The Danish Health Care Sector

1. The Danish Health Care Sector Christian Nøhr Virtual Centre of Health Informatics Aalborg University Denmark

2. Society is changing Machine Intellectual Material Information Products Service Sequence Parallel Employees Entrepreneurs Hierarchy Network Local Global

3. Industrial society Stable situation New stable situation Cost of change (investment) Cost of change POST-Industrial society Stable situation Continuous change Investment Running cost

4. In healthcare: Evidencebased medicine Quality assurance Clinical databases Hospital accreditation As a basis for and as methods for professional change (running cost)

5. Facts • 5,301.345 inhabitants • Summer June July, 20 – 25 0 C winter December - February with some snow and 0 – minus 50 C • EU member with exceptions

6. Health care • Free, public (87 % tax paid) • Covering both primary and secondary health care sector, and for travelling in Europe • Free medicine in hospitals, outside some medicine is free, rest partly paid (50 – 75 %), if more than 400 US$, then the rest is free. • General practitioners 1 : 1200 persons • Private, but > 99 % has contract with public health system • You can change physician once a year (august)

7. Health care • Health is around 8 % of GNP • 76 hospitals, number steadily declining

10. Health care • Health is around 8 % of GNP • 76 hospitals, number steadily declining • Number of private hospital beds < 100 • Mean duration of hospital stays is 6 days

11. Gennemsnitlig antal indl.dage: Samlet: 28,4 i 1936 til 7,8 i 1987

12. Reasons for the decline in no. of bed days pr. admission • patients with less serious illnesses are hospitalised • changed care practice (patients discharged after surgery) • increase in diagnostic functions (group of patients for observation has grown) • births are hospitalised (typical bed days is < 3 days) • increase in number of out patients • chronic diseases are treated in nursing homes or in their own homes • patients are discharged earlier and are in worse conditions • patients moving between departments

13. Health care • Health is around 8 % of GNP • 76 hospitals, number steadily declining • Number of private hospital beds < 100 • Mean duration of hospital stays is 6 days • Health care provided by county • 14 with 200.000 – 630.000 inhabitants

15. Basic Values: • Free and equal access to health care services • Solved within the public health care services jointly financed by taxes • Freedom of choice

16. Responsibility and organisation The State: Establishment of the overall political values and goals for the public health care nationwide The Counties: Running hospital services and administration of the Health Care Reimbursement Scheme The local authority: Home nursing, dental care + a number of preventive health schemes for children and young people. Health Care Reimbursement Cards

17. Operationally Public institutions and clinics (Hospitals) Liberal professions with public subsidiaries as per agreement with the authorities (GPs, dentists, physiotherapists etc..)

18. In relation to many other countries • The individual’s financial status, attachment to the labour market, or personal insurance are irrelevant in respect to access to health care services • 2. A very decentralised structure • Physically < 30 min. between hospitals • Local authority decide on both service and tax level

19. P a t i e n t s Emergency ward Hospital General Practitioner Practising specialist Pharmacist Dentist

20. 90% of patients are treated in primary sector 10% are referred to secondary care

21. 90% of resources are spend on secondary care 10% of resources are spend on primary health

23. Registration • Unique personal identification since 1969. Ex. 060355-1761 ddmmyy-generated, unequal last digit = male, + internal control. • Central registration • Cancer diagnoses since 1943 • Death certificates since 1977 • Pathological Dept. conclusions since 1997 • All inpatients 1977 • including diagnosis, length of stays, +++ • All hospital contacts 1997 • Unique ID on medicine

24. Health and informatics • Uses unique personal identification system • General practitioners uses > 10 different systems, but close to all have one • Hospitals focus on patient administrative systems for more than 15 years • Systems for other health care areas are small, local, and not integrated • National strategy and some recommendations

25. 1: Automated record: PAS – Character based, mainly used by sectretaries • 2. Computerized medical record: Mainly scanned documents by means of: OCR and ICR • 3 & 4. Traditional paper records transformed into EMR.integration is essential, datacapture and datapresentation from various legacy systems, lab, PACS, RIS, Haematology etc. • 5. The complete integrated record. Information from the entire health care sector. Accessible across sector boarders and county boarders. The patientcan be responsible for his/her record eventually hosted by third party.

26. Why electronic health care records • Legal demand for registration of events • Still more complex system • increasing demand for efficiency – more activities in fewer days • KASIK-report, 1992: 19% of all working time spend on documentation • Growing demands from patients • ...patientassociations • ...politicians • …clinical staff

27. Documentation – analogue world Patient Physician Nurse Physio- therapist Occupa- tional- therapist Social- worker Psycho- logist Clinical dietician others Medication Medication Note Note Note Note Note Note Note Note

28. Documentation – as a principal in EHR Physician Patient Nurse Medication Note Note Note Note Physiotherapist Note Occupational therapist Note Note Notat Note Note Note Social worker Note Psychologist

29. Why develop and implement EHR • Documentation • One patient – one record • The record can be in more places at the same time • Reuse of data • Planning • Booking • Ordering & Answer • Patientflow • Quality assessment quality assurance • Integration • Patientadministration systems (PAS) • Service systems (PACS, Lab., Pathology etc)

30. Demands for application of EHR • Readiness and maturity • Organisation • Technical issues – network, workstations etc • EHR-system • Methods and backbone design • Classifications • SKS • ICD-10 (ICPC) • Nursing classification (Behandlings og plejeklassifikation) • Drugs, DFDG • HL7 • Exchange and communication standards • Medcom

31. Further applications • Patient flow • Support standard patient flows (care plans etc) • Clinical databases • Automated feeding of indicators • Research • Aggregation and statistical calculations • Administrative and management data • Aggregation, follow-up and control

32. From Division of labour Division of knowledge Patientflow To Patientflow Patientflow Shared labour Shared knowledge

33. Number of Staff categories: 1970: 4 categories  6 boarders 1995: 13 categories  78 boarders • Frustrated doctors • lost control of their own workplace and “everyday life” • Drown in paperwork, while the big decisions are made behind their back • Administrators revenge (Janteloven) • Management is hiding in their ivory tower • No common feelings or common goals in the hospital community • Changes are happening too fast • Too much talk about saving money • Ordinary days are stressful, split up and timetabled • Options to research, travel and update skill and knowledge are scanty • Quality of care are decreasing

34. Doctors are walking into a trap of competence. They loose their central role in the hospitals unless they redefine it. Hey must learn to think in economy, planning and organisation, or they will end up as skilled workers without influence. The power is taken by business people, who will run the hospitals as commercial companies. Finn Borum in MM 8.februar 1999 We are far from the situation where the hospital doctor feel the same pride of the invisible patient he cared for by saving resources as of the patient who were relieved when the doctor were too lavish with the resources. Finn Borum i MM 8.februar 1999

35. Management of the hospitals • Market based management principle: • Based on following ideas: • Two actors make deals where one part gains and the other one does not get less • Actors have all information about relevant parameters • Everyone act rational – maximising utility (homo economicus) • Every deal is converting market value to a higher personal value • Increased personal value fulfilment will lead to aggregate utility maximisation

36. Management of the hospitals • Market based management principle: • The ideal market exists when: • Actors are autonomous and free • Actors have full information – also about long term effects • No monopolies, no cheat and no coercion

37. Management of the hospitals • Market based management principle: • Organisation: • The institution is arena for internal competition as well as participant in external competition on the market • The institution will try to attract patients and perform treatment in the most cost effective way • Internally the institution will establish systems to reward competitiveness and create economic incitements in each subdivision

38. Management of the hospitals • Market based management principle: • Actors: • Hospital management: • Position the hospital in the best market position • Hospital staff: • Maximise their efforts in competitive parameters • Patients (customers): • Make informed choices of hospitals, departments and provider

39. Management of the hospitals • 2. Clinical professional management principle: • Based on following ideas: • The professionals regulate their own profession through systematic and compulsory training and education and discipline. It is based in technical specialised knowledge and skills and it has service prior to profit written in its code of ethics.

40. Management of the hospitals • 2. Clinical professional management principle: • Based on following ideas: • The provider is the supporter of the patient • Main focus is on cure prior to profit • The provider authority is based on scientific objectivity and the professions self-control and self-regulation

41. Management of the hospitals • 2. Clinical professional management principle: • Organisation: • secure professional clinical development and autonomy • offer the best treatment possible to the single patient • institutions will be organised to develop knowledge, skills and technology for treatment • protect autonomy for the treatment and research functions will be the natural aims of the management

42. Management of the hospitals • 2. Clinical professional management principle: • Actors: • Hospital management: • Support the professional development, respect the clinical authority in planning and operation • Hospital staff: • Secure the professional autonomy, individual treatment and resource slack due to the impossible standardisation of research and individualised treatment • Patients: • Have faith in the professional advice and accept the authority of the provider

43. Management of the hospitals • 3. Political / public management principle: • Based on following ideas: • The political level is the authoritative distributor of public resources • The democratic process will decide who gets what and when • Decisions are made according to input from citizens and NGO’s • When decisions are made they are carried out by a neutral and rational agent

44. Management of the hospitals • 3. Political / public management principle: • Organisation: • The neutral and rational agents will secure that we get the most out of the resources • The public bureaucracy will carry out the decisions made by the county politicians by planning, coordination and control activities • Other hospitals in the county are not regarded as competitors, but as colleagues from the same planning universe

45. Management of the hospitals • 3. Political / public management principle: • Actors: • Politicians • Prioritise and make decisions according to personal and political party interests • County officers • Implement political decisions efficiently through planning, coordination and control mechanisms • Hospital management • Coordinate the daily routines and communicate decisions from above and information from below

46. Management of the hospitals • 3. Political / public management principle: • Actors: • Professional staff • Do the daily job in the best possible way given local limits • Other departments are colleagues and only competitors for resources from the county level. • No competition to attract patients. • Patients • Will act as citizens who can impact the democratic decision process – mainly at elections every 4 years