Capitol Correspondence - 06.10.19

Danish Challenges with Integrating Electronic Health Records Form Parallels to EVV Challenges in US

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ANCOR is sharing this article by Politico Pro because ANCOR members have expressed interest in increasing the use of electronic health records in the disability space. Our members’ interest is because of the widely-understood benefits of medical and care professionals being able to easily share records across team to ensure everyone is on the same page when supporting an individual. Additionally, even if the article below focuses on the country of Denmark and electronic health records and parallels to veterans affairs in the United States, it also carries strong parallels with challenges surrounding electronic visit verification (EVV) in the disability field in the United States. The parallels include difficulties with: adapting technologies to an area of practice they were not designed for; going live before stakeholders are comfortable with using the technology; lack of on-the-ground technology expertise; and government officials being reluctant to move away from a significant financial investment after it is made.

As shared by Politico Pro:

“For three years, a dour anesthesiologist and computer architect named Gert Galster tunneled in the electronic guts of Epic Systems, trying to convert the premier U.S. digital health software into a workable hospital management system for Copenhagen and the surrounding region.

After Galster and his colleagues had done what they could, 45,000 clinicians in eastern Denmark were plunged into the Epic system. Like the U.S. Department of Veterans Affairs, the Danes had expected that tech from a big IT vendor would make it easier for doctors in an excellent health care system to work, share patient information and keep tabs on costs. But the Danish experience produced results that varied from frustrating to disastrous — a sobering lesson for the VA, which recently began a transition involving another big vendor.


It’s been said that when culture and science go to war, culture wins. In that sense, this tiny Scandinavian country’s problems with its expensive IT transformation may have a lesson for the rest of the world, including the VA, which serves a population roughly twice the size of this nation of 5.6 million. The VA has begun implementing Cerner — Epic’s leading competitor — replacing its homegrown VISTA platform that had been designed for treating veterans and their unique problems like missing limbs, PTSD and Agent Orange syndrome.

Denmark’s evolving experience could show what is lost — or, eventually, gained — when a country, a region or a mammoth institution surrenders its way of doing things and conforms with a computer system designed for an alien culture.

In the Epic case, as Galster plunged deep into the software to reconfigure it for Danish clinicians, he realized how much it reflected a fundamental difference between the United States and Denmark, where trust and consensus are key components of the health care system.

‘We thought, naively, diagnosis is the same in the U.S. and Denmark. People get the same kinds of illnesses, the same treatments. We rely on the same textbooks in medical school.’ But an IT system that requires collaboration among its users ‘depends on the culture where that collaboration takes place,’ he said.

In Denmark, for example, while the IT separated activities for doctors and nurses, it did not freeze one out of the other’s jurisdiction. A nurse could prescribe medicine in an emergency and explain later. In Epic, any attempt to take a forbidden role caused a “full stop.”


Epic has done thousands of software implementations — a big reason the Danes chose it — but the Danish project was still one of its biggest, involving 18 hospitals in a region with 2.8 million residents.

As the go-live date of May 20, 2016 approached, Galster and his colleagues strongly argued for a delay. But the authorities followed what they described as Epic’s strategy, ‘throw it all out there, fix the problems later, build the road while you’re traveling down it,’ said Nils Jakob Knudsen, an endocrinologist who served as a clinical adviser for the installation.


Hartling later admitted his process for going live at the hospitals sequentially over 18 months was flawed. The implementation team was focused on getting new hospitals onto Epic to avoid the cost and complexity of running multiple systems simultaneously. That meant there wasn’t sufficient staff to handle the thousands of complaint tickets filed by frustrated clinicians as each hospital went live.

Epic had difficulty integrating its system with the national medical record system, which is meant to be accessed whenever a patient is seen. Three years in, the integration still didn’t work. ‘It has been a big challenge for Epic,’ said Marianne From, a senior leader on the project.


Efficiency has declined at Copenhagen-area hospitals. A mid-2018 survey found that 57 percent of heart patients in one Epic area had to wait more than 30 days for appointments, compared to 4 percent in a non-Epic region. In a February 2019 poll, physician satisfaction with the Epic system was 12 percent. Fully 60 percent expressed deep dissatisfaction.


Søren Lauesen of Copenhagen’s IT University notes that many big IT projects, including a land registry and police case management software, have been expensive and problematic for Denmark’s public sector, which is thin on the ground and lacks computer expertise.


While some officials and doctors expect the Epic system to improve, the wounds are deep. Denmark’s experience suggests something important can be lost in technology implementation. That’s a lesson some VA officials are keeping in mind, since unlike Danish doctors, VA clinicians can quit and join the private sector if push comes to shove.


As for Epic, some politicians in the governing Christian Democratic coalition want to rip it out and install Systematic. That seems unlikely. After you spend half a billion dollars on an IT system, ‘you come to live with it,’ Bansler said.”