1. No category

Finland - experience with
ePrescription –
national and cross-border
Viveca Bergman, Development Manager, THL
EXPAND Multi-Stakeholder Engagement Workshop
28th January 2015, Brussels
Aim of the presentation
•  To highlight impact and implications of adopting the eP
service, in terms of legal, organizational, technical and
semantic requirements
•  To help interested delegates to prepare for deployment of
eHealth cross-border services in order to encourage further
uptake of services and EXPAND assets
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28.1.2014
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eHealth Status Finland
•  100% EHR coverage in both specialised and primary care on local
and regional level. The rolling out of the National Archive of Health
Information, the Kanta Services is still ongoing but covers 87% of
population.
•  Finland experiencing a rapid pace of ICT development in a highly
decentralised health care system facing major structural reforms.
•  ePrescription in production since 2010. Full scale roll-out in public
and private health practically finished to date (over 90% of all
prescriptions).
•  THL (National Institute for Health and Welfare) responsible for
operational management and Kela (Social Insurance Institution of
Finland) for technical deployment. The roles in national and cross
border settings defined by law.
•  epSOS provided a timely opportunity to develop and
implement cross-border use of eP
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EHRs in Finland
Specialised Health Care
Primary Health Care
Ei Oetojärjestelmää, 10.06% Oma Oetojärjestelmä, 1.41% Dapal, 3.16% Muut, 7.65% DomaCare, 0.91% Acute, 7.81% SoMMedic, 9.06% DynamicHealth (Doctorex), 36.24% Safe, 2.16% MediPro, 8.89% in private sector
EPR:s
Promeda, 4.32% Mexwin, 0.17% Mediatri, 2.16% Meditree, 1.33% Maestro, 0.17% Elbit, 1.33% Hilkka, 3.16% Population of Finland
28.1.2015: 5 475 614
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eDispensations and reimbursed prescriptions
01/2009–12/2014 in Finland
Apteekit
31.03.2012
Miljoonia reseptejä
Julkinen terveydenhuolto
31.03.2013
Yksityinen terveydenhuolto
31.12.2014 (>5000 res/v)
5.0
4.5
4.0
ePrescriptions
3.5
Reimbursed
prescriptions
3.0
2.5
2.0
1.5
1.0
0.5
0.0
1
4
2009
7
10
1
4
2010
7
10
1
4
2011
7
10
1
4
2012
7
10
1
4
2013
7
10
1
4
2014
7
10
1
4
7
10
2015
2014: 40 000 000 eDispensations
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The use of ePrescriptions (%) in the public health care
December 2014
Pohjoinen
Lappi (05/2014):
Länsi-Pohja:
Pohjois-Pohjanmaa:
Kainuu (05/2014):
Keski-Pohjanmaa:
Approximately 92 %
85 %
94 %
86 %
94 %
86 %
Käyttöaste (%) = 100 * (n/N), jossa
n = sähköisten lääkemääräysten lkm
N = kaikki potilastietojärjestelmiin
kirjattujen lääkemääräysten lkm
(Laskennassa ovat mukana
ensimmäisen kerran kirjoitetut ja
uudistetut sähköiset
lääkemääräykset)
Keskinen
Etelä-Pohjanmaa:
Pirkanmaa:
Päijät-Häme:
Kanta-Häme:
98 %
91 %
93 %
92 %
Itäinen
Keski-Suomi :
Pohjois-Savo:
Etelä-Savo (05/2014):
Itä-Savo:
Pohjois-Karjala:
93 %
92 %
85 %
95 %
96 %
Läntinen
Vaasa:
Satakunta:
Varsinais-Suomi:
83 %
94 %
97 %
Eteläinen
Etelä-Karjala:
Kymenlaakso:
Helsinki-Uusimaa:
93 %
93 %
94 %
All pharmacies and public
health care organisations have
joined the eP Centre .
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Lähde: STM
Sairaanhoidon erityisvastuualueet,
sairaanhoitopiirit ja keskussairaalat 1.2.2013
Viveca Bergman / THL
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What had to be done?
- a brief history of the Finnish ePrescription
• 
Government decision in 2002: Finland should have a nationwide interoperable EHR system by
the end of 2007
• 
By 2005 agreement on the National Archive of Health Information (KanTa) : ePrescription service,
Patient Access and Patient Data Repository.
–  Architecture of centralized storage (Kanta) with Pharmacy Information Systems and HIS
systems as the clients. Messaging based on structured documents.
• 
Act on Electronic Prescriptions in 2007
–  New legislation was needed to allow the new features
• 
Placing the centralized service to the Social Insurance Institution of Finland (Kela)
• 
Consent management, privacy & security aspects
–  Mandated the adoption of the ePrescription system for pharmacies, for health care units and
for doctors and dentists practicing in health care unit (remaining voluntary for doctors and
dentists not practicing in these units)..
–  The purpose of the Act was to improve patient and drug safety and to facilitate and streamline
the prescribing and dispensing of pharmaceuticals.
• 
Amendments to Act on Electronic Prescriptions and Act on the Electronic Processing of Client
Data in Social and Health Care in 2010 which re-scheduled National Health Information System
project, and in 2014 a new Amendment making the ePs mandatory for all actors as of 2017….
–  ”
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Enablers in place for cross-border services
•  Mature national eHealth
infrastructure; nationwide
coverage of eP and eD <
Kanta
•  EU-level produced
common/additional services
and specifications < epSOS
•  Robust standards-based
national system with data in
structured form
•  Roles of competent actors in
cross border deployment
regulated by law.
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FI-SE Pilot Use cases and coverage
•  eP and eD as Country A and B
•  Operation Dec 2013 – June
2014
•  Country A coverage national,
Country B limited to a border
region in Northern Finland
consisting of pharmacies in 3
municipalities
•  Cross-border UC regarded as
a natural extension of
–  the Nordic agreement on
exchange of prescriptions
–  the national eP Services (EU
prescription was on paper)
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epSOS building blocks now available as
EXPAND assets were taken into use….
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Core components from epSOS -
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Circle of trust of epSOS and LFA
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epSOS Web Portal
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combined with national assets…
My Kanta - National Patient Portal for
consent giving
a specific epSOS consent was
required
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Viveca Page
Bergman
19 / THL
Legal framework permitting the dispensation of
foreign ePs not fully compliant with the Finnish
ePs
Laki
sähköisestä lääkemääräyksestä annetun lain (61/2007)
muuttamisesta
Eduskunnan päätöksen mukaisesti… lisätään… 23 a §… Rajat ylittävä sähköinen
lääkemääräys
Muualla kuin Suomessa laadittu sähköinen lääkemääräys voidaan hyväksyä ja toimittaa
Suomessa toimivassa apteekissa, vaikka lääkemääräys ei täytä kaikkia tässä laissa
sähköiselle lääkemääräykselle säädettyjä vaatimuksia. Hyväksymisen edellytyksenä on
kuitenkin, että se täyttää Euroopan unionissa hyväksytyt tai Euroopan unionin ja Euroopan
talousalueen jäsenvaltioiden kesken sovitut vaatimukset ja lääkemääräys välitetään
suomalaiseen apteekkiin lääkemääräyksen oikeellisuuden varmistavan ulkomaisen ja Suomen
kansallisen yhteyspisteen kautta. Tämän lain mukainen sähköinen lääkemääräys voidaan
vastaavasti luovuttaa potilaan suostumuksella toimitettavaksi muualla kuin Suomessa.
Edellytyksenä lääkemääräyksen luovuttamiselle ulkomaille on, että luovutus tapahtuu Suomen
ja vastaanottajamaan kansallisen yhteyspisteen kautta. Kansaneläkelaitos toimii Suomessa
kansallisena yhteyspisteenä reseptikeskuksen, apteekkien ja ulkomaan kansallisen
yhteyspisteen välillä. Kansaneläkelaitos on kansalliseen yhteyspisteeseen tallennettavien
tietojen rekisterinpitäjä.
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The path towards implementation 2011-2014
•  No major technical issues encountered, but the preparation
phase exposed legal, organizational and semantic issues
that had to be addressed
•  Within the given time frame full integration of epSOS solutions
into national infrastructure not possible > chosen eD portal
solution not a sustainable approach.
•  Organisational: localisation of FWA not a mere translation,
responsibilities according to national law differed from those
set out in FWA.
•  Semantic: challenges in mapping (e.g. EDQM, ATC, UCUM).
Unstructured data > eP incomplete and certain types of
prescriptions were ruled out.
•  Legal: not possible to establish NCP at Kela without revision
of national legislation
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We got there – the first ever medication dispensed
abroad on an ePrescription in Europe
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Succesful dispensation abroad and up-to date dispensation
information in the patient portal at home
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Bergman
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Real-life FI-SE pilot also revealed shortcomings
•  For example in FI-SE pilot:
–  17 dispensations made successfully
–  34 cases: patient had not given consent or pharmacist entered
patient id wrongly
–  15 cases: prescription out of the scope of the pilot, of which
•  2 time-based prescriptions (not based on prescribed amount)
•  4 combination medications
•  9 prescriptions in which package size not structured
•  Negative feedback on cross-border service reported to PGEU
by SE/FI pharmacists
http://www.ehealth2014.org/wp-content/uploads/2014/07/Pres_Wilkinson_J.pdf
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Prescriptions ”out of scope”, case Finland
No Description 1 central nervous system drugs 2 Reason Sugges+on with regards to pivot Difference in classificaOon (what is a CNS No change drug and what is not) in different countries No change drugs with potential for recreational use (narcotics) Out of scope of epSOS in general 3 drugs to be prepared in the pharmacy 4 base creams 5 clinical nutritional preparations 6 care accessories, dietary supplements and
bandages 7 prescriptions valid for defined time periods 8 iterated prescriptions 9 combination medications PreparaOon instrucOons only in Finnish/
Swedish No ATC code or strength, which are mandatory in pivot No ATC code or strength, which are mandatory in pivot No change Include à make ATC code and strength opOonal in pivot Include à make ATC code and strength opOonal in pivot No ATC code and some other information No change which is mandatory in pivot
No informaOon on package size and number of packages No change. Some countries are able to send suitable info (amount to be dispensed at once). Difficult to calculate the remaining No change. Some countries are
amount. IteraOon rules vary among able to send suitable info
countries. (amount to be dispensed at
once).
ATC code system not designed for this use Allow providing non-­‐structured case. Text-­‐based strength not allowed. strength informaOon (text) 10 combination packages Package size is difficult to structure. No change 11 the prescription is in held state NaOonal rules No change 12 the prescription is in reservation state NaOonal rules No change 13 package size is not in structured form Package size is difficult to structure. No change 29/01/15
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Reflections based on our experience
•  In order to be able to sustain the services, continuous support for
centralized cross-border services is required:
–  Reliable maintenance (including support, development, and
version management) of the common components produced by
epSOS
–  Reliable maintenance of the semantic infrastructure established
by epSOS
–  Cooperation with the standardization bodies
•  Features to be developed and maintained at EU rather than national
level:
–  Standards, common terminologies, classifications, code sets, and
other specifications.
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•  National deployment requires mature assets. It is not possible to
introduce a cross-border service at national level if the service is
significantly different from the national standards.
•  In the pharmacies the sustainable solution is an integrated
crossborder functionality not causing extra work load.
•  Minor and major issues identified during the operation as regards
the epSOS Pivot (semantics) > extension needs. Status quo may
become a risk for sustained interoperability.
•  Focus should be on securing the operational use of the existing
UCs, and not that much on inventing new ones. The real challenge
now lies with deployment.
•  Supportive infrastructure and collaboration between all the relevant
national authorities required (In Finland: Kela, THL, Population
Register Centre, Finnish Medicines Agency, Pharmaceutical
Information Centre, and the National Supervisory Authority for
Welfare and Health, and Data Protection Authority). NB: also
beyond the eHealth domain.
•  .
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Cost estimation
•  National deployment ?
•  Kanta services: estimates 200 – 500 ME
•  Savings - yes
•  Cross-border eP/eD:
•  Technical development: 245 000 e (in-house)
•  Infrastructure & testing: 45 000 e /yr
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Thank you!
[email protected]
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