Information Infrastructure in Norway

Transcription

1 GPs The HistoricalEvolution of Health Information Infrastructure in Norway Ole Hanseth University of Oslo Early 1980 ies: EPR Early 1990 ies: ~100% 3 suppliers (70%, 20%, 10%) Additional applications (instruments) & services Connected to national information infrastructures and services 70 ies: PAS, Lab Lbsystems EPR 84: Nora > > DocuLive 95: MEDAKIS: Hospitals 5 regional hospitals + Siemens Aim: National standard going global DIPS: Bodø, extended functionality + generification, 3 of 4 regions RIS & PACS Rapidly growing number of applications (NH: >200 EPR ) National architecture standard: MOA > > SOA + portal Chart & medication systems Connected to national informationinfrastructures infrastructures and services 2002: Health care reform Improve collaboration Government taking over hospitals 5 (4) regional companies Regional IT strategies, standards, companies EPR, PACS, RIS,.. 100% National ICT Mergers & Acquisitions: UNN, Helse Sør Øst, OUS,... Integration and sharing of systems

2 National informationinfrastructures infrastructures 1987: Exchange of lab reports (1 system: 3 weeks, 100% 1993) 1990: Standardization of messages 1992: KITH (responsible for standardization) di ti Pilots failures A few successes: Lab reports, discharge letters,.. ELIN projects Lighthouse projects.. Solutions rather than messages, lots of new messages required, also services eprescriptions (app. 500MNOK ).. another failure? National lhealth hnetwork thevery surprising extreme complexity The current situation High and rapidly growing number of applications, registers,.. High and rapidly growing complexity, heterogeneity.. A few working national services From sending to sharing (strong inertia) Where will we be in 5 10 years? Future legacy systems? Perceived problem: Lack of centralized power (standards: from ought to to have to ) Innovation??? New reform: Focus on collaboration, national ICT company Huge demand for new national information infrastructures A very common model Hos oss ligner situasjonen mer på dette EPJ/ PAS

3 Pharmacy/Medication Safety Physician Clinical Practice Clinical Decision Support Physician Results Rules and Data Severity Medication Outpatient MAR Order Sets Report Writer Order Entry Prescriptions Order Entry Review Alerts Warehouse Adjustment Comparative Substitution/ Task Lists/ Outcomes Resource Dosing Formulary Provider Database Cost Workflow Pathways Protocols Measurement Utilization Documentation Access Tools Ambulatory Provider Positive Access to Rounding Patient History/ Patient Locator/ Credentialing Drug Practice Profiling Patient Drug Interactions Tools Problem Lists Patient Lists Identification Databases Enterprise Patient Access Robot Interface Core Information Components Admission/ Enterprise Eligibility User Interface/Portal Registration Scheduling Verification Presentation layer Service layer Departmental/Support Services Radiology/ Lab Cardiology PACS Emergency Pathology Surgery Department Data Aggregation and Reporting Tools Common Master Person Clinical Research Index (MPI) Data Medical Repository Repository Vocabularies Order Decision Rules Standard Entry Support Engine CDM Repository Technical Request for Consumer Denial Authorization Portal Clinical Documentation Patient I & O Flowsheets Assessment Vital Signs Integration layer Blood Bank Other Departmental Systems Security Integration Consumer PDA Tools Tools Content Support Kardex Transition Planning Task Lists Non-MD Orders Care Plans Specialty Documentation Health Information Care Chart (Deficiencies) Transcription/ Dictation Coding Support Precertification Authorization Initial & Concurrent Review Discharge Planning Clinical Denial Critical Care Documentation Patient Education Interfaces to Monitors Legacy systems Document Imaging MRN and Merge Workflow Tools Release of Information Electronic Signature CDMP (?) Payor Communication and Notes Social Services Support InterQual Support for LOC Post Acute Placement Work Lists Readmit Alerts Pathways Disease Patient Supply Charges Interface to ERP System Supply Chain Tracking & Reconciliation Support for Product Standards Solution Sets Solution Components Kilde: John Quinn, Ernst & Young, 2002 eprescription MyPresciptions Information on medicins in use eprescriptions information Prescription information EPJ- Systems Prescription Recall Hand-over message Deleted prescription Reply from Medicine Agency Consent information Reference number eprescriptions Exchange Request for expedition Prescription information Hand-over message Request for assessment by Gvt Medicine Agency Pharmacysystem Notification Applicationto of Medicine i Agency hand-over Reply on application Application NAV Prescriptionand expedition information GP information Reply on Refund request Refund request Refunds and control (NAV) FEST (Gvt Medicine Agency) Application (Gvt Medicine Agency) Prescription and expedition information

4 Collaboration Reform Summary Care Record (Kjernejournal) On top of eprescription solution +++ Integration of all solutions in all institutions across all borders Fürst A few other projects Lab report transfer solution, 1987, 3 man weeks + 1 evening Lab ordering solution Northern Norwegian Health Care Well/Dips Interactor Interactive admission letters BlueFox SummaryCare Record Systems Some conclusions Scotland: 3 MGBP (4M Euros, 4 M USD) Denmark: Official, top down 10 M Euros, Faded out after about 4 years, officially cancelled after 8 Unofficial, bottom up Great success Norway (eprescription) 500 MNOK, currently piloted in one GP office UK Started 2004, earlyadoption2007adoption 2007, further deployment is frozen Spent 240 MGBP Successes Many applications Lab reports DIPS CSAM portal Regional/national governance structures Evolutionary, bottom up Needs Extension and generification (scalability) Failures Standardization MEDAKIS National info. infrastructures Top down, specification driven Standardization, pilots: dead ends Strategic projects always fail (Complexity: technology, organization (actors)) 1st law of techn.: 1st version never works

5 More conclusions Rli Relying on the traditional model dl.. Following the textbook Project, controlled from thetop, closed world, moderate complexity Ex.: one single info model for the whole world covering all of health care, describing the objective world as it is A new model dlis needed: dd Understanding complexity Learning from the Internet Different architectures Complexity = number of types of components & links & speed of change Side effects effects orders dis orders Propagation of side effects Stabilizing, self reinforcing processes Destabilizing, self destructive processes Actor Network ktheory, Complexity Science, Si Reflexive Rfl Modernity Understanding The dynamics of complex systems How to avoid making them The Internetexperience experience Development/standardization strategy Tl Telecom: No innovations i for 100 years!! Internet: Range and speed of innovations Development/standardization strategy: Evolutionary, bottom up we believe in rough consensus and running code Architecture End 2 end (Lessig) + programmable terminals (Benkler) = generativity (Zittrain) Generativity Unprompted innovation by huge number of actors without coordination Capacity for leverage, adaptability, ease of mastery, accessibility Non appliance Organizing, governance Commons Based Peer Production (Benkler) Regulation a la Lessig ( code is law ) Market/organizing, social norms, techn./architecture, law Successes Bottom up Evolutionary Bootstrapping, extending, generification Small, simple, i.e. flexible standards d Focus on specific needs for the first users Generate network effects Failures Top down Specification driven Many actors (complex organization) Complex solution Complexity bootstraps!!

6 Architecture hospitals Architecture National IIs Transition (slow) towards SOA + clinical portal Successes SOA like Failures MOA/IIA The EDI Paradigm National Infrastructures The EDI Paradigm Message Oriented Architecture Examples: eprescription, lab reports, discharge letters,.. Exchange of messagesbetween applications (Lab systems, EPR systems, pharmacy applications,..) Application vendors do the job.. But they don t: lack of incentives, users requests other features, small & financially i weak,.. Information flow ICT architecture t Project organization GP offices Hospitals GPs EPR NAV Pharmacies Labs NAV systems Pharmacy systems Hospital systems Lb Lab systems Vendors of GPs EPR NAV s dev. org. Vendor of the Pharmacies system Vendors of hospital syst. Vendors of Lab systems

7 MOA: eprescriptions, Patient Care Summary SOA Hospitals EPR EPR GP offices GP offices Hospitals Pharmacies Pharmacies Social security offices Homes for elderly Social security offices Homes for elderly An alternative architecture Differences GP offices Hospitals NAV Pharmacies Labs Information flow GP office GP GP s computer GP computer GP s EPR system Client module Lab/hospital Communi cation system/n Server module etwork Lab system ICT architecture Project org. Lab/hospital Project organization Reduced complexity Organizational Smaller number of actors Those that have incentives do the job Technological (up to 8 versions of the same software module) Combines easily with bottom up/evolutionary standardization and development Allows experimentation/innovation increased benefits

8 Generativity revisited Internet: Generativity = end 2 end MOA: end 2 end = non generativity!! SOA not end 2 end but generative Generativity matter! Generative Health Care Information Infrastructures: More research is desperately needed! Governance & Regulation More market : mandatory dt outsourcing to monopolies FLOSS/CBPP Licenses Collaboration Technological support Cultivate collaboration/sharing culture Examples: national systems for quality indicator registers (>60) Web based diabetes journal Data mining (research) myjournal (Architecture) Thank you!