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Electronic patient records in the Netherlands

Country: 
Netherlands
Partner Institute: 
University of Maastricht, Department of Health Organization, Policy and Economics (BEOZ)
Survey no: 
(12) 2008
Author(s): 
Dr. Huibert Tange
Health Policy Issues: 
New Technology, Benefit Basket
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes yes yes no no

Abstract

The Dutch Ministry of Health is establishing a national infrastructure for data exchange between electronic patient records (EPR's). The core of this infrastructure is an index that connects all EPR's of a patient. In 2008 the first pilots come to an end and the first subsystems will be rolled out. It is a highly complex development with many stakeholders involved, which makes a successful outcome not yet evident.

Purpose of health policy or idea

It is important that healthcare providers share patient medical information in a fast and reliable way. This will prevent communication errors and enhance quality of care. The Dutch Ministry of Health aims at establishing a national infrastructure for data exchange between electronic patient records (EPR's). By this way, health-care providers that are connected will always have up-to-date information about the patient. The core of this infrastructure is the "national switch point", an index with pointers to all registered EPR's of a patient. In 2008 the first regions are being connected to the switch point. No information will be stored centrally on the switch point itself. The EPRs reside with the providers.

Main points

Main objectives

The national infrastructure consists of

  • An authorisation system with ID cards for patients (BSN) and providers (UZI)
  • A certification system for EPR's (GBZ) and connection-service providers (ZSPs, ie. companies that take care of the connection of an EPD system to the national infrastructure); without certification the EPRs cannot be connected to the switch point. There are three types of requirements: functional requirements (about how to register and exchange information), implementation requirements (about how to connect and secure the system and about technical performance), and exploitation requirements (procedural measures to keep information accurate, timely, and secure) 
  • The national switch point, which is paid for by NICTIZ (the National IT Institute for Healthcare in the Netherlands), which again is a foundation supported by the Ministry 
  • A library of messages based on the communication standard HL7v3.

The implementation follows the following order of priorities:

  • First, in 2008, the pilot and roll-out of three subsystems: the electronic medication record, the electronic out-of-hours record for general practitioners, and the electronic declaration system (for reimbursement data).
  • Second, in the next few years, the pilot and roll-out is planned of several medical domains that are characterized by an integrated care approach (stroke, diabetes, perinatal care).

The first will mainly affect primary care, the second will also affect hospital care.

Type of incentives

  • Legislation: a new law to make the use of the new authorisation system obligatory as of 2009.
  • Certification of information systems before they can be connected to the switch point.
  • Financial incentives for providers who use certified information systems.

Groups affected

Patients (better care, more control of medical data), providers (better communication, less medical errors, better quality of care), insurers (better cost control, efficiency gain), authorities (better quality control, more transparancy)

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent neutral system-neutral

Political and economic background

There is a certain pressure to comply with the EU standard for EPR's (CEN13606), but so far the Dutch authorities stick with the (American) HL7v3 standard. There is an international development to merge both standards, but the outcome is still uncertain.

Change of government

New legislation (see above) to be empowered in 2009.

Complies with

Communication standards, either HL7v3 or CEN13606.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes yes yes no no

Origins of health policy idea

The main driving force behind the EPR development in The Netherlands is the Ministry of Health. The EPR program can be seen as part of a broader authority-driven development to restructure the Dutch healthcare. Pillars of this restructuring are a shift of power from providers to consumers and a shift of control from authorities to insurance companies. The national EPR infrastructure fits well in these shifts.

The idea of a national EPR infrastructure is developed by NICTIZ (the National IT Institute for Healthcare in the Netherlands) which was founded in 2002 and which grew out to a national coordination point and knowledge centre for IT and innovation in the healthcare sector.

The implementation of the EPR infrastucture is coordinated by the Ministry of Health itself.

Initiators of idea/main actors

  • Government: The MoH is the main advocates of the EPR
  • Providers: General practitioners support the general idea, but are opposed to a national infrastructure (because they see that at a national level it takes much time so they question its viability).They prefer the development of regional infrastructures.The hospital sector is still rather indifferent.
  • Payers: The health insurers are more preoccupied with another program (DBC) that is related to the restructure of the Dutch Healthcare, concerning the shift from output-driven to input-driven reimbursement.
  • Patients, Consumers: Patient organizations welcome the EPR as an instrument that supports patient autonomy. In the future patients may be able to access/edit the information in the different EPRs on their own, but only if they make use of certified systems themselves.
  • Others: Information system vendors are in a dependent position since certification will be necessary in the future to enter the market.
  • Political Parties: The political parties are broadly supporting the EPR infrastructure developments and take every new delay seriously.

Approach of idea

The approach of the idea is described as:
new: The EPR program follows a steady strategy from initiation to development and implementation since 2002. The time frame of the program hampers, since every phase is confronted with serious delays.

Innovation or pilot project

Pilot project - In the Enschede region there is a pilot of the electronic out-of-hours record; in the Amsterdam and Rotterdam regions there are pilots of the electronic medication record.

Stakeholder positions

New legislation that makes the use of the new authorisation system obligatory, is now in the approval phase and will be active in 2009.

Actors and positions

Description of actors and their positions
Government
Ministry of Healthvery supportivevery supportive strongly opposed
Providers
hospital sectorvery supportiveneutral strongly opposed
GP organisationsvery supportiveopposed strongly opposed
Payers
Payersvery supportiveneutral strongly opposed
Patients, Consumers
patient organization NPCFvery supportivevery supportive strongly opposed
Others
Information system vendorsvery supportivesupportive strongly opposed
Political Parties
Parliamentvery supportivevery supportive strongly opposed

Actors and influence

Description of actors and their influence

Government
Ministry of Healthvery strongvery strong none
Providers
hospital sectorvery strongneutral none
GP organisationsvery strongstrong none
Payers
Payersvery strongvery strong none
Patients, Consumers
patient organization NPCFvery strongstrong none
Others
Information system vendorsvery strongneutral none
Political Parties
Parliamentvery strongstrong none
patient organization NPCF, ParliamentMinistry of HealthInformation system vendorshospital sectorPayersGP organisations

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Health providers, in particular general practitioners, support the idea of an EPR but doubt the viability of the plans. They make much of each setback to prove that they're right. Setbacks have been caused by technical problems, privacy concerns, and time-consuming calls for tender.

Monitoring and evaluation

One of the pilot projects (Enschede) has been evaluated by a regional research institute (Telematica Instituut). This evaluation has led to several suggestions for improvement, e.g. about the distribution of ID cards.

Expected outcome

Strong points of this development are:

  • The choice for a national communication infrastructure instead of one single national EPD.
  • Central control at the level of the national authorities.
  • Focus on patient autonomy.

Points of concern are:

  • Dependency on one national switch point, which makes the system sensitive to disturbances and other disasters. There should be more attention to robustness of the infrastructure.
  • The high complexity of the EPR program, involving different projects with many interdepencies, puts a heavy demand on project management and program coordination.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high

This is a highly complex development with many stakeholders involved, which makes a successful outcome not yet evident.

References

Sources of Information

Author/s and/or contributors to this survey

Dr. Huibert Tange

Suggested citation for this online article

Dr. Huibert Tange. "Electronic patient records in the Netherlands". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/nl/a12/1