The Computerworld Honors Program
Honoring those who use Information Technology to benefit society
LOCATION:
Copenhagen, N/A, DK

YEAR:
2007

STATUS:
Laureate

CATEGORY:
Healthcare

NOMINATING COMPANY:
IBM

ORGANIZATION:
The Danish National eHealth Portal

PROJECT NAME:
Sundhed.dk

Short Summary
Global health care is at a crossroads. Rising costs due to diseases becoming more expensive to treat and the emergence of new medical technologies and treatments, ageing and overweight populations, the chronically sick getting younger, and an obsolete health care system put pressure on the health care sector to optimize the delivery of care.

Health care systems must be improved in order to provide better quality service to more people, more efficiently and at lower cost. These complex factors create an urgent need to break down industry silos, establish partnerships, and increase collaboration to drive progress towards a patient-centric and cost-effective model. This transformation will require more than technology; it will require innovation and a shift to a more open, collaborative, and integrated system.

The Danish National e-Health Portal named sundhed.dk (“sundhed” means “health”) helps drive the optimization of the Danish health care sector by providing a shared infrastructure in Danish health care that enables all parties in the health sector to collaborate across professional and IT-related boundaries with the individual patient at the center.

Sundhed.dk has transformed the Danish health care sector from a silo-oriented structure towards a patient-centric structure. This shift in orientation has been achieved by an approach that places emphasis on optimization of work routines, prevention of diseases, taking action in time, supporting the right treatment, using the patient’s capacity, and collaboration within the sector.

In a testimony presented to the Congress of the US in January 2007, the President of The Commonwealth Fund, Karen Davis, stated, “Public satisfaction with the health system is higher in Denmark than in any other country in Europe. This is related to the emphasis Denmark places on patient-centered primary care, which is highly accessible and supported by an outstanding information system that assists primary care physicians in coordinating care.”


Introductory Overview
Denmark has been first mover on many IT initiatives within health services. The majority of these initiatives are based on a common infrastructure, which has helped put Denmark in pole position and create a patient-centric health sector. Sundhed.dk is a public, internet-based portal that collects and distributes health care information among citizens and health care professionals. It is unique in bringing the entire Danish health care sector together on the Internet and providing an accessible setting for citizens and health care professionals to meet and efficiently exchange information.

All Danish citizens have access to sundhed.dk, enabling patients to communicate and patients and their families to get an overview of correct and updated health care information, making the health care services appear close-by, open and familiar. Additionally, every citizen has his own personal page (available upon identification), which reflects the specific situation of this particular citizen. Here, the citizen can find accurate and updated health care information, e.g. view treatments and diagnoses from his own hospital patient record, book appointments with his general practitioner (GP) and send secure e-mails to health care authorities, order medication from pharmacies and renew prescription drugs, monitor own drug compliance, survey shortest waiting lists for operations and quality ratings of hospitals, register as organ donor, and get access to local disease management systems in out-patient clinics.

By giving access to own health information and supporting a pathway approach, the patient now is encouraged to participate actively in own treatment – realizing the vision of shared care. For example, sundhed.dk allows diabetes patients and health care professionals in one region to access the diabetes management solution DiaLog Shared Care, which is integrated into existing Lab Systems, Hospital Information Systems and Electronic Health Records (EHR). In a questionnaire study from 2006, more than 90% of the diabetes patients indicate that by means of the DiaLog solution they are better able to follow the development in their diabetes, intervene and exercise self-care. 70-80% of the health care professionals say that direct patient access means more problem-oriented interviews, increased co-responsibility, improved self-care and higher patient satisfaction.

The portal provides the 150,000 Danish health care professionals with a better foundation for decision-making. By giving health care professionals easy access to the latest patient information from most hospitals and laboratories in the country via the secure portal they get the opportunity to make quick and well-founded decisions in specific situations during treatment. In this way, the patient will experience interaction with the health care services as a much more coherent pathway.

Sundhed.dk is an important supplement to the local EHR systems at the individual hospitals and GPs. The EHR systems at hospitals contain their own patient data, but not data from other hospitals or laboratories. However, this data can be found via sundhed.dk. It gives the health care professionals access to important knowledge outside their organization and professional discipline.

Health care professionals need to be able to exchange information with other health care professionals across geographical, organizational, and technical borders. During the course of a treatment, they must be able to take into account previous examinations, lab tests, medication and compliance, and conclusions in order to provide the optimal treatment for the patient – and to avoid repeating work already performed. Sundhed.dk gives the health care professional an opportunity to find out what other professionals have examined and concluded.

In January 2007, a reform was implemented in Denmark. 15 counties were merged into five regions, and 271 municipalities were consolidated to 98. Sundhed.dk supported the reform by tying the former counties together and allowing them to communicate as one region from Day 1.


Benefits
Has your project helped those it was designed to help?   Yes

What new advantage or opportunity does your project provide to people?
Various parties within the Danish health care sector benefit from sundhed.dk – ranging from individual citizens and health care professionals to the Danish society as a whole. Examples include:

Traditionally, doctors’ and pharmacies’ handling of prescriptions takes place manually – but through the Prescription Server at sundhed.dk, a large part of this handling is now effected electronically. Calculations based on a MedCom survey and the Danish Medicines Agency’s own calculations show that substantial economic savings have been obtained. In Denmark alone, with a limited population of 5.3 million, about 1.5 million prescriptions are issued electronically every month – corresponding to annual savings of more than 12 million Euro.

The Medicine Profile on sundhed.dk automatically registers all purchases of prescribed medication in Denmark as individual, personal medicine profiles for every citizen to help improve the quality of drug therapy. In the annual report 2003-2004 from the Danish Pharmaceutical Association, reference is made to Danish and international studies, which show that 6-14% of all cases of hospitalization in medical wards is due to problems related to medicinal products. In Danish figures this corresponds to between 68.000 and 158.000 cases of hospitalization a year. Obviously, even a small reduction in medication errors has great impact on both economy and quality of life.

Improved quality of life is also the key word for the about 50,000 Danes who are currently having AC therapy. The Center for Selfmanaged Oral Anticoagulant Therapy is working on a pilot project with a group of these patients who make measurements themselves and enter the results on sundhed.dk. Algorithms then calculate whether the patient’s medication dosage has to be adjusted. Normally, patients having AC therapy must go to the local hospital at regular intervals – but with the web-based decision support, patients can now avoid the frequent visits.


Has your project fundamentally changed how tasks are performed?   Yes

How do you see your project's innovation benefiting other applications, organizations, or global communities?
Sundhed.dk is a result of a joint national effort to support health care professionals and citizens’ interaction through IT. A comparatively modest investment in infrastructure and a shared system has actually resulted in the development of services that are used across municipalities and regions all over Denmark – and have thus helped regional and local parts of the health service avoid massive investments in solutions that could only be used regionally and locally instead of being compatible.

The portal’s range of information and services has proved that it is possible to work across sector borders and specialist fields to present the user with a single point of entry that provides a general view and guides the user to the relevant information and the relevant services. Thus, sundhed.dk integrates systems that are specific to the Danish health service – but other regional or national health services, or completely different sectors or industries, will be able to obtain similar benefits by making use of the experience gained from sundhed.dk of building transparency and sharing information and systems.

Other organizations and communities can also benefit from sundhed.dk’s approach of establishing agreement on a shared basis and platform so that new services/solutions developed for one region or one purpose are made in such a way that they can also be used elsewhere as organizations and workflows are adjusted to the new electronic possibilities.

Sundhed.dk has demonstrated the benefits of integrating all new self-service solutions on the same portal, using the same security solution, thus allowing the users to get easy access to all the solutions in one go. Experience shows that many users make use of several of the offers when they visit the portal, a fact that underlines the value of gathering an entire sector in a single place.


The Importance of Technology
How did the technology you used contribute to this project and why was it important?
The challenges of the project were to provide a patient-centric and cross-sector health care infrastructure with the capability of collaboration and sharing of highly sensitive information. It was to enable a broad general access for citizens, health care professionals and IT systems. The infrastructure had to support high availability combined with the capability of deploying new functionality and access to new information at low cost and with a minimum time to market.

These challenges were met by providing an abstraction layer on top of existing platforms and applications, which made it possible to make software functionality available as agile, reusable services in a secure, private and confidential manner. Through an Internet-based, service-oriented portal environment supported by a range of standard integration packages, the project has built a national common infrastructure.

The information shared and accessed via sundhed.dk is highly sensitive personal information. As you have to meet the challenge of providing access for every health care professional and citizen, the open Internet is unavoidable. The very foundation for starting a project like the Health Portal therefore is strong security and privacy technology. The security and privacy infrastructure is based on user identification through digital certificates, portal user management, and network and database encryption.

Presentation management is supported by a role-based and personalized, customizable portal environment. The portal must provide information to a large range of user groups: physicians; GPs; pharmacists; dentists: chronically sick, frequent users; occasional users; etc. Every user group has its own special requirements with regard to the information it needs and how it is presented. To handle all these user groups’ special and sometimes personal requirements combined with almost 100 different applications, adding new applications to the portal every three months, it is crucial to have technology handling presentation management.

One of the fundamental ideas of sundhed.dk is to provide access to all the existing IT systems already residing in hospitals, out-patient clinics, labs, GPs, national databases, etc. In the process of integration, there will be all kinds of different IT systems with different capabilities to provide access to the information. Some will be able to provide online access directly to the information and some only to their graphical user interface. Others will not be able to meet the high availability requirements for online access and will have to provide the information asynchronously.

The challenges of integration can be a boundary that will hinder the very start of a project. To succeed, the technology stack therefore has to support a range of different ready-to-use, low-cost, short-time-to-market integration packages. The Health Portal’s integration framework supports such packages and is based on a service-oriented architecture providing integration to nationwide, existing IT systems by means of web services, remote portlet concepts, and single sign-on.

More than 800 health care professionals provide documents to the portal about medicine, diseases, treatments, guidelines etc. To help the end user find the information on the portal, every document must be tagged and categorized by the editors. To ensure this, it is crucial that some of the tagging is provided automatically. The portal information architecture therefore supports technology based on content management, automated meta-tagging and a thesaurus-based search engine.

To give health care professionals such as doctors on emergency duty access to critical patient information like medical history, allergies to medicine, etc., the portal must be available 24/7/365. Therefore, the Health Portal’s hosting environment is based on technology supporting high availability through a full mirrored environment combined with a complete matching standby environment.

Sundhed.dk is based on IBM WebSphere Portal Server, IBM WebSphere Application Server, IBM DB2, and IBM Tivoli Access Manager.


Originality
What are the exceptional aspects of your project?
Sundhed.dk is a peaceful revolution of communication and collaboration within the Danish health care sector. While most public-sector websites are about to adjust to current requirements and expectations, sundhed.dk was developed from the outset with just this type of service and dialog in mind to enable all parties within the Danish health sector - including the patient - to communicate and collaborate via a single, shared web interface by means of a shared infrastructure.

The portal provides a high return on investment on the solutions that are developed. Advisor Thomas Weis Moeller from Danish Regions says, “We started posting all available health care jobs in certain professions in public hospitals on the portal and eliminated print advertising. This allowed us to save 6.5 million euro a year. I have never seen this kind of immediate return of investment.”

Among other factors contributing to a high return on investment is the fact that users are able to develop solutions and services based on local needs – but if the solutions are made available via sundhed.dk, they can be reused by other parties as the need arises or they become able to digitalize their processes and data. This way, sundhed.dk helps promote the general digitalization process in the Danish health service.

Sundhed.dk has become an integrated part of the everyday life of the Danish health sector and of Danish citizens and an invaluable tool for the Danish health sector in leveraging the patients’ own capacity more and more, improving treatment quality and reducing total costs – exactly the opposite of the general trend within health care. A Gartner Industry Research Report from May 2006 concludes, “Through careful use of IT, the Danish health system has saved money, improved efficiency and laid the foundations for improvements in the quality of care.”


How is it original?
The idea behind sundhed.dk was to create a single point of access to the Danish health service for citizens and health care professionals by gathering existing as well as future information and communication within the health care sector. Behind the user friendly interface of the portal lies a complex infrastructure of connected networks and databases from many parties in the health sector. This infrastructure across sectors and technologies has been created with very few means by using existing data as the basis, connecting the databases and at the same time supporting an efficient and structured exchange of data among relevant parties in the health sector.

Based on MedCom’s (Denmark’s coordinating organization for health care IT) existing infrastructure, sundhed.dk has transformed the Danish health service from consisting of information islands of independent, individual solutions and databases, each with its own limited group of users, into a structure that is based on the joint use of standard solutions and sharing of data.

With this structure it is possible at all times to include new ways of using existing solutions and include new groups of users in solutions that could previously not be shared – and at a very limited cost, at that. An example of this is the ongoing development of the so-called “Agreement Book”. Patients missing appointments for interviews or surgery costs the Danish health service a considerable amount of money. It is expected that this cost can be reduced significantly through an automatic transfer of appointments to the patient’s personal Agreement Book from which the patient can receive reminders via mail and at some point also via sms (text messages). The price of the solution is very moderate as all agreements between patients and health care professionals are already registered in systems at hospitals, out-patient clinics, GPs etc.


Is it the first, the only, the best or the most effective application of its kind?   All of the above

Success
Has your project achieved or exceeded its goals?   Achieved

Is it fully operational?   Yes

How many people benefit from it?   5.3 mill

If possible, include an example of how the project has benefited a specific individual, enterprise or organization. Please include personal quotes from individuals who have directly benefited from your work.
Sundhed.dk integrates many independent solutions, each aimed at its own target group that obtains various benefits by using the portal. Examples from sundhed.dk newsletters include:

E-Journal on sundhed.dk gives access to hospital records for GPs, thus enabling them to read details and relevant information from hospitalizations as soon as the hospital has put them in their EHR systems. GP Joergen Damsgaard says, ”It always takes some days to get a discharge letter, and it’ll make my work easier if I can get the information right away by means of e-Journal, for instance if a patient calls me and is uncertain about something in connection with the medication after being discharged.”

My e-Journal is a personalized access to hospital records for citizens. 43-årige Jannie Larsen says, ”My e-Journal will be a tool to help me understand my own situation and to ask my GP for in-depth explanations, when required. I think my e-Journal can shorten the way between citizens and the hospital.”

GP Claus Bache says about electronic prescription renewal, ”Not so long ago, we became two doctors instead of just one, and since then the secretary has been very busy. We hope that the new possibilities will mean that we don’t have to hire more staff and that we can avoid the costs involved. The electronic prescription renewal will especially benefit chronically sick patients who get non-addictive medicine.”

GP Anny Adeler says about electronic lab results available via sundhed.dk, ”I get an overview of the course of disease because I can always look up the tests that a patient has had. It saves resources because I can quickly look up figures while having the patient with me. Previously, I had to ask my secretary to have figures faxed from the lab – and it involved a lot of people’s time.“


How quickly has your targeted audience of users embraced your innovation? Or, how rapidly do you predict they will?
Sundhed.dk has been in operation since 2003 and is constantly being developed through new functionality with additions about every three months since its launch. The original objectives of making functionality that works available to citizens and health care professionals have been met – and the constant demand for new solutions that are to be developed for or integrated with sundhed.dk ensures that the possibilities on sundhed.dk keep increasing.

Sundhed.dk has up to 270,000 unique users every month, and the support from the citizens is fast increasing. Out of the 42% of the Danes who know sundhed.dk, more than half used the portal in the course of 2006.

The high degree of use was made clear for instance in mid-September 2005 when information on all cases of hospitalization in Denmark recorded during the past 30 years in the National Register of Patients was made available on the portal. Normally, there have been between five and ten requests a year from patients who wanted access to their own diagnoses and treatments – but in just one month, 41,000 Danes accessed their own hospital treatments on sundhed.dk.

The usefulness of sundhed.dk varies from target group to target group, which naturally affects adoption rates. The target groups that gain the most benefits (such as the chronically sick and other heavy users of health care) embrace the new services and possibilities on sundhed.dk relatively more quickly than the average Danish citizen.


Difficulty
What were the most important obstacles that had to be overcome in order for your work to be successful? Technical problems? Resources? Expertise? Organizational problems?
The overall critical factor in bringing sundhed.dk to reality has been the organizational and political aspects. The successful implementation first of all needed a powerful management with the participation of the most important stakeholders. The project had to make fast results, focusing on the stakeholders’ benefits. Communication standards were needed – and of course a well-planned IT project.

The project was broken down into three main phases. The first phase of the implementation was concluded with the launch of sundhed.dk as an information portal on 10 December, 2003. Efficient communication and distribution of guidelines were among the national benefits of this version. The next version supported collaboration based on functionality such as a reduction of double tests and entering of information only once. In 2004, the final phase of the portal was implemented, now turning sundhed.dk into a full portal offering full communication and the ability to monitor and optimize treatment by sharing the same EHRs.

The Danish health care authorities provided a vision and strategic direction for a national, interoperable health care system, but they relied on the private sector to provide a competitive technology industry, privately operated support services, and shared investments in health IT adoption. One of the main reasons for the success of sundhed.dk is that throughout the process, great emphasis has been put on allocating sufficient resources for establishing the right conditions for developing and running the portal, involving the right stakeholders at all times.

To optimize the actual value of sundhed.dk now and in the future, the focus will continue to be not only on the technology itself, but also on the prerequisites for leveraging its potential – thus making it imperative to carefully align incentives, maintain and elaborate a culture of collaboration, and maintain a correct balance between central and local leadership.


Often the most innovative projects encounter the greatest resistance when they are originally proposed. If you had to fight for approval or funding, please provide a summary of the objections you faced and how you overcame them.
The biggest objection faced by the sundhed.dk project was of an organizational nature. It was a major challenge to embed local and regional websites in a new, national brand that people could not identify with right away. The challenge was emphasized by the fact that, in the idea and establishment phase, the sundhed.dk project was based on the regional and local environments that were resourceful and leading in the web area. Thus, paradoxically, the project had to work closely together with the environments that, with the new national brand, would lose the most in terms of identity and feeling of ownership for their own website. As regards resources, criticism was voiced by general practitioners who maintained that their IT systems would require expensive upgrading if they were to handle the coexistence with sundhed.dk. Parts of this criticism should probably been as a consequence of the fact that in the early phases of the project it was not yet natural for everyone to see their own activities in a national perspective where an effort was made to coordinate everything. It was a challenge to make the general practitioners adopt the national, joint, public digital signature. It was difficult to install, and initially the solution did not provide the required mobility as regards switching from one machine to another or visiting patients. Here, the sundhed.dk project succeeded in establishing an excellent collaboration with the General Practitioners’ Organization, practice consultants, and the Association of County Councils, and through a joint effort the parties were able to roll out the signature. Today, the practice sector is the best covered sector (more than 90% of Danish GPs have a digital signature), and it has become a general agreement requirement that all GPs are to have electronic signatures at the end of 2007.
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