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Electronic Health Record in Denmark

Country: 
Denmark
Partner Institute: 
University of Southern Denmark, Odense
Survey no: 
(14) 2009
Author(s): 
Lene Grosen
Health Policy Issues: 
New Technology, Quality Improvement
Reform formerly reported in: 
Evaluation of the implementation of EPRs
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes yes no

Abstract

As a consequence of the structural reform of 2007 a national organization "Digital Health" was established to govern and coordinate the future development towards a convergence of existing local solutions to ensure IT throughout the healthcare sector. A strategy for 2008-2012 has been developed.

Recent developments

Structural reform supports coordinated introduction of health IT

By the structural reform of 2007 the former 14 counties were replaced by five regions, and the number of municipalities was reduced by 1/3, from 273 to 98 (also see Kjeld Møller Pedersen. "Implementation of health care reform". HealthPolicyMonitor, November 2006. www.hpm.org/survey/dk/a8/6). Until 2006 only the counties and the municipalities had the authority to decide how much they wished to invest in health IT, and they also had  the freedom to decide which technical standard they wanted to use. As a consequence of the reform, a marked change in the planning and coordination of  health IT took place. 

A national organization, Digital Health, was established to govern and coordinate the future development, following an agreement between the central government and Danish Regions. 

The Ministry of Health and Prevention now has the ultimate authority as to the implementation while responsibility for the running part is located in the regional councils and the municipal councils. Under section 193 of the Danish Health Act, the Minister of Health and Prevention may lay down requirements for health care solutions, if necessary. In this way the structure of power has changed.

Before the structural reforms, a close collaboration between the counties and the state was common in many areas. E.g. in 2003 the former counties and the central government  made an agreement that all hospitals should introduce electronic medication as well as a text module to the electronic health record by the end of 2005. The counties did not reach the goal by the end of 2005, however, and a political discussion began about the reason for the significant delay. The opposition in the Danish parliament raised the issue in a debate with the health minister in 2006. Thus, the former structure with 14 counties was accused of being ineffective as to the implementation of an electronic health record. This argument was also used in introducing the structural reform.

National Strategy for Digitalization 2008-2012

Digital Health has published a national strategy for the process of becoming digital from 2008 to 2012 for the Danish healthcare service. The strategy concentrates on the three following objectives:

  1. Digitalization - a staff tool for supporting healthcare quality and productivity
  2. Digitalization - improving services and involving citizens and patients
  3. Creating digital coherence by strengthening cooperation betweeen the many healthcare players as individual players, the public sector and across the healthcare service.

The national strategy for digitalization of the health care service 2008-2012 is based on a number of fundamental principles (National Strategy of Danish Helath Care Service 2008-2012,  p. 21). These principles apply to joint activities forming part of the strategy, as well as initiatives to be launched by individual players.

The principles are aimed at ensuring:

  • stronger cooperation through management, governance and
    coordination
  • step-by-step development of digital communication
  • step-by-step convergence of local solutions
  • well-structured projects and needs-based development
  • inclusion of the international dimension
  • further development and adaptation in the long term
  • IT throughout the healthcare service (primary and secondary sector, citizens etc.)

The first three initiatives are:

  • Implementation of a shared electronic medication record, where all the relevant professionals have an overview of a patient's medication
  • Implementation of a national patient index, so the health professional has the opportunity to see if there is information about an actual patient in IT-systems
  • Implementation of solutions of tele-medicine; for example homecare soloutions

Development since 2005

Status for hospitals: In 2009, the status for implementing  the shared electronic medication record and a text module is that all hospitals have a shared electronic medication record and all the regions have implemented as a minimum a first generation text module (not integrated in the clinical process).

Status for primary care: All family doctors have electronic records and the major part has been using electronic tools to support the workflow since 1992. The family doctors have a very advanced use of  IT and they use the IT-tools in a very proactive way to find potential chronic risk patients. 10 percent of family doctors have a data capture module integrated in their electronic record system.  The data from the systems are sent to a central database, the Data-Capture Module (DCM). From this database it is possible for each family doctor to see an overview of the quality of the treatment of chronic patients.

Danish databases in primary care and the National Indicator Project

  • The Data-Capture Module (DCM) is a Danish invention that collect data from a range of different EPJ software systems in general practice. When collecting systematic data concerning day to day work in general practice it is crucial that valid data can be obtained with a minimum time and effort for the GP. The idea of the Data-Capture Module is to catch data from the GPs PC system while he is working and with none or little disturbance of the GP.   
    Most of the routine data are collected automatically of the DCM in quality assurance project and in research projects. The capture of unstructured information can be triggered by different "events", such as setting an ICPC-code, the prescription of a medication or ordering of a test etc. Results: The data can be obtained and used for different purposes.   The programming of the Data-Capture Module has been completed and all 12 EHR systems have been certified in its use for collecting data on e.g. indicators of diabetes care and electronic audits. The data are stored in the family practice data base (DAMD).
    The family practice data base (DAMD) is a general practice specific database and in that sense it is the first of its kind in Denmark. Other clinical data bases houses data on a single clinical entity only. To establish the data base a change of the data regulation law will probably be necessary. Right now it is working on dispensation from data regulation rules.   
    It is important for GPs to send data to a database run by an organisation that GPs trust and it is important that GPs receive their data back in a comprehensive form. Moreover it is not possible for single GPs to establish cooperation with a range of clinical data bases that also houses data from the secondary health sector. It is planned that cooperation will be established through the DAMD. A DAMD steering committee, an expert group and a centre of competences has been assigned to the DAMD database.  
  • Connecting to the National Indicator Project (NIP) By now, 2 years of diabetes data have been collected and these data are send from the DAMD database to the Danish National Indicator Project, where they are analysed together with hospital data. The NIP aims to document and improve the quality of care at the national level. For this purpose, disease specific clinical indicators, standards and prognostic factors were developed for eight diseases. The project has been implemented in all clinical departments. All results are published in order to inform the public and to give patients and relatives the opportunity to make informed choices (see Jan Mainz. "The National Indicator Project". HealthPolicyMonitor, October 2008. www.hpm.org/survey/dk/a12/3).

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent rather system-neutral system-neutral
current current   previous previous

As a consequence of the structural reform  of 2007 the health IT policy has been centralized. On the one hand there are now stronger regions and stronger municipalities. The area has been profesionalized and it is the reason why there is very high professional expectations to create solutions that can make a difference for the professionals in the health sector. On the other hand, there is also a risk that IT professionals define the level of ambitions so high that a solution will never function in the real workflow.  

A new effort is to monitor the whole patient journey from the first visit at the family doctor to the hospital and to the homecare in the municipality. Since 2005 there is a tendency to focus on the results and the process and not so much on the products.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes yes no

Initiators of idea/main actors

  • Government: In 2006 a committee was set up for Digital Health (the new national IT organisation).The chairman is from the Ministry of Finance; other members are top officials from Ministry of Health, Danish Regions, Local Government Denmark, Danish Medicines Agency
  • Parliament: All parties have a great interest in the Health IT issue.
  • Providers
  • Payers: Compared to other sectors, the Health Sector lags behind in its ability to offer effective IT solutions, eg. booking of an entire course of treatment across several sectors. Citizens have expectations of IT-solutions similar to banking/booking systems.
  • Patients, Consumers
  • Scientific Community: There is a demand for data in the scientific community and therefore there is great focus on how IT can support this development.
  • Private Sector or Industry: There is a great interest in creating transparency with regard to the use of IT standards, thus making the market open. However, as a consequence of the structural reform, the market has become smaller because there are fewer purchasers.
  • International Organisations: There is a a large potential for sharing experience from other countries for example IT architectures.
  • Media: Adverse events brought to the press may have enormous political impact and therefore also contributes to the wish of politicians of having IT and quality measurement introduced.

Stakeholder positions

The health IT issue is often on the poltical agenda. All poltical parties agree upon the objective of more investments in health IT. In addition, all interest groups such as physicians, nurses, patients, private vendors and pharmacy firms support the overall objective. A new national strategy for Digitalization of Danish Health Care has also been developed and a new national unit called Digital Health has been established. The strategy should be implemented via a more binding cooperation on all levels.  

The ultimate authority is the Ministry of Health and Prevention. The responsibility for running the systems is located in the regional councils and the municipal councils . Under section 193 of the Danish Health Act, the Minister for Health and Prevention may lay down requirements for healthcare solutions, if necessary.  

The regions and the municipalities plan and manage their own projects within the frame of what has been decided on the national level. Close cooperation between the national, regional and municipal level is very important. However, the responsibility for running the health service is placed on the players. This will ensure the best incentives to streamline the work process. The consequence is that the regions and the municipalities are major players for the succesful implementation of a national strategy.

Accordingly, in the agreement between the Danish Government and the Danish Regions about the finance of the regions for 2007, the text said that the Ministry of Health has the responsibility for establishing a common healthcare documentation framework and for developing classification systems. The regions and the municipalities have the operational responsibility for handling the IT operations in the regions while the central unit (Digital Health) acts as a central requisitioner who coordinates and prioritizes the measures required to achieve the strategic objectives.

The stakeholders have different priorities. Regions and municipalities have a focus on the running and consolidation of the IT systems as well as on the development. The politicians are also interested in the day-to day running of the system when there are individual cases in the press, but otherwise the political parties focus mainly on the development of fast pragmatic solutions. For example, the national patient index, where either all important patient data is accessible or provides instructions as to where the data can be found.  

The funding context has changed. Nowadays, it is the Ministry of Finance that decides the projects that are going to be funded.  The former counties also collaborated before the reform with regard to the development of IT-soloutions to the hospitals. Accordingly, the most fundamental change is the funding.

Actors and positions

Description of actors and their positions
Government
Danish regionsvery supportivevery supportive strongly opposed
Ministry of Health and Preventionvery supportivevery supportive strongly opposed
Ministry of Financevery supportivesupportive strongly opposed
Association o fMunicipalitiesvery supportivesupportive strongly opposed
Danish Medicines Agencyvery supportivesupportive strongly opposed
Parliament
Oppositionvery supportivesupportive strongly opposed
Governmentvery supportivevery supportive strongly opposed
Providers
Professional interest organizationvery supportivevery supportive strongly opposed
Payers
Tax payersvery supportivesupportive strongly opposed
Patients, Consumers
Patientsvery supportivesupportive strongly opposed
Patient associationsvery supportivesupportive strongly opposed
Scientific Community
Research unitsvery supportivesupportive strongly opposed
Scientific associationsvery supportivevery supportive strongly opposed
Private Sector or Industry
Private IT companiesvery supportivesupportive strongly opposed
IT associationsvery supportivesupportive strongly opposed
International Organisations
International Organisation for Standardisation (ISO)very supportiveneutral strongly opposed
Integrating the Healthcare Enterprise (IHE)very supportiveneutral strongly opposed
Media
Mediavery supportivesupportive strongly opposed
current current   previous previous

Influences in policy making and legislation

In 2007, the Health Act was changed so that the Minister of Health now has the authority to set binding standards for the use of IT within the healthcare service. In other words, the stage was set for another governance structure; paragraph 193 in the Health Act.

Similarly, it was been decided who was to receive access to a patient's electronic data. According to paragraph 42 it is now possible for health professionals to see all historical data about patients without permission. However, a condition is that the patient is in ongoing treatment, the data can only be accessed during an active contact with the patient. Patients can still withhold their consent that professionals can see their data. If a patient does not consent to other health professionals being able to access his or her data, the treating physician makes a note in the record. After 2011, an interactive solution is planned to enable patients to access their own record and to themselves close the whole record or parts of the record to healthcare providers.

The regions are responsible for the data in the electronic health records in the hospitals and the National Board of Health is responsible for the data of the national registers and databases.

Legislative outcome

Enactment

Actors and influence

Description of actors and their influence

Government
Danish regionsvery strongvery strong none
Ministry of Health and Preventionvery strongvery strong none
Ministry of Financevery strongvery strong none
Association o fMunicipalitiesvery strongvery strong none
Danish Medicines Agencyvery strongvery strong none
Parliament
Oppositionvery strongstrong none
Governmentvery strongvery strong none
Providers
Professional interest organizationvery strongvery strong none
Payers
Tax payersvery strongvery strong none
Patients, Consumers
Patientsvery strongstrong none
Patient associationsvery strongvery strong none
Scientific Community
Research unitsvery strongstrong none
Scientific associationsvery strongvery strong none
Private Sector or Industry
Private IT companiesvery strongvery strong none
IT associationsvery strongstrong none
International Organisations
International Organisation for Standardisation (ISO)very strongstrong none
Integrating the Healthcare Enterprise (IHE)very strongstrong none
Media
Mediavery strongstrong none
current current   previous previous
Danish regions, Ministry of Health and Prevention, Government, Professional interest organization, Scientific associationsOpposition, Patients, Research units, IT associations, MediaMinistry of Finance, Association o fMunicipalities, Danish Medicines Agency, Tax payers, Patient associations, Private IT companiesInternational Organisation for Standardisation (ISO), Integrating the Healthcare Enterprise (IHE)

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The Danish regions and municipalities are directly involved in the implementation of new common national solutions. For instance, all three parties have a great interest in a succesful implementation of the shared electronic medication record. The interested parties are very much involved both in the development of the solution as well as having a committment to how the implementation process should take place.  

In a way, the hospitals have lost their influence on which IT solution to choose, but the IT-health experts also have an interest in contributing to the development of a cohesive national system. One of the major challenges is the financing. The focus is on some robust business cases and now it is the Ministry of Finance choosing the project to invest in.

Monitoring and evaluation

The national strategy runs from 2008 to 2012 and therefore no concrete products have yet been implemented in full scale. As mentioned above three initiatives have been launched. It is the plan that the shared electronic medication record and a part of the national patient index will be implemented as a pilot project early 2010.

In the area of tele-medicine there are already results from the pilot project, e.g. treatment of patients with chronic diaseases in their own home (Harrell 2009).

Expected outcome

The government investment in health IT has been increasing since 2005, and there is a strong focus on how to coordinate initiatives between the actors. There is a strong focus on the return of investments and good and solid business cases for new initiatives.Citizens have also become more critical as consumers. There is a need for insight into the quality of treatment and also to use comprehensive IT-tools to e.g. booking.  

As a reaction on the delays that made implementing a nationwide electronic health record by the end of 2005 impossible, there is now focus on how to develop a model for governance that commits the five regions and the municipalities to implement solutions in correspondence to national standards and requirements. Models of governance from Sweden and Canada have been used as inspiration. As a result of the structural reforms many national working groups with representatives from the counties and the municipalities have been established. Thus, on one hand the comittment to national solutions is strong, on the other hand the decision processes are much more complicated.  

Why not only one electronic health record? The health sector comprises several IT solutions, and it is not possible to merge all these into one electronic health record. Today the challenge is to integrate all these solutions so the final user will regard all the solutions as one system. Even within one kind of treatment it is not possible to join all the systems because the former counties have invested a lot of funds in various systems that were established before 2005. The heavy investments in these systems cannot be abolished within the near future.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low high very high
current current   previous previous

The IT-solutions have made it possible to monitor the quality within 10 groups of diagnosis. The hospitals and the family doctors have to report data to a national database. The data is then used to benchmark the providers, and the impact of this process has been a professional interest in improving quality, but also an interest in collaborating with the other health professionals. Accordingly, there has been a development in a more proactive direction since the former HPM survey in 2005.  There is also some resistance to collecting data, because of fear of the abuse of data and "big brother"-tendencies.  

Lessons learned since 2005 are that it is a very complicated task to implement health IT. A succesful implementation requires a close coordination between the central government and the executive actors. The new national organization Digital Health has adressed the issues and is also about to solve the problems.

References

Sources of Information

  • Harrell, Eben. In Denmark's Electronic Health Records Program, a Lesson for the U.S. Time. Thursday, Apr. 16, 2009. www.time.com/time/health/article/0,8599,1891209,00.html?iid=perma_share.
  • National Strategi for digitalisering af sundhedsvæsenet 2008-2010 [National Strategy for Digitalisation of the Danish Health Care Service 2008-2010]. Copenhagen. Sammenhængende Digital Sundhed i Danmark, december 2007.

Reform formerly reported in

Evaluation of the implementation of EPRs
Process Stages: Implementation, Evaluation

Author/s and/or contributors to this survey

Lene Grosen

The author works as deputy manager at the Danish Quality Unit of General Practice.

www.linkedin.com/pub/lene-grosen/5/679/700.

Suggested citation for this online article

Grosen, Lene. "Electronic Health Record in Denmark". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/dk/a14/5