Insider report: Establishing public health e-services in Croatia

1
Insider reportEstablishing public health
e-services in Croatia

• Damir KalpicFaculty of Electrical Engineering
  and ComputingUniversity of ZagrebUnska 3, 10000
  Zagreb, Croatia
• http//www.fer.hr/Damir.Kalpic/
• damir.kalpic_at_fer.hr

2
History

• PRESENTATION BASED ON RELATED OCCASIONAL
  PERSONAL/INSTITUTIONAL ENGAGEMENT
• Topics
• Sporadic computerisation efforts / Islands of
  computerisation
• Croatian Health Insurance WB Loan in 90-ties
• WB Loan for health computerisation in a Croatian
  county
• Study of computerisation for the largest Croatian
  hospital complex in 2002 (KBC Zagreb - FER)
• Public tender for software in 2002
• Primary health care (Cap Gemini, EY)
• Central Server of Primary health care (Cap
  Gemini, EY)
• Hospital information system
• Evaluation of the procurement status in 2004
  (FER)
• Telemedicine

3
Sporadic computerisation efforts / Islands of
computerisation

• Developments
• based on occasional donations
• based on occasional injections of money
• based on local enthusiasm incentives
• by own modest computing staff
• Partly functionally satisfactory
• Not integrated
• Not maintained

4
Croatian Health Insurance WB Loan in 90-ties

• Alphanumeric application (Informix, Unix)
• Whole country covered
• Functionally adequate
• Never fully completed
• Improperly maintained
• Due to (unnecessary?) dispute with the developer
• New version currently under development

5
WB Loan for health computerisation in a Croatian
county

• Bidding announced (only) in Financial Times of
  London
• International references required
• BIS Healthcare Group, UK had them
• Macedonia
• Bosnia Herzegovina
• Did not have even a Web site
• Project in Croatia Copy Paste from Macedonia

6
WB Loan for health computerisation in a Croatian
county (cont.)

• Findings after a few million
• Unfortunately, there is no computing expertise in
  Croatia
• If patients data are stored in a database, they
  can be retrieved later
• If patients visits are scheduled via Internet,
  they do not have to wait so much, etc.
• Results
• WB forbade to BIS Healthcare Group to apply for
  WB financed projects for a number of years
• The responsible person in Croatia moved to a
  better paid position

7
Study for computerisation of the largest Croatian
hospital complex (KBC Zagreb) in 2002

• Large, complex, heterogeneous
• Different levels of computerisation
• Weak in-house IT Department
• Large savings possible, especially on medication
• Tendency to buy an ERP after a WB loan
• Advice
• Instead of paying back the loan, finance the
  gradual improvement by local contractors
• If WB loan ERP
• Payment according to achieved and user-accepted
  functionality, not on consultanthour base
• Licence prices according to per capita GDP
• What happened?

8
ERP Maturity testCampbell R. B., ERP Show me
the Money! Axilogic Consulting Inc.
http//www.axislogic.com/erpstory.htm (2002)

• You have a company strategy.
• Your employees (management at least) know the
  details of this strategy.
• The strategy includes an action plan so that it
  will be met.
• You see IT as an enabler and do what is required
  to keep it up.
• Your IT management is close to your business
  organization.
• Management is aggressive and is willing to take
  risks.
• Management is good at communicating goals and
  measuring progress.
• The organization is structured in a comprehensive
  fashion.
• Employees have a taste for change and innovation.
• Your organization has successfully completed
  'large' projects in the last five years.

9
Primary health care(G2)

• Public tender for software in 1998
• Bidding published in a local (Cakovec) newspaper
• Oracle based application for nurse doctor
• CASE produced and unpolished
• Developers ignored feedback from doctors nurses
• Failed!
• Public tender for software in 2003
• 5 solutions for general practitioners accepted
  and regionally assigned
• Smart ID cards for medical staff temporarily
  introduced
• Pilot project with connection to the central
  health server
• Delayed deployment allegedly until the end of
  2005

10
Central Server of Primary health care(G1)

• Cap Gemini Ernst Young tender
• Central Server of Primary health care
• Developer Ericsson Nikola Tesla
• Central Health Server

11
Role of G1 as seen by developer
12
G1 Architecture
13
National Information System on Health
Infrastructure based on G1

• System architecture
• Multi-tiered communications,
• Component based design,
• Asynchronous point-to-point communication,
• Usage of open systems norms and recommendations.
• Main components of NISHI are
• HCSI (HealthCare System Integrator),
• EPRS (Electronic Population Register System),
• HRRS (Health Resource Register System),
• EHCRS (Electronic Healthcare Record System),
• HCP (Health Care Portal).

14
Hospital information system

• About 3000 required functionalities in the tender
  (Dr. Dragan Schwarzs tender)
• A year period to establish representative
  functionality
• All activities regarded as part of the bidding
  procedure
• No financial compensation for developers
• Tough conditions only the strongest could
  afford it
• Very favourable for the purchaser
• In April 2003 4 suppliers were chosen and
  assigned to 4 hospitals
• In February 2004 Ministry of finance cancelled
  the bidding!

15
Hospital information system (cont.)

• In July 2004
• b4b a Croatian SAP based developer
• After cancellation continued with developments
• High integration and functionality
• Working with historical data
• Ready for a (risky?) Big Bang deployment
• Ericsson Nikola Tesla Consortium including
  smaller developers with relevant experience
• After cancellation continued with developments
• Partly integrated and modest functionality
• Developed components in full use
• IBM Croatia
• Allegedly the worlds best hospital SW
• Did absolutely nothing!
• AME, Austria
• After cancellation went home

16
Evaluation of the procurement status in 2004

• Recommendations after evaluation
• G1
• Good concept as central health server, not
  primary health alone
• To continue with developments
• G2
• Pay to developers and deploy their solutions
• Hospitals
• Restore the legal status of the bidding
• Continue with both systems
• Acceptance test on real data
• Let them both survive if they deserve

17
Telemedicine

• In 2005 Kovac Kalpic in the Procurement
  Committee for TM equipment
• Meticulous considerations which bidder is better
• No organisational efforts by the Ministry for TM
  deployment
• Result
• TM equipment purchased for the Adriatic islands
  but mostly unpacked?

18
Further developments (1)

• Suggested Coordination Board for the Health IS
• Ministry of Health
• Croatian Health Insurance Institute
• Representatives of hospitals
• Representatives of primary health care
• Public Health Institute
• Representatives of developers
• FER?
• Why? Coordination problems
• Health Insurance Institute does not accept
  reports on CD but rather on printed A3
• Glue on recipes to be printed disables printers
• Hiding of citizens unique identification number
• Unilateral decisions, regardless on other
  stakeholders, etc.
• Supported by (most) stakeholders
• Never constituted!

19
Further developments (2)

• Report accepted but the Ministry did not do
  anything for a year
• Popular TV contact show (Otvoreno, Hloverka Srzic
  Novak)
• in 2005
• Primary health care software developers
• Actual and former Minister of health
• FER (Kalpic)
• Result
• (New) Minister obviously misinformed
• The person in charge in the Ministry of health
  was selling his SW product instead
• Fired after the TV show

20
Current status

• FER (Kovac Kalpic) nominated to the Committee
  for procurement of the Integrated hospital
  information system
• New tender for 7 hospitals announced for February
  2006
• Consider saving the existent solutions
• Too many at a time!
• Do not forget the role of G1, the hospitals
  cannot communicate among themselves
• Primary health care allegedly deployed?
• Smart ID cards to be introduced in the future
  with resumed Unique Citizens Identifier

21
Speculation about conclusion

• Significant rationalisations possible through IT
• Romania (Info World) 30 savings
• Insufficient care regarding computing expertise
  within the Ministry of health
• Not enough legal security for SW suppliers
• Same pattern of behaviour as 35 years ago!
• Public biddings time place
• End of July
• Between Christmas and New Year
• A village newspaper XOR Financial Times
• MOTIVATION FOR SUCCESS?

22
Related published papers

• D. Kalpic, K. Fertalj, V. Mornar, M. Kos A
  Proposal for Information System Development for
  Clinical and Hospital Centre Zagreb, 1st Croatian
  Congress on Telemedicine with International
  Participation, Abstract, Ivica Klapan (ed.),
  Makarska 16-18.05.2002.
• D. Kalpic, V. Mornar, M. Kovac Personal
  authentication and privacy protection on
  Internet, TELEMED 2004, 2nd Croatian Congress on
  Telemedicine with International Participation,
  Zagreb, 19.05.2004.
• D. Kalpic, Damir Mornar, Vedran Kovac, Mario
  Fertalj, Krešimir Kos, Mladen An insight into
  efforts to establish computerization and
  e-services for public health in Croatia //
  Proceedings of the 2005 Networking and Electronic
  Commerce Research Conference (NAEC2005) / Gavish,
  Bezalel (ed.). Dallas Southern Methodist
  University, Dallas, USA, 2005. 75-91
• D. Kalpic, V. Mornar, M. Kovac, K. Fertalj, M.
  Kos Establishment of computerization and
  e-services for public health in Croatia,
  Abstract, 3rd Croatian International Congress
  on Telemedicine and e-Health, Hvar, 2006