Shareing experiences in eHealth development.

1Knowledge for welfare and health Päivi Hämäläinen Unit for eHealth and eWelfare

National Research and Development Centre for Welfare and Health 13.10.2006

Sharing experiences in eHealth development

The case Finland

Päivi Hämäläinen MD, PhD, MAHead of Unit for eHealth and eWelfare,

Stakes, Finland


Knowledge for welfare and health Päivi Hämäläinen Unit for eHealth and eWelfare2

The electronic health record, the idea of a patient summary and the new legislation in Finland

• EHR deployment situation in Finland•The history of the EHR (structures)• EHR policy/strategy• Core data• Finnish patient summary• The new eHealth legislation of Finland



not in use, but planned(9)piloting (4)in use (419)

General practitioners work in health care centres (270). The number of gp´s using electronic patient records is high.

2005EHR in 95,6 % of health centres .The main way of recording patient data in 99,4 % of them

2003EHR in 93,6% of health care centres

Genimap Oy

in use (18)

18/21 Hospital Districts ofFinland have EPR: The use of EHR covers evenly the departments of conservative, operative, and psychiatric treatment



The current regional networksfor exchange of electronic patientinformation

in use

(6)piloting (3)planning

(11)

0

20

40

60

80

100

Patient record Images Laboratory

Hospitals Health centres

Patient information flow between organisations in the end of 2005 (% of organisations)

Information is exchanged alsooutside to regional networks in bilateral set ups.

Genimap Oy



History of the Finnish EHR 1.

In the 1980´s The Association of Local and Regional Authorities designed a set of paper health records for primary care and specialized care and they became widely used. The idea was that there is always a continuity of the document on the next visit to the same organization (life long history). In the different clinics of each hospital the pages had the same structure but with stripes of different colours. Laboratory, x-ray etc pages were shared. GP file became to be always life long within the same health care centre. The "look" and the structure was transferred directly to several products first of EPRs.

The municipalities have a strong decision-making power in arranging services, which includes also the utilization of information andcommunication technology (ICT). As a result of this the ICT utilization and the choice of EHR products has varied between municipalities and organizations.



History of the Finnish EHR 2.

Finland became a country with lots of (one-organization) EHR´sthat have common looks and elements but no interoperability for exchange of information between organizations.

When bilateral and regional networking became technically possible, the organizations and regions started to define commonstructures of e-documents for the exchange (PACS, eReferral. eDischarge letter, eLab results) on local levels.

Also, when building information networks became technically available, a government supported project (Makropilotti) established ways to read the EHRs of an other organization (with patient consent)



In 2002 the government saw that promoting a more advanced use of EHR´s could be used as a tool in securing the future of health care (a wide health care program)

The Decision in Principle by the Council of State on securing the future of health care, given 11.4.2002

”Nationwide electronic patient records will be introduced…by the end of 2007”

The National Health Project, The EPR project is one of the main projects; Ministry of Social Affairs and Health; a preparatory working group 2003-2004, an implementing working group 2005-2007, budget for national level planning/implementation 800 000 euros/year 2003-07

>Regional implementation, state funding circa 10 milj euros yearly 2004 - 2005 and 5 milj 2006 and 15 milj expected 2007.



The EHR strategy defines the common semantic and technical structure that should be used in every EPR system in all organisations (includes core data, codes, interoperability standards)

1. Core data, code server (semantic interoperability)

2. Open standards for interoperability (xml-based HL7 CDA R2-standards)

3. National guidelines for data safeguarding (informed consent, secure archiving, e-signature, identification of patients, documents, professionals and organizations by ISO/OID-standard, PKI architecture)



Ydintiedot

Potilas

Hoidon antaja

Hoitojakso, - tapahtuma

tai palveluketju

Tunnistetiedot

Hoitotyö

Toimenpiteet

Toimintakyky

Tutkimukset

Ongelmat jadiagnoosit

Fysiologisetmittaukset

Terveyteen vaikuttavat tekijät

Suostumus Hoitotahto

Jatkohoitoakoskevat tiedot

Elinluovutus -testamentti

Apuvälineet

Lausunnotja todistukset

Hoitoprosessin tiedot

Yhteenveto

Lääkitys

Muut tiedot

Core data elements

Patient

Care giver

Care context:Process of careEtc.

Identification

Nursing data

Operations

Functional cap.

Investigations

Problems anddiagnoses

Physiologicalmeasurements

Health hazards

Agree to move data Treatment will

Treatment planOrgan donor will

Devices

Medicalcertificates

Clinical data

Summary

Medication

Other data

From Dr. J Komulainen University of Kuopio 1.2. 2006



Core data elements are located inside medical documents.

Core data can be extracted from these documents, for example to produce various listings:

DiagnosesMedicationsRisk data

Core data can be “recycled” to be included in new documents, for example referrals, doctor’s orders and medical certificates.




The place in the structured documentand/or the structure of the code are designed so that the computers understand that the data is "core" data and what kind of "core" data it is



Structure of the document with HL7-CDA R2

Piia Potilas010150-xxxxSouthern hospitalDermatology clinicreferred from GP

texttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttexttext

lab cgh fbg yhgprocedure xxc-234dg ICD-10medicine dfg ghj

allergy cccblood type ab

discharge : HL7-CDA R2

xxxx

ePrescription HL7-CDA R2

Decision support warning system



Core data elements

Patient care

Administration

ClinicalDecision support

Statistics

Qualityassessment

Scientificresearch




How to get the core data structuresin to all the EHR systems (products) ?

a national code server has been established

the code server stores all the common (= official versions) of different core data elements (semantics):

classifications, codes , HL7-structures, terminology

the electronic patient record products take the codes in to theirproducts from the server (updates 1-2/year)

taking the codes is free of charge and the code server (and the classification work befind it) is supported by the Ministry of Healthand Social Affairs





CodeServer



How can we make physicians and other professionals use codes?

Finnish Medical Society Duodecim has produced, together with clinicians, a large amount of synonyms that make it possible for the professionals to use their "every day" wordings and they do not have to remember the codes, just put the information on the right field in the "page" of the structured EHR

The computer will be able to handle the structured information



How is the EHR idea implemented today and how far away from the vision are we in Finland ?1. The project for common structures of the EPR was started in 2003 and is funded by the ministry and lead by the Association of Local and Regional Authorities

2. ”The minimum data set” or “core data” was defined in co-operation with different interest-groups (professionals, administration, software-enterprises), also publicly available for comments through internet, finalised and published in 2004.

3. Implementation into existing EPR-systems in pilot organizations is happening. 7 regional projects have formed clusters with software enterprises and the work is coordinated by the Association and the ministry. All major vendors are participating. Some of the elements have all ready been put in to products that are currently in testing phases and more will start running soon. MoH has promised to support projects after 2007 up to 2009.



How is the idea implemented and how far away from the vision are we in Finland ?4. More specifications for certain specialities are worked up on (occupational health care, psychiatry, dental care, child and school health care, nursing, emergency care)

5. Staff training to use to core data and the newer version of EHR products is ongoing

6. HL7 has made structures of several main documents, and they have been accepted in several products.

7. The code server was built in 2003-2004 and has been providing the main codes since 2004. In production ICD-10, Nordic codes for surgical procedures, national codes for laboratory tests and x-ray procedures, main HL7 document structures, some statistical codes. In addition a long list of other codes are given out from the code server for testing/piloting.

8. A study has been made on what codes are still missing from the list of defined core data. Preparations to have the synonyms available together with the codes has been started.



xxBBxxxxAAxxxxCCxx

BBAACC

HL7 structure of summaryThe patient summary

in the Finnish concept?It would be done by marking the chosen "core" patient data as "summary data". When you would open the file in the "summary mode" only this marked data would be shown.

Some of the regions have a set of "summary type" data in their regional spine-systems. Finland starts to build the national EHR archive next year. The national needs for creating a special patient summary will then come up, but the main idea is to share full documents.

The over all structures of Finnish EHR:s and the way the information is organized are rather common and the archive system will give access to all main documents, so it is possible that there is no national need for a summary in the form that it is planned/used in many other countries.

Discharge letters are all ready available and in wide electronic use.



Is European/international work needed?

Yes, if we want to have a summary for (international) patient data exchange situations, we still need to define together with other countries which data is the patient summary data that should be included in these situations of international collaboration on different care setups.

Medical expertise from true clinical situations,"business cases" should be the driver in the process of defining the data set for



Government decision 2006 and the current policy;

The national digital archive of (life long) patient documentsOne connectivity centre and exchange of data via the

archiveCitizens to have access (log+ health data)The National Social Insurance Institute (Kela) will provide

the archive systemNational PKI system for professionals by the National

Authority for medicolegal Affairs (TEO)National code server located at Kela, content by StakesLegislation in effect 1.7. 2007, also for the ePrescriptionSystem to be built by 2011Stronger steering role by the Ministry, close co-operation

with Kela, TEO, Stakes and a permanent national advisory board nominated by government

There is funding for 2007, planning and defining has started, call open



Thank you for your attention!

correspondence; [email protected]

STAKES Unit for eHealthand eWelfareHelsinki, Finland

Shareing experiences in eHealth development.

Health & Medicine

healthpivi hmlinen unit

development centre

future of health care

national health project

health apreparatory

finnish ehr

wide health care program

mahead of unit