What the American Health Care System Can Learn From Denmark: A Conversation with Ib Johansen
Some things you may not know about Denmark: It rains, on average, 
every other day. They have the oldest national flag in the world. And their health care system uses electronic communication. Imagine going to see a new doctor and not having to fill out all the new patient forms because your information is online for the doctor to see. Imagine no more faxing over records from your previous doctor, no more waiting for your x-rays to be delivered, and no more waiting at the pharmacy – just fast, efficient care. We were lucky enough to sit down and talk with Ib Johansen, whose work at Medcom is instrumental in making Denmark’s system run smoothly.
ZocDoc: Not many Americans know very much about how far advanced Denmark is in the healthcare space. Tell us a little about Denmark’s electronic communication, and how this was started.
Johansen: In Denmark, we’ve developed communication thus far for almost all IT systems in the health sector. We have implemented all prescription and medication information, and all discharge letters and summaries from hospitals. This also includes outpatient notes, injury reports, x-ray reports, lab reports and lab orders. Reimbursements from health insurance have been made electronic, along with referrals to hospitals and private specialists, and referrals to psychologists. All private physicians have electronic health records today so they can communicate and transfer documents electronically, as well.
From the beginning it was a grassroots effort; we thought it was a good idea to exchange information electronically. And now it has become mandatory that you must communicate electronically. There was a state-wide agreement that this was a good idea.
ZocDoc: What were the first grass roots initiatives?
Johansen: In the beginning, you could receive discharge letters and summaries from hospitals electronically. You could receive lab results and reports electronically, and send all the claims electronically to omit the paperwork. And last but not least, you could sync electronic prescriptions to have a medication record for a patient.
ZocDoc: How big was the initial network of people using this system?
Johansen: Less than 50 people. Doctors were interested in having this type of documentation so they could save time reporting and typing things in.
ZocDoc: What kind of resistance did you meet, if any?
Johansen: There was lots of resistance! There’s bound to be when you invest in computers, and you have to change the work flow. There was lots of promotion during yearly conferences for doctors, and lots of meetings with hospital owners. And gradually, as awareness increased, the doctors who resisted against it became convinced it was a good idea just to save money and time. Physicians save 50 minutes a day on average, and this helps them provide higher quality, of course.
ZocDoc: As electronic communication was being implemented, how did the work flow change for people?
Johansen: I would say people just accepted that it would be a little different. For example, with electronic prescriptions: normally they would have had to type into the electronic medical record what kind of medication a patient would have. Then afterward, they would have had to handwrite a prescription. But then they saw that at the same time they updated patient information in the medical record, they could just press a button and the prescription would be sent electronically to the pharmacist. So instead of having two things to do, they just had one. They realized this was a good idea.
ZocDoc: With so much patient data being stored electronically, how do you make sure your software is accurate and secure?
Johansen: Physicians are very aware of this. And patients want the data to be reliable. Medcom has arranged for all the software vendors to pass an approval process so they can have the data in the right way with the right content. It is mandatory to pass this approval process. In the beginning, it was not. But that was in 1999. After a couple of years, it became obvious that this should be obligatory. And all the software vendors accepted this because they got a stamp that they were approved, which made them a leader in the market compared to the companies that weren’t approved. It was a marketing issue, too.
Also, it is not allowed in Denmark to interconnect systems directly. This is for security purposes. So you’re not allowed to connect a physician’s system with a pharmacist’s system, for example. You have to send the documents electronically. And on the patient side, we have a national identifier for everyone.
ZocDoc: What is the next step in Denmark?
Johansen: Today we have made it so a doctor can look up and just ask a question – “Give me the lab results on this specific patient from all the labs in Denmark” – and he has access to it just by using the web service. The way we are changing is to give patients access to see their own health records and their own medication just through the health portal. Everything is transferred electronically, but now we are focusing on the patient.
ZocDoc: Do all patients go to public hospitals for treatment?
Johansen: All treatment is done in public hospitals. We have approximately 3% of treatments done in private hospitals because we have a waiting time guarantee when you are referred by a physician to a hospital. If the hospital cannot treat a patient in one month, then the patient is allowed to have his treatment done by a private specialist in a private hospital. And the public hospital has to pay for it. So private hospitals are not playing a big role, but they are helping public hospital reduce waiting times.
ZocDoc: How do hospitals prioritize patients?
Johansen: First come, first serve. If you are referring a patient with a cancer diagnosis, the patient must have feedback in 48 hours that they can receive treatment, and the treatment can start in 8 days. And of course you can be admitted to an emergency ward if you have a heart attack, for example. Then you would not be on the waiting list. But the hospitals must keep this 1 month waiting time guarantee. Otherwise the patient can choose among any of the hospitals in the country. This, of course, can all be done online. Patients can go to the health portal and check the waiting time for a specific disease or treatment – it is publicly available on the internet. Then they can see how many cases this specific hospital has done in the last 12 months. They can choose among hospitals with a high experience and long waiting time, or a low experience and very short waiting time. It’s up to the patient to decide.
ZocDoc: We are ZocDoc, after all, so we have to ask: Are patients able to book appointments online?
Johansen: Patients can make appointments online for a physician’s office, but they can also have email consultations. It is mandatory in Denmark that physicians offer phone consultations to their patients between 8 and 9 in the morning. For telephone consultations, physicians are offered 25 Danish crowns, or $5 US. For email, it is double. So they are interested in email consultations. We see a great demand from younger people who prefer email consultations.
ZocDoc: What advice would you give to other countries looking to implement electronic communication in health care?
Johansen: You could refuse compensation to doctors who do not communicate electronically, but I would not recommend this.
It’s important that you have doctor associations behind it, that they think it’s a good idea. If they are against it, then forget about it. It’s also important that the government and politicians are behind this and they are aware of the benefits of it.
You can also forget about implementing it within 2 or 3 years. It takes time because you have to change the way people are working and thinking. So just focus on the most frequent things first.
