This short series explores the state of healthcare IT and digital health in Finland, Norway, Denmark, and on a broader scale. The topics addressed include national healthcare infrastructure, access to healthcare, care for the elderly, and more.

Nordics Series 1/4: Denmark, Elderly Care and 34 Years of Access to Doctor Notes (Erik Jylling)

Denmark has had electronic health records for years. Doctors can access information about a patient’s diagnosis, medical visits, an overview of medications, diagnostics, lab results. Once a day, data from all healthcare institutions, regardless of the vendor, get transferred to the patient portal.

However, this is all available as free text from the GP’s office, says Erik Jylling, the executive vice president of Danish Regions. Through the patient portal patients can decide who can see their information and can also see who has been loking at their data. If it’s an unauthorized clinician, that clinician in a hospital would lose his job if there was not a sufficient reason to browse through the patient’s record.

Denmark offers its residents universal health coverage - everyone is eligible for healthcare, including registered immigrants and assylum seekers. The government sets the regulatory framework, but healthcare is executed financed and planned on regional and municipal levels. There are 5 regions and 98 municipalities. 

Denmark also has an electronic national medication register, where all the patient’s medications are stored. So how much paper is still used in healthcare in Denmark? “It's all electronic and it's electronic by law. You cannot provide a service within the healthcare state if you're not connected to the infrastructure. So all prescriptions, everything is electronic. Of course, the patient has a right to have their own patient records in a hard copy. You should be able to do offer tthat, of course,” says Erik Jylling, who has been deeply involved in planning, organizing, and leading the Danish healthcare system with the view from different professional perspectives and positions, practical and political. 

He earned an M.D. with 25 years of practical experience in anesthesiology and intensive care medicine. He has worked as a consultant, head of department, and in superior leading positions on hospital and organization level.  
Therefore he not only knows a lot about the healthcare system but also the difficulty of cultural and organizational change required to create healthcare improvements. 

One such change happened in 1987, when doctors were required to start sharing medical notes with their patients. “The Danish medical association and the doctors at that time, they were strongly against it. It was a start of a transition. Everything should be transparent. If you suspect the patient to have a tumor in this lung, you should tell the patient, I suspect you have a tumor in your lung. You shouldn't tell the patient I want you to undergo some diagnostic testing because you have some evil flu. You have to be straight. You have to be honest. Today no doctor could imagine a situation where they shouldn't be transparent and honest with the patient. So that's just an example of cultural change, where you have a lot of resistance in the beginning, but you, as a leader, as a manager, you have to keep a pressure and at the same time acknowledge the resistance, communicate about the resistance and talk about it. So you gradually achieve change,” Erik Jylling says today. 

Tune in for the full discussion: 

Questions addressed: 

• You have 25 years of practical experience in anesthesiology. For starters: do you miss clinical practice? 

• You held various positions during your career - worked as a consultant, head of the department and superior leading positions in hospital and organizational level. This is an excellent basis for understanding how new healthcare policies should be structured and how change can be implemented. Can you talk a little bit about the changing roles in your career and the challenges that came with them?

• When you were head of the department and in leading positions in hospitals, what have you learned about organisational change and how to motivate people to adopt new policies/solutions? 

• What kind of trainings and education did you obtain when you got to the management positions (in terms of leadership, human resource management)? 

• How do regions compare in terms of their ambitions, progressiveness, and access to healthcare? 

• We’re in the age of the grey tsunami and one of the admirable things about Denmark is that Danish senior citizens have the right to enjoy home care services for free, including practical help and personal care, if they are unable to live independently. How would you describe the elderly care homes market? Are there a lot of levels of sophistication of these homes? How much do they differ? 

• Do you see that because elderly care is well organized that impacts the uptake of digital health solutions for the elderly? The new Digital Health Strategy 2018-2022 includes an increased focus on assisted living technology to help elderly people stay healthy in their own homes and increase their quality of life.

• Digitalization of Danish healthcare has reached a level where all Danish citizens now have access to their own Electronic Health Record, and so have all doctors. Let’s clarify that: what do the doctors see, what do the patients see? How much can patients restrict who sees what? How accurate are these “online” records - are all institutions automatically adding data in them? How does the infrastructure work?

Nordics Series 2/4: Nordics Series 2/4: Norway, Long and Healthy Life and Data (Nard Schreurs)

In this episode, Nard Schreurs, a journalist by background who’s been working with e-health since 2007, and has both started and built up Healthworld and the EHiN conference, talks about why do Norwegians have not only high life expectancy but more importantly a high number of healthy years, what are people satisfied and dissatisfied about the healthcare system, and more.

Equal access to healthcare is among the strongest societal values in Norway.” People who are working on healthcare and digital health are really trying to find solutions applicable for all the people,” says Nard Schreurs. “If you're the prime minister or the richest person in Norway or just a student or somebody working at a supermarket, you've got the same rights and the same digital access to your health data,” he adds.

What’s less good in Norway are waiting times for some procedures and worries that the equality would erode. “In some countries, you can get access to new treatments quite quicker than in Norway because it's a slow system. The question is, how long can we manage to have a mutual system, which is trust-based and also based on equality, if some people move out and go to other countries to get better treatment and they come back and they say there, they have managed to treat me, but here in Norway, they can't,” he also comments.

From the IT perspective, DIPS AS is the leading supplier of eHealth systems to Norwegian hospitals, covering 80% of hospitals, 15% is covered by EPIC, explains Schreurs.

Nard Schreurs has a background as a journalist in Computerworld and editor of the supplement «Health IT». He has worked with e-health since 2007, and has both started and built up Healthworld and the EHiN conference . EHiN (e-health in Norway) moved in 2016 to Oslo Spektrum.

EHiN has grown from about 600 participants in 2014 to 1700 in 2019. 2300 people registered for the fully digitalised EHiN in 2020.

Nard is also a member of HIMSS Governing Council Europe and the Nordic Community.

Tune in for the full discussion.

Questions addressed:

• Norway, which has roughly 5,3 million people has a long life expectancy - 82.8 and 70.4 healthy years of life. For comparison, life expectancy in Italy is 83.4 years but only 66.8 healthy years. Netherlands 81.9 but only 59.2. What would be a general description of how Norwegians take care of their health? Not only from the healthcare but societal/social perspective? 

• Norway has a national healthcare system structure, with a high % of GDP for healthcare - 10,5%.  Norway has universal health coverage, funded primarily by general taxes and by payroll contributions shared by employers and employees. Enrollment is automatic. How satisfied are people with the healthcare system, what seem to be its biggest weaknesses and strengths?

• On paper it seems that eHealth in Norway is exemplary: The National Health Network, a state enterprise, provides efficient and secure electronic exchange of patient information between all relevant parties within the health and social services sector. Virtually all GPs use electronic health records and transmit prescriptions electronically to pharmacies. Electronic communication systems are used for referrals, for communication with laboratories and radiology services, and for sick leave. Most GPs receive their patients’ hospital discharge letters electronically. There is also a secure website for accessing patients’ core medical records. How well do these solutions work in practice? Germany for example hardly introduced ePrescription in July this year and EHRs in January this year.

• What are in your opinion the key successes in the digitalization of healthcare in Norway that other European countries could learn from? 

• What is currently the biggest focus of healthcare digitalization in Norway? 

• Norway Health Tech is a Norwegian center of excellence in health technologies and a cluster organization of approx. 280 institutions comprising of companies, hospitals, investment firms, as well as knowledge and research institutions - all with a focus on health technology and innovation. Can you name a few health tech solutions/companies that stand out in terms of success? 

• In terms of digitalization, a lot of discussions revolve around the value of data and the secondary use of data. A survey by Accenture from 2020  showed that while patients in Norway are willing to share their data with doctors - 66% of the surveyed confirmed that, however, only 37% said they’re willing to share data for medical research in non-commercial areas and only 28% said they’d share their data for commercial purposes. Any comment? 

• Very few companies globally were successful with COVID tracing apps, but Norway has been forced to stop loading data to its national Covid-19 track and trace app after a ruling by the national data privacy watchdog. 

Nordics Series 3/4: Finland: Secondary use of data, unlocking the full usability of data (Minna Hendolin, Jukka Lähesmaa)

The secondary use of health data refers to using health data, such as patient records, for purposes other than the primary reason for which they were originally collected. This can include research, decision-making, and innovation. 

European Commission has made the creation of a European Health Data Space (open in new window) as a priority for 2019-2025. The proposal stems from the GDPR. There are currently no common practices for the secondary use of health data in Europe. 

Finland has well-established regulations and processes for the use of data for secondary purposes. This is overseen by the Social and Health Data Permit Authority Findata, which facilitates data permit processing and improves data protection for individuals.

This episode is a recording of a panel discussion that took place during the eHealth Days, organized as part of the Slovenian presidency to the Council of EU, end of August.

Speakers:

•  - Minna Hendolin, Leading Specialist – HealthData at the Finish innovation fund SITRA, Finland

• Jukka Lähesmaa, Senior Specialist, The Ministry of Social Affairs and Health, Finland

• Angel Martin (Brussels), chair of MedTech Europe’s Digital Health Committee and AI and Data WG

• Dipak Kalra (UK), President of The European Institute for Innovation through Health Data

Listen to the discussion:

Questions addressed:

• Finland is the first country in the world that have digitized national health registries originating in the 1960s. The country also digitized biobank data from the 1920s. You have 100% penetration of Electronic Health Records. Can you briefly outline what is enabling Finland to be so digitally advanced?  

• Since 2019 Finland has had a regulated process of using healthcare data for secondary uses - FINDATA is a centralized institution that grants or rejects proposals for secondary use. Can you explain how the process of approvals and denials for secondary use looks like? 

  • Follow up Q: Can you name any examples of research findings that were the result of the secondary use of data? 

• Dipak Kalra, in your career, you’ve been involved in the research and development of Electronic Health Record architectures and systems across Europe. How do you see good practices from Finland apply or relate to healthcare systems in other European countries?  (problems with different methodologies, problem of lack of support and funding for the implementation of standards) 

• ANGEL: You are the Chair of MedTech Europe’s AI Working Group. What do you see as the main potential of AI development in healthcare in Europe? Europe is not seen as the front runner in AI development. 

  • Follow up: What are the main challenges industry is facing to develop AI? 

• DIPAK:  In June, MedTech Europe published a report “Unlocking the full benefits of health data”. Already in the executive summary, you warn that regulatory and legal challenges continue to limit access to health data by medical technology companies to develop new solutions for treating patients and advance personalized medicine and treatments. What’s also challenging for MedTech are inconsistent national strategies. Dipak, how do you see we could harmonize the data space to achieve the goal of having a European Health Data Space by 2025?  

The second round of questions: 

• Trust seems to be one of the key factors in unleashing the potential of data. If patients don’t trust medical devices and doctors don’t trust algorithms, this brings new barriers to success. 

• One of the solutions often mentioned when it comes to trust is federated analysis, where the institution or company doing the research, doesn’t get a copy of original data, for example from a hospital. Instead, it outlines a research question and gets an answer based on the hospital’s data, but never sees the data, just the result. Can you mention a few examples of where federated analysis is already used? 

• What is the industry perspective of building a trustworthy and efficient AI value chain in healthcare?

Nordics Series 4/4: Europe Can Learn About Collaboration (Anna Adelöf Kragh)

This discussion revolves around healthcare in the Nordics more broadly, data standards and interoperability across Europe, a successful pilot project from the 2000’s called epSOS, in which 12 EU Member states worked on cross-border healthcare interoperability, and what that project tells us about ambitions in Europe to achieve the European Health Data Space by 2025. The speaker in the episode is Anna Adelöf Kragh, Partner at VENZO_Public and Healthcare - an innovative consultancy firm specializing in human-centric digital transformation. Anna has more than 10 years of experience working with governance, strategy and project management within the public and healthcare sector. For example she worked on various projects related to healthcare interoperability and digitalization for the European Commission, Nordic Ministerial Council in the project for the Nordic e-health cooperation group.

Questions addressed:

You currently work in Denmark, but did a lot of work in Sweden and internationally. You speak Swedish, Danish and Norwegian. For a brief introduction: what’s your opinion of healthcare in the Nordics? How would you describe it in the context of other European countries? 

• The Nordic countries attribute high percentages of their GDP to healthcare. They also have a good digital foundations. Can you make any comparisons in terms of the state of eHealth in Finland, Sweden, Denmark and Norway? 

• If we look at Sweden: can you share any facts you see as quite unique for the Sweedish healthcare system? For example, I was quite impressed to read that both fathers and mothers get 16 months of paid parental leave after the birth of a child. https://borgenproject.org/10-facts-about-healthcare-in-sweden/ 

• Sweden attributes a lot to of it’s GDP to healthcare - 11%. While the system is universal, it does have some participation fees, but with a high-cost ceiling. For example, according to the Swedish law, hospitalization fees are not allowed to surpass 100 kr (Swedish Krona), which is equivalent to roughly 11 USD, a day prescription drugs have a fee cap and patients never pay more than 2,350 kr ($255) in a one-year period. In the course of one year, the maximum out-of-pocket cost is 1,150 kr ($125) for all medical consultations. What are your experiences of the nordic healthcare systems? 

• Throughout your life informatics and especially semantic interoperability have been your focus. We’ve got a lot of good standards today, some of them competing. Before we dive further: can you talk a little bit about the complexity of international terminology and the difficulty of achieving international interoperability? 

• Is there such a thing as the best standard? 

• How are you observing the development of healthcare interoperability on a global or regional level? The flow of data is mostly being addressed with the use of FHIR.

• When one hears the word “interoperability” in healthcare, it mostly causes headaches, because the more often than not the lack of interoperability. The state of digitalization is improving, however. Can you think of any well executed/exemplary cases of interoperability projects? 

• You worked on the epSOS project, which was a project by the European Commission, aimed at proving that interoperability can work despite the different medical heritage of countries. This was a three-year project that included 12 EU Member states. It started 10 years ago and after the end it felt as if nothing larger happened. What were the learnings and findings of that project? 

• How helpful was that project to the efforts of building a European Health Data Space, which predicts that will promote better exchange and access to different types of health data (electronic health records, genomics data, data from patient registries etc.).