Less is more: Denmark focuses on superclinics
As part of our #SmartHealthSystems study which examines the digital transformation of healthcare systems in 17 countries, we have visited five of these countries to take a closer look at what they have achieved. In each country, we have explored the political, cultural, technological and economic factors driving success as well the obstacles to advancing digitization strategies in healthcare. The findings of our cross-national study will be published in November 2018. Until then, we will be highlighting thought-provoking insights and best practices from other countries here in our blog. Our second blog contribution featuring Denmark explores how telemedicine was conceptually integrated into the inpatient care sector.
Denmark is a small country that thinks big. The city of Aarhus is an example of just how far this thinking can go. Just north of Denmark’s second largest city, a satellite community of some 270,000 is emerging. While the royal residence of Marselisborg and the rainbow-colored ARoS art museum in Aarhus attract visitors to the city, the main attraction to the north is Aarhus University Hospital, home to a massive clinic facility.
With construction of the hospital building on the expansive grounds recently completed, much of the hospital staff has already moved in to their new facility. The construction of all buildings and moving logistics are scheduled to be completed by March 2019. And the numbers are impressive: the hospital will boast 11,000 employees, 44 clinical departments and 1,150 beds. Each year, the hospital is expected to treat 100,000 in-hospital patients, 900,000 outpatients, carry out more than 80,000 operations and bring some 5,000 babies into the world.
But this is not the only megaclinic to be found in Denmark. According to the reform plan, the small country will have a total of 16 such super hospitals by 2025. Six of these are new construction projects in Aarhus, Aalborg, Gødstrup, Odense, Køge and Hillerød. The other ten projects involve extensive renovations to existing hospitals. A sum of €6.5 billion is being invested in the 16 construction Projects.
Denmark’s hospital landscape – specialization and centralization
It all began with the 2007 Danish Municipal Reform, which reduced the number of municipalities in the country from 270 to 98 and did away with the country’s 13 counties (amter), replacing them with five regions. These regions have been tasked with managing the healthcare system. Eighty percent of their resources come from the state, the rest from the municipalities.
As part of the municipal reform, the Danish government also introduced a quality fund slated to improve the quality and efficiency of healthcare provision in Denmark in an effort to address the shifting demographics of an aging population and growing number of patients with chronic conditions. As a result, there is a growing need to develop outpatient care facilities while also providing highly specialized therapies.
Drawing on these findings, Denmark developed its own national hospital strategy [PDF] that has been gradually implemented with care and has been guided by the principle of “less is more.” Whereas Denmark featured 100 public hospitals in 1999, today there are only 32, some of which have multiple locations. Several clinics were simply shut down, while others consolidated. In the region of Southern Denmark, some 35 hospitals were reduced to five hospitals in 12 locations.
There are now fewer hospitals, but each of them feature the finest state-of-the art infrastructure and are efficient. By the end of the process in just a few years, a maximum of 20 locations across the country are scheduled to provide care for 5.7 million Danes. Each facility will provide care for approximately 300,000 residents. For the purpose of comparison: Germany has some 1,950 hospitals for just over 83 million people. That’s some 42,500 residents for each hospital. Although there is a discussion in Germany about hospital specialization and centralization (see our Faktencheck Krankenhausstruktur, in German only), the implementation of any such strategy is still in its infancy.
When told of how few hospitals Denmark has, many German patients raise their eyebrows in surprise. Most are uncomfortable with the idea that the nearest hospital might be so far away. Indeed, the Danish hospital reform did increase a patient’s average distance to the next hospital. However, polls show that most Danes prefer to travel 60 kilometers to a modern hospital with excellent facilities than five kilometers to lesser-equipped hospital.
Furthermore, one of the goals in restructuring Denmark’s hospital landscape was to resolve as many problems as possible outside of the clinics. This means that only patients with serious cases are admitted into the hospital, and their stays are kept as short as possible. According to Healthcare Denmark, the average length of stay is only 3.7 days; the average stay in Germany is almost twice as long.
“We call them super hospitals so that the population thinks they’ll be good. And they will be great,” said Søren Lindgaard, director of the Health Innovation Centre of Southern Denmark, while speaking at a conference for hospital reform held in Thuringia two years ago that offered insight into the Danish example. “It’s better if citizens accept the compromise of a somewhat longer journey to the hospital in exchange for treatment by a highly specialized physician.”
Telemedicine as part of a new hospital structure
While hospitals are themselves in investing in digital innovations like telemedicine, projects in Germany often find it difficult to establish themselves as part of standard care (see our opinion on this in our blog). A project underway in Odense offers a good demonstration of how telemedicine can improve efficiency and patient care. In Odense, premature babies are sent home with their parents earlier than is commonly done. Normally, babies that are born preterm are held in hospitals longer to receive medical attention. Even when they’re in a stable condition, they require nursing care until they can be breastfed or drink from a nursing bottle and no longer require tube-feeding.
This can involve a long hospital stay over weeks or months of time, which is also a heavy burden for parents. In large cities like Copenhagen there are enough nurses to arrange situations in which nurses come with parents to their homes to help take care of the child. But in more rural areas like the island of Funen, there are limited resources for such things. The Odense hospital therefore decided in 2015 to introduce a pilot telemedicine project to assist parents in taking care of premature babies at home.
The project involves providing parents a telemedicine “travel bag.” Each travel bag includes an iPad with stand (so that mothers do not have to hold the iPad and child at the same time) that parents can use to communicate with the hospital and a scale that automatically transfers data to the hospital. A nurse “visits” the baby and parents twice a week through the iPad, which allows her to see how the baby is doing. The parents can upload pictures and/or videos and, in the case of an emergency, initiate a video conference at any time. On average, every nurse takes care of six babies through telemedicine consultations.
And in cases where the baby continues to be fed through a tube, parents receive training before being sent home. They also receive first-aid training tailored to the needs of infants so that they can identify early signs of a possible deterioration in an infant’s condition. The only requirement for telemedicine treatment is that the baby be at least 34 weeks old, have a weight of 1,500 grams and be able to maintain its body temperature.
Feedback from parents and nurse specialists alike is positive: “It feels like you’re sitting with the family in their living room,” reported one nurse in a Danish TV program. “I have 20 minutes – with no interruptions – for the family.” That is more time than when the parents are in the clinic. Parents also report that it is a huge relief for them to shorten their stay in the hospital by days or even weeks. They feel that they are well-prepared for care at home and they have more quiet as well as breastfeeding time.
Telemedicine use was an initiative of hospital staff
It is worth noting that the project was initiated by nurses in Odense’s pediatric ward who worked together with a doctoral candidate in medicine to develop the model. The clinic actively supports initiatives like this. Every employee can submit suggestions for the use of new technologies or telemedicine projects via an open platform. An innovation board reviews the submissions, allocates financial resources for promising projects and provides expert staff tasked with evaluating them.
The first evaluations of the preemie project show that infants between five and 14 days old could go home earlier than beforehand. Another positive outcome is that this frees up beds, which allows the hospital to admit more serious cases. Since having been launched, the Odense model has prompted interest among other hospitals in developing similar projects.
Bundling resources and expertise through centralization in order to improve efficiency and using telemedicine to ease pressures on hospital staff as well patients – these were and are key objectives in Danish hospital reform. And in fact, Danes spend on average only one-third of the time spent by Germans in hospitals. The advantage here is that in Denmark patients are less likely to undergo operation, and are less frequently subject to an operation, which reduces the risk of acquiring a virus in hospital. But perhaps the biggest benefit hospital reform is the fact that the less time patients have to spend in hospitals, the more satisfied they are.
Note: This blog post was written in cooperation with Cinthia Briseño. She supports on-site research for the survey #SmartHealthSystems with her journalistic contributions to our blog.
The study is carried out by empirica Communication and Technology Research on behalf of the Bertelsmann Stiftung.
Follow us as we take a closer look at e-health developments in various countries for our study throughout the course of 2018.
We will publish the full results of our international study in November 2018. Until then, we will be highlighting thought-provoking insights and best practices from other countries here in our blog. If you are interested in keeping up-to-date with our latest analyses, we recommend that you sign up for our email newsletter: