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What is the status of electronic health records?

  • Australia

    The National eHealth Transition Authority has been working to establish interoperable infrastructure to support communication across the health care system. A national e-health program based on personally controlled unique identifiers has commenced operation in Australia, and 2.5 million patients and nearly 8,000 providers have registered. The record supports prescription information, medical notes, referrals, and diagnostic imaging reports. Following a review, government is taking a number of steps to increase uptake by both patients and providers, which has been poor to date, by improving usability, clinical utility, governance, and operations. In addition, an opt-out approach will be tested to replace the current opt-in approach. The new Australian Commission for eHealth will begin oversight in July 2016, taking on the e-health roles of the Department of Health and the National eHealth Transition Authority. The current PIP eHealth Incentive, which aims to encourage GPs to participate, will also be reviewed for potential improvements.

  • Canada

    Uptake of health information technologies has been slowly increasing in recent years. Provinces and territories are responsible for developing their electronic information systems, with support from Canada Health Infoway; however, there is no national strategy for implementing electronic health records and no national patient identifier. According to Canada Health Infoway, provinces have systems for collecting data electronically for the majority of their populations. Interoperability, however, is limited. In 2014, 42 percent of GPs reported using exclusively electronic records to enter and retrieve patient clinical notes, and 38 percent used a combination of paper and electronic charts. In the same survey, 87 percent of GPs report that their patients are not able to access their personal health record for any function, and only 6 percent reported that patients can request appointments online.

  • China

    Nearly every health care provider has set up its own electronic health record (EHR) system. Within hospitals, EHRs are also linked to the health insurance systems for payment of claims with unique patient identifiers (citizenship ID). However, EHR systems vary significantly by hospital and are usually not integrated or interoperable. Patients often have to bring with them a printed health record if they would like to see doctors in different hospitals. Even if hospitals are owned by the same local bureau of health or universities in the same region, different EHR systems may be used. Patients generally do not use EHR systems for accessing information, appointment scheduling, secure messaging, prescription refills, or accessing doctors’ notes.

  • Denmark

    Information technology (IT) is used at all levels of the health system as part of a national strategy supported by the National Agency for Health IT. Each region uses its own electronic patient record system for hospitals, with adherence to national standards for compatibility. Danish general practitioners were ranked first in an assessment of overall implementation of electronic health records in 2014. All citizens in Denmark have a unique electronic personal identifier, which is used in all public registries, including health databases. A shared medical card—accessible by all relevant health professionals—has been implemented. It contains encoded information about each patient’s prescriptions and medication use. General practitioners also have access to an online medical handbook with updated information on diagnosis and treatment recommendations. Attempts to develop national clinical databases to monitor quality in primary care were aborted in 2015, as they were found to violate privacy rights and to endanger the trust between GPs and their patients.

    Sundhed.dk is a national IT portal with differentiated access for health staff and the wider public. It provides general information on health and treatment options, and access to individuals’ own medical records and history. For professionals, the site serves as an entry to medical handbooks, scientific articles, treatment guidelines, hospital waiting times, treatments offered, and patients’ laboratory test results. The portal also provides access to available quality-of-care data for primary care clinics, all of which use IT for electronic records and communication with regions, hospitals, and pharmacies.

  • England

    The National Health Service (NHS) number assigned to every registered patient serves as a unique identifier. Most general practice patient records are computerized. Some practices use electronic systems to allow patients to make appointments or e-mail their GP, but there is no requirement for practices to have that capability. Records are not routinely linked between providers.

    A move to make primary, urgent, and emergency care services paperless by 2018, and all other parts of the NHS by 2020, is being enforced by requirements that NHS organizations show progress toward that end in the intervening years; they risk having funding removed if universal digital care records are not implemented by 2020.

    NHS Choices will serve as a single point of access for patients to register with a GP, book appointments and order prescriptions, access apps and digital tools, speak to their doctor online or via video link, and view their full health record. All NHS patients have the right of access to their own health records (in some cases it is possible electronically) and can apply in writing to have a copy of their records held by their general practice, hospital, or dentist. By 2016, all patients will be able to have access to their GP electronic record in full, and by 2018 it is hoped that access will extend to data from all health and health care interactions.

    Electronic transfers are widely used by GPs to send prescriptions to pharmacies, and for the storage and distribution of digital scans, X-rays, and other images.

    NHS England has been developing a program for collecting data and for linking electronic records from general practice with those from hospitals and other care settings, for purposes of research and planning in health and social care services. Full implementation has been delayed because of concerns about confidentiality, but piloting in 265 general practices started in 2014.

  • France

    A high-level electronic health record (EHR) project is currently being implemented across the entire country. Approximately 551,000 patients, or 0.8 percent of the population, have an EHR, and an estimated 600 hospitals and 6,000 health professionals use them. Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Interoperability is ensured via a chip on patients’ health cards. By law, patients have full access to the information in their own records, either directly or through their GP. All “structured information” included in EHRs must be communicated, but handwritten notes are excluded. The sharing of information between health and social care professionals is not currently permitted, but will be tested as part of the PAERPA (Personnes Agées en Risque de Perte d’Autonomie) program for hospice residents.

    A national agency for health information systems was created for the purpose of expanding uptake and interoperability of existing systems, and the health records are available on a government website.

  • Germany

    About 90 percent of physicians in private practice use electronic health records (EHRs) to help with billing, documentation, tracking of laboratory data, and quality assurance. The use of online services to transmit billing information and documentation from disease management programs is obligatory. Hospitals have implemented EHRs to varying degrees. Unique patient identifiers do not exist and interoperability is limited, as data safety concerns represent a significant obstacle.

    As of 2015, electronic medical chip cards are used nationwide by all the statutory health insurance (SHI)-insured; they encode information as to the person’s name, address, date of birth, and sickness fund, along with details of insurance coverage and the person's status regarding supplementary charges (Company for Telematics Applications for the Electronic Health Card, 2015). In 2015, the Federal Cabinet proposed a bill for secure digital communication and health care applications (E-Health Act), which provides concrete deadlines for implementing infrastructure and electronic applications, and introduces incentives and sanctions if schedules are not adhered to. SHI physicians will receive additional fees for transmitting electronic medical reports (2016–17), collecting and documenting emergency records (from 2018), and managing and reviewing basic insurance claims data online. From July 2018, SHI physicians who do not participate in the online review of the basic insurance claims data will receive reduced remuneration. Furthermore, in order to ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan, starting in October 2016. In the medium term, this medication plan will be included in the electronic medical record.

  • India

    The establishment of a composite health information system (HIS) is proposed in the government’s 12th five-year plan. The HIS will be based on adoption of national electronic health record standards, linked systems at the state and national levels, issuance of a unique health card to every citizen, and creation of a national health information center.

    States can develop systems to suit their needs and priorities, as long as they are consistent with standards set by the new National eHealth Authority (NeHA). NeHA will be the nodal authority responsible for development of the HIS and for enforcing the laws and regulations relating to privacy and security of patient health information and records.

  • Israel

    All health plans have electronic health record (EHR) systems that link all community-based providers—primary care physicians, specialists, laboratories, and pharmacies. All GPs work with an EHR. Hospitals are also computerized but are not fully integrated with health plan EHRs. The Ministry of Health (MoH) leads a major national health information exchange project to create a system for sharing relevant information across all hospitals and health plans.

    Each citizen has a unique identification number, which functions as a unique patient ID. Patients have the right to get copies of their medical records from hospitals and health plans, and patients can access some components of their EHR online, but the full records are not generally available. Efforts are under way to set up secure messaging systems linking patients and their GPs.

  • Italy

    The New Health Information System has been implemented incrementally since 2002 to establish a universal system of electronic records connecting every level of care. It provides information on the services, resource use, and costs, but does not cover all areas of health care; in particular, primary care is not covered, while hospital, emergency, outpatient specialist, residential and palliative care, and pharmaceuticals are. It currently contains administrative information on care delivered, as medical information appears more difficult to gather. No unique patient identifier exists at the national level.

    A core component of the New Health Information System is the nationwide clinical coding program known as “bricks,” one of the most mature elements of Italy’s developing electronic health program. It aims at defining a common language to classify and codify concepts; at sharing methodologies for measuring quality, efficiency, and appropriateness of care; and at allowing an efficient exchange of information between the national level and regional authorities.

    Some regions have developed computerized networks to facilitate communication between physicians, pediatricians, hospitals, and territorial services and to improve continuity of care. These networks allow automatic transfer of patient registers, services provided, prescriptions for specialist visits and diagnostics, and laboratory and radiology test outcomes. A few regions also have developed a personal electronic health record, accessible by patients, that contains all patient medical information, such as outpatient specialty care results, medical prescriptions, and hospital discharge instructions. Personal electronic health records should provide support to patients and clinicians across the whole process of care but diffusion is still limited.

    There is also a slow movement from paper to electronic prescriptions. By the end of 2014, 80 percent of all prescriptions (drugs and specialist care) were to be issued electronically, but only five regions declared that they were able to reach the goal on time.

  • Japan

    Electronic health record networks have been developed only as experiments in selected areas. Interoperability between providers has not been generally established. Currently, experiments are under way to make personal health information available to patients and providers via cloud computing. The Social Security and Tax Number System (SSTNS), a system of unique identifiers, will begin in 2016. It will be used for social security from its inception, and for health services, possibly including medical records, starting in 2018.

  • The Netherlands

    Authorities are working to establish a central health information technology network to enable providers to exchange information. All Dutch patients have a unique identification number (burgerservicenummer). Virtually all general practitioners have a degree of electronic information capacity—for example, they use an electronic health record and can order prescriptions and receive lab results electronically. At present, all hospitals have an electronic health record.

    Electronic records for the most part are not nationally standardized or interoperable between domains of care. In 2011, hospitals, pharmacies, after-hours general practice cooperatives, and organizations representing general practitioners set up the Union of Providers for Health Care Communication (De Vereniging van Zorgaanbieders voor Zorgcommunicatie), responsible for the exchange of data via an IT infrastructure named AORTA; data are not stored centrally. Patients must approve their participation in this exchange and have the right to withdraw; access to their own files is granted by providers upon request.

  • New Zealand

    New Zealand has one of the world’s highest rates of information technology (IT) use among primary care physicians, with almost 100 percent uptake. The government’s goal is universal electronic access to a core set of residents’ personal health information by 2014. However, despite some progress, that goal is unlikely to be met, owing to the complexity of implementing a national patient portal. Clinicians and vendors are working together on numerous projects: there is a larger emphasis on supporting and enabling integrated care, and a shift toward regional investment decisions and solutions. However, challenges with legacy systems remain.

    Increasingly, primary care IT systems provide services such as structured electronic transfer of patient records, electronic referrals, decision support tools with patient safety features, and patient access to health information in a secure environment. In the near future, there will be more emphasis on facilitating secure sharing of patient information among community, hospital, and specialist settings, including common clinical information; providing all consumers with an online view of their information; and supporting the development of shared-care plans (in which a number of health professionals are involved in a person’s care). However, current levels of interoperability are limited.

    The National Health IT Board works with a number of sector groups and receives advice from, among others, clinicians, consumers, and vendors. The Health Information Standards Organisation supports and promotes the development and use of standards to ensure interoperability between systems. Every person who uses health and disability support services has a unique national health number, facilitating the process of building interoperable systems.

  • Norway

    A national strategy for health information technology (HIT) is the responsibility of the Directorate for Health, with implementation by a departmental steering committee. Every resident is allotted a unique personal identification number, which is used in primary care and for hospitals’ medical records. Secure messaging is not a part of that system, but several GPs use such messaging systems, for instance to request prescriptions. Some GP and specialist outpatient offices have electronic booking, while most hospitals do not. All patients have the right to see or get a copy of their complete record, including doctors’ notes, but there is not yet an electronic solution for doing so. An ongoing project on patient access currently gives 2.3 million inhabitants access to their core medical record, also allowing for correction of personal information.

    The National Health Network is charged with providing efficient and secure electronic exchange of patient information between all relevant parties within the health and social services sector. It provides secure telecommunication for GPs, hospitals, nursing homes, pharmacists, dentists, and others.

    HIT in primary care is fragmented, and some areas of service lack resources and equipment for its implementation. Still, virtually all GPs use electronic patient records and transmit prescriptions electronically to pharmacies. HIT is also used for referrals, communication with laboratories and radiology services, and sick leave. Most GPs receive electronic discharge letters from hospitals. Where after-hours emergency care is organized within the same patient record network, patient histories remain available and primary care providers are able to access information regarding emergency visits. All hospitals use electronic records.

    The lack of structured electronic records in primary and secondary care precludes automatic data extraction; hence, there is still insufficient data for quality improvement at local and national levels.

  • Singapore

    Singapore is building a sophisticated national electronic health record system. The system collects, reports, and analyzes information to aid in formulating policy, monitoring implementation, and sharing patient records. The long-term goal is to allow medical professionals to access clinical data on patient treatment and safety. System capabilities include: a master index that matches patient records from a variety of sources and includes a unique identifier as well as other patient identity information; a summary care record for each patient that offers an overview of recent medical activity; access to overviews of specific events, such as hospital admissions; and access to health data in Singapore’s registries for immunization, medical alerts, and allergies.

    When fully developed, the system will allow data to be accessed and viewed in appropriate formats by medical professionals, patients, and researchers. Data sources will include the electronic medical record systems of public hospitals and polyclinics. There are plans to enable patients to view and possibly contribute to their personal health records.

  • Sweden

    Generally, both the quality of IT systems and their level of use are high in hospitals and in primary care; more than 90 percent of primary care providers used electronic patient records for diagnostic data in 2009 (Health Consumer Powerhouse, 2009). Nearly all Swedish prescriptions are e-prescriptions. Patients increasingly have access to their electronic medical record for the purposes of scheduling appointments or viewing their personal health data, but there is variation in this regard between county councils. The Swedish eHealth Agency (eHälsomyndigheten) was formed in 2014 to strengthen the national e-health infrastructure. Its activities focus on promoting public involvement and providing support for professionals and decision makers.

  • Switzerland

    A national e-health service called eHealth Suisse (an administrative unit of the Federal Office of Public Health [FOPH]) is coordinated by the federal and cantonal governments and has three sets of responsibilities. First, all providers in Switzerland should be able to collect and store information on their patients’ treatment electronically. Second, health-related websites and online services will be required to undergo quality certification and a national health website will be constructed. Third, necessary legal changes will be made to realize these measures.

    A key element of eHealth Suisse is the SHI subscription card, which encodes a personal identification number and all necessary administrative data. If allowed by the insured person, information about allergies, illnesses, and medication can be recorded on the card. The insured person also decides who is allowed access to this information (all, selected, or no providers). GP e-health is still at an early stage (Vilpert, 2012), and there are ongoing discussions about incentives for physicians to adopt new technologies.

    Hospitals are generally more advanced; some have merged their internal clinical systems in recent years and hold interdisciplinary patient files. However, the extent of this integration varies greatly among hospitals and among cantons, despite efforts by eHealth Suisse to convince providers of the benefits of electronic health records for medical practice. An interoperable national patient record is not a priority for eHealth Suisse, since the principles of decentralization, privacy, and data protection are regarded as very important.

  • United States

    The 2009 American Recovery and Reinvestment Act led to significant investment (more than $30 billion) in health information technology. The legislation established financial incentives for physicians and hospitals to adopt electronic health record (EHR) systems, under what is known as the Meaningful Use Incentive Program. As of 2014, 83 percent of physicians used some form of EHR system, and three of four (76%) hospitals had adopted at least a basic EHR system, representing an eightfold increase since 2008.

    The Meaningful Use Incentive Program is designed to gradually raise the threshold for EHR functionality above which providers receive incentives and avoid penalties. The current focus is on information exchange.