Healthcare ICT and HMIS in Norway

1. Healthcare ICT and HMIS in Norway MiriaGrisot

2. Overview • Norwegian healthcare system • Organization and services • National IT strategy for healthcare • Current Reform • ICT in thehealthcaresector • Primaryhealthcare + Hospital information systems • National initiatives • HMIS/Central registries • Current reform • Qualityindicators • Hospital reporting

3. Somefacts • Total population 4953000 (2011) • Life expectancy at birth 81.2 (2010) (1st Japan, 2nd Switzerland) • Total health spending accounted for 9.4% of GDP in Norway in 2010 (1st US, then Netherlands, France, Germany, Norway...) • In terms of health spending per capita, Norway is ranked the second highest among OECD countries in 2010 (after the United States) • In Norway, 85.5% of health spending was funded by public sources in 2010(well above the OECD average of 72.2%) • Norway employs more human resources in the health sector than most OECD countries (more doctors (4.7 per 1000 in 2010), more nurses (14.4 per 1000)) • The number of hospital beds for curative care in Norway stood at 2.4 per 1000 population in 2010 (below the OECD average of 3.4): • as in most OECD countries, the number of beds per capita in Norway has fallen over time, coinciding with a reduction of average length of stays in hospitals.

5. Healthcare sector • Norway has a predominantly public health care sector. • The Norwegian health system is characterized by universal coverage: the health system is built on the principle that all legal residents have equal access regardless of socioeconomic status, country of origin, and area of residence. • It is financed mainly through taxation and only to a small extent by out-of-pocket payments (see Frikort). • Unique personal number • Health care services are provided at two governmental levels: • primary care is at municipal level, • and specialized care is at regional level.

6. Municipal Health services: primarycare • 430 municipalities • consists of  • general practitioners services, • emergency room services, • physiotherapy, • nursing homes, • midwife services • and nursing services, (including health visitor services and home-based services).  • The health services are performed by personnel employed by the municipality or private personnel with a reimbursement agreement with the municipality.   • The municipality also runs preventative health services + Health 'Stations' and school-based health services • (Except for a few institutions with advanced rehabilitation services) long-term care does not exist within the hospital sector but it is integrated in primary health care. • Primary health care and social care services also care for patients recovering after a hospital stay.

7. Municipalhealth services (somenumbers) • On average a municipality has 10,000 inhabitants (range from 250 to 500,000 people) • The larger cities are subdivided into boroughs (city districts) covering services for about 30,000 inhabitants each. • A municipality with 10,000 inhabitants will have about 10 GPs, 90 nursing home beds and 150 nurses, nurses aids and home helpers working in home care for elderly and disabled people. • In 2010, there were 0.83 GPs per 1 000 population.

8. Municipalhealth services • Primary health care services are financed by the municipalities, which receive their income from taxes and a block grant from the central government. • The funding of the primary health care services is supplemented by user-payments. • The general practitioner scheme was introduced in 2001, states that: • Every inhabitant is entitled to be listed with a general practitioner (GP) of his or her choice, (almost all residents (99.6%) are registered in the scheme). • Every GP is now responsible for a list of individual patients • GPs’ role as gatekeepers: patients need to see their GPs before they can be referred (referral letter) to the hospital (except in emergencies). 

9. Regional Health Authorities - 2002 • hospitals and institutions:organised in enterprises/ trusts under four Regional Health Authorities:  • Helse Nord (covers thecountiesof Nordland, Troms and Finnmark)  • Helse Midt-Norge (Nord-Trøndelag, Sør-Trøndelag and Møre og  Romsdal)  • Helse Vest (Rogaland, Hordaland and Sogn og Fjordane)  • Helse Sør-Øst  (Vest-Agder, Aust-Agder, Telemark, Vestfold, Østfold, Buskerud, Oppland, Hedmark, Akershus, Oslo)  • The RHAs have structured the hospitals around 25 health enterprises (65 hospitals) • (Before 2002 the hospitals have been owned and run by the counties for over 30 years). • In 2010, the private hospitals (both not-for-profit and for-profit privately owned hospitals) accounted for 1 601 beds, approximately 10% of the total of 16 117 beds.

10. 4 Regional Health Authorities - 2002 Helse Nord Helse Midt-Norge Helse Sør-Øst Helse Vest

11. Regional Health Authorities (specialisedcare) • There is a system of referral to specialist care, with primary care physicians as gate keepers. • Patients may choose the hospital. • (They are not, however, allowed to choose a hospital that is more specialised, e.g. a university hospital, than the one they have been referred to.) • Free choice of hospital for elective treatment was introduced from 1 January 2001 (Frittsykehusvalg, www.frittsykehusvalg.no) • to strengthen patients’ positions as decision-makers (informed choice) • to even out differences in waiting times for treatment. • Some studies indicate that relatively few patients seem to have opted for the possibility of receiving treatment outside of the hospitals’ natural catchment areas.  • Patients are willing to wait a considerable length of time to avoid travelling. The reluctance to travel increases with age and decreases with level of education.

12. Specialsedcare • Emergency or electivepatients via GP • Waiting lists are primarily relevant for the specialist health care sector (which includes both specialist visits and surgical/medical treatment) • Specialist health care is financed through a combination of a basic allocation and (since 1997) activity-based financing using diagnosis-related groups (DRGs). • In 2007, somatic patient treatment was funded 60 % by the basic allocation and 40 % by the activity-based allocation • The state has responsibility for specialist services such as public hospitals and psychiatric institutions, ambulance and emergency call services, hospital pharmacies, laboratories and some of the drug rehabilitation institutions.

13. The Coordination Reform • Reconfigurerelationbetweenprimary & secondaryhealthcare • Shifttowardsprevention • Continuityofcare • Financial, legal, adminmeasures

14. The Coordination reform – premises • interaction between primary care and specialized care lacks mediating structures. • each care sector belongs to separate levels of public administration: local and national. • different systems of funding and different administrative, political and professional cultures. • Specialist health care sector: high competence, highly medical and diagnostic intensive.  • Municipality health services are characterized by lower skills, where as much as 29% of the labor force is performed by personnel without appropriate formal health professional education, mostly in long-term care.

15. The Coordination Reform 1st Jan 2012 • addresses a serious lack of coordination between hospitals and primary health care • how:increase the quality of information transfer between the levels, establish arenas where physicians at the different levels can interact and establish grounds for mutual learning. • Means: (heavily) on economic incentives • targets the administrative level

16. The Coordination reform • more patients should be taken care of in primary health and long-term care instead of being referred to hospital treatment • discharge from acute hospitals should take place earlier. • establishment of pre-hospital low threshold wards in primary health care  • municipalities are gradually obliged to establish primary emergency 24-hour care for patients who do not need specialized hospitalization

17. IT strategy in healthsector Breadth/vision Concretization /implementation

18. IT strategy in healthsector • S@mspill 2.0 • Specificvision/aims e.g.: • Relevant and goodqualityinformationonhealth , lifestyle, services, treatments is availableoninternet. • The patient has access to his ownhealthinformation, ownmedicalrecord, overviewofprescriptions and medications, discharge letters, freecard and more. • Via an interactive services is possible to (for instance) change appointments at the GPs or otherproviders. • New services oninternet support selfcarepossibilities. • Patients and usersexperiencethathealthpersonnel has a goodoverviewontheirhealth status and healthhistorywhentheycome in contactwithhealthcare services.

19. One resident – One record • improved quality, improved patient safety, more efficiency and better use of resources • quick, easy and secure access to all necessary information. • regardless of where in the country the patient is receiving treatment • Citizens should have quick access to simple and secure digital services.

20. Main actors • Ministryof Health and Care Services • Health Directorate • Regional Health Authorities • Hospital trusts • Municipalities • Nasjonal IKT (RHAs) www.nasjonalikt.no • KITH (Kompetansesenter for IT i helsevesenet) www.kith.no • Norsk Helsenett SF www.nhn.no • NSEP (Norsk Senter for Elektronisk Pasientjournal) www.nsep.no • NST (Nasjonalt Senter for Telemedisin) www.telemed.no • ..

21. Healthcare ICT in Norway… • Early mover on Health ICTs: • National ICT strategiessince 1996 • First to implement EPR (public hospitals and GPs) • 1980’s- 90’s: Development initiativeson a nationalscale • Widelydigitizedsector: • Hospitals, general practitioners, nursinghomes, pharmacies, private sectorspecialists • … butweakeron linking themtogether • GPs first to implementEPRs, ~100 % coverage

22. National Information infrastructure • all GPs use electronic patient records, and most receive discharge letters electronically from hospitals, but uptake by municipality home care and nursing homes has been slower owing to more complex and integrated information system requirements. • GPs often communicate electronically with laboratories outside their unit, and many can send prescriptions electronically to the pharmacy. • Many GPs can also order X-rays and outpatient specialist services directly through the electronic network. • All hospitals use electronic health records. • The lack of structured patient records in both primary and secondary care precludes automatic data extraction.

23. Electronic PatientRecord System (EPR) • Simple: • Text-based, nographics/images • Freetext, not structuredtext (sometemplates) • Chronologicalstructure (not problem-centered) • No decisionssupport/expert system functionality • SomeintegrationwithPatient Administrative System (patientdemographic data) • Few standards defined • So: • Limited value in comparisonwith grand visions • Far easier to implementthan ”grand vision” EPRs

24. Norwegian Health Network • Norwegian Health Network • Secure, separate broadbandnetwork for healthcaresector • Established 2004 (RHFs), provider role • State-ownedsince 2009: strategicrole • www.nhn.no • Every day 250.000 electronic messages are sent through the health network (2011) (before e-prescription) • includes a high-quality video conference network (30.000 meetings in 2011)

25. Inter-hospital communication • Privacylawprohibitssharingofcomplete EPR files when a patientgoes to another hospital • Discharge letters areautomatically sent, and theother hospitals can ask for otherreports from the EPR (not automatic) • Sharingof images and examinationresults • Electronic (NHN) and paper (mail, fax)

26. Region North: standardized systems portfolio: Same EPR system, same PACS system, sharedbloodbank system, same microbiology system…

27. Main challenges: • To digitize hospitals • To maintaincontrol over growing no. of systems • To achieveinter-organizationalcollaboration (digital communication)

28. DirectorateofHelath • Helsedirektoratet.no • IT og helse • E-resept • Kjernejournal • Helsenorge.no • Fritt sykehusvalg • Min fastlege • Mine Resepter • Frikort • (…)

30. Health Information Management • Norwegian Instituteof Public Health • QualityIndicators/Quality registers • Reporting from hospitals

31. Norwegian Instituteof Public Health • fhi.no • Health registers • responsible for ten out of 14 mandatory national health registries • A project has been established to modernise the mandatory national health registries: Gode helseregistre – bedre helse • The goal is that the national health registries shall provide current, reliable and secure information about • the population's health • and the quality of healthcare. • This includes information about disease incidence, unexpected changes in incidence patterns such as during an epidemic, and knowledge about risk factors and causes of disease.  • Goal is having real time data and a simpler linkage between the different registries. • All registries should have electronic solutions for collecting and handling data.

32. Registries • The Central Health registries • nationwide • Reporting • In some cases, data are personally identifiable, • Strict regulation for their access/use. • The core registers are used primarily for health monitoring, research, quality of healthcare, managementand management. • None of them are based on the consent of the data subject. • Medical Quality registries • To ensure quality of treatment • Few are national • There are about 200 medical quality registers,of which 12 have official status as a national • mostof current medical quality registers are based onconsent.

33. Gode helseregistre – bedre helse 2010-20 • Strategy for modernizingthecentralhealth registers, and themedicalquality registers • Should be able to answer to e.g. • How manypeople have diabetes in Norway today? • And whichotherhealthporblem do they have? • How do pregnant womenrespond to influenza? • How manychildrenareoverweight and whichhealth problems do they have? • Now, they do not provideanswers…

34. Strategy – concrete and visionary • Introductionofelectronicreporting to all registries • Useofstructured and specificpatientrecord systemas basis for developing a newreportingsolution to thenationalregistriesusing Norsk Helse Nett • …

35. National registres • Helsedirektoratet • Kvalitet og planlegging • QualityIndicators • E.g. fritt sykehusvalg • Norsk pasientregister (NPR) • When patients receive referral or treatment in a hospital, a clinic or a contract specialist - what we call the specialist health - a series of data are recorded at the treatment site.  • A selection of these details sent to the Norwegian Patient Register (NPR). • For current patients, it collected information on year of birth, sex and residence.  • From 1 March 2007 it is also registered the personal number in encrypted form. (it can be decrypted if necessary, such as when the information is to be connected with other registers). • Data from the register used regularly for waiting list statistics, National quality indicators for specialist health, Statistics of activity in the specialist health, Research, Activity-based funding, …

36. 14 Central Health Registries • The Norwegian Cause of Death Register • The Medical Birth Registry of Norway • Register for InducedAbortion • The Norwegian Surveillance System for Communicable Diseases and The TuberculosisRegistry • The Vaccination Register • The Norwegian Surveillance System for Resistance Against Antibiotics in Microbes • The Norwegian Surveillance System for Infections in Hospitals • The NorwegianPrescription Database • The Norwegian Cardiovascular Disease Registry • The Cancer Registry of Norway • The NorwegianPatientRegistry • The Norwegian Information System for The Nursing and Care Sector • ePrescription • The Registry of the Norwegian Armed Forces Medical Services

39. 19 nationalmedicalquality registries • Regional Health authorities: • South-EasternNorway • Child and youth diabetes + Neonatal medicine + Cerebral palsy + Trauma + Colorectal cancer + Prostate cancer • Central Norway • Myocardialinfarction + Cerebral stroke + Vasculardiseases/vascularsurgery • Western Norway • Intensive care + Diabetes in adults + Cleft lip and palate + COPD (KOLS) + Arthroplasties + Hip fractures + Cruciate ligaments + Multiple sclerosis (register and biobank) • NorthernNorway • Back surgery + Hereditary and congenital + neuromusculardiseases

40. Hospital reporting • Main system is PAS (not the EPR) • ICD codes (+others) entered by clinicians • Hospitals report activities – gettheirincome • Activity-basedcost (DRG system) • The recipient (Norw. Patientregistry) forwards to healthauthorities, and provides data also for otheruses (researchetc)

41. Activity-basedfundings - DRG system • (in Norwegian: the ISF scheme) • DRG (Diagnosis Related Groups) is a patient classification system that yields a simplified description of hospitals activity and patient mix, and is used as the basis for funding. • Each individual DRG represents both medical and financial information. Patients that are classified together in the same DRG are medically very similar and require roughly equal resources to treat. • Each year, around one million stays are classified, and the results are used to monitor activity and productivity • At present, the system lacks adequate standardisation in coding practices across hospitals and regions. • Assessment available at helsedirektoratet.no

42. Reporting from PAS systems

43. PAS Patient administration system • On patients: • Recordpatient personal information • Summaryofcontacts • Waiting lists • Time booking and notifications to patients • Register ofarrivals/discharges • Patient Hotel stays/movementswithinthe hospital • On hospital personnel and resources: • Register ofemployees and roles • Schedulingofworkshifts • Economy and resourceuse • Register of services delivered • Variousreports

44. PAS patient administration system • It is used to keep track of the patient logistics on site and the formal interaction with other healthcare providers. • Key Features • Patient search and registration • previouspatienthistory • uniqueness in the identification of the patient • Referral management • Referral management is the process from when the service requester sends a request to a service provider until the service provider either rejects the request, or accepts the request to provide healthcare to the patient. • Encounter management • keep track of where the patient is/shall be, the reason for the stay (diagnosis), what treatment is given (procedures), evaluate further examination or treatment after planned treatment is given, and to enable collection of any vital information necessary to create a correct patient bill/invoice pr hospital stay. • Inpatients: managing room and bed capacity and utilization • Outpatients: utilization of personnel (physician, nurse, etc.) rooms and other medical equipment • Booking • search capabilities to find available time slots for different types of services and resources • Clinicaladministrationwork lists: finding which patients are currently in different scenarios • Billing and finance integration • grouping/calculation engine to identify a Health care resource Group (HRG) or Diagnosis related group (DRG) code that is used as the basis for the calculation of the cost of services given. • Reports, Exports, Analysis • reports, for  example ad-hoc reports supporting the work process of the users, reports for activities performed by the hospital which is to be reported to the owners and the government. • export of data which has to be sent to the finance applications used by the hospital to ensure comprehensive follow-up of the billing process to all parties that retrieve bills • Letter module • functionality for creating and printing letters to patients, as well as letters to next of kin and health personnel

45. ICD 10 and NCSP code help

46. Reporting: qualitymonitoring • Quality/performance/efficiency: • Handledlocally by Dept/Hospital management • Publicationof data relating to: Patientsatisfaction, Waiting times, Complications etc. • Qualityoftreatment: • Professional groups (e.g. urologicalsurgeons) have initiatedvoluntaryreporting systems • Manual data entry (not pulling from EPR) • Exist for >60 areas • Varyingcoverage, quality, security – a nationalharmonizationinitiative.

47. Publicationofresults: • Qualityindicators: • http://helsenorge.no/Helsetjenester/Sider/Oversikt-over-nasjonale-kvalitetsindikatorer.aspx • Information for patients: • www.helsenorge.no • www.frittsykehusvalg.no

48. Security/privacypolicies • Data protection and information security principles: • EU Directive 95/46/EC (the Data Protection Directive) • National laws • National ”CodeofConduct” defined (incl. practical guidelines) • www.normen.no (also in English) • Norwegian Health Network requiresimplementationofCoC • Datatilsynet

49. The codeofConduct • the Code specifies which measures are deemed necessary to achieve satisfactory information security for such processing of health and personal data. • The Code regulates organizations’ manual and electronic processing of health and personal data, but is particularly relevant for the electronic processing. • E.g.: Message distribution and e-mail containing sensitive personal data • Clearly defined areas of responsibility must be established between the sender, recipient, and any message distributor, and the responsibilities shall be stated in the agreements between the organizations and the message distributor.

50. Helsedirektoratet.no • Tall og analyse • Qualityindicators • Rapport generator • Om aktivitet data