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Regional electronic health record deployment

Ten years ago, Galician Healthcare Service faced the challenge of changing the way its information was managed. Nowadays, managers benefit from a common source of information and knowledge
Javier Quiles del Rio MSc
Head of Application Design and Development
Jorge Prado Casal
Head of Change Management and Deployment
Benigno Rosón Calvo
General Manager,
IT Department, Galician Health Service,
Santiago de Compostela, Galicia, Spain
Galicia is Spain’s north-western region, bounded by Portugal to the South and surrounded by the Atlantic Ocean West and North. It has a population of 2,795,422 people. The urban population that lives in cities with more than 30,000 inhabitants is above 1,200,000. The rural population includes 1,500,000 individuals, who live scattered across a hilly territory.
Regarding age, the population of Galicia is growing older. More than 22% of people living in Galicia are now over 65 years old, and this ratio is expected to rise to almost 25% by 2020. 
These conditions are increasing demand on the way healthcare services are provided and they have necessitated significant investment in healthcare facilities. 
In Spain, healthcare policies are assigned to regional authorities, and services are mainly provided by public institutions that cover primary, secondary and tertiary care activities. In the Region of Galicia, public healthcare services are provided by Galician Health Service (Servizo Galego de Saúde – SERGAS). The main resources for SERGAS to accomplish this task comprise seven hospital trusts with tertiary care services, and seven rural hospitals with secondary care services. Another 460 primary care centres complete the network of healthcare facilities in the region. A total of 38,000 professionals (including 11,000 nurses and 9000 physicians – both general practitioners and secondary care specialists) work at SERGAS, which is considered the biggest organisation in Galicia.

Our IT environment and strategy
Information technology (IT) has played a relevant role in the organisation, and has attracted increasing investment, since the 1990s. In the last five years, an average of  €39.77 million, which represents approximately 1% of total SERGAS budget, has been dedicated to IT infrastructure, software acquisition and development, IT deployment and other IT services.
IT policy is co-ordinated from a central unit, highly synchronised with hospitals’ IT departments. Corporate systems are clearly defined, based on a common infrastructure for all hospitals. A powerful 10Gbps backbone interconnects the main data processing centre with seven data processing centres in each of the main hospitals, using a ‘high-availability’ star configuration model in a private network. Wireless LAN’s are currently under deployment in several health centres, following corporate policies. Business critical data processing is based on Unix clusters that are settled in the eight distributed data centres. All these facilities contain more than 1100 servers and store over 1100 Terabytes (TB).
Regarding primary care, 99% of the 460 centres are also connected to the corporate network, via dedicated connections with bandwidths of 100Mbps to 512Kbps, depending on the infrastructure available from telecom providers, which is restricted in remote and isolated locations. Desktops follow standard configurations defined by common policies.
A total of 1300 pharmacy offices have been connected to SERGAS’ corporate network in the last three years through a second private network. This project, deployment of which was completed in 2011, allows all stakeholders to be incorporated into the e-Prescription value-chain, making a paperless model for medicine administration available to 99% of Galicians.
Main information systems are also deployed in a corporate way for all healthcare centres at SERGAS. Such systems include hospital information systems, radiology information system, pathology information systems, e-prescription systems, primary care scheduling system, hospital pharmacy and prescription system, speech recognition system, human resources system, business intelligence platform, and the electronic health record system, called IANUS.
Regarding software solutions, a mix of commercial solutions and self-developed software is used. The model for software development is subcontracting specialised companies that combine healthcare business knowledge and software development skills. Project management is performed by SERGAS IT staff who fill the gap between healthcare professionals and software developers from external companies.
The ability to adapt software to organisational requirements is one of the keys to our IT policy’s success. Core systems, on which the organisation bases its critical operational processes, must be adapted continuously, and it is difficult to obtain such a flexible response from a vendor that must cope with requirements and needs from many different clients. Commercial solutions have been selected and purchased mainly for specific departmental software, where specialisation is very high and focused companies perform and provide high quality solutions. Products for speech recognition, digital image management and display, hospital pharmacy management and laboratory management are examples of this.
Our EHR Global System: Ianus (TM)
Our organisation’s investment and deployment effort in the last five years was focused on electronic health records and e-Prescription. IANUS is our self-developed solution for clinical information, and has been designed to provide a unique EHR solution for primary healthcare centres and hospitals.
Each hospital works on its own ‘IANUS node’ and there is also an IANUS node connecting primary care centres. These nodes have the same function and configuration, and they are all fully interconnected, providing all information available either in hospitals or in primary care to the IANUS node network (for example, radiology, pharmacy, laboratory, outpatient scheduling, nursing care reports). Each one serves all information to any other node requesting it.
Any user can see all information recorded both in primary care and in the assigned hospital, and information from any other hospital is available online and easily reachable. Figure 1 shows how this information is displayed. 
The e-Prescription system is totally integrated into our EHR. From any registered clinical problem, physicians can associate an electronic prescription, selecting the indicated medicine, dose, frequency of administration and period of time for treatment that can reach up to one year for patients with chronic disease. The system automatically calculates the packages that the patient should pick up each time he/she goes to the pharmacy, and this information is made available to the pharmacy office’s system online. The introduction of the system raised satisfaction among professionals and users: the former because of the reduction in patient visits to renew their treatment, thus freeing more time for clinical procedures, and the latter because they find it simpler to obtain their treatment on time.
The e-Prescription system has been complemented with a business intelligence and data mining tool to explore and detect how prescription could be improved and optimised. Several clinical programs have been launched using data analysis results, to control and improve medical treatment of patients who use more than ten different prescription medicines at once. From these data analyses, deviations on cost of several medicines can be detected and controlled. 
Other milestones
Another great advance reached with an integrated EHR has been the global communication of images between centres. All 14 hospitals are able to view medical images from any other centre, the same as more than 50% of our primary care centres where broadband (more than 1Mbps is guaranteed. This situation has allowed a reduction of almost 95% in film printing, but the most important achievement is the wide availability of information to healthcare professionals and avoidance of repeating procedures potentially harmful to patients.
Although development of the system has been a difficult task, far more difficult has been the associated change management. A lot of effort was put into planning deployment of the tool at each hospital with hospital managers. More than 16,000 training hours have been dedicated to explaining the new way of registering and accessing clinical information to 22,000 users including both primary care and hospitals. In primary care centres, scattering made this task even harder for the more than 3000 general practitioners in Galicia. The helpdesk is another strength of our IT department, and has obtained ISO 9001:2008 certification. Helpdesk service registers more than 420,000 requests per year. It resolved 95% of queries in just the first week.
Information security has been a critical issue from the beginning of the project. From its initial design, IANUS incorporates a digital signature, based on a smartcard with a personal digital certificate for each professional. Another key security feature is the control of the relationship between the professional and the patient being accessed, which is verified before the professional can access any data related to patients. Furthermore, registration and log-in is required by all users before each access to patient data. This allows an exhaustive tracking of all security issues regarding privacy.
IT systems’ usage and ROI
The use of the EHR is, seven years after deployment, reaching its highest performance in Galicia. System usage figures for 2011 include the following:
  • 14,336 users
  • 2,785,634 patients have an electronic patient record available online 
  • 59,085,430 electronic prescriptions
  • 16,841,908 clinical observations registered on the health records made by primary care
  • 5,459,130 clinical observations registered on the health records made by secondary and tertiary care
One of the methods that helped produce the high number of EPRs, potentially transferring data from paper to electronic records, is the introduction of speech recognition technology. This has been in use since 2006, when it was installed in the radiology departments and fully integrated with the reporting system. Results were absolutely positive, because more than 250 users found the system easy to train and obtained good results from the first week of use. Average time in radiology reporting lowered from three to less than one day, and the number of procedures with digital report available rose from 40% to more than 55% after two years.
These good results lead to deployment of the system in Pathology, where it has more than 100 users and a positive response from the users. Several experiences have been carried out in other clinical departments, with promising results. Application of speech recognition technology to EHR is currently focused on reporting tasks, but there are plans to extend the use of voice recognition to provide complete EHR control. This feature would allow clinicians to use voice commands to control the EHR functionalities and, for example, introduce patient identification data to access the patient record without typing, or create e-prescriptions by using only voice commands. These new features are currently under development, as integration between EHR and speech recognition software has to be improved. Some economical consequences of EHR, ePrescription and digital imaging deployment include:
  • €6,800,000 saved in film printing since 2006
  • €728,000 saved in prescription paper forms in 2011
  • €102,000,000 saved using electronic prescription system to obtain the most efficient medicine
  • 2,000,000 patient visits for medicine renewal avoided, freeing up more than 150,000 hours of physicians’ time to increase the duration of the clinical visits of patients.
IT performance was investigated in a questionnaire to healthcare professionals, in which they were asked to name the most adequate investments made to improve their work. Of the respondents, 77% stated that IT deployment had been the most critical issue for improvement, and 70% said that EHR had been the most valuable tool introduced in the last five years.
For the near future, in order to maintain the high level of current health services in a context of economic austerity, SERGAS must manage to introduce a means of achieving useful results, promoting prevention of illness and healthy lifestyles, and adopting a model focused on the user, giving them autonomy and empowerment. This is the goal of SERGAS’ Innova-saúde innovation plan 2012–2015, funded by the European Regional Development Fund, which will promote the development and implementation of 14 innovation projects in care delivery while facilitating the flourishing of innovative business around the health sector of the Galician Region. The aim is to transform the Galician healthcare model towards a new patient-centred model, taking into account patient needs, by: 
  • Developing new delocalised tools, such as telehealth, telemonitoring and web 2.0 portals for patients and professionals, to avoid unnecessary hospitalisation and the saturation of hospital services but at the same time allowing easier communication and access
  • Creating safer, easier (applying new technological solutions to reduce as much as possible human error in medical processes) and smarter services, changing the structure of assistance services to meet optimum quality and security needs.
IANUS  is a regional global electronic patient record system, which covers functionalities for clinical data registration and consultation to all health care professionals. The capabilities of such a global system, connecting all players in the healthcare value-chain, have been proved in the deployment of e-Prescription, which has been completed for more than 2,700,000 patients in two years. The gap between primary and secondary care information is bridged and healthcare models in this new global information scenario are yet to be discovered, but they will be developed on a unified system, centred on the patient.