CASE STUDY: MEDCOM - THE DANISH HEALTHCARE DATA AND

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1 * CASE STUDY: MEDCOM - THE DANISH HEALTHCARE DATA AND INFORMATION NETWORK 1 Abstract MedCm is a natinal healthcare data and infrmatin netwrk fr enabling secure electrnic cmmunicatins between all actrs in the health and scial care sectrs in Denmark. The service has been perating since 1994, and by nw mre than 3,500 hspitals, pharmacies, hmecare prviders, GPs and specialists are cnnected. Mre than 2.5 millin messages are transmitted mnthly, equal t mre than 70% f all cmmunicatin between these parties. Access fr citizens and patients is als prvided. MedCm is nw cnsidered a Eurpean leader in the field f electrnic healthcare integratin. Case characteristics Sectr fcus Human health Business fcus Natinal health and care services netwrk Gegraphical fcus Denmark, Nrdic and Baltic Cuntries Case bjectives Backgrund and bjectives Extended health and care services rganisatin Electrnic cmmunicatins Standardisatin Autmatisatin f internal and external prcesses = sme relevance fr case; = high relevance The histry f the Danish healthcare data netwrk ges back t the end f the 1980s, when interest in electrnic cmmunicatins between the varius parties in the healthcare sectr grew and several prjects were started. MedCm was funded in 1994 t lead n the develpment f natinal EDI standards fr the mst frequently exchanged messages between the primary and secndary healthcare sectr. Since 1 This case study was cnducted by empirica GmbH, Oxfrdstr. 2, Bnn, Germany. 1

2 then its rle has been significantly expanded and the netwrk nw cntributes t the develpment, testing, disseminatin and quality assurance f all electrnic cmmunicatin acrss the Danish healthcare sectr. The latest prject aims t intrduce internet technlgy t healthcare cmmunicatin s that mdern IP-based, but still secure electrnic cmmunicatin can take place between healthcare prviders and their patients. MedCm is a cperative venture between authrities, rganisatins and private firms linked t the Danish healthcare sectr. MedCm is lcated within the Danish Centre fr Health Telematics, a prject rganisatin established by the Cunty f Funen t give advice and supprt t health bdies n the use f health telematics. MedCm is funded by The Ministry f Health, The Ministry f Scial Affairs, The Assciatin f Cunty Cuncils in Denmark, Cpenhagen Hspital Crpratin, Cpenhagen and Frederiksberg Lcal Authrities, The Natinal Bard f Health, The Danish Pharmacy Assciatin and DanNet. The first MedCm prject was carried ut in , with the aim f develping and testing natinwide EDI cmmunicatin standards fr the messages mst cmmnly used between general practitiners and the rest f the healthcare sectr fr example discharge letters, labratry results and prescriptins. MedCm II was carried ut in and ensured large-scale disseminatin f the cmmunicatin standards develped in the first prject perid. In additin, a number f pilt prjects were carried ut, with cmmunicatin in areas such as lcal authrities, physitherapy and dentistry, as well as telemedicine prjects. MedCm III ( ) reflected a cnslidatin f the healthcare data netwrk thrughut the cuntry and fur prject lines hspital, lcal authrity, telemedicine/internet and internatinal prjects which each separately cvered a grup f regins. MedCm s IV ( ) fcal areas are: the Internet Strategy, the purpse f which is t intrduce a natin-wide Internet based healthcare data netwrk and achieve large-scale use f web lkup, telemedicine and ther Internet-based frms f cmmunicatin in the healthcare sectr the Lcal-Authrity prjects, the purpse f which is t achieve large-scale use f MedCm s standards fr cmmunicatin between hspitals and lcal-authrity hme care cvering 75% f all Danish lcal authrities. Exhibit -1: Lcal Authrity prject In Denmark, hme and residential care is the respnsibility f lcal authrities. The integratin f these services int the netwrk is a frward-lking decisin which will benefit all lder citizens: 2

3 Surce: the XML-EPR Cmmunicatin prject, the purpse f which is t achieve largescale natin-wide use f all relevant MedCm messages fr cmmunicatin internally in hspitals and between hspitals MedCm s SUP (Standardised pull f patient data) prject, the purpse f which is t achieve Internet access t PAS (Patient Administrative Systems) and electrnic patient recrds (EPR) bth within a cunty and acrss cunty bundaries. Activities The MedCm standards, which are used at present in the healthcare data netwrk, can be directly re-used fr data exchange via the Public Healthcare Prtal, which is being develped n the initiative f the Assciatin f Cunty Cuncils. By linking tgether existing secure intranets, MedCm has established the healthcare internet, knwn as HealthcareDIX (Sundheds-DIX), via VPN cnnectins t VPN ndes. Operatin is user-financed, and 13 cunties, CHC, Cpenhagen Lcal Authrity, tw dctrs systems, KPLL and Dan Net are currently taking part in the netwrk. The wrk n the healthcare internet cnsists in the develpment f a series f Web-based services, which are made available t the parties cnnected t the netwrk. Tday, mre than 40 types f letters based n MedCm standards have been established. The MedCm standards are based n cnsensus amng healthcare prfessinals n cntent and applicatin. A set f messaging slutins has been running fr ten years; they are the basis fr the integratin between varius systems. MedCm's messaging systems are used in the fllwing areas: (1) eprescriptins: frm primary care dctrs (GPs and dctrs n call); (2) ereimbursement: t public insurance frm GPs, dctrs n call, specialists, pharmacies and dentists; (3) edischarge letters and referrals: between hspitals and specialists, physitherapists and GPs; (4) elab requests and results: between GPs and specialists and labratries (in bth state and private hspitals); (5) epathlgy and micrbilgy requests and results: between GPs and specialists and labratries; (6) eradilgy requests and results: between GPs and specialists and hspitals; (7) ecrrespndence: free text letters between parties; and (8) emunicipality: administrative and clinical messaging between hspital and cmmunity care centres. 3

4 Exhibit -2: The Danish Healthcare netwrk Since 2001, these messages have been supplemented with Internet-based slutins and web-access t infrmatin. MedCm has established a secure Internet infrastructure which prvides standards fr basic web services and cperates clsely with the new Public Health Prtal. A number f services have been established ver the years. A hspital sectin receiving an acute patient can make an nline infrmatin search thrugh the labratry s analysis results. A small surgical ward can request a secnd pinin frm university hspital experts regarding x-rays r vide recrdings; a patient can bk an appintment with a GP r participate in a cnsultatin via the Internet. MedCm currently handles ver 2.5 millin messages a mnth. 100% f hspitals, pharmacies, emergency dctrs, 92% f GPs, 98% f labratries, 62% f specialists, and 26% f lcal authrities are cnnected t it. MedCm enables hspitals t use electrnic referrals, and avid data re-entry. The prfessinal quality f referrals has risen, and discharge letters are stred directly. 4

5 Exhibit -3: Medcm messages by type and number MedCm -The Danish Health Data Netwrk Messages/Mnth O1 O2 O3 O4 Prescriptins = 73% 81% Disch. Letters = % Lab. reprts = % Referrals = 45 % Reimbursement = 66 % Surce: The mnthly status and number f messages sent can be mnitred at the MedCm website by individual cunty. Cunties are ranked frm 1 t 15, and natin-wide labratries are ranked frm A t C accrding t hw large a prprtin f EDI messages are sent in relatin t the ttal cmmunicatin f each type f message. The number f EDI users in the cunty is als shwn. In this way, a public cmpetitin is entertained t imprve verall perfrmance. New applicatins n the Internet-based Health Data Netwrk The netwrk's Internet Strategy under implementatin since 2002 enables these key applicatins and services: Access t patient X-ray infrmatin: The Internet X-ray Image and Descriptin Search prject prvides healthcare prfessinals with direct web-based access t essential patient infrmatin stred in the diagnstic radilgy department system f anther cunty r hspital. Teledermatlgy: The verall bjectives f the teledermatlgy prject are t supprt the patient s free chice f specialist, t replace r supplement general referrals t dermatlgists with telemedicine cnsultatins, t ensure that patients have equal access t dermatlgical assessments f skin images, t supprt the cntinuing educatin f GPs thrugh cmmunicatin with dermatlgists, and t establish the natinwide prvisin f telemedicine skin-image cnsultatin. EDI cmmunicatins: Althugh it is pssible t send any kind f EDI cmmunicatin, e.g. XML, EDIFACT, HL7 r DICOM, an pen standard fr EDI-mail has als been develped t ensure cmpatibility with existing VANS-based cmmunicatins and interperability between the new IP-based netwrk and the ld VANS netwrk. 5

6 Web requisitins fr clinical-bichemical and immunlgical tests: The departments f clinical bichemistry and immunlgy will be able t receive electrnic requests that GPs fill in via a standard frm n a Web Prtal. The Danish Natinal Health Prtal - One Prtal fr Citizens and Prfessinals: The infrastructure f the Health data netwrk is als the basis fr the develpment f the Danish Health Prtal, called ( Health Denmark ). It is the main access pint t the primary Health Prtal f the Danish health authrities, and enables cmmunicatin and services between health prfessinals and citizens. The prtal als prvides facilities fr citizens t bk appintments with GPs, cnduct cnsultatins with their GP and renew their prescriptins nline. 2 Exhibit -4: The Danish Health Prtal The prtal went live in December 2003 and is designed t give Danish residents a reliable place t turn fr advice regarding health, medical treatment and disease preventin. Amng the cntributrs t the site are cunties and municipalities, which play leading rles in lcal and reginal health-care initiatives. The prtal is nw mving ahead with plans t have all public health rganizatins, including the Ministry f Health, Danish Medical Assciatin, and prfessinal health and patient rganizatins, assist with cntent. Functins already available t all users are: Overview f the structure f the health service Site map with cntact infrmatin fr the entire health service 2 6

7 Hspital patient infrmatin (examinatin, treatment, pst-treatment) E-bking fr wn GP, prescriptin renewal, cnsultatin, change f GP etc. Infrmatin abut health, illnesses and preventin Infrmatin abut chice f hspital and ther patient rights Handbk f medicine and interactive database Infrmatin abut general preparatin fr cntact with the health service Waiting-list infrmatin and infrmatin abut quality and perfrmance E-cmmerce fr prescriptin-nly drugs Self-generated infrmatin frm all reginal health authrities, hspitals, departments etc. Practice declaratins t supprt chice f GP Access t current status cncerning public reimbursement in persnal medical expenses. Functins available fr healthcare prfessinals are: Access t data stred in electrnic patient recrds Access t labratry test results Access t editing wn practice declaratin (GPs) Persnalisatin (wn prfile and custmised infrmatin) Visit data and access t cnfidential phne numbers e.g. hspital departments Prfile areas: practice infrmatin Reginal clinical guides, cnsensus reprts and reference prgrammes Natinal clinical guides Access t jb vacancy bard fr the healthcare sectr. The Health Prtal in cnjunctin with MedCm was the verall winner in the categry fr e-health administrative supprt tls and services fr citizens at the e-health Minister Cnference in Crk, Eurpean Supprt The MedCm prgramme has been develped thrugh interactin with EU prjects which the centre has c-rdinated and/r in which it has cperated, i.e. CC, PICNIC, Primacm and WISE. The Cllabratin IT service frm PICNIC has been established within MedCm's secure Internet infrastructure. The Open Surce PICNIC cmpnents give access t infrmatin n specialist availability and cst. Once a service has been selected and bked, the service supprts an n-line telecnsultatin r an ffline secnd pinin with "medical chat" and the exchange f medical data and images. Other examples f jint internatinal prjects are Prpractitin, JUST, Open ECG and HC-Interest, and lately Infbimed. A highly relevant example f internatinal cperatin is the Cittis Interreg 3a-prject, in which three German hspitals have been linked up t the Danish Health Data Netwrk fr the purpse f exchanging telemedical services with Danish hspitals. Mst recently a Baltic interreg prject has started as a feasibility study t link the Nrdic netwrks with thse f Estnia and Lithuania and t exchange health services. 7

8 Internatinal Perspective: Nrdic Health care Netwrk Since the beginning f 2000, there has been ever clser cperatin between the rganisatins in the five Nrdic cuntries which are wrking n the applicatin and implementatin f IT slutins and electrnic cmmunicatin in the health service. Nrway, Sweden and Denmark are all invlved in the wrk f establishing natin-wide clsed IP-based healthcare data netwrks. This firstly led t a number f bilateral meetings, exchange f dcuments and experience, t the great satisfactin f all the participants. Plans fr IP-based healthcare data netwrks became reality in the spring f In Sweden, the Swedish Sjunet netwrk has already gne thrugh its secnd tendering rund, and is a well-established netwrk in which all the cunty cuncils (landsting) take part. In Nrway, five reginal netwrks have been set up fllwing the re-rganisatin f the healthcare sectr int five regins, and it is planned that these netwrks will be linked tgether. Bradly speaking, Nrway has fcused n develping telemedicine, Sweden n establishing a secure IP-based infrastructure and Denmark has develped and implemented EDIFACT cmmunicatin n a large scale. The establishment f the Nrdic Health care Netwrk serves several purpses, but verall the netwrk is intended t fster greater exchange f experience and ideas between the Nrdic cuntries. Experience t date has shwn that there are great similarities and interesting differences between the structure f the health service, the use f IT and the develpment and implementatin f IT in the health service in the Nrdic cuntries. The aim f the Nrdic Health care Netwrk is t utilise these similarities and differences t: ensure the greatest pssible re-use f slutins acrss natinal and reginal bundaries in the Nrdic cuntries assist in creating an pen and hmgeneus Nrdic market fr IT slutins fr the health service create cntact and the pssibility f exchange f experience between natinal and reginal prjects infrm bradly abut Nrdic slutins and prjects supprt the develpment f a Nrdic market fr healthcare services slve practical prblems in cnnectin with healthcare prjects in the Nrdic cuntries In summary, MedCm is ne f the mst interesting examples fr the stepwise, bttm-up develpment f a natinal health cmmunicatins netwrk prviding fr the integratin and cperatin f a wide variety f health and care systems actrs, and fr the expansin int ther Member States. In the first phase f develpment, the general practitiner was the pivtal pint in cmmunicatin, which primarily passed between medical practices, hspitals, labratries and pharmacies. Then the lcal authrities als jined in and became an imprtant partner in cperatin, in hme care and ther areas. Messages in the frm f prescriptins, labratry results, X-ray results, discharge letters etc. were exchanged in steadily increasing numbers between mre and mre users. By the end f the nineties, the healthcare data netwrk was already frwarding in bth breadth and depth mre and mre users jined in, and the ptential applicatins were extended t include new types f messages. Later n the internet pened up cmpletely new pprtunities bth in relatin t the patient and in dialgue with healthcare prfessinals. By linking tgether existing secure intranets, MedCm has established the healthcare internet, knwn as HealthcareDIX (Sundheds-DIX), via VPN cnnectins t VPN ndes. At the same time, MedCm IV has been cncerned 8

9 with the expansin and quality assurance f EDI cmmunicatin, as well as the develpment and implementatin f cmmunicatin t and frm electrnic patient recrds. MedCm is nw cnsidered a Eurpean leader in the field f electrnic healthcare cmmunicatin and received an hnurable mentin at the ehealth 2003 Ministerial Cnference. Planning is underway t expand activities beynd the Nrdic Cuntries int, e.g., als sme f the new Member States. Lessns learned User influence frm the very beginning The principle f a very high degree f user influence in the develpment f the Healthcare Data Netwrk was adpted at that early stage, and it is very much a basic principle f the netwrk tday. The users define requirements and preferences, after which the technical experts find ways f respnding t the users needs. 3 Imprved access t care and quality f care The health netwrk and MedCm standards have made electrnic patient bking and GP prescriptin renewal pssible. Telecnferencing has been carried ut in pilt prjects. The new Public Health Prtal creates new pssibilities fr infrmatin n health services and access t services. Messaging des nt heavily impact access t care, since messages are mainly directed twards prfessinals. Hwever, the prfessinals' access t the specialists' evaluatins has been imprved, as has the prmpt access t examinatin reprts. Prmpt, cmplete and valid infrmatin regarding the whle perid f care is the mst imprtant benefit. Electrnic cmmunicatin enables direct reuse f data and autmatic validatin f data prir t sending it. It als remves errrs resulting frm re-entry f data and incrrect interpretatins f handwriting. Organisatinal changes Alngside the develpment f MedCm, there has been cnsiderable psitive experience f the significant wrk invlved in carrying ut rganisatinal changes under the impact f the new infrmatinal technlgy. Only if rganisatinal changes are made can the imprved cmmunicatin really prve effective. Cst benefits Several studies cnfirm significant financial savings (each study nly cvers ne prtin f the prgramme). This des nt include the time savings resulting frm electrnic cmmunicatin. Fr example, mre time has becme available fr the care and treatment f patients. This is particularly true f hspitals where n significant persnnel reductins have been registered after the intrductin f EDI cmmunicatin. A cnservative estimate f the ptential financial benefits in the cmmunicatin flws that were studied culd thus be an annual saving f abut 84 millin Eur within the Danish healthcare sectr. A recent study The cst benefit f electrnic patient referrals in Denmark, which fcused nly n the quantifiable cst benefits assciated with the peratin f electrnic patient referrals in the Danish healthcare system, shws that full adptin f electrnic referrals will give a ptential annual saving f 3,512,146 Eur r 0.65 Eur per capita. There is ne ther cst that can be linked t pstal rather than electrnic referrals: the 3 Claus Duedal Pedersen & Christina E. Wanscher (2004): The Stry f MedCm 9

10 cst f delay in treatment fr the patient. The study fund that abut 217,160 referrals per year are sent t the hspital by pst and that these take an average f 1.33 days lnger t reach the hspital than an electrnic referral r fax. This extends the patient waiting time and, fr patients unfit t wrk, creates a cst t sciety. GPs estimate that between 5% and 10% f patients referred t hspital are classed as unfit fr wrk at an average cst t sciety f 939 Eur per day. This suggests that the increased patient waiting times caused by psting referrals culd cst sciety apprximately 1,343,026 Eur per year. Other studies shw that abut 50 minutes are being saved per day in each GP practice; telephne calls t hspitals were reduced by 66%; 2.3 have been saved per message which translates int 60 millin Eur per year. In terms f human resurces, mre than 25 thusand persn-mnths are saved. Given the average mnthly emplyee salary f 3,350 Eur, this translates int savings f 22.5 Eur millin. A develpment f natinal as well as internatinal significance MedCm, the Danish health data net, has cnsistently participated in the internatinal cperatin and has cntributed t the exchange f experience and inspiratin. MedCm and the Danish health data net have acquired valuable experiences that shuld play a part in the develpment f future ehealth systems and services nt nly in Denmark but als t serve as example t all the cuntries that are preparing their deplyment strategies. 4 References and acknwledgments We are very grateful t Dr. Niels Rssing, Knsulent, and Mrs. Christina E. Wanscher, Danish Centre fr Health Telematics, MedCm, fr reviewing and editing this case study and prviding us with additinal infrmatin. MedCm the Danish Healthcare Data Netwrk - Status, plans and prjects, Dec / MC-S177, The cst benefit f electrnic patient referrals in Denmark. Summary reprt published by ACCA and MedCm in cllabratin with the Eurpean Cmmissin Infrmatin Sciety Directrate General, 2004, Claus Duedal Pedersen & Christina E. Wanscher (2004): The Stry f MedCm (prepared fr the PICNIC prject bk; kindly sent t us n July 13, 2004) Cannaby Sharn and Claus Duedal Pedersen: The cst benefit f electrnic patient referrals in Denmark. An analysis by ACCA and the Danish Centre fr Health-Telematics, ehealth Cnference 2004, Crk, 5 & 6 May 2004, The Danish ehealth experience: One Prtal fr Citizens and Prfessinals, 2004, pn6h3gdcgarwvagvhb76lll4kwvhazq2snzdg2mee/the+danish+ehealth+experience.pdf Cntact e-business c/ empirica GmbH, Oxfrdstr. 2, Bnn, Germany Eurpean Cmmissin, Enterprise & Industry Directrate General, 4 Cmmentary by I. Iakvidis in: MedCm the Danish Healthcare Data Netwrk - Status, plans and prjects, Dec. 2003, p

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