Thursday, April 07, 2011

Talking about transparency in Copenhagen

I am in Copenhagen to speak at a conference sponsored by Dagens Medicin, a newspaper for professionals and decisions makers in the medical and health care sector. According to my host, Kristian Lund, editor-in-chief, "The overall purpose of the conference is to inspire decision makers in Danish health care to improve leadership by using quality data. We are especially interested in hearing about your way of working with data and patient safety." As an outside guest, I am joined in a related topic by Johan Kips, Director of the UZ Leuven, the largest hospital in Belgium (2000 beds), who is here to address the attendees on the use of data to direct quality improvement. (Kristian -- another blogger! -- and Johan are in the accompanying photo.)

This is a fascinating topic to discuss in this venue, as the Danish health care system is quite good, but it does face interesting challenges. Here is a part of a summary from the WHO European Observatory on Health Systems and Policies.

Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment.

. . . More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system.

This gives part of the context for a point Kristian wrote in my letter of invitation, "You will have a unique opportunity to influence Danish health care management in a rare situation since the government is ready to invest more than 5 billion Euro in new hospitals. Denmark is also about to reform the allocation of specialities and we are in the process of re-evaluating the education of specialists."

Here is a bit more background. Denmark currently spends about 8% of its GDP on health care (not counting the educational subsidy to those studying to be doctors and nurses.) There is an expectation that this will be quickly rising, to over 10%, within just a few years. There is pressure on the government to spend more to enhance and expand services. For example, while treatment of heart disease is excellent, cancer care is considered less than adequate by US standards, with less use of imaging and chemotherapy; and there is a desire to upgrade it. There is also a huge building program going on -- eight new hospitals are under construction. Too many hospitals are engaged in high-level procedures, and there is a need to consolidate those, but there is reluctance from those currently engaged in those arenas. I had heard previously that the primary care system was very good, with quick care and integrated electronic medical records. The former is true. It is easy to get an appointment quickly, and the care is excellent. The latter is not. Integrated EMRs are not present at the primary care level, although they are at the hospitals. Finally, there is budget pressure: When the end of the fiscal year arrives and a hospital is behind on its budget, it "manages by congestion," delaying procedures until the next year. A colleague here jokingly said, "I don't know why people from abroad come to visit, thinking our system is wonderful. We think it is awful."

I have talked on several occasions about the convergence of issues and health care design between the US and the nationalized systems of other developed countries. Denmark seems to provide another example of this. As my hosts indicated, we face the same demographic challenges and the same desire on the part of the public for the latest and best in health care technology. It is always helpful to share stories and ideas in pursuit of improved care for all.


Surafel Tsega said...

I am a medical student from the United States, here for a brief stay to study the Danish health care system. A friend of mine directed me to this post, and I'm glad he did.

In my two weeks here following residents and physicians in the hospital and outpatient clinics, I have seen some of the same problems you've mentioned here, and more:

- With specialties concentrated in only a few hospitals, patients are oftentimes shuttled back-and-forth between hospitals. For example, what may initially be presumed as an abdominal surgery case may actually be a gynecologic issue. That patient would have to be transferred from one hospital to another for further management as not all hospitals have a gynecology department (or general medicine ward, etc. etc.). Though most hospitals are only a short distance away from each other, it is difficult to coordinate care if things are spread out over several hospitals (with medical records that can't be easily accessed electronicall).
- Speaking of medical records, the EMRs are certainly great to some extent. Physicians (both in the hospital and in private practice) can see lab results, radiology reports, and discharge summaries for their patients. Unfortunately, the flow of information isn't complete or bidirectional. Outpatient medications are not part of the system; neither are daily notes as an inpatient or outpatient.

... I'll stop here so that this comment doesn't equal the length of your post.

But it's interesting to see the convergence you speak of first hand, and to also see future problems we may face as we try to emulate other nations.

Paul Levy said...

Thank you, Surafel, for filling out the picture.

Anonymous said...

I was amazed by the host's comments about reforming the 'allocation of specialties' and re evaluating their training. Imagine the reaction of American physicians to that kind of overt government control! There would be riots in the streets.

Surafel's remarks are also very timely. One wonders if a 'diagnostic shop' housing all specialties might be useful under that scenario - although it would only work for non-emergent cases. Like it or not, gynecology is kind of an essential component of hospital care for women; it is obstetrics which could be allocated..

nonlocal MD