An Baltic healthcare network and interoperability challenges

1. An Baltic healthcare network and interoperability challenges Cisco eHealth think tank meeting Brussels 25. January 2005 Claus Duedal Pedersen MedCom

2. Agenda • Short presentation of MedCom and the status of electronic communication in Denmark • Creating a national healthcare network • Creating a interoperable Nordic healthcare network • Baltic eHealth – extending the network and developing trans-border healthcare services. • Why interoperability is difficult – case: The Nordic ePrescription • Discussion

3. FynCom 5 people Responsible for the electronic communication in the region of Funen Owned by the county of Funen MedCom 11 people Responsible for the electronic communication in Denmark Owned by the Danish health care sector The Danish Center for Health-telematics. • International projects • 5 people • Participation in EU and Nordic projects regarding electronic communication in healthcare • Owned by the county of Funen

4. MedCom - the Danish Health Care Data Network What? Who? All the stakeholders A non-profit co-operation between authorities, health care professionals and IT vendors. Create a marked for electronic communication in the Danish Health Care Sector. Ministry of Interior and Health (chairman) Ministry of Social Affairs Association of County Councils Association of Local Authorities National Board of Health Copenhagen Hospital Corporation Copenhagen Local Authority Frederiksberg Local Authority Danish Pharmaceutical Association Association of Danish Doctors DanNet (Danish Telecom)

5. MedCom - What has our focus been so far ? The most frequent flow in primary Health Care

6. Prescriptions 1039105 = 73% 1000000 900000 800000 Disch. Letters 800566 = 85 % 700000 600000 500000 400000 Lab. reports 543040 = 82 % 300000 200000 Referrals Referrals 100000 40113 =40% 0 Reimbursem 92 93 94 95 96 97 98 99 20 O1 O2 O3 13290 = 47 % MedCom, the National network: 2.7 mio. EDI messages/month GP´s with EDI : 1929 = 88 % Specialists with EDI: 485 = 76 % Hospitals with EDI : 79 = 100% Pharmacies with EDI: 332 = 100 % Doctors on Call: 15 = 100 % Health Insurance: 16 = 95 % 50 messages /min

7. 2002 - 2005MedCom IV:Intenet and EHR communication • Establish a secure IP-based network • Large scale communication project using the network • XML standards for communication with Electronic Healthcare Records in hospital • SUP – Web access to information in existing hospital systems • Communication between Homecare and Hospitals Budget 52 mill. Dkr. =6.9 mill. €

8. Background for the Internet project • The internet is here to stay !! • The pilot project in MedCom III had shown the possibilities, but the security issue was not solved. • The agreement between GP and counties – all GP must have a fast secure Internet connection before the end of 2005. • Backbone for communication between hospitals • The national health care portal www.sundhed.dk.

9. Challenges for communication in healthcare • Everybody wants to exchange data (at least ideally!) • Every small part of the health system has its own firewall, security administration, access control mechanisms etc • The solution: The connection agreement system 

10. The health sector is not like other sectors of modern society: • in most sectors (finance, transport), organizations exchange data via a few well-known applications • in the educational and research sectors, there are not as strict barriers between parties • in public administration everyone keep to themselves, exchange messages and use a few common applications • but in the health sector there is a rising need for exchanging both data and a large number of applications (many of which are not pre-defined), • and at the same time, privacy and security has to be respected.

11. Building the Danish healthcare network Pharmacy Laboratory Hospital Pharmacy County Pharmacy net Hospital Pharmacy Hospital Central node GP-system Municipality GP GP Autorites

12. The principle behind the technical infrastructure • Connecting exiting secure networks with Virtual Private Network (VPN) – to a central node. • Using existing internet connections • The “central node” adjusts to the exiting network – reuse of network structure and equipment • An new top-domain www.health.medcom (mail security) • The existing EDIFACT communication must not be disrupted

13. VPN VPN 1: VPN connections: E.g. X-ray webserver DNS Cache + Server VPN koncentrator VPN VPN VPN PIX 515E Nokia Internet VPN VPN VPN VPN VPN Pharmacy GP Municipality DanNet Laboratoty County County GP system KMDnet Pharmacy Net Pharmacy GP Municipality GPs County Pharmacies

14. 2. level of security • VPN-connections to a central “HUB” • Agreement system that controls access between IP-addresses

15. VPN VPN IP agreement on datapull from a GP DNS Cache + Server VPN koncentrator VPN VPN VPN PIX 515E Nokia Internet IP xxx www.X-ray.medcom VPN VPN VPN VPN VPN Pharmacy GP Municipality DanNet Laboratoty County County GP system KMDnet Pharmacy Net Pharmacy GP Municipality GPs County IP yyy Pharmacies

16. The ”agreement” system

17. The connection agreement system • Eliminates the need for administering a huge number of VPN tunnels • Establishes documentation of who ordered what connection and how long it is supposed to exist • Simplifies security administration • Is a simple and inexpensive solution to a problem that is common to all nation-wide health care systems

18. 3. level of security • VPN-connections to the central node • Agreement system that controls access between IP-addresses • User-id and password (in the future PKI)

19. VPN VPN 3: Login and password / Digital signature DNS Cache + Server VPN koncentrator VPN VPN VPN PIX 515E Nokia LOGIN Internet VPN VPN VPN VPN VPN Pharmacy GP Municipality DanNet Laboratoty County County GP system KMDnet Pharmacy Net Pharmacy GP Municipality GPs County Pharmacies

20. Example of an login box form the healthcare network.

21. Communications projects • Web access to x-ray pictures and x-ray reports • Web access to laboratory data • Telemedicine: • Dermatology • Videoconference for tele-psychiatry and treatment of alcohol abuse • Telemedicine: Collaboration services • Web access to healthcare data in existing hospital systems (SUP). • Web requisition of laboratory exams • Backbone for the National health portal “Sundhed.dk” – the citizens access to the Danish healthcare system.

22. Objective of Baltic eHealth • Promote eHealth as a tool to counteract rural migration • Give decision makers tools and information about eHealth • Get decision makers to use eHealth as a tool to counteract rural migration

23. Business model Guidelines & business model • Legal • Reimbursement • Organisational • Cultural / linguistic

24. eRadiology

25. eUltrasound

26. Vilnius Tallinn Denmark ??? Norway BHN Sweden The Baltic Healthcare Network

27. Works on top of different network architectures • Where all traffic passes a central hub (Denmark) • Where there is a separate network for the whole health sector (Sweden) • Where the network is a cluster of clusters (Norway) • It may also be applied when connecting remote hospitals (Lithuania and Estonia)

28. The Nordic network

29. Interoperability is not only physical: Case: ePrescription between Denmark and Sweden Background • Both countries use the edifact standard for communication • The ePrescription is widely used in both countries (75% in Denmark and 25% in Sweden) • Prescriptions are very easy to make electronic due to the high degree of law regulation. • The Nordic network would be the backbone for the communication BUT

30. Why the prescription? • There is a increasing number of people working in one country and living in the other. Increase the service for the citizens • It have since 1970 been possible to take the paper prescription with you a cross the boarder • Increases the competition – making the internal market work. • Create an example of best practices and inspire other member stats to do the same. • Creating a Nordic market for IT vendors.

31. The challenges • The edifact standard was not used in the same way so it is not possible to send a Danish prescription directly to a Swedish pharmacy – a “mapping service” between the two networks is needed. • Ensuring an up-dated medication list for the GP prescription. All GP systems has to get both the Danish and Swedish information • The reimbursement question

32. Two attempts to make a Nordic prescription were blocked • An eTen proposal in 2003 - Norma • Stopped 24 hours before submission deadline from the Danish Medicine Agency, because of political anxiety for the development in cost for the health insurance. • A project proposal to the Nordic council 2004 • Stopped by the Danish pharmacy Association because of fear of competition from the Swedish Pharmacy monopoly. There is a price variation up 75% between Denmark and Sweden – in most cases the drug is cheaper in Sweden.

33. Some lessons learned • National networks can be created from regional networks in a easy and inexpensive way • Trans-national networks can be established with preserved security • Physical interoperability does not guarantee working interoperability of services