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HIE Policy Lessons From Europe

August 5, 2009
by David Raths
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Can lessons learned about health information exchange in European countries translate to the United States? That's the question posed in a recent report, "Accomplishing EHR/HIE (Ehealth): Lessons From Europe" co-authored by Fran Turisco, research principal, emerging practices, in CSC's Healthcare Group.

In a recent phone interview, I asked Turisco to expand on some of the report's findings, and her responses highlight how different cultural attitudes about government's role in health care may cause the biggest differences in the way HIEs are implemented in the United States.

As the report notes, in countries such as Denmark and the Netherlands, physician adoption of EHRs has been widespread for almost 20 years. Those countries and the United Kingdom have had success with the type of nationwide HIE implementation the United States is now embarking on. Some countries had the advantage of focusing on interoperability issues rather than having to worry about boosting EHR adoption rates at the same time.

In Denmark, Turisco noted, there's a generally positive attitude toward government. Although citizens pay very high tax rates, "there's a basic trust level with government," she said. That translates into acceptance of things like a national patient identifier number, a concept that faces strong opposition in the United States, perhaps because of a distrust of government. Even in European countries where the trust level is not as high, they have been able to adopt unique patient identifiers, Turisco noted.

That trust question applies to other privacy and security issues as well. "What I learned from talking to people in Europe on privacy and security is that you need to make it clear that you are doing this for the right reasons," she said. "Patients have to understand why it's being done and they must have the opportunity to opt out. In Great Britain, they have only a 1 percent opt-out rate, but it's crucial that patients have that option."

The government's role in funding HIEs may be different in the United States as well. In Europe, the governments fund almost everything related to HIE. Despite the HITECH Act funding, HIEs in the United States will still have to figure out how to become self-sustaining.

Turisco had praise for the recent work of the Office of the National Coordinator for Health IT on several fronts. First, like many European counterparts, ONCHIT has made sure technology is seen as playing a supporting role in healthcare improvement.

"With the meaningful use definition, they have done a great job of stressing that this is a part of health reform, not about the technology itself," she said.

The CSC report notes that "when technology appears to lead the effort, there are likely to be issues with stakeholder and end user buy-in and adoption. This was the case with UK's National Health Service (NHS) program. The fact that the name of the program was the National Program for Information Technology (NPfIT) and the CIO was the responsible person at each health trust lead to a perception of an IT-centric- project, not care-centric initiative. To overcome this perception and gain buy-in, the NHS is considering a rebranding effort."

Another lesson from Europe being applied in the current U.S. effort, she said, is that policy, certification and standardization decisions have to be made at the highest levels. "When you start regionalizing those decisions, that's when things go awry. We have seen that in Europe and in the United States," she said.

Also, she believes ONCHIT has started out doing a better job than some European counterparts of communicating with stakeholders and the public. There are open policy and standards committee meetings, and a free flow of information, she said. "Our organization sent in a question via the ONCHIT web site, and received an answer within 24 hours," she added.

Finally, she noted, although the European countries have been through these issues on a much smaller scale, it basically involves addressing the same stuff. "The same issues emerge," she said, "and you just have to meet those big issues head on."



What can we learn from their experiences?

I've always been an advocate of learning from the experiences of others, including what has worked, and what has not worked. In my former life as a technology "geek" I told my staff that we needed to avoid the "not invented here syndrome." Often technology people will explore opportunities to create unique solutions, and spend many hours doing so, when a more effective strategy might be to investigate the experiences of others.

I also commented on this paper briefly at http://www.myhealthtechblog.com/2009/08/csc-reports-effective-care-throu...

Exemplars are invaluable. "Discovering" a solution that works is far better/faster/cheaper than "Inventing" a new solution to a well understood existing problem. I applaud Fran's valuable work, and agree with Deborah's statement to that effect.

In that spirit, I think we need to also learn from the European and US experiences with adopting, for example, ICD-10. The US system of multiple payers including government, and healthcare system actors as a whole have demonstrated formidable opposition to modernization in terminology. Completely understandable economic interests have taken us down an entirely different road.

What can we learn from those experiences?