Copenhagen has turned on its lights and you can feel its magical Christmas spirit. Opentelehealth and Healthcare Denmark co-organised a two day conference on 30 November and 1 December 2022 in the Danish capital to showcase to foreign countries the virtual care study tour and implementation of national telehealth. digitalswitzerland was invited to participate with other important stakeholders from Austria, Czech Republic, Finland, Germany, UK and Switzerland to get inspired by the Danish approach to digital health.
In 2022, Denmark was the most competitive country in the world and the most digital country in the world¹. It is also the second happiest country globally², right after Finland. Denmark has one of the best and most digital healthcare systems. So many different characteristics make this Nordic country an interesting one to follow and learn from.
Its healthcare system is based on four pillars:
- Universal coverage
- Financed by general taxes
- Free and equal access
- High degree of decentralisation
With three different levels of responsibility:
The general practitioners (GPs) act as gatekeepers in the healthcare system. In case of problems, they redirect the patients to the specialists of hospitals. It is only in case of emergency that you can directly go to the hospital. 90% of the people are not referred. This avoids long waiting queues at the hospitals and ensures that the right people have quick access to care. Each region has its own triage number which you can call for information; they are responsible to redirect you to the right location based on their availability. The nurses play the most important role in this triage. Next step would be to have AI support the triage.
The Danish healthcare system is expensive within a global comparison; 10% of the country’s GDP is used for healthcare expenditure³. 85% of it is paid by taxes from the citizens: Municipalities pay 41% and regions 59%⁴. Specialist hospitals take up most of the costs⁴. GPs only receive 8% of the costs even though they are responsible for 90% of the cases.
Denmark, like most other countries, is currently facing two key challenges in healthcare: shortage of workforce and increase of chronic diseases in its population.
The nation is way ahead of Switzerland in its digitalisation of its healthcare system. An insightful summary video of the timeline can be seen here. Three key dates are the following in the evolution of its healthcare system: since 1968, citizens have had a unique identifier number, the CPR number. In 2000, EPR was rolled out in Denmark and since 2013, the country has had a national service platform in place.
The Danish healthcare system follows a top-down approach to governance with many solutions integrated within the backbone. This model relies on principles. Everything is digitalised, for example the prescriptions are fully digitalised.
In the future, they need to ensure digital inclusion and increase their digital literacy levels.
The WHO has defined telehealth since 1998 as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”
Nowadays the definition has evolved and we distinguish telehealth in three different ways:
- Synchronous telehealth which relies to telehealth done via phone, live video feed, consultation (individual or family conferences) and webinar
- Asynchronous telehealth which relies to telehealth done via text messages, e-mail consultation, Interactive websites
- Remote monitoring telehealth which enables you to capture your vital signs, blood glucose, etc. from your home
Telehealth has been used for centuries. In 1879, in order to decrease unnecessary medical visits, the phone was used to consult doctors. In 1905, the first tele electrogram took place and in 1925, the first patient was diagnosed via radio. It was only in 2005 that the first synchronous video consultations happened in Denmark for diabetes and heart patients.
Telehealth reduces travel time and high volumes of patients in clinics. This enables healthcare professionals to spend time on the parents who most urgently need their help. The goal shouldn’t be to save money but to provide care for everyone and save staff time.
Synchronous telehealth is already a first positive step, but it doesn’t decrease time to care as the healthcare professionals have to care for the patients in real time. Telehealth, which combines synchronous, asynchronous and remote monitoring are tailored to the individual and helps them to support more patients at the same time. One size doesn’t fit all, it needs to be tailored to each patient’s needs.
Three key factors of telehealth are: staff empowerment, patient safety and patient satisfaction. Staff empowerment is needed, as when you give healthcare professionals more freedom, they will be more effective in their jobs. Patient safety is key and in order to avoid any human error, you need to make sure to have a system with multiple intermediate layers. Patient satisfaction is important and comes from Value based healthcare as it focuses on the quality of care instead of the quantity of care.
A telehealth use case in the North Jutland region of Denmark where 0.6 millions of the Danish population live. They started their pilot in 2011 with COPD patients⁵ as they wanted that wherever they were these patients all had access to the same care – principle of equality of health. They onboarded local representatives in each region and municipalities onto the programme, as they are more connected to the local ecosystem.
The nurses are the pioneers of the programme as they are in direct contact with the patients. They onboard the patients to the programme and check that everything is going well two weeks after their onboarding.
The patients are empowered into active players in their health. They have access to all the components of the device and have all the information to react accordingly to the different measurement results.
Their telehealth kit comprises of (see image below):
- Blood pressure monitor
- Pulse oximeter
- Ipad with the corresponding App (incl. questionnaires) and a tablet pen
- Weighing scales
- Instructions with links to access videos and communities to interact with
It is important that the device is easy to use for an elderly population. OpenTelehealth was responsible for developing the technology behind the solution, ensuring it was easy to use for the patients. The patients send their measurements through once a week. The nurses have access to the measurements of the patients and can react in case the patients have multiple alarming measurements. This plays the role of a triage before sending the patients to the hospital.
This virtual care does not cure patients but it decreases hospitalisation and slows down the deterioration of patients, as well as having a positive impact on mental health. It is therefore targeted at long term patients and not for acute care.
After the successful pilot for COPD patients, Denmark has also started a second pilot for heart failure patients since 2018. The aim is to start a national implementation and include in it the patient satisfaction. The plan will focus on additional diseases such as diabetes type 2, in the upcoming future and focus more on prevention. How to integrate this system to the electronic patient health record will also be a top priority.
Opentelehealth has developed a solution to support many diseases and devices, unlocking the possibility to customise systems based on client demands. It allows for the monitoring of 45 different vital signs and can easily integrate new measurements if needed with every release. This has the advantage of creating an open solution which can be integrated in different systems.
The original software platform developed as part of a joint project reaching across Denmark. It was funded by the Danish government with the explicit purpose of demonstrating the effectiveness of large-scale remote health management. The project was successfully concluded in 2015, and now serves as the basis for the current nationwide rollout of COPD⁶ home monitoring.
TAYS, a successful telehealth implementation in Finland
Sydänsairaala was founded in 2004 as the first heart centre in Finland. It turned into a company in 2010 which is publicly owned. The aim is that by 2025, patients will pay for health value. The telehealth solution has been very beneficial, decreasing waiting time in emergency from 7 days to 29 minutes and decreasing emergency room visits by 42%.
The solution helps patients monitor vital signs from the comfort of their homes. They are helped by nurses which follow them remotely and intervene in case of problems. The system is directly implemented in the electronic patient record.
The company is working in collaboration with Siemens Healthineers for the hardware and Opentelehealth for the software and are financed by public payers.
Doccla, the virtual ward
Doccla, is a startup which creates hassle-free virtual wards, meaning that patients are monitored at home and not only at the hospitals. They are well implemented within the UK and work closely with the NHS. The product is device agnostic, uses Opentelehealth platform and reduces the clinical capacity. Patients are very satisfied with this new solution. The approach is simple: you identify which patients need virtual care and give them the package containing the needed device, the patient is onboarded virtually and the NHS monitors the vital signs with a constant support of patients when needed. This solution is tailored for acute patients which stay on average 7-10 days on the platform and chronic patients which stay multiple months to years. Each hospital has its own champion which can spread the solution locally. The team agrees with each hospital upon a clear decision tree of different actions which need to happen once the patients enter too many alarming measurements.
The Doccla solution has decreased emergency administration by 29%⁸, decrease A&E⁸ attendance by 20%⁹ and decrease the bed days of patients by 30%¹⁰.
Doccla distinguishes itself by offering a support layer with clinical capacity support. It is easily integrated with other devices and electronic health records.
It will focus in the future more on prevention.
Biorithm, Advanced pregnancy care
Biorithm delivers high quality care at low costs to pregnant women to help monitor their pregnancy. This enables patients to have an optimal journey and ensure that the appropriate care is offered. Nurses can monitor 16 people at the same time.The device is easy and adaptable to use. Pregnant women are a highly engaged and proactive group and want to monitor their health.
Cardiolyse for heart attack prediction
80% of cardiovascular diseases can be prevented. Cardiolyse supports ECG analysis. They are device agnostics and no personalised reporting, sharing wellness scores with risk stratification to predict if the patient will have a heart attack. The different devices offer different leads and therefore precision quality. Cardolyse developed an additional layer on top of the Opentelehalth solution. They aim to decrease the remissions by ⅓ and decrease patients’ travel time. They will focus in the future on post-discharge patients, chronic patient monitoring, early screening and prevention and clinical trials.
Lifelight.AI, turning a smartphone into a medical device
Lifelight.AI has the vision to turn every smartphone/tablet into a personal health monitoring device. It will revolutionise the world of healthcare. With one device, you will be able to capture your blood pressure, pulse and breath rate simply by looking into the device’s camera for 40 seconds.
Switzerland has a lot to learn from Denmark in regards to digitalising its healthcare system. These two days were very enriching and enlightening, showing how easily digitalisation can positively disrupt the healthcare system and the future of telehealth. We need to bring learnings to Switzerland and learn from the Nordics’ experience and enable things to finally move within Switzerland.
As illustrated, this will only be possible with the support of all the different players in healthcare systems and with ongoing collaboration. We do not need to reinvent what other countries have already invented but we need to learn from them and leverage their solutions so we can tailor them to our needs.
For more reading in the topic of digital health, read our recent study: A Swiss digital healthcare system: What the population thinks.
¹IMD Report 2022
²UN’s 2022 World Happiness Report
³Health at a Glance 2021: OECD Indicators
⁴Statistics Denmark 2022
⁵Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing-related problem
⁶Chronic obstructive pulmonary disease
⁷RPM Pilot in Luton- patients known to Respiratory and Heart Failures Services , Cambridgeshire Community Services, NHS Trust, March 2021
⁸Accident and emergency
⁹RPM Pilot in Luton- patients known to Respiratory and Heart Failures Services , Cambridgeshire Community Services, NHS Trust, March 2021
¹⁰Asthma pathway : Case Study – Northampton General Hospital, Doccla Ltd, March 2022