Making digital the ‘new normal in healthcare’: Stockholm’s approach

An interview with Daniel Forslund, chairman of the innovation and development committee in the region of Stockholm, Sweden.
By Leontina Postelnicu
07:26 am
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Update: HIMSS20 has been cancelled due to the coronavirus. Read more here.

Given the pace of scientific and technological advancements, Sweden, one of the early adopters of digital, is well-positioned to leverage the opportunities of the transformation that we're seeing around the world.

But as Daniel Forslund [pictured on the right], chairman of the Stockholm region's innovation and development committee, explains, it's not all that simple. 

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Stockholm, the country's capital and largest city, is now making it mandatory for healthcare providers to offer digital services in an effort to tackle the gap between the expectations of consumers and the reality. 

Ahead of HIMSS20, MobiHealthNews caught up with Forslund to talk about their plans.

This interview has been edited for length and clarity.

MobiHealthNews: You are currently chairman of the innovation and development committee in the region of Stockholm. In 2014,  you made the move to politics and were elected commissioner for innovation and eHealth, with responsibility for the policies, investments and initiatives relating to this area. What can you tell our readers about these roles and your work to digitise services and bring innovation into healthcare?  

Daniel Forslund: That area has been my passion for many years, because I was working as a civil servant at the national level for many years with these kind of aspects. So I felt that I needed to [generate] even more change and also move to the regional level and move into politics because I felt that there were too few decision makers actually focusing on innovation and digitalisation.

I could also see that there was a slow uptake of new innovative solutions in healthcare, due to the lack of leadership from the regional politicians and decision-makers. So then I decided to be one myself. So, that's the background, because I was focusing on the national policies and legislation beforehand, but those national policies were not worth anything if the regional level didn't take very well to drive change and work harder [to overcome] the obstacles for innovation on the local and regional level.

That’s what I'm now focusing on very much in my role as chairman of the innovation and development committee, providing support for innovative solutions. We have an internal innovation fund where we can fund projects and help health professionals to improve their own healthcare organisation for example with new smart digital tools or new innovative ways of working or new treatment or working methods. We’ve been doing lots in building an innovation organisation to help both health professionals and managers who are in healthcare so that they can get the support and, well, development work in different ways, and also help them to collaborate with entrepreneurs or companies or researchers and academia to help us solve challenges and problems within our organisation.

We have also decided to set a new set of policies and regional regulations on how innovation should be driven within our hospitals and primary care centers and also within our administration. We now have a governing policy that says that innovation should be seen as a core part of how you both govern the county council and how you manage your daily life in healthcare. But innovation should always be a part of that. And that's a requirement for our care providers to also work with.

MobiHealthNews: From what you say, it seems that your work spans across the entire digital health ecosystem, you mentioned startups, academia and many others. Could you give us an overview of some of the initiatives that are driving this agenda forward?

Forslund: At the regional level, I have been focusing on a new mandate and the new agreement with our care providers that they need to go digital because, up until last year, it was voluntary to offer digital services and a lot of care providers did, of course, since decades back, but we could still see [a] very big fluctuation between the care providers, especially in primary care. But some offered a lot of these services and online meetings, for example. Some offered almost no online services.

Now, we have expanded our regional guarantee for care because we have a set of rules that are guaranteeing care within a certain waiting time and of certain quality. So now we expanded that to also include the contact through digital means. The patient can now demand of the care provider in Stockholm, both public and private, that you should be able to make an online appointment, you should be able to have an online meeting with your doctor or nurse. You should always be able to read your medical records online, whichever care provider you visited in Stockholm.

And so we are going from voluntary to obligatory e-services in Stockholm from this year through a decision we made last year, and that’s one of the decisions to really make digital the new normal in healthcare.

We need, us policymakers, to make that clear, that this is not no longer an add-on that you could make use of voluntarily. Patients expect this to be the normal way of contacting healthcare, it shouldn't only be through telephone or sitting in a waiting room, people now use digital contact methods as the most common contact method. We have seen that through private initiatives in Sweden, with smart entrepreneurs, launching doctor’s apps where you can meet a doctor through a video conference, have a conversation over chat, for example, or digital triage that have been very successful. Over a million Swedes a year are now using those kind of services. So that's why we are now also enforcing this policy so that at all the care providers should could offer these kind of services because that's what patients expect.

MobiHealthNews: Is this only in Stockholm or across Sweden?

Forslund: For now, it's only in Stockholm. We are piloting this way of making this mandatory for care providers, but many regions are looking in the same direction and seeing what we need to do to make it clear for care providers that they are now expected to invest in digital skills and digital tools for offering these kind of services.

That’s also one of the points that we are discussing now on the national level. The national level can't enforce that kind of regulations, but there is now an inquiry, a national inquiry looking into whether we can expand those sort of national rules and regulations in this area to make it clear that healthcare should be offered both in physical and digital means always. That's also a part of the discussion now in the steering committee for the eHealth vision in Sweden.

MobiHealthNews: Did you find a lot of resistance when trying to get this in place?

Forslund: Yes, there was actually somewhat of a resistance, especially in the first phase of this work, because we started to prepare care providers already three years ago saying that, okay, we are going in this direction, new rules are coming, so prepare for that.

At first, there was a bit of skepticism, especially from the primary care physicians, the GPs, because they felt, I think, also threatened [by] the entrepreneurs offering these kinds of services. And they also had fears that you can't treat a patient online, it's hard to set a diagnosis, it could almost be impossible to have these kinds of meetings because they never tried. So what we did was to start with pilot projects where our primary care centres could then try for themselves to offer these services and see, well, when can an online meeting work, when can it actually be better for a patient to have a follow-up meeting online instead of travelling long distances for a short meeting with your GP.

That actually changed the perception of digital transformation amongst many care providers because they felt that, okay, this is actually working fairly well, they were surprised that they could handle more and more patients, even with diseases that they didn't think was possible to offer support [for] online.

MobiHealthNews: Now, you mentioned the steering committee for the eHealth 2025 vision, which you are a part of. What can you tell us about the work that is currently being undertaken to deliver on the commitment made?

Forslund: Well, we have just finalised our working plan for how to realise the ambitions in our national strategy and that means that we have pointed out the areas of special interest that we are now focusing on to deliver this ambitious vision to be the world leader of eHealth, making use of the possibilities of technology.

That means that we have now identified four specific areas where we are, well, directing extra resources and committing money and time for making progress. We are now, from this working plan, also pointing out who is supposed to be responsible for the delivery of that reform process and also how to finance the different projects and initiatives that are taken within the different areas. We are in a very intense phase actually in the national work to show the sector that we have even higher ambitions than before and committing extra resources, both from the national government and from regional governments, to, well, make progress.

MobiHealthNews: What do you see as the main challenges that you will need to overcome to sort of make this a reality?

Forslund: It’s a lot about the boring stuff like, like policies and legislation, because many of the laws in this area were written long before digital health was even an issue. So many of the, both reimbursement systems, our agreements with care providers, our national legislation when it comes to both data protection and integrity and the sharing of data is a bit outdated, because technology has now been moving very, very fast when it comes to well, new possibilities of interacting with patients and so on.

That means that there are structural obstacles within our legislative framework and policies and how we reimburse care providers that are actually slowing down the implementation of new smart services or perhaps create uncertainties, can we actually use an AI-supported decision support within healthcare, for example, can we use cloud based services. There are many things that are a bit unclear in the current legal framework that we have to clarify and update and then be more in line with the current technical capabilities and possibilities, because the previous legislation didn't foresee those kind of possibilities, for example.

That is one of our main focus right now, to identify those obstacles. But it’s also about updating the basic digital infrastructure, because Sweden was an early adopter when it comes to digital transformation. We started this work already in the late 1980s, so we were very early in the digital development, but that also means that the basic technology that was put in place in those days is now really coming to the end of a life span.

We have to make big investments for the coming five years to implement more modern EHR systems, for example, a better infrastructure for identifying, authenticating healthcare professionals within the healthcare system and having a higher level of information security, for example, and things like that. That will require a new negotiation between the national and regional governments to finance that big pool of investments because many other smaller regions perhaps cannot make those investments themselves, they need a co-financing model, I think, with the national government to make this happen.

So that's what we are going to discuss later this spring, find a new model of co-financing and also then increasing the pace of shifting out older technologies and replacing them with new and modern ones.

Daniel Forslund will be speaking at HIMSS20 in the ‘Population Health Management Toolbox for the Future’ panel discussion on Monday 9 March from 11:05 – 11:50 in room W331A and the ‘Policy Changemakers Awards Luncheon’ on Tuesday 10 March from 11:45-13:30 in room W340A. HIMSS20 will take place from 9-13 March at the Orange County Convention Center in Orlando, Florida.

MobiHealthNews is a HIMSS Media publication.

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