Netherlands' e-health systems linked to top healthcare performance
In the Netherlands, e-health initiatives have made remarkable progress over the last decade. Many initiatives have been deployed at national, regional and local levels. Indeed, the Netherlands, together with Denmark, is now considered the leading e-health nation in Europe 1.
This article describes the way the Dutch have approached the use of electronic tools (computers, internet, software, etc.) for healthcare purposes.
For several years in a row, the Dutch healthcare has now been found “the best healthcare system in Europe” according the European Health Consumer Index2. This index measures healthcare systems on factors like: patient rights, e-health, waiting times, outcomes, range of services and access to pharmaceuticals. The Netherlands scored well in all categories, but was never the best -- except for e-health.
It is also interesting to note an observation of The Consumer Powerhouse for the outstanding performance of the Dutch healthcare system: “Politicians and bureaucrats seem to be further removed from operative healthcare decisions in the Netherlands than any other country in the index,” and argues that this is an important reason for the Netherlands’ top-tier performance.
Use of healthcare IT in general
The adoption of IT technology in healthcare has traditionally been high in the Netherlands.
All hospitals have used HIS solutions for many years and most of the hospitals are either working with an EHR or are on the road to implementation. Digitization in radiology is close to 100 percent. All hospitals have a PACS, and many are already working with second or even third generation PACS.
More than 98 percent of GP’s use a practice management/EMR solution. E-prescribing was introduced in the 1990s and currently has a penetration of around 90 percent for the primary care sector.
All these scores are remarkable, as the hospitals and physicians are not specifically funded for IT, but have to do the investments out of their own annual budgets. This is particularly true in the area of PACS – the country has 100 percent digital radiology without government involvement or subsidies.
Dutch e-health approach
In 2005, the Dutch Ministry of Health embarked on a journey to implement a national Electronic Health Record for all Dutch citizens. Its goal is to improve the effectiveness and quality of care through the optimal use of information and communication technologies. Though the Dutch efforts may not often be cited in international contexts, the progress over the last years has been impressive.
The Dutch follow both a top-down as well as a bottom-up approach. On the one hand, work is being done to establish a country-wide infrastructure (called AORTA) including elements like an electronic healthcare provider card, a country-wide patient- and provider registry, security standards and legislation for one unique country-wide patient-ID.
The Dutch approach strongly supports a gradual integration and co-existence with existing HCIT solutions – not a “big bang” replacement. Healthcare providers have invested heavily in HCIT over the last years and these solutions should be leveraged within the overall e-health infrastructure.
In parallel, local and regional initiatives have resulted in many implementations of e-health solutions. These regional solutions were not sponsored by or financed by government, but by autonomous cooperation of healthcare providers (hospitals, GPs, etc.) that organize themselves into regional Health Information Exchange (HIE) organizations, either as separate companies or non- profit organizations.
Both the national and the regional approaches assume the principle of autonomous healthcare providers. Each healthcare provider has responsibility for “his” piece of the patient information. Therefore the approach of a virtual EHR has been adopted. Information “stays at the source,” thereby creating a “virtual” record whereby healthcare providers can access specific information from other systems online through secured connections, single sign-on, etc.
An important element of the EHR is the definition of standards for the exchange of information as part of the (regional or national) EHR. On the national level, standards have been defined for information exchange of medications, patient summaries and other data sets, using HL7V3. This work is done by the National Institute for ICT in HealthCare (NICTIZ), which also manages the coordination of AORTA. At the regional levels, not just HL7V3, but also older standards are supported (like Edifact and OZIS) in order to provide a transition for the HCIT systems that do not yet comply with HL7V3.
Especially at a regional level, many applications and solutions were deployed, varying from an electronic medication service (showing all of the patient’s medication), a web service for weekend/evening doctors in duty, (allowing them to access a specific view to the patient’s record during out-of-office hours) and integrated solutions for disease management like diabetes.
Web-based patient portals have been introduced, allowing patients to schedule appointments, re-order medication and have e-consults. Web-based referral services have been introduced, allowing referring physicians to create and manage their referrals. It shows the services offered by hospitals and clinics, waiting times etc. It also allows hospitals and clinics to define their services interactively and add them to the referral service. These services have shown dramatic reductions in unnecessary hospital visits and secondary visits, reducing cost and improving patient satisfaction.
Experience shows that involvement of healthcare providers in regional initiatives (covering 500,000 – 1 million patients) provides a good basis for success. Using existing regional cooperation structures, it creates a better understanding of the needs/benefits of the individual healthcare providers. The mutual trust stimulates willingness to share information. The implementations are done faster with greater acceptance. Fast and iterative software development approaches complement this flexible organizational approach.
All these solutions are bought by the HIE’s, and made by in an open competitive market by small and large IT companies (both national and international). The open competition model and using standardized interfaces stimulates HCIT providers to continuously work on the cutting edge of e-health solutions. Using standards like IHE and HL7 discourages lock-in to specific vendors. At the same time, co-existence with older de facto standards and even proprietary protocols allow for a gradual and smooth introduction and transition into the new e-health world.
In the coming years regional initiatives are expected to cover the entire country, whilst in parallel all regional solutions will connect to the country-wide infrastructure. The solution space is now being extended to new services like other disease management solutions, home-care, youth-care and more.
Marcel Swennenhuis is President of Topicus Healthcare in the Netherlands. The company develops physician practice management systems, patient portals and regional health information exchanges. www.topicus-healthcare.com