The Australian Digital Health Agency, established in July 2016, has national responsibility for digital health strategy. An interoperable national e-health program based on personally controlled unique identifiers is now in operation. Around 4 million patients and more than 8,900 providers, two-thirds of whom are in primary care, are registered. The record supports prescription information, medical notes, referrals, and diagnostic imaging reports. Patients are also able to add information about allergies, adverse reactions, and their wishes for their health care in the event that they are too unwell to communicate.
Uptake of health information technologies has been slowly increasing in recent years. Provinces and territories are responsible for developing their own 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. However, interoperability 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.
In June 2015, a law addressing the national electronic patient record was adopted; it will come into effect in 2017 and should increase care coordination, quality of treatment, patient safety, and efficiency in the health care system. Insured persons are free to opt into such a record and to decide who is allowed to have access to specific details of their treatment-related information. The records are being stored in decentralized form. Providers will have to take part in certified communities (organizational units of health specialists and their institutions) to be able to read the records. Whereas ambulatory providers are not obliged to join such communities, hospitals and long-term care institutions are legally bound to join and to offer their services using an electronic patient record.
For some years, a national e-health coordination service called eHealth Suisse (an administrative unit of the FOPH) has been in place under the joint responsibility of the federal and cantonal governments. The confederation will provide partial funding for the development of networks constituting the infrastructure for the electronic patient record.
GP e-health is still at an early stage, and there are ongoing discussions about incentives for physicians to adopt new technologies. Hospitals are generally more technologically 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.
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 (insurance ID or citizenship ID). However, EHR systems vary significantly by hospital and are usually not integrated or interoperable. Patients often must bring with them a printed health record if they want to see doctors in different hospitals. Even if hospitals are owned by the same local bureau of health or affiliated with the same universities, different EHR systems may be used. Patients generally do not use EHR systems for accessing information, scheduling appointments, sending secure messages, refilling prescriptions, or accessing doctors’ notes.
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. The government has implemented an electronic medical card containing encoded information about each patient’s prescriptions and medication use; this information is accessible by the patient and all relevant health professionals. 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 (DataFangst) 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.
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. In 2015, the Federal Cabinet passed 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 (2016–2017), 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 online review of the basic insurance claims data will receive reduced remuneration. Furthermore, 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.
The initiative to fully integrate electronic health records (EHRs) has faced multiple delays, and the integration of information systems between health care professionals and hospitals remains limited. The EHR project (Projet dossier medical personnel) covers 587,443 patients as of 2016, or 0.8 percent of the population, and an estimated 731 hospitals. 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. The sharing of information between health and social care professionals is not currently permitted but will be tested as part of the Paerpa program for hospice residents.
The government has created a national agency (ASIP santé) for expanding the uptake and interoperability of existing health information systems.
The National Health Service (NHS) number assigned to every registered patient serves as a unique identifier. All general-practice patient records are computerized. Since April 2015, GP practices have been contractually obliged to offer patients the choice of booking appointments and ordering prescriptions online. As of March 31, 2016, practices are required to offer patients access to their detailed coded record—including information about diagnoses; medications and treatments; immunizations; and test results. Practices are not required to allow patients access to information that clinicians enter in free-text fields. Where electronic records are not available to patients, such as in dentistry, they can request a paper copy. Records are not routinely linked among providers.
The NHS had aimed to make primary, urgent, and emergency care services paperless by 2018, and all other parts of the NHS by 2020. However, this time line has already slipped, and a recent independent review of digital use in the NHS suggests that 2023 is a more reasonable target for trusts to reach digital maturity.
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.
The Ministry of Health and Family Welfare in 2015 set up a National Health Portal that provides the public with information on diseases, health services, health programs, and insurance schemes. In addition, a Health Statistics Information Portal has been set up to provide information and data on health indicators, compiled from multiple sources.
Recognizing that multiple health information systems are in use across the public and private sectors, the imnistry has proposed creation of the National eHealth Authority to set regulations and standards. States would be able to develop systems to suit their needs and priorities, provided they were consistent with standards set by the authority. The authority also would be responsible for developing health information systems and enforcing laws and regulations related to the privacy and security of patient health information.
All health plans have electronic health record (EHR) systems that link all community-based providers—primary care physicians, specialists, laboratories, and pharmacies. All general practitioners (GPs) work with an EHR. Hospitals are also computerized but are not fully integrated with the health plan EHRs. The Ministry of Health (MoH) is leading a major national health information exchange project to create a system for sharing relevant information across all hospitals and health plans.
Each citizen has an identification number that 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 full records are not generally available. Efforts are under way to set up secure messaging systems linking patients and their GPs.
The New Health Information System (Nuovo Sistema Informativo Sanitario) has been implemented incrementally since 2002, with the goal of establishing a universal system of electronic records connecting every level of care. It provides information on services, resource use, and costs, but does not encompass all areas of health care; in particular, primary care is not included, while hospital, emergency, outpatient specialist, residential, and palliative care, as well as pharmaceuticals, are. It currently registers administrative information on care delivered, but medical information appears to be 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,” (mattoni) one of the most mature elements of Italy’s developing electronic health program. It aims to define a common language for classifying and codifying concepts; to share methodologies for measuring quality, efficiency, and appropriateness of care; and to allow 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 the automatic transfer of patient registers and of information on services provided, prescriptions for specialist visits and diagnostics, and laboratory and radiology test outcomes. A few regions have also developed a personal electronic health record, accessible by the patient, that contains all of his or her medical information, such as outpatient specialty care results, medical prescriptions, and hospital discharge instructions. Personal electronic health records are meant to provide support to patients and clinicians across the whole process of care, but diffusion is still limited.
There is also a slow shift under way 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 had reached the goal on time.
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, a system of unique identifiers implemented in 2016, will be phased-in for health care services, including medical records, starting in 2018.
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.
A national strategy for health information technology (HIT) was initiated in 2016 and is the responsibility of the Directorate of eHealth. Every resident is allotted a unique personal identification number, which is used in primary care and for hospitals’ medical records. General practitioners (GPs) use secure messaging to request prescriptions or to address patients’ questions. 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 as yet no electronic method for doing so. An ongoing project on patient access currently gives 3.1 million inhabitants access to their core medical record.
The National Health Network, a state enterprise, 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, for communication with laboratories and radiology services, and for sick leave. Most GPs receive electronic discharge letters from hospitals. Where after-hours emergency care is organized within the same patient record network as primary care, patient histories remain available, and primary care providers are able to access information regarding emergency visits. All hospitals use electronic records.
The lack of standardized, 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.
The ability to access and share accurate clinical information is central to the New Zealand Health Strategy, with increasing emphasis on investing in regional hospital systems that support and enable integrated care.
In 2015, the Ministry of Health announced the Digital Health Work Programme 2020. The program aims to ensure appropriate access to health and wellness information facilitated by a single electronic health record. The electronic record will collect and present existing core health information in a single view, accessible by consumers and clinicians. Data will also be able to be shared with social-sector professionals.
Current levels of interoperability between health information systems are limited. However, the ability to provide services such as structured electronic transfer of information is increasing. Primary care providers can transfer patients’ records securely between practices, send electronic referrals, and receive electronic hospital discharge summaries.
Well over a third of primary care practices have implemented a patient portal, and more than 140,000 patients have registered to access their information through the portal. This advancement supports the Health Strategy’s goal of enabling health care consumers to have an active role in managing their own health, to engage more conveniently with the system, and to move services closer to home.
A recent survey found that 359 of 992 general practices have implemented provider portals, giving after-hours facilities and some hospital emergency departments access to primary care information. Providers in community, hospital, and specialist settings in one of New Zealand’s four regions can now access a shared view of clinical information, and the other three regions are reviewing their information systems to enable information-sharing. Implementation of electronic prescribing is under way in primary care and in hospitals. The use of telehealth to deliver services remotely is also increasing.
The Health Information Standards Organisation promotes the development and use of standards to ensure interoperability between systems, and SNOMED CT (Systematized Nomenclature of Medicine—Clinical Terms) has been endorsed as a national standard for clinical terminology in New Zealand. Every person who uses health and disability support services has a unique national health number, facilitating the process of building interoperable systems.
Singapore is building a sophisticated national electronic health record system. The system collects, reports, and analyzes information to aid in formulation of policy, monitoring of implementation, and sharing of patient records. The long-term goal is to allow medical professionals to access clinical data on patient treatment and safety.8
When fully developed, the system will allow data to be accessed and viewed in appropriate formats by medical professionals, patients, and researchers. Data will come from public hospitals’ and polyclinics’ electronic medical record systems, among other sources. There are plans to enable patients to view and possibly contribute to their personal health records in the near future.
Both the quality of information technology (IT) systems and their level of use are high in hospitals and in primary care, although the type of systems used vary by care setting and by county council. Nearly all Swedish prescriptions are e-prescriptions. Patients increasingly can access their electronic medical records to schedule appointments or view personal health data, although this access varies among county councils.
To make it convenient to access care, everyone in Taiwan carries an electronic National Health Insurance (NHI) card with a unique personal health identifier. The card contains personal information, insurance data, the six most recent medical visits, diagnoses, drug prescriptions, drug allergies, major illnesses, organ donation consent, palliative care directives, and public health records (including immunizations). Providers are required to report to the National Health Insurance Administration (NHIA), on a 24-hour basis, each patient visit and service delivered, thus enabling the tracking of individual and national aggregate service utilization in nearly real time. This provides the NHIA with a good sense of overall expenditures at any point in time and helps it identify and manage heavy users of NHI services. The card also helps the government identify and track public health threats and infectious disease outbreaks, as it did in the 2003 SARS epidemic.
The NHI card has made administration simpler and more efficient. NHIA administrative costs accounted for just 1.07 percent of total NHI expenditures in 2014.
Two recent personal health information innovations, both information technology (IT)–driven, are worthy of note. One is NHI PharmaCloud, a cloud-based, patient-centered drug information system that the NHIA introduced in 2013. Taking advantage of the vast database NHIA has created since its inception, PharmaCloud enables doctors (during clinic and outpatient visits, house calls, and emergency department care) and pharmacists to know in real time a patient’s medication history for the past three months. PharmaCloud also provides prescribers clinical and safe-use information to help prevent drug adverse reactions and reduce waste.
My Health Bank, introduced in 2014, is another cloud-based innovation that provides comprehensive health and medical records for any insured person upon request. Records can be updated at any time. In addition to increasing the transparency of important personal health information, the initiative is intended to assist patients in self-managing their health.
All hospitals and clinics use electronic patient medical records. However, owing to a lack of infrastructure investment, NHI systemwide interoperability does not yet exist and interhospital exchange of patient medical records is limited.
The 2009 American Recovery and Reinvestment Act led to significant investment (more than USD30 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 EHR Incentive Program. As of 2015, 84 percent of physicians used some form of EHR system, and three out of four hospitals (76%) 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.