COPENHAGEN, Denmark — For three years, a dour anesthesiologist and computer architect named Gert Galster tunneled in the electronic guts of Epic Systems, trying to convert the premier U.S. digital health software into a workable hospital management system for Copenhagen and the surrounding region.
It nearly drove him mad.
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After Galster and his colleagues had done what they could, 45,000 clinicians in eastern Denmark were plunged into the Epic system. Like the U.S. Department of Veterans Affairs, the Danes had expected that tech from a big IT vendor would make it easier for doctors in an excellent health care system to work, share patient information and keep tabs on costs. But the Danish experience produced results that varied from frustrating to disastrous — a sobering lesson for the VA, which recently began a transition involving another big vendor.
The problems were evident from the start. Epic’s medical terms were not tagged for easy translation, so Galster and his colleagues had to rely on Google Translate. There were howlers. “C-section,” in the Danish version, referred to an executive suite, not an emergency birth procedure. The American specialty “speech and language pathologist” does not exist in Denmark. The Danish system for a short time offered surgeons the choice of amputating the left leg or the “correct” leg.
The translation problem went deeper than mere words, said Galster, one of 1,400 hired for the $500 million implementation of Epic in eastern Denmark. Epic might work in the United States, he thought, but its design was so hard-coded in U.S. medical culture that it couldn’t be disentangled.
“When you open the hood in the Epic system, it plays ‘U.S.A, U.S.A, U.S.A,’” he said.
The U.S. and Danish health care systems are starkly different. Denmark has socialized medicine; Danes don’t need insurance and don’t have medical bills. U.S. hospital systems and doctors’ offices bought digital record systems primarily to bill more efficiently — the care component came later. In Danish hospitals, nurses and doctors dispense the drugs, not pharmacies.
It’s been said that when culture and science go to war, culture wins. In that sense, this tiny Scandinavian country’s problems with its expensive IT transformation may have a lesson for the rest of the world, including the VA, which serves a population roughly twice the size of this nation of 5.6 million. The VA has begun implementing Cerner — Epic’s leading competitor — replacing its homegrown VISTA platform that had been designed for treating veterans and their unique problems like missing limbs, PTSD and Agent Orange syndrome.
Denmark’s evolving experience could show what is lost — or, eventually, gained — when a country, a region or a mammoth institution surrenders its way of doing things and conforms with a computer system designed for an alien culture.
In the Epic case, as Galster plunged deep into the software to reconfigure it for Danish clinicians, he realized how much it reflected a fundamental difference between the United States and Denmark, where trust and consensus are key components of the health care system.
“We thought, naively, diagnosis is the same in the U.S. and Denmark. People get the same kinds of illnesses, the same treatments. We rely on the same textbooks in medical school.” But an IT system that requires collaboration among its users “depends on the culture where that collaboration takes place,” he said.
In Denmark, for example, while the IT separated activities for doctors and nurses, it did not freeze one out of the other’s jurisdiction. A nurse could prescribe medicine in an emergency and explain later. In Epic, any attempt to take a forbidden role caused a “full stop.”
Galster became convinced that Epic would never work properly for Denmark — and that once it was installed, they would never get rid of it.
The birth of a Scandinavian health care system
In 1864, after the Prussians stripped Denmark of the final vestiges of an empire that once extended over parts of current-day Germany, Sweden, Norway and Iceland, the nation turned inward. Surrendering its dreams of imperial grandeur, it focused on building a cohesive and progressive Danish society. Its first social democratic government took office in 1924.
Danes pay high taxes but in exchange get free education, generous child care, parental leave and unemployment insurance. They are most proud of their health care system. While they can’t always get the new, expensive drugs, it is easy to see a doctor. The health bureaucracy is relatively small, and health care accounts for 10.3 percent of Danish GDP — compared to 18 percent in the U.S.
As in the rest of the developed world, however, Denmark’s population is getting older, sicker and more expensive to treat. In 2007, the country undertook a reorganization that centralized health care decision-making while giving general practitioners more duties. The Ministry of Health department that’s responsible for building 16 new hospitals as part of the overhaul is also overseeing digital upgrades throughout health care.
Denmark had some distinct advantages over the United States when it started on its digital journey. Unlike the U.S., where getting the health care industry to agree on computer standards is a seemingly endless process, Denmark put its little horse before the cart. In 1994, the Health Ministry created an agency that brings together industry and providers to agree on software standards that are then imposed systemwide.
Another key is Denmark’s unified national identification system. Since 1967, everyone in the country at birth gets a unique personal ID. Unlike the U.S. Social Security number, the Danish tag is used in health care, banking and real estate — a single number that tracks you throughout public records.
This reflects a society that in general trusts the state more than private enterprise, notes Lisbeth Nielsen of the federal Health Data Authority. “It’s kind of the other way around from the U.S.”
“We know where all the Danes are right now and we can find their data,” said Jorgen Scholer Kristensen, medical director at the University Hospital in Aarhus, Denmark’s No. 2 city. “To some people that’s scary, but in health care it’s fantastic.”
Each citizen’s record includes medical appointments, medications and the entire history of care. There’s a space to request drug refills and others indicating preferences for organ donation, resuscitation and power of attorney. The patient can control who sees what parts of the record; the default setting allows any doctor in, but there’s an audit trail, and snooping can lead to firing or prosecution.
To be sure, the Danish IT system is far from perfect. Doctors in hospitals complain that GPs send them inadequate information, and vice versa. Both say nursing homes — run by municipalities — don’t share enough data.
The old Copenhagen-area hospital computer systems crashed frequently, and the continued use of paper records in some departments was worrisome, says Gitte Fangel, the nurse who led the Epic rollout. She recalled sitting with a patient dying of cancer “because her paper pathology results were put in a box where no doctor saw them.”
And so, after one failed attempt in 2008, and a bidding process that ended in 2013, Copenhagen and another region in eastern Denmark decided to replace all their systems with Epic. They called the new system Sundhedsplatformen, or Health Platform.
“It was an absolute necessity to get a more stable system,” says Svend Hartling, who leads the region’s health care administration. “The goal was to make it easier to be a patient and easier and better for our staff.”
In the bidding for Sundhedsplatformen, Epic beat out Systematic, whose main specialty is defense logistics software. Since 2002, Systematic has been building out an electronic health record system in the western Denmark region. Systematic has had its problems, but user satisfaction is high because physicians are deeply involved in building it. Some Danish cynics say eastern Denmark, which includes Copenhagen, would never have picked Systematic simply because it was created in western Denmark, and the two have long competed.
In addition, the fabulous Epic Systems campus in Wisconsin, with its tree houses, Montessori-style conference rooms and whimsical, Tolkienesque buildings, was seductive to Nordic techies weaned on Hans Christian Andersen.
“They went to Epic and fell in love,” said Joergen Bansler, a computer scientist at the University of Copenhagen.
‘Indescribable, total chaos’
Epic has done thousands of software implementations — a big reason the Danes chose it — but the Danish project was still one of its biggest, involving 18 hospitals in a region with 2.8 million residents.
As the go-live date of May 20, 2016 approached, Galster and his colleagues strongly argued for a delay. But the authorities followed what they described as Epic’s strategy, “throw it all out there, fix the problems later, build the road while you’re traveling down it,” said Nils Jakob Knudsen, an endocrinologist who served as a clinical adviser for the installation.
The system was turned on first at Herlev Hospital, a 28-floor tower overlooking Copenhagen’s northern suburbs — and created what Galster called “indescribable, total chaos.” Many who were there are still traumatized by having seen battle-hardened doctors and nurses weeping openly for days.
“There were no pilots, no tests, just go-live,” said Galster. “I’ve worked on health IT for 20 years and never seen anything like it. This was worse than amateurish.”
“Doctors and nurses couldn’t document their work, they couldn’t understand what was going on. They were being exposed in real life to a system they hadn’t seen before.”
Hartling later admitted his process for going live at the hospitals sequentially over 18 months was flawed. The implementation team was focused on getting new hospitals onto Epic to avoid the cost and complexity of running multiple systems simultaneously. That meant there wasn’t sufficient staff to handle the thousands of complaint tickets filed by frustrated clinicians as each hospital went live.
Epic had difficulty integrating its system with the national medical record system, which is meant to be accessed whenever a patient is seen. Three years in, the integration still didn’t work. “It has been a big challenge for Epic,” said Marianne From, a senior leader on the project.
Doctors who were used to having secretaries, like Henrik Flyger, a leading breast cancer surgeon, struggled to enter medical orders into a system they did not understand. At first, many of the medication orders disappeared. The booking system did not work properly. Patients had to be physically in the hospital to be scheduled for an operation. The culture shock was immense and demoralizing.
“You have exported burnout,” Flyger said.
The hospitals fired then rehired their medical secretaries.
In the U.S., inpatient and outpatient visits are entirely separate. In Denmark, 80 percent of patients “float in and out” of the hospital, said Mette Rosendal Darmer, chief cancer nurse at Rigshospitalet, the country’s leading research hospital. A leukemia patient, for example, might come in daily for chemotherapy for a while. A bed was ready if she needed it. If not, she went home.
“Home is better,” she said, “Fewer bacteria, they eat more, they’re happy to be with their family. They are only at our place when they absolutely need it, and it’s less expensive.”
With Epic, the Danish clinicians had to reenter diagnoses and medications each time patients went between inpatient and outpatient in differently configured screens. Medications didn’t transfer from one to the other either.
To prevent medication errors, “the nurses check and check and check,” said Dinne Leth-Miller, a pharmacist at Rigshospitalet.
Reports to the Danish Patient Safety Board suggested the clumsy go-live may have contributed to deaths or injuries, though none were confirmed. Amid negative audits by government agencies, press coverage was terrible. Doctors told reporters that Epic had ruined their love of medicine.
“We are always afraid that we’ll overlook something that can have fatal consequences,” internist Per Boye Hansen wrote in the newspaper Politiken in December 2017. “There is very little time for the individual patient. Most of the day is spent sitting in front of the computer and clicking the mouse.”
“I’m one of the few believers left,” says Knudsen, the endocrinologist. Hopes were placed on a February update, but “it got worse instead. It’s going in the wrong direction.”
There were, of course, doctors who liked the Epic system. Lone Norgaard Petersen, a cancer specialist at the Rigshospitalet, treated four patients with esophageal cancer one morning. Between appointments, she and her nurse smoothly entered documentation into the system.
Norgaard liked being able to show patients MRI images and graphs of their tumor markers, data presentations that previously were unavailable. Unlike Flyger, a surgeon, she liked being able to see into all corners of the system.
“I have more independence now,” she said.
Light in the tunnel?
Efficiency has declined at Copenhagen-area hospitals. A mid-2018 survey found that 57 percent of heart patients in one Epic area had to wait more than 30 days for appointments, compared to 4 percent in a non-Epic region. In a February 2019 poll, physician satisfaction with the Epic system was 12 percent. Fully 60 percent expressed deep dissatisfaction.
Epic offered to install its software for free in general practitioners’ offices. They refused. “You couldn’t give us enough money to install Epic. We’ve seen how it works.” said Jonathan Schlusser, head of the national GP organization.
Since the Epic go-live, hospitals send out discharge letters to GPs every time a patient moves out of a hospital department — “nonsense that’s a copy-paste of everything in the patient record,” Schlusser said. This generated a safety issue because “in that five pages of gibberish there are five lines the doctor probably should read but doesn’t,” he said. So the government hired a consultant who used artificial intelligence to read the Epic discharge letters and find the useful information in them, he said.
In late 2018, 71 physicians around Copenhagen signed a petition calling for the system to be scrapped. They included Jacob Rosenberg, a physician at Herlev who was also a politician with the libertarian-right Liberal Alliance. Doctors are powerful in Danish hospitals; when they stood up to oppose Epic, it created a knot of resistance.
Afzal Chaudhry, chief information officer of Addenbrooke’s Hospital in Cambridge, England, thinks a surplus of Danish democracy has slowed Epic’s success. His own hospital in 2015 was the first in Europe to implement Epic — successfully, after some rough patches. He has visited Copenhagen several times to help the Danes. “You can’t just impose things on people, but somewhere between the clinical team and the management, there has to be a mindset that agrees,” he said.
Epic, which has customers in six other European countries, has learned from the project that it needs to be more hands-on, for example by getting involved with clinicians when the EHR is being configured, said its “relationship manager” for Denmark, Scott Dinkle.
He said Epic was at fault for providing recommendations that led its partners to hire inadequate numbers of staff for the project, but took a jab at the Danish government, saying Sundhedsplatformen’s problems connecting with the national medication database stemmed from its complexity. The requirement to adopt to the standard user interface design “prevented them from using more efficient approaches that our customers outside of Denmark use,” he said.
Søren Lauesen of Copenhagen’s IT University notes that many big IT projects, including a land registry and police case management software, have been expensive and problematic for Denmark’s public sector, which is thin on the ground and lacks computer expertise.
“We’re an easy target for a big company like Epic,” he said.
While some officials and doctors expect the Epic system to improve, the wounds are deep. Denmark’s experience suggests something important can be lost in technology implementation. That’s a lesson some VA officials are keeping in mind, since unlike Danish doctors, VA clinicians can quit and join the private sector if push comes to shove.
While the Copenhagen region struggles with Epic, the rest of the Danish health care system has moved forward in its own way.
Systematic last year beat Epic for contracts to create unitary digital health systems for the rest of the country.
The Health Ministry has overseen the creation of an app called MyDoctor, integrating it into the national health system with the hopes of avoiding the siphoning off of healthy patients that has occurred through the use of private apps in Sweden and the U.K., whose health care systems are also primarily government-run.
Danish GPs, who use their own IT systems, are implementing electronic decision supports that “respect the autonomy and professionalism of the doctors while making it easier for them to make the right decisions,” says Henrik Prinds Rasmussen, a physician in Kolding, in central Denmark.
The same respectful notion underlies Denmark’s approach toward patients with behavior-related diseases like emphysema and diabetes. For better or for worse, doctors tell patients to set their own goals rather than using rewards or cudgels to encourage smoking cessation or exercise.
Prinds Rasmussen says this approach goes back to the Danish philosopher Soren Kierkegaard, who argued that to change a person, “one must first and foremost take care to find him where he is and begin there.”
As for Epic, some politicians in the governing Christian Democratic coalition want to rip it out and install Systematic. That seems unlikely. After you spend half a billion dollars on an IT system, “you come to live with it,” Bansler said.
“At one point I thought, this just isn’t right for us,” said Nanna Skovgaard, the Health Ministry’s digital director. But “Epic is too big to fail.”
Reporting for this story was supported by a grant from the Commonwealth Fund through the Association of Health Care Journalists.