National EHR — Can we learn from Shared Record Initiatives implemented around the World?
Legislation, benefits, access and semantic interoperability
Without a clear answer to the subject of access to the National EHR in New Zealand, maybe we can learn a little from early adopters around the world. The EHR has been a subject of discussion for some time now around the world, with a very common message — The healthcare model is unsustainable and needs to change, the Shared Electronic Health Record will be a key enabler to this change. Benefits are significant and projected savings, cost and lives are immense.
If we do a quick scan around the world for just what activity there is in this space, there are some definite surprises. As you would expect the United States is an active participant, as is the UK and Australia. Even Canada put in a good showing.
Referring to the recent Deloitte’s report https://www.health.govt.nz/system/files/documents/publications/independent-review-new-zealand-electronic-health-records-strategy-oct15.pdf commissioned by the New Zealand Ministry of Health, for example, comparative case studies cited there include British Columbia, Denmark, Kaiser Permanente in the USA and Singapore. All of them National solutions except Kaiser which is a private healthcare provider, but all of them with similar populations to New Zealand, and expect similar challenges.
Other countries who have demonstrated significant success with the EHR include: Austria, Jordan, Estonia, India, Netherlands, UAE, Saudi Arabia and Switzerland. (Compliments of Wikipedia).
Comparing the various countries efforts, the associated use and adoption rates, the statistics that present are definitely very interesting and go some way to highlighting significant differences in the local legislative and privacy frameworks. Estonia for example, was the first country to implement a national shared record, in 2008, populated with what is essentially the entire populations records, from birth to death.
In every case though there are suggestions of the ongoing benefits, the savings to be had, and according to the Australian My Health Record projections up to 5,000 lives a year could be saved once it is fully operational.
Adoption by any population though is key to the success of an implementation of this scale. People need to be assured it is being done in their best interests, and there are safeguards in place to prevent malicious or unauthorised access to the data being stored. The initial attempt by Australia to introduce what was known as the Personally Controlled EHR (PCEHR) as an opt-in service, seemed to be an attempt to gain general confidence by slow take up and once the value of this record had been established, people would be keen to participate. Unfortunately, and many dollars later, they had to backtrack and implement the service as an opt-out, renaming it along the way to improve the brand reputation. Being opt-out, the take-up is now significantly improved. As above, this is now labelled as My Health Record and seems to be enjoying great acceptance.
the effort to provide a detailed summary of the various issues facing each country as it looks to implement a shared medical record would be significant, and well beyond the brief of this article. However, looking at the examples shown, and matching them with the various country political and social considerations it seems to imply, purely anecdotally, that those countries with more highly controlled environments (authoritarian may be a better description) the adoption appears to be much greater and with less pushback or concerns expressed by the general population. It is almost as though the government decides that it will be in the interests of their people, and on that basis they just go ahead and make it happen. I’m sure New Zealand Minister Coleman would love to be in a position to take that approach to meet his deadline.
However, as with many of these shared record initiatives, once people get used to the idea it becomes easier each time. GP2GP for example, introduced in New Zealand about 6 years ago, was one of the first of the New Zealand initiatives for sharing information by sending structured data between Medical Practices. At the time privacy and policy issues needed to be adequately addressed before the solution would be implemented in anything other than a small trial. Subsequent services have benefitted from the work done to alleviate the concerns, and have been met with much less resistance. As with so many of these initiatives though, the technology is the simplest component of the solution, policy, governance and legislation are all far more onerous.
And so to “Semantic Interoperability”. What a lovely term, and what does it really mean?
This is a concern within the health eco-system, both locally and internationally, and is a challenge any of these data sharing solutions face. It gets mentioned in a high number of the country EHR case studies and, unless care is taken to define clear data sharing standards internationally.
Essentially what it refers to is the ability for disparate systems to receive and consume the data sent from another system in an intelligent manner. This becomes the holy grail for data transfers and sharing between practitioners. It is a problem that needs to be addressed within each country health Eco-system, as well as the International Stage.
For countries where there will be only a single platform for shared EHRs this is less of an issue, but with the world shrinking, due to ease of travel, the requirement to share structured clinical records between countries becomes an ever increasing requirement.
I’m not sure that we fully understand just how complex it will be to facilitate an international agreement on standards for shared clinical data that will truly allow sharing between nationalities.
