2008 - Edel Kirketerp
Report from a Danish participant joining the Portuguese HOPE Program
Introduction of myself:
My name is Edel Kirketerp Nørskov and I am a 56 years Old Danish woman.
I am educated as a nurse, and for the last 20 years I have been working as a leader in hospital wards. Beside my nursing education I have a university degree in Public Management, Health Economy and Patients Rights. On top of that I have taken a Masters degree in Ethics and Values in Organisations (MEVO).
My present occupation at Kolding Hospital is chief-nurse of a paediatric ward with app. 180 employers; doctors, nurses, nursing-helpers, psychologists, social worker, kindergarten teachers and hospital-clowns.
My motivation for being a HOPE participant:
For several years I have been part of HOPE-programs in my hospital as the local coordinator Lisbet Bennike often has asked me to introduce my wards to HOPE-participants. I have always found this was a great opportunity to communicate with health professionals from other countries and in other fields. I think I have done this quite well, because I have often experienced that our guests have contacted me afterwards for further news or just to say thank you for interesting information. I have wanted to be a HOPE participant for many years, but you really have to plan a stay for almost 1 year in advance, and as I have a family there has always been something to celebrate in May or June. Besides that I have been occupied studying for my degrees.
But this year I structured my workload so I could participate in the HOPE-program. Fortunately I got the chance to stay in my first priority, Portugal.
“Preparing-time” before being a HOPE-participant:
I want to mention that the time period between your decisions of being a participant to the day you actually are in the middle of it, is rather long, so I tried to prepare myself as good as possibly. All the Danish HOPE-participants, the national- and local coordinators met in Copenhagen in January 2008 for a kick-of meeting to our stays in the different places. The national coordinator Niels Erik Sanden had planned a program with a good introduction to the topic of the year: Improving continuity of care: The role of IT with lecturesconcerning the topic.
I found it valuable to be presented for the HOPE-group, and that we all had the opportunity to ask questions to former participants. Right away I established contact with another Danish nurse who also had chosen her stay in Portugal.
From January 2008 I had close mail contact to the Portuguese national coordinator Francisco Matoso and my local coordinator Marta Temido. Both coordinators were so very helpful with information and adequate answers to all my many questions. I also found information about Portugal facts-figures through books and internet. Francisco provided the participants with a link to literature about “Health in Portugal 2007”.This small book of 100 pages was publishes in accordance to Portuguese Presidency of the Council of the European Union in 2007. I price this book very high. It is current with recent facts-figures about Portuguese Health-Care-Systems. Besides health-system information, reading the book gave me a relevant introduction to the Portuguese history, people and society.
Arriving in Portugal:
The other Danish participant Heidi and I travelled together to Lisbon where we arrived Saturday 26th of April late afternoon. The national coordinator Francisco was waiting in the airport and drove us to our hotels. Later in the evening we met with the other HOPE-participants and Francisco took us all out for a drink. This was a very positive start at our stay in Portugal.
On Sunday Francisco arranged for the Swedish participant Harriet and I to go by train to Coimbra (2 hours from Lisbon) where we would spend the next 4 weeks together with a Spanish participant.
Arriving in Coimbra we were met by our 2 local coordinators Marta Temido and Rui Moutinho. They drove us to a Nursing Residence and made sure that we were ok with the conditions. Afterwards they took us for a short sightseeing in Coimbra and showed us the closets shopping-centres. Before they left us we knew the program for the next day. Perhaps is seems naive to mention these things, but I think that this positive and well structured arrival gave us mental energy to the HOPE-program.
In Coimbra we were 3 participants, Harriet from Sweden, Manolo from Spain and myself Edel from Denmark, each of us had a local coordinator. Our program was planned to be in English, but Manolo spoke Spanish/Portuguese. The only word (so he said) he could pronounce in English was beautiful, so it was really a positive challenge to communicate with Manolo.
On the second day of the program the 3 coordinators went through the program with us, and they gave us lot of opportunity to ask questions.
During the stay we visited 3 different hospitals in Coimbra;
- Centro Coimbra Hospital (Hospital dos Covôes, Maternity Hospital and Paediatric Hospital)
- University Hospital of Coimbra
- IPOFG Oncological Institute.
Besides the hospitals in Coimbra we visited 4 other hospitals:
- Hospital de Âgueda, local hospital
- Hospital de Cantanhede local hospital
- Santa Maria Hospital Lisbon in connection with a National Meeting
- Hospital Torres Novas in connection with a National Meeting
We also visited:
- The Regional Health Authority in Coimbra, ARSC
- Department of Public Health and Planning, Coimbra
- A Primary Health Care Unit, Coimbra
- A Long term care-center Santa Isabel, Coimbra
- ACSS, Department of Central Administrative Systems; Lisbon
During the stay there were planned 4 National Meetings;
- Porto, 30th. of April
- Lisbon, 9th. of May
- Lisbon, 16th. of May
- Torres Novas, 21st. of May
All 7 HOPE-participants in Portugal were together by the National Meetings and we had the opportunity to work on the final presentation.
I found there were very few changes in my program. Everyday the coordinators have arranged transport for us either by themselves, a driver from the hospitals or some other key-persons. We were never left on our own.
Benefits from the program
The year’s topic: Improving continuity of care: The role of IT appeals to the HOPE-participants in too ways; the ones who sees care as the primary topic and IT as a tool, and the ones who sees IT-systems as the primary topic and care as a tool. The different views and interests in the topic created some really amusing discussions between healthcare professionals and IT managers.As I talk about benefits from the program, my focus is on care/the patient-pathways and I look at IT as a tool, which can improve continuity.
In Denmark we have a National Strategy for Healthcare and in the last 8 years also a strategy how to use IT-systems within the healthcare system, which means communication between primary and secondary healthcare systems. In my department we have electronic patient’s records (EPJ), PACS (X-ray) LABKA (blood samples), medical prescription-system, and e-communication with the GPs and recently we have tried (yet not very successfully, though) speech-recognition. I find you spare administrative-time using IT. You have a lot of data, which is stored in a database the same second as you make a patient registration. The same patient’s data can be used by several health professionals at the same time, independent of localisation. You don’t have to look for patients paper records.IT-systems can provide hospital administrators with data using for pathway quality and different static’s. Stored data can also be used for research, benchmarking and documentation in situations with patients complains.
The Healthcare System in Denmark is organised under The Ministry of Health and under that different departments which provide the Healthcare System with politics for patient- treatment and care. When Denmark change government, the politics within healthcare continues, this means that the governing political party in big terms respects former decisions regarding healthcare development.
In Portugal I found that the governing party has a big influence on the healthcare strategy and politics. Back in the nineties Portugal had their first National Strategy for IT in healthcare, but after very few years a change of government also changed this strategy, or rather the strategy was not maintained and further developed. Everywhere we went during the program we heard of SONHO, the original hospital IT-administrative system and SINUS the original health-centre -system. SAM IT-system used by doctors and SAPE IT-system used by nurses. IGIF was the National Institute who was supposed to maintain and develop the IT-systems, but back in the nineties the Institute was closed by the new government. The consequence was that the systems were neither maintained nor developed.
Of course the Portuguese healthcare system had to keep up with the demands to hospital development which requires modern IT equipment, and commercial IT came into the hospitals, which means that Portugal right now within healthcare have the old systems; Sonho, Sinus, Sam and Sape which are still in use in a lot of places. Besides that also a lot of other IT-systems, whose biggest problem are that they can’t communicate with each other, either within hospitals or to the primary healthcare-system.
Portugal is very aware of this problem and has created ACSS which is an Institute of IT-development and Communication in Health-systems. In connection to one of the national meetings we (HOPE-participants) were so fortunate to have information about ACSS´ visions, missions and strategies of the future IT in Portuguese Health System. In my opinion this was very ambitious and clever, and I really wish for Portugal, that they will succeed in this great strategy, and look at the many mistakes we have already done in other European countries, and avoid the mistakes and make something unique for Portugal.
In several hospitals they use IT-systems, but also a patient’s paper record. I found that Portuguese healthcare professionals made a lot of double documentation as the doctors and nurses made their documentations in two different systems, and from what I saw used each others notes in a very small extend.
In three bigger hospitals we were showed, that storing patients paper records is becoming a major problem for the Portuguese health-system because of a specific law which forbid the hospitals to destroy patient’s records. In some hospitals we were told, that the records of deceased patients were vacuum-packed to spare room.In the same hospitals we saw big archives with records and up to 15 employees to maintain it.
In my hospital which I will characterize as a middle big Danish hospital we have closed manning of the archives because of the EPJ.
"Keep" the patients away form the Emergencies
Being a General Practioner (GP) in Denmark is a respected job as well amongst people as in the doctors National Association. The GP is gatekeeper for the hospitals, and the Danish health strategy is, that the more the GP can treat and cure in the healthcare centre the better because of the lower costs. Also the GP has a lot of preventative patients’ treatment.
The GP is organised privately which means that he owns his clinic and the staff gets their salary from the GP. If the GP needs equipment for the clinic, he is responsible for the costs. Consulting the GP in Denmark is free. The GP is paid for patient’s treatment from the public Health Department. When the GP document his work in the electronic patients administrative system the Health Department right away receives the information, and the GP is paid monthly for these consultations. A Danish GP has a good salary. Besides working in the clinic from 8 – 16 o’clock, he also take duty from 16 – 24 and 24 – 08.A group of doctors’ share these duties so each doctor approximately have 2 – 3 duties pr. Month. By this system the patient can contact a GP all 24 hours. Acute severe treatment naturally goes to emergencies.
The Danish GP has close contact with the secondary healthcare system by electronic communication.
I found that being a GP in Portugal was a less prestige full job for a doctor than working in the hospital. The GP was paid a salary by the Health Board, which also paid for his staff, clinic and equipment. Often a GP was alone with no professional contact to other doctors in the centre during his working-hours. It wasn’t possible for the Portuguese patients to come in contact with the GP after normal working hours. If the Portuguese patients needed medical treatment they by first choice went to the closets Hospital Emergency. Patients were prepared to wait for many hours as long as they were consulted by a hospital-doctor.
We saw some crowed Emergencies and the HOPE-coordinators told us, that this was a big problem in Portugal. In Portugal the Health Ministry had tried to prevent patients to seek the Emergencies by collecting a fee for going to hospital. As far as I understood the problem still existed, and the hospitals had to employ people to collect the fee of 5 euro.
The Health Ministry was also trying to reorganize the primary health sector from Health Centres and Extensions Health Centres into Family Health Units, which should be more attractive for doctors to work as a GP with multi-professionals and self-organized teams, a functional and technical autonomy, a basic set of services and a retributive system rewarding the productivity, accessibility and quality. I find this construction very interesting and positive.
In Portugal you had focus on making a priority of emergency of the patients who used the emergencies.
In 2 hospitals we saw the Manchester Triage, which is a smart effective system to differentiate between the patients needs for having acute consultation. A nurse triaged a patient, some kind of a screening, and according to how many points a patient obtained he was given a colour, read was attended immediately, orange attended after 10 minutes, yellow attended after 1 hour, green attended after 2 hours and blue attended after 4 hours. If you could wait for more than 4 hours you were asked to go home again and consult your GP the next day. In one hospital this system was connected to a patient’s information screen, which showed the people in the waiting room when they could expect to be treated.
I found this triage interesting as we in these months are preparing something similar in my children’s department. These 2 emergencies had a philosophy of being paperless which was a perfect example of continuity in care helped by IT.
I was very impressed about the IT-system used in these two hospitals. The system was called ALERT and was innovated/developed in Portugal by two brothers, one of them a doctor the other one technical engineer. In Covôes Hospital in Coimbra we had a demonstration of the Alert System by the superior nurse, and we found it was used interdisciplinary.
Attending the HIT-conference in Paris at the end of the HOPE-program we went to Alerts showroom and found that the system is developed to a lot of fields within healthcare. Even though the Alert is a rather new invention, it is in short time known and used worldwide.
In paediatric hospital in Coimbra we were introduced to telemedicine used by a paediatric cardiologist. He showed us an example of a newborn baby at a hospital 200 km. away from Coimbra. By a web camera is was possible for him to follow an echocardiography while he at the same time was communicating with the doctor who was making the investigation.Fortunately the baby was well which the paediatric cardiologist could say in app. 5 minutes.
Even tough telemedicine has been practiced for several years, it is still impressive to see have helpful a tool IT is, concerning this area. We were told that the paediatric hospital in Coimbra several times a week had web contact with Tonga in Africa. The doctors from Tonga and from the other hospitals close to Coimbra were all trained by this paediatric cardiologist, which in my opinion only qualified the investigations.
Usually the doctors in Portugal are working 42 hours a week. In the mornings the worked at the public hospital and after lunch the doctors worked in private clinics. But paediatric doctors worked all the hours at the public hospital. I am not at all generalising but I don’t find this special amongst paediatricians. You find the same pattern in Denmark.
Portuguese Continuous Care Network:
In these years Portugal is reconstructing the Healthcare –system by the philosophy that the treatment for disability or illness most often begins with acute medical care, usually provided in an acute care hospital before you begin rehabilitation. Acute medical care aims to stabilize the patient and lessen any further complications. Rehabilitation begins after the patient is stable and the doctors conclude there will be no further complications, and rehabilitation is the most important objectives of Portuguese Continuous Care Network.
The primary aim of this network is for people with disabilities or illness to be able to carry out activities of daily living, such as eating, dressing, bathing, so they can live as independently as possible. The rehabilitation must preferentially be done at patient’s homes through teams, but if it isn’t possible, there are special intermediate care units where patients can stay for a certain period of time. We saw some examples of the network combined with long-term care and palliative care units.
I think this philosophy of patients care is good and quite similar to other European countries, where you avoid having patients hospitalized more than necessary. The expensive hospital-beds are used for the patients with the acute need.
In one of the network centres there was a small operation-theatre where they made minor day to day surgery. It was created on the idea, that the patient saw as few professionals as possible. One week before the surgery the patients were investigated by a doctor and given information of the operation and the rehabilitation by a nurse. This team of professionals also made the operation, and before the patients left the clinic the same doctor and nurse made sure, that the patients could manage on their on and call the team if necessary.
The next day the patients had a call from the nurse, and the third day the nurse went on a home-visit. The staff was very pleased with these working conditions and the patients were very satisfied with the security that the felt from the professionals. This is really a splendid example of continuity of care but not with IT as a helping tool.
Is a service which promotes the rational use of medications during preconception phase, during pregnancy and even during lactation.
The objective of releasing information, carefully selected and appraised, supported on bibliography, is to support clinical and therapeutic decisions. SIMeG is the only service in Portugal that associates bibliographic research to a clinical evaluation specialized in Obstetrics and Paediatrics for each question that is presented. The service was created to give specialized information, the most up to date as possible and that it might be provided in time, so that the evaluation and the decision concerning the clinical situation in analysis might be the most correct as possible.
This service is prepared for giving answers to the request and information, gathering specialized information collecting it in a database and contributing to a surveillance program. The service can be used by everyone by green line, telephone, e-mail, and fax and personally in opening hours. Information provided is free of charge. This system is used by doctors but also pregnant women and others who want to be pregnant. I find SIMeG a very useful and preventative system, which give important information to ordinary people as well as professionals.
Accreditation IPO, Coimbra:
Our program at IPO-institute showed me a proud ness amongst the professionals working with a patient-group which can be difficult to cope with, because of the several tragic incidents. But we found a warm and caring atmosphere everywhere in this hospital, which had 900 employers. IPO-institute Coimbra made patients satisfactory investigations, and they had very fine results. The hospital was accredited in 2005. The accreditation process had been though to make the professionals to accept all the registrations but the hospital saw great benefit in the quality of treatment and care. They were going through a new process at the end of this year. There was a lot of research amongst doctors as well as nurses at this hospital. Papers and posters were showed at international conferences.
Social value from the HOPE-program:
We were 3 participants in Coimbra, and I must admit that it was lucky that the Swedish participant and I made friends so quickly and had so much in common, otherwise I think that I could have felt lonely. Our coordinators had lunch with us three times and a Sunday afternoon we were out for a student’s parade. Our coordinators were very busy people and we didn’t have much social time with them. The final stay in Paris was wonderful. I have never thought it would be possibly for me to dance in a “French Pavilion”.
How to use the HOPE experiences in my present job:
I was very impressed by Manchester-Triage and I am at the moment trying to find international literature about this subject. The IT-system Alert was fascinating and I have already arranged with my hospital board and the IT-chief that Alert consultants are visiting my hospital together with the Swedish participant which was an application manager. My hospital uses IT in every system concerning the patients, but we are open to learn new things.
On the next quality-meeting at my hospital where the whole leader-team will be present I have one hours lecture about my stay in Portugal.
I hope that I can keep contact with Portugal for mutual information concerning quality for the patient’s treatment and care and especially how it is organised.
Suggestions to future programs:
As HOPE is an exchange program I was a little disappointed not having the possibility to show our coordinators how my hospital was organised. I had prepared a presentation to my host on recommendation from the Danish national coordinator, but we didn’t have time. I know that my Swedish college also had a presentation. So perhaps in future programs this could be a subject. More time with the coordinators would have been valuable. Perhaps a gathering dinner where coordinators not were going to works afterwards.
Personal value from the HOPE-stay:
I found that my stay in Portugal was a great privilege and a challenge for me personal. I meet so many friendly people. I felt that Portugal opened many doors to us 7 participants. It was 5 wonderful weeks which I will always remember with great joy. Only time will show if my contacts through this stay will become friends, which I sincerely hope.
I am recommending every hospital professional to be a HOPE-participant, but you have to plan the stay at least one year in advance. And if you have a family, make sure that they will support you in your choice.