Borderless HEALTHCARE COMMUNICATION Collaboration IT-service

Collaboration in telemedicine between Danish and German health services

South Region Schleswig County of Funen Technologie-Region K.E.R.N. 2

Odense Flensburg Kiel Healthy COMMUNICATION at the international level

t the national level, expanded electronic communication fer the patient, this is to be backed up by flexible and re- A between the parties in the health service has long liable communication of patient data. shown its value. This applies for instance to the area of telemedicine, where a large number of projects have In the ciTTis project, hospitals in four regions on either demonstrated the opportunities that direct exchange of side of the Danish-German border have joined forces to images, text and sound provides for on-line healthcare gain experience from international telemedicine. A service cooperation. which makes it clear which expert resources are Some of the most important available at any given time benefits consist in a rise in is being developed and the quality of treatment and tested under the project. better utilisation of resour- In addition, a cooperation ces. At the same time, the platform, a Collaboration new communication tech- IT-Service, is being estab- nology helps remove the lished for use in flexible barriers that geography can telemedicine collaboration. put in the way of patient An important element in treatment. The healthcare the project is the organisa- expert is no longer any further away than the nearest PC tional development, which is to ensure that the project with a network connection. The necessary specialist know- partners are all able to benefit from the new opportunities ledge is available where it is needed – without the patient for cooperation. having to be moved to receive the best treatment. The project focuses on both technological and organisa- The idea behind the ciTTis project is to make use of posi- tional development. The greatest challenge is purely tive national experience at the international level. Health- organisational, while the communication solutions from a care professionals in one country are to be able to draw purely technical point of view primarily necessitate adap- easily and quickly on the knowledge that other experts in tation to current conditions. the network possess. The patient is to be given the best possible treatment provided in the most efficient way At the same time, the project intends to promote commer- possible, regardless of whether the situation necessitates cial IT development within the four regions. crossing national borders. If it becomes necessary to trans-

Patients: Healthcare professionals:

Equal access to the best and Quality and development fastest treatment through cooperation The health service is becoming increasingly specialised. Highly Healthcare experts acquire their continuing training to a great extent specialised knowledge is possessed by a relatively small number of through collaboration in their daily work with colleagues in the same people, and in many ways technological developments also support or related specialities. Previously, this continuing training in practice the centralisation of treatment facilities. At the same time there is a was almost synonymous with collaboration with colleagues in the great need to achieve effective utilisation of resources in the health same department and the same hospital. For the same reason, there service. These trends have to harmonise with the wish to give all has been a clear trend towards specialists looking for special units patients equal access to the quickest and best treatment. Part of the with a high scientific level. The new information technology provides solution, in popular terms, is to move knowledge, so that there is ex- an opportunity, in popular terms, to break down the barriers in health- pert knowledge where is needed, or to move the patient and patient care cooperation. As a healthcare professional it is possible to look data to the place where the treatment is to take place. Whatever the for sparring partners regardless of distance and national boundaries. circumstances, this involves communication, and in this context, This strengthens individual development of qualifications and raises advanced information technology offers excellent opportunities. the quality of the work done. 3

Four parties, one project Six project participants from four regions are involved in ciTTis. These are South Jutland County and Region Schleswig, represented by the hospitals DIAKO and Malteser Krankenhaus St. Franziskus-Hospital in Flensburg, as well as County of Funen, represented by the Danish Centre for Health Telematics and Odense University Hospital and the Technologie-Region K.E.R.N, represented by Klinik für Diagnostische Radiologie am Universitätsklinikum Schleswig- in Kiel. The project has received assistance under the EU’s Interreg IIIA, both for the regional cooperation between County of Funen and the Technologie-Region K.E.R.N. and for the cooperation between South Jutland County and Region Schleswig. The Interreg assistance finances 50 per cent of the project budget. The remaining 50 per cent is funded by the participants. ciTTis timetable

Project 2002 2003 2004 2005

1. Project management

2. Analysis of technical conditions

3. Recommendations, guidelines and support

4. Procedural analysis

5. Development of new procedures

6. Software development

7. Pilot implementation of IT collaboration service

8. Dissemination of project results

1. Effective project manage- 3. Preparation of guidelines and 5. Based on the results of the 6. Development of software for ment and quality assurance recommendations on the analyses referred to above, collaboration service and the of all major results through- basis of an analysis of tech- from a workshop for clini- communication standards to out the project. nical conditions. Support for cians on their procedures and be used. 2. Analysis of technical stan- regional implementation. best practice from other tele- 7. Installation of collaboration IT dards, interoperability, laws 4. Identification of relevant pro- medicine projects, the new service in the various organi- and regulations, equipment cedures, including problems procedures where the new sations. and applications with respect and delays in these proce- technology supports and 8. Dissemination of project to harmonisation and the dures. contributes to a more appro- knowledge and experience preparation of guidelines. priate flow are described. the healthcare sector and in- dustry through printed matter, Start of project in the spring of 2002, end in the spring of 2005. website and conferences.

Politicians:

Effective utilisation of resources, satisfied patients, regional development The general public wants the best possible treatment of diseases and illnesses and at the same wants the lowest possible costs for the health service. It is the task of the politicians to accomplish this complex task, and in this context information technology is a useful tool. In many ways, health service trends are leading to an increased concentration of knowledge and resour- ces. This is a situation that may be difficult to handle in reality, where the patients also regard the proximity of treatment facilities as an important quality in itself. Information technology makes it possible to utilise knowledge and resources regardless of distance. The result is higher quality, better utilisation of resources and more satisfied patients. At the same time, the development work on IT solutions in itself helps support regional business develop- ment – all the participating regions attach great importance to business development in the area of IT. 4

Knowledge Patients BLAZES CROSS trails borders

n many situations there an available neurosurgeon surgery at Odense I may be a shortage of through the IT Collabora- University Hospital. expert assistance when a tion Service and is told that Odense University patient needs treatment. a neurosurgeon at Odense Hospital initially responds The local place of treatment Universitetshospital will be to the referral by asking may, perhaps, lack experts available in 30 minutes. Hospital to carry in a particular area, or the A request for assistance out several tests before experts at the place of and a reservation for this surgery can be carried out. treatment may need a assistance is sent to Odense The tests are performed, second opinion. University Hospital from and the results are for- An example: the local hospital. warded. CT/MRI scans and a The patient is trans- After a road-traffic acci- referral describing the ferred to Odense and dent, a male motorist is patient’s clinical situation undergoes surgery. She is hospitalised with a severe are sent to Odense Univer- t is not always sufficient transferred back to Hader- head injury. The patient is sity Hospital. I to exchange knowledge slev and data on the treat- unconscious. The neurosurgeon ana- between experts for treat- ment process and post- The local hospital takes lyses the images and other ment to progress. treatment are sent from a CT/MRI scan, but wants a information concerning the Diagnosis, surgery and Odense University Hospital second opinion on the situ- patient. The surgeon follow-up treatment may in to Haderslev Hospital. ation. The hospital looks for returns his neurological/ many cases involve several The patient chooses radiological report. hospitals, and it is vital that radiotherapy in Flensburg. The optimum healthcare the communication process Haderslev Hospital sends expertise has been avail- is smooth and effective for relevant data to the hospital able for treatment without the sake of the patient. in Flensburg. the need to move the patient, it should be noted. The general practitioner in refers a female patient to Haderslev Hospital. He makes the diagnosis of lung cancer, and refers the patient for

South Jutland County: County of Funen:

South Jutland Odense University The Danish Centre for County Hospital Health Telematics is the regional authority for 23 is one of the largest Danish is an office community of project organisations, all of which are local authorities. The country hospitals, with a standard capa- working on the development of healthcare communication at regional, runs three somatic hospitals and city of 1,193 beds and with national and international levels. These include FynCom, the regional additionally has utilisation agree- almost 120,000 treatment healthcare data network in County of Funen, MedCom, the national ments with the Danish Rheuma- episodes a year. Its work encom- healthcare data network in Denmark, and International Office, which tism Association and the board passes both basic tasks and a takes part in international healthcare IT activities and EU projects. of the self-owned institution large number of national and Aabenraa Hospital. The total regional tasks. The hospital has somatic capacity is 904 beds. significant research and training activities. 5

The vision: BORDERLESS Good Research enters a new communication prospects technological phase

ithin a period of Digital information, including The Klinik für Diagnostische Waround ten years, tele- the digital transfer of diag- Radiologie will, among other medicine will become an nostic X-ray images, is things, use the ciTTis project essential, decisive factor in developing at a rapid pace, to strengthen the clinic’s medical practice. Tele- and great opportunities are research profile. With medicine will be part of the presenting themselves. The Germany’s second largest day-to-day treatment, with Department of Diagnostic university hospital behind us, healthcare professionals Radiology at Odense Univer- we can move our research involved in virtual collabo- sity Hospital has joined the collaboration forward into a ration to strengthen the patients. The general pub- ciTTis project in order to be new technological phase. treatment of patients. lic can access healthcare in the vanguard of the de- This applies to all levels, experts regardless of geo- velopment of digital image regionally, nationally and Technology is gaining gro- graphical location. transfer and the transfer of internationally. und in this area from one descriptions. The immediate The particular type of re- year to the next. It is now The regions and hospitals prospects are improved search we carry out is well technically possible to carry outside the traditional edu- cooperation with the other suited to the electronic out on-line videoconferen- cational centres have better hospitals in the southern exchange of information. cing and transfer texts, prospects of attracting and region and cooperation with Aspects such as the synergy images, video clips and holding onto experts by major north German hospi- effect generated by interna- audio data between diffe- establishing virtual spe- tals, in the transfer of tional collaboration mean rent healthcare professio- cialist teams. Hospitals, patients and in the discus- that we can step up our nals and between health- specialists and others will sion of specific diagnostic research initiatives without care professionals and be able to offer their servi- problems that require spe- having to make significant ces on virtual markets for cialist knowledge. investments. Researchers in healthcare services. Kiel will be in the frontline, Senior Consultant and positions in Northern In the light of the standard- Jens Karstoft, M.D., Germany will become more ised solutions and health- Odense University Hospital attractive. care processes, the IT indu- In the longer term, our treat- stry will be able to develop ment and training program- projects for growing mar- mes will be improved. New kets. research results can be dis- seminated much more rapid- ly, and by using flexible K.E.R.N Region Schleswig: distance-teaching facilities, we will be able to offer in- Klinik für Diagnostische DIAKO, Diakonissen- Malteser Krankenhaus service training to many Radiologie am krankenhaus Flensburg. St. Franziskus-Hospital more doctors. Universitätsklinikum This hospital consists of specia- with nine specialist departments, Schleswig-Holstein in Kiel. list departments with capacity 350 beds and 750 staff treats Professor and Director The department has all modern and skills roughly equivalent to a about 23,000 patients annually M. Heller, M.D., Klinik für equipment for imaging diag- regional hospital in Denmark. from the northern , as Diagnostische Radiologie am nostics at its disposal. The The hospital has 542 beds in 15 well as South Jutland County. It Universitätsklinikum department takes part in national specialist departments and cooperates closely with DIAKO. Schleswig-Holstein in Kiel and international research treats more than 50,000 cooperation, serves patients in patients a year. The hospital the north German area and takes part in the training of trains specialists and scientific students at the universities of staff in its specialist field. Kiel and Lübeck. 6

The diagram shows the technical architecture behind Collaboration We have the IT-service. Its core is an Open Source Java Server, which among other things handles the two main components. Ress handles the user ad- TECHNOLOGY ministration, and Cols deals with the actual inter-user communication. at our disposal

elemedicine enables are many benefits to it, but Thealthcare professionals the potential of telemedi- to collaborate quickly and cine is not least in estab- directly with other specia- lishing a system that makes lists on patient treatment. it possible to join all kinds of telemedicine applications It is a network-based IT together, regardless of service, developed and technological platform and tested successfully over a commercial interests. This large number of projects. is precisely where the Telemedicine solutions nor- ciTTis project comes in. mally focus on a very spe- cific area of work, where The EU project PICNIC has applications and services in Connected users/ the parties concerned agree identified a number of soft- a regional healthcare net- applications on working methods and a ware components – Colla- work. Some of these com- Available healthcare technical solution. There boration IT – that can link ponents will be used in specialists together different software ciTTis and will constitute a Price list of different set of technical tools, which types of resources are to be usable by all IT Profiles of organisations suppliers in Open Source. and healthcare specia- Standards already lists developed will be used to Definition of the exchange information – for exchangeable types of example SCP-ECG, information DICOM, EDIFACT, XML Billing CDA.

Collaboration IT-service will contain information on:

Screens:

These screens show how two or more healthcare professionals use the program to discuss an X-ray. One of the benefits of using Collaboration IT-service – instead of sending the images and then discussing the images over the telephone – is that the discussion is saved and can serve as documentation later on. 7

Major

Experienced and focused CHALLENGES on development Great potential in Participating in the ciTTis pro- for communication collaboration ject will allow DIAKO to utilise the experience we have gain- and organisation In South Jutland County we ed from regional and interna- are well aware of the great tional collaboration. We have he technology is far fying the requisite organi- potential that exists in expan- already been taking part for T from doing it alone. In sational changes to make ding our national and inter- many years in a telemedical relation to a project like Collaboration IT-Service national collaboration. network with the St. Franzis- ciTTis it is not unrealistic to work as effectively as possi- In many areas, the last ten kus-Hospital in Flensburg and estimate the effort made ble across organisations years have brought signifi- the Association of General with respect to develop- and frontiers. cant development in the Practitioners in Flensburg. In ment of the technology at working relationships within addition, we have had five around 30 per cent, while The telemedicine solutions what is commonly referred years of successful collabora- the requirements for orga- will additionally include a to as the southern region – tion in teleradiology with nisational development number of protocols speci- Funen, Southern and South three other hospitals. Trans- constitute the remaining 70 fying the data and technical Jutland. This applies, for ex- nationally, we treat patients per cent. standards which are to be ample, to the hospital area. from Denmark and Norway. exchanged in different We are accustomed to thin- With ciTTis, we anticipate ex- sequences of events. The king in terms of cooperation panding the good specialist where our German neigh- networks to include multina- Technology events are typically infor- bours are concerned. It is tional specialist networks and 30% mation in the form of a only natural for us to expand consequently improve the Organisation referral, image, video clip, the cooperation further, and joint treatment of patients in 70% clinical e-mail, X-ray report, etc. the new technology is a fan- all four regions. The close tastic new tool in this area. personal contacts that con- Alongside the development An important product of the In the ciTTis project we see sequently emerge between of the necessary technical project is therefore harmo- an obvious opportunity for specialists from both countri- tools, a set of guidelines nisation of clinical and the hospitals in the Danish es promote this development. will be developed which administrative practice in and German regions to Of further interest is the describe the necessary diagnostics and patient supplement and strengthen development of a new chip- healthcare basis for using treatment and therefore a one another. This will benefit based patient card, which is Collaboration IT services in stronger cultural commu- the patients, who receive the due to replace the present- healthcare organisations. nity. best possible treatment in day health insurance card in In conjunction with this, the most straightforward 2006. The Federal state of ciTTis will focus on identi- way. At the same time, it Schleswig-Holstein has been benefits the healthcare sec- given the task of testing this tor, because the experience patient card in the model Regional development sharing is synonymous with region of Flensburg and is a valuable growth in quality. conducting a pilot project, Regional development which the project gives rise. The which is expected to be of – an important project will probably inspire inter- Claus Toftgaard, significance to the whole added bonus. regional and international tech- Hospital Director, Federal Republic. The project includes the develop- nology cooperation and con- Haderslev Hospital ciTTis and the patient card ment of hardware and software tracts. External suppliers and project are part of a mutual solutions, which will be of inter- interested parties who monitor relationship of development, est to all suppliers of telemedical the project will acquire valuable which in its trans-boundary equipment. The project will knowledge of procedures and professional, interdisciplinary net- dimension encompasses the emphasise the involvement of standards. work in support of local treat- whole of Europe. potential suppliers in all the At the same time, the tele- ment facilities. regions, so they receive informa- medical solutions developed Medical Director tion on the content, aims and during the project will help retain Ulrich Schroeder, M.D., results of the project and on and attract healthcare staff who DIAKO, Diakonissen- relevant technology services to would otherwise not have a krankenhaus Flensburg 8

Secure electronic health information

The EU supports health pro- DIAKO Diakonissen- South Jutland County jects that could potentially krankenhaus Flensburg Skelbækvej 2, pave the way for a joint e- Knuthstrasse 1, DK-6200 Aabenraa health strategy. Wide-ranging D-24939 Flensburg experience has already been Contact: accumulated through the Contact: Dr. Ulrich Schroeder Claus Toftgård, Hospital Director ciTTis project, providing a Tel.: +49 461 812 2015 Tel.: +45 7427 3501 inted in Denmark by one2one. Print run:1000. basis for developments that e-mail: [email protected] e-mail: will first and foremost mean [email protected] better healthcare services Malteser Krankenhaus for EU citizens, but which will St. Franziskus-Hospital, Danish Centre for also offer major gains in Radiologische Abteilung Health Telematics terms of health and medical Waldstrasse 17, County of Funen research. D-24939 Flensburg Rugårdsvej 15 DK-5000 Odense C The secure exchange of vital Contact: health information now plays Dr. Kamel Moubayed Contact: an ever-increasing role in Tel.: +49 461 816 2556 Claus Duedal Pedersen individual EU countries and is e-mail: Tel.: +45 6613 3066 also a high priority in the [email protected] e-mail: [email protected] EU’s common health policy initiatives. This is one of the Klinik für Diagnostische Odense University Hospital areas where the ciTTis pro- Radiologie am Universitäts- Sdr. Boulevard 29, ject will bring its experience klinikum Schleswig-Holstein DK-5000 Odense C of electronic communication in Kiel to bear as a useful tool for Arnold-Heller-Strasse 9 Contact: Bjarne Hjorth exchanging health-related D-24105 Kiel Tel.: +45 6541 2146 information across borders. e-mail: The project will benefit health Contact: [email protected] sector workers and patients Prof. Dr. Martin Heller alike. The EU Commission is Tel.: +49 431 597 31 53 following the ciTTis project e-mail:

with interest and has high [email protected] Pr February 2004. Edited by Claus Duedal Pedersen, MedCom. Journalistic work: arki•tekst kommunikation. Layout: Christen Tofte. expectations in respect of the further benefits to be gained from the project.

Jean Claude Healy, Head of Unit, The European Commission

COUNTY OF FUNEN

Rugårdsvej 15, 2.sal, DK-5000 Odense C Telephone +45 6613 3066 Fax +45 6613 5066 www.health-telematics.dk