Primary care physicians' communication networks in ...

Primary Care Physicians' Communication Networks in Central Europe Sandor Vari' ,Morten Bruun-Rasmussen', Bostjan Bercic3Gem Nagy4Ilias Iakovidis' 'VARIMED Ltd., Budapest, Szalanci U 5, H-1124 Hungary, varimed(ii,matavnet.hu 2 Danish Centre for Health Telematics, 3

Heden 18, 5000 Odense C, Denmark, mbrmhealth-telematics.dk INFONET, Planina 3,4000 Kranj, Slovenia. bostian.bercic@,infonet.si

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Semmelweis Hospital, Dept. of Anesthesiology and Intensive Therapy Miskolc P.O.Box 187 H-3501 Hungary medaninf@,alplia.bzlo~i.hu

'European Commission, Directorate-General Info&ion Society Rue de la h i 200, Brussels, Belgium, B-1049, Ilias.IAKOVIDJS!ii:cec.eu.int The need to curtail health care costs in general by the transfer of patient from the secondary to the primary health care sector. 0 The demographic trends towards aging populations, with their greater dependency and higher health care needs; 0 The increasing involvement of primary care in prevention 0 The political changes in the structure of the health care systems with the enhancement of the gatekeeper role for GPs. Health care providers can no longer focus solely on treating the illness they must treat the patient. The multi-disciplinary care team has an essential role to play in the provision of comprehensive care to those with complex needs in the community and the sharing of information between members of the team is critical to ensure the co-ordination and continuity of care. Information technology applications can play a major role in facilitating this integration of the health care system. The ruling characteristic of general practice in organizational terms is its dispersion: small units, often single handed doctors working independently and acting as both gatekeeper and advocate for their patients withii the secondaqdtertiary sector. Within such a set-up, the need to facilitate communication and information exchange is enormous, between GPs and their hospital colleagues, between GPs and other members of the Primary Health Care Teams and between individual GPs. There are differences between European countries with respect to the organization of health care, the

ABSTRACT

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The complexity of the Health care system is increasing. More and more information is sent between e.g. hospital departments and general practitioners. The demands are growhg as to timeliness and quality of the information sent. The future must be seen as to lie in electronic communication network The European Commission under the Fourth European Framework of the NCOCOPERNICUS programme sponsored PRIMACOM - the acronym PRIMACOM stands for PRIMAry Care Physicians COMunication Network - project (PL961090). The objective of PRIMACOM was to establish Regional Health Care Network in regions in Hungary and Slovenia. In the project, experience from Denmark and Italy has been used and European standards for exchange of discharge letters. PRIMACOM has paved the way for other implementation projects and has been supporting dissemination of the Regional Health Care Network technology. This implies a better service for patients, higher professional standards and a more efficient health care sector. Keywords: primary, network,

secondary care, regional

INTRODUCTION Across Europe, four main factors are increasing the importance of the Primary and Community Health Care sectors:

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position of general practice within the health care system and with respect to the implementation of information technology. In some countries the GP has a key role as the gatekeeper to services. In others general practice is very poorly developed. In some countries there is a very high level of computerization amongst GPs and good national support for the implementation of information technology within primary care, while within other countries the use of information technology in general practice is in its infancy (Table 1). Compute

Denmark Germany Hungarv Belgium Italy RerAreland France Spain Portugal Slovenia

65 55 I45 30 30 27 25

20 10

Patient

Gate-

1 0 1 0

1

1

1 0 1 1

implicates that data once entered can be re-used in another system by other health care professional. Thus, data may be integrated in the receiving system, be presented in new ways (i.e. present laboratory data as graphs), be aggregated and used for new purposes as billing, research and health surveillance. By using EDIFACTs in combination with electronic mailbox systems, many different systems and communication partners can be interconnected Existing systems can be used as long as they contain data in structured form. Any vendor can connect to the (logical) health care network by converting their data to a common structure - the EDIFACT. The regional health care network establishes communications between the most important parts of the health care sector the hospital and the Health Care primary Centers.

0 1 0 0 1 0 1 1

A

Table 1. Use of computers in general practice in relation to health care system characteristics. In Denmark and UK there are national strategies and programs for implementation of electronic communication between health care sectors. In these countries where the general practitioner has a specific position and acts as the central co-ordinator of the information related to the patient, holds a patient list, and functions as a gatekeeper in the health care system. In Denmark a large scale Regional Health Care Network is running in daily use in the County of Funen. A national program in Denmark aims at transforming regional networks based on 1ocaVnational standards to a national network based on European standards. [l] The basic idea of using European standards for textmessages - the Electronic Data Interchange for Administration, Commerce and Transport (EDIFACT) standard - is that structured data can be transmitted from one system to another. This

Figure 2. Structure of a Regional Health Care Network On longer terms communication can be established between the GPs' electronic health care record system (EHCR), the hospital's patient administration system (PAS), the laboratory's information-system (LIS), the municipalities' home care system, the pharmacy system (PIS), and the radiology department's information system (RIS). The essential part of the integration technology comprises a regional mailbox system and a standardized interface integrated in the individual information systems already used in the region. [2] The mailbox system is the hub of the health information system and functions in the same way as an ordinary e-mail system: From the mailbox, each participant (physician, laboratory, hospital) fetches 29 1

Hungary - the Miskolc region The health care system in the Misckolc region has three levels, primary, secondary and tertiary care: General Practitioners Specialists at ambulatory care 0 Specialists at hospitals. The Miskolc region has 450,000 inhabitants. In Miskolc town there are more than 100 General Practitioners and four hospitals. Most of policliiics are attached to hospitals but some specialists are working in group practices. The General Practitioners have the gatekeeper role, with some exemption, for instance gynecology. GP-s generally working in well-equipped offices, with one ore two nurses per doctors. GPs have patients’ list generally having 1.550 to 2.000 patients in each. Primary care pediatricians treat children below 14 and adults are treated by ordinary GPs. Written discharge and referral letters performs the connection between the levels of health care.

his or her personal mail - and via that mailbox letters are sent to other participants. Unlike many other integration methods, the mailbox technique works around the clock, even if the recipient’s computer system is not active. And the mailbox technique is highly suited to standardization. The mailbox may be Internet based, and the transmission of the structured (EDIFACT) message may take place via the Internet. The other important aspect of the integration system is the setting-up of a communications module in the existing computer systems in the region, e.g. in the physician’s electronic health care records and the hospital’s PAS system. The communications module consists of two standard programs, i.e. a communications program and an ED1 converter. The ED1 converter changes the data of the application (i.e. an electronic record system) to a valid EDIFACT message. The communication program connect the system to the mailbox, transmit the message and shuts down the connection. This methodology ensures the maximum of security in a simple way. [3] There are basically three different ways of setting up the mailbox services: 0 Setting up a X.400 message handling system with complete protocol connectivity from the remote User Agent at the sender’s computer to the remote User Agent at the recipient’s computer. Using VANS suppliers (Value Added Network Savices), that may use any message handling system There is usually no complete protocol connectivity from the sender to the recipient. Users are usually linked to the mail box service with a ftle transfer protocol. Using Internet mail (Simple Mail Transfer Protocol) as the message handling system. These three dflerent alternatives basically support the same functional requirements. The aim of the PRIMACOM project was to establish regional networks between the most important parts of the health care sector using existing technology, common EDIFACT standards and electronic “store and forward” mailbox techniques.

Slovenia - the Gorenjska region The health care system in the Gorenjska region has two levels, primary and secondary care: General Practitioners in private clinic 0 Specialists at hospitals. The Gorenjska region has 200.000 inhabitants and there are 120 General Practitioner’s clinics and one hospital. The General Practitioners have the gatekeeper role. Written discharge and referral letters performs the connection between the levels of health care. Implementation process The works to be done in PRIMACOM were divided into a number of activities, which natural could be identified and the overall flow is described below: Study of the existing infrastructure The aim of the study was to describe the existing infrastructure and to identify the needs for new technology, standards and upgrading of hardware and software. Upgrade of the misting infrastmcture The upgrading was based on the Infrastructure report. The upgrading included new communication technology, upgrading of hardware and software and Internet connections.

MATERIAL AND METHODS

In Hungary and Slovenia the General Practitioner has a similar role holds a patient list, and functions as a gatekeeper in the health care system. All applications installed on pilot experimental networks at the two sites in Hungary and Slovenia are integrating Health Care Primary Centers and one referral Hospital.

Education and training 292

A workshop was organized in Denmark with demonstration of the Regional Health Care Network in the County of Funen. Also a training course in how to implement EDIFACT were held. Technical personnel, users and regional project managers from Hungary and Slovenia participated in the workshop and training course.

also used for “progress reports”, in cases where the patient remains under the care of the hospital physician. In the PRIMACOM project, the message to be implemented (MEDDIS) is a usual EDI-Message. The acronym MEDDIS stands for “discharge report”. The EDIFACT message is divided into a number of main sections, segment groups and segments. The segments are made up of data elements which may hold codes covering countries, hospitals, medicines, languages, etc., the associated code meanings or free text. Segments and data elements containing certain types of information, e.g. name and address, are given a unique identifier and reused in various EDIFACT standards. In PRIMACOM MEDDIS therefore denotes any letter from a hospital-based physician, or specialist outside a hospital, to a GP. The PRIMACOM MEDDIS message was based on the functional description in the CEN TC 251 PT3024 Document.

Customization of systems The Danish Electronic Patient Record System, Medex, was translated into Hungarian. Necessary (Hungarian) classification and coding systems were also build into the Medex system, before installation in Hungary. In Slovenia the Electronic Patient Record System provided by InfoNet were also customised to be connected to the Governmental Network. Implementation of standards An English version of the EDIFACT Message Implementation Guide (MIG) for discharge letters was used as basis for the work The European standard is very broad, and a smaller and more precise version was needed to make the message implementable. The adjustment of the standard to use for implementation in Hungary and Slovenia was based on the implementation Danish experiences. The customized record system was installed at the user locations and connected to the networks. The Hospital departments generated a few discharge letters and in the first test were to check if the message (file) was received correctly at the GP clinics.

RESULTS Surveyed physicians in Hungary and Slovenia overwhelmingly agreed that they do not have sufficient information about telemedicine. Their awareness of telemedicine’s applications and capabilities is minimal. Also, responding physicians indicated little knowledge regarding such important issues as cost-effectiveness, reimbursement, liability, and potential primary care benefits. In general, however, physicians’ attitudes toward telemedicine are favorable. The aims of the PRIMACOM project have been to establish Regional Health Care Networks in Hungary and Slovenia based on European standards and experiences from the European Communities.

Dissemination After checking that data was send correct from the Hospital departments in EDIFACT MEDDIS format and received and unpacked in the GP clinic systems, more locations were added to the network

PRIMACOM: the result3 0 Regional Health Care Networks have been established in regions in Hungary and Slovenia. In Hungary the Regional Health Care network is based on Internet services. In Slovenia the Regional Health Care Network is based on the Governmental Network, which include Internet services. European standards for sending discharge letters have been adjusted and implemented in regions in Hungary and Slovenia. Discharge letters are daily send out electronically from Hospitals to General Practitioners in regions in Hungary and Slovenia.

The PRIMACOM discharge letter Prior to PRIMACOM project in the two central European regions a discharge report was made whenever a patient was discharged from hospital (inpatient department), or when care terminated for a patient (outpatient department). It should be noted however, that the term “discharge report” is rather ambiguous. Discharge reports are usually send when a patient had been admitted to an in-patient department, and is discharged out of the hospital, or when a patient fell under the care of a hospital physician, and is discharged from care by that physician. However, the term “discharge reports” is

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regions are usually not charging any fee for the proposed service. Accordingly to its statutory mission, they do not have the mission of "making business", but they are dedicated to provide the best services for their citizens with as high a quality as possible to the lowest cost possible. Benefits for the health care authorities concern more savings than revenues. The work in PRIMACOM based on the European standards for Electronic Data Interchange (EDI) made by CEN TC 251. The European ED1 standards for Health Care have already been implemented in several regions in European member states and especially the Danish experiences have been a valuable input to initiate the work in the two regions. From the early beginning of the project it has been planned only to implement one standard for electronic exchange of discharge letters between Hospitals and General Practitioners clinic. The most essential part of the integration technology comprises a regional mailbox system and a standardized interface integrated in the individual IT systems implemented in the regions. The standardization of the Healthcare messages themselves (encoded in EDIFACT) was the ultimate goal. At this higher level, medical practitioners were able to decode and comprehend the meaning of the specific clinical message irrespective of where it was generated It is highly desirable for the General Practitioner to gain access to both interpersonal email and structured messages through one integrated system. It is also the key to gaining the cost benefits offered by the electronic exchange of health care information. Besides the many positive aspects, in building regional health care networks a lot of barriers have been identified in PRIMACOM: The different organizations have to agree about the transfer and content of data to be transferred. 0 Who is going to finance and maintain the establishment of the network? In most cases the benefit from the electronic communication is for the receiver, but the sender have most of the cost for the electronic communication. Cost of equipment and skills necessary for regular and smooth use of computer protocols in data entry and exchange. Political awareness is relatively high but not always supported with proper distribution of resources.

PRIMACOM has provided standard only for the discharge letter and demonstrated the use of best practice. To disseminate the results a workshop was held in Budapest the 2"d November 1999. Among the participants were Board of Hungarian General Practitioner, Ministry of Health Slovenia, University Medical School of Hungary, National Institute of Primary Care and Physician Associates Budapest. Results in Hungay - the Mkkolc region An Internet based mailbox system has been established Discharge letters from all departments in Semmelweis Hospital are daily send electronically to the GP, which are connected to the network. 8 General Practitioners Clinic are connected to the network and receive daily all their discharge letters from Semmelweis Hospital electronically. The Danish Electronic Patient Record System Medex has been translated to Hungarian and adjusted to local use in Hungary and installed in the 8 General Practitioners Clinic. The Hungarian Company PRAXINFO, which develops and sells Electronic Medical Record systems have been educated in implementing EDIFACT messages. Results in Slovenia - the Gorenska region Use of the secure governmental network and mailbox for transfer of discharge letters Transfer of discharge letters from General Hospital Jesenice, General Hospital Novo mestro, and General Hospital Slovenj Gradec. Connection of Primary Health Clinics for receiving of discharge letters in Kranjska Gora, Jesenice, Kranj, Radovljica, Bled, Novo Mesto and Slovenj Gradec. The Slovenian Company Infonet, which develops the Electronic Patient Records systems for the Hospitals and Primary Health Care Centers have been educated in implementing EDIFACT messages. The fact that more users connected to the network in the Miskolc region in Hungary and that the Gorenjska region in Slovenia has paved the way for a national Health Care Network is major achievement. DISCUSSION The PRIMACOM project has been based on the regions and the regional health care authorities. The 294

Safety of the data is one of the highest priorities of legislation and raises public awareness of the topic sometimes hinders politicians to make update and sound decisions, but exchange of data between the providers of care is fostered if the safety is assured Today the pilots have the infrastructure and technology in place and a limited numbers of partners are using the systems daily to exchange data. In the future it will be much easier to disseminate the concept and get new organiZations and users connected to the regional health care network. The concepts can also easier bee expanded with new messages for exchange of laboratory request and reports, referrals, prescriptions, reimbursement claims and many more. It is not any longer a technical problem to establish electronic communication in two Central European countries in the health care sector. More details on the challenges towards wider implementation can be found in [4]. The standardization of network application services (in this case email and electronic messaging in general) and network protocols are significant in the proliferation of global network services. Scaling the advancements and the rollbacks it is clear there is an enormous potential to apply information technology to support the work of general practicdprimary care and to improve the quality of work in this sector in Central Europe. There is no doubt about it in the near future information technology application will be a fundamental feature of the GP office. Such a future may not be very far away that already computerization has become the rule rather than the exception for GPs in many parts of Europe and Central European countries.

part of the care process. They became more prepared to, and are now better able to see, the possibilities of the future. PRIMACOM also provided valuable experience even for many outside the project. These results should be regarded as essential reading for anyone involved in or considering regional health care networks. PRIMACOM has documented that once a technical solution has been developed it is possible to transfer the knowledge across borders and promote establishment of regional and national health care networks. The user involvement from the very beginning of the project has been determinant for the possibility of wide adoption of the European standard messages in the regions. PRIMACOM has opened many perspectives for exploitation of the results. It has paved the way for establishing regional and national health care networks in Hungary and Slovenia. Reaching fullscale implementations, however, will require additional resources. We are convinced that electronic messaging within health will benefit the quality of care, even with positive cost / benefit analyses. Finally, it cannot be stressed sufficiently that all these results are valuable irrespective of the technology used. All standardization and consensus activities, and all experiences gained will remain valid whether EDIFACT, HL7, XML, or any technology emerging in the future, is used. The views developed in this paper are that of the author and do not reflect necessarily the position of the European Commission

CONCLUSION The existing methods of communication - paper, telephone and, more recently fax are more or less able to support our present health care systems but are likely to prove inadequate in the coming years. There will be greater demands for information relating to both the administrative aspects of health care and the clinical interventions made by all the involved professionals. Making the most efficient use of old and new technology, to counter market imperfection, requires making decisions based on a better-informed health care system, PRIMACOM provided valuable experience for all participants in the project. Health care professionals came in contact with health care delivery of the future, in which communication will be an integral

1. MedCom - the Danish Health Care Network towards the year 2000. March 1998.09.04

REFERENCES

2. Morten Bruun-Rasmussen, Knut Banstein, Sandor Vari, Bostjan Bercic. “Building Regional Health Care Networks in Europe”. Proceedings of MIE 99 conference, Lubljana, Slovenia. 3. Morten Bruun-Rasmussen, Knut Banstein, Sandor Vari, Bostjan Bercic. “Regional Health Care Networks”. Proceedings of Eurasia Online ‘98 conference, Almaty, Kazakhstan. 4. Iakovidis I., Towards Personal Health Record: Current situation, obstacles and trends in implementation of Electronic Healthcare Records in Europe,” Intern. J. of Medical Informatics, vol 52, NO 123, pg. 105 -1 17 (1998). 295