|Implemented in this survey?|
The Government has made progress in implementing electronic health records in Austria (ELGA). ELGA aims at improving health care quality and economic efficiency. Currently preparations are under way to tender for investments in the basic architecture. Issues of interoperability and patient access are not completely resolved, probably wanting better regulations. In addition, acceptance and implementation cost may be underestimated. Resistance from many providers is still an important barrier.
The development of the electronic health record (ELGA) is broadly aided by legislation and by new organisational bodies responsible for timely implementation of current and future legislation on behalf of the Federal Health Agency, a cooperative body governing developments in the health sector (see survey (4)2004):
ARGE-ELGA (Arbeitsgemeinschaft Elektronische Gesundheitsakte), the task force for implementing electronic health records, was founded in September 2006 on the basis of an agreement between the federal government, federal states (Länder) and the Austrian federation of social insurance associations. The main tasks of ARGE-ELGA are (Philippi 2007):
IHE-standards are standards to be followed by the industry to ensure interoperability across different applications. The main goal of this effort is to implement ELGA to enhance quality, effectiveness and effciency of care provision. In summer 2008, ARGE-ELGA was appointed national focal point in the framework of the EU funded project "European Patient Smart Open Services" (www.epsos.eu).
Objectives of ELGA
The policy goal for introducing ELGA is to use information technology (IT) to support integrated provision of care across providers. ELGA aims at documenting health related information on the level of patients in a variety of data repositories. Data and information may be retrieved from providers and from patients. ELGA will facilitate timely access of patient information at each provider level irrespective of the place where a provider delivers services.
ELGA operates on two key functional levels:
primary functions (first implementation phase until 2012):
secondary functions (possible functions beyond 2012):
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
ELGA is certainly innovative as it reflects a comprehensive and inclusive national strategy to use IT to mitigate adverse effects resulting from administrative fragmentation of the system. At the same time the degree of innovation is also the source of resistance towards ELGA coming from many stakeholders. In addition, there is still a lack of transparency in the Austrian health care sectors and activities of providers are compartmentalized and not very patient-centred.
The degree of controversy will probably remain high, as there is still a lack of systematic support of doctors. Doctors mainly fear that doctor-patient relationships will suffer and confidentiality is endangered. Another issue here is certainly that doctors fear close monitoring of their activities and sanctions if they deviate from standards requested from payers. In this context pressure will probably increase on single-headed offices as there exists evidence that adoption rates of bigger ambulatory care units are much higher compared to those in small scale offices (DesRochers et al 2008). Thus, ELGA may trigger re-organizing ambulatory care provision which has been resisted so far (see survey (11)2008).
Once implemented ELGA will certainly fundamentally change the process of care delivery and thus has potential to make care safer and more cost-effective. Obstacles in this context may be lacking efforts from providers and/or regional decisions makers to really make existing e-health applications interoperable across regions and sectors. The current governance framework is rather decentralized, reflecting policies in last years to empower regional health policy makers and to givem them more autonomy in decision-making.
Discussions around investements in ELGA applications also reflect this. For example, hospital owners are not only operators but - to a large extent - also payers of care provision in this sector. Thus, uncertainty exists to which degree providers may be able to reap benefits of investments in e-health. The same problem may also occur for doctors. These issues are widely discussed in the literature (see Anderson et al 2006). In addition, studies show that pay-offs of investements in e-health might take as long as 15 years (Girosi 2005), increasing uncertainty over investment decisions.
So far public visibility seems not very high. There are activities in the civil society (Initiative ELGA) to raise public awareness regarding issues of data security and other dangers with e-processing of health related information. ARGE-ELGA has initiated informal cooperation with this initiative to ensure transparency. Overall, many experts claim that the process of ELGA implementation lacks transparency. For example, the study on costs and benefits of ELGA has not been presented to the public. While it was available on the internet site of the "Initiative ELGA" between September and October 2008 the study was removed from the web because officials from the Ministry said that there is not yet a final version available.
|Implemented in this survey?|
The Ministry of Health is governing the design and the process of implementing ELGA and is determined to keep the deadline for rolling-out ELGA in 2012.
While the implementation of the e-card has already created considerable resistance from practising doctors, opposition towards ELGA seems even stronger. Main issues concern cost of investment and maintainance of adequate hard- and software. Another concern regards the availiability and reliability of IT applications in offices. In addition, medical providers seem to fear that ELGA may disturb the trust relationship between them and patients. Issues of rising autonomy of patients through the possibility to command their health information and through their ability to restrict providers to access this information may also play a role here. Doctors see also problems with data security. In this context, liability issues become relevant because legislation holds doctors accountable for many years; thus the likelihood of malpractice law suits may increase if medical records may be electronically followed-up and if patients authorise third parties to do so. Furthermore, doctors fear increasing dependency from the IT industry and cost involved in keeping up hard- and software to necessary standards.
Other providers, e.g pharmacists seem supportive; they piloted e-medication application in a region in Austria; results of descriptive evaluations seem encouraging for a nation-wide roll-out of this service (see survey (12)2008).
Hospital owners fear high investment cost as currently electronic storage of patient data has already emerged and issues of interoperability are not yet clarified. There are many different applications across federal states and/or providers and it is claimed that gradual replacements are necessary to avoid high investment outlays. However, technicians and developer widely believe that international IT standards (IHE-Integrating the Health Care Enterprise) as envisaged to ensure interoperability of the ELGA architecture will help to reduce cost growth; thus investment risks may be overestimated by hospital providers.
The payer side and in particular health insurers seem broadly supportive as they expect that e-health applications have potential to contain cost growth in the health sector.
Patient advocates seem generally supportive and see in ELGA potential to actively involve patients via web-based health portals and by granting unrestricted access to all personal information. By this transparency will increase and patients may be empowered by receiving specific and quality "rated" health information. In addition patients may decide who will have access to their data. However, patient advocates claim that the policy process of developing ELGA is not very transparent. For example, commissioned work on costs and benefits of ELGA was not officially presented. This is thought to reflect governance problems in the administration and is assumed to be responsible for a very low level of public visibility.
Initiative ELGA (www.initiative-elga.at/enter.htm) is a web-based platform of people (mainly doctors and citizens) who aim to systematically gather information on developments in e-health and to raise awareness about data security issues, which may emerge. While they are not opposing ELGA per se, they seem cautious with respect to the benefits of ELGA. So far their influence is weak, reflecting also a low level of involvement of practising doctors in this initiative.
|Ministry of Health||very supportive||strongly opposed|
|Judiciary||very supportive||strongly opposed|
|Practising doctors||very supportive||strongly opposed|
|Other providers, e.g pharmacists||very supportive||strongly opposed|
|Hospitals||very supportive||strongly opposed|
|Health Insurer||very supportive||strongly opposed|
|Consumer protection||very supportive||strongly opposed|
|Patient advocates||very supportive||strongly opposed|
|Initiative ELGA||very supportive||strongly opposed|
|Private Sector or Industry|
|Industry||very supportive||strongly opposed|
|Ministry of Health||very strong||none|
|Practising doctors||very strong||none|
|Other providers, e.g pharmacists||very strong||none|
|Health Insurer||very strong||none|
|Consumer protection||very strong||none|
|Patient advocates||very strong||none|
|Initiative ELGA||very strong||none|
|Private Sector or Industry|
Commissioned by the Federal Health Agency in 2006, the technical feasibility of ELGA was evaluated (IBM Machbarkeitsstudie 2006) and results from this effort are the basis of the current work programme of the ARGE-ELGA. Three action levels should aid the implementation of ELGA:
Prerequisites of ELGA
The e-card will be the electronic key to access patient information (see survey (10)2007) and by 2012 it should be used to access relevant health-related information in various repositories. However, additional legislation and regulations are necessary to ensure comprehensive data security. For example, the mode of patient participation is not yet clarified. Patient participation is envisaged as voluntary within an (re)opting-in, opting-out model but regulation is not yet developed.
In May 2007 the Federal Health Agency endorsed the implementation plan for the first phase and commissioned ARGE-ELGA to develop detailed plans for implementation. To ensure that necessary investments are not too expensive for providers, consensus was reached to build the ELGA architecture in a gradual manner. In this context a cost-benefit analysis was presented in spring 2008, which provides estimates for investment cost and for monetary benefits (Burchart 2008).
In July 2008 the road map for the implementation of ELGA was presented (http://futurezone.orf.at/stories/276191). Currently ARGE-ELGA is drafting calls for investment tenders in the basic architecture.
A study from July 2008 estimated costs and benefits of core applications of ELGA, e.g. e-medication, e-medical report etc. (Burchert 2008). While investment and operating costs have largely been estimated on the basis of current labour costs, benefits were evaluated drawing on results gained from pilot projects (e-medication and discharge management). In this context realised cost reductions were used and aggregated through
Some economic benefits were also estimated, e.g. avoided sick leave. Provider time saved through e-health applications has not been taken into account. Regarding the methodological approach the title of the study seems misleading as it does not monetarize any benefits relevant for patients or providers. Rather it just looks at possible savings from reduced provider activities.
Investment costs will be in the order of 136 Million Euro, about 40 percent are investments in central infrastructure, the remainder share is borne by providers (76 Mio. Euro). Almost 70 percent of these costs are needed to adjust current IT infrastructure of providers. Total cost will be evenly borne by hospital providers and by providers outside hospitals. Annual operating costs are estimated to be about 36 Mio. Euro, cumulated over 9.5 years they will be 190 Mio. Euro.
Cost savings may be achieved in the order of 142 Mio. Euro to 227 Mio Euro per year, corresponding to about 0.5 to 0.8 percent of total spending on health. Efficiency factors were introduced to account for uncertainty of these results, e.g. calculated benefits were adjusted by 50 percent and 20 percent respectively. Cumulated over 9.5 years benefits are estimated to reach 965 Mio. Euro. They may range between this value and 493 Mio. Euros, depending on underlying assumptions made.
On the basis of these calculations the introduction of ELGA seems justified. The benefit from e-medication through reductions of adverse drug effects is estimated to contribute most to overall expected savings. In this context no benefits for patients, e.g. QUALYs are estimated. E-medical reports will probably save up to 104 million per year. The study does not evaluate how generated benefits are distributed across providers. Benefits are currently assumed to only accrue to payers, e.g. social health insurance.
Progress has been made in the last two years and there is reason to believe that deadlines for ELGA implementation as laid out will be met timely.
First, reflecting efforts in many other countries to improve health care delivery through information technology, Austria's approach seems in line with what other countries have been doing in this field (see also Anderson et al 2006). While the time frame for ELGA implementation in Austria appears ambitious the Austrian approach seems very comprehensive and inclusive compared to what other countries did so far. However, issues of interoperability have become an important barrier, as major costs for up-grading existing systems will be necessary. Either practising doctors or hospital providers, reflecting fragmentation in financing of the Austrian health care system, mainly finance these costs.
Second, there appears to exist still a lack of compliance in particular of ambulatory care physicians to participate, even though efforts were increased to involve them actively in designing relelvant components.
Third, to enable patients to administer their own health data is certainly forward-looking. Important issues of secure patient access to the portal are still unresolved and there are still participation risks on behalf of patients. In particular when doctors remain resistant towards ELGA.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
ELGA has potential to improve both quality of care delivery and the level of efficiency. In light of continuous efforts to make care delivery more responsive to patient needs, electronic processing of patient data will help achieving this goal. However, there remain uncertainties regarding acceptance from both providers and patients. Implementation and acceptance cost are probably underestimated so that benefits on quality and financial sustainability may well be smaller than expected.
The level of equity may remain unchanged even though ELGA has potential to ensure access to high quality care even to disadvantaged groups. On the other hand there are still issues unresolved with regard to computer literacy of these groups. Thus, ELGA may even increase the "digital divide" and may reduce equal opportunities for patients. However, as people become increasingly computer literate this negative effect may vanish in the future.
ANDERSON, G, et al (2006). "Health Care Spending And Use of Information Technology In OECD Countries". Health Affairs 25(3).
BURCHERT H (2008). ELGA - Monetäre Quantifizierung der Kosten und des Nutzen der Kernanwendungen mit den Methoden einer Kosten-Nutzen-Analyse. Debold & Lux, Hamburg, available between September and October 2008 at: www.initiative-elga.at/ELGA/kosten-infos/Kosten_Nutzen_Analyse_Debold_und_Lux_2008.pdf
DesRoches, C., et.al (2008). "Electronic Health Records in Ambulatory Care - A National Survey of Physicians". N Engl J Med 359; 1 July 2008.
GIROSI, F. et al. (2005). Extrapolating Evidence of Health Information Technology Savings and Costs, Pub. no MG-410 (Santa Monica, Calif.: RAND).
IBM (2006). Machbarkeitsstudie ELGA, im Auftrag der Bundesgesundheitsagentur, November 2006, Wien. www.arge-elga.at/fileadmin/user_upload/uploads/download_Papers/Arge_Papers/
Philippi, Th. (2007). "Electronic Health Record Development in Austria". Eurohealth 13(3): 23-24.
Vereinbarung gemäß Art. 15a B-VG über die Organisation und Finanzierung des Gesundheitswesen, 2005-2008 und 2008-2013.
Maria M. Hofmarcher
Reviews provided by:
Theresa Philippi, Deputy Programme manager of the task force implementing electronic health records ( ARGE-ELGA)
Robert Hawliczek, Head of the Department of Radiooncology, Sozialmedizinisches Zentrum Ost-Donauspital, Speaker of managing doctors in the Chamber of Physicians
Gerald Bachinger, President Patient Advocacy Austria