Importance of IT Solutions in the Danish Healthcare Sector
Molshree Pandey heads the Innovation Centre Denmark (ICDK) at Royal Danish Embassy in India. She is responsible for nurturing and developing innovation networks, new product concepts and process innovation with companies, universities and key industry leaders in Denmark and India.
Jeppe Mulvad Jensen is also affiliated with Innovation Centre Denmark, India.
With a population of only 5.5 million, Denmark has managed to become a frontrunner with innovative, IT-based solutions in the healthcare sector. Digitalization has become a central part of the foundation on which the Danish healthcare sector is based and new ways of optimizing and innovating health care solutions by the use of ICT are continually being developed and implemented.
Digitalization and ICT solutions are extensively integrated in the Danish healthcare sector and Denmark is regarded as a market leader in e-health and IT based healthcare solutions in general. Denmark’s comprehensive digitalization of the healthcare system helps answer two very important questions: “why digitalize?” and more importantly “why is Denmark a success story?” While the questions are simple and the answers multifaceted, it may be argued that two important prerequisites were imperative in driving the development, namely:
• IT solutions as a response to national challenges
• A pre-existing framework
IT solutions as a response to national challenges
Denmark’s healthcare system is tax-funded and all citizens have universal and free access to healthcare services. Like many other Western countries, Denmark’s healthcare system has been under financial pressure as a consequence of an increasing dependency ratio. This is a numerical indicator that describes the ratio of dependents (those not in the labor force) to the working-age population. Since the 1970’s, Denmark has experienced birth rates below 2, which, in turn, means that the group of elders (dependents) has grown while the size of the labor force has decreased, thereby increasing the dependency ratio. As the group of elders has increased, health expenditures has proportionally increased but, at the same time, funding of the healthcare system (i.e. the tax basis) has come down considerably, owing to the decreasing size of labor force. Facing this challenge, the Danish healthcare sector, policy makers, researchers and other relevant stakeholders have been forced to rethink and reform the Danish healthcare sector. ICT solutions and digitalization have played a key role herein.
A pre-existing framework
While national challenges have incentivized the implementation of IT in the Danish healthcare sector, the existing digital infrastructure and framework in Denmark has been an important driver in the process of developing and implementing IT solutions. In this regard, the following four factors have contributed to making Denmark a frontrunner:
• Universal penetration of broadband
• E-ready population
• Civil registration number
• Secure handling of data volumes and strict legislation
Perhaps the most important prerequisite for an extensive digitalization of a healthcare sector that connects all the relevant stakeholders (citizens, authorities, pharmacies, general practitioners, hospitals, etc.) is a universal penetration of broadband and Internet connectivity. According to a Eurostat study from 2014, more than 9 out 10 Danish households have access to the Internet, which reflects the universal penetration of broadband in Denmark. In addition, Danish citizens are among the most e-ready in the world. This is evident by the fact that Denmark comes first in a Eurostat study of EU countries, ranked according to the percentage of individuals interacting online with public authorities. Thus, 88.1% Danes in the age of 16-74 interacted with public authorities online in 2015. With almost universal access to Internet and a highly e-ready population, the introduction and implementation of IT-based solutions and digitalization of the healthcare sector has been relatively easy and has only been made easier by the civil registration number.
The civil registration number is a unique and personal identifier introduced in 1968 consisting of 10 numbers that is given to all Danish citizens at the time of birth. The registration number is used as an identifier in almost all areas, like taxation, banking, social services, healthcare, etc. and public as well as many private institutions’ register and archive information according to civil registration numbers. In 2003, a digital signature linked to each personal civil registration number was introduced to enable online verification, i.e. a secure online access to personal information. Combined, the system of civil registration number and digital signature would form the basis of the digitalization that the healthcare sector would later undergo, by providing a framework to register as well as access information online.
While online access to healthcare information does have many advantages, it is also associated with certain risks. Digitalizing the healthcare sector means digitalizing highly personal and sensitive information, and therefore, safeguarding measures are of crucial importance in order to create a trustworthy system for all stakeholders. Denmark has a long tradition of personal data protection and strict legislation is in place to ensure the highest possible standards of data protection. In addition, a public authority, the Data Protection Agency, has the primary responsibility for making sure that the requirements to personal data protection are met as well as the enforcement of the laws on personal data security and the processing is taken care of. The existence of strict and explicit requirements to personal data processing and an effective enforcement agency has enabled the digitalization of highly sensitive data and has, therefore, become a key underpinning of the Danish healthcare sector.
Digital solutions in the Danish healthcare sector
To understand how these drivers have enabled the implementation of innovative solutions and improved efficiency in the Danish healthcare sector, let us look at the following three areas of digitalization:
• Digital workflows
• Electronic health records (EHR)
• Patient portal – Sundhed.dk
As previously argued, the Danish healthcare sector consists of multiple actors, some of which include general practitioners (GPs), pharmacies, hospitals, laboratories, municipal/ regional/ national authorities and citizens. Though most of these actors are part of the same healthcare system and are bound to work together, they operate as individual entities. Therefore, digitalization processing between them has been a core element of optimizing workflows and improving efficiency. As is evident in the table below, digitalization has been comprehensive in both scope and effort.
Digitalization of the Danish healthcare sector is however not limited to workflows. EHR systems have been widely adopted in the Danish healthcare system for years and by 2007, there were 27 different EHR systems. Since 2011, the 5 regions that constitute Denmark have been consolidating the number of EHR system and by 2015 the number was reduced to 1 EHR system per region. The EHR systems allow healthcare practitioners to electronically register, exchange and access patient data such as medical history, medication, vaccines, allergies and the like of more than 85% of the Danish population. According to a recent study by MedCom, 100% doctors in Denmark exchange EHR data electronically. In comparison, a research study conducted by ‘research2guidance’ and published in May 2015, concluded that the average of the 28 EU countries covered was a mere 34%. The 5 different EHR systems are linked to the “National Health Record”, which allows healthcare practitioners to access data from all EHR systems, i.e. regardless of where the data was registered and where it is accessed. Furthermore, Danish citizens can access their own personal data on ‘sundhed.dk’ (“health”.dk), by using the previously mentioned digital signature.
sundhed.dk is a patient portal that allows all Danish citizens above the age of 15 to be a part of a huge virtual medical world. The portal allows patients to:
• Access personal health data (medical history, medication, vaccines, etc.)
• Renew prescriptions
• Access results from laboratory tests
• Make appointments and communicate with personal GP
• Look up waiting times at public hospitals
• Register for organ donation in the case of death
• Interact with other patients and medical experts of the healthcare sector
According to the study conducted by ‘research2guidance’, the highest number of appointments taken online can be found in Denmark, Spain and Finland.
The advantages of digitalization
The advantages of digitalization are many and great, some of which might be obvious and intended and others surprising and indirect. The following four advantages are worth highlighting:
• Cost efficiency
• Patient empowerment
• A solid basis for decision making
• Conducting research
Cost efficiency and cost savings are derived from several different digitalization initiatives. Digitalization of workflows, EHR systems accessible by all healthcare practitioners and a patient portal allowing patients to access personal healthcare information online – these facilitate online exchange of information that previously would have been sent by ordinary mail or fax. In addition, by improving workflows and greatly reducing time spent on exchanging information between different parts of the healthcare sector, the administrative burden is lightened and healthcare professionals can devote their time and skills on patients. Equivalently, the digitalization of the interaction between citizens and the healthcare sector facilitated by sundhed.dk (e.g. online renewal of prescriptions, online appointments and communication with GPs, etc.) diverts their free time thus to more important work.
Online personal access to health data has greatly contributed to transparency in the health sector. Patient access to personal healthcare information means the patient is more well-informed about his or her own health condition, has greater insight into his or her treatment and can access the same data as any healthcare practitioner. As a consequence, dialogue and trust between patients and practitioners have been improved and patient involvement has been strengthened. Thus, patient empowerment has been a key benefit of digitalizing healthcare data.
While patient access to individual healthcare information has given patients greater insight into the decision making process related to treatments, it has also given healthcare practitioners a more solid basis for decision-making. By having easy and quick access to patients’ entire medical history, allergies, medication and the like, healthcare professionals can make more well-informed decisions, which, in turn, increases patient safety and improves treatments. Moreover, it is more likely that the information that is accessed is accurate as data is automatically integrated into the EHR system and therefore only has to be written down once while there is no risk of lost paperwork. Finally, it allows healthcare professionals to track and monitor the course of diseases over time.
The extensive patient registries containing detailed and continually updated patient data offer a unique basis for epidemiological research as well as scientific research in pharmaceuticals and clinical pharmaceutical research. As the EHR systems contain information of more than 85% of the Danish population, the sample size available for retrospective cohort studies is indeed immense. However, it is not only Denmark’s extensive patient registries that make Denmark an attractive location for conducting research. Denmark has achieved the Barcelona objective of investing at least 3% of GDP in R&D, has a strong tradition of collaboration between all actors involved in healthcare and has a strong position in pharmaceuticals and medical devices.
The digitalization of the Danish healthcare system has been extensive and highly successful, which might be contributed to imperative prerequisites that have been conducive to the implementation and acceptance of IT solutions. While this article has been limited in scope and has focused on digitalization, digitalization is only a small part of the wide adoption of IT solutions in the Danish healthcare sector. Denmark is also regarded as a market leader within tele-medicine, tele-health and medical devices and IT based solutions have thus penetrated in almost all areas of the healthcare system. As a frontrunner, the Danish healthcare sector can offer important lessons for other countries.