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EHR-Implement D14 Results of European Survey

March 31, 2010 1/125

National policies for EHR implementation in the European area: social and

organizational issues

EHR-IMPLEMENT Project ID: 2006112

Results of a European Survey

Deliverable id D14 Document name D14- Results of the European

Survey Date 30.03.2010


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Table of Contents Table of Contents ...................................................................................................... 2Table of Figures ........................................................................................................ 41 Introduction ........................................................................................................ 5

1.1 Purpose of the document ............................................................................... 51.2 Structure of the document .............................................................................. 51.3 Audience ...................................................................................................... 5

2 Executive Summary ............................................................................................. 63 Objectives of the Survey ....................................................................................... 74 Structure of the Survey ........................................................................................ 7

4.1 EHR Context (Part 2) ..................................................................................... 84.2 Importance of social, cultural and political factors (Part 3) ................................. 8

5 Conducting the survey .......................................................................................... 85.1 Distribution of the Questionnaire ..................................................................... 85.2 Intended addressee ....................................................................................... 95.3 Challenges ................................................................................................... 95.4 Number of Surveys completed and countries represented ................................... 9

6 Presentation methodology .................................................................................... 107 About the EHR Implementation context (Q3-Q12) ................................................... 12

7.1 About the National Healthcare Systems (Q3) ................................................... 127.1.1 The Question ......................................................................................... 127.1.2 The Overall Results ................................................................................ 137.1.3 Comments added by the respondents ....................................................... 147.1.4 Interpretation ........................................................................................ 16

7.2 About the present and previous National and Regional e-Health strategy ........... 177.2.1 Is there a National and/or Regional e-Health strategy currently defined in the country? (Q4) .................................................................................................... 177.2.2 Was there a (previous) National e-Health strategy? (Q5) ............................ 267.2.3 Details about the (actual) e-Health strategy, more especially related to EHR systems (Q6) ..................................................................................................... 30

7.3 Actual status regarding the use of EHR systems ............................................... 367.3.1 At your knowledge, what is the penetration of EHR systems for clinical use? (Q7) 367.3.2 What is the approximate penetration of PEHR (Personal Electronic Healthcare Record) systems? (Q8) ........................................................................................ 39

7.4 About education in the use of Health IT .......................................................... 407.4.1 Is there an education and training program in the use of IT in general? (Q9) . 40In the schools (before university or specific health professional education) ................ 40In the university / specific educational curriculum ................................................... 407.4.2 Is there an education and training program in the use of specific IT applications for healthcare? (Q10) .......................................................................................... 417.4.3 Is there training in the registration (coding) and the processing of clinical data provided? (Q11) ................................................................................................. 437.4.4 Is there training in the use of the healthcare professional's own application? (Q12) 44

8 About the importance of Social, Political and Cultural issues related to large scale implementation of EHR systems (Q13-Q44) ................................................................. 46

8.1 How important are the use of EHR systems and sharing of patient data for the public health (Q13-Q15) ......................................................................................... 46

8.1.1 Improvement of the health system (Q13) ................................................. 468.1.2 Decrease of the public health related costs (Q14) ....................................... 488.1.3 Other (Q15) .......................................................................................... 50

8.2 What are the large scale use of EHR systems and sharing patient data important for? (Q16-Q19) ..................................................................................................... 51

8.2.1 Quality and continuity of care (Q16) ......................................................... 52


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8.2.2 To avoid redundant exams and to reduce costs (Q17) ................................. 548.2.3 To avoid care induced harm (Q18) ........................................................... 568.2.4 To involve the patient in his/her own health(care) (Q19) ............................. 58

8.3 How important are the following issues for the large scale deployment of EHR systems and sharing of patient data? (Q20-Q22) ....................................................... 60

8.3.1 Patient’s trust in sharing patient’s data (Q20) ............................................ 608.3.2 Patient’s support for the services (Q21) .................................................... 638.3.3 Other related issues (Q22) ...................................................................... 65

8.4 How important are the following issues related to the health care professionals for the large scale deployment of EHR systems and sharing of patient data? (Q23-Q27) ...... 66

8.4.1 Acquiring the required skills to use IT in general (Q23) ............................... 668.4.2 Acquiring the required skills to use Health IT systems and more especially EHR systems (Q24) .................................................................................................... 688.4.3 Being rewarded for the use of (agreed) EHR systems, e.g. participating in research, etc… (Q25) ........................................................................................... 708.4.4 Being financially rewarded for the use of quality labeled EHR systems (Q26) . 728.4.5 Other related issues (Q27) ...................................................................... 74

8.5 How important are, on behalf of the healthcare professionals, the following issues in order to enable sharing and availability of patient data for the healthcare professionals? (Q28-Q32) ............................................................................................................ 75

8.5.1 Trustful relations with the health authorities regarding the (re)use of the “shared” healthcare data (Q28) ............................................................................ 758.5.2 Cooperative relations between the healthcare professionals, overcoming competition between them (Q29) .......................................................................... 778.5.3 Cooperative relations between the healthcare professionals, overcoming competition between them (Q29) .......................................................................... 798.5.4 Trust in the sharing of patient data on itself: privacy and security guaranteed (Q30) 818.5.5 Involvement of the healthcare professionals in the services (e.g. professional supervision on the services) (Q31) ........................................................................ 83

8.6 What do the national authorities consider as important issues favouring a large scale deployment of EHR systems? (Q33-Q44) .......................................................... 85

8.6.1 A clear vision on e-Health, before defining a strategy and implementation policy (Q33) ....................................................................................................... 868.6.2 A clear and consistent legal context, more especially regarding professional responsibility when sharing patient data (Q34) ....................................................... 888.6.3 Direct involvement of the healthcare professionals in the design and program definition (Q35) .................................................................................................. 918.6.4 A clear and consistent legal context, more especially regarding security and privacy when sharing patient data (Q36) ............................................................... 938.6.5 The quality and reliability of the EHR systems for use by the healthcare professionals (Q37) ............................................................................................. 958.6.6 The quality of the content of an EHR and indirectly the quality of registration by the healthcare professional (Q38) ..................................................................... 978.6.7 The availability and the continuity of funding for implementation of eHealth and large scale EHR implementation (Q39) ................................................................ 1008.6.8 The availability of a consistent and comprehensive infostructure for the large scale implementation of the EHR-systems (identification services, access management services, time stamping, ...) (Q40) ..................................................................... 1028.6.9 Health IT specific education and training (Q41) ........................................ 1048.6.10 An intense private/public cooperation (Q42) ............................................ 1068.6.11 A simultaneous and coordinated approach, national and European (e.g. for interoperability) (Q43) ....................................................................................... 108

9 Overview of the results for Question 13 to Question 44 ......................................... 11110 Ranking of the factors important to EHR deployment and data sharing ................. 11211 Most important social, political and cultural factors ............................................ 115

11.1 Highest percentage “very important” ............................................................ 11511.2 Highest percentage “very important” and “important” ..................................... 115


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11.3 Weighted score .......................................................................................... 11512 Less important social, political and cultural factors ............................................ 116

12.1 Highest percentage “not important” .............................................................. 11612.2 Highest percentage “not important” and “no opinion” ..................................... 11612.3 Lowest percentage “very important” ............................................................. 11612.4 Lowest weighting scores ............................................................................. 117

13 Differences between the countries based on “type of access to secondary care” .... 11814 Differences between the countries based on “type of employment of the healthcare professionals” ........................................................................................................ 12215 Conclusions .................................................................................................. 125

Table of Figures Figure 1: Countries / Regions Surveyed ................................................................ 10Figure 2: Social, political and cultural factors as responded by countries with no “free access” at all to secondary care. ........................................................................ 119Figure 3: Social, political and cultural factors as responded by countries where “direct” access to secondary care is discouraged. ............................................................. 120Figure 4: Social, political and cultural factors as responded by countries with a free / unlimited access to primary as well as to secondary care ....................................... 121Figure 5: Social, political and cultural factors as responded by countries with mainly “employed” healthcare professionals ................................................................... 123Figure 6: Social, political and cultural factors as responded by countries with mainly “independent” healthcare professionals, based “fee-for-service” or “capitated” payment or any combination of those payment options. ......................................................... 124


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1 Introduction

1.1 Purpose of the document

This deliverable contains the results of the “Focused Survey on EHR Implementation across European countries”. The questionnaire used for that survey was described in Deliverable D13 “Questionnaire of the Survey on EHR Implementation in the Member States”. This document reports on the options taken to collect the required data to conduct such a survey. The option discussed here is the one about the questionnaire that has been developed and the distribution of that questionnaire over the different European Countries, member states and non-member states.

1.2 Structure of the document

We first address the scope of the survey, the collection of the results and the way the results should be interpreted. We discuss in a further part of the deliverable the figures obtained per question, resulting in some top overall social, political and cultural factors important for the large scale deployment and use of EHR systems. The results for each question are then analysed in order to identify differences between the countries, depending on the “organisational context of healthcare” in each of the studied countries. Top factors are then identified as well as the social, political and cultural factors listed as less important. We finalise this deliverable with some overviews per groups of countries.

1.3 Audience

This deliverable can be distributed freely within and outside the consortium.


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2 Executive Summary

The Annex I of the Grant Agreement defined that a “Survey” should be conducted that focuses on the existence of National Strategies regarding e-Health in general, more especially related to the large scale use and deployment of EHR systems. The consortium decided to base this survey on a questionnaire, to be completed by one single well informed representative person per country or region, representing a national or regional authority. This deliverable is about the results of the Survey.

Collecting the data was not that easy, identifying authorities or representatives of authorities willing to comment their National Strategies, not always successful Strategies.

The survey illustrates some confusion regarding the concept “EHR” within this project, more especially when addressing general, political and strategic issues. Some respondents clearly interpret “large scale implementation of EHR systems” as the implementation of “large scale EHR systems” or “centralised EHR systems” while other respondents are focusing on a broad deployment of interoperable independent information systems, resulting in a virtual “overall EHR”.

Countries with a large installed base of clinical information systems like Austria, Denmark or Ireland are focusing on “centralised services for sharing patient data” or “patient summary” services. These patient summaries are obviously also EHR systems.

This “confusion” does not affect the other results of the survey, considering that the same political, social and cultural factors will influence both, the large deployment of EHR systems and the deployment of large scale EHR systems. The survey firstly highlighted that most of the countries or regions has an ongoing e-Health Strategy (14 on 17). The strategies are not fully comparable in goals nor in budget.

Most of the countries or regions (12 on 17) did not report a previous e-Health strategy. Only two countries (Norway and England) reported a successful previous strategy, one of them mentioning “but it could be better”. The reasons for failure were management failure in one country; insufficient funding, top-down approach, no use of standards and competing projects in another country; insufficient funding, top-down approach, politically driven, lack of stakeholders support, unrealistic schedule in the third country, lack of interoperability of the existing applications. The fact that only 5 countries reported a previous “e-Health strategy” may indicate that even no consensus could be reached on setting up such a strategy.

The penetration of EHR systems for professional use1

, for clinical use seems increasing all over the continent, reaching some 65% in average. Differences are important, not only on “having” such systems but on “using” them for clinical purposes as well as related to the intensity of using them.

The penetration of Personal EHR systems is reported in most countries as less than 1%.

1 Based on the answers of the respondents. There are surely more specific and quantifiable reports available.


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The survey clearly illustrates the important organisational framework differences between the countries, e.g. different in the way healthcare professionals are employed and paid, different in the way secondary care can be accessed.

These two examples are used to illustrate the impact of political, social and cultural factors on the way healthcare is organised and provided, as well as on how related services, IT services are “evaluated”.

A slightly different weighting of some of these factors was given within the EHR-Implement survey to the factors by the respondents of the countries or regions with on one hand employed healthcare professionals and on the other hand self-employed healthcare professionals. The differences between the countries or regions depending on the way access is provided to secondary care are even less important.

The difference between “important” and “very important” is of course rather subjective. Most of the investigated issues are considered as important to very important by all the respondents.

Big differences were not expected and have not been found between the surveyed countries, reflecting the increasing degree of convergence between them.

The most prominent differences are, beside on health IT related education, found in how to support the market and more especially the vendors and how to grant some ‘profit’ or ‘advantage’ to the healthcare professionals, using those EHR systems.

3 Objectives of the Survey

The objectives of the Survey were described in the Annex I to the Grant Agreement. They are: “ 1. To obtain general information on EHR implementation policy and action plan in the

Member States 2. To focus on the key issues previously identified by in-depth analysis and analyze how

they are addressed in the countries undergoing EHR implementation 3. To identify the differences and similarities of EHR implementation at the European

level 4. To sensitize the policy makers on social and organizational issues.”

4 Structure of the Survey

The Questionnaire used for the Survey has three main parts: • Part 1 (question 1 to 2) were intended to identify the person, the service that

completed the survey. It did also give some specification of its affiliation or role in the national healthcare organisation. This information is not available as agreed with most of the respondents.

• Part 2 (question 3 to 12) related to the local EHR “context”, describing e.g. the present and/or past e-Health strategies and the overall penetration and use of Health IT in the country of the respondent.

• Part 3 (other questions) addressing more in detail social, cultural and political factors influencing the up-take and large scale implementation of EHR systems.

Each of the questions can be answered by selecting a proposed answer and can be completed with comments from the respondent.


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4.1 EHR Context (Part 2)

This part of the Questionnaire addresses general issues regarding present or past e-Health strategies and the National Healthcare System in place. The latter is mainly in order to – eventually – identify differences between the countries based on those contextual factors. This section has questions:

• About the National Healthcare System • About the current and previous e-Health strategies • About the actual status regarding the use of EHR system and of PEHR (Personal

Electronic Healthcare Record) systems • About educational aspects related to the use of Health IT

4.2 Importance of social, cultural and political factors (Part 3)

This part of the Questionnaire lists the possible social, cultural and political factors, enabling the respondent to define, for each of them, a degree of importance: very important, important, not important, without an opinion. The questions are split in three subsections:

• Section 1: For what do you consider large scale use of EHR systems to be important, e.g. to reduce health induced patient harm, to reduce costs of healthcare, etc...

• Section 2: Which issues do you consider as being important for a large scale deployment of EHR systems?

• Section 3: Which issues should be addressed in order to enable (health) professionals to share patient data?

5 Conducting the survey

5.1 Distribution of the Questionnaire

The EHR-Implement partners were requested and contractually required to complete the questionnaire. This covers the following countries:

• Belgium • Denmark • France • Greece • Ireland • Slovenia • United Kingdom

The EuroRec network was addressed for the other countries, through the National ProRec centres, members of EuroRec. The partners of the EHR-QTN

Thematic Network project, coordinated by EuroRec, were also requested to support the initiative and to help to collect completed questionnaires in their respective countries.

The following countries, additionally to the Members of the EHR-Implement consortium, were solicited:

• Austria • Bulgaria • Croatia


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• Czech Republic • Cyprus • Estonia • Germany • Hungary • Italy • Luxembourg • Netherlands • Norway • Poland • Portugal • Romania • Serbia • Slovakia • Spain

The Questionnaire was thus distributed to 25 countries, 3 of them not being an European Union Member State.

5.2 Intended addressee

The EHR-Implement Consortium was mostly interested in getting “the” or at least a “high level” official opinion on the statements surveyed. It was therefore decided to limit the number of respondents to one per country or per region, the latter in case of a distributed responsibility for e-Health within a given country, as in the United Kingdom, Spain or Belgium. One of the consequences is the limited number of “answers” collected. This has an impact on the statistical analysis and the presentation of the results.

5.3 Challenges The identification of the “service” or the “person within the service” that should be asked to complete the survey was an important challenge. Getting that person to effectively complete the questionnaire was another challenge. This required much more efforts than originally expected. Quite some public servants, representing heath authorities, don’t feel themselves in position to “comment” or to formulate “considerations” regarding running or even regarding past public initiatives related to the implementation of EHR systems and/or or National or Regional e-Health strategies in general.

5.4 Number of Surveys completed and countries represented

We obtained 17 answers, representing 17 countries or regions. The countries / regions represented in the Survey are displayed in Figure 1.


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Figure 1: Countries / Regions Surveyed The countries surveyed are representative for the different regions in Europe:

• Southern Europe: Portugal, Greece and Cyprus • Western Europe: Ireland, England, France and Belgium • Northern Europe: Denmark, Norway and Estonia • Central and Eastern Europe: Austria, Slovenia, Czech Republic, Hungary,

Serbia and Romania.

6 Presentation methodology

Part 2 of the survey are mainly “textual” specifications regarding the context of use of EHR systems and Health IT in general, including political options and strategic plans.

We display the question and the different answers from the respondents. Each question is followed by an “interpretation”. The “interpretation” should be considered as purely “descriptive” and not at all “inferential”.


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The results of part 3 of the survey are quantifiable and presented as a pie, with a percentage for the different answers: very important, important, not important and no opinion.

A cross tabulation is then added analysing the answers in function of criteria related to the dominant

way healthcare is provided in the different countries.

A first distinction is based on the “access to secondary care”, distinguishing three groups of countries.

• Countries with no free access to secondary care. Secondary care can only be used after / on recommendation of a primary care healthcare professional, of course excepted emergencies.

The following countries were classified in this category:

• Estonia2

• Ireland

• Norway • Portugal • Slovenia • United Kingdom

• Countries with free access to secondary care, but with increasing restrictions,

e.g. financially or to repeated access to that secondary care. These restrictions may still be very limited.


• Slovakia • Romania • Cyprus • Belgium3

• Countries with “full free” access to secondary care. This does not mean “for free” but without regulatory access, other than waiting lists.


• Austria • Czech Republic • Serbia • Denmark • Greece • France4

A second distinction was made between the countries based on the main mode of payment of the healthcare professionals.

• Countries with mainly employed healthcare professionals, more especially in secondary care. The following countries were classified in this category:

• Ireland • Slovakia • Cyprus

2 Access to some specialties is possible without referral: dermatology, gynaecology, psychiatry, some infectious diseases (HIV and TBC) and acute traumatology. Access is always possible but then without health insurance coverage. 3 Can be challenged… limitations are still minor. 4 Restrictions are planned.


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• Portugal • Serbia

• Countries with “independent” healthcare professionals, paid either on the

basis of a fee for service or even on “capitated” / contractual basis or sometimes a mixture of both modes of payment. The following countries were classified in this category:

• Fee-for-service (mainly) with or with patient co-payment: o Estonia o Romania o Czech Republic o Belgium o Greece o France

• Contractual Flat Fee or capitated: o Denmark

• Combination of fee-for-service and a flat fee per patient: o Norway o Austria o Slovenia o United Kingdom

Each question is, after the pie and the comments, followed by an “interpretation”. A few questions were not answered by all 17 respondents. This explains why the number of total responses can be different for each of the questions. When the total number of responses exceeds 17, this indicates that the respondents indicated more than one answer (multiple select question) (e.g. Q12). Since only 17 respondents have answered the questionnaire, only descriptive statistics have been presented. No inferential tests have been performed. Conclusions and interpretations drawn from these figures should thus be taken with caution.

7 About the EHR Implementation context (Q3-Q12)

7.1 About the National Healthcare Systems (Q3)

7.1.1 The Question This question intended to specify the overall organisational and financial context for providing care in the different countries, in order to be able to eventually identify important or even small differences between those countries depending on that organisational framework. Healthcare in Europe, organisationally as well as regarding funding, is always “centralised”, either as a tax based system or as an “public insurance” based system, with only different degrees of “coverage”, different degrees of “social corrections” and including different degrees of co-payment by the patients. The respondents were asked to select the organisational models for providing healthcare that fits best for their country, regarding the

• Overall organisational structure and funding of the healthcare • Contractual status of the healthcare professionals (employed or independent or

anything between)


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• Access to secondary (free or only when referred from primary care, emergencies excepted).

• Way of payment of the healthcare professionals, important for the countries where most/all healthcare professionals are not employed.

It was not intended to start, with this question, a comprehensive study of the organisational differences between the countries and within the countries between primary care and secondary. The main options were asked for.

7.1.2 The Overall Results

7.1.2.1 Regarding the organisational structure and funding of healthcare in general

7.1.2.2 Regarding the contractual models for healthcare professionals

It appears from the comments that different models exist in the same country with more especially differences between primary care (more self employed professionals) and hospital care (more employed professionals).


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7.1.2.3 Regarding the “access to (secondary) care”

7.1.2.4 Regarding the way care is paid for

7.1.3 Comments added by the respondents

7.1.3.1 Regarding the organisational structure and funding of healthcare in general

• More detailed information regarding the Estonian healthcare organisational framework:

- State based coverage for all citizens with health insurance with co- payment by the patient - Healthcare providers are private, municipal or governmental - Family doctors (private companies) - Hospitals (shared companies or foundations) - 94 % (1 272 051 people) of population had health insurance through Estonian Health Insurance Fund at the end of 2003. (EE)

• The Irish Health Service provides healthcare to all Irish citizens. The funding model is mixed. - The State pays all the costs for approximately one third of the population (Medical card holders).


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- It pays a high percentage of costs for all health services delivered in the acute hospital sector (with a small co-payment), all the costs incurred in post hospital care and the costs of long stay care.

- Costs of primary health care is partially funded by State (medical card & GP card- approximately 50% the population) and privately funded by the balance of the patients. Drug purchase costs that exceed a specified amount (€100/month) are also reimbursed for all patients who hold a drug refund card (not means tested).

- The OECD estimates that the Irish State (essentially the HSE) pays approximately 80.7% of all health related costs. (IE)

• More details on the Romanian healthcare system: Public health insurance, one national for most of the population and other three for some professional groups. There are some complementary private insurance, open for all, for additional services. (RO)

• Comment on the Austrian healthcare system: Practically all Austrians are covered via one of several public health insurance agencies. (AT)

• More details on the French healthcare system: The national health insurance system covers about 76,5 % of health expenditures, the complementary insurance funds accounts for 15% of the remaining share, and household for 8,5%. In some cases, the state covers 100 % of the health expenditures. (FR)

7.1.3.2 Regarding the contractual models for healthcare professionals

• More details on the Irish model: All clinicians in the acute hospital and community care services are employed by the HSE. Primary care clinicians are generally self employed. (IE)

• The primary care GPs are mainly independent and self-employed with municipal contracts. Some GPs are employed in a municipality. Specialist level physicians (hospitals) are employed. (NO)

• The primary care GPs are mainly independent and self-employed with municipal contracts. Some GPs are employed in a municipality. Specialist level physicians (hospitals) are employed. (SK)

• The physicians in public hospitals (Romania has only a few number of private hospitals) are employed. The family doctors and the specialists for outpatient healthcare have private cabinets and most of them have contracts with health insurance houses. (RO)

• I would say most physicians working in hospitals are employed whereas most primary care physicians have contracts with the public social security system. (AT)

• Besides the private sector, where the professionals are essentially independent or contractual, in the primary care, the professionals are majority employed while in the secondary care are employed and contractual. (PT)

• Both in primary and in secondary care the majority of physicians is self employed, but in some, a few hospitals (especially University hospitals) physicians are employees. (BE)

• Hospital physicians employed / primary care physicians contracted (UK) • Primary care and secondary cares (without hospital admission) are delivered by physicians (GP and

specialists) in private surgeries and to a lesser degree by salaried physicians working in hospitals and health centres. Almost all privately-practising physicians work on a fee-for-service basis according an agreement with the National health insurance (CNAM). The patient is reimbursed after paying the physician (from 65 % to 100%). (FR)

7.1.3.3 Regarding the “access to (secondary) care”

• In order to be admitted to a hospital, patient has to first be seen on a primary care level (e.g. a family physician). Emergency care is available to everyone at all times. (EE)

• More details on the Irish “access to care” model: - Free access to primary as well as to secondary (hospital care) - Free access to primary care, limited access to secondary care - No access to secondary care without previous access to primary care (mandatory gate keepers) - Other: All citizens have a right to access hospital based and associated follow up care. There is a

small element of co-payment required of citizens who do not hold medical cards. (Maximum of €900 in any 12 months) .Citizens who attends emergency departments of hospitals without a GP referral pays a charge of €100. (IE)

• Access to the secondary care is usually on the request or recommendation of GP's, some specialists, and directly by emergency services. (SK)

• Normally the family doctor or an outpatient specialist directs the patient to a hospital, to have full coverage from the public health insurance. However, the patient can go directly to the hospital with other payment options. (RO)

• The standard way is that the patient sees a GP first and is then transferred to a specialist respective to the hospital if necessary. However, with some restrictions it is also possible to go directly to a specialist respective to a hospital (e.g. in emergency situations, accidents, ...) (AT)

7.1.3.4 Regarding the way care is paid for

• Patient has a compulsory co-payment (if patient has health insurance). The rest of the health care service’s cost is covered by the Health Insurance Fund. (EE)

• There is a mixed funding model:


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o Clinicians employed by the HSE are paid on a salary basis. Medical clinicians also have a right to earn income from “private patients” – which are determined by their contracts.

o All other clinicians (nurses/allied health professionals/administrative staff) are paid on a salary basis.

o General Practitioners are paid on 2 bases: o A flat caption fee for medical card patients (state funded) o A private fee basis for other patients (IE)

• Different payment models for the primary and specialist care level respectively. However, both models rely on a mixed system with fee for service and state given block/matching grants whereas the grants constitutes the largest component. (NO)

• Mixed payment: employed status (mainly in hospitals or private policlinics, contractual (insurances), or paid directly by patients. (SK)

• For Romania we have: o per patient and for some services for the family doctors, covered by the health insurance houses o fee for service (completely or partially covered by health insurance) for physicians in outpatient

healthcare o a kind of DRG based payment system to the hospitals, with employed physicians

• Primary care physicians are paid via “fee for service” whereas in hospitals an Austria-specific DRG-system is used. (AT)

• Salary Based/Fee for Service, Contractual / Flat fee (CY) • Most of the health care professionals are civil servants and receive a salary fixed by law. Some hospitals

have incentives related with the production especially for physicians. Some health centres also pay more for the activity in previously defined key performance areas. (PT)

• Mixed payment (explain), DRG for inpatient, fee for service for outpatient secondary care, capitated and fee for service for primary care. (SB)

• Fee-for-service (with some contractual flat payment) is the rule in primary care as well as in secondary care. Some primary care centres have a capitated agreement with the National Health Insurance. (BE)

• In the United Kingdom o Mixed payment (explain) for primary care, mix of fee for service, flat fee and top-up payments for

quality o Employed status for hospital staff

• For France: o Fee-for-service is the most common in primary care and secondary care for privately-practising

physicians. o In hospitals, most MD’s are salaried

7.1.4 Interpretation The variation between the countries is important. These differences are used to define “clusters” in order to investigate differences in evaluation of the factors affecting large scale implementation of EHR systems. These clusters were listed in section 6 of this deliverable.


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7.2 About the present and previous National and Regional e-Health strategy

7.2.1 Is there a National and/or Regional e-Health strategy currently defined

7.2.1.1 The Overall Results

in the country? (Q4)

7.2.1.2 Evaluation For three countries only, no “formal” e-Health strategy seems to be in place. This does not preclude that nothing happens in these countries. This seems to be encouraging.

7.2.1.3 Description of the current e-Health strategies 1. Estonia

• Name/ Title of the programme: Electronic Health Record

• Start Date: 2005

• Foreseen end date: 2008

• Origin / Organisation / Authority responsible: Ministry of Social Affairs

• Coordinator: Estonian eHealth Foundation

• Availability of the documentation: http://eng.e-tervis.ee/miscellaneous/electronic-health-record-4.html

• Budget: 25.000.000 EEK ( approx. 1,6M€)

• Goals: Described in the next section

2. Ireland


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• Name/ Title of the programme: “An Information and Communications Technology

strategy for healthcare"

• Origin / Organisation / Authority responsible: Health Services Executive

• Coordinator: National Director of ICT Services

• Budget: Total funding required is a matter of annual negotiation between the HSE management and the Irish Department of Finance. The case for increased investment in Health ICT is widely accepted by policy makers and the Board of the HSE.

• This programme is not formerly launched in public. 3. Norway

• Name/ Title of the programme: 'Samspill 2.0/Tramwork 2.0" (Cooperation/Collaboration/Interaction), National ICT-strategy for the Health Sector)



• Origin / Organisation / Authority responsible: Ministry of Health and Care Services

• Coordinator

• Availability of the documentation: http://www.helsedirektoratet.no/samspillplanen

• Budget: 40M NOK per year


4. Slovakia

• Name/ Title of the programme: "Program of eHealth"- development and implementation of the informatics in Health care in the Slovac Republic


• Foreseen end date: 2013-2018

• Origin / Organisation / Authority responsible: Ministry of Health of the Slovac Republic

• Coordinator: National Health Information Center

• Availability of the documentation: www.nczisk.sk


http://www.helsedirektoratet.no/samspillplanen�

http://www.nczisk.sk/�


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5. Austria

• Name/ Title of the programme: eHealth Inititive (EHI)

• Start Date: june 2005

• Origin / Organisation / Authority responsible: Austrian Ministry of Health

• Coordinator: Arbeitsgemeinschaft für Datenverarbeitung (ADV), eHI Committee

• Availability of the documentation: http://ehi.adv.at

• Goals: Described in the next section 6. Cyprus

• Name/ Title of the programme: Integrated Health Care Information System


• Origin / Organisation / Authority responsible: Ministry of Economics

• Coordinator: Ministry of Health

• Budget: 50 M€

• Goals: Described in the next section 7. Czech Republic

• Name/ Title of the programme: 'Věcné záměry projektů eHealth”


• Origin / Organisation / Authority responsible: 'Ministry of Health – Inter-ministerial coordination committee for eHealth implementation’

• Coordinator: 'Ministry of Health – Inter-ministerial coordination committee for

eHealth implementation

• Availability of the documentation: http://www.mzcr.cz/Pages/350-vecne-zamery-projektu-ehealth.html (in Czech only)

• Goals: Described in the next section 8. Serbia

• Name/ Title of the programme: Program for work, development and organization of Integrated Health Information System e-Health



• Origin / Organisation / Authority responsible: Ministry of Health of Serbia

• Coordinator: Expert Council of Ministry of Health for Medical Informatics

http://ehi.adv.at/�

http://www.mzcr.cz/Pages/350-vecne-zamery-projektu-ehealth.html�

http://www.mzcr.cz/Pages/350-vecne-zamery-projektu-ehealth.html�


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• Availability of the documentation: www.zdravlje.gov.rs

• Budget: 60 M€

• Goals: Described in the next section 9. Denmark

• Name/ Title of the programme: Common Medication Card



• Origin / Organisation / Authority responsible: Connecting Digital Health in Denmark

• Coordinator: Connecting Digital Health in Denmark

• Availability of the documentation: www.sdsd.dk

• Budget: 10M€

• Goals: Described in the next section 10. Portugal

• Name/ Title of the programme: Plano de Transformação dos Sistemas de Informação

Integrados da Saúde (IT Transformation Plan for Health)



• Origin / Organisation / Authority responsible: Ministry of Health/ ACSS

• Coordinator: ACSS

• Availability of the documentation: www.acss.min-saude.pt

• Goals: Described in the next section 11. Slovenia

• Name/ Title of the programme: eZdravje



• Origin / Organisation / Authority responsible: Ministry of Health

• Coordinator: Ministry of Health

• Budget: 67M€


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http://www.sdsd.dk/�

http://www.acss.min-saude.pt/�


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12. Belgium

• Name/ Title of the programme: eHealth Platform


• Origin / Organisation / Authority responsible: RIZIV/INAMI,FPS Health, Crossroads Bank for Social Security

• Coordinator: eHealth Platform organisation

• Availability of the documentation: www.ehealth.fgov.be

• Budget: 80M€ for 5 years


13. Greece

• Name/ Title of the programme: Regional Integrated Healthcare Information Systems (OPSY)




• Coordinator: Information Society SA

• Budget: 50 M€


14. United Kingdom

• Name/ Title of the programme: Nation Programme for IT



• Origin / Organisation / Authority responsible: NHS Information Authority

• Coordinator: NHS Connecting for Health

• Availability of the documentation: www.connectingforhealth.nhs.uk

• Budget: 12,4 B€ over 10 years


http://www.connectingforhealth.nhs.uk/�


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15. France

• Name/ Title of the programme: Programme de relance du DMP et des systèmes d'information de santé partagés




• Coordinator: ASIP Santé

• Availability of the documentation: www.asipsanté.fr

• Budget: 150 M€ per year


7.2.1.4 Goals of the different National Strategies 1. Estonia

- Improved quality and efficiency of health services - Patient services will be better, faster, and more competent - Patients will be more informed - Medical statistics will improve - Less paperwork

2. Norway The vision is based on ensuring continuity of care for patients and clients through increased electronic interaction. The superior goal for the health sector is better quality of treatments and an increased interaction. The aim is that patients and clients shall experience a continuity of cure and care throughout the treatment chain when they use the health care services. Electronic interaction is decisive in order to ensure an improved information flow, which is a necessity in order to achieve the stated goals. The goals in the previous strategies (running from 1997) are partly achieved. The fundament for electronic interaction (i.e. infrastructure (The national Health Network), a code of conduct on information security and standards for message exchange) is established in the previous strategies, but it is not yet fully deployed and operational. The present strategy is therefore prioritizing to increase the implementation and dissemination rate of the available electronic services in order to ensure the everyday use. 3. Slovac Republic

• Goal 1=To create legislative, standardizing and architectonic eHealth frame • Goal 2= To create secured infrastructure for materializing eHealth vision and mission • Goal 3= Informatization of processes and services in health system based on public

resources • Goal 4= Support of new processes and forms of health care and health services


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4. Austria

Support for the development, harmonisation and coordination of electronic health services. 5. Cyprus 'To pilot and then implement an Integrated Health Care Information System’ 6. Czech Republic

'national EHR; ePrescription; patients´ eIdentification; consolidation of national health registries; clinical decision + HTA (Health Technology Assessment; portal for eEducation 7. Serbia

• Establishment of Integrated Health Information System • Standardization of information system • Implementation of Action Plan by 2015

8. Denmark

Access and update to all patients individual medication card/data from all health organisations (GP, Hospitals, Municipality...) 9. Portugal

• Clinical information quality improvement for a better clinical decision and good practice;

• Improvement of information and resources sharing among healthcare professionals; 10. Slovenia

To increase effectiveness of health system by:

• Redesign and optimization of current health and health related processes • Redesign and upgrade of ICT infrastructure • Establishment and implementation of national health informatics standards,

which will be based on EIF (European interoperability framework) • Establishment of national health information system with its components:

• Health net (zNET) • Health portal (zVEM) • EHR

• Establishment of Centre for Health informatics (CIZ), which will work under the Ministry of Health

To increase quality of health processes with education and training for different groups in the area of e-services in health with:

• development, execution and maintenance of the programs regarding patient empowerment

• development, execution and maintenance of the programs regarding other key partners empowerment

• development and maintenance of the professional training for e-health To ensure total quality and security in health system. 11. Belgium General goal: Information exchange between all actors in healthcare with specific precautions for guaranteeing security and privacy protection Objectives:

- Quality and continuity of health delivery services;


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- Patient safety; - Simplification of administrative burden in health sector; - Support of health policies.

Through a well organized electronic information exchange between all Belgian actors in the health care sector, with the necessary guarantees with regard to information security and privacy protection

12. United Kingdom

Implement integrated care records across England 13. France

- Promote collaborative medicine - Engage patient - Improve healthcare production - Develop services to patients and healthcare professionals: medical electronic

record, secure e-communication - Define and publish standards

7.2.1.5 Comments related to the National Strategies The comments were provided by the national respondents and are taken as they were collected in the National Surveys. 1. Estonia The development of eHealth projects in Estonia begun in 2005. There were four eHealth projects initiated by the Ministry of Social Affairs and supported from the EU Structural Funds. In October 2005, the Ministry of Social Affairs together with professional health care associations and organizations established the Estonian eHealth Foundation. The purpose of the Estonian eHealth Foundation has been to manage eHealth projects and develop the national health information system. The three eHealth projects led by the Estonian eHealth Foundation - Electronic Health Record, Digital Registration, and Digital Image as well as the Digital Prescription project developed by the Estonian Health Insurance Fund ended in 2008. These four projects are the first developments of the health information system launched in fall 2008. The interfacing of the health care organizations with the health information system will be done gradually depending on the differences of the information technology capacity and software solutions of these organizations. The development of the components of the health information system will take place until 2013. According to law, all health care services providers have to interface with the nationwide central Health Information System in order to be able to exchange data as of January 1, 2009. The obligation of health care service providers to conclude an interfacing contract with the Estonian eHealth Foundation since it is the authorized processor of the Health Information System is derived from three laws regulating eHealth area in Estonia: 1. Health Care Services Organisation Act. 2. Health Information System’s Statute. 3. The Statute no 53 of Ministry of Social Affairs on The Composition of Data, Conditions and Order of Maintaining of the Documents Forwarded to the Health Information System. 2. Ireland

The HSE has developed a strategy titled “An Information and Communications Technology strategy for healthcare. This document has been approved by the Board of directors of the HSE. It has not yet been formally launched in public. However it is widely circulated amongst HSE staffs who wish to learn more about ICT policy. 3. Romania The Ministry of Health (MoH) has a Strategic Plan for 2008-2010 underlining the necessity of a new, comprehensive, integrated health services information system, with patient monitoring, registers for non communicable diseases, geographic information system, sites for disseminate information and education etc. But no national e-Health strategy is in force now. Some strategies were discussed and proposed in the last years and in this moment there is a project in progress to propose a new one. A proposal (in Romanian) is at the address:


March 31, 2010 25/125

http://www.ms.ro/fisiere/proiecte_normative/256_588_Anexa%20strategie%20e-sanatate.doc There are some national e-Health projects (programmes) proposed or in progress, loosely connected to each other: • programme (1) The most important eHealth project in Romania in the last years – started in 2003 and still in progress – was the Unique Integrated Information System of Social Health Insurances (SIUI) of Romania, realized by HP and SIVECO Romania, funded by the insurance system. The new information system addresses all hierarchical structure of the Social Health Insurance System of Romania: the National House of Health Insurance, the County Houses of Health Insurance, and the medical and pharmaceutical service suppliers. The SIUI has components for finance, accounts, investments, inventory, purchase, payroll, human resources, buildings and appliances maintenance etc. as well as a planning system with “what if” type simulations. Among the benefits, the elimination of double registered insured persons or double reporting of services, rapid statistical reports, better monitoring and control of the resources, eliminating waiting times etc. are expected. In 2004 a pilot of SIUI was installed in Constanta County (608000 insured persons, 361 GPs etc.) and in 2008 and 2009 the system was rolled out in other counties. References (in Romanian) http://www.cnas.ro/ & http://193.151.30.188/cnas/ • programme (2) An important project, funded by Phare, was the “Improvement of accountability and transparency in the allocation and use of healthcare resources through implementation of a computerized monitoring system for hospital morbidity and a hospital case based financing system”, realized between 2005 and 2007 and now in operation. The main objectives of the project were: to develop a national system for reporting and monitoring of hospital activity, based on data about individual patients. The system uses international standards of patient classification (DRG type coding and grouping systems) that reflect EU and WHO recommendations. It assures a hospital payment system based on the numbers and types of patients (cases) treated, reducing unnecessary hospitalizations and excessive hospital length of stay, and improving the quality of care. The former US DRG assignment, in use since 2000, was replaced with the Australian AR DRG version 5 classification, and it was implemented gradually, starting with 1 January 2007 in all public hospitals. The new reporting requirements for DRG related data were incorporated into an updated Minimum Basic Data Set (MBDS). Various training activities were made. The computer systems for DRG data were updated, including advising as to whether hospitals should have access to in-house DRG assignment software, and if so, how it might be done. The appropriate endowment of 431 public hospitals and 42 county health authorities, with workstations, printers, software etc. was realized. • programme (3) A bidding for a programme will be organized in 2009 for a national e-prescription project, covering mainly the relationships between pharmacies and the health insurance system. The budget of the project will be up to 21M Euro, 80% from the European Regional Development Fund. A better control of the prescriptions and avoiding of errors due to incompatibilities or allergies is expected. Source: press statements • programme (4) A feasibility study for an Integrated Health Information System (IHIS) was started in 2009. The main objective of this new information system should be: the integration of the main Romanian health information systems, a citizen focused solution in the public health and a patient-focused solution in the curative medicine. • programme (5) A feasibility study for an „Operational Programme for advancing of Economic Competitiveness – Patient Health Record is in progress in 2009. The solution should be a centralized national database, connected to the other health records of the patient and accessible through a health-card 4. Portugal The eHealth strategy is included in the overall strategic named “IT Transformation Plan for Health” (PTSIIS), which is running and summarized above. Some projects considered in this plan are already in place. PTSIIS is being under evaluation and revision and it is foreseen to have (until the end of 2009) a more concrete one including an action plan for e-Health till 2013.

7.2.1.6 Interpretation For three countries only, no “formal” e-Health strategy seems to be in place. This does not preclude that nothing happens in these countries. This seems to be encouraging.


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7.2.2 Was there a (previous) National e-Health strategy? (Q5)


7.2.2.2 Interpretation Two on three of the countries did not have a previous National e-Health strategy. This includes the three countries without a running e-Health strategy. Seven countries are reporting that the actual e-Health strategy is the first defined. Three countries are reporting a failure of their previous e-Health strategies. This means that three on five (60%) reported previous e-Health strategies failed. This is not unexpected but at the same time disappointing.

7.2.2.3 Description of previous e-Health strategies

7.2.2.3.1 Successfully ended e-Health strategies 1. Norway

• Name/ Title of the programmes: 1. 1997-2000: In 1997, the Ministry for Health and Social Affairs released the first national plan for ICT development in the health and social sectors - ‘More health for each bIT’. 2. 2001-2004: The second strategy, ‘Say @!’. 3. 2004-2007: The third, Te@mwork 2007, outlined the governmental measures to promote greater electronic interaction in the health and social sector.

• Start Date: 1997 + 2001 + 2004

• End date: 2000 + 2004 + 2007

• Origin / Organisation / Authority responsible: Ministry for Health and Social Affairs

• Coordinator: Ministry of Health and Care Services


March 31, 2010 27/125

• Availability of the documentation: www.sdsd.dk

1. “More Health for each bIT”: http://www.regjeringen.no/nb/dep/hod/dok/veiledninger_og_brosjyrer/1996/mer-helse-for-hver-bit.html?id=87401

2. “Say@”: http://www.regjeringen.no/nb/dep/hod/dok/veiledninger_og_brosjyrer/2001/i-1018-b.html?id=87689

3. “Teamwork 2007”: http://www.helsedirektoratet.no/samspill/publikasjoner/te_mwork_2007___electronic_interaction_in_the_health_and_social_sector_48934?dummy=null (English document)

http://www.helsedirektoratet.no/publikasjoner/rapporter/s_mspill_2007_quot__ny_strategi_for_elektronisk_samarbeid_i_helse__og_sosialsektoren_5708 (Norwegian document)

• Budget: approx. 40M NOK annually

• Goals:

The vision of the “More health for each bIT” strategy was to build bridges between the many islands of ICT development and initiatives within the Norwegian health care sector. The vision of “Say @” was to achieve ICT-based interaction in the services on a broad basis, and not just as pilot projects. The vision and the main goal in “Teamwork 2007” were to increase the continuity of the patient care and cure throughout the treatment chain by the use of electronic interaction. The strategy had two overarching perspectives: Improving the information flow in the sector and to ensure a greater inclusion of new actors in electronic interaction based services (at that time electronic interaction initiatives had mainly been developed between health enterprises (hospitals), GPs and the National Insurance Service). In the earliest strategies the areas of priority were chosen on an understanding that comprehensive national measures were necessary in order to realise the full potential of ICT in the sector. The prioritized areas in the later strategies have not been so broad, but have to a larger extent focused on implementation in a few selected areas.

• Success Factors (as reported by the respondents):

• Good Management • Even though the use of ICT not have been implemented in ordinary use within all

services, the earlier as well as present strategies have contributed to knowledge in regard to identifying important success criteria in regard to goal achievement such as: - Stronger governmental/superior guidance and broad anchoring in the sector

as a whole. - The importance of clear and consistent health political goals. Whereas the

underpinning of that ICT is a measure to support the agreed upon goals and not a goal in itself has been especially important.

- Clarification in regard to financial responsibilities among the affected actors. Alignment of anticipation in regard to the possibility for financial reimbursements when undertaking ICT investments.

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http://www.regjeringen.no/nb/dep/hod/dok/veiledninger_og_brosjyrer/1996/mer-helse-for-hver-bit.html?id=87401�

http://www.regjeringen.no/nb/dep/hod/dok/veiledninger_og_brosjyrer/2001/i-1018-b.html?id=87689�

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http://www.helsedirektoratet.no/publikasjoner/rapporter/s_mspill_2007_quot__ny_strategi_for_elektronisk_samarbeid_i_helse__og_sosialsektoren_5708�




March 31, 2010 28/125

2. United Kingdom

• Name/ Title of the programme: Information for Health



• Origin / Organisation / Authority responsible: Department of Health

• Coordinator: NHS Information Authority

• Availability of the documentation: superseeded

• Budget: circa £200M per year

• Goals: To support local procurement and delivery patient record systems

• Success Factors (as reported by the respondents):

• Good Management • Bottom-Up approach .... “but it could be better!”

7.2.2.3.2 e-Health strategies ended with a failure 1. Serbia

• Name/ Title of the programme: Program for development of Unified Health Information System

• Start Date: 15.11.1995

• End date: 21.7.2009

• Origin / Organisation / Authority responsible: Ministry of Health of Serbia

• Coordinator: Republic Institute for Public Health

• Availability of the documentation:

• Goals: 'Development and implementation subprograms for Establishment of Unified Health Information System’

• Reasons for Failure (as reported by the respondents):

• Management Failure

2. Denmark

• Name/ Title of the programme: National Strategy for the Health Care Sector


• End date: 2007


March 31, 2010 29/125


• Coordinator: Shared between National Board of Health and the Danish Regions

• Budget: finally not allocated

• Goals: Paperless EHR in 2005, national EHR model


• Insufficient funding • Top-Down approach • No use of standards • Competing projects

3. France

• Name/ Title of the programme: Implementation of DMP (Personal Medical Record)


• End date: 2008 (interrupted)


• Coordinator: GIP DMP

• Goals: To implement a digitized personal medical record for each beneficiary of the national health insurance (about 50 million)


• Insufficient funding • Top-Down approach • Politically driven project • Other: Problem of interoperability with the professional softwares, unrealistic

schedule (+++), lack of stakeholder involvement, lack of ancillary services; lack of some legal supports

7.2.2.4 Comments added by the respondents The comments were provided by the national respondents and are taken as they were collected in the National Surveys.

o Even it was not a strategy, MoH had, since 1971, structures and contracts for IT applications. In 1974 a database with all healthcare units and all physicians in Romania was in use, currently updated and used for decisions at central and sometimes county level. The application, with many changes, is still in use. The next step was a file with the more expensive equipments to plan further endowment, national registers for chronic diseases and statistical tables. The success of these applications was due mainly to the successful top-down approach and to the willingness of the MoH top management.


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In eighties the first hospital information systems were implemented. In the nineties the disappearance of the previous pyramidal state owned system, the decentralization, privatization and the use of PCs not connected to a central server disorganized the healthcare IT environment. (RO)

7.2.3 Details about the (actual) e-Health strategy, more especially related to EHR systems (Q6)

This section contains a number of questions regarding EHR implementation related aspects of the actual e-Health strategies, covering domains like implementation approach, supplier support and/or user incentives.

7.2.3.1 Does the strategy include an EHR implementation policy and action plan?

7.2.3.1.1 The Overall Results

If yes, at what level:


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The questionnaire offered the following possibilities regarding the EHR implementation policy and action plan:

• At hospital level • For physician’s practices • Regarding the Personal EHR (at patient level) • Other, enabling the respondent to provide some more information.

Five respondents selected more than one possibility and even completed them by describing implementation strategies related to kinds of shared EHR systems, considering the Patient Summary as an instance of an EHR. Respondents who filled in ‘Other’:

“The strategy envisions that the EHR framework will exist at a national level. Given the relatively small size of the Irish population the issues experienced in other larger European counties should be avoided. In practical terms the EHR framework is likely to be hosted on a regional basis (4 locations with a virtual environment to share data).

Respondent 1 for Ireland

The framework will be updated by transaction sets from: • The Acute hospitals (which have different application vendor portfolios) • Primary care GP’s • Other Community based care providers • Long term and residential care providers This will take place on a phased basis.”

“Home care/primary care.” Respondent 2 for Norway

Respondent 3 for the Slovac Republic


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“Key elements of the informatization of the Slovak Health care are: • National Health Information system • National Health portal for professionals and laymen • Network – communication of HCPs with the international interoperability • Introduction of the use of Personal electronic cards for patients and health professionals • Electronic multimedia Health documentation with the aim of the application of optimal clinical procedures • Telemedicine • ePrescription and eMedication • IS of home health and social care • Knowledge advisory and expert systems for clinicians and management • Development and introduction of systems for illness prevention, and support of Public Health status • Introduction of systems for evaluation and guidelines of clinic procedures security and quality, • Certification of the clinical guidelines, • Application of international ICT standards for eHealth • Introduction of the university level education and trainings in medical and health informatics”

“A nationwide EHR system named “ELGA” will be developed. All hospitals, primary care physicians, pharmacies and dentists having contracts with the social security system will be connected over a national EHR system. The patients shall also receive access to the system.”

Respondent 4 for Austria

“National level (Digitalisation of the health sector).” Respondent 5 for Denmark

7.2.3.1.2 Comments added by the respondents The comments were provided by the national respondents and are taken as they were collected in the National Surveys. The comments are related to the question “Does the strategy include an EHR implementation policy” with as answer “no” • General EHR implementation guidelines were included and followed by the Estonian eHealth Foundation:

- Reuse as much as possible the existing IT services - X-road for secure data change - Estonian ID card for authentication - Minimal changes in the healthcare providers side - Cost-effectively adapt to local needs - Central system developed in parallel with hospital integration (EE)

• Under the coordination of the Health Secretary of State it was created in April 2009, a EHR working group comprising several health actors (public and private), professional orders and universities with the mission “to promote the reflexion in this domain [EHR] and to define principles and guidelines that contribute to the specification and lead to the implementation of an EHR system in Portugal”, through the research, identification and discussion of relevant information stemming from case studies and the share of experiences and knowledge among diverse agents in the healthcare domain. Reports on the “state of art” and high level “orientations for the definition of functional and technical requirements” were delivered for public comments. There’s a high level roadmap until 2012, when it is foreseen to have a pilot in place involving Healthcare Centres and Hospitals from the public and private sectors. In the next months, the group will be working on a detailed plan. The results produced by the Work Group will form the basis for the continuity of actions that will ultimately lead to the implementation and nationwide availability of a Portuguese EHR system, prepared for cross-border interoperability. (PT)

7.2.3.1.3 Interpretation The different answers given to this question illustrates some confusion regarding the concept “EHR” within this project. Some respondents clearly interpret “large scale


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implementation of EHR systems” as the implementation of “large scale EHR systems” or “centralised EHR systems” while other respondents are focusing on a broad deployment of interoperable independent information systems. Countries with a large installed base of clinical information systems like Austria, Denmark or Ireland are focusing on “centralised services for sharing patient data”.

7.2.3.2 Is the strategy regarding EHR implementation based on:


‘Other’:

• “We are still developing our requirements strategy for the EHR framework. We will place greater emphasis to conformance to consistent data standards than on the traditional approach of the merits of a specific application package. However it is likely that we will eventually chose one such solution. The main emphasis is achieving interoperable exchange of patient “events” or documents.” (IE)

• “Interoperability with European EHR system” (SK) • “Not defined and ongoing process: small steps and usable solutions” (DK)

7.2.3.2.2 Comments added by the respondents

• The system will be based on the IHE-XDS framework with a central registry holding metadata and links to the actual documents, which will reside at local repositories. (AT)

• Central spine and local systems (UK)

7.2.3.2.3 Interpretation Four countries only are reporting a “unique centralised system”: Romania, Estonia, Cyprus and France. France’s answer is clearly related to a centralised implementation of the “personal health record” and not primarily related to the professional EHR. Cyprus and Romania are in a early stage of implementation and might well consider such a central EHR system. We could not conclude that a central patient summary isn’t what they intended.


March 31, 2010 34/125

7.2.3.3 Is there a support foreseen to the suppliers for the development of the EHR systems?


If yes, amount per supplier or globally:

7.2.3.3.2 Comments added by the respondents The United Kingdom made a comment that each contract has his proper funding attached. This not be considered as “support” for the suppliers but a price for products/services. (UK)

7.2.3.3.3 Interpretation Financial or other support to the suppliers of EHR system is even not under discussion in most of the countries.


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7.2.3.4 Are there incentives for the users of EHR systems?


If yes, what (e.g. funding, training, ...):

• “Trainings (e.g. The training sessions held in the framework of the Ministry of Social Affairs led project User Training on National Paperless Health Information System” (EE)

• “The main incentives is that the HSE has a process to encourage business users ( clinicians/administrators etc.) to articulate proposal for solutions within the context of an overarching strategy. This promotes inter agency collaboration (strengths in numbers) while allowing arguments for exceptions. Funding is handled on a shared basis, with HSE paying for all nationally approved solutions. Local agencies then have to find funds for local needs or other unique requirements.” (IE)

• “Training” (SB) • “Training (partially funding by Health Insurance)” (SI) • “Financial incentive for physicians making use of a Quality Labeled EHR system (810

Euro/year)” (BE) • “Training (within the auspices of Community Support Frameworks)” (GR) • “Central funding for core solutions” (UK)

7.2.3.4.2 Comments added by the respondents Two of the countries reporting that no incentives are in place actually indicate that such incentives are considered in the near future. (AT)(DK)

7.2.3.4.3 Interpretation A large majority of the countries are providing incentives to the users of EHR systems, mostly related to support training in the use of the e-Health and/or EHR applications.


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7.2.3.5 If yes, do these incentives require that the EHR system has been quality labelled?


7.2.3.5.2 Interpretation Most of the countries did not answer that question. They should be considered as “NO” answers. The concept of quality labelling may still need to be sold to them. There is – up to now - no convincing link between incentives for the users and quality labelling of the EHR systems. This might be due to the small number of countries with quality labelling.

7.3 Actual status regarding the use of EHR systems

7.3.1 At your knowledge, what is the penetration of EHR systems for clinical use? (Q7)

7.3.1.1 The Overall Results A distinction was made between primary or ambulatory care (including privately practicing medical specialists), hospital care, paramedics care and home care.


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7.3.1.1.1 In primary / ambulatory care

These figures have to be interpreted considering the comments given by the respondents and considering that we clearly requested the penetration of EHR systems for clinical use.

The following comments were added to these figures: • Approximately 10% of health care service providers are processing/exchanging documents in the

electronic health record systems. NB. There are total of 18719 health care service providers (5633 physicians, 1494 dentists, 604 midwives, 11006 nurses) in Estonia. (Source: Estonia’s Health Care Board Register). Currently 3402 health care service providers (includes all employees) are processing/exchanging documents in the Health Information System (Source: Estonian eHealth Foundation). (EE)

• 80% of GP practices have PC systems installed. However the proportion that actively use these for clinical management is much lower. (IE)

• All GPs have a personal computer (MoH gave in 2008 11000 laptops, one to each GP; a free endowment). It is expected all of them have some patient data on their computers, because of the “per capita” payment of GPs. In ambulatory care the number of physicians having their patient data on EHR is not too high, but we have no figures. (RO)

• In primary / ambulatory care => About 70% of Austrian GPs use an EHR system that stores medical data such as diagnoses (http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/gp_survey_final_report.pdf page 29). I don’ t know of a statistics that distinguishes between GPs and specialists, public and private. (AT)

• Currently there is a multiplicity of experiences in what concerns Electronic Clinical Files, which have had positive results, even at a regional or local scope. Some of these, developed under the Ministry of Health or coming from I&D projects in universities are:

o Supplier Product Applies to ACSS SAM-H (application to support the daily physician activity) Hospitals ACSS SAM-CS (application to support the daily physician activity) Primary healthcare

institutions ACSS SAPE (application to support the daily nurse activity) Nursing (at Hospital and

Healthcare centres) FMUP ICU Hospital H. S. Sebastião Medtrix Hospital


March 31, 2010 38/125

University of Minho AIDA PCE Hospitals Aveiro Digital Telematic Health Network (RTS) - Regional Electronic Clinic File Regional

Network Açores Digital SIS-ARD Regional Network Sistema Regional de Saúde Região Autónoma da Madeira Processo Clínico Electrónico Único Regional Network

o Processo Clínico Electrónico Único (Sistema Regional de Saúde – Região Autónoma da Madeira): The implementation of the Unique Clinical Electronic Process came under the Madeira Digital Program (Madeira island) and aimed to record in electronic format all the information related to clinical observation, diagnosis and treatment of patients.

o Telematic Health Network – Aveiro: Summarized “Regional Electronic Clinic File” (RECF) that combines patient’s clinical information, which derives from various sources of clinical information, geographically distributed throughout the region’s various healthcare institutions. (PT)

7.3.1.1.2 In hospital care The questionnaire offered different choices regarding the use of EHR system in hospital care:

• No centralised EHR, with most clinical departments with departmental systems (5 countries with a penetration of 90% in UK, 76% in RO and 50% in IE, main option in SB and most hospitals in BE)

• A centralised EHR (kernel, summary,…) with departmental EHR systems (interactive/duplication) (4 countries with a penetration of 20% in SI and 8% in UK, the predominant model in Austria and in the largest hospital in BE)

• One central EHR per hospital (8 countries with penetration of 100% in NO, 60% in DK, 70% in SI, 30% in FR). The Slovac Republic précised that most hospitals have their own EHR system.

Hereby some comments provided by the respondents:

• Approximately 8% of acute hospitals have an integrated portfolio of applications that build a foundation for an integrated clinical record. About 50% of agencies have one or more applications. (IE)

• 100% (several partial/specialist information systems exist in departments, in addition to the hospital-wide EHR) (NO)

• Almost all hospitals have their own interne electronic information system. (SK) • In Romania all patients in all public hospitals are counted with their diagnosis and main services, in a DRG

system reporting to the health insurance houses. A survey (not yet published) done by CNOASIIDS at the end of 2008 gave that 76% of the hospitals have computerized patient data in clinical departments, centralised mainly at department level. There are few examples with a system centralised at the hospital level. Upon the same survey, 53% of the physicians in hospitals use currently the IT equipment. (RO)

• In hospital care => I don’t know of a corresponding statistics. I would say practically all hospitals in Austria use EHR systems, although in most hospitals there is still a mixture of paper-based and electronic health documentation. Mostly there should be centralised EHR systems, which are sometimes accompanied with additional departmental systems. (AT)

• 90% (if by EHR we include patient administration, laboratory, etc.) (UK)

7.3.1.1.3 In paramedics care Only three countries provided figures: United Kingdom (50%), Belgium (over 50% but mainly for administrative purposes) and France indicated 0%. Ireland, Slovakia and Romania indicated “very few” systems in use.

7.3.1.1.4 In home care Denmark indicated 100% use of a care EHR, Slovakia 83%, Belgium over 75% (for administrative purposes mainly), United Kingdom 5%. Very limited but no quantified use in Ireland and Romania. No use at all in France and Slovenia.


March 31, 2010 39/125

7.3.1.2 Interpretation Facts are what they are. More precise or accurate figures might be available on the market. There is still some work to do, more especially in hospital care, paramedical care and home care, in most of the countries.

7.3.2 What is the approximate penetration of PEHR (Personal Electronic Healthcare Record) systems? (Q8)

7.3.2.1 The Overall Results 10 respondents answered 0%, less than 1% or “not applicable”. The other respondents provided some comments rather than a figure indicating a percentage of use of PEHR systems. Analysing these comments leads to the same conclusion.

7.3.2.2 Comments added by the respondents • “At the moment PEHR are tested in several projects, mostly in hospital care.” (NO) • “Pilot project on use of PEHR is under the preparation, it could start in September – October 2009” (SK) • “I don’t know of a corresponding statistics. PEHRs are more or less just upcoming in Austria, I would assume

that less than 1 % of the population uses a PEHR currently.” (AT) • “Unclear how to answer this. There is approximately a 40% penetration of EHR systems in the public sector.

No estimate is available for the private sector.” (CY) • “IZIP system - the only representative of countrywide available Patient Health Record - registers over

1.000.000 Czech citizens (of 10.000.000 entire country population) and over 9.000 health care professionals (of approx. 40.000 of country total) as users”. (CZ)

• “Minimal” (GR) • “Very small. The Health space initiative is live and allows citizens to make their own records and also to

access their national summary. The initiative is popular, but still in pilot form” (UK)

7.3.2.3 Interpretation The penetration of PEHR (Personal Electronic Health Records) is either “not applicable”, 0% or less than 1%. None of the countries reported a substantial, take up of these systems. Some countries are reporting “pilot projects”. There seems also to be some confusion between “personal subsets” or “personal views” on professional (hospital) records, or “centralised copies of parts of the


March 31, 2010 40/125

7.4 About education in the use of Health IT The purpose of the next four questions is to investigate the actual status regarding the education in the use of Health IT. Education is considered as an important factor for the acceptance of health IT as well as for the quality of use of that Health IT. Aspect regarding when/where that education is given, regarding its mandatory status and who pays for it are also addressed in the next questions.

7.4.1 Is there an education and training program in the use of IT in general? (Q9)

This question addresses IT education and training in general, not specifically linked to healthcare.


In the schools (before university or specific health professional education)

In the university / specific educational curriculum


March 31, 2010 41/125

7.4.1.2 Comments added by the respondents • Yes: Many Irish schools have ICT facilities and learning programs. (IE, regarding non university schools) • Yes – but on specific courses. There is a range of university based courses. There are also vocational training

courses developed in collaboration with the Irish computer Society. This program is called “HITS” (Health Informatics Training System. This is a broad spectrum foundation course in informatics for health professionals. (IE, regarding university level education)

• provided in school but to my knowledge they are optional (AT, regarding non university level) • In most university studies there are IT courses, in some of them also mandatory (e.g., informatics, medicine)

(AT, regarding university level education)

7.4.1.3 Interpretation Education and training in the use of information technology (IT) is largely available in 80 to 90% of the countries. IT education in general is mandatory before reaching university level in two on three reported countries, while in majority optional at university level. This may indicate that the more we have mandatory IT education and training before reaching the university, the less that education is considered as mandatory at university level.

7.4.2 Is there an education and training program in the use of specific IT applications for healthcare? (Q10)

This question addresses the issue of specific education and training in health related IT applications (in general, not including specific EHR system training).

7.4.2.1 The Overall Results In the university / specific educational curriculum


March 31, 2010 42/125

Integrated / accepted as part of the postgraduate / continuous education

7.4.2.2 Comments added by the respondents • Planned - there is concept of training program at universities (SK, for the university level) • Several mandatory IT courses in the medicine curriculum (AT, mandatory at university level) • It is being progressively introduced. In some courses like Nursing it is already included in the curricula. (CZ,

university level)

7.4.2.3 Interpretation Education and training in Health IT applications is yet largely available in 65% of the countries, either during the curriculum and/or as part of the postgraduate / continuous education. Education and training in Health IT applications is only mandatory during the university curriculum in one on four of the countries. This looks like an important obstacle for the intense professional use of IT applications by the future health professionals.


March 31, 2010 43/125

7.4.3 Is there training in the registration (coding) and the processing of clinical data provided? (Q11)

7.4.3.1 The Overall Results In the university / specific educational curriculum

Integrated / accepted as part of the postgraduate / continuous education

7.4.3.2 Comments added by the respondents • No: but we are working on it (UK, postgraduate as well as university level) • Some elements of informatics training included in specialist registrar training. (IE) • There are several mandatory courses in the medicine curriculum (e.g., statistical analysis of clinical data) (AT,

optional at university level) • In what concerns the International Classification for Nursing Practice, it is mandatory for all Nursing curricula.

It has been used the version 1.0, but version 2.0 is already translated and starting to be used in the very near future. (PT)


March 31, 2010 44/125

• International Classification of Diseases is part of some curricula. Although, even in the courses in which the codification is not included, in general there’s information available about it for students knowledge. (PT)

7.4.3.3 Interpretation Specific education and training in data capture of clinical data, in processing clinical data and in the use of clinical coding schemes seems largely available in the reported countries. There are even more countries mentioning a mandatory training and education in these skills than in using health IT applications in general. Structuring and coding clinical data indeed applies also to paper based record keeping.

7.4.4 Is there training in the use of the healthcare professional's own application? (Q12)

This question intended to investigate specific training in the use of EHR systems, more especially on who provide that training and at what (financial) conditions.


7.4.4.2 Comments added by the respondents

• Training in application usage is generally provided to all staff who require it by their employer organisation. Some set up training may be provided by vendors GP trainers are employed to deliver training to their colleagues. But the actual training is free of charge. (IE)

• Funded by Community Support Frameworks. (GR) • Often paid for by the National Programme, but free to the end user. (UK) • Normally, the supplier gives in the contract also some training how to use the specific applications. If it is

a greater project, the “train the trainer” approach is used. (RO) • I assume that this is a typical service provided by the application suppliers. (AT)


March 31, 2010 45/125

• There is a Concept of development of eHealth Learning in frame of Postgraduate education (Slovak Health University – for practicing health care professionals), Universities level for student of medical science, Health education for IT professionals with participation of industry (firms of IT technologies). (SK)

• In the future (FR)

7.4.4.3 Interpretation Application specific training seems largely available, for free as well as to be paid. For free training is mentioned 22 times, to be paid 9 times. Most support is provided “for free” by:

• the suppliers of the systems (8 times) as a mandatory service included in the service agreement..

• the employer, e.g. the hospital or the employing health organisation (8 times) • user clubs or similar organisations (3 times).


March 31, 2010 46/125

8 About the importance of Social, Political and Cultural issues related to large scale implementation of EHR systems (Q13-Q44)

8.1 How important are the use of EHR systems and sharing of patient data for the public health (Q13-Q15)

These questions relate to “public health”. How important are EHR systems for “public health” and for what? How important is sharing of patient data for “public health” and for what?

8.1.1 Improvement of the health system (Q13)



March 31, 2010 47/125

Access to care * Improvement of the health system Cross tabulation

Improvement of the health system

Total Very important Important

Access to care No access to secondary

care without previous

access to primary care

Count 6 0 6

% within Access to care 100,0% ,0% 100,0%

Free access to primary as

well as to secondary care

Count 3 3 6

% within Access to care 50,0% 50,0% 100,0%

Free access to primary care,

limited access to secondary

care

Count 3 2 5


Total Count 12 5 17


Payment of the healthcare professionals * Improvement of the health system Cross tabulation

Improvement of the health system


Payment of the healthcare

professionals

Non-employed status (fee-

for-service, contractual flat

fee, or combination of both)

Count 7 5 12

% within Payment of the

healthcare professionals

58,3% 41,7% 100,0%

Employed status Count 5 0 5



100,0% ,0% 100,0%

Total Count 12 5 17



70,6% 29,4% 100,0%


March 31, 2010 48/125

8.1.1.2 Comments added by the respondents No comments provided by the respondents.

8.1.1.3 Interpretation All respondents (100%) consider that EHR systems and that sharing of patient are very important / important in order to improve the performance of the health system as a whole. There is a difference between the countries with no free access to secondary care (excepted emergencies) and the other countries. All countries without free access consider this as very important, while that percentage drops to 60% in countries with “limited” access and 50% in countries with “full free” access. The same difference is found between the countries with “employed” healthcare professionals (100%) and the other countries (fee-for-service, capitated or a combination of both) with on 58% considering this as “very important”.

8.1.2 Decrease of the public health related costs (Q14)



March 31, 2010 49/125

Access to care * Decrease of the public health related costs Cross tabulation

Decrease of the public health related costs

Total Very important Important Not important No opinion




Count 3 2 1 0 6

% within Access to care 50,0% 33,3% 16,7% ,0% 100,0%



Count 1 1 4 0 6




care

Count 2 2 0 1 5

% within Access to care 40,0% 40,0% ,0% 20,0% 100,0%

Total Count 6 5 5 1 17

% within Access to care 35,3% 29,4% 29,4% 5,9% 100,0%

Payment of the healthcare professionals * Decrease of the public health related costs Cross tabulation


March 31, 2010 50/125

Decrease of the public health related costs



professionals




Count 3 4 4 1 12



25,0% 33,3% 33,3% 8,3% 100,0%

Employed status Count 3 1 1 0 5



60,0% 20,0% 20,0% ,0% 100,0%




35,3% 29,4% 29,4% 5,9% 100,0%


8.1.2.3 Interpretation One on three respondents does not consider EHR systems and sharing patient data important in order to reduce “public health” related costs. This is more especially the case in countries with full free access to secondary care. Two on three of these countries are considering this aspect as not important. Only 25% of the countries with self-employed healthcare professionals consider this as very important, 60% of the countries with employed healthcare professionals as standard model.

8.1.3 Other (Q15)

8.1.3.1 The Overall Results Three respondents have provided other criteria, and they were all labelled ‘Very important’:

• Continuity of care


March 31, 2010 51/125

• Easier and better communication between clinicians, clinicians and insurances, easier and more precise billing and accountancy • To improve safety and quality

8.1.3.2 Interpretation These suggestions seem more related to the provision of patient care than related to “public health”.

8.2 What are the large scale use of EHR systems and sharing patient data important for? (Q16-Q19) These questions are related to the care as such. Is the use of EHR systems and/or is sharing patient data, e.g. important to realise continuity of care and/or to improve the quality of the care provided to individual patients?


March 31, 2010 52/125

8.2.1 Quality and continuity of care (Q16)


Access to care * Quality and continuity of care cross tabulation

Quality and continuity of care





Count 5 1 6




Count 5 1 6


Free access to primary care, Count 3 2 5


March 31, 2010 53/125


care


Total Count 13 4 17


Payment of the healthcare professionals * Quality and continuity of care cross tabulation

Quality and continuity of care



professionals




Count 8 4 12



66,7% 33,3% 100,0%




100,0% ,0% 100,0%

Total Count 13 4 17



76,5% 23,5% 100,0%


8.2.1.3 Interpretation 100% of the respondents consider the use of EHR systems and sharing of patient data as very important to important. This was obviously expected. There is a slight difference depending on the mode of payment of the healthcare professionals. All countries with employed healthcare professionals consider this as “very important”. This is only true for two on three respondents of countries with self-employed professionals.


March 31, 2010 54/125

8.2.2 To avoid redundant exams and to reduce costs (Q17)



March 31, 2010 55/125

Access to care * To avoid redundant exams and to reduce costs cross tabulation

To avoid redundant exams and to reduce costs





Count 3 3 6




Count 4 2 6




care

Count 3 2 5


Total Count 10 7 17


Payment of the healthcare professionals * To avoid redundant exams and to reduce costs cross tabulation

To avoid redundant exams and to reduce costs



professionals




Count 5 7 12



41,7% 58,3% 100,0%




100,0% ,0% 100,0%

Total Count 10 7 17



58,8% 41,2% 100,0%


March 31, 2010 56/125


8.2.2.3 Interpretation Two on three respondents consider this aspect of cost savings and reduction of duplication of exams as very important. No one consider it is “not important”. Nothing unexpected. There is once more a difference between the country groups, depending on the mode of payment. 100% of the countries with employed healthcare professionals consider this as very important, while the majority of the countries with self-employed professionals do not consider this as “very important”, but obviously as “important”.

8.2.3 To avoid care induced harm (Q18)



March 31, 2010 57/125

Access to care * To avoid care induced health harm cross tabulation

To avoid care induced health harm





Count 3 3 6




Count 3 3 6




care

Count 3 2 5


Total Count 9 8 17


Payment of the healthcare professionals * To avoid care induced health harm cross tabulation

To avoid care induced health harm



professionals




Count 6 6 12



50,0% 50,0% 100,0%




60,0% 40,0% 100,0%

Total Count 9 8 17



52,9% 47,1% 100,0%


March 31, 2010 58/125


8.2.3.3 Interpretation Half of the respondents consider the use of EHR systems and sharing patient as important, but not as “very important” in order to avoid idiopathic harm to the patient. There is no significant difference between the countries depending on the mode of payment or the degree of free access to secondary care.

8.2.4 To involve the patient in his/her own health(care) (Q19)



March 31, 2010 59/125

Access to care * To involve the patient in his/her own health(care) cross tabulation

To involve the patient in his/her own health(care)

Total Very important Important Not important




Count 1 5 0 6

% within Access to care 16,7% 83,3% ,0% 100,0%



Count 2 3 1 6

% within Access to care 33,3% 50,0% 16,7% 100,0%



care

Count 0 3 2 5

% within Access to care ,0% 60,0% 40,0% 100,0%

Total Count 3 11 3 17


Payment of the healthcare professionals * To involve the patient in his/her own health(care) cross tabulation

To involve the patient in his/her own health(care)



professionals




Count 1 9 2 12



8,3% 75,0% 16,7% 100,0%

Employed status Count 2 2 1 5



40,0% 40,0% 20,0% 100,0%




17,6% 64,7% 17,6% 100,0%


March 31, 2010 60/125


8.2.4.3 Interpretation The involvement of the patient in its own care is clearly the less important argument in favour of the use of EHR systems and/or of sharing patient data. Only 1 of the countries with self-employment healthcare professionals labelled it as “very important”, while 3 countries clearly indicated this as not being an important argument or aspect of the use of EHR systems. Up to 40% of the countries with “free access” to secondary care consider this aspect as “not important”.

8.3 How important are the following issues for the large scale deployment of EHR systems and sharing of patient data? (Q20-Q22)

The survey investigates in these questions the elements that may affect the large scale deployment of EHR systems as well as the large scale sharing of patient’s data. What conditions need to be met in order to enable such applications/ services, more especially the role of the patient enabling those services?

8.3.1 Patient’s trust in sharing patient’s data (Q20)



March 31, 2010 61/125

Access to care * Patient's trust in sharing patient's data cross tabulation

Patient's trust in sharing patient's data





Count 6 0 0 0 6

% within Access to care 100,0% ,0% ,0% ,0% 100,0%



Count 4 2 0 0 6

% within Access to care 66,7% 33,3% ,0% ,0% 100,0%



care

Count 1 2 1 1 5





March 31, 2010 62/125

Payment of the healthcare professionals * Patient's trust in sharing patient's data cross tabulation

Patient's trust in sharing patient's data



professionals




Count 7 4 1 0 12



58,3% 33,3% 8,3% ,0% 100,0%




80,0% ,0% ,0% 20,0% 100,0%



8.3.1.3 Interpretation Patient’s trust is considered as essential for deploying services for patient data sharing. The more the “regulated” system (no free access to secondary care, employed healthcare professionals), the more importance given to this aspect.


March 31, 2010 63/125

8.3.2 Patient’s support for the services (Q21)


Access to care * Patient's support for the services cross tabulation

Patient's support for the services





Count 2 4 0 0 6




Count 3 3 0 0 6




care

Count 0 2 2 1 5

% within Access to care ,0% 40,0% 40,0% 20,0% 100,0%



March 31, 2010 64/125

Access to care * Patient's support for the services cross tabulation






Count 2 4 0 0 6




Count 3 3 0 0 6




care

Count 0 2 2 1 5




Payment of the healthcare professionals * Patient's support for the services cross tabulation




professionals




Count 3 8 1 0 12



25,0% 66,7% 8,3% ,0% 100,0%




40,0% 20,0% 20,0% 20,0% 100,0%




29,4% 52,9% 11,8% 5,9% 100,0%



March 31, 2010 65/125

No comments provided by the respondents.

8.3.2.3 Interpretation Active support of the patients is considered as important, but not as one of the most important aspects. This can interpreted that public opposition or hostility to the services should be avoided. There is no important difference between the countries on the basis of kind of employment or possible restriction of access to secondary care.

8.3.3 Other related issues (Q22)

8.3.3.1 The Overall Results Three respondents have indicated ‘other related issues’. One respondent labelled ‘Access to updated patient-information in the patient treatment i.e. proper information where it is needed, when it is needed and in the right form’ as ‘Very Important’. (NO) Another respondent provided three more issues (GR):

• Healthcare Professionals Involvement (very important) • Suitable Infrastructure (Codifications, National Registries etc) (very important) • Education / Training (important)

Finally, a third respondent labelled ‘Demonstrating benefits for patients (eg access to care, availability of information, prescriptions, etc.)’ as ‘Very important’. (UK)

8.3.3.2 Interpretation There are indeed more issues to be considered.


March 31, 2010 66/125

8.4 How important are the following issues related to the health care professionals for the large scale deployment of EHR systems and sharing of patient data? (Q23-Q27)

The survey is questioning the importance of IT skills, the importance of education and training of the healthcare professionals as favouring or hampering factor for a large scale deployment of EHR systems and for sharing of patient data, as estimated by the healthcare authorities. The survey makes a distinction between general IT skills and specific skills related to health IT on one hand and EHR systems on the other hand.

8.4.1 Acquiring the required skills to use IT in general (Q23)



March 31, 2010 67/125

Access to care * Acquiring the required skills to use IT in general cross tabulation

Acquiring the required skills to use IT in general





Count 3 2 1 6




Count 3 2 1 6




care

Count 1 4 0 5




Payment of the healthcare professionals * Acquiring the required skills to use IT in general cross tabulation

Acquiring the required skills to use IT in general



professionals




Count 4 6 2 12



33,3% 50,0% 16,7% 100,0%




60,0% 40,0% ,0% 100,0%




41,2% 47,1% 11,8% 100,0%


March 31, 2010 68/125


8.4.1.3 Interpretation There is a large consensus in considering general IT skills as an important issue, though not as one of the main issues. This might be due to the yet important efforts done in most of the reviewed countries. Slightly more importance is given by the countries with employed healthcare professionals.

8.4.2 Acquiring the required skills to use Health IT systems and more especially EHR systems (Q24)



March 31, 2010 69/125

Access to care * Acquiring the required skills to use health IT system and more especially EHR systems cross tabulation

Acquiring the required skills to use health IT system and

more especially EHR systems





Count 5 1 6




Count 3 3 6




care

Count 3 2 5


Total Count 11 6 17


Payment of the healthcare professionals * Acquiring the required skills to use health IT system and more especially EHR systems cross tabulation

Acquiring the required skills to use health IT

system and more especially EHR systems



professionals




Count 7 5 12



58,3% 41,7% 100,0%




80,0% 20,0% 100,0%


March 31, 2010 70/125


8.4.2.3 Interpretation Acquiring skills in using health IT systems and in using EHR systems in general scores higher than for the overall skills in IT. Countries with a highly regulated healthcare (employed healthcare professionals, no free access to secondary care) have slightly higher scores for this issue.

8.4.3 Being rewarded for the use of (agreed) EHR systems, e.g. participating in research, etc… (Q25) This question investigates the importance of “indirect advantages” for the healthcare professionals as incentive to make use of health information systems and more especially HER systems. Examples are e.g. participating in research project, feedback and benchmarking, etc…



March 31, 2010 71/125

Access to care * Being rewarded for the use of (agreed) EHR systems, e.g. participating in research, etc... cross tabulation

Being rewarded for the use of (agreed) EHR systems, e.g. participating

in research, etc...





Count 0 5 1 0 6

% within Access to care ,0% 83,3% 16,7% ,0% 100,0%



Count 1 3 2 0 6




care

Count 1 3 0 1 5




Payment of the healthcare professionals * Being rewarded for the use of (agreed) EHR systems, e.g. participating in research, etc... cross tabulation

Being rewarded for the use of (agreed) EHR systems, e.g. participating in research,



professionals




Count 1 8 3 0 12



8,3% 66,7% 25,0% ,0% 100,0%




20,0% 60,0% ,0% 20,0% 100,0%




11,8% 64,7% 17,6% 5,9% 100,0%


March 31, 2010 72/125



8.4.3.3 Interpretation Getting a return on “investment”, a return for the efforts done when using (agreed) EHR systems is expected to be “important” but not a “very important” incentive, and therefore not essential. There is no substantial difference between the countries based on their kind of healthcare system (degree of access to secondary care and/or employment model).

8.4.4 Being financially rewarded for the use of quality labeled EHR systems (Q26)



March 31, 2010 73/125

Payment of the healthcare professionals * Being financially rewarded for the use of quality labelled EHR systems cross tabulation

Being financially rewarded for the use of quality labelled EHR systems



professionals




Count 3 6 0 3 12



25,0% 50,0% ,0% 25,0% 100,0%




,0% 25,0% 50,0% 25,0% 100,0%




18,8% 43,8% 12,5% 25,0% 100,0%

Access to care * Being financially rewarded for the use of quality labelled EHR systems cross tabulation

Being financially rewarded for the use of quality labelled EHR systems





Count 0 4 2 0 6

% within Access to care ,0% 66,7% 33,3% ,0% 100,0%



Count 2 1 0 2 5




care

Count 1 2 0 2 5





March 31, 2010 74/125


8.4.4.3 Interpretation

Financially rewarding the use of labelled EHR systems is not (yet) considered as an important incentive for the use of EHR systems, especially not in countries with employed healthcare professionals and/or a limited access to secondary care.

8.4.5 Other related issues (Q27)

No other related issues have been identified by the respondents.


March 31, 2010 75/125

8.5 How important are, on behalf of the healthcare professionals, the following issues in order to enable sharing and availability of patient data for the healthcare professionals? (Q28-Q32)

The next questions identify issues from the point of view of the healthcare professionals that may hamper clinical or patient data sharing if not addressed properly.

8.5.1 Trustful relations with the health authorities regarding the (re)use of the “shared” healthcare data (Q28)



March 31, 2010 76/125

Access to care * Trustful relations with the health authorities regarding the (re)use of the "shared" healthcare data cross tabulation

Trustful relations with the health authorities regarding the (re)use of the

"shared" healthcare data





Count 3 2 1 0 6




Count 4 2 0 0 6




care

Count 3 0 1 1 5

% within Access to care 60,0% ,0% 20,0% 20,0% 100,0%



Payment of the healthcare professionals * Trustful relations with the health authorities regarding the (re)use of the "shared" healthcare data cross tabulation





professionals




Count 6 4 2 0 12



50,0% 33,3% 16,7% ,0% 100,0%




80,0% ,0% ,0% 20,0% 100,0%




58,8% 23,5% 11,8% 5,9% 100,0%


March 31, 2010 77/125


8.5.1.3 Interpretation Trust regarding possible (ab)use of the “shared” healthcare data are considered as important to very important by the healthcare professionals. No significant differences are noticed between the countries, at least not based on organisational aspects of care.

8.5.2 Cooperative relations between the healthcare professionals, overcoming competition between them (Q29)



March 31, 2010 78/125

Access to care * Cooperative relations between the healthcare professionals, overcoming competition between them cross tabulation

Cooperative relations between the healthcare professionals,

overcoming competition between them





Count 1 5 0 0 6




Count 2 3 1 0 6




care

Count 1 3 0 1 5




Payment of the healthcare professionals * Cooperative relations between the healthcare professionals, overcoming competition between them cross tabulation





professionals




Count 3 8 1 0 12



25,0% 66,7% 8,3% ,0% 100,0%




20,0% 60,0% ,0% 20,0% 100,0%




23,5% 64,7% 5,9% 5,9% 100,0%


March 31, 2010 79/125


8.5.2.3 Interpretation Good professional relations between the different healthcare professionals are considered as an important condition to the successfully implementation of EHR systems and to sharing care, but clearly not as one of the most critical factors. There is no significant difference between the countries based on employment status or on access to secondary care.

8.5.3 Cooperative relations between the healthcare professionals, overcoming competition between them (Q29)



March 31, 2010 80/125

Access to care * Cooperative relations between the healthcare institutes, overcoming competition between them cross tabulation

Cooperative relations between the healthcare institutes, overcoming

competition between them





Count 3 3 0 0 6




Count 2 2 2 0 6




care

Count 1 2 1 1 5




Payment of the healthcare professionals * Cooperative relations between the healthcare institutes, overcoming competition between them cross tabulation





professionals




Count 4 5 3 0 12



33,3% 41,7% 25,0% ,0% 100,0%




40,0% 40,0% ,0% 20,0% 100,0%




35,3% 41,2% 17,6% 5,9% 100,0%


March 31, 2010 81/125


8.5.3.3 Interpretation Good cooperative relations between healthcare institutes, e.g. hospitals, is considered as an important factor for the large scale use of EHR systems and probably more especially for data sharing between the healthcare professionals. This is not the most important issue identified and there is no significant difference between the groups of countries based on employment status or on the kind of access to secondary care regulatory foreseen.

8.5.4 Trust in the sharing of patient data on itself: privacy and security guaranteed (Q30)


Access to care * Trust in the sharing of patient data on itself: privacy and security guaranteed cross tabulation


March 31, 2010 82/125

Trust in the sharing of patient data on itself: privacy

and security guaranteed

Total Very important Important No opinion




Count 6 0 0 6

% within Access to care 100,0% ,0% ,0% 100,0%



Count 4 2 0 6




care

Count 4 0 1 5

% within Access to care 80,0% ,0% 20,0% 100,0%



Payment of the healthcare professionals * Trust in the sharing of patient data on itself: privacy and security guaranteed cross tabulation

Trust in the sharing of patient data on itself: privacy

and security guaranteed

Total Very important Important No opinion


professionals




Count 10 2 0 12



83,3% 16,7% ,0% 100,0%




80,0% ,0% 20,0% 100,0%




82,4% 11,8% 5,9% 100,0%


March 31, 2010 83/125


8.5.4.3 Interpretation Quite large consensus to consider that on behalf of healthcare professionals trust in privacy and security related issues is one of the most important issues, at least indicated as one of the most important issues. There is no significant difference between the countries depend on organisational issues related to the care.

8.5.5 Involvement of the healthcare professionals in the services (e.g. professional supervision on the services) (Q31)


Access to care * Involvement of the healthcare professionals in the services (e.g. professional supervision on the services) cross tabulation

Involvement of the healthcare professionals in the services (e.g.

professional supervision on the services) Total


March 31, 2010 84/125

Very important Important Not important No opinion




Count 2 3 0 0 5




Count 3 1 1 1 6




care

Count 3 0 0 2 5

% within Access to care 60,0% ,0% ,0% 40,0% 100,0%



Payment of the healthcare professionals * Involvement of the healthcare professionals in the services (e.g. professional supervision on the services) cross

tabulation


professional supervision on the services)



professionals




Count 5 3 1 2 11



45,5% 27,3% 9,1% 18,2% 100,0%




60,0% 20,0% ,0% 20,0% 100,0%




50,0% 25,0% 6,3% 18,8% 100,0%


March 31, 2010 85/125



8.5.5.3 Interpretation Involvement of the healthcare professionals in the design / exploitation / supervision of the EHR related services and/or of services of sharing patient data are consider as very important to important. This issue is not a top issue to be addressed.

8.6 What do the national authorities consider as important issues favouring a large scale deployment of EHR systems? (Q33-Q44)

The next set of questions lists important issues for a large scale deployment of EHR systems, from the point of view of the healthcare authorities. What do they consider as important, most important elements / risks for such a large scale deployment of EHR systems? Most of the issues addressed are obviously important, but it may be interesting to rank each of them. There might be some differences in appreciation between the issues and also between the countries for the same issues.


March 31, 2010 86/125

8.6.1 A clear vision on e-Health, before defining a strategy and implementation policy (Q33)



March 31, 2010 87/125

Access to care * A clear vision on e-Health, before defining a strategy and implementation policy cross tabulation

A clear vision on e-Health, before defining a

strategy and implementation policy

Total very important important




Count 5 1 6




Count 3 3 6




care

Count 3 2 5


Total Count 11 6 17


Payment of the healthcare professionals * A clear vision on e-Health, before defining a strategy and implementation policy cross tabulation

A clear vision on e-Health, before defining a

strategy and implementation policy



professionals




Count 6 6 12



50,0% 50,0% 100,0%




100,0% ,0% 100,0%

Total Count 11 6 17



64,7% 35,3% 100,0%


March 31, 2010 88/125



8.6.1.3 Interpretation A clear vision on e-Health, before even starting to define a concrete strategy and an action plan, is considered as “very important” by all the countries with a more regulated health care (employed healthcare professionals). This is only the case for 50% of the other countries.

8.6.2 A clear and consistent legal context, more especially regarding professional responsibility when sharing patient data (Q34)



March 31, 2010 89/125

Access to care * A clear and consistent legal context, more especially regarding professional responsibility when sharing patient data cross tabulation

A clear and consistent legal context, more especially regarding

professional responsibility when sharing patient data

Total very important important not important




Count 5 1 0 6




Count 5 0 1 6




care

Count 4 1 0 5





March 31, 2010 90/125


8.6.2.3 Interpretation

As expected, also a consistent legal framework regarding professional responsibility when sharing patient data is considered as very important, in all the countries, one excepted (DK), may be because yet available and not anymore an issue.

Payment of the healthcare professionals * A clear and consistent legal context, more especially regarding professional responsibility when sharing patient

data cross tabulation





professionals




Count 9 2 1 12



75,0% 16,7% 8,3% 100,0%




100,0% ,0% ,0% 100,0%




82,4% 11,8% 5,9% 100,0%


March 31, 2010 91/125

8.6.3 Direct involvement of the healthcare professionals in the design and program definition (Q35)


Access to care * Direct involvement of the healthcare professionals in the design and program definition cross tabulation

Direct involvement of the healthcare professionals

in the design and program definition





Count 6 0 6




Count 5 1 6



March 31, 2010 92/125



care

Count 3 2 5


Total Count 14 3 17


Payment of the healthcare professionals * Direct involvement of the healthcare professionals in the design and program definition cross tabulation

Direct involvement of the healthcare professionals in

the design and program definition



professionals




Count 9 3 12



75,0% 25,0% 100,0%




100,0% ,0% 100,0%

Total Count 14 3 17



82,4% 17,6% 100,0%


8.6.3.3 Interpretation Direct involvement of the healthcare professionals in the design and program definition is considered as very important. The more the healthcare system has been “regulated” (employed healthcare professionals, , slightly less in countries with independent (non employed) healthcare professionals.


March 31, 2010 93/125

8.6.4 A clear and consistent legal context, more especially regarding security and privacy when sharing patient data (Q36)



March 31, 2010 94/125

Access to care * A clear and consistent legal context, more especially regarding security and privacy when sharing patient data cross tabulation

A clear and consistent legal context, more especially regarding security and

privacy when sharing patient data





Count 6 0 6




Count 5 1 6




care

Count 4 1 5


Total Count 15 2 17


Payment of the healthcare professionals * A clear and consistent legal context, more especially regarding security and privacy when sharing patient data cross tabulation


security and privacy when sharing patient data



professionals




Count 10 2 12



83,3% 16,7% 100,0%




100,0% ,0% 100,0%

Total Count 15 2 17



88,2% 11,8% 100,0%


March 31, 2010 95/125


8.6.4.3 Interpretation A clear and consistent legal framework regarding security and privacy is one of the top scores in this survey: 100% “very important” for the countries with employed healthcare professionals and/or no free access to secondary care.

8.6.5 The quality and reliability of the EHR systems for use by the healthcare professionals (Q37)



March 31, 2010 96/125

Access to care * The quality and reliability of the EHR systems for use by the healthcare professionals cross tabulation

The quality and reliability of the EHR systems for

use by the healthcare professionals





Count 5 1 0 6




Count 4 1 1 6




care

Count 2 3 0 5




Payment of the healthcare professionals * The quality and reliability of the EHR systems for use by the healthcare professionals cross tabulation

The quality and reliability of the EHR systems for

use by the healthcare professionals



professionals




Count 6 5 1 12



50,0% 41,7% 8,3% 100,0%




100,0% ,0% ,0% 100,0%




64,7% 29,4% 5,9% 100,0%


March 31, 2010 97/125


8.6.5.3 Interpretation The quality and the reliability of EHR systems is largely accepted as being an important success factors for the deployment of those systems as well as for “sharing patient”. The more important the role of the authorities in the healthcare, the more regulated the healthcare, the more importance is given to this issue.

8.6.6 The quality of the content of an EHR and indirectly the quality of registration by the healthcare professional (Q38)

This question does not address the quality of the systems but the quality of their content, indirectly how these systems are used by the healthcare professionals. A good system only used partially or not as expected will result in poor quality of the content. This has a negative impact on data sharing. This issue is related to the need for specific training and education.


March 31, 2010 98/125


Access to care * The quality of the content of an EHR and indirectly the quality of registration by the healthcare professional cross tabulation

The quality of the content of an EHR and indirectly the quality of

registration by the healthcare professional

Total very important important not important no opinion




Count 5 1 0 0 6




Count 3 1 1 1 6


Free access to primary care, Count 2 3 0 0 5


March 31, 2010 99/125


care




Payment of the healthcare professionals * The quality of the content of an EHR and indirectly the quality of registration by the healthcare professional cross

tabulation





professionals




Count 6 4 1 1 12



50,0% 33,3% 8,3% 8,3% 100,0%




80,0% 20,0% ,0% ,0% 100,0%




58,8% 29,4% 5,9% 5,9% 100,0%

8.6.6.2 Comments added by the respondents No comments provided by the respondents. 8.6.6.3 Interpretation The number of votes considering the quality of the EHR systems and subsequently the quality of the patient data registration as not important is very low (1 only). There is nevertheless a difference in evaluation between the countries: the more regulated countries (no free access to secondary care, employed healthcare professionals) the more they consider this as a critical factor. This does not mean that the latter ones does not consider it as important, but may be not really as an “issue” or problem.


March 31, 2010 100/125

8.6.7 The availability and the continuity of funding for implementation of eHealth and large scale EHR implementation (Q39)


Access to care * The availability and the continuity of funding for implementation of eHealth and large scale EHR implementation cross tabulation

The availability and the continuity of funding for implementation of

eHealth and large scale EHR implementation





Count 4 2 0 6


Free access to primary as Count 3 3 0 6


March 31, 2010 101/125

well as to secondary care % within Access to care 50,0% 50,0% ,0% 100,0%



care

Count 2 2 1 5




Payment of the healthcare professionals * The availability and the continuity of funding for implementation of eHealth and large scale EHR implementation cross tabulation

The availability and the continuity of funding for implementation of eHealth

and large scale EHR implementation



professionals




Count 5 6 1 12



41,7% 50,0% 8,3% 100,0%




80,0% 20,0% ,0% 100,0%




52,9% 41,2% 5,9% 100,0%


8.6.7.3 Interpretation Funding is important but is not considered by the healthcare authorities as one of the most important factors influencing the large scale implementation of EHR systems.


March 31, 2010 102/125

8.6.8 The availability of a consistent and comprehensive infostructure for the large scale implementation of the EHR-systems (identification services, access management services, time stamping, ...) (Q40)

The info-structure is defined here as a number of information management related tools and/or services, that should be available and used consistently by the different EHR systems.


Access to care * The availability of a consistent and comprehensive infostructure for the large scale implementation of the EHR-systems (identification services, access

management services ,time stamping, ...) cross tabulation

The availability of a consistent and comprehensive infostructure for the large

scale implementation of the EHR-systems (identification services, access

management services ,time stamping, ...)


Access to care No access to secondary Count 5 1 0 6


March 31, 2010 103/125






Count 5 0 1 6




care

Count 2 3 0 5




Payment of the healthcare professionals * The availability of a consistent and comprehensive infostructure for the large scale implementation of the EHR-systems

(identification services, access management services ,time stamping, ...) cross tabulation

The availability of a consistent and comprehensive infostructure for

the large scale implementation of the EHR-systems (identification

services, access management services ,time stamping, ...)



professionals




Count 7 4 1 12



58,3% 33,3% 8,3% 100,0%




100,0% ,0% ,0% 100,0%




70,6% 23,5% 5,9% 100,0%



March 31, 2010 104/125

8.6.8.3 Interpretation These services and tools are considered as important for the success of any large scale deployment of EHR systems, more especially in countries with employed healthcare professionals and also more explicitly in countries with no free access to secondary care.

8.6.9 Health IT specific education and training (Q41)



March 31, 2010 105/125

Access to care * Health IT specific education and training cross tabulation

Health IT specific education and training





Count 1 5 0 6




Count 0 5 1 6

% within Access to care ,0% 83,3% 16,7% 100,0%



care

Count 2 1 2 5




Payment of the healthcare professionals * Health IT specific education and training cross tabulation

Health IT specific education and training



professionals




Count 1 8 3 12



8,3% 66,7% 25,0% 100,0%




40,0% 60,0% ,0% 100,0%




17,6% 64,7% 17,6% 100,0%


March 31, 2010 106/125


8.6.9.3 Interpretation Education and training related to Health IT is not considered as one of the crucial factors when deploying EHR systems. This is clearly especially the case for countries with “independent” healthcare professionals.

8.6.10 An intense private/public cooperation (Q42)



March 31, 2010 107/125

Access to care * An intense private/public cooperation cross tabulation

An intense private/public cooperation





Count 2 2 1 1 6




Count 0 3 1 2 6




care

Count 1 2 1 1 5




Payment of the healthcare professionals * An intense private/public cooperation cross tabulation

An intense private/public cooperation



professionals




Count 1 4 3 4 12



8,3% 33,3% 25,0% 33,3% 100,0%




40,0% 60,0% ,0% ,0% 100,0%




17,6% 41,2% 17,6% 23,5% 100,0%


March 31, 2010 108/125


8.6.10.3 Interpretation The importance of private/public cooperation for the large scale deployment of EHR systems is considered as important, though with an important number of countries considering this element as less crucial. This seems to be especially true for countries with independent healthcare professionals and free access to secondary care. This might be interpreted as that “public” involvement should be avoided or even that this cooperation yet exists. This is then not anymore an issue neither.

8.6.11 A simultaneous and coordinated approach, national and European (e.g. for interoperability) (Q43)



March 31, 2010 109/125

Access to care * A simultaneous and coordinated approach, national and European (e.g. for interoperability) cross tabulation

A simultaneous and coordinated approach, national

and European (e.g. for interoperability)





Count 5 1 0 6




Count 3 2 1 6




care

Count 3 0 2 5





March 31, 2010 110/125

Payment of the healthcare professionals * A simultaneous and coordinated approach, national and European (e.g. for interoperability) cross tabulation

A simultaneous and coordinated approach, national and

European (e.g. for interoperability)



professionals




Count 6 3 3 12



50,0% 25,0% 25,0% 100,0%




100,0% ,0% ,0% 100,0%




64,7% 17,6% 17,6% 100,0%


8.6.11.3 Interpretation The more publically dominated care (employed healthcare professionals, no free access to secondary care) the more importance is given to a coordinated national and European approach. 8.6.12 Other No other remarks have been provided by the respondents.


March 31, 2010 111/125

9 Overview of the results for Question 13 to Question 44

Very

important

Important Not

important

No

opinion

How important are the use of EHR systems and sharing of patient data for the public health?

Improvement of the health system 70,6% 29,4% ,0% ,0%

Decrease of the public health related costs 35,3% 29,4% 29,4% 5,9%

What are the large scale use of EHR systems and sharing patient data important for?

Quality and continuity of care 76,5% 23,5% ,0% ,0%

To avoid redundant exams and to reduce costs 58,8% 41,2% ,0% ,0%

To avoid care induced health harm 52,9% 47,1% ,0% ,0%

To involve the patient in his/her own health(care) 17,6% 64,7% 17,6% ,0%

How important are the following issues for the large scale deployment of EHR systems and sharing of patient data?

Patient's trust in sharing patient's data 64,7% 23,5% 5,9% 5,9%

Patient's support for the services 29,4% 52,9% 11,8% 5,9%

How important are the following issues related to the health care professionals for the large scale deployment of EHR

systems and sharing of patient data?

Acquiring the required skills to use IT in general 41,2% 47,1% 11,8% ,0%

Acquiring the required skills to use health IT system and more

especially EHR systems

64,7% 35,3% ,0% ,0%

Being rewarded for the use of (agreed) EHR systems, e.g.

participating in research, etc...

11,8% 64,7% 17,6% 5,9%

Being financially rewarded for the use of quality labelled EHR

systems

18,8% 43,8% 12,5% 25,0%

How important are, on behalf of the healthcare professionals, the following issues in order to enable of sharing and

availability

Trustful relations with the health authorities regarding the (re)use

of the "shared" healthcare data

58,8% 23,5% 11,8% 5,9%



23,5% 64,7% 5,9% 5,9%

Cooperative relations between the healthcare institutes,


35,3% 41,2% 17,6% 5,9%

Trust in the sharing of patient data on itself: privacy and security

guaranteed

82,4% 11,8% ,0% 5,9%



50,0% 25,0% 6,3% 18,8%

What do the national authorities consider as important issues favouring a large scale deployment of EHR systems?

A clear vision on e-Health, before defining a strategy and

implementation policy

64,7% 35,3% ,0% ,0%

A clear and consistent legal context, more especially regarding 82,4% 11,8% 5,9% ,0%


March 31, 2010 112/125


Direct involvement of the healthcare professionals in the design

and program definition

82,4% 17,6% ,0% ,0%


security and privacy when sharing patient data

88,2% 11,8% ,0% ,0%

The quality and reliability of the EHR systems for use by the


64,7% 29,4% 5,9% ,0%



58,8% 29,4% 5,9% 5,9%

The availability and the continuity of funding for implementation

of eHealth and large scale EHR implementation

52,9% 41,2% 5,9% ,0%

The availability of a consistent and comprehensive infostructure

for the large scale implementation of the EHR-systems

(identification services, access management services ,time

stamping, ...)

70,6% 23,5% 5,9% ,0%

Health IT specific education and training 17,6% 64,7% 17,6% ,0%

An intense private/public cooperation 17,6% 41,2% 17,6% 23,5%

A simultaneous and coordinated approach, national and

European (e.g. for interoperability)

64,7% 17,6% 17,6% ,0%

10 Ranking of the factors important to EHR deployment and data sharing

An average “weighted score” was calculated of each of the statements, based on 3 points for “very important”, 2 points for “important”, 0 points for “no opinion” and minus 1 for “not important”. Hereby the table with the number of answers per selection, the total score obtained and the ranking for each of the factors.


March 31, 2010 113/125

Very

important

Important Not

important

No opinion

How important are the use of EHR systems and sharing of patient data for the public health?

Improvement of the health system 12 5 46 4

Decrease of the public health related costs 6 5 5 1 23 26

What are the large scale use of EHR systems and sharing patient data important for?

Quality and continuity of care 13 4 47 3

To avoid redundant exams and to reduce costs 10 7 44 9

To avoid care induced health harm 9 8 43 10

To involve the patient in his/her own health(care) 3 11 3 28 23

How important are the following issues for the large scale deployment of EHR systems and sharing of patient data?

Patient's trust in sharing patient's data 11 4 1 1 40 13

Patient's support for the services 5 9 2 1 31 20

How important are the following issues related to the health care professionals for the large scale deployment of EHR systems and sharing of patient data?

Acquiring the required skills to use IT in general 7 8 2 35 18

Acquiring the required skills to use health IT system and more especially

EHR systems

11 6 45 6

Being rewarded for the use of (agreed) EHR systems, e.g. participating in

research, etc...

2 11 3 1 25 25

Being financially rewarded for the use of quality labelled EHR systems 3 7 2 4 21 27

How important are, on behalf of the healthcare professionals, the following issues in order to enable of sharing and availability



10 4 2 1 36 16

Cooperative relations between the healthcare professionals, overcoming


4 11 1 1 33 19



6 7 3 1 29 22

Trust in the sharing of patient data on itself: privacy and security 14 2 1 46 4


March 31, 2010 114/125

guaranteed



8 4 1 3 31 20

What do the national authorities consider as important issues favoring a large scale deployment of EHR systems?

A clear vision on e-Health, before defining a strategy and implementation

policy

11 6 45 6



14 2 1 45 6

Direct involvement of the healthcare professionals in the design and

program definition

14 3 48 2

A clear and consistent legal context, more especially regarding security

and privacy when sharing patient data

15 2 49 1

The quality and reliability of the EHR systems for use by the healthcare

professionals

11 5 1 42 12



10 5 1 1 39 15

The availability and the continuity of funding for implementation of eHealth

and large scale EHR implementation

9 7 1 40 13

The availability of a consistent and comprehensive infostructure for the

large scale implementation of the EHR-systems (identification services,

access management services ,time stamping, ...)

12 4 1 43 10

Health IT specific education and training 3 11 3 28 23

An intense private/public cooperation 3 7 3 4 20 28

A simultaneous and coordinated approach, national and European (e.g. for

interoperability)

11 3 3 36 16


March 31, 2010 115/125

11 Most important social, political and cultural factors We defined the “most important” factors in different ways:

1. The highest percentage of “very important” 2. The highest percentage of “very important” and “important” 3. The statements with the highest “weighted score”.

11.1 Highest percentage “very important”

1. A clear and consistent legal context, more especially regarding security and privacy when sharing patient, from point of view of authorities: 88,2%

2. A clear and consistent legal context, more especially regarding professional responsibility when sharing patient data, from point of view of authorities: 82,4%

Direct involvement of the healthcare professional in the design and progam definition, from point of view of authorities: 82,4% Trust in sharing of patient data on itself: privacy and security guaranteed, from point of view of the healthcare professionals. 82,4%

5. Large scale use of EHR systems and sharing of patient data are important for quality and continuity of care. 76,5%

11.2 Highest percentage “very important” and “important” Nine statements have a 100% percentage “very important” and “important”. They are listed on the basis of the percentage of “very important” answers.

1. A clear and consistent legal context, more especially regarding security and privacy when sharing patient, from point of view of authorities.

2. Direct involvement of the healthcare professional in the design and program definition, from point of view of authorities.

3. Large scale use of EHR systems and sharing of patient data are important for quality and continuity of care.

4. The use of EHR systems and sharing of patient data for public health are important for the improvement of the health system.

5. Acquiring the required skills to use health IT systems and more especially EHR systems are important to realize large scale deployment of EHR systems and to realize sharing of patient data.

11.3 Weighted score

1. A clear and consistent legal context, more especially regarding security and privacy when sharing patient data.

2. Direct involvement of the healthcare professionals in the design and program definition.

3. Large scale implementation of EHR systems and sharing of patient data are important for quality and continuity of care

4. Healthcare professionals should have full trust in the sharing of patient data on itself: privacy and security guaranteed

5. Large scale implementation of EHR systems and sharing of patient data are important for the improvement of the (public) health system


March 31, 2010 116/125

12 Less important social, political and cultural factors We defined the “less important” factors in different ways:

1. The highest percentage of “not important” 2. The highest percentage of “not important” and “no opinion” 3. The lowest percentage as “very important” 4. The lowest average “weighted score”.

Not important does not necessary mean that the issue isn’t important to healthcare but not considered as important to a large scale deployment of EHR systems and to sharing of patient data.

12.1 Highest percentage “not important”

1. Use of EHR systems and sharing of patient data is important to the decrease of the public health related costs. 29,4%

2. An intensive private/public cooperation as an important issue favouring a large scale deployment of EHR systems, from the point of view of the health authorities. 17,6%

3. Being rewarded for the use of (agreed) EHR systems, e.g. by participating in clinical research. 17,6%

4. Cooperative (good) relations between the healthcare institutes, overcoming competition between them, as an important issue to enable sharing and availability of patient data. 17,6%


12.2 Highest percentage “not important” and “no opinion”

1. Being financially rewarded for the use of quality labelled EHR systems, from the point of view of the authorities (regarding the healthcare professionals). 37,5%

2. Intensive private/public cooperation as an important issue favouring a large scale deployment of EHR systems, from the point of view of the health authorities. 41,1%

3. Use of EHR systems and sharing of patient data is important to the decrease of the public health related costs. 35,3%

4. Involvement of the healthcare professionals in the services (e.g. professional supervision on the services) is an important factor. 25,1%

5. Being rewarded for the use of (agreed) EHR systems, e.g. by participating in clinical research. 23,5% Cooperative (good) relations between the healthcare institutes, overcoming competition between them, as an important issue to enable sharing and availability of patient data. 23,5%

12.3 Lowest percentage “very important”


2. Large scale use of EHR systems and sharing patient data is important to involve the patient in his/her own health(care). 17,6% Health IT specific education and training is important for the large scale deployment of HER systems. 17,6%


March 31, 2010 117/125

4. Intensive private/public cooperation as an important issue favouring a large scale deployment of EHR systems, from the point of view of the health authorities. 17,6%

5. Being financially rewarded for the use of quality labelled EHR systems, from the point of view of the authorities (regarding the healthcare professionals). 18,8%

12.4 Lowest weighting scores

1. Health IT specific education and training of healthcare professionals is important for large scale deployment of EHR systems and for sharing of patient data.

2. Being rewarded for the use of (agreed) EHR systems, e.g. participating in research, etc... as a factor influencing success of large scale use of EHR systems and of sharing of patient data.

3. Large scale implementation of EHR systems and sharing of patient is important to decrease of the public health related costs.

4. Healthcare professionals should be financially rewarded for the use of quality labelled EHR systems.

5. An intense private/public cooperation is important for a large scale deployment of EHR systems and for patient data sharing.


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13 Differences between the countries based on “type of access to secondary care”

We regrouped and analysed the answers of the different countries based on the type of access to secondary care. The conditions to be met in order to have access to secondary care are different from country to country: from full free access (without or without important limitation) to no free access at all, except for emergencies. Countries with no free access are more regulated than the more “liberal” systems, especially the ones with full free access. This different approach also affects the way authorities are thinking about the importance of some of the factors on a large scale deployment of EHR systems and on sharing of patient data. Their answers indicate more “absolute” statements regarding some aspects, with up to five statements with 100% “very important” answers, compared to not one single of the other countries. The countries with no free access to secondary care have only five statements with less than 100% for “very important” plus “important”. The other countries have 15 such statements. Remarkable is also that the countries with no free access have only two statements with no one single “very important” answer, both related to “rewarding” healthcare professionals:

• Healthcare professionals should be rewarded for the use of (agreed) EHR systems, e.g. by participating in research, etc…

• Healthcare professionals should be financially rewarded for the use of quality labelled EHR systems.

The top scores for these countries are:

• The use of EHR systems and sharing of patient data are important to improve public health.

• Healthcare professionals need to trust sharing of patient data as such: privacy and security needs to be guaranteed.

• Patient’s trust in sharing data is important for the large scale deployment of EHR systems and sharing of patient data.

*

• Direct involvement of the healthcare professionals in the design and definition of the program is a very important success factor.*

• A clear and consistent legal context, more especially regarding security and privacy when sharing patient data is very important to realise large scale implementation of EHR systems and sharing of patient data.*

The top scores for the countries with “free access” are partially the same (marked with *

) with two different ones:

• The use of EHR systems and sharing of patient data are very important for the quality of care and for the continuity of care.

• The healthcare professionals should acquire the skills to use health IT systems and more especially EHR systems.

• Trustful relations with the health authorities regarding the use / re-use of shared healthcare data is considered as very important to enable that sharing of patient data.

The next tables illustrate the differences between the groups of countries, when regrouping them on the basis of the kind of access to secondary care they allow to their citizens.


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Figure 2: Social, political and cultural factors as responded by countries with no “free access” at all to secondary care.


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Figure 3: Social, political and cultural factors as responded by countries where “direct” access to secondary care is discouraged.


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Figure 4: Social, political and cultural factors as responded by countries with a free / unlimited access to primary as well as to secondary care


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14 Differences between the countries based on “type of employment of the healthcare professionals”

We regrouped in a similar way as described in the previous section the answers of the different countries but now based on the dominant type of employment, healthcare systems based on employed healthcare professionals or based on self-employed healthcare healthcare professionals. We did not make a distinction between the countries with mainly capitated payment (flat annual fee per patient) or fee-for-service payment approaches for the self-employed healthcare professionals or countries with mixed kinds of payment. The differences between the two groups of countries are significant. The countries with employed healthcare professionals defined ten statements as “very important” for 100%. None of the countries with self employed did it. This is clearly illustrated in the two next tables. The lowest score in the “employed” group of countries is: Healthcare professionals should be rewarded financially for the use quality labelled EHR systems in order to favour the large scale deployment of EHR systems and sharing patient data. 75% of the countries do not consider this as important. The group of countries with “self-employed” countries consider the same issue as very important or at least as important for 75% of the respondent. No single one of these countries with self-employed healthcare professional considers this factor as not important.


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Figure 5: Social, political and cultural factors as responded by countries with mainly

“employed” healthcare professionals


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Figure 6: Social, political and cultural factors as responded by countries with mainly

“self-employed” healthcare professionals, based “fee-for-service” or “capitated” payment or any combination of those payment options.


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15 Conclusions The main conclusions of the survey are: 1. It was / it is not so easy to get information from public agents / authorities regarding

actual and even more regarding past e-Health strategies and action plans related to the deployment of EHR systems. This more especially the case for countries where a previous e-Health strategy failed or where no e-Health strategy has been defined. Another issue was the problems with diverging strategies between different regions of the same country, resulting also in difficulties to identify the most appropriate respondents. We nevertheless succeeded in getting 17 answers from as much different countries or health regions.

2. One of the results is an overview of the existing and for some of the countries previous e-Health strategies, more especially regarding the use of EHR systems and regarding realising sharing of patient data.

3. Some answers given by the respondents indicated some confusion regarding the

concept “EHR” within this EHR-Implement project. Some respondents clearly interpret “large scale implementation of EHR systems” as the implementation of “large scale EHR systems” or “centralised EHR systems” while other respondents are focusing on a broad deployment of interoperable independent information systems.

Countries with a large installed base of clinical information systems like Austria, Denmark or Ireland are focusing on “centralised services for sharing patient data”. The differences between the countries are so important that we need to be very careful with general conclusions.

4. There is a large consensus between the countries on what’s important in order to deploy largely EHR systems and/or in order to realise sharing of patient data. We nevertheless realised a ranking between the statements, some statements being generally considered as “very important” while other statements were listed as “important”.

5. The survey highlighted some interesting differences between the countries depending

on some healthcare organisational issues. We studied differences between the countries based on two criteria: • The patient access to secondary care • The dominant kind of employment: self-employed or employed.

We found a higher degree of consensus between the countries without free access to secondary care or even more between the countries with employed healthcare professionals. The other countries have a more “nuanced” position on most of the statements. The differences are most prominent between countries with mainly employed healthcare professionals and countries with mainly self-employed healthcare professionals.