International overview

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Digital Health Evidence Review: This section provides an overview of which countries have EHRs, PHRs and portals and how these systems are implemented.

What is the legislation that guides EHRs and PHRs?

Many countries have either implemented or taken significant steps towards implementing EHR or PHR systems. One resource that aims to summarise this information is the Atlas of eHealth. [1] There is wide variation globally in the legislation that governs digital health and many aspects are not specific to EHRs. Some countries that have EHRs do not implement new legislation specific to the electronic records but rely on existing general health records and data protection legislation to govern EHRs (e.g. Denmark, Hungary). [2] Table 1 provides examples of different types of legislation that can govern EHRs and some of the countries that have this EHR specific legislation present or absent.

Table 1 Examples of countries where specific EHR legislation is present or absent [2]

What legislation governs Examples where legislation
—present—
Examples where legislation
—absent—
Mandatory use of EHR by healthcare providers

Estonia
Finland
Romania



Australia
Czech Republic
Hungary
UK
The content of EHRs

France
Finland
Luxembourg





Cyprus
Hungary
Ireland
Norway
Poland
UK
The use of common terminology



Austria
Bulgaria
Estonia
Italy
UK




Australia
Belgium
France
Hungary
Romania
Patient’s consent to create EHRs



Australia
France
Italy
Slovenia
UK





Bulgaria
Estonia
Finland
Malta
Netherlands
Poland
Patient’s right to know who accessed EHR



Australia
Finland
Denmark
Norway
Slovakia



Belgium
Estonia
France
UK

How have EHRs and PHRs been implemented internationally?

For all countries implementation is an ongoing journey as they explore introducing new legislation, relaunching EHRs, incentivising healthcare providers and including additional functionality. The timelines below show examples from England, US, Australia, and Singapore in the past decade. Each example highlights the changing nature of implementing digital health records.

Timeline England
  • In England, the Summary Care Record (SCR) was introduced in 2008 and led by the National Health Service (NHS). It is a summary of GP record information that is intended for use in emergency or out-of-hours care. [3]
  • A 2010 report [4] highlighted significant shortfalls of the SCR implementation and because of this the ongoing implementation of additional EHRs was assigned to primary care trusts.
  • A locally led approach was also implemented for patient online access to GP records. The NHS launched resources and provided support but each GP clinic was responsible for implementation. Patients need to go via their GPs to receive access to these online systems.
  • Canada also has a similar approach to EHR implementation where national standards are set but implementation to these standards is locally led.
Timeline United States
  • Introduction of Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 promoted meaningful use of EHR throughout the US as a national goal.
  • The program offers incentive payments to eligible professionals and hospitals that adopt and demonstrate meaningful use of EHRs.
  • The key objectives for the three stages are data capture and sharing, advance clinical processes and improved outcomes. [5]
  • Canada and Australia also provide incentives to healthcare providers who adopt and use EHRs.
Timeline Australia
  • Personally Controlled Electronic Health Record (PCEHR) launched in 2012 and was opt-in registration process for individuals who wished to use the system.
  • The system was relaunched as My Health Record in 2015.
  • There were successful opt-out participation trials in 2016 and a full move to opt-out planned for 2018.
  • The policy decision between opt-in and opt-out is a feature of those countries who require consent to create EHRs. In a review of European countries, 8 out of 29 required consent to create EHRs and of the 8, half were using an opt-in model and the other half an opt-out model. [2]
Timeline Singapore
  • National Electronic Health Record (NEHR) launched in 2011 and was voluntary for patients and for healthcare providers.
  • High levels of adoption occurred amongst public healthcare providers but uptake in the private sector was limited. [6]
  • The government announced in 2017 its intention to introduce new legislation that would make it mandatory for healthcare providers to use NEHR.
  • Other countries such as Estonia, Finland and Romania already have this legislation in place (please see Table 1 above).

Summary

The policy and legislation that guides EHRs and PHRs varies internationally. This means that in each country the implementation journey is unique. It is important to acknowledge these differences when comparing digital health services internationally.


1 World Health Organization (WHO). Atlas of eHealth Country Profiles. 2015.
Available from: http://apps.who.int/iris/bitstream/10665/204523/1/9789241565219_eng.pdf [Accessed 1st Sept 2017].

2 Milieu Ltd - time.lex. Overview of the national laws of electronic health records in the EU Member States and their interaction with the provision of cross-border eHealth services. 2014.
Available from: https://ec.europa.eu/health/ehealth/projects/nationallaws_electronichealthrecords_en [Accessed 16th Dec 2017].

3 National Health Service (NHS). Your health and care records.
Available from: https://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/what_to_do.aspx [Accessed 20th Dec 2017].

4 Greenhalgh T, Stramer K, Bratan T, Bryne E, Russell J, Hinder S, Potts H. The Devil's in the Detail: Final Report of the independent evaluation of the Summary Care Record and HealthSpace programmes. 2010. London: University College London.

5 The Office of the National Coordinator for Health Information Technology. Meaningful Use Definition & Objectives. 2015.
Available from: https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives [Accessed 16th Dec 2017].

6 Ministry of Health Singapore. Future phase of NEHR.
Available from: https://www.moh.gov.sg/content/moh_web/home/pressRoom/Parliamentary_QA/2015/future-phase-of-nehr.html [Accessed 11th Sept 2017].