Health information systems: policy and practical solutions

1
Health information systems policy and practical
solutions

• European eBusiness Support Network
• Achievements and challenges
• Oslo December 3.- 4. 2007

2
Health policy in Norway

• Interoperability in the health sector
• Consecutive national plans for IT support of
  health care
• New plan from 2008 (IT support of patient
  trajectories)
• Interoperability within health systems.
  (Hospitals)
• Interoperability between systems and sectors
• eMessages and web services
• Sector responsibility of solutions according to
  the plans
• Hospital sector and private specialists (few
  private hospitals)
• 4 health regions
• Many private specialists in small units.
  Agreements with the hospital sector and the
  authorities on some financial support.
• Community sector
• Nursing homes and home nursing. Health service in
  schools. Public health service
• Primary care physicians
• Enlisted patients (more than 98 of the
  population)

3
Hospital relevant health policy

• National committee of hospital ICT established
• Projects on support of processes
• Projects to change law and regulations to permit
  regional or national patient databases
• Interchange of information, or reading in patient
  databases?
• Preproject on National Record of Patient Summary
• Up to 200 different small systems in one hospital
• How to reduce the number of applications?
• How can one hospital wide system support more
  functions?
• Three systems sharing the marked. One system
  seems to be ruled out within few years leaving
  only two systems back.
• How to integrate relevant specialized department
  systems?
• Not been successful the lasts 15 years
• Relevant integration technology exists and firms
  established
• Supported by Innovation Norway

4
Health policy in Norway

• National projects
• Interoperability projects in all 3 sectors
• User governed (user requirements)
• National architecture of interoperability and
  standards
• National health register of addresses. Public Key
  Infrastructure (PKI)
• Mandatory national test and approval under
  consideration
• Support to vendors. Innovation Norway
  participates
• Patient summary on medication project
• In three communities. Potential of being nation
  wide
• Support of vendors. Innovation Norway
  participates
• ePrescription
• Includes support of correct prescription
• Free choice of pharmacies
• Support of vendors
• 250 mill NOK

5
The interoperability projects that put user
requirements in front
Laws and regulations National health plans
International standards
Development and tests Methods and coordination
National standards
ELIN-o
Functional requirements
Functional requirements
Functional requirements
User groups
User groups
User groups
EPR
EPR
EPR
Hospitals
Community care
Gen. practitioners
Projects
Projects
Projects
ELIN(-a)
ELIN-k
ELIN-s
Preliminary project will start in 2007 Planning
of several main projects Patient summary project
ELIN stops end of 2007 ELIN-a follow up from 2008
may be realised
ELIN-k in community care Phase 1 in 2007
Functional requirements
Functional tests and approval
Seamless communication
6
The situation at start of ELIN

• Five health regions
• Health net established in one of the regions
• Another on its way. No common demands on platform
• EPR systems in practically all medical praxis's
  and most hospitals. Few systems in nursing care
  in the communities
• Different platforms. GP systems more successful
  than hospital systems
• A comprehensive standard of EPR established
• No demands on implementation
• Some Edifact message standards established
• No demands on implementation. Lots of formats
  (dollar, XML coming up). Local adjustments. DES
  keys for encryption.
• Most messages over X400 protocol. One national
  email server.
• Lab results. Private laboratory in front. Some
  discharge letters
• No national register of EDI addresses (plans)
• No public key infrastructure (PKI) (plans)
• No functional requirements from users of the
  systems
• Vendors offered different solutions based upon
  their user contact

7
The original ELIN project

• User oriented development of electronic
  communication between electronic patient records
• Vision
• Relevant and necessary information accessible
  when needed for patient care

8
What does ELIN mean?

• Electronic interchange of health information
• The project is from the small medical offices
  point of view.
• (Both GPs and specialists)

9

• Background
• Agreement on the need of electronic co-operation
  in health care based upon functional requirements
  from physicians.
• Somebody has to represent the small medical
  offices
• Departmental initiative, recommended in report
• Gains
• Development and testing of several new solutions
  on electronic communication based upon national
  standards
• Finances
• The Directorate of Health (ShDir)
• The National Industry Fond (Innovation Norway)
• The Norwegian Medical Association (Dnlf)
• National committee of hospital IT-solutions (NIKT)

10
The project runs through 3 phases

• Phase 1
• Until December 2004
• Discharge letters and lab.results with
  application message receipt excluding the
  simultaneous sending of paper. Some Internet
  patient service. Public Key Infrastructure.
• Phase 2
• Until July 2006
• Referrals and requisition. Communication with the
  patient. Internet booking of appointments.
• Phase 3
• Until December 2007
• The good referral letter and The good case
  summary report. Dialogue function. From Edifact
  to XML for all solutions. National encrypted
  enveloping (ebXML). Refinements of the solutions

11
The functional requirements

• Part 1 - Generals from all parts
• National standards and security. General
  requirements.
• Part 2 - Requisition and answers
• Decision support system included in some
  solutions
• Part 3 - Referrals and discharge letters
• Some demands on content and presentation
• Part 4 - Medical certificates and reports of
  disability
• Electronic management at the National Insurance
  Administration
• (Part 5 - Prescription)
• Separate national project. Common pharmaceutical
  lists of medicaments. Signature. Management of a
  central part of the national ePrescription
  project. Separate requirements.
• Part 6 - Communication with the patient
• Automatic documentation in EPR, integrated
  solution. Direct booking of appointments

12
The ELIN method of developing functional
requirements

• An expert group of physicians define work
  processes and develop functional requirements
  that ultimately can be tested.
• Validation against law and regulations.
• Validation against national standards of EPR and
  health communication
• Close cooperation with national standardisation
  authorities
• Validation against response groups
• Physicians with no special IT interest or
  knowledge
• Programmers of EPR systems (redefining work
  processes)
• Related parts in the patient trajectory
• Validation against functional testing
• Development of test procedures
• Approval of the expert group
• Integrated in the vendor development agreements
• Test and updates after development iterations
• Final approval of expert group

13
The ELIN method of testingfunctional
requirements
Seamless Communication
Seamless Communication
Testscenarios
Approved message standards
Testserver
Functional test of EPR communication
EPR GPs
EPR others
Test- hospital
Test Lab Functional requirements
Pilot B-test
SAT Site Acceptance Test
FAT Factory Acceptance Test
14
The situation at the end of the project
The national architecture of interoperability
15
ELIN
Test and approval
Relevant documents

• Use of XML
• Data types
• Attachments
• FAQ
• Help functions
• Concepts

Internet
Norwegian Health Net
Address- catalogue
ebXML
PKI- catalogue
Application receipt
Message header
Content standard(health information)
Personal signature
Mailbox
16
Challenges even though user demands are put
forward in all sectors

• Should the national architecture of
  interoperability be mandatory?
• Should national test and approval be mandatory?
• Should test of basic user requirements be
  mandatory?
• What about the eBusiness and vendor perspective?
• Economic support or fully financed projects?
• What about new ideas and innovation?
• How to learn from our European neighbors?
• Are we moving towards a national patient data
  base?

17
The workshop of today

• We will discuss eHealth information initiatives
  and cases addressing interoperability and
  security issues illustrated by 3 cases and a
  panel discussion
• Case B1
• The Norwegian ePrescriptions programme
• By Nina Fladsrud, The Norwegian Directorate of
  Health and Social Services.
• Quality of prescriptions and availability of
  drugs
• Case B2
• European Health Center of Excellence
• By Project Director Kaare Finbak, Hewlett Packard
• Views on the health sector from a technology
  vendor perspective
• Case B3
• The Italian eHealth National Plan Governance.
  Implementation and diffusion of EHR
• By Dr. Paulo Donzelli, director general for
  Research and Digital Innovation Projects of the
  Department for Innovation and Technology and
  Visiting Senior Research Scientist at the
  University of Maryland
• A nation-wide Electronic Health Record
  infrastructure