Daniel Forslund, Commissioner for Innovation and eHealth, Stockholm County Council.

Moving towards a holistic healthcare ecosystem

Sweden is on the verge of a major reshuffle of its healthcare IT infrastructures. Because Sweden was an early adopter, many of its first generation systems are approaching the end of their life-cycle. More than half of the 21 Swedish regions are procuring or planning to procure new IT solutions now. Creating a patient-centric ecosystem that brings together digital services and real-world care is what these efforts are chiefly about, says Daniel Forslund, Commissioner for Innovation and eHealth at the Stockholm County Council.

Q. How is healthcare IT and healthcare IT procurement organised in the Swedish healthcare system?

Healthcare in Sweden lies within the responsibility of the 21 Swedish regions or counties, and these counties are responsible for procuring the major IT systems that hospitals and doctors in primary care use. It is different from region to region, but in Stockholm, 80% of both public and private healthcare providers use the system that the regional government acquires. It is possible to use other systems, though, or to connect them to the regional system.

Q. Many Swedish counties are currently renewing their healthcare IT infrastructures. How much progress has been made in the Stockholm County?

In December 2017, we took the decision to open the procurement process which is on the way now. It is a major effort, worth in total 2.2bn Swedish kroner, equaling €230m. The goal is to have a vendor dialogue in 2018, go into the preparation phase in 2019 and start the rollout in 2020. This is really an ongoing process more or less all over Sweden now. Some other counties have procured already, some are still making up their minds. And there is a massive interest of both Swedish and international vendors, of course. Exciting times lie ahead.

Q. What are the main requirements that the new Swedish IT solutions will have to address? 

There are two main pillars. One is, obviously, the internal digital documentation within healthcare organisations and the digital communication between healthcare providers. This is nothing new in Sweden, but the new systems will of course have to address it. We are expecting a more modern, somewhat more modular and more standardised approach than with the legacy systems, an architecture that makes it easier to add additional modules, for example decision support tools. The other challenge, and that will be the real challenge, is patient involvement. There is an increasing pressure for change in all Swedish regions. 

Q. Who is driving this change?

The patients are pressing. We have had a national healthcare portal for citizens for more than a decade now, but it has come of age and is not as modern as patients expect it to be these days. There are several private entrepreneurs in Sweden that have built up digital patient tools during the last 3 years or so, for example tools that allow patients to meet doctors or nurses online or to send images for teleconsultations. There are also tools that help in writing and dealing with prescriptions. These companies have been extremely successful in 2017, the number of patients using them has increased nearly twentyfold. We are talking of hundreds of thousands of Swedes who are accustomed to meeting doctors online now, or to have mobile access to care providers. This digital healthcare system started completely separate from the traditional healthcare system in Sweden. But both worlds are getting closer now, traditional players are starting to engage in digital patient services, and the Swedish citizens expect traditional and digital providers to work together more closely. On the IT side, this will require regional healthcare IT infrastructures that can accommodate the digital providers. We have to make it easy for patients to have digital contact to care providers and to book both digital and real-world appointments, depending on what suits their needs best.

Q. This sounds as though it is not only a technical challenge. How is healthcare policy in Sweden coming to terms with the new world?

It is absolutely a policy challenge. What we basically want to achieve is that patients are not only free to choose their doctor or hospital, but also free to choose whether they want an online appointment or a regular appointment. To make this happen, we changed the reimbursement system in Stockholm in January 2018, among other things, and other regions are following. Doctors now get exactly the same amount of money for a video consultation as they would get for a conventional in-office consultation, and patients have to pay exactly the same fee, too, around €20 per visit. This could result in a major shift in how medical care is provided in Sweden.

“The number of patients using tele- and video consultations has increased nearly twentyfold. We are talking of hundreds of thousands of Swedes who are accustomed to meeting doctors online now”

Q. Are there any rules in place in Sweden that define which type of doctor-patient contacts can take place online or per video consultation and which cannot?

There is no national regulation at the moment, but The National Board of Health and Welfare is working on recommendations to define which kinds of digital contacts are safe and when they should be avoided. On a regional level, we are also planning to offer guidelines for care providers supporting them to decide when a digital consultation is appropriate and when it is not.

Q. Are there any plans to also connect mobile patient sensors to the new healthcare IT solutions that are now being procured? And what efforts are under way to ensure cross-regional interoperability?

This is part of the package, yes. For Stockholm, one of the requirements in our procurement process is that the healthcare IT solutions offer a standardised way to link devices on the side of the patient. This will be especially helpful in chronic diseases that affect many people, like diabetes. In terms of standards, this has been a long and troublesome road for us. Many old legacy systems haven’t cared much about standards, but this has to change now. The regions started to meet a couple of years ago, and we have reached a general agreement now that certain technical and semantic standards should be mandatory. We still have to find a practical way to implement this agreement, but we are on track.  

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