Shareing experiences in eHealth development.

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

Sharing experiences in eHealth
development
The case Finland

Päivi Hämäläinen MD, PhD, MA
Head of Unit for eHealth and eWelfare,
Stakes, Finland

National Research and Development Centre for Welfare and Health 13.10.2006

2

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


3

2005
General practitioners work in health care centres (270).
EHR in 95,6 % of
The number of gp´s using electronic patient records
health centres .
is high. The main way of
recording patient
18/21 Hospital Districts of data in 99,4 %
Finland have EPR: The use of EHR covers evenly of them
the departments of conservative,
operative, and psychiatric treatment

2003 in use, but planned
not (9)
piloting
EHRuse 93,6% of (419)
in (4)
in
health care centres
in use (18)

Genimap Oy


4
The current regional networks
for exchange of electronic patient Patient information flow
information between organisations in
the end of 2005 (% of organisations)

100

80
60
40
20

0
Patient record Images Laboratory

Hospitals Health centres

planning(6)
Information is exchanged also
piloting (3) outside to regional networks in
in use (11) bilateral set ups.

Genimap Oy


5

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 and
communication technology (ICT). As a result of this the ICT utilization
and the choice of EHR products has varied between municipalities and
organizations.

6

History of the Finnish EHR 2.

Finland became a country with lots of (one-organization) EHR´s
that 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 common
structures 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)


7

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.

8

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)


9

Core data elements
Ydintiedot
Identification Clinical data
Hoitoprosessin tiedot
Tunnistetiedot
Patient
Potilas Problems ja
Ongelmat and Functional cap.
Toimintakyky
diagnoses
diagnoosit
Investigations
Tutkimukset
Care giver
Hoidon antaja Physiological
Fysiologiset
measurements
mittaukset Operations
Toimenpiteet
Care context:
Hoitojakso,
- tapahtumacare
Process of Nursing data
Hoitotyö Medication
Lääkitys
taiEtc.
palveluketju
Summary
Yhteenveto Devices
Apuvälineet

Terveyteen Health hazards
vaikuttavat tekijät
Other data
Muut tiedot

Elinluovutus - Lausunnot
Medical Jatkohoitoa
Organ donor will Treatment plan
testamentti ja todistukset
certificates koskevat tiedot

Suostumus
Agree to move data Treatment
Hoitotahto will

From Dr. J Komulainen
University of Kuopio 1.2. 2006


10

Core data elements are located inside
medical documents.
Core data can be extracted from these
documents, for example to produce various
listings:
Diagnoses
Medications
Risk data
Core data can be “recycled” to be included
in new documents, for example referrals,
doctor’s orders and medical certificates.



11

The place in the structured document
and/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


12

Structure of the document with HL7-CDA R2

Piia Potilas allergy ccc discharge : HL7-CDA R2
010150-xxxx blood type ab xxxx
Southern hospital
Dermatology clinic
referred from GP
texttexttexttexttexttexttext
ePrescription HL7-CDA R2

lab cgh fbg yhg
procedure xxc-234
dg ICD-10
medicine dfg ghj Decision support warning system


13

Patient care Clinical
Decision support

Scientific
research
Core data Statistics
elements
Quality Administration
assessment



How to get the core data structures
14

in 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 their
products 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 Health
and Social Affairs


15


16

CodeServer


17

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


18

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.


19

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.

HL7 structure of 20

The patient summary xxBBxx summary BB
xxAAxx AA
in the Finnish concept? xxCCxx CC

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.


21

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 theUnit for eHealth and eWelfare
Knowledge for welfare and health Päivi Hämäläinen current
22
policy;
The national digital archive of (life long) patient documents
One connectivity centre and exchange of data via the
archive
Citizens to have access (log+ health data)
The National Social Insurance Institute (Kela) will provide
the archive system
National PKI system for professionals by the National
Authority for medicolegal Affairs (TEO)
National code server located at Kela, content by Stakes
Legislation in effect 1.7. 2007, also for the ePrescription
System to be built by 2011
Stronger 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 openResearch and Development Centre for Welfare and Health
National 13.10.2006

23

Thank you for your
attention!
correspondence;
paivi.hamalainen@stakes.fi

STAKES Unit for eHealth
and eWelfare
Helsinki, Finland


Shareing experiences in eHealth development.

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