Strukturert EPJ. Relevans for NPM? Kjell Krüger M.D., MHA, spes. Geriatri/indremedisin Bergen kommune/ Emetra AS

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1 Strukturert EPJ Relevans for NPM? Kjell Krüger M.D., MHA, spes. Geriatri/indremedisin Bergen kommune/ Emetra AS


3 NPM NPM has thus been a reform wave with a core idea, but with varying and inconsistent implementation in different countries. It has been characterized by a one-dimensional and economically-oriented thinking Led to efficiency gains, but also increased bureaucracy It has now been supplemented and modified by post-npm reforms in many countries, characterized by less emphasis on efficiency thinking and more emphasis on the management and coordination (Christensen 2010)

4 Kritikk NPM The results are inefficiency, poor service, red tape and frustrated employees" (Fiskaa 2009). Thus, the system will never be so robust that it generates activity statistics as detailed and valid as expected by the authorities (Tøndel 2007). The coding is time consuming and it feels bureaucratic, especially as extra employees are appointed in order to check whether the codes are correct (Kongsvik 2012).

5 Ny digital trend The character of the post-npm regime is currently being formed. A range of connected and information technology centred changes will be critical for the current and next wave of change. The overall movement incorporating these new shifts is toward digital-era governance (DEG) DEG offers a perhaps unique opportunity to create selfsustaining change, in a broad range of closely connected technological, organizational, cultural, and social effects (Dunleavy P 2006).

6 Adekvate styringsparametre Characteristics of NPM within three main categories. He consider interestingly only a few of these factors still to be in force in NPM-countries, namely the factors regarding improved performance measurement user control valuing public sector equity mandatory efficiency dividends (Dunleavy P 2006).

7 Grunnleggende NPM svakhet Man har målt det man kan måle, ikke det man bør måle antall prosedyrer X er ikke like givende som antall prosedyrer X uten komplikasjoner

8 Utfordringen Kan kvalitetsparametere (med høyt presisjonsnivå) produseres gjennom det daglige dokumentasjonsarbeidet, samtidig som det rasjonaliserer arbeidet?


10 Hvordan er disse funksjonene mulige? Strukturert EPJ

11 Mye av medisinen er strukturert


13 Slik opererer datamaskinen If BP_systolic < 110 And Drug_ATC contains Then Warning: Pasienten står på blodtrykksmedisin og har systolisk blodtrykk under 110

14 Altså må parameterene være grundig stykket opp og strukturert BP_systolic BP_diastolic BP_systolic BP_diastolic BP_systolic 160 BP_diastolic 100 BP_systolic 130 BP_diastolic 95 BP_systolic 120 BP_diastolic 80 BP_systolic 105 BP_diastolic 55 BP_systolic 107 BP_diastolic 60

15 Problemet med de fleste journalsystemene Epsum lirumepsum lirum Epsum lirum Epsum lirum Epsum lirum Epsum lirum BT: 120/80. Noen dager seiner var blodtrykket 100/70.

16 Prosess-støttende maskineri

17 Populasjons filtre Oversiktsbilde

18 Filter (populasjons-) bibliotek


20 Kritiske behandlingsforskjeller fra sykehjem til sykehjem

21 Kritiske behandlingsforskjeller fra sykehjem til sykehjem


23 Prosent av pasientene ikke veid ,6 No weight 30 days P = < Before After

24 Prosent AF pas. marevanisert 12 On warfarine 10 9,6 8 P = ,5 0 Before After Figur 6, Change of warfarin medications in percentage of number of patients per institution before and after 14 months of intervention with alarm ( patient has atrial fibrillation but no warfarin ) and subgroup definition filter ( patients with atrial fibrillation without warfarin ). Alarms and filters included in electronic patient record system. In two nursing homes in Bergen, Norway (N = 188). Red line indicates the prevalence of atrial fibrillation in nursing homes in Bergen (18.8 %).

25 % patients using neuroleptics Use of neuroleptics before and during implementation Date Figure 3. Time-series on rate of patients using neuroleptics in 3 nursing homes before and during implementation with a structured medical record system with decision support, among patients in three nursing homes in Bergen Red line represents the developing institution (not included in the studies). Blue line represents institution E and green line institution F, both institutions included in the before-after study. Red arrow indicates implementation startup.


27 Oppfølging avdelingsnivå

28 Overvåking institusjonsnivå

29 Overvåking flere institusjoner