Healthcare ICT and HMIS in Norway Miria Grisot 1
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- Slide 1
- Healthcare ICT and HMIS in Norway Miria Grisot 1
- Slide 2
- Overview Norwegian healthcare system Organization and services
National IT strategy for healthcare Current Reform ICT in the
healthcare sector Primary healthcare + Hospital information systems
National initiatives HMIS/Central registries Current reform Quality
indicators Hospital reporting 2
- Slide 3
- Some facts 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. 3
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- 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.
5
- Slide 6
- Municipal Health services: primary care 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. 6
- Slide 7
- Municipal health services (some numbers) 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. 7
- Slide 8
- Municipal health 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). 8
- Slide 9
- Regional Health Authorities - 2002 hospitals and institutions:
organised in enterprises/ trusts under four Regional Health
Authorities: Helse Nord (covers the counties of Nordland, Troms and
Finnmark) Helse Midt-Norge (Nord-Trndelag, Sr-Trndelag and Mre og
Romsdal) Helse Vest (Rogaland, Hordaland and Sogn og Fjordane)
Helse Sr-st (Vest-Agder, Aust-Agder, Telemark, Vestfold, stfold,
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. 9
- Slide 10
- 4 Regional Health Authorities - 2002 10 Helse Nord Helse
Midt-Norge Helse Vest Helse Sr-st
- Slide 11
- Regional Health Authorities (specialised care) 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 (Fritt sykehusvalg,
www.frittsykehusvalg.no)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. 11
- Slide 12
- Specialsed care Emergency or elective patients 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. 12
- Slide 13
- The Coordination Reform Reconfigure relation between primary
& secondary healthcare Shift towards prevention Continuity of
care Financial, legal, admin measures 13
- Slide 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. 14
- Slide 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
15
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- The Coordination reform 1)more patients should be taken care of
in primary health and long-term care instead of being referred to
hospital treatment 2)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 16
- Slide 17
- Breadth/vision Concretization /implementation IT strategy in
health sector
- Slide 18
- S@mspill 2.0 Specific vision/aims e.g.: Relevant and good
quality information on health, lifestyle, services, treatments is
available on internet. The patient has access to his own health
information, own medical record, overview of prescriptions and
medications, discharge letters, freecard and more. Via an
interactive services is possible to (for instance) change
appointments at the GPs or other providers. New services on
internet support self care possibilities. Patients and users
experience that health personnel has a good overview on their
health status and health history when they come in contact with
health care services. 18
- Slide 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. 19
- Slide 20
- Main actors Ministry of 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.. 20
- Slide 21
- Healthcare ICT in Norway Early mover on Health ICTs: National
ICT strategies since 1996 First to implement EPR (public hospitals
and GPs) 1980s- 90s: Development initiatives on a national scale
Widely digitized sector: Hospitals, general practitioners, nursing
homes, pharmacies, private sector specialists but weaker on linking
them together GPs first to implement EPRs, ~100 % coverage 21
- Slide 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. 22
- Slide 23
- Electronic Patient Record System (EPR) Simple: Text-based, no
graphics/images Free text, not structured text (some templates)
Chronological structure (not problem-centered) No decisions
support/expert system functionality Some integration with Patient
Administrative System (patient demographic data) Few standards
defined So: Limited value in comparison with grand visions Far
easier to implement than grand vision EPRs 23
- Slide 24
- Norwegian Health Network Secure, separate broadband network for
healthcare sector Established 2004 (RHFs), provider role
State-owned since 2009: strategic role 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) 24
- Slide 25
- Inter-hospital communication Privacy law prohibits sharing of
complete EPR files when a patient goes to another hospital
Discharge letters are automatically sent, and the other hospitals
can ask for other reports from the EPR (not automatic) Sharing of
images and examination results Electronic (NHN) and paper (mail,
fax) 25
- Slide 26
- Region North: standardized systems portfolio: Same EPR system,
same PACS system, shared bloodbank system, same microbiology
system
- Slide 27
- Main challenges: To digitize hospitals To maintain control over
growing no. of systems To achieve inter-organizational
collaboration (digital communication) 27
- Slide 28
- Directorate of Helath Helsedirektoratet.no IT og helse E-resept
Kjernejournal Helsenorge.no Fritt sykehusvalg Min fastlege Mine
Resepter Frikort () 28
- Slide 29
- 29
- Slide 30
- Health Information Management Norwegian Institute of Public
Health Quality Indicators/Quality registers Reporting from
hospitals 30
- Slide 31
- Norwegian Institute of 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. 31
- Slide 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, management and
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 most of current medical
quality registers are based on consent. 32
- Slide 33
- Gode helseregistre bedre helse 2010-20 Strategy for modernizing
the central health registers, and the medical quality registers
Should be able to answer to e.g. How many people have diabetes in
Norway today? And which other health porblem do they have? How do
pregnant women respond to influenza? How many children are
overweight and which health problems do they have? Now, they do not
provide answers 33
- Slide 34
- Strategy concrete and visionary Introduction of electronic
reporting to all registries Use of structured and specific patient
record system as basis for developing a new reporting solution to
the national registries using Norsk Helse Nett 34
- Slide 35
- National registres Helsedirektoratet Kvalitet og planlegging
Quality Indicators 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, 35
- Slide 36
- 14 Central Health Registries The Norwegian Cause of Death
Register The Medical Birth Registry of Norway Register for Induced
Abortion The Norwegian Surveillance System for Communicable
Diseases and The Tuberculosis Registry The Vaccination Register The
Norwegian Surveillance System for Resistance Against Antibiotics in
Microbes The Norwegian Surveillance System for Infections in
Hospitals The Norwegian Prescription Database The Norwegian
Cardiovascular Disease Registry The Cancer Registry of Norway The
Norwegian Patient Registry The Norwegian Information System for The
Nursing and Care Sector ePrescription The Registry of the Norwegian
Armed Forces Medical Services 36
- Slide 37
- Central health registers FromId Responsible institution The
Cause of Death Register1925/51 Birth Id NIPH The Medical Birth
Registry of Norway (MFR)1967 Birth Id NIPH The Abortion Registry
1979/ 2007 Avid NIPH The Norwegian Surveillance system for
Communical Diseases (MSIS)1977 Birth Id NIPH The Childhood
Vaccination Register (SYSVAK)1998 Birth Id NIPH The Norwegian
Surveillance System for Antibiotic Resistance in Microbes
(NORM)2003 Avid NIPH The Norwegian Surveillance System for
Infections in Hospitals (NOIS)2005 Avid NIPH The Norwegian
Prescription Database (NorPD)2004 Pseudony m NIPH The Cancer
Registry of Norway1952 Birth Id H S- The Norwegian Patient Registry
(NPR)2007 Encrypted HDIR The Information System for nursing and
care services (IPLOS)2005 Pseudony m HDIR
- Slide 38
- Central health registers FromId Responsible institution The
Norwegian Armed Forces registry2005 Birth Id FD National Database
for Electronic Prescriptions (eResept)2007 Birth Id HDIR
- Slide 39
- 19 national medical quality registries Regional Health
authorities: South-Eastern Norway Child and youth diabetes +
Neonatal medicine + Cerebral palsy + Trauma + Colorectal cancer +
Prostate cancer Central Norway Myocardial infarction + Cerebral
stroke + Vascular diseases/vascular surgery Western Norway
Intensive care + Diabetes in adults + Cleft lip and palate + COPD
(KOLS) + Arthroplasties + Hip fractures + Cruciate ligaments +
Multiple sclerosis (register and biobank) Northern Norway Back
surgery + Hereditary and congenital + neuromuscular diseases
39
- Slide 40
- Hospital reporting Main system is PAS (not the EPR) ICD codes
(+others) entered by clinicians Hospitals report activities get
their income Activity-based cost (DRG system) The recipient (Norw.
Patient registry) forwards to health authorities, and provides data
also for other uses (research etc) 40
- Slide 41
- Activity-based fundings - 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 41
- Slide 42
- Reporting from PAS systems
- Slide 43
- PAS Patient administration system On patients: Record patient
personal information Summary of contacts Waiting lists Time booking
and notifications to patients Register of arrivals/discharges
Patient Hotel stays/movements within the hospital On hospital
personnel and resources: Register of employees and roles Scheduling
of work shifts Economy and resource use Register of services
delivered Various reports
- Slide 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
previous patient history 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 Clinical administration work 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
- Slide 45
- ICD 10 and NCSP code help
- Slide 46
- Reporting: quality monitoring Quality/performance/efficiency:
Handled locally by Dept/Hospital management Publication of data
relating to: Patient satisfaction, Waiting times, Complications
etc. Quality of treatment: Professional groups (e.g. urological
surgeons) have initiated voluntary reporting systems Manual data
entry (not pulling from EPR) Exist for >60 areas Varying
coverage, quality, security a national harmonization initiative.
46
- Slide 47
- Publication of results: Quality indicators:
http://helsenorge.no/Helsetjenester/Sider/Oversik
t-over-nasjonale-kvalitetsindikatorer.aspxhttp://helsenorge.no/Helsetjenester/Sider/Oversik
t-over-nasjonale-kvalitetsindikatorer.aspx Information for
patients: www.helsenorge.no www.frittsykehusvalg.no 47
- Slide 48
- Security/privacy policies Data protection and information
security principles: EU Directive 95/46/EC (the Data Protection
Directive) National laws National Code of Conduct defined (incl.
practical guidelines) www.normen.no (also in English)www.normen.no
Norwegian Health Network requires implementation of CoC
Datatilsynet 48
- Slide 49
- The code of Conduct 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.
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- Slide 50
- Helsedirektoratet.no Tall og analyse Quality indicators Rapport
generator Om aktivitet data 50