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Toward one national e-health strategy

Country: 
Schweiz
Partner Institute: 
Università della Svizzera Italiana, Lugano
Survey no: 
(11)2008
Author(s): 
Crivelli, Luca
Health Policy Issues: 
Neue Technologien, Organisation/Integration des Systems, Patientenbelange
Reform formerly reported in: 
Creation of an IT-based health care platform
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja nein nein nein nein
Featured in half-yearly report: G-politik in Industrieländern 11

Abstract

In June 2007 the Federal Office for Public Health outlined a national e-health strategy for Switzerland at the request of the Federal Council. Following the presentation of this document an ?e-health? office for coordination between the Confederation and the cantons was created. In 2009 the electronic card will be introduced for the insured. After a trial phase, characterized by the realization of regional IT platforms, finally the e-health strategy will be implemented at national level.

Neue Entwicklungen

In October 2004 the Federal Assembly set down the legal bases for the introduction of an eletronic card for the insured, by creating a specific article of law (42a) in the Federal Health Insurance Act (FHIA) [see ref. 1]. In February 2007 the Federal Council then presented a decree regulating the application of the law and the details on the functioning of the card [see ref. 2]. How the new system, which should come into force in 2009, will function was recently illustrated even more clearly than in the decree by the Federal Office of Public Health in a policy paper dated 1st April 2008 [see ref. 3], while the technical requirements are contained in a second decree of application dated 20th March 2008 [see ref. 4]. The instrument adopted by Switzerland corresponds to an "extended insured's card" where not only administrative data necessary to optimize the transactions from a management point of view are stored, but also some personal health care data of great benefit in emergency cases (blood group, allergies, drugs currently being taken, the patient's biological testament such as organ donation). However, it is still not a proper "patient's card" able to grant access to his/her own eletronic health records through an internet platform for example. For the moment the objectives of the "insured's card" are limited to improving administrative efficiency, increasing the quality and safety of an intervention in case of emergency (thanks to access to the personal health care data by the health care operator) and to the empowerment of the patient, who is called on to exercise his/her own responsibility by means of the decision to register certain personal data on the card or not. However, the Confederation hopes that leeway will be left to the cantons to try out solutions which move in the direction of a real eletronic health record through decrees enacted at cantonal level and of temporary valence, so that in time the insured's card will change into a fundamental part of the Federal Council's e-health strategy. Therefore the insured's card is inserted into a wider context, that of an e-health strategy at national level.

 Suchhilfe

Characteristics of this policy

Innovationsgrad traditionell recht innovativ innovativ
Kontroversität unumstritten neutral kontrovers
Strukturelle Wirkung marginal recht fundamental fundamental
Medienpräsenz sehr gering gering sehr hoch
Übertragbarkeit sehr systemabhängig recht systemneutral systemneutral
current current   previous previous

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja nein nein nein nein

Initiators of idea/main actors

  • Regierung
  • Leistungserbringer: see ref. 8 and 9
  • Kostenträger: Agreement on the basic principles, but different view with respect to implementation details (see ref. 10)

Stakeholder positions

The guidelines for the e-health strategy adopted by Switzerland are contained in a policy paper drawn up by the Federal Office of Public Health on the mandate of the Federal Council and presented in its final version on 27th June 2007 [see 5]. The cantons also helped to develop the strategy through the Conference of the Cantonal Directors of Public Health.

After confirming the central position of the individual in the Swiss public health care system, thus making it clear that developing new technologies does not represent an objective in itself as much as a support instrument to create value for the patient, the strategic plan defines the boundaries within which the electronic health services will have to develop in the next few years and the relative networking, establishing a clear set of priorities.

The aim of e-health is not so much to reproduce the present health care processes in the digital sphere as to define new ones, if possible better than the present ones, thanks to ICT support. In this way the added value of the whole operation should lie in the improved coordination of the health care providers and of the health care processes, which is necessary to overcome the present fragmentation of the Swiss health care system.  

Vision of the strategy

The spirit of the strategy is expressed by the underlying "vision", which thus summarizes the aims of the initiative:

  • to allow Swiss citizens to make the relevant information regarding their health status available to the physician of their choice, that is independent of the place and time of the consultation, in order to obtain appropriate health care;
  • to enable citizens to participate actively in the decisions regarding relevant health-enhancing behaviors and treatment choice, thus honing their own skills in the matter. Information and communication technologies should be used to guarantee the networking of the health care players and to grant the best health care processes from the point of view of quality, safety and efficiency.

Three fields of action

The strategy is divided into the following three fields of action:

  1. Electronic patient record. A systematic collection of medical, nursing, administrative data and of prevention measures managed by the patient is intended by this name. Ideally the electronic patient record should embrace the time horizon of the person's whole life. More concretely it is a question of realizing a web interface by 2015 which enables the patient and his health care provider to bring together all the information relevant to his/her health status and case history in real time, in spite of the fact that the data are stored in different archives (in the local information systems of single physicians or other providers such as hospitals and pharmacies). Each health care operator would therefore be responsible for writing up and keeping his/her information up-to-date, which would simply be shared and brought together within the patient's electronic record. The milestones of this first field of action are the following:

    - By 2008: definition of the standard for the electronic extraction of the relevant information from the local information system of single providers which must be shared to make the health care process efficient.

    - During 2009: introduction of the insured's card, which allows for the life-saving data to be stored.  

    - From 2009: encouraging the cantons to experiment with new electronic services on the base of the insured's card.

    - By the end of 2010: introduction of a secure authentification system of all health care providers and of electronic signatures, to be used in the electronic exchange of data.

    - From 2012: electronic authentification of all citizens (with the option of an electronic signature).

    - By the end of 2012: electronic transmission of medical data in a structured way among the main players in the health care system (acute hospitals, integrated networks of care, the majority of medical practices), without data loss and interruptions, by means of the electronic extraction of relevant data from the respective local information system.

    - By the end of 2015: all people in Switzerland have access to their own electronic health records at any time and in any place.

  2. On-line services. The state has shown interest in the diffusion of health information and advice, drawn up in a comprehensible manner for a public of lay persons, selected in a targeted way and respecting quality criteria. The information concerns the features of the health care supply and the health consequences of certain behaviors, which would increase the population's health literacy. By 2015 the Federal Government hopes that a web site will be opened, activated by the electronic patient record, which would enable selective and structured information to be extracted, of interest for the patient and of certified quality. The milestones of this second field of action are the following:

    - By the end of 2009: definition of the quality standards to set up an on-line database on health.

    - By the end of 2010: the information offered by the Confederation, the cantons, municipalities and international organizations, are accessible through a single health care web site.

    - By the end of 2012: quality insurance (EBM) of the information offered on the web site, into which also private bodies could be integrated in time.

    - By the end of 2015: secure access for citizens to their own electronic health record through the web site, with the opportunity to call up specific information in a structured way.

  3. The third field concerns the basic framework conditions needed to implement the strategy, above all at legislative level and regarding the diffusion of the necessary skills in the population and among providers, by offering the relative training. In this case too the strategic plan defines the various stages and allocates a time limit which will have to be respected to be able to meet the deadline of 2015 and to realize progressive empowerment of the citizens in using the information relative to their own health and diseases.

    - Creation of a coordination group Confederation-cantons, already operative from the beginning of 2008.  

    - By the end of 2008: clearing the juridical questions still open in order to continue with the carrying out of the strategy, in accordance with the legislative competences of the Confederation and the cantons; definition of a process for the progressive expansion of "e-health" architecture on a national scale; definition of the juridical framework to realize the PPP (Public Private Partnerships); assessment process of the cantonal trials; process of a systematic collection of best practices at international level; definition of a process for the transfer of scientific research results carried out at national and international level to the project management

    - Beginning 2009: Creation of an on-going training plan for health care providers in the  field of e-health.  

    - By the end of 2013: inserting "e-health" and computer courses into the basic training of medical faculties, of nursing schools and other health care professions. 

    Finally new models of financing in the health care sector can be imagined, able to encourage the diffusion and development of e-health.

Actors and positions

Description of actors and their positions
Regierung
Federal Councilsehr unterstützendsehr unterstützend stark dagegen
Federal Office of Public Healthsehr unterstützendsehr unterstützend stark dagegen
Conference of cantonal health ministerssehr unterstützendsehr unterstützend stark dagegen
Leistungserbringer
Physician Association (FMH)sehr unterstützendstark dagegen stark dagegen
Swiss hospital association (Hplus)sehr unterstützenddagegen stark dagegen
Kostenträger
santesuissesehr unterstützendneutral stark dagegen
current current   previous previous

Influences in policy making and legislation

The strategy defined by the Federal Council does not meet with the favor of the main players in the system, for whom realizing e-health means assuming significant costs to finance the change. All the players criticize the authorities for the late involvement of the stakeholders in drawing up the strategic plan.

According to the Swiss hospitals [see ref. 8] Switzerland would need a health care strategy rather than an e-health strategy. The creation of a coordination office between the cantons and Confederation appears superfluous in their opinion while it has not been clarified enough who will bear the costs of the strategy. The opposition of the FMH, the head organization of Swiss physicians [see ref. 9a and 9b], is even more structural and substantial; they fear that the information of a clinical nature put onto the insured's card could be exploited by the health insurers and do not think that the protection of personal data is guaranteed. Finally although in principle the health insurers are in favor of a national e-health strategy, they deplore the lack of clarity concerning the costs and financing of the whole operation, in the fear which is probably justified that they will be called on to bear a significant part of these costs [see ref. 10].

Actors and influence

Description of actors and their influence

Regierung
Federal Councilsehr großgroß kein
Federal Office of Public Healthsehr großgroß kein
Conference of cantonal health ministerssehr großgroß kein
Leistungserbringer
Physician Association (FMH)sehr großneutral kein
Swiss hospital association (Hplus)sehr großneutral kein
Kostenträger
santesuissesehr großgroß kein
current current   previous previous
Federal Council, Federal Office of Public Health, Conference of cantonal health ministerssantesuisseSwiss hospital association (Hplus)Physician Association (FMH)

Positions and Influences at a glance

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

Adoption and implementation

The task of implementing the e-health strategy was given to a new organ which was set up on 1st January 2008 on the basis of an agreement stipulated between the Confederation (the Department of Home Affairs) and the cantons (the Conference of Cantonal Directors of Public Health) [see ref. 6]. For the moment the new organ, whose activity is foreseen until 31st December 2011, with the possibility of an extension, is an e-health office for coordination between the Confederation and cantons with a somewhat limited budget; its decisions will not have legal force but only advisory value. The office submits to the indications of a steering committee, which the management levels of the two signatory institutions are part of. With the signing of this agreement the Confederation and cantons declare their commitment to collaborate in implementing the e-health strategy in the interest of a general solution at national level. On 10th April 2008 the steering committee defined six sub-projects required to implement the strategy and clarified the governance structure [see ref. 7]. The six sub-projects are: (1) juridical bases, (2) technical standards and architecture, (3) training, (4) trialing and PPP, (5) on-line services, (6) reimbursement and incentive mechanisms.

Expected outcome

As with every management instrument, e-health also presents some risks and different opportunities.

 Risks:

  • In medical practices and hospitals the number of patients who think they are well informed will increase, although their information is lacking from the point of view of quality or their ability to interpret the data. In these cases the doctor-patient relationship might be burdened with extra transaction and communication costs in order to correct these false perceptions on the part of the patient.
  • E-health might increase the mobility of patients, possibly weakening the tie to their own doctor and leading to more frequent changes in the care provider than is socially and personally optimal. The outcome might be negative both from the point of view of quality and of costs. E-health makes the transfer of clinical information from one doctor to another easier, but there are aspects which cannot be transferred. Among these the "relational assets" built up over years of relationships between doctor and patient can be mentioned; on the one hand these encourage the doctor's empathy toward his/her patient and on the other they are intangible assets which, as with any investment, affect the quality of the diagnosis and therapy. Too frequent changes in doctor could lead to an immediate and total depreciation of these "relational assets". At the same time if it is easy to change, an attitude of increased "health consumerism" might arise also toward treatments which are neither appropriate nor necessary.  
  • In spite of the security mechanisms and access keys which can be introduced thanks to technology, the collection of sensitive data gathered together in one single database raises the possible problem of personal data protection, which might not be totally guaranteed under the growing political pressure to control health care costs more effectively.
  • Finally there is a problem linked to the perverse effects of the great amount of transparency realized with electronic health care due to the possible repercussions which electronic tracks left in the information systems might have in terms of liability insurance; malpractice claims might increase as a result of the possibility to reconstruct more easily the succession of events and of health care intervention decisions which were taken by a particular health care provider. This transparency might lead to clinical decisions which are more conservative and more risk-averse than necessary and to the duplication of diagnostic and therapeutic acts which enable the complaint that not everything possible was undertaken to be avoided.

Opportunities:

 The advantages expected from the e-health strategy are the following:

  • the immediate availability of life-saving data in emergencies;
  • the possible reduction in medical errors, the increase in the quality of diagnosis and the improvement in the appropriateness of the therapy,
  • encouraging the development of quality circles thanks to the more rapid sharing of information;     
  • a reduction in administrative costs and in the duplication of examinations;   
  • the emission of e-prescriptions, with the chance of completely superivising the total amount of drugs the patient is taking,  
  • data to implement epidemiological research on the effects of preventive measures;  
  • access to telemedical and teleconsulting services;
  • more self-determination (voice) and more freedom of choice (exit) for the patient.  

Impact of this policy

Qualität kaum Einfluss relativ starker Einfluss starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering high sehr hoch
current current   previous previous

References

Sources of Information

  1. Federal Assembly (2004), Bundesgesetz über die Krankenversicherung (Gesamtstrategie und Risikoausgleich), Änderung vom 8. Oktober 2004 (www.admin.ch/ch/d/ff/2004/5479.pdf).
  2. Federal Council (2007), Verordnung über die Versichertenkarte für die obligatorische Krankenpflegeversicherung vom 14. Februar 2007 (www.admin.ch/ch/d/sr/8/832.105.de.pdf).
  3. Federal Office of Public Health (2008), Das System "Versichertenkarte" [1. April 2008] (www.bag.admin.ch/themen/krankenversicherung/04108/04109/index.html?lang=de)
  4. Federal Department of Home Affairs (2008), Verordnung des EDI über die technischen und grafischen Anforderungen an die Versichertenkarte für die obligatorische Krankenpflegeversicherung vom 20. März 2008 (www.admin.ch/ch/d/as/2008/1555.pdf).
  5. Federal Office of Public Health (2007), Strategie "eHealth" Schweiz (www.bag.admin.ch/themen/krankenversicherung/04108/index.html?lang=de).
  6. Swiss Confederation and Conference of the cantonal health ministers (2007), Rahmenvereinbarung über die Zusammenarbeit im Bereich "eHealth" + Erläuterung zur eHealth Vereinbarung vom 6. September 2007 (www.bag.admin.ch/themen/krankenversicherung/04108/index.html?lang=de).
  7. Swiss Confederation and Conference of the cantonal health ministers (2008), Aufträge Teilprojekte Strategie eHealth (www.bag.admin.ch/themen/krankenversicherung/04108/index.html?lang=de).
  8. Hplus - Die Spitäler der Schweiz, Stellungnahme zur nationalen Strategie "eHealth" vom Bundesamt für Gesundheit BAG (www.hplus.ch/fileadmin/user_upload/Spitalinformatik___Statistik/eHealth/
    spitalinformatik_ehealth_stellungnahme_fragekatalog.pdf
    ).
  9. FMH, Stellungnahme der FMH zur Versichertenkarte in der aktuellen Form (www.fmh.ch/shared/data/pdf/fmh_mediencommuniqué_versichertenkarte_
    310807.pdf
     und www.fmh.ch/shared/data/pdf/fmh_medienmitteilung_de_070913.pdf).
  10. Santesuisse, Anhörung: Nationale Strategie "eHealth" (www.santesuisse.ch/datasheets/files/200703301210300.pdf).

Reform formerly reported in

Creation of an IT-based health care platform
Process Stages: Strategiepapier, Pilotprojekt

Author/s and/or contributors to this survey

Crivelli, Luca

Proof-reading by Mary Ries

Empfohlene Zitierweise für diesen Online-Artikel:

Crivelli, Luca. "Toward one national e-health strategy". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/ch/a11/3