Networking in Healh Care:
An Issue of Connection or Co-operation?
- The Evolution of Sjunet, the Swedish Health Care Network

By: Gustav Malmqvist
Director of ICT, BSc, RN
County Council of Västernorrland
Dept of IT & Development
87185 Härnösand
Sweden
Tel: +46-611-80366
E-mail: gustav.malmqvist@lvn.se

Abstract

Sjunet is the infrastructure for communication of health care data and services in Swedish health care, including various forms of telemedicine. Sjunet started as a regional project and today practically all Swedish hospitals and primary care centres are connected. Sjunet is as much a cooperative network as it is a technical communicative platform. Sjunet possess the capacity for better use of restrained resources in the Swedish health care system. However successful in connecting hospitals it may be, further research on the network's potential for more efficient use of resources and possible change of health care structures is needed.

Background

Seven county councils initiated Sjunet as a project in 1998 within the R&D programme "ITHS" funded by The Swedish Knowledge Foundation and the Federation of County Councils. The initial investment of 1 ,400,000 Euros was shared equally by ITHS and the seven county councils. Since 2001 Carelink, a collaborative organisation for ICT in Swedish health care, is responsible for Sjunet in close cooperation with all the county councils and representatives for the private care providers and local authorities.

Description of Sjunet

Practically all Swedish hospitals and primary care centres as well as some national authorities and vendors are connected to Sjunet and use it both for telemedicine and administrative communication. The network infrastructure allows secure communication and distribution of patient data, pictures, medical applications and services for which the Internet is not acceptable. The idea from the beginning was to form a layered infrastructure consisting of a secure network (1), a set of common services (2) and telematics applications (3). Sjunet is continuously under development especially what regards establishment of new services and connecting other branches of the health care and more service providers.

The Network

Sjunet is an IP-based broadband network, connecting all Swedish hospitals, primary care centres and many other health services. Sjunet is built up of nodes connecting the firewalls in the 21 county councils and regions separate from the Internet. Users connected to a county council network can reach either the Internet or Sjunet depending on what kind of service they need to access. In its first version Sjunet was set up as a virtual private network (VPN) with "tunnels" on the Swedish part of the Internet, and was delivered by the Swedish telecom company Telia. The VPN technology guaranteed that information was not accessible from or communicated through the public Internet and the network provider guaranteed that the available bandwidth was sufficient for applications and services. From 2003 the network is based on VLAN technology from Song Networks with built in redundancy, technically separated from the Internet, as shown in Figure 1. The separation from the Internet means better availability what regards bandwidth. The bandwidth is determined by how much each county council purchase for access to Sjunet. Normally 10-100 Mbps is sufficient for most applications.

Figure 1: Sjunet as VLAN with redundant connections between county councils

The Services

From the very beginning of Sjunet the need for certain common services was obvious. Some services relate to the functionality of the network infrastructure. Others are practical services where a need for co-operation has been identified or for which it is more cost efficient to procure the service in collaboration.
Infrastructure services are e.g. DNS, protocols, nodes and directory services. Of special interest is the provision of security certificates following the PKI standard from a CA-server (see Figure 2) that allows decryption and authentification of messages sent on Sjunet. All hospitals connected to Sjunet can make use of this service, which is procured by Carelink from the vendor Steria. The PKI infrastructure relies on another joint service, the health personnel directory. This is built up with X500 directories in each member organisation within Sjunet. The directory allows the use of secure messaging as well as providing correct contact details for health care staff in Sweden.
Joint services are in some cases related to the infrastructure. Carel ink has procured and financed a videoconferencing platform (see Figure 2) which is up and running from the beginning of 2003. It facilitates multi-user videoconferences as well as interconnection between Sjunet and ISDN- based videoconference equipment. The platform, -being operated from Orebro County Council (see Figure 1), is thus an important hub for many telemedicine applications in Sweden and abroad. Another frequently used service on Sjunet is the web-based national telephone directory, which is jointly procured and available at all hospitals and primary care centres. Connection to governmental services such as population registries and national health insurance and other e-Government services is currently under development.

Figure 2: Services on Sjunet

The Applications

Most health telematics applications on Sjunet are various forms of telemedicine in daily practice and can be grouped in:

• Medical messages; electronic prescriptions, orders and results, secure e-mail
• Videoconferencing; consultations, rounds, planning, supervision and education
• Telephony services; IP-telephony, joint health information services
• File transfers; teleradiology, telepathology, administrative files
• Web-services; quality registries, archives, databases, prescriptions and education
• Application sharing; remote access to EPR, HIS and RIS systems

A widespread application allover Sweden using Sjunet is teleradiology, that previously was using ISDN. Recently a teleradiology service has been established in Barcelona where Spanish radiologists can provide services to Swedish hospitals. There is also an increasing amount of transfer of other types of medical images such as ultra-sound, EGG, EEG and EMG examinations. Whatever network technology, some telematics applications become daily practice while others are abolished when the pilot project and funding has come to an end. A national report 1999 said: "most applications in telemedicine have taken place through pilot projects and are somewhat isolated. The impact on the organisations and on- management has not been sufficiently addressed." (Tornqvist et al., 2000) p 24
Electronic prescriptions are transferred to the pharmacy using EDI either from EPR systems or with use of a web service (Figure 3). On average 18% of all first time prescriptions are transferred through Sjunet and in some counties up to 95% are transferred electronically. (Apoteket, 2003)

Figure 3: Sjunet used for electronic prescriptions

The Usage of Sjunet for Telemedicine

There is to date no comprehensive national registry on the usage of Sjunet. For some services and telemedical applications the use is well known: Apoteket AB continuously evaluates the frequency of e-prescriptions and Telia AB tracks the use of the national telephone directory web. The latest national survey of the use of telemedicine in Sweden was done in 1998 before the implementation of Sjunet. Holm-Sjogren et.al showed that teleradiology was the most widespread application (20%). Telemedical videoconferencing along with telepathology and telecardiology was emerging in a lot of pilot projects. (Holm-Sjogren et al., 1998) At that time most telemedicine was used within each county.

Proven or Potential Benefit

Since Sjunet is an infrastructure hosting a lot of services it is by nature difficult to evaluate the total cost-benefit of Sjunet.
Cost-benefits. Sjunet lowers the cost of transferring information. A cost- benefit analysis in Uppsala County Council estimated a yearly net benefit of 0.6 MEuro from using Sjunet compared to other alternatives. The greatest economic gains result from removal of expensive ISDN lines, improved collaboration, lower staff costs and less physical transportation.
Access to care. Remote services can bridge lack ot-resources or expertise in some areas or specialities. In Vasternorrland, the transfer of MRT images from Solleftea to the Telemedicine Clinic in Barcelona can reduce by half the 58-week waiting time for MR examinations. In northern Sweden, advanced radiation therapy is offered in Sundsvall with dose planning and field simulation delivered by specialists in Umea. This allows the patients to be treated closer to home and so avoid tiring travel.
Quality of care. By using specialist resources, regardless of physical location, it is possible to increase quality of care. Using Sjunet for teleradiology, diagnoses are made more rapidly which could even save lives. Co-operation among specialists also improves the diagnostic process and treatment. Remote EEG and EMG examinations in the region of Uppsala allow more efficient use of expertise in neurophysiology, shorten diagnostic lead times and improve treatment planning.

The Cost of Sjunet

The initial investment was 1,400,000 Euros for the infrastructure and basic services development. 200,000-500,000 Euros per year is required for further development and maintenance within Carelink. Each county council pays 12,000 Euros anually for connection (if 1 OM bps is used). Operational costs of applications are not included in this and vary by size and type.

Discussion

Using health telematics is definitely easier and more cost efficient with a permanent infrastructure, such as Sjunet, than e.g. ISDN. The concept of infrastructure then includes standards, rules, security and availability.

The Evolutionary Nature of Sjunet

The project Sjunet was preceded by a couple of reports from the Federation of County Councils. (Landstingsforbundet, 1997). Sjunet is managed and further developed within Carelink, with a steering committee and several working groups with representatives from all county councils. This form of maintenance guarantees the regional and local commitment for Sjunet. It also enhances the co-operation between county councils and the spread of best practice between actors. However a national strategy is needed for how Sjunet could bridge lack of resources or solve inefficiencies in the Swedish health care system.

Incentives for Structural Changes -Further Research

In a governmental report the future role of telemedicine/telehealth was treated (Socialdepartementet, 2002). As in many other works e.g. (Greenacre, 2000) and (Wootton, 2000) the need for national strategy for telemedicine is stressed. In my view there is also a need for research on how organisational incentives would promote or counteract the use of Sjunet as a co-operative platform. Incentives for changing organisational structures and ways of delivering specialised care, and medical education in Sweden should also be investigated.