Imagine you live in Slovakia, suddenly feel an abdominal pain so strong that makes you feel you can't wait until your general practitioner has some slots free for you, and decide you need to visit the ER department. At the moment, unless you have a good enough memory to remember any previous diagnosis and medication prescribed to you or you have already been a patient at that particular healthcare facility, there is no chance for the medical personnel on duty there to find any information about your health records. Yes, in the year 2017 when robots are used to perform surgeries and Slovak medical students are using virtual medicine techniques, the country still lacks basic access to a nationwide unified database of medical records. Its introduction has been missing its deadline by about 5 years already, at a total cost reaching almost 47 million euro, amidst the threat of penalties imposed both by the European Union and the national watchdogs. After a series of controversies and changes it has been decided that patients will use their regular ID card which has an electronic chip inside to allow their doctor to access their online health records. Those who care more about the security of their data can use some 6 figure PIN code in order to control who and how has access to these sensitive data. Even if National Centre for Healthcare Information works with estimates that between 5 and 40 percent of doctors do not have the technical equipment required - be it a good computer or proper access to the internet - the new deadline for the implementation of the first phase of the eHealth system is December 31st, 2017. I discussed all these issues with Peter Blaškovitš, the head of the National Centre for Healthcare Information which is in charge of managing of eHealth in Slovakia.
The first studies related to the eHealth project were done in 2008, then it has been recording delays, which in my opinion have been caused by political changes at the helm of the Health Ministry as each team had its own ideas about how it should look. Various analyses estimate that we would have saved about 100 million euro per year if we had had the system in place - via, for example, avoiding unnecessary or duplicated tests. The project as such was finalized at the end of 2015. I do not want to be too technical. What I want to say is that we are now in the implementation phase. There was a pilot phase which was run last summer on a sample of 10 doctors - both general practitioners and specialists - and one pharmacy which aimed at identifying errors and other shortcomings. The system has a total of 150 services on offer from the classical medical records to e-prescriptions for medications, to appointment history and so on. Now we are in the most difficult phase in my opinion because buying the hardware and writing the code is less complicated than persuading tens of thousands of healthcare providers to register with the system. Currently we have been working on introducing 17 hospitals into the system.
Given that the philosophy of the whole healthcare system in Slovakia is based on the idea of general practitioners being central figures acting as sorts of gatekeepers and the reality that the vast majority of GPs are in fact working in smaller private practices, not hospitals, with various degrees of informatization I was wondering how Blaškovitš''s office plans to motivate them to join the eHealth system as soon as possible so that no bottlenecks will appear at the end of the year when the official deadline will come into force. In their case the procedure says that they are supposed to ask the providers of their IT system to update it so it becomes compatible with the eHealth system. It's estimated that this upgrade might cost them between 300 to 400 euro. Those doctors who are still not computer friendly might need a bigger investment.
Indeed it has been easier to deal with hospitals and bigger providers because they already have some IT department or an external company dealing with this issue on regular basis. Individual smaller medical practices have indeed proven a tough cookie, mainly in some regions where they are dispersed over a wide area. We have been targeting, on one side, the software providers to engage them to communicate with their doctor-clients, and on the other hand we have been preparing an information campaign for doctors as such. It uses different channels and forms from leaflets to video clips on YouTube for example with the aim being to inform them about what eHealth implies. But I want to make one thing clear: as of January 1, 2018 this is a compulsory system for all doctors and healthcare providers in Slovakia. Doctors can't choose if they want to use it or not. They must use it. Then we target patients because they need to know what the benefit is to their health, for example, that they could access their health records online.
Those criticizing the current design of the eHealth system, being doctors involved in the pilot phase or IT experts, say that the Health Ministry has been obsessed by security issues and data protection so the result is a quite rigid system that does not allow easy interaction between users. Blaškovitš who took office last year agrees.
Yes, indeed security is at a very high level which of course has its negative side effects as it increases the complexity of the system. On the other hand we have to bear in mind that this is the place where the data on the health status of the entire population of the country is stored so yes, protection is very, very important. Imagine what happens if somebody hacks into this system- there are many actors who would be very interested in this data from commercial insurers to drug companies or somebody who for example wants to find sensitive information about an important person. I can admit, however, that now in 2017 there are technological solutions which could solve some of the security in a better way than when the parameters of the system were set.
In its current form, specialist doctors cannot see among themselves data from imagistics and radiology, such as CT scans for example, unless they work in the same medical facilities. Patients are entitled to a second opinion, and imagine a neurologist who - because she or he cannot see the image based on which another colleague set the diagnosis - will most probably sent the patient to have another scan, so the goal of saving money by avoiding duplicity goes out the window.
This has never been planned as being included in the first phase of the project that we want to implement this year. It will be part of the second phase for which we have been preparing an application for funding from the national programme called "Integrated infrastructure" which uses money from EU structural funds. However, I don't think that it would be right, fair and responsible to start working on this part until we have the first phase of the eHealth fully implemented. If by the middle of this year we see that we have the implementation of the first phase under control then we can launch the first steps of the second phase this year. I think that the lengthiest part will be the public tender. But all in all I would say if we have the necessary contracts signed we could start implementing it in the first quarter of 2018.
Everybody dealing with healthcare in Slovakia likes to speak about how the patient should be the centre of attention and this applies to the eHealth system too. In the current form, patients can access their medical records online and can read them if they want, change their address or marital status…and that's about everything. They cannot click for example on the name of their disease and learn something more about it. They cannot even contact their doctors through the system for additional questions. Patients may be the focus but in a passive way. There is an additional website with some very general medical information but it's not very user friendly. Blaškovitš says that his team plans a redesign which will try to solve these issues.
I agree that this first phase of the project offers a passive look at somebody's health records. Those who are interested can find information on that National Health Website which are written by professionals because you know we try to avoid people misinterpreting all sorts of information they can find online. That site can also help people choose a doctor. We want to make it more user friendly, if you want, something like Facebook has with that timeline- from the date of birth we will add all other events concerning that user's health- this is a diagnosis, this is the drug prescribed, click on it to find out more. If you have a baby, once it's recorded there you can click on the icon and be directed to the baby's health records. We plan to make other changes too, for example, patients can decide which specialist can have direct and unlimited access to their online records. Currently the legislation says that only the general practitioner has such unlimited access but we understand that for chronic patients the long term relationship with their specialist is very important so why not allow them to choose who can access what?
How has the issue of the patient's informed consent been solved?
We are working on a piece of legislation that will introduce electronic informed consent. Until then it will remain on paper.
How will researchers and health policy analysts benefit from eHealth - because no matter how much money it saves by eliminating duplicity in medical tests for example - its added value is in the potential for data mining for the design of preventative programmes or medical research? Do you expect to help your institution, the National Centre for Healthcare Information, to improve its analytical capabilities because you have been often criticized for standing on a top of big amount of data which is collected but not efficiently used?
The eHealth system will offer data to researchers, of course in an anonymized form. Of course we first need to have data on it so we can speak about data mining for research in a year's time from January 2018 following the deadline for providers to join the system. It will be our centre that has first access to this metadata so we will try to present it in such a form that can be used for analysis. I do agree that we simply sit on top of data and do not use it efficiently. We do publish a lot of statistical data and it's not done in a dry way- you have some graphics and analyses in our yearbooks for example. Yes, I know we have problems with the national oncological register having very old data there but I have to say that even in other countries, such as in the USA for example, the latest data is still at least two years old, so even if eHealth will reduce the time for data collection we will still need to 'clean the data' so to speak which implies some delay. It's not only up to statisticians; independent doctors have to check the accuracy of that very complex data too. If something is not clear then they have to contact their colleagues who have treated that particular oncological patient and clarify the situation. And talking about statistics I should not forget to say that one of the benefits of eHealth for doctors is that it eliminates a lot of bureaucratic tasks they have to do when it comes to sending all sorts of reports about their activity. Once they're using eHealth there will be no need for them anymore because we can collect it direct from the system. It saves not only money in the healthcare system but doctors' time too because they can spend more time with patients for example.
Concluded Peter Blaškovitš the head of the National Centre for Healthcare Information, adding that his team is negotiating with health insurers for tools to motivate those doctors who still struggle with meeting the technical requirements for using eHealth. One proposal is to introduce a system of loans which can be paid back via a compensation mechanism agreed with health insurers.
Still waiting for eHealth to take off
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