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 Norway
• 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 Finland
• 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 Denmark 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, Netherlands
• 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