1. Introduction

There are different ways to describe the co-operation between different actors in health care. At least in publicly funded systems like in Finland, hierarchies and bureaucracy used to be typical features in regional collaboration. However these features soon met their boundaries and it was noticed that they can not be the developing base for the health care in the future.

Also a market approach to health care can be observed in many European countries. After experimenting with market- style changes to their health systems, policy- makers in many countries are gradually moving back from competition to co-operation, partnership and alliances.  There is a recognition that markets and medicine may not always mix well. Competition is not always and everywhere, especially in rural regions like North Karelia in Finland, conducive to effective collaboration and pursuit of wider health goals.

It is now acknowledged that there is a role for government and regional public policy in the development of health care systems. Hierarchies, market mechanisms, or at least the attempt to mimic these, have led to fragmentation and low trust relationships both within health care systems and between them and other sectors. Instead of co-operating, those managing and providing health services have resorted to competitive behaviour in order to secure their survival. This has not always been in the best interests of patients’ needs or those of local communities or to implement large innovations of telemedicine.

2. Patient management applications

North Karelian Hospital District (NKHD) situated on the Eastern Border of Finland is one of the 21 hospital districts in the country. NKHD consists of one central hospital for secondary, specialised care, one mental hospital and 15 health centres.

NKHD has been developing patient management applications in TERVE and in CHIN projects which both are supported by EU. In these projects NKHD  has several important goals, like the seamless care which could guarantee flexible co-operation and networking between the health centres and the central hospital. The goal is to minimise waiting times, unnecessary tests and costs and provide ”one-stop-shopping” services for the patients. NKHD’s area is a sparsely populated one and thus it sets some special requirements for health care organisation. E.g., because of long distances, the patient transfers from health centres to central hospital have to be considered case by case to minimise costs and still guarantee safe and high level care.

One of the applications to improve the care processes is the intelligent referral. The purpose is to build up a networked environment, through which the general practitioners in the health centres around Joensuu can book up resources in the central hospital. The services available through the network include reservations for a specialist, resources for small operations (like operating theatre, surgical team, equipment,..) etc. Within this development and definition work some new concepts, like the trouble identification has been taken into use. The trouble id’s are simple codes or names for the most commonly used reasons to send patients from the health centres to secondary care level. The trouble id’s are called simply e.g. ”backache” or ”legal abortion” etc. This makes it easy for the GP to make referrals for certain most common cases. The system will also make it possible for the GP to follow his or her patient’s treatment in another institute and get ready for the discharge and the treatment continuation on the basic level.
The idea of electronic patient record is also bound together with the developing work of these applications. EPR idea means patient information fastened to individual patient and this information can be situated in different places of the regional network (different servers or intelligent workstations). Professionals have access to these information always when needed. Thus it is not necessary  for the doctors to give actively any feedback information to each other. So the traditional patient record in archive does not exist any  more.

CHIN-project also develops different kind of applications for the so called Core-CHIN-services, public services and  professional services. The patient management applications belong partly to the professional services and partly also to the services included in Core-CHIN applications. The ones belonging to the Core-CHIN-applications, like DX-Multimodality and WebMed have already proceeded to commercial stage.

Fig.1 The differences of data and process parts in developing new regional service  model into health care.

These patient management applications will take care of some of the processes running in the health care. It is clear that they will not cover all the actions needed in each patient case or other information processing task. Thus, the interfacing with the other information systems (legacy systems) is of great importance. Otherwise the process improvements , which are one of the reasons to develop new systems, cannot be achieved. In the cases described above this critical issue will be solved by using open integration platforms, HL7-standards and standard database tools.

It is clear that the new applications represent a great potential in process improvements. They make it possible for the carer to follow up individual patients throughout the process and ensure the best possible arrangements for the patients. The advantages of the systems are twofold. First, the health care providers are able to improve their processes, the seamlessness of  the processes and the chains of the processes. This will make it possible to use the resources in an optimal way, to reduce unnecessary tests etc. They will also provide an easy and effective access to the information needed in health care and patient case management. Second, for the patients this means easier access to the health care resources. In many aspects ”one-stop-shopping” services can be provided for the patients. After the first contact the patients need not to worry about the next steps, like booking time for a specialist after visiting a GP. All this will be taken care by the system interactively in co-operation with the patient.

The different user groups (GP’s, specialists) have been deeply involved with the definitions and development of the new services and they are devoted to test and evaluate them and take them into use.
 

3. How to create new public services? How to reform public administration?

These questions are mentioned in the title of my presentation. In public sector and especially in health care, markets were seen as attractive model because they allegedly offered incentives to change behaviour and improve performance. In their absence, how will a change to be brought about? What incentives will operate? How can partnerships be made to succeed? Are hierarchies and command and control systems the only alternatives to markets in health care? If so , history suggests that they have not been too successful either in securing change. Does the solution to create new public services in health care therefore lie in a  mix of public and private components and in using new ICT (information and communication technology) in networked regional organisations?

Healthcare is faced with rapidly developing new technologies. Implementing ICT into health care you can meet also many management problems. We also need to reform new structures to support the alliances and partnership for health and healthcare. Can the different cultures and value systems be effectively harnessed in a joint endeavour to improve health? What management skills are required in networked and in teleinformatically supported regional organisations? What managerial tools are required and how does the managers formulate standards and targets within such fluid new structures?

I do not have answers to these questions but  I will underline some of our own experiences in North Karelia Hospital District:
 

Health care itself is not expensive. Expensive is the way how we do it. In the future the development of health care costs depend on how the grass-root level is working and is regionally organised.  In this work you must however remember that you can not shrink to greatness!

One should not fall in love with the new technologies. New ICT  means only more costs  if we do not change our working manners, regional core processes and regional structures. ICT itself has no any special value to health care.

Health care must be active now. We must know exactly what we want from telemedicine and teleinformatically supported health care services. If we do not, we will eventually lose our autonomy and very soon we will only become a part of teleoperators’ and adp- companies’  business.