created for This desire, with a solid foun- Danish population offer these expanding basic communication dation in healthcare, can be met communication options to solutions among hospitals and by supplementing the standard interested local authorities at local authorities. messages with the possibility of the end of 2004 The local authorities and healthcare communication 21

Participants in project North Jutland Vejle County: County: Fredericia MedCom IV Local- ● County taking part in the Aalborg Authority Group local-authority project Læsø West Zealand ● County not taking part in the County: ● Lene Meyer Grosen, Project local-authority project Funen County: Holbæk Manager, Frederiksb. County ● Local authority in the healthcare Odense Slagelse ● Marianne Strand, Project data network Årslev Manager, Stenløse Loc. Auth. ● Local authority in the healthcare Ørbæk Frederiksborg ● Kim Snekkerup, network additionally taking part Ryslinge County: Administrative Consultant, in the Hospital-Local Authority Rudkøbing Frederiksværk Frederiksværk Local XML project Svendborg Stenløse Authority ● Slangerup Lisbeth Rasmussen, Senior Nursing Officer, Fun. County Helsingør ● Alice Kristensen, Project Manager, Svendborg Local Roskilde County: ● Authority Skovbo ● Lissi Veltzé, Home Care ● Roskilde Manager, Ørbæk Local Auth. Køge ● Susanne Grøntoft Larsen, Vallø Sen. Systems Consultant, CHC ● Merete Halkjær, IT Cons., CHC: Copenhagen Local Authority Copenhagen ● Anne-Marie Falch, Project Frederiksberg Manager, North Jutl. County ● ● Isabelle Andersen, Head of ● ● Copenhagen Day Care, Læsø Local Auth. ● ●●● County: ● Kirsten Skovrup, Head of ● ●● ● ● Søllerød Section, Aalborg Local Auth. ● ● ● ● ● Lyngby-Tårbæk Jens Henning Rasmussen, ● Head of IT, Roskilde County ●● ● Storstrøm County: ● Agnete Seidelin, Project Co- ● Højreby ordinator, Roskilde Loc. Auth. ● Næstved ● Anne Danborg, Head of ●● ● Nakskov Home Care, Skovbo Local Sakskøbing Authority ● Birgit Nielsen, Project Manager, Storstrøm County Hospital-Local Authority XML project timetable ● Søren Skafte Jensen, IT Officer, Nakskov Local Auth. 2002 Project preparation ● Kim Østerbye, Senior IT 2003 January Supplier co-operation agreements and pilot participant co- Consultant, Ribe County operation agreements signed. ● Lene Bilslev-Jensen, Project May Information to all Danish local authorities concerning dis- Cons., The Digital Taskforce semination activities in 2004. ● Bentt Nielsen, Development September Supplier testing and MedCom certification carried out. Consultant, National Board of Social Services December Minimum of 3 months of pilot operation carried out. Continued Marketing from relevant parties behind MedCom. ● Dorthe Skou Lassen, Project dissemina- Manager, MedCom tion in 2003 ● Lars Hulbæk, Project 2004 Dissemination co-operation agreements with counties/ CHC Manager, MedCom End Spearhead dissemination in (at least) one county with all ● Iben Søgaard, Project local authorities carried out. Secretary, MedCom Whole of 04 Marketing from relevant parties behind MedCom. 22 MedCom IV – status, plans and projects

eight areas of assessment at four The Hospital-Local Authority levels of functional capacity and records the allocation of services project and Common Language in a services catalogue. In addition, the effect of the home and the use of technical aids on the Common Language II is a con- person’s functional capacity is ceptual framework which the assessed. The registration of tech- local authorities can use to de- nical aids follows a classification scribe the functional capacity of system in accordance with an citizens whose needs are assessed international standard on “Tech- by the local authority and the nical Aids for Disabled Persons”. services provided in the area of Common Language II is based the elderly and disabled. Com- on ICF, which forms part of the mon Language II provides an Health Service Classification overview of the citizen’s overall System (SKS). The development functional capacity. of Joint Language II is being co- The overriding objective of ordinated and integrated with the Common Language II is to work of the National Board of create political and technical co- be used for broader technical Health with ICF within SKS. herence in the effort that is development, as well as manage- MedCom is monitoring devel- made. The target group for rial and political priority-setting. opment by being represented in Common Language II is poli- Common Language II has not the National Association of Local ticians and specialised staff, been developed to be used in the Authorities (KL) reference group primarily the needs assessors. clinical situation, where services for Common Language. Common Language II consti- are provided at the home of the The development of Common tutes a clinical database that col- individual citizen. Language II is being dealt with lects information on all citizens A needs assessor makes a by KL and can be followed on whose needs are assessed and can functional assessment through the KL website: www.kl.dk/fs

Commentary

Better coherence The Minister of Social Affairs, Henriette Kjær

“Many elderly people find that they have to tell the same story time after time. The same personal information has to be given to the home care service, the hospital, the GP and perhaps the home care service again,” says Henriette Kjær, the Minister of Social Affairs "That isn’t clever, it’s inappropriate! It also happens that elderly people simply ’slip out’ of the system, because during the course of an illness changes may have occurred in the elderly person’s home care – and he or she is simply discharged. The systems therefore have to become better at talking to each other. Under the MedCom co-operation, targeted effort is made to disseminate the electronic communication between hospitals and local authorities, so that better coherence is created between the social and healthcare sectors. The result might perhaps be that elderly people avoid having to give the same information repeatedly. It would, in any case, be a good start.” The local authorities and healthcare communication 23

sentatives of general practitioners The LÆ form and the National Association of Project Group Local Authorities. The procedure project in using LÆ forms comprises The participants in the project’s two steps: pre-analysis group are:

The project on LÆ forms is in- 1. A request is sent from the ● Morten Hein, tended to ease the written com- local authority requesting Ministry of Social Affairs munication between the local completion of a certificate. ● Marie Munk Jensen, authorities and general practition- The application can be sent to Ministry of Finance ers and between the local authori- a GP or to a specialist in pri- ● Anne Marie Nielsen, ties and specialists both in hospi- vate practice. Esbjerg Local Authority tals and in private practice. 2. The recipient sends relevant ● Claus Nielsen, National Asso- LÆ forms are used in many information back to the local ciation of Local Authorities areas in municipal administration, authority on a certificate. ● Lars Nielsen, for instance in connection with Odense Local Authority voluntary early-retirement pen- The purpose of the LÆ form ● Mette Brøsted Nielsen, sion and sickness benefit. Elec- project is to make it possible to Esbjerg Local Authority tronic versions of the forms are a carry out both steps one and two ● Jens Parker, General Prac- natural part of doctors’ practice electronically. titioner, Copenhagen systems, but at present the forms ● Charlotte Henius Meier, Nat. are not sent electronically. Timetable Assoc. of Local Authorities The LÆ forms are standard- ● Morten Elbæk Petersen, The ised by the certification commit- April-Oct. 2003: Pre-analysis. Public Healthcare Portal tee of the Danish Medical Asso- November 2003: Start-up of ● Marianne Rosted, ciation, which consists of repre- technical pilot project. Aalborg Local Authority ● Kurt Samsø, Århus Local Authority Form Healthcare Healthcare ● Dorte Schwartz, server portal DIX Copenhagen Local Authority ● Lene Bilslev-Jensen, Ministry of Finance

● Lars Hulbæk, MedCom ● Dorthe Skou Lassen, Local County Internet authority MedCom

●

Medical practice Local authority Doctors’ Dan Net Medical practice system County Medical practice Medical practice ● KMD ● network ● ●

Local authority Medical practice County

The LÆ form project is intended to prepare the way for the electronic ● The partici- exchange of more of the forms used in the healthcare sector. The project is pating municipalities are: testing integration between the basic systems of the healthcare sector via a Aalborg, Århus, Esbjerg, central form server, which is accessed through the Healthcare Portal and Odense and Copenhagen the HealthcareDIX. 24 MedCom IV – status, plans and projects

Commentary

Co-operation and coherence Ejgil W. Rasmussen, Mayor Chairman of the National Association of Local Authorities

“Good co-operation between healthcare professionals in local authorities and counties is vital if we are to be able to make a coherent effort, particularly in relation to the elderly and in community healthcare in the

Photograph: Søren Wesseltoft Fotografi Photograph: Søren Wesseltoft local authorities,” says Ejgil W. Rasmussen, Chairman of the National Association of Local Authorities. “Unfortunately, far too often we see failure of communication when a person moves between the various bodies involved. Electronic communication between the parties may help towards them all being updated for example on a person’s insulin treatment, so that the home care service healthcare service can implement the necessary cost changes or so that the necessary action plan reaches all the parties who are concerned with the person. The National Association of Local Authorities has therefore actively re-entered the MedCom co-operation. In line with the local authorities having reached almost 85% coverage of electronic care records, the opportunities for electronic co-operation have substantially increased. And new areas are appearing in the fields of healthcare and vulnerable children and adolescents. Here it is important that the experts become aware of any failures as early as possible.”

Perspective

The IT Lighthouse’s local authority-medical practice communication

The IT Lighthouse project “Exchange of information in the healthcare sector” comprises a range of communication flows between the care system of Aalborg Local Authority and four general practitioners with four different doctors’ systems. It specifically relates among other things to communication on home care status, prescription renewal and correspondence.

Home care status: Regular updating of the doctors’ system with information on services provided by the local authority to the patient/client. Prescription renewal: Prescription renewals directly from the medication card of the care system to the doctors’ system. Correspondence: Patient-attributable, but non-structured exchange of information.

In April 2003, the statistics for communication between the local authority and the four doctors showed that 14 correspondence messages, 2196 messages on home care healthcare status and 212 prescription renewals were sent in the course of the month. The project is being carried out under the project management of Aalborg Local Authority. Further information can be found at: http://www.detdigitalenordjylland.dk/index.php/m/142 Hospitals and healthcare communication 25

The hospitals and healthcare communication

● MedCom’s SUP project has The XML EPR communication From hospital resulted in participating coun- project is essentially based on ties having established extract the experience acquired in Med- to hospital systems and transfer of EPRs Com’s present communication and patient data to a county/ projects with the primary sector, inter-county SUP database/ while the SUP project is based The aim behind MedCom’s hos- browser, from which secure on a similar project carried out pital projects is to support the Internet access to relevant by the counties of Vejle, Viborg electronic communication of internal and external users is and Århus. patient data between hospitals in established. different counties. No nation-wide communication The Hospital Project Managers Group between hospitals MedCom’s two hospital projects ● Finn Mathiesen, Today it is possible to carry out are co-ordinated by the Hospital Danish Society of Radiology EDI communication between Project Managers Group. ● Lisbeth Nielsen, any hospital and any medical Association of County Councils practice, regardless where in the ● Karin Argir, Capio Diagnostik ● Sanne Nørgaard, country the hospital or medical ● Lone Behnfeld, CSC Scandihealth practice is located. It is not, South Jutland County ● Helle Stockfleth Olsen, however, possible at present to ● Hans Henrik Bøttger, Statens Serum Institut carry out EDI communication Århus County ● Jan Petersen, between hospitals in different ● Anne-Marie Falch, National Board of Health counties. North Jutland County ● Jørgen Hjelm Poulsen, Danish The projects are intended to ● Ole Filip Hansen, Society for Clinical Biochemistry support the introduction of EPR Viborg County ● Jens Peder Rasmussen, systems in the hospitals and ● Morten Hansen, Vejle County Systematic ensure that information can be ● Lone Hassingboe, ● Kim Østerbye, Ribe County exchanged between IT systems in North Jutland County treatment units in different coun- ● Hans Erik Henriksen, IBM ● Karin Demkjær, MedCom ties – and therefore also to sup- ● Svend Holm Henriksen, ● Lars Hulbæk, MedCom port the communication between Odense University Hospital ● Gitte Henriksen, MedCom treatment units and other parties ● Søren Rosenørn Jakobsen, ● Henrik Bjerregaard Jensen, within the hospitals and between Acure MedCom hospitals in the same county. ● Michael Johansen, B-DATA ● Ib Johansen, MedCom The objective is that by the ● Jørgen Schøler Kristensen, ● Jens Rahbek Nørgaard, end of 2005: DADL MedCom ● Per Wagner Kristensen, DADL ● Claus Duedal Pedersen, ● the XML communication ● Dorthe Skou Lassen, MedCom project has resulted in large- Funen County ● Iben Søgaard, MedCom scale nation-wide use of all ● Søren Lorentzen, relevant MedCom messages Frederiksborg County for communication between hospitals. 26 MedCom IV – status, plans and projects

Taken together, the two way as has been done for Health’s national G-EPR devel- projects will signify a marked communication with the pri- opment, which in the longer improvement in electronic com- mary sector. term is intended to result in sub- munication: stantially more uniform and ● MedCom’s SUP project will advanced EPR systems in the ● The XML EPR communica- provide easy and unimpeded Danish healthcare sector. tion project will boost the browser access to record data MedCom’s XML EPR stan- efficiency of daily routine across hospitals and internally dards will therefore be broadened communication between the for the large groups of doctors in the autumn of 2003, so that treatment units of the hospi- and nurses who are not using they are prepared for the com- tals and between these and the EPR and PAS systems munication of the corresponding the clinical diagnosis units in concerned beforehand. messages as EPR systems based the form of referrals, reports, on G-EPR are introduced. discharge summaries, labora- The projects are co-ordinated tory results etc., in the same with the National Board of

Laboratory communication between counties With the introduction of the have developed a module, automatically into the cumula- “Good Laboratory Results” so that RPT01 – clinical bio- tive reply schema of the local and common IUPAC analysis chemistry results can be laboratory, immediately after codes in all the counties and received directly from other approval in the service labora- national laboratories, it laboratories. tory. Without any manual became possible to exchange Samples which are forward- keying at all. The same laboratory results between the ed from the local laboratory MedCom standard, RPT01, clinical biochemistry systems for analysis in an out-of- which is used to send results of the various counties. county or service laboratory to medical practices is used. CSC-Labka and B-Data are received and introduced

RPT01 between counties, April 2003

From / To N. Jutland Viborg Århus Ringkøbing Ribe Vejle S. Jutland Funen Zealand W. Storstrøm Roskilde Frederiksb. CHC Copenhagen Bornholm KPLL SSI Greenland North Jutland 33 Viborg Århus 534 32 Ringkøbing Ribe 325 Vejle 88 South Jutland 266 Funen West Zealand 12 Storstrøm Roskilde Frederiksborg CHC Copenhagen Bornholm KPLL SSI 1 1398 47 Medilab 66 227 The hospitals and healthcare communication 27

Primary sector Medical Nursing Home Specia- practice homes care lists The XML EPR c. 13% project

Other The XML EPR communication hospitals project is working to adapt Med- c. 10% Com’s communication standards for the primary sector to communication of the corresponding messages within the hospital and Clinical service Clinical Other clinical between hospitals – that is to say c. 40% treatment unit treatment to the communication of refer- units rals, summaries, laboratory EPR c. 23% results etc. Other service These messages are used at c. 13% the rate of 150-250 per hospital bed per week in the hospital’s HOSPITAL treatment units and consequently tie up substantial resources: on Administration Communication needs of average around 10% of total c. 4% treatment units working time in the hospital. The objective is that by the end of 2005 the XML EPR G-EPR descriptions of important areas project at national level has led of work, e.g. image diagnostics. to extensive use of all relevant The development of EPR The basic structure is aimed MedCom messages for commu- systems is to be based on the at making EPR systems more nication internally in the hospi- national G-EPR, Basic structure structured and uniform at tals and between hospitals – to for Electronic Patient Record. G- national level. At the same time, the same extent as is the case EPR describes a common model more uniform use of data will today in the primary sector. for documentation of the clinical make it easier to exchange work process and will gradually information between the EPR be expanded to include detailed systems. A G-EPR reference

Perspective

XML EPR of the contents of paper records. That is to say, laboratory results, X-ray results, referrals etc. can be com- Hospital paper records are full of forms which it municated in MedCom’s EPR standards. would be advantageous to exchange electronically. MedCom’s standards cover by far the greater part ■ Electronic ■ Paper

Funen County 0 200 400 600 800 1000 Århus County 0 500 1000 1500 1 Within department 2 Within hospital 2 Within hospital 3 Hospitals within county 3 Hospitals within county 4 Hospitals betw. counties 4 Hospitals betw. counties 5 Primary sector 5 Primary sector 6 Other 28 MedCom IV – status, plans and projects

implementation has been started ject is based on existing IT Implementation of up which comprises a test data- systems and on communication XML EPR base for the testing of G-EPR. between the IT systems used in In line with the introduction the healthcare sector today. The methods and timetables for of EPR systems based on the introduction of EPR systems G-EPR, new ways of obtaining OiO – Public differ widely in the individual more flexible access to data in information Online counties and CHC. For this the healthcare sector will arise. reason, the XML EPR communi- G-EPR thus creates the frame- MedCom’s XML documentation cation project is divided into two work for the long-term develop- is drawn up in accordance with implementation periods: Group ment of EPR systems and joint the guidelines for OiO – Public 2004 and Group 2005 – and use of patient systems in Den- Information Online (see into three communication pack- mark. The XML EPR communi- www.oio.dk/xml). OiO is a col- ages: the Primary Package, the cation project is to be viewed as lective concept for the documen- Hospital Package, the Clinical part of a realistic option for com- tation of standards for the public Package. munication between EPR sys- sector drawn up by the Ministry It is intended that every coun- tems, based on a joint G-EPR of Science, Technology and ty or CHC chooses which com- structure. Development in co-operation munication packages and which While G-EPR necessitates the with the National Association of implementation periods are best development and introduction of Local Authorities and the Asso- suited to its own IT strategy. a new type of EPR systems, the ciation of County Councils. Each communication package XML EPR communication pro- covers fundamental communica-

Primary Primary sector Medical Nursing Home Specia- sector Medical Nursing Home Spec Primary Medical Nursing Home Specia- practice home care lists practice home care list sector practice home care lists

Other Other Other hospitals hospitals hospitals

l service Clinical Other Clinical Clinical Other Clinical service Clinical Other treatment clinical service treatment clinical treatment clinical treatment treatment unit treatment unit units unit units units EPR EPR EPR service Other service Other service HOSPITAL HOSPITAL HOSPITAL

istration Administration Administration

Hospital Package Clinical Package Primary Package

Between hospitals and EPR and PAS: Between radiology departments, Between EPR and medical practice – XML Discharge summary EPR and any PAS: possibly via PAS: XML Outpatient summary XML Image diagnostics summary XMLEDI Discharge summary XML Hospital referral XML Image diagnostics referral XMLEDI Outpatient summary XML Booking result XMLEDI Hospital referral XMLEDI Correspondence letter Between laboratories, EPR and any XMLEDI Booking result XML Personal master data PAS: XMLEDI Correspondence letter XML Medication data XML Laboratory results XML Pathology results Between EPR and home care – XML Microbiology results possibly via PAS: XML Immunology results XMLEDI Admission advice XML Laboratory request XMLEDI Admission result XML Pathology request XMLEDI Discharge advice XML Microbiology request XMLEDI Warning of completion of treatment XMLEDI Correspondence letter The hospitals and healthcare communication 29 tion needs between treatment Timetable for the XML EPR units and other major parties: communication project ● The Hospital Package covers communication between hos- MedCom IV 2002 2003 2004 2005 pitals and mutually between 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 treatment units. XML EPR project Hospital group ● The Clinical Package covers communication between Prim. and clin. packages G-EPR co-ordination treatment units and labora- Comm. study tories and radiology depart- Technical group ments. Healthcare adjustment ● The Primary Care Package XML standards covers communication Supplier bids TK System development between treatment units, Testing medical practices and the Dissemination group A home care service. Dissemination group B Hospital Package The Correspondence Letter mes- G-EPR adjustment sage should be included in all XML standards Supplier bids TK communication packages, as this System development message is already implemented Testing today in all doctors’ systems and Dissemination group A is in addition expected to be im- Dissemination group B plemented in all local-authority care systems. The Correspon- the counties are already using at which have implemented the dence Letter will therefore be the present in the areas concerned. same communication packages only message capable of being Communication of the Clinical both within the country and at sent between almost all parties in Package, for example, will in- national level. the healthcare sector, apart from volve the county’s laboratory The XML EPR communica- laboratories and radiology systems, radiology systems and tion project is equivalent in size departments. EPR systems. and implementation to the pro- Depending on which commu- After the implementation jects carried out in the primary nication packages the individual period, it will be possible to sector since 1994. The project county/CHC chooses to take communicate the messages con- may involve roughly the same part in, it will be necessary to cerned between all hospital number of IT systems and involve the IT suppliers which departments and all hospitals require the development of

What can be done more easily?

● The whole communication packages are disseminated at once – greater impact and overview. In the primary sector the individual messages are introduced individually over the years. Dissemi- nation of whole communication packages on a large scale will make both system development and implementation substantially more efficient. ● Prior testing bypasses MedCom. In the primary sector, a number of pilot projects were carried out in 1994-1996 which were to test communication for the first time. Today it is possible to carry out prior testing of both the sending and receipt of messages, so that it is possible to start directly with dissemination. ● Mandatory positive and negative acknowledgement safeguards logistics. In 2002, mandatory acknowledgement for the primary communication was introduced. This eases administration and fault-tracing, and it is consequently expected to be used on the hospital side from the outset. 30 MedCom IV – status, plans and projects

roughly the same number of

Primary Medical Nursing Home Specia- communication interfaces. On sector practice home care lists the basis of experience from communication in the primary Unchanged sector, however, it is possible to Other hospitals EDIFACT with substantially improve efficiency primary sector. and simplify implementation and dissemination. XML between Clinical Clinical Other In a single area, however service treatment clinical hospitals in diffe- implementation is more com- unit treatment rent counties, plex. In the primary area EDI- units Other EPR internally FACT is used as communication service between depart- syntax, while XML syntax is used HOSPITAL ments and in the hospital area. For this between hospitals Admini- reason it is necessary to convert stration in the county. the EDIFACT message of the Primary Package to XML syntax. XML between and in hospitals. EDIFACT to the primary sector. Almost all IT suppliers have XML EDIFACT conversion of the primary package opted to take part in the communication with the primary sector. Provided this remains the Primary Medical Nursing Home Specia- sector practice home care lists case for communication in the Full coverage hospital area, the project will with EPR and altogether comprise over forty Other hospitals S&A. Only 50% clinical IT systems. ECR in home care

Full coverage Clinical Clinical Other service treatment clinical with PAS. Only unit treat- Participants ment 7% EPR in treat- units Other EPR ment units With the exception of service Ringkøbing, all counties HOSPITAL Full coverage west of the Great Belt have with LIS and RIS Admini- decided to take part in stration MedCom’s XML EPR project. Counties east of Use of Clinical IT today: Virtually full IT coverage everywhere – the Great Belt have not yet however only 7% EPR in treatment units and 50% ECR in home taken a decision in the nursing. autumn of 2003.

Number of interfaces if all communication packages are implemented

Number Interfaces Interfaces systems per system total

EPR systems 8 35 280 PAS systems 6 25 150 X-ray systems 8 6 48 Laboratory systems 6 8 48 Blood-bank systems 4 4 16 Pathology systems 4 6 24 Microbiology systems 5 6 30 Total 41 90 596 The hospitals and healthcare communication 31

Dose dispensing and pharmacy systems currently used in those phar- new prescription macies that can dose-pack. In connection with a planned review of the MedCom is taking part in the development of a EDI prescription in the autumn of 2002, a wish new message for the electronic exchange of dose was expressed by the Dose Dispending Group information between pharmacies. XML mes- for it to be possible to state on the prescription sages have now been developed for this area whether it is desired that a drug is dose- under MedCom, so that both information on dispensed. medication which can be dose-dispensed and Following an agreement with the Danish billing information can be transferred electroni- Medicines Agency this is now possible, and Med- cally between the pharmacies. Com has produced a new version of the EDI- The messages were tested in the first quarter FACT prescription with associated examples of of 2003 in a pilot project between the various text and has sent it out to all relevant suppliers.

The doctor The phar- The pharmacy sends the dosage card to the The packing phar- sends a macy packing pharmacy macy sends an prescription receives the acknowledgement, to the prescription confirmation of pharmacy and issues a The pharmacy sends the dosage card to the order and bill to dosage card doctor following a request from the latter the pharmacy

To support the work of IT suppliers on XML EDIFACT conversion, MedCom has developed a Web-based converter, available via www.medcom.dk or directly at the address http://web.health-telematics.dk/xmledi 32 MedCom IV – status, plans and projects

Commentary

Digitisation supports quality and coherence Vagn Nielsen, Head of Department, Ministry of the Interior and Health, Chairman of the MedCom Steering Group

With the startup of MedCom’s XML EPR communication project, the focus has been on the communication of referrals, summaries, laboratory results etc. within the hospitals and between the hospitals. The routine communication of these message types is quite extensive in the hospital sector, and it is therefore expected that the digitisation of this area will contribute to a major boost in the quality and coherence of patient progressions. I would like to emphasise the fundamental need for the project to be in agreement with the national standardisation work (Basic structure for Electronic Patient Record) taking place under the National Board of Health. Against this background, it is anticipated that the project will also boost the dissemination in the hospital sector of electronic patient records based on G-EPR, Basic structure for Electronic Patient Record.

Perspective

The XML EPR communication project and G-EPR

It has been decided that the development of EPR systems is to be based on the national G-EPR, Basic structure for Electronic Patient Record. G-EPR describes a common model for documentation of the clinical work process and will gradually be expanded to include detailed descriptions of important areas of work, e.g. image diagnostics. The development of G-EPR is expected to take place over a prolonged period, as all the elements in the basic structure are not yet ready. A number of solutions partially based on G-EPR will therefore be put into use and developed gradually as the individual elements in the main structure are completed and migration to a full EPR based on G-EPR takes place. All these systems and their variants should be assured of communication coherence and co-existence. It is intended that this coherence is ensured by:

● MedCom IV’s XML EPR standards being assured of G-EPR compatibility in the development of XML-extended standards, which in addition to the content of present-day elements are expanded to include G-EPR elements, as these are developed. ● G-EPR migration solutions incorporate communication solutions based on XML EPR.

The XML EPR communication project is therefore to be seen as part of a realistic option for communication between EPR systems, which is based on a joint G-EPR structure. The hospitals and healthcare communication 33

MedCom’s SUP SUP PAS: DB SUP project Internet EPR ➡ Internet browser server The purpose of MedCom’s SUP project is to provide access to viewing PAS and EPR patient SUP MedCom records via a fairly general Inter- extract program XML standard net browser – both within the county and across county bound- SUP – Standardised Extract of Patient Data aries. After the project has been carried out, it is expected that the basis. Simple Internet lookup fairly general Internet browser. county/CHC has put into effect: will often be more appropriate The SUP database/browser for such groups of personnel can either be established as a ● electronic SUP extracting of than having to use the complex county database or jointly patient record data from all production systems concerned between several counties. departments that use the IT directly. All users with secure Internet systems mentioned It is intended that every coun- access can gain access to an SUP ● Internet access for relevant ty/CHC chooses which EPR database in the same way as healthcare professionals in and/or PAS systems are to be access is obtained to other web- their own county and other implemented in which imple- sites on the Internet. counties who have a legiti- mentation periods, on the basis On the website, the user is mate need justified in health- of what fits in best with the asked for his password – and if care terms for the information county/CHC’s own IT strategy. the user is set up in the SUP The SUP project means that database, he can obtain an over- The project is intended to pro- extract programs are established view of the extracts of the patient vide access to viewing selected from the PAS and EPR systems record contained in the database patient data in the PAS and EPR of the county. by searching on the patient’s civil systems of others – whether these These extracts of patient data registry (cpr) number. are used elsewhere in the same are transferred via a nation-wide Continued browsing in an county or in other counties. MedCom XML standard to an SUP record is illustrated below In addition, a major user SUP database/browser, which and proceeds according to the group will be doctors and nurses makes it possible to gain access same principles as are normally who are not users of the PAS to viewing selected record data applied on the Internet. and/or EPR systems on a daily and patient information via a Use of the SUP browser is

The user chooses record D and obtains an overview The user chooses note overview – and reads a note. of the contents of the record. 34 MedCom IV – status, plans and projects

logged in the same way as the ● users who have access to SUP data. The project will be part of use of other patient systems. Use extracts from records on the the Public Healthcare Portal. is checked by the county’s securi- SUP servers of others have to The aim of MedCom’s project ty organisation in the same way be able to use PC installations is to expand the SUP solution to as the use of other IT systems – that have installed VPN all the participating counties. It with the difference that access by access to the secure Health- has not yet been clarified external users also has to be careInternet. whether the individual counties checked. in this context will put into Timetable effect their own SUP solutions or The closed join forces on common develop- HealthcareIntranet Most counties in western Den- ment and operation. mark have decided to take part With a view to speeding up A closed, nation-wide Health- in MedCom’s SUP project. commissioning of the SUP careIntranet (SundhedsIntranet) The aim of the project is to system and minimising risk and is being constructed in 2003 as provide access to the EPR and costs, it is expected that all the part of MedCom’s Internet PAS patient data of the counties participating counties will join strategy. The HealthcareIntranet via a general Internet browser. forces for a common SUP solu- is based on linking together For this to be possible, regular tion in a start-up period up to existing county intranets in set- extracts of patient data from the autumn of 2004. The start- ting up VPN connections to a EPR and where appropriate PAS up period is based on a solution nation-wide node (the Health- systems to the SUP system have currently being put into practice careDIX – SundhedsDIX). The to be established. in Vejle. node is operated by UNI-C. The project is based on the In this event, it is expected The communication of SUP existing SUP project, which is that: extracts is expected to take place being carried out by the counties in the use of the nation-wide of Vejle, Viborg and Århus. In ● the SUP solutions of the HealthcareIntranet in such a way this project it is planned that a counties can be implemented that Version 2 will be put into effect with access via the Healthcare with extracts of record data from Portal at the beginning of ● SUP extracts from EPR and Vejle County. The project is March 2004. PAS systems are transferred to based on an SUP database de- ● programming of SUP extract the SUP database via the veloped by IBM and an SUP systems from the counties’ HealthcareIntranet. browser solution developed by B- EPR and PAS systems can start at the beginning of December 2003. ● Vejle County puts into effect SUP extracts with access via Healthcare the Healthcare Portal in mid- DIX November 2003. ● completed tender documents are available for extract suppliers at the end of October 2003. ● costs in the establishment and operation of the common solution have been clarified in mid-September 2003.

County Vejle County Network County Network The SUP project uses the closed HealthcareIntranet The hospitals and healthcare communication 35

Timetable for SUP start-up project

2003 2004 SUP Start-up project Aug Sep Oct Nov Dec Jan Feb Mar Apr Maj June July Aug Sep Oct Nov Dec Counties’ attitude to SUP Start-up project 19 Vejle SUP in operation via Healthcare Portal Overheads and organisation of joint SUP solution 8 Completed tender documents for extract systems 30 Bids received from suppliers 27 Adjustment of existing SUP DB/Browser Extract systems: Development Implementation and mapping Testing Dissemination: Users joining DIX and SUP via portal Improvements and possible invitation to tender

Participants Project manager EPR system PAS system North Jutland County Anne Marie Falch With the exception of Viborg County Ole Philip Hansen B-Data Ringkøbing, all counties Århus County Hans Henrik Bøttger AAA Vejle County Morten Hansen IBM + CSC west of the Great Belt have South Jutland County Klaus Bo EPJi GS Åben decided to take part in Ribe County Kim Østerbye Accure/Nora MedCom’s SUP project. Funen County Dorthe Skou Lassen MediCare FPAS 36 MedCom IV – status, plans and projects

International activities

Work was also done in other France: United Kingdom: European countries in the nineties on the development of EDI- EDISANTE – L’échange UkeHA – UK based communication in the de données informatisé eHealth Association. healthcare sector – based on the dans la Santé. Web-based Electronic forum for healthcare same technological foundation as exchange of healthcare data. This communication in the United in Denmark. association of players in the Kingdom. UkeHA represents all The UK, the Netherlands and healthcare area works to develop organisations and individuals the Scandinavian countries have and promote use of the Internet with an interest in the develop- been working on large, EDI- to pass on healthcare data. ment of eHealth – electronic based healthcare data networks www.edisante.org healthcare communication in the since the start of the nineties. United Kingdom. Similar projects and national Netherlands: www.ukeha.org.uk strategies have seen the light of day in all European countries in Nictiz – Nationaal ICT Czech Republic: recent years. No other countries Instituut in de Zorg. have, however, achieved a level of Nictiz is attached to the Dutch Medtel. Medical Tele- use that comes close to that in Ministry of Health and is aimed matik is an independent Denmark. Co-operation organi- at disseminating electronic non-profit organisation which sations have also been established patient records and ensuring aims to ensure electronic health- in IT within the healthcare sec- electronic communication in the care communication in the tor in other European countries Dutch health service. Czech Republic and between the – organisations that are more or www.nictiz.nl Czech Republic and other less similar to MedCom. On the European countries. Medtel is initiative of the Swedish Care- Italy: financed by the Czech Ministry Link, these organisations have of Health. www.medtel.cz been brought together in an FIASO – Federazione organisation known as ELO, Italiana Aziende Sweden: which at present comprises: Sanitarie e Ospedaliere. Association for healthcare and Carelink – the Swedish Denmark: hospital operation in Italy. network for healthcare FIASO puts the citizen at the communication. Carelink is a MedCom. centre in relation to the services national co-operative body, the www.medcom.dk that can be obtained through the aim of which is to promote the health service. www.fiaso.it use of IT in the Swedish health Finland: service. www.carelink.se Norway: STAKES – Research Germany: and development cen- KITH – Informasjons- tre for the social and health- teknologi for et bedre ATG – Aktionsforum care area. helsevesen. Information techno- Telematik im Gesund- The task of STAKES is to pro- logy for a better health service. heitswesen. Action forum for mote welfare and health. The The principal aim of KITH is to healthcare telematics. The aim of objective is for the whole Finnish ensure that information and com- ATG is to integrate telematics as population to have equal access munication technology are used an important tool in the health to effective social and healthcare to achieve effective and reason- service for the development of services of high quality. able co-operation and develop- up-to-date treatment and care of www.stakes.fi ment in the health service. high quality. www.kith.no www.atg.gvg-koeln.de International activities 37

– and vice-versa. Ideas and ex- PRIMACOM International periences from similar projects in virtually every EU member state PRIMACOM – PRIMAry Care interaction have had a great impact on the Physicians COMmunication situation and the prospects for Network carried out and evaluat- the use of information and com- ed pilot projects in Hungary and The Danish development work munication technology in the Slovenia with western European took on an international dimen- Danish health service. At the co-operating partners. This work sion as long ago as the early same time, we find that the comprised: nineties. The background was a Danish development work has wish on the part of the Danes to also left its mark in the way oth- ● development of the necessary enter into close co-operation er countries have chosen to tools and guidelines with related communication exploit the potential of the new ● establishment of contact projects abroad in order to gain technology. between software firms in and provide inspiration. In brief, Denmark, Italy, Hungary and the intention was to achieve Slovenia synergies in the interaction International ● electronic contact between between these projects across healthcare professionals national boundaries. projects ● communication of structured Experience has shown that the messages to ensure re-use of effort put into international co- 1996-1999 data in different systems, operation was both correct and which are based on European necessary. There are countless standards, existing infrastruc- examples of how experience from CoCo ture and regional systems a national project has been of Coordination and Continuity in benefit at the international level Health Care was the main WISE heading of the CoCo project, which brought together 11 13 organisations in 10 EU mem- regional project organisations in ber states joined forces in the Websites 10 countries. WISE co-operation – Working The majority of the projects in Synergy for Europe – to MedCom: focused on the communication exchange knowledge and experi- www.medcom.dk to and from the GP, in the form ence in efforts to establish and of written messages – prescrip- expand regional healthcare data CoCo: tions, referrals, discharge letters, networks in Europe. WISE was a www.medcom.dk/dansk/coco requests etc. However, CoCo kind of umbrella for EU projects PrimaCom: also covered projects relating to concerned with regional health- www.primacom.dk multimedia communication care data networks, including between the primary and sec- CoCo. The idea behind WISE Picnic: ondary sectors. was to view the regional and www.medcom.dk/picnic The building-blocks in CoCo national effort in healthcare were the regional projects. CoCo communication in an inter- JUST: passed on standards, guidelines, national perspective and broaden www.justweb.org test systems and other services to experience and solutions at ciTTis: the regions. Communication was European level. WISE focused www.cittis.dk carried out and tested in pilot on User Group Support, Synergy projects. The pilot projects Promotion and External Promo- Open ECG: emphasised that the regional net- tion. One of the results of the www.openecg.net works could be slightly different project was the book “Building with regard to size and aim, but Regional Health Care Networks HC-INTEREST: that they should be built up on in Europe”, published by IOS www.hc-interest.dk the basis of the same standards Press. and the same structure. 38 MedCom IV – status, plans and projects

Commentary

A development of national as well as international significance Commentary by Ilias Iakovidis, Ph.D., Deputy Head of Unit-eHealth, European Commission, DG Information Society

Within the vast working area of eHealth, which focuses on application of information and communication technology, the fast and reliable communication of vital health data has a high priority. Electronic communication is the cornerstone of effective and quality health services and is highly advantageous not only to professionals but certainly also to the patients. The EU is supporting initiatives in this field during the last 15 years and has in different ways supported a cross border co-operation on eHealth applications with the ultimate objective of supporting citizen centred health care. MedCom, the Danish health data net, has consistently participated in the international co-operation and has contributed to the exchange of experience and inspiration. At the same time, MedCom has managed to initiate a development of the Danish health data net, which has been recognised with honourable mention as the “best practice” example in the recent eHealth 2003 Ministerial Conference. MedCom and the Danish health data net have acquired valuable experiences that should play part in the development of future eHealth systems and services not only in Denmark but also to serve as example to all the countries that are preparing their deployment strategies. The European Commission follows new MedCom projects with great interest and it is very gratifying that the Research and Development programmes of EU is part of the success of MedCom.

PICNIC mented in the pilot projects that International offer PICNIC – Professionals and projects Citizens Network for Integrated ● telemedicine collaboration Care. The EU project involves services 2000-2002 regional system suppliers, tech- ● shared record services nology centres, companies and ● reimbursement services universities in nine EU member Propractition states. JUST The Propractition project focuses The objective of PICNIC is on the continuing training of to support/assist the regional sys- Fifteen partners from seven healthcare professionals using the tem suppliers in implementing countries are taking part in the Internet and websites. The objec- the next generation of secure, JUST project. JUST supplies IT tive of Propractition is to teach user-friendly healthcare data net- support for training in action to doctors to co-operate, so that works and to bring together the be taken in the event of acci- two doctors each in their own European market for healthcare dents, among other things in the hospital, for example, can reach telematics services. form of a CD with an interactive agreement on diagnosis and PICNIC provides/offers multimedia course and a website. treatment in difficult cases. Open Source components for Both aim to teach volunteers Web services for the healthcare how they can help when they data network and a structure for encounter cardiac arrest, an local healthcare data networks. asthma attack or a person who is Components have been imple- unconscious. The contents of the International activities 39

CD comply with international OpenECG ● tested the EHR messages in a recommendations and are used pilot project where medical by several European organisa- OpenECG aims to increase messages were generated/com- tions in conjunction with first- knowledge of and disseminate bined on the basis of the basic aid courses for volunteers. the use of the electronic ECG elements and the models standards. OpenECG brings together representatives from International national cardiology centres, hos- Nordic pital directors and producers of projects and dealers in ECG equipment. co-operation An open ECG portal will help 2002-2004 producers and system integrators in creating equipment and soft- In 2001, Nordic co-operation ware which together can ensure was initiated between organisa- ciTTis smooth exchange of electrocar- tions working on healthcare data The aim of this INTERRREG diograms. System managers and networks at national level. KITH project is to develop a structure users can find the necessary from Norway, CareLink from that can bring together all forms information to draw up suitable Sweden, STAKES from Finland, of telemedicine solutions, so that and clear specifications in con- the Icelandic Ministry of Health they can be used in the collabo- nection with the purchasing of and MedCom have since met ration between healthcare profes- new IT systems via the portal. twice a year. sionals across all forms of tele- The aim is to develop experi- medicine solutions. Co-operation HC-INTEREST ence and establish projects across in telemedicine involves the use boundaries. In several cases of a protocol which shows the The Nordic project knowledge of communication data stream in connection with HC-INTEREST – Health Care solutions or the infrastructure in the co-operation between health- record INTEroperability and healthcare data networks has care professionals. The clinical Record STructure – has created been re-used in another Nordic documents and images are trans- the basis for Electronic Health country. ferred by means of European Care Records (EHR), which can standards. be used in all the Nordic coun- A large part of the INTER- tries. The objective is to exchange REG project will focus on the and consequently re-use informa- organisational changes that fol- tion in different EHR systems. low when it is possible for co- The project is based on Euro- operation to take place across pean standards for EHR models organisational and geographical and messages and combines these boundaries. The project will with national enhancements, so develop guidelines on how best that models and messages suit to implement the new IT co- Nordic needs. Medical treatment operation service. was used as a test area on the The IT co-operation service is basis of the Danish National an environment where it is possi- Board of Health model. The ble to carry out examination, HC-INTEREST project has monitoring, treatment and administration of patients using ● produced proposals for the direct access to expert knowledge basic elements of a har- and patient information, regard- monised EHR structure less where the patient or the ● developed operational EHR relevant information is in purely messages on the basis of the geographical terms. proposed basic elements in the structure and terminological standards 40 MedCom IV – status, plans and projects

Perspective

Nordic Health care Network group Since the beginning of 2000, there has been ever closer co-operation between the organisations in the five Nordic countries which are working on the application and implementation of IT solutions and electronic communication in the health service. Norway, Sweden and Denmark are all involved in the work of establishing nation-wide closed IP-based healthcare data networks. This firstly led to a number of bilateral meetings, exchange of documents and experience, to the great satisfaction of all the participants. Plans for IP-based healthcare data networks became reality in the spring of 2003. In Sweden, the Swedish Sjunet network has already gone through its second tendering round, and is a well- established network in which all the county councils (landsting) take part. In Norway, five regional networks have been set up following the re-organisation of the healthcare sector into five regions, and it is planned that these networks will be linked together. In Denmark, MedCom is well under way with a large-scale pilot project in which all the counties, pharmacies, Copenhagen Local Authority, a number of GPs and other parties are connected to a closed network. Broadly speaking, Norway has focused on developing telemedicine, Sweden on establishing a secure IP- based infrastructure and Denmark has developed and implemented EDIFACT communication on a large scale. Against this backdrop, the first meeting of the Nordic Health care Network was held in conjunction with the Vitalis conference in Gothenburg on 4 March. It was decided at the meeting to form a permanent Nordic working group and make the group a sub-group of NTA.

Aims of the Nordic Health care Network

The establishment of the Nordic Health care Network serves several purposes, but overall the network is intended to foster greater exchange of experience and ideas between the Nordic countries. Experience to date has shown that there are great similarities and interesting differences between the structure of the health service, the use of IT and the development and implementation of IT in the health service in the Nordic countries. The aim of the Nordic Health care Network is to utilise these similarities and differences to:

● ensure the greatest possible re-use of solutions across national and regional boundaries in the Nordic countries ● assist in creating an open and homogeneous Nordic market for IT solutions for the health service ● create contact and the possibility of exchange of experience between national and regional projects ● inform broadly about Nordic solutions and projects ● support the development of a Nordic market for healthcare services ● solve practical problems in connection with healthcare projects in the Nordic countries

Published in December 2003 by MedCom, Rugårdsvej 15, 2., 5000 Odense C. Editor: Lars Hulbæk, MedCom. Text: arki•tekst kommunikation. Layout/dtp: Christen Tofte. Printed in Denmark by: one2one. Print run: 1000. ISBN: 87-90839-67-6 2000-2002 inwhichallsenders dation project duringtheperiod MedCom carriedoutaconsoli- Good EDILetters Doctors Good EDIletters receiving MedCom capable ofsending/ Pattern at12September 2003 CTL PRE RUC REQ RPT REF No No Yes Yes Yes Yes Yes Yes DIS Yes Yes Yes Yes Yes Yes Yes Yes Version ofsystem Grant entitlementforspecialists edNegative acknowledgement Send Negative acknowledgement Recip. Prescriptionoldversion GP Send Send Laboratoryrequest Send Laboratoryresults Specialistreferral Recip. Recip. Hospitalreferral Send Specialistsummary Send Dischargesummary Recip. Message notpossible Message possible ’ systems Positive acknowledgement Neg. VANS acknowledgement Positive acknowledgement Prescr. neww. dose-d. Prescr. neww/odose-d. Specialists WebReq Microbiology request Pathology request Immunology results Cervix cytologyresults Microbiology results Pathology results Specialist referral Image diag.referral Correspondence letter Image diagnosticssummary On-call GPservicesummary Correspondence letter Physiotherapy summary Booking result Specialist summary On-call GPservicesummary Image diagnosticssummary Casualty summary Outpatient summary ’ s e. e. 50 021.0 585 05 01 14. 2002 05.07 rev.8 rev.7 undergone testingforeachindi- EDI Letters. messages asdescribedinGood concerned canuseMedCom’s approval meansthatthesystem went testingandapproval. The in thehealthcare sectorunder- and recipients ofEDImessages . . ..1- .33 24520A301164351.9.2 3.5 6.4 1.1 3.0 01A 5.2 0204 3. 3.93 15-4 1.5. 7.0 6.7 Æskulap All doctors’ systemshave Æskulap Win

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Patina 41 42 MedCom IV – status, plans and projects

What can the counties do now?

Overview of Green indicates that the Yellow indicates that the EDIFACT messages messages are underway and message has been started have been disseminated to and is being disseminated. in operation in more than 50% of possible the individual messages. The numbers in Red indicates that the counties and CHC the boxes indicate what message has not yet been percentage of messages are put into use. sent electronically.

Position Counties Lab. at 19 September 2003 m bing ø ø rhus Roskilde Frederiksborg CHC Copenhagen Bornholm KPLL SSI Capio North Jutland Viborg Å Ringk Ribe Vejle South Jutland Funen Zealand West Storstr

EDI-doctors % 949291828796988992868890817989 Spec. H doctors % 65 78 50 72 42 67 81 69 70 60 51 64 53 52 80 3 Discharge summary 94 92 91 82 65 96 98 89 92 86 88 90 81 79 89 4 Outpatient summary 94 92 91 82 65 96 98 89 92 40 88 10 5 0 89 5 Casualty summary 94929182096988992868890512089 6 Image-diagnostics summary 94 92 20 82 87 96 98 89 92 86 88 0 70 0 89 16 On-call GP service summary 949291828796988992868890817989 43 Specialist summary 52 66 38 30 65 55 70 55 52 45 41 46 41 40 68 50 Physiotherapy summary 12 13 15 18 15 17 25 15 12 12 13 14 12 13 16 49 Booking result 51 60 5 0 0 50 0 60 25 20 25 0000

1 Admission referral 65 26 0 70 65 51 74 59 20 51 60500 7 Image-diagnostics referral 65 65 10 51 74 59 22 51 00007000 44 Specialist referral 6 25 10 8555410413113

9 Clinical chemistry results 94 92 91 60 87 96 98 89 92 86 88 90 80 79 89 11 Pathology results 94 92 91 82 87 96 98 89 92 86 88 90 80 79 89 13 Clinical microbiology results 94 92 91 82 87 96 98 89 92 86 88 0 80 79 89 55 54 Clinical immunology results 94 92 0 78 87 96 0 89 0 86 88 00000

8 Clinical chemistry request 020000000000 00 0 10 Pathology request 0 32 0 0 0 63 0 54 0 0 10 45 0 0 0 12 Clinical microbiology request 0 32 0000000000000 0

14 GP billing 54 73 20 52 43 75 71 50 70 20 55 71 48 45 0 14 Specialist billing 39 43 13 33 21 25 58 25 50 26 24 27 21 36 0 15 Pharmacy billing 100 100 70 100 36 74 100 85 88 79 100 100 86 55 0 48 Dentist billing 12 4 6 15 12 27 9 32 18 1 22 30 17 27 0 47 On-call GP service billing 100 100 100 100 100 100 100 100 100 100 100 100 100 100 53 Physiotherapist billing 10 2 30 4 8 9 13 10 40 4 25 14 46 42 0 SSI billing 100 100 0 100 100 100 100 100 100 100 100 100 100 100 0 88 MediLab billing 100 100 100 100 100 100 100 100 100 100 100 100 0 94 KPLL billing 100 100 100 100 100

25 GP prescription 80 82 68 59 64 75 77 70 66 61 60 54 37 43 84 17 On-call service prescription 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Staff 43

Centre for Health Telematics

Centre manager Consultant Deputy Chief of Henrik Bjerregaard Lars Hulbæk Section Jensen MedCom Tove Lehrmann MedCom Mobile +45 4036 8615 FynCom Mobile +45 4036 8619 Lhf@ Mobile +45 4036 8618 hbj@ health-telematics.dk tle@ health-telematics.dk health-telematics.dk

Deputy Manager Secretary Consultant Ib Johansen Pia Reinhardt Juel Henning Voss MedCom Medcom International Mobile +45 4036 5620 Mobile +45 2066 8700 Mobile +45 3034 1555 ijo@ prj@ hvo@ health-telematics.dk health-telematics.dk health-telematics.dk

Secretary Secretary Secretary Anita Folleraas Annette Larsen Jennie Søderberg MedCom MedCom International anf@ ala@ Mobile +45 4026 6308 health-telematics.dk health-telematics.dk jsb@ health-telematics.dk

Consultant Claus Consultant Consultant Duedal Pedersen Dorthe Skou Lassen Niels Rossing MedCom MedCom/FynCom International Mobile +45 4036 8629 Mobile +45 4040 5402 Mobile +45 2178 2191 cdp@ dsl@ nr@ health-telematics.dk health-telematics.dk health-telematics.dk

Project assistant Consultant Consultant Gitte Henriksen Karin Demkjær Tove Kaae MedCom MedCom/FynCom International Mobile +45 2342 2256 Mobile +45 2320 2786 Mobile +45 2427 5739 ghe@ kde@ tok@ health-telematics.dk health-telematics.dk health-telematics.dk

Secretary Secretary Building assistant Iben Søgaard Karina Hasager Alis Jørgensen Medcom FynCom The Centre ibs@ Mobile +45 2612 0361 Mobile +45 5131 8566 health-telematics.dk khs@ health-telematics.dk

Consultant Consultant Jens Rahbek Lisbeth Jørgensen Nørgaard FynCom Medcom Mobile +45 2427 5739 Mobile +45 2482 1453 lij@ jrn@ health-telematics.dk health-telematics.dk MedCom IV – status, plans and projects

MedCom IV projects

Cph. County CHC Cph. Local authority KPLL

Infrastructure project Web lookup, laboratory Web requesting Web lookup, X-rays FUNEN COUNTY Rugårdsvej 15, 2.sal, 5000 Odense C Teledermatology Telephone +45 6613 3066, Fax +45 6613 5066 Hospital-local authority www.medcom.dk LÆ forms XML EPR Ministry of the Interior and Health Slotsholmsgade 10-12, 1216 Copenhagen K SUP Telephone +45 3392 3360, Fax +45 3393 1563 ● Local authorities