The Australian Digital Health Agency, established in July 2016, has national responsibility for the country’s digital health strategy. An interoperable national e-health program based on personally controlled unique identifiers is now in operation. More than 6 million patients (one-quarter of Australians) and 13.4 million providers are currently registered. As of February 2019, all Australians have a My Health Record created for them unless they have opted out of the system, although individuals can choose to delete their record at any time.32 The record supports prescription information, medical notes, referrals, and diagnostic imaging reports. Patients can view their own medical information and control who can see it, as well as add information about allergies, adverse reactions, and their health care wishes in the event that they become unable to communicate.
Information technology is coordinated nationally by the Department of Informatics, which is linked to the Ministry of Health. However, states and municipalities use different information systems, leading to data integration challenges and making it difficult to implement a national integrated electronic health record (EHR).
Since the late 1990s, the Ministry of Health has developed policies and initiatives to implement a National Health Card with an individualized number for each person, to better monitor utilization and to optimize service provision.
Recently, the Ministry of Health launched e-SUS software intended to integrate the multiple information systems within SUS.
In 2017, 90 percent of health care providers in the public sector used computers and 77 percent had access to the Internet.28 In 2018, about 19,000 of the 42,600 primary care units used EHRs. Of these, 9,373 primary care units were using the Ministry of Health EHRs, and 9,790 had their own systems.
Uptake of health information technologies has been slowly increasing in recent years. Provinces and territories are responsible for developing their own electronic information systems, with national funding and support through Canada Health Infoway. However, there is no national strategy for implementing electronic health records and no national patient identifier.
According to Canada Health Infoway, provinces have systems for collecting data electronically for the majority of their populations; however, interoperability is limited. In 2017, 85 percent of GPs reported using electronic medical records, but patients have limited access to their own electronic health information.43
Nearly every health care provider has set up its own EHR system. Within hospitals, EHRs are also linked to the health insurance systems for payment of claims, with unique patient identifiers (insurance ID or citizenship ID). However, EHR systems vary significantly by hospital and are usually not integrated or interoperable. Patients often must bring with them a printed health record if they want to see doctors in different hospitals. Even if hospitals are owned by the same local bureau of health or affiliated with the same universities, different EHR systems may be used.
Patients generally do not use EHR systems for accessing information, scheduling appointments, sending secure messages, refilling prescriptions, or accessing doctors’ notes. There is no national strategy for establishing standardized EHR systems; however, some regions are in the preliminary stages of planning to establish regional EHRs.
IT is used at all levels of the health system as part of a national strategy supported by the National Agency for Health IT. Each of the five regions uses electronic health record (EHR) systems for hospitals, with adherence to national standards for compatibility. All citizens in Denmark have a unique electronic personal identifier that is used in all public registries, including health databases. The government has implemented an electronic medical card storing encoded information about each patient’s prescriptions and medication use; this information is accessible by the patient and all relevant health professionals.
General practitioners also have access to an online medical handbook with updated information on diagnosis and treatment recommendations. Two regions are currently implementing a comprehensive new EHR and data capture system developed by EPIC. While the initial implementation has been problematic, it is expected to provide benefits in the long run. The three other regions are using a system developed by Systematic. Shared standards facilitate communication between the two IT systems at the general level, but with a number of challenges at the detailed clinical level.
The national health information portal, Sundhed.dk, offers differentiated access for health staff and the wider public.23 It provides general information on health and treatment options and access to individuals’ own medical records and history. For professionals, the site serves as an entry to medical handbooks, scientific articles, treatment guidelines, hospital waiting times, treatments offered, and patients’ laboratory test results. The portal also serves as a communication platform for referral, discharge, and prescription information among primary care providers, regions, hospitals, and pharmacies.
The NHS number assigned to every registered patient serves as a unique identifier. All general practice patient records are computerized. Since April 2015, all GP practices have been contractually obliged to offer patients the choice of booking appointments and ordering prescriptions online. As of March 31, 2016, practices are required to offer patients access to their own detailed coded record, including information about diagnoses, medications and treatments, immunizations, and test results. Practices are not required to allow patients access to information that clinicians enter in free-text fields. When electronic records are not available to patients, such as in dentistry, they can request a paper copy.
The NHS is aiming to move to a paperless system across primary, urgent, and emergency care services by 2020. Beginning in October 2018, all NHS providers are required to receive all referrals to outpatient services from GPs electronically.41
The NHS website serves as a single point of access for patients to register with a GP, book appointments and order prescriptions, access approved apps and digital tools, find information about local services, and learn about health in general. The website will eventually allow patients to speak to their doctor online or via video link and view their full health record.42
The electronic health record (EHR) project (Projet dossier medical partagé) covered roughly 1,882,503 patients at the end of 2018, and an estimated 731 hospitals (one-third of all hospitals). Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Interoperability is ensured via a chip on patients’ health cards.21
The initiative to fully integrate EHRs has faced multiple delays, and the integration of information systems between health care professionals and hospitals remains limited.22 By law, patients have full access to the information in their own records, paper or electronic, either directly or through their GP. The sharing of information between health and social care professionals is planned as part of the deployment of EHRs to nursing homes, which started in 2019.23
Since 2015, electronic medical chip cards have been used nationwide by all the SHI-insured; they encode information including the person’s name, address, date of birth, and sickness fund, along with details of insurance coverage and the person’s status regarding supplementary charges.18 Patients can decide whether they want clinical data, such as on medications, to be stored and whether these are to be passed on to their physician.
In 2015, Parliament passed a law for secure digital communications and health care applications; the E-Health Act provides concrete deadlines for implementing infrastructure and electronic applications (such as documentation of willingness to donate organs) and introduces incentives and sanctions if schedules are not adhered to.
SHI physicians receive additional fees for sharing electronic medical reports with other providers (since 2016–2017), collecting and documenting emergency records (since 2018), and managing and reviewing basic insurance claims data online. In the future, SHI physicians who do not participate in online review of the basic insurance claims data will receive reduced remuneration.
Furthermore, to ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan. In the medium term, this medication plan will be included in the electronic medical record.19
The Ministry of Health and Family Welfare published the first national standards for electronic health records (EHRs) in 2013. An expert committee was then established to support the adoption and implementation of an EHR system throughout the country. As of 2016, however, survey results have revealed that uptake of the system has been slow as compared to other middle- and high-income countries.61 Currently, there is no universal patient identifier.
The National Health Protection Scheme presents a new opportunity to use IT to improve quality of care and detect fraud. The program will run on a state-of-the-art system with built-in intelligence and data-processing capabilities. It Is designed to detect fraud and misuse and provide an electronic tracking mechanism for complaint and grievance redressal.62 The new National Health Authority has already set up the PM-JAY Dashboard and other IT systems for hospital empanelment, beneficiary identification, and transaction management. There will also be a fully functional PM-JAY portal to serve as a single access point for information related to the scheme.
All health plans have electronic health record (EHR) systems that link all community-based providers: primary care physicians, specialists, laboratories, and pharmacies. All GPs work with EHRs. Hospitals are also computerized but are not fully integrated with health plan EHRs. The Ministry of Health is leading a major national health information exchange project to create a system for sharing relevant information across all hospitals and health plans.
Each citizen has a unique patient ID. Patients have the right to get copies of their medical records from hospitals and health plans, and patients can book appointments and access many components of their EHR online (such as lab test results), but full records are not generally available. Efforts are underway to set up secure messaging systems linking patients and their GPs.
The New Health Information System (Nuovo sistema informativo sanitario, or NSIS) is being implemented incrementally, with the goal of establishing a universal system of electronic records connecting every level of care. It currently provides information on approximately 85 percent of services included in the LEA. Primary care is not included, but hospital, emergency, outpatient specialist, residential, and palliative care are, as well as pharmaceuticals. The NSIS currently registers administrative information on care delivered, but medical information appears to be more difficult to gather. No unique patient identifier exists at the national level, while in most regions administrative records are linked together using unique patient identifiers generated at the regional level.
Monitoring and implementation of the NSIS has been assigned to a steering committee, which includes representatives of the central government, regions, and professional colleges.
The national contract for primary care physicians and pediatricians requires them to have computerized systems; in addition, GPs working in teams are requested to connect all their computers to provide shared access to patient medical records.
Some regions have developed computerized networks to facilitate communication among physicians, pediatricians, hospitals, and territorial services and to improve continuity of care. These networks allow the automatic transfer of patient registries and information on services provided, prescriptions for specialist visits and diagnostics, and laboratory and radiology test outcomes. Fourteen regions have also developed a personal electronic health record, accessible by patients, that contains all of their medical information, such as outpatient specialty care results, medical prescriptions, and hospital discharge instructions. Twenty-one percent of people in these regions have activated their personal health records.
There is also a shift underway from paper-based to electronic prescriptions. Currently, 86 percent of all prescriptions (for drugs and specialist care) are issued electronically. However, in a few regions, the proportion is below 50 percent, especially with regard to drugs.
Electronic health record networks have been developed only as experiments in selected areas. Interoperability between providers has not been generally established. The government has been addressing technical and legal issues prior to establishing a national health care information network so that health records can be continuously shared by patients, physicians, and researchers by 2020.32 Unique patient identifiers for health care are to be developed and linked to the Social Security and Tax Number System, which holds unique identifiers for taxation.
Virtually all GPs have a degree of electronic information capacity. For example, they use electronic health records (EHRs) and can order prescriptions and receive lab results electronically. At present, all hospitals have an EHR.
Providers must allow patients access to their own files on request, but few hospitals have standard online access options for patients. Electronic records, for the most part, are not nationally standardized or interoperable between domains of care. In 2011, legislation to install a national EHR system failed in Congress. Since then, the integration of EHR systems among providers has been left to the field.
In 2011, hospitals, pharmacies, after-hours GP cooperatives, and organizations representing GPs set up the Union of Providers for Health Care Communication (Vereniging van Zorgaanbieders voor Zorgcommunicatie), responsible for the exchange of data across various platforms and settings via the National Switch Point (LSP).37 Patients must approve their participation in this exchange, and have the right to withdraw. The LSP uses unique provider identification numbers and patient social security numbers under the oversight of the Central Healthcare Information and Occupation Access Point, a government agency. In practice, use of this system is limited.
Other initiatives have focused on improving data exchange. For example, MedMij is a private organization that develops data standards to ensure that portals, provider systems, and apps can be linked to exchange information securely.
The ability to access and share accurate clinical information is central to the New Zealand Health Strategy, which provides high-level direction for the country’s health system.11
In 2015, the Ministry of Health announced, and has responsibility for, the Digital Health Work Programme 2020. The program aims to ensure appropriate access to health and wellness information facilitated by a single electronic health record. The electronic record will collect and present existing core health information in a single view, accessible by consumers and clinicians. Data will also be able to be shared with social-sector professionals.
Current levels of interoperability between health information systems are limited. However, the structured electronic transfer of information is increasing. Primary care is most advanced. Across the country, primary care providers can transfer patients’ records securely between practices, send electronic referrals, and receive electronic hospital discharge summaries. In one of New Zealand’s four regions, providers in community, hospital, and specialist settings can also access a shared view of clinical information. The other three regions are working on enabling information-sharing in these settings. Implementation of electronic prescribing is under way in primary care and in hospitals. The use of telehealth to deliver services remotely is also increasing.
A recent survey found that 509 of 992 general practices have implemented provider portals, giving after-hours facilities and some hospital emergency departments access to primary care information.12 The Health Information Standards Organisation promotes the development and use of standards to ensure interoperability between systems, and a national standard for clinical terminology (the Systematized Nomenclature of Medicine — Clinical Terms) has been endorsed. Every person who uses health and disability support services has a unique national health number, facilitating the process of building interoperable systems.
Over half of primary care practices have implemented a patient access portal, and approximately 473,000 patients have registered. The portal gives patients access to their medical records and test results and allows them to book appointments with GPs, order prescription refills, and email a GP. The portal supports the New Zealand Health Strategy’s goals of moving services closer to home and enabling health care consumers to actively manage their own health and engage more conveniently with the health system.
The eHealth Directorate is responsible for the national strategy for health information technology. The National Health Network, a state enterprise, provides efficient and secure electronic exchange of patient information between all relevant parties within the health and social services sector. It provides secure telecommunication for GPs, hospitals, nursing homes, pharmacists, dentists, and others.
All residents have a unique personal identification number, used in primary care and for hospital medical records. Virtually all GPs use electronic health records and transmit prescriptions electronically to pharmacies. Electronic communication systems are used for referrals, for communication with laboratories and radiology services, and for sick leave. Most GPs receive their patients’ hospital discharge letters electronically. Some GP and specialist outpatient offices have electronic booking, while most hospitals do not.
There is also a secure website for accessing patients’ core medical records. To gain access, health professionals must identify themselves, and their activity is logged.20 All adult patients have online access to their core medical records, which include an overview of prescribed medicines. (A separate website for information about prescriptions only is also available.) Patients can request access to their complete medical record.
After-hours emergency care is organized within the same patient record network as primary care, and primary care providers can access information regarding emergency visits. All hospitals use electronic records.
Since 2011, Singapore’s national electronic health record (EHR) has been progressively deployed to both public and private health care institutions to support the goal of “One Patient, One Health Record.” The national EHR is owned by the Ministry of Health and managed by Integrated Health Information Services. The secure system collects summary patient health records from different health care providers, and authorized health care professionals can access the EHR to have a holistic and longitudinal view of a patient’s health care history.54 As of 2019, more than 1,300 health care institutions participate in the national EHR.55
Singaporeans and permanent residents can access some of their health records via HealthHub, a national one-stop health portal. They can also track and manage their medical appointments, request medication refills or renewals, and view bills and make payments at select public hospitals, national centers, and polyclinics.56
In 2016, the government developed a vision of Sweden as a world leader in e-health by 2025. The strategy involves four overarching tactics:
- coordination and communication among health care stakeholders
- development of common concepts in the field
- implementation of standards for health information exchange
- creation of national drug lists that assist health care professionals in efforts to improve patient safety.
High-quality information technology systems are deployed in hospitals and primary care practices, and adoption rates are high in these settings as well. However, the types of systems used vary by care setting and by region.
Patients age 16 and older can increasingly access their electronic medical records to view personal health data, read physician’ notes, schedule appointments, and refill prescriptions. According to the Swedish eHealth Agency, 99 percent of all Swedish prescriptions were e-prescriptions in 2017.
To access their records, patients log in using a personal identification number (the same 10-digit number used for accessing all public services) and a personal electronic encryption code called BankID. The level of information available to patients varies to some extent across regions.
In June 2015, a law addressing a national EHR was adopted; it came into effect in 2017. By spring 2020, an EHR with unique identifiers will be rolled out in all regions and should increase care coordination, quality of treatment, patient safety, and efficiency in the health care system. EHealth Suisse, a joint initiative of the federal and cantonal governments, is coordinating the introduction of the EHR.
The program is voluntary; insured persons are free to opt in to the EHR and to decide who is allowed to have access to specific details of their treatment-related information. The records are being stored in decentralized form.
Providers will have to take part in certified communities (organizational units of health specialists and their institutions) to be able to read the records. While ambulatory-care providers are not obliged to join such communities, hospitals and long-term care institutions are legally bound to join and to offer their services using the EHR.
The uptake of the EHR in primary care is still in its early stages. Forty percent of physicians and outpatient centers handle their medical records exclusively on paper,and there are ongoing discussions about incentives for physicians to adopt new technologies.26 Hospitals are generally more technologically advanced; some have merged their internal clinical systems with external providers. However, the extent of this integration varies greatly among hospitals and among cantons.
Everyone in Taiwan carries an electronic NHI card bearing a unique personal identifier to access care. The card encodes personal information, insurance data, notes from recent medical visits, diagnoses, drug prescriptions, drug allergies, major illnesses, organ donation consent, palliative care directives, and public health records (including immunizations).
The NHI PharmaCloud is a cloud-based, patient-centered drug information system that the NHIA introduced in 2013. PharmaCloud takes advantage of the vast database the NHIA has created to enable doctors and pharmacists to access a patient’s medication history from the past three months. PharmaCloud also gives prescribers clinical recommendations and safe-use information to prevent adverse drug reactions and reduce unnecessary prescriptions.
My Health Bank, introduced in 2014, is another cloud-based innovation that provides comprehensive health and medical records from the previous three years for any insured person on request. Records can be updated at any time. In addition to increasing the transparency of important personal health information, the initiative is intended to assist patients in managing their own health. A personal e-health record book contains the patient's complete medical history from the past year, which can be downloaded from the Web for the patient's own use.
In 2015, the NHIA developed the NHI MediCloud system, which incorporates patient data in the PharmaCloud system and in 11 additional records systems; the data includes Chinese medicine prescription use, examination and test results, surgeries, dental care and oral surgery, drug allergies, and hospital discharge summaries.32
All hospitals and clinics use electronic patient medical records. However, owing to a lack of infrastructure investment, NHI still has no systemwide interoperability, and the electronic exchange of patient medical records among hospitals is limited.33
The Office of the National Coordinator for Health Information Technology, created in 2004, is the principal federal entity charged with the coordination of nationwide efforts to implement and advance the use of health information technology and the electronic exchange of health infor-mation. In 2017, an estimated 96 percent of nonfederal acute care hospitals and 86 percent of office-based physicians had adopted a “certified” electronic health record (EHR) system. Eighty percent of hospitals and 54 percent of physician offices had adopted an EHR with advanced ca-pabilities, such as the ability to track patient demographics, list medications, store clinician notes, and track medication orders, laboratory tests, and imaging results.41,42
The 21st Century Cures Act, passed in 2016 to promote the use of EHRs overall, requires that all health care providers make electronic copies of patient records available to patients, at their request, in machine-readable form.