Evaluation of the implementation of EPRs

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 6

Abstract

According to an agreement from 2003 between the central government and the counties, all hospitals should have introduced EPRs based on common standards by the end of 2005. A new report evaluating the progress concludes that this goal will not be achieved and that a significant delay is likely. A principal the question of the rationale in having counties develop individual systems and the consequent problem of securing communication across the various systems.

Neue Entwicklungen

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

There is general consensus that a nationwide EPR should be implemented. The visibility of this initiative has been high following the evaluation of the implementation and the prediction that significant delays are likely. In contrast to the consensus regarding the overall objective, there have, as mentioned above, been conflicting views on how well the implementation process has been conducted.

Purpose and process analysis

Current Process Stages

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

Stakeholder positions

There is general agreement among political parties, organizations of physicians and nurses, patient organizations, analysts and commentators etc. that EPRs should be introduced into the Danish health care system.

The Minister of Health announced in July 2003 that the system would be implemented by the end of 2005 and has not renounced on that announcement up until now. However, following the critical evaluation report (for a summary of the main message of the report please see the section on monitoring/evaluation below) by the EPJ-Observatoriet (a public body instituted by the MoH) the Minister of Health and the Association of Counties have acknowledged that the goal of a general implementation by the end of 2005 will not be met. The Minister of Health and the Association of Counties in unison denies that the breakdown of the timetable is a matter of great concern. Nor is it, according to these two parties, an indication of basic incentive problems within the existing health care system. Both argue that the delay is understandable and contribute it to the complexities inherent in the health care sector and in implementing new technology. They now say that the system will be implemented by the end of year 2008. The Minister of Health adds that the new administrative structure of the health care system (which reduces the number of counties) will ease the implementation of the system.   

Political parties outside the government (including the party that forms part of the governments parliamentarian base) have, following the evaluation, been critical towards the governments handling of the implementation process. Two party health care spokes-persons express concern that the process has not been cost-effective. Several spokes-persons express concern that the Minister of Health has failed to satisfactorily inform the parliament committee on health.

Following the critical report there have been calls from employees organizations that the central government should assume sole or principal responsibility for the task of implementing a nationwide EPR system.

Influences in policy making and legislation

The delay has not caused the government to change the basics of the implementation process. The Minister of Health suggests that the planned introduction of a new administrative systems (with fewer counties called regions and a more potent National Board of Health) will ease the implementation.

Legislative outcome

n/a

Adoption and implementation

The main actors have been the counties and the central government represented by the National Board of Health. The National Board of Health has been the primary actor in the development of national standards.

For a thorough description of the actors please see the previous report on EPR from 2004.

Monitoring and evaluation

According to the annual agreement from 2003 between the central government and the counties (in Denmark it is the counties which own and run hospitals) all hospitals should have introduced Electronic Patient Record's (EPR's) based on common standards by the end of 2005. A new report evaluating the progress concludes that this goal will not be achieved. The report sketches a worst case scenario according to which the nationwide EPR will not be implemented until year 2020.

Expected outcome

It can be observed that the timetable for the implementation of the system has been broken. The system will not been implemented nationwide by end of 2005 as planned and consequently there has been little direct effect on outcome. Indirectly the failed implementation process may have influenced outcome as resources may have been wasted and the potential improvement of quality not realised. There has repeatedly been expressed concern about the cost-effectiveness in having several counties developing their own systems of EPR and it now appears that the effort by the central authorities to achieve coordination has failed. The likelihood is that at some point in time the government and the regions will succeed in the implementation of a nationwide EPR-system. A separate but very relevant question is if the implementation has been carried out in a cost-effective fashion. One would expect that this will be a subject not only for researchers but also for more official types of inquiries. Specifically, one would expect the National Audit Office of Denmark (an institution under the authority of the Parliament) to take an interest in the implementation process.

Impact of this policy

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

The introduction of EPRs has the potential of significantly increasing quality and cost-efficiency of services provided. However, due to the failed implementation this potential has not materialized.  

The interesting question relating to the failed implementation process is whether the delays and lacking coordination should be attributed to unavoidable "complexities" or to fundamental problems with incentives in the present system. One of the commonly used rationalisations of a public integrated health care system is that transaction costs are comparatively low, that actors are willing to cooperate and share information because that are spared from being placed in a competitive environment, that the system is not "fragmented" (to use one of the popular value-laden adjectives which blossom in the literature on health care systems) etc. The Danish experience with the implementation of EPRs suggests that the workings of a public integrated health care system is more complicated than is recognised when modelling it as if managed by a "benevolent, omniscient and omnipotent" planner. The complaints by politicians that they have not been well informed by the Minister of Health suggests that asymmetric information is a relevant problem also in a politically managed health care system. That several counties have chosen not to coordinate efforts and develop mutually compatible EPJs can be explained by either an incentive to "empire-building" or as a way to insulate against the effects of free-choice schemes (by making it more difficult/less attractive for consumers to choose out-of-county providers) or a combination of both. 

One additional sideeffect of the recent development is that the Minister of Health has lost credibility in his effort to make the overall system accountable. The Minister came into office in 2001 and has been involved in the policies regarding the implementation of EPR to such an extent that he must be considered no less a responsible part for the project than the counties. At the same time he has pushed for a new policy approach based on transparency regarding performance by, e.g., the setting of explicit and known goals. The fact that he has now renounced on the goal of a nationwide EPR by the end of 2005 (and only admitted the postponment shortly before deadline and only when facing out-side pressure) and that he has vehemently denied the seriousness of the postponement, is likely to make it difficult for him to institute and enforce a regime that punishes lack of goal fullfillment. The actors will probably choose his own strategy and seek to avoid being held accountable by making a reference to the notorious complexities of the health care sector.

References

Sources of Information

The evaluation of the progress has been published by The Danish Electronic Health Record Observatory (a public institution established by the MoH). The Observatory's homepage is www.epj-observatoriet.dk. The evaluation is part of the annually published status report from the observatory and is available (in Danish only) from this link: Status rapport 2005.)

Reform formerly reported in

Electronic Patient Records in hospitals Process Stages: Umsetzung

Electronic Patient Records in the Danish HC Sector Process Stages: Umsetzung

Author/s and/or contributors to this survey

Michael Appel

Empfohlene Zitierweise für diesen Online-Artikel:

Michael Appel. "Evaluation of the implementation of EPRs". Health Policy Monitor, October 2005. Available at http://www.hpm.org/survey/dk/a6/1