IT brings the Danish health sector together Danish Healthcare and IT

Denmark, with 5.5 million inhabitants number of aspects that closely link I eHealth including telemedicine is and divided into five administrative IT to the provision of health and implemented in municipal, regional regions, has a predominantly public social care: and national collaboration. healthcare provision with 60 public and several small, private hospitals, I Homecare, nursing homes, 3500 primary care physicians, GPs, rehabilitation etc. are municipal Danish Health Sector I North Region and 250 pharmacies, not to mention tasks that integrate with the health- I Mid Jutland Region dentists, physiotherapists etc. care system, meaning patients 5.5 Mn. inhabitants I Region of Southern I Sealand Region can be discharged early from the 95% Citizens with access to I Capital Region of Denmark In addition to this, the Danish health- hospital. the Internet I Regional Municipality of care sector is characterised by a I Broadband penetration is the 5.8 Mn. mobile phones highest in Europe and more than 95% of the population have access 60 Public hospitals with to the Internet. 21000 beds ■ I All healthcare institutions and >10 Small private hospitals Rønne GPs have access to both the open and the secured Danish Health Data 3500 GPs in 2100 clinics Regionerne: Network. All GPs have an electronic 811 Private Specialists ■ Nordjylland patient record system and use + 205 part time Midtjylland Syddanmark electronic communication and trans- 250 Pharmacies Sjælland actions extensively. 2700 Dentists in 1650 clinics Hovedstaden I About 15 different electronic 1829 Psychotherapists in patient record systems are inter- 580 clinics ■ Regionskommune Viborg operable in the GP sector and four 224 Chiropractors different homecare records are used 726 Psychologists in the municipalities. Through a ■ consensus process with vendors of 5 Regions Hillerød almost 100 systems, all patient 98 Municipalities ■ management systems for hospitals, 1 Private Health GPs, homecare and pharmacies have Insurance ■ incorporated the messaging system Sorø after special certification. I A unique personal identifier is issued to all Danish citizens at birth, and a software-based PKI digital signature is widely used, instead of the hardware-based chip card.

2 It couldn’t work without IT

Over the last 20 years, IT communi- principle in the overall communi- In addition, videoconferences take cation has become indispensible to cation approach is that, as far as place and X-ray images, as well as the Danish healthcare services. Data possible, information must follow sound and moving pictures, are is stored digitally and the communi- the patient and not the other way exchanged and these underpin the cation of text, images and sound via around. cooperation between the specialists the Danish Health Data Network has involved. Citizens have access to become an integrated part of the The Danish healthcare services have both information and communica- cooperation between all groups in come a long way with this develop- tion with the entire healthcare ser- the health sector. It is impossible to ment. Overall, there has been signi- vice via the web portal, sundhed.dk, imagine daily life without it. ficant computerisation of the work and telemedicine solutions increa- tools used for record-keeping in singly enable patients to have direct The fundamental requirement is that hospitals and at GPs’ surgeries, for access to treatment and monitoring information must be available where example. Millions of messages – in their own homes. and when it is needed. It must be prescriptions, referrals, requisitions, communicated without error and laboratory reports, etc. – are com- There are still many IT solutions with a high level of data security municated via the Danish Health awaiting development, implementa- that ensures the confidentiality of Data Network every month. One of tion and distribution. The develop- personal data. the biggest current projects con- ment process never stops. We do cerns the Shared Medical Card, feel, however, that we are on the On this basis, IT solutions are devel- which gives all members of the right track and this view is con- oped and distributed to the entire Danish healthcare services on-line stantly supported by the everyday health sector and always with the access to an individual patient's experiences of eHealth in the citizen as the primary focus in terms status in terms of their medication. Danish healthcare sector. of the communication approach. The objective is for properly functioning communication to ensure that there for citizens is access to the best possible diagnosis, treatment and care using the most effective method and in a form that is as easy and accessible as possible. In practice, this means that those involved in the individual patient’s course of treatment must have access to all the relevant informa-

tion. They must also be able to ob- Bertel Haarder Bent Hansen tain a second opinion from specia- Danish Minister of Interior and Health Chairman of the Association of Danish lists as required. Another basic Regions

3 Focus on the citizen

The citizen is at the centre of the receives the best possible treatment organisation of eHealth in Denmark. from the health services. It is there- The aim is to make it easy for him or fore entirely appropriate to use her to communicate with the Danish the term “welfare technology and healthcare services and to obtain services” to refer to eHealth. information about health and ill- nesses. At the same time, it is a The two most important access stated goal that the communication routes to the Danish healthcare ser- between the parties involved in vices for citizens are their GP and the Danish healthcare services must the web portal, sundhed.dk. The be organised in such a way as to emergency department is of course ensure that the citizen always a third option, in the case of sudden illness or accident. nicate directly with the Danish The Danish Health Data Network The patient's GP healthcare services to a certain The Danish Health Data Network Every citizen has their own doctor, extent via sundhed.dk. or GP as they are known. He or she Citizen handles common health problems The citizen is in the picture and assesses on a case-by-case The internal communication of the basis whether they need to involve Danish healthcare services is based specialists in the treatment or to on the needs of citizens. For exam- refer the patient to a hospital. A ple, a citizen can collect his or her large proportion of GPs have their medicine from the pharmacy imme- GP sundhed.dk own website, where the citizen can diately after the GP has sent an

Dentist Physio- make consultation appointments electronic prescription. Other exam- therapist and renew prescriptions, among ples are notifications of admission, other things. discharge letters and rehabilitation programmes which the hospital

Chiropractor Psychologist Web-based information and sends to the municipal authorities. communication This ensures that the citizen The web portal, sundhed.dk, is the receives the correct follow-up access route to a great deal of promptly after hospital treatment. Municipality Hospital information on health, illness and Another example is patients, not the areas of the Danish healthcare least those who have chronic illness, X-ray Laboratory Pharmacy services. Here, citizens can find who are in direct contact with their information on classifications, treat- GP or hospital department via tele- ments, waiting lists, and much medicine solutions. more. It is also possible to commu-

4 sundhed.dk

Citizens and healthcare professionals both searching for information via sundhed.dk

sundhed.dk is the official Danish health information and to communi- general health information, book eHealth Portal for the public Danish cate with each other. appointments with their GP and healthcare services – the word renew prescriptions, as well as gain ‘sundhed’ means health in Danish. Two purposes and two profiles access to their own medication sundhed.dk has two purposes – the data, for instance. For the health- The Danish healthcare services are first is to support the national goals care professionals, sundhed.dk the joint public services of all the of the Danish healthcare services features include on-line services for Danish health authorities and provi- and the second is to communicate access to laboratory test results and ders and they are brought together the current activities of the Danish to data stored in electronic patient virtually at sundhed.dk. This makes healthcare services. records. it possible for patients, their fami- lies and healthcare professionals The portal features on-line services alike to access general and individual for the general public, who can find

5 Flow of electronic messages in the health sector

Messages General sundhed.dk Hospital Municipality from and to... Practitioner

Citizen On-line booking of Information and consultation communication appointments. between the On-line citizen and the consultations. Danish health- Prescription renewal care services

sundhed.dk Information and communication between healthcare professionals

Read the flowchart as follows, General Transfer of for example: Practitioner patient record Referrals. Request for prescription renewal Bookings Once the patient has been examined, the doctor sends an X-ray referral to the Imaging Diagnostic Department and receives an X-ray report in return. Hospital Booking report. Notification of admission and discharge. Discharge letters Notification of completion of treatment. Healthcare report. Rehabilitation programme. Admission response. Homecare status.

All parties Letters of correspondence

Public Health Insurance Billing

6 Laboratory Imaging Diagnostic Pharmacy Physio- Psycholo- Chiro- On-call Medical Health Department therapist gist practor GP specialist Visitor

Requisitions X-ray referrals Prescriptions Referrals Referrals Referrals Discharge Referrals letters Lab reports X-ray reports Discharge Discharge Discharge Discharge letters letters letters letters

Requisitions X-ray referrals. Prescriptions Notification X-ray discharge of birth reports

Billing Billing Billing Billing Billing Billing Billing

7 Citizens, patients and eHealth

Bruno Elmer Berggreen is an elderly citizen, who is a widower and lives alone. Chronic bronchi- tis and diabetes have weakened Bruno to such an extent that he receives direct help with cleaning and other chores in his home from municipal homecare. Recently, Bruno has had serious problems with pain in his hip.

Citizen Citizen GP GP Laboratory Hospital

GP sundhed.dk Laboratory X-ray X-ray Hospital Laboratory X-ray

This description is very simpli- 1. Bruno Elmer Berggreen 2. Bruno goes to the 3. The doctor receives the 4. Bruno is referred to the fied in order to provide a clear makes an appointment with appointment with his doctor report for the requested hospital, where the doctor overview of the electronic his GP because of the pain and is examined for the examinations and on that has access to the X-ray and communication in relation to in his right hip. cause of his pain. The basis decides that Bruno lab-reports that the GP the patient’s course of treat- The appointment is made doctor takes blood tests should be referred to the ordered. The hospital sends ment. via the eHealth portal which are sent to the Hip Arthroplasty department a request for Bruno to be sundhed.dk. laboratory and orders an at the hospital. admitted for treatment. X-ray examination.

8 Citizen Citizen Municipality GP Hospital Citizen

Hospital Municipality Hospital Municipality GP Pharmacy Municipality Pharmacy Municipality

5. Bruno is admitted to the 6. Bruno is discharged from 7. The homecare nurse 8. The GP receives the 9. The municipality receives hospital. The hospital sends hospital and comes home. orders pain relief medicine discharge letter and a copy the rehabilitation pro- an automatic notification Municipal homecare receives and a prescription renewal of the rehabilitation gramme and starts the to the municipality so that a notification in advance from the GP. pr0gramme from the hospi- rehabilitation process. municipal homecare is when he is discharged from tal. The GP also receives the aware that he has been the hospital. request for prescription admitted. renewal from municipal homecare and sends it to the pharmacist.

9 Millions of messages every month

computer system – for example, the electronic patient records at the GP 50 clinic as well as at the hospital and the citizen care record at municipal 45 homecare.

40 At the same time, the simple trans- mission of messages from sender to 35 recipient has now been supplemen- ted by forms of communication 30 where the recipients retrieve the in- formation themselves, such as look- 25 ing up the laboratory test report.

20 Putting the idea into practice A communication standard is speci- 15 fied for each individual message, which is tested and then implemen- 10 ted and distributed for general use by MedCom. An important experi- 5 ence is that implementation and distribution require detailed infor- 0 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 mation, and to a certain extent organisational adjustment, if elec- tronic communication is to work most effectively. Million messages per year. It all started as a pioneer project, include the transmission of all stan- when one GP decided on his own dard messages for healthcare com- It is characteristic of this develop- initiative to develop a solution that munication and between almost all ment that it is user-led to a large would enable him to send electronic involved parties. Electronic messa- degree and that a number of public prescriptions to the pharmacist. That ges have replaced paper ones, officials act as coordinators in the was at the beginning of the 1990’s, which in many cases used to be process. They have, to a great and that was the start of the Danish sent by post. Sending messages extent, specified the framework and Health Data Network. electronically is much faster and guidelines, which have subsequently more accurate, as data only has to provided the conditions for private More accurate and effective be written down once. It is also suppliers to be able to develop and Since then, the Danish Health Data more effective, as data is automati- market communication solutions Network has been expanded to cally integrated into the recipient’s under market conditions.

10 The vision of the paperless hospital

These days, many Danish hospitals are carrying out extensive develop- ment work in relation to electronic patient records (EPR). At some hospitals even, EPR has been im- plemented and is already in use, although not in its fully developed form. The vision is that these records will replace paper records in the not too distant future and will in fact become the definitive main source for all relevant patient information.

The individual patient’s course of treatment typically involves several health professionals, partly because treatment and care take up many hours of the day and partly because holistic treatment can easily involve a number of specialists, each with a different area of expertise. Previously, many of the specialists involved each had their own paper record, which made the coordination and organisation of a flexible course of treatment more difficult.

In the future, all relevant information will be gathered in one place and will be accessible anytime from any- where. Initially, the idea is to have a shared EPR for each individual hospi- tal, but this is also a natural basis for providing an interconnected EPR system for the entire hospital net- work and in the longer term for the Danish healthcare services as a whole.

11 Telemedicine

The ultimate purpose of developing I that diabetics are able to have In providing services to patients and implementing telemedicine their blood sugar levels monitored over distances, the Danish health solutions in Denmark is to provide from their own home. sector can use telemedicine solu- patients with the best information I that patients with chronic bron- tions to monitor diabetics and heart and the best treatment as close to chitis can measure their lung func- patients, but also to conduct con- them as possible. Telemedicine is tionality from home and they can sultations with alcoholics under- ideal for patients living in remote also have electronic consultations going treatment, for example. areas, such as islands, but is also with their doctor. particularly important for patients I that the time spent in hospital New forms of telemedicine solutions who need contact with the health can be reduced for COPD patients, are continually being developed for service because of long-term or thus radically improving their quality communication between healthcare chronic illness and telemedicine can of life. professionals. These include video also be used as a collaborate plat- I that a visiting homecare nurse conferences and specialist consulta- form for health professionals and can obtain specialist advice on-line tion during the video transmission specialists. when treating sores in the patient's of operations. Telemedicine is also own home (teledermatology). used to transfer duties between In cases of chronic illnesses, tele- hospitals, such as X-ray and medicine solutions can mean, for mammogram screening diagnosis. instance:

12 International projects

In large parts of the development process, the parties behind the Västerbotten Danish Health Data Network have stressed the importance of inter- Mid-Norway national cooperation. A number of specific projects have been carried Sweden out over the years and the results Norway are reflected in the achievements in healthcare communication, both for Tallinn Denmark and for the collaborative partners and countries. Estonia

Alongside actual cooperation on projects, there is also significant cross-border networking taking place. In this respect, the Danish Denmark healthcare sector is particularly in- BHN Lithuania volved in the Nordic and European networks. Funen Vilnius

It is only natural that some institu- tions and countries are further place emphasis on different areas of where they are used to diagnose along with their development work eHealth. As a result, international and determine further treatment. in certain areas than others. The po- cooperation is a kind of give and Similar cooperation has been sitions of strength change, however, take situation for all concerned – established between Denmark and as the individual countries typically no-one takes part solely to learn or Sweden for diagnosis based on to teach but rather to do both. mammogram screening.

A good example of an international This cooperation is possible because cooperation project is the transfer the Danish Health Data Network is of tasks from resource-weak areas connected not only to the Norwe- to resource-strong ones. Specifically, gian and Swedish national Health this relates to X-ray diagnosis, Data Networks, but also to regional where X-ray images are taken in networks in Estonia and Lithuania, Denmark, for example, and trans- so that data and images can be mitted to Estonia, where the reports transmitted via a closed and secure are made. The results are trans- network called the Baltic Health mitted back to the Danish hospital, Network (BNH).

13 There are many behind the successes

It is a feature of the Danish Health Data Network that many different groups – large and small, public and private, users and suppliers – have worked closely together to develop the communications solutions into what they are today. The requirements have mainly been specified by the users, in the form of healthcare professionals. A number of public groups have worked together with the healthcare professionals to define the standards, framework and guidelines, while private suppliers have provided the solutions under market conditions.

Three public institutions operate at national level:

Digital Health “Connected Digital The eHealth Portal is the official MedCom was established in 1994, Health in Denmark” provides the Danish eHealth portal for the public primarily to serve the needs of GPs. framework for the computerisation healthcare services. The portal can It currently manages the secure of the Danish healthcare sector and be accessed with a digital signature Danish Health Data Network and the goal is to create a coordinated – different for citizens and pro- intersectoral communication for health service, where doctors, fessionals. Citizens can gain access more than 50 MedCom standardised practitioners and citizens have to general and personal information and certified message of various access to all necessary health data. and professionals have access to a types. Today more than four million The Shared Medical Card, for exam- number of services including reading messages are transmitted per month. ple, is a project running under SDSD, electronic records etc. under the which will give all members of the ruling of the Danish Data Protection MedCom also focuses their efforts Danish healthcare services on-line authorities. on telemedicine at a national and access to an individual patient’s international level, and is closely in- status in terms of their medication. volved in many European projects.

The organisation creates the chan- nels of communication through which the health data must flow as well as the language in which the systems should communicate. Through cooperation with regions, municipalities and hospitals SDSD works on making the many, local, well-functioning systems communi- cate with one another.

14 of IT in the Danish health sector

Private suppliers: Suppliers of Suppliers of pharmacy systems medicine systems Suppliers of X-ray systems Cito Data A/S CSC Scandihealth Apoteksdata I/S ACURE – an IBM Division Agfa Healthcare NNIT-PharmaNet Logica Danmark A/S Logica Danmark A/S FICS Danmark A/S EDB Gruppen Suppliers of TM Software Formatex healthcare systems Systematic Software Engineering A/S IT-driftscenter Sectra A/S Rambøll Informatik A/S Suppliers of Medos CSC Scandihealth A/S doctor’s systems Medical Insight Lyngsoe Systems A/S GE Healthcare Technologies KMD A/S Nordteamgruppen ApS First Impression MyClinic A/S Avaleo ApS PC-Idé/PC-Praxis CSC Scandihealth Zealand Care A/S EG Data Inform Medwin Carestream Health (Kodak) A-Data ApS Suppliers of Datagruppen Vejle MultiMed ApS Suppliers of hospital systems Profdoc A/S laboratory systems Formatex Logica Danmark A/S Aver & Lauritzen ApS CSC Datalab ApS, LABKA EDB Gruppen EM-data A/S Logica Danmark A/S Formatex Docbase A/S Skejby Sygehus EM-data A/S Lægernes edb-central IT-driftscenter Odense IT-driftscenter Odense Dan-Med-Soft ADBakt ACURE – an IBM Division Structura IT ApS Capio Diagnostik a.s. CSC Scandihealth First Impression MyClinic A/S NordTeamGruppen ApS First Impression MyClinic A/S Medol ApS TietoEnator A/S FICS Danmark A/S Profdoc Safirlis TM Software Linet Misys Healthcare Systems – Systematic Software Engineering A/S International Databyrån för Skejby Sygehus informationsbehandling AB Gamma-Soft

15 Danish Regions Association of Danish Regions. www.regioner.dk sundhed.dk The Danish eHealth Portal. www.sundhed.dk

MedCom A national public project organisa- tion involved in cooperative ventures with authorities, organisations and private firms. www.medcom.dk

Digital Health Connected Digital Health in Denmark. www.sdsd.dk

Local Government Denmark Association of Danish Municipalities. www.kl.dk

Text: arki•tekst kommunikation Photos: Nils Lund Pedersen (pages 5, 6, 8, 9, 11 right), Alex Tran (page 4), Colourbox (pages 11 left, 12 right), Grafik & Klinisk Foto, OUH (page 14), Regionshospitalet Viborg, Skive, Kjellerup (page 15) Graphic Design: Christen Tofte Printed in Denmark 2010 by one2one, Odense