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 .