Electronic Referrals in Health Care a Review

Vigdis Heimly

The Norwegian University of 01-09-09 Science Vigdis Heimly, and Technology, NTNU IDI, Design and use of informaton systems group Norwegian Centre for Informatcs in Health and Social Care MIE 2009 Health Care in

• Public health system

• Hospitals are owned by the government and organized under 4 regional health authorites (RHAs)

• Municipalites have responsibility for primary care: GPs, nursing homes, homecare

• Patent has one GP as primary contact

• GP is gatekeeper to specialized care

01-09-09 Vigdis Heimly, NTNU Electronic referrals

01-09-09 Vigdis Heimly, NTNU Status for one month in 2007

• 8200 electronic referrals sent

– 6300 of these within RHA North Norway

• 125 000 discharge summaries were sent in

01-09-09 Vigdis Heimly, NTNU History of electronic referrals in Norway • First natonal standards in 1996

• Natonal requirement specifcaton for communicaton modules in 2002

• EHR-vendor are provided with funding for implementaton of the modules

• Ministry of health has instructed the RHAs to facilitate receival of electronic referals

01-09-09 Vigdis Heimly, NTNU Why are volumes low?

• Norwegian study in 2008 indicated that most challenges were not technical, but organizatonal

• Some technical issues did stll need to be sorted out

01-09-09 Vigdis Heimly, NTNU Organizatonal challenges

• Specialists did not see enough benefts by introducing the system compared with the costs. (Lang waitngtme for patents, no real competton for patents) • Specialist were reluctant to new systems that could bypass the outpatent clinic • Senders and receivers did not have a common understanding of how the technical (XML) standard should be used

01-09-09 Vigdis Heimly, NTNU GP’s requirements

• Not peer to peer systems where GP flls out informaton in a system at the hospital based on the hospitals’ requirements

• One interface from EHR-system

• Seamless transfer of informaton to hospital

01-09-09 Vigdis Heimly, NTNU Is this a problem for Norway in partcular? Which lessons can be learnt from other countries?

01-09-09 Vigdis Heimly, NTNU Criteria for review

• Documentaton available in English

• Research papers

• Natonal projects and projects from countries with public health care system

• Not pilots

– Pilots are ofen successful

01-09-09 Vigdis Heimly, NTNU The review process

• Initated search for research papers

• Hard to fnd documentaton

• Referral projects regarded as implementaton projects, not neccessarily followed by researchers

• Few reviews done, mostly Telemedicine in general

• Project documentaton is ofen lacking or not 01-09-09 Vigdis Heimly, NTNU Benefts

• Evaluaton of the Peijas system in

• Hasmans study

• Danish study of quantfable costs

01-09-09 Vigdis Heimly, NTNU Optmistc start

• Finnish projects in Helsinki and Oulu

– Electronic referral and consultaton

– Conclusion from early stages: Promising

• Early projects in and Norway

– Messaging, EDIFACT later XML

– Pilots were promising, but infrastructure for full difusion was lacking. Few EHR-systems in hospitals

01-09-09 Vigdis Heimly, NTNU Difcult contnuaton

• Norwegian booking project

– Initated by government to facilitate free hospital choice

– The system was not integrated with EHR-systems at the GP’s ofce or in the hospital

– GP’s were to a limited degree involved in the planning

– Specialists did not want GPs to prioritze ”their” patents 01-09-09 Vigdis Heimly, NTNU Zorg Domain,

• System intends to create a common domain for GPs and specialists

• Includes referrals and discharge leters

• Use of clinical guidelines and clinical trajectories

• The distributon of tasks between specialists and GP can be changed because of the system

• Specialists were reluctant to use it 01-09-09 Vigdis Heimly, NTNU Choose and book, NHS

• Controversial system

• Long difusion tme, but the number of users have increased signifcantly

• Costly

• Was not suited for the clinician’s and patent’s needs in the frst version

01-09-09 Vigdis Heimly, NTNU Choose and book

01-09-09 Vigdis Heimly, NTNU Denmark

• Refost-Referral hotel in 2008

– GPs deposit referrals in hotel

– Patent pics up referral from hotel and chooses specialist

– Promising

01-09-09 Vigdis Heimly, NTNU Conclusions

• There is not one best soluton, difers with organizaton of health system and from country to country

• Difusion of electronic referrals is complicated because collaboraton from many actors is needed

• 01-09-09What’s in it for Vigdis me? Heimly, Who NTNU has to take the