This chapter describes the relationship between the structure and organisation of the Dutch health system and the management, use and sharing of health data to improve health outcomes and achieve public policy objectives. The four fundamental laws that govern the four domains of the Dutch health system are discussed (public health, social care, curative care, and long-term care), which determine not only the health system’s architecture but also how data are exchanged within it. The chapter then describes in more detail the concepts of health data infrastructure, data governance and an integrated health information system; the key components of an integrated health information system; and how it can help countries to advance policy objectives. Examples from across OECD countries illustrating the development of health data governance frameworks and interoperable electronic health record systems are presented to inform the review of the current situation in the Netherlands.
Towards an Integrated Health Information System in the Netherlands
2. The structure and governance of the Dutch health information system in comparison with OECD countries
Abstract
This chapter first outlines the key features of the Dutch health system in terms of its structure and organisation, and how these influence the generation, management and use of data. The scope includes the four laws that govern four domains of the Dutch health system: 1. public health, 2. social care, 3. curative care, and 4. long-term care. These laws lay the foundation for not only the overall structure of the health system but also how data flow between the various stakeholders and organisations within it. The result is a fragmented and heterogeneous health information landscape.
The second part of the chapter describes what is meant by a health data infrastructure and an integrated health information system, its key components, and how it can help countries advance policy objectives. Progress across OECD countries in the development of health data governance frameworks and in the development and governance of interoperable electronic health record systems are presented to inform the review of the current situation in the Netherlands.
The Dutch health system is fragmented by design
The Dutch health system (defined here as the overall approach to promote individual and population health through social, preventative and curative means) is a combination of managed competition where individuals, health care purchasers and providers determine price, quality and service based on supply and demand within policy and regulatory parameters set by the government (Van Driesden G, 2021[1]). The system is perhaps best viewed in terms of the laws that govern public health, social care, curative care and long-term care:
1. Public Health Act:
a) Regulates public health interventions such as population-level screening and control of infectious disease
b) Stipulates the remit of local governments in promoting public health and well-being.
2. Social Support Act:
a) Stipulates that local governments are responsible for social support, informal care, and volunteer work
b) Governs the provision of domestic help, day centres, support, and short-term stays at health facilities
c) Requires sheltered accommodation for people with psychosocial problems.
3. Health insurance Act:
a) Provides for basic entitlements to health care through the funding of basic health insurance
b) Requires that individuals purchase basic health insurance
c) Stipulates that health care providers may not exclude anyone from basic health insurance.
4. Long-term Care Act:
a) Regulates health care for people who require 24‑hour care and permanent supervision
b) Provides that people who have received a special-needs assessment are entitled to care either at home or in a designated facility
c) Requires that health care administrative offices procure sufficient care or provide personal budgets.
This arrangement creates the basic architecture for how Dutch health and social care data are collected, stored and managed (Figure 2.1).1
Figure 2.1. Four key types of health data in the Netherlands
Image credits: © Shutterstock.com/Moab Republic, Shutterstock.com/Cube 29, Shutterstock.com/Millering, Shutterstock.com/Qualit Design.
In addition, the Dutch system works largely on a mixture of competition and market mechanisms, and it relies heavily on the private (not-for profit) sector. It has limited government involvement on a national level (health care) and substantive involvement on municipal level (social care). While it has performed very well in comparison to other OECD countries. It is highly fragmented across health settings and sectors – exemplified by the separate approaches toward managing and using public health data, health care data and social care data.
Fragmentation in health systems is certainly not unique. However, in contrast to other most countries where it is a result of either legacy factors or unintended policy consequences, it is a design feature in the Netherlands to ensure market mechanisms can function as intended. For example, the competition law explicitly prohibits exchange of information between providers in order to maintain the market mechanisms. However, an exchange of data can lead to actions that benefit public health, a role allocated to the government via the constitution law. This illustrates the need for some legal reform on data exchange for the benefit of public health.
Fragmentation and the consequent high number of data custodians – does not ipso facto impede nation-wide co‑operation, co‑ordination, and data standardisation, but it makes indispensable co‑ordinated, national policies, legislations, incentives, and governance mechanisms to support and encourage actors toward the common goal of optimising the use of existing data.
Many institutional actors characterise the regulatory landscape of Dutch health and social care
Fragmentation characterises not only Dutch health system provision but also its regulation and governance. A high number of institutional actors and organisations have a stake in governance and regulation, data creation and processing, and data interoperability and exchange.
Governance and regulation
The key regulatory institutions, the Nederlandse Zorgauthoriteit (NZa), the Dutch Health Institute, the Inspection of health care and youth, and the Authority for Consumers and Markets, all have part of the mandate in data governance and part access to the data. Municipalities, health insurers and zorgkantoren have siloed mandates for financing of health and social care.
The central government, meanwhile, is advised by different (independent) committees like the Gezondheidsraad, Sociaal en Cultureel Planbureau, Wetenschappenlijke Raad voor het regeringsbeleid, Raad voor Volksgezondheid en samenleving (curative care, long-term care, social care, and public health), Zorginstituut Nederland (curative care, long-term care), Rijksinstituut voor Volksgezondheid en milieu (RIVM), and the GGD (public health). The Informatieberaad Zorg (IB) is the (informal)advisory body in which parties come together to work towards safe exchange of information, however their focus is on curative care and primary uses of information.
The Dutch system also relies on input from confederations and representatives’ organisations like the Verbond van Nederlandse Ondernemingen en het Nederlands Christelijke Werkgeversverbond (VNO-NCW), the Federatie Medisch Specialisten, Beroepsvereninging Verzorgenden Verpleegkundigen (V&VN), Jeugdzorg Nederlan (JN), Nederlandse Vereniging van Ziekenhuizen (NVZ), the Nederlandse Federatie van Universitaire Medische Centra (NFU), and the Patiënten‑federatie Nederland.
Generating data, data processing and analytics capacity
Together, health and social care providers generate an immense amount of data but these data are most commonly kept within the organisation/sector. Some providers have realised the potential of integrating data with other providers and multiple initiatives to exchange data have started for example between collaborating hospital groups (Santeon group), regional health and social care provider alliances (Beter Samen in Noord), and municipalities and health insurers (gemeentezorgspiegel). However, not all providers have the capacity to do so, some are not able to access the data they generate for secondary purposes, due to a lack of human capital (skills) or financial resources for EHR data processing and analytics tools.
There is sharing of de‑identified personal health data for secondary purposes, for example GP’s sharing data with an academic network for primary care, is done within sector specific research organisations such as Nivel (health care), Vilans (long term care and social care), and Trimbos (mental health and addiction).
The Centraal Bureau voor de Statistiek (CBS) has a lot of experience in data processing, linkage and analytics. However, its mandate is limited in the health arena. The) in co‑operation with CBS and the Ministry of internal affairs are trying to standardise data collection and use on a national level for all municipalities working with a diverse range of data from living conditions, education, economy, public health and social care. Noting that most individual municipalities, as most individual health and social care providers, do not have the capacity for data processing and analytics for secondary purposes.
Standard-setting for data content and exchange
Dutch claims data are well standardised and have clear custodianship. The Nederlandse Zorgauthoriteit (NZa) collects hospital activity data (DRG), Vektis collects reimbursement data, and the Zorginstituut Nederland (ZiN) collects data to enable risk equalisation among the many insurers in the Dutch health care market and public reporting on providers as part of the existing accountability mechanism.
Data on the quality of specialised care is most often managed through Quality Registries by professional networks and collected via private data custodians in specialised registries (e.g. DICA, DHD, Dutch cancer registry). Data generated by individual providers and health care professionals are less standardised as individual providers and provider organisations have different preferred tools (including indicators), EMR vendors (including some organisations with different content within the ‘same’ EMR system) and priorities in data standardisation. The TWIIN initiative co‑ordinated by the Vereniging van Zorgaanbieders voor Zorgcommunicatie (VZVZ) and RSO Nederland has the overarching goal to lay the foundation of rules and infrastructure for these disparate entities to exchange data. The ambition is to create a data infrastructure with nationally co‑ordinated authorisation and privacy design through: 1) exchange of medical images between health care providers, 2) exchanging laboratory results with pharmacies, and 3) exchange of data in perinatal health care. This initiative is not structurally funded but received start- up funding from Zorgverzekeraars Nederland (ZN), an umbrella organisation for Dutch health insurers.
The Nederlands Normalisatie‑Instituut (NEN) is a non-for-profit private company and the Dutch collaborating partner with the European EN-norms and the international ISO-norms. Ministerie van Volksgezondheid, Welzijn en Sport has asked NEN to develop standards and certification schemes for electronic data exchange in health care together with the health care sector.
Nictiz is one of the important organisations developing standards for health data exchange in the Netherlands. Together with input from other parties that develop standards, like the Zorginsituut Nederlands, they have built up a library of standards on all five levels of interoperability 1) organisational, 2) process, 3) information, 4) application, and 5) IT-infrastructure.
There are initiatives to facilitate data exchange in health care. Medmij is a standard for the exchange of health care data between the care professional and the patient. Vendors of personal health environments can acquire the MedMij label to showcase safe and trustworthy data exchange practices. This initiative from the Informatieberaad Zorg and the Patiëntenfederatie Nederland is voluntary for vendors of personal health environments.
The LSP, co‑ordinated by the VZVZ, is a platform in which patients/clients can authorise certain health care providers to share their data when needed. This platform started to facilitate access for health providers to patients’ medication in emergency situations. It is an opt-in system and therefore does not cover the whole population. A proposal was recently heard in the senate that an opt-out system for health care data exchange would still maintain the right to choose and would be more fitting for the needs of patients.
Modern health systems (and societies) rely on integrated data and information
Twenty-first Century health systems will be built around information: the right information reaching the right person at the right time. This enables providing high-quality integrated care to all people in need, as well as better public health practice, health system management, and research and innovation. While health systems will continue to be structured, funded and organised differently, success – in terms of better care, public health, system management and research – will be characterised by a comprehensive, coherent, standardised and integrated approach to managing (electronic) health data.
A data infrastructure and information system
Any endeavour whose goal is social and economic advancement relies on infrastructure. Putting data to work successfully is no exception. Data infrastructure comprises data assets supported by people, processes and technology (Open Data Institute, n.d.[2]). It includes the bodies or institutions that create, maintain and manage the data as well as the institutions, policies and rules that guide their use. A data infrastructure can be seen as an ecosystem of technology, processes and actors/organisations needed for the collection, storage, maintenance, distribution and (re)use of data by the different end users. As an analogy, a rail infrastructure includes not only the tracks and trains but also the resources, people and equipment to maintain them, regulations and traffic control rules, as well as ticketing and other passenger services. A strong data infrastructure enhances the efficiency and productivity of using data.
It is necessary to distinguish between data and information. Data are raw figures and facts and, in and of themselves, may not be very valuable. Information, on the other hand, is meaning and insights that are obtained from the analysis of data. Thus, this report focusses on obtaining value from health data within the Netherlands by developing a system that yields information. A data infrastructure is the foundation. A health information system not only collects, manages, compiles standardises and exchanges data it also derives meaning and information from health data through analysis and review. It is a system because the focus is on data exchange and integration of information across different stakeholders. This requires supportive laws, policies, governance, hardware and software, expertise and analytical models as well as public communication channels, strategic planning, implementation guidelines, and audit and evaluation mechanisms.
An integrated health information system means that electronic data are FAIR (findable, accessible, interoperable, reusable), and can be exchanged and securely used by other actors and institutions that serve the public interest. The result is that data can flow, safely and securely, to where information can be extracted from them to create knowledge that advances human health and well-being.
Individual-level data are needed for both primary and secondary uses
An integrated health information system can help not only directly improve care quality, outcomes and patient empowerment by enabling patients and their health care providers to access important information, it would also raise the country’s capacity to use these data for other important purposes including:
Managing health system performance on national, regional and network level
Public health monitoring and surveillance
Opening new communications channels with patients to improve patient-centred care such as the active use of patient-reported metrics (PROMs and PREMs)
Introduction of new digital services such as e‑prescriptions or telehealth
Better targeting of reimbursement for services to reward value
Biomedical research and development
Innovation such as big data analytics and artificial intelligence that will enhance knowledge‑based decisions for patient care and health system governance.
Every data point should serve many uses, from informing a physician caring for a patient to helping patients manage their care, to health care quality monitoring indicators, value‑based payments, real-world evaluation of the effectiveness of therapies and contributing to clinical decision support tools (artificial intelligence). Recent advances include that individuals’ data are now used to inform decisions about their care and the care of others. The distinction between using data for primary purposes (direct patient care) and secondary purposes (e.g. research, public health monitoring) is therefore increasingly blurred.
For this reason, health data today cannot be easily categorised as personal or non-personal when the data pertain to individuals. A simple data processing step, such as removing personal identifying information like names, addresses, health insurance numbers and birth dates from a data set, does not yield anonymous data because it is increasingly easy to re‑match the data to other datasets and re‑identify individuals with some probability of success. More complex manipulations or aggregations of data to try to guarantee anonymity may destroy the quality, validity and usefulness of the data to produce valid information and research results.
Even the simple data processing step of removing personal identifying information must be carefully considered, as the linkage of datasets may require this information, for example to link hospital inpatients to mortality data to find out how many patients died in the weeks following a procedure. Mechanisms that allow re‑identification for approved data uses, such as investing in pseudonymisation and secure storage of re‑identification keys, are recommended by the OECD (see Annex B).
The key elements of an integrated system that enables primary and secondary uses of data are: approaching health data as a public good; implementing standardised data terminologies and formats (a single ‘language’); a common data model and standardised analytics; and comprehensive data governance that uses a ‘privacy-by-design’ approach. These are outlined next, followed by a section on the interoperability of electronic medical records.
Approaching data as a public good
Countries making strides in putting their data to work have recognised that data are a valuable resource that should be used to generate public benefits. Significant public investment in health and health care are a key reason why health data are a public good – this includes public investment in health care provision, in health data development and in funding health research.
But there is also an economic argument for seeing data as a public good in the modern era of Big Data, high performance computing and modern analytical techniques including machine learning and artificial intelligence. Data represent immense value both because of the information they potentially contain and because they can be used and re‑used ad infinitum. Their use by one actor does not preclude their use by others. More importantly, like other public goods such laws or language, data are instrumental in building social value through knowledge and information. Their exclusivity is not intrinsic, but is imposed by man-made laws, conventions, and institutions. In net terms, their commodification hampers human development.
Moreover, the social and economic value of data increase exponentially with their size. For example, a researcher looking for biomarkers that will uncover a precision therapy will find a single dataset comprising 10 million records is much more valuable than 100 separate datasets of 100 000 patients that cannot be linked or analysed as a whole (such as via the personal data train). In the private sector, forward-looking firms have realised that even a small slice of analytics on a huge data pool can generate far greater returns than hoarding much smaller puddles of data for proprietary use.
But to fulfil their potential in secondary uses as well as the primary objectives of improving patients’ care, experience and outcomes, data held in various places by different custodians must be coded in formats and languages that enable them to be exchanged and linked.
Data must be standardised to common technical and semantic formats
The main reason why health data are not put to work is a lack interoperability. This happens when the information systems of data holders have been developed without the use of common standards which prevent data from being exchanged or when data are exchanged, make it very difficult for the data to be interpreted or integrated with other data. Without the ability to share and interpret data easily, every data exchange becomes a costly and time‑consuming data integration project.
Data standards in health and health care include the methods, protocols, terminologies, and specifications for the collection, exchange, storage, and retrieval of health data from many different sources such as electronic medical records, insurance claims, laboratory test results, prescription medicine dispensing records, vaccination and public health records, population surveys and more (see Box 2.1).
Therefore, the most efficient solution to maximise the value of data held in silos is to agree on and adopt common standards for data terminology and exchange. Increasingly, such standards are becoming global, enabling multi-country collaboration in the development of IT systems and tools, cross-border access to clinical information for travellers who fall ill, as well as in undertaking multi-country medical and health research.
An intermediary solution exists to improve health data interoperability – mapping data from multiple organisations that use different data standards to a Common Data Model (CDM). A CDM organises data into a standard structure that makes it possible for data and the meaning of data to be shared for analytical applications, allowing for efficient data pooling and data integration for health statistics and research. The CDM is not, however, a practical solution for all situations where interoperability is needed such as the exchange of data among health care providers for direct patient care or the development of a patient portal.
It should be stressed that an integrated health information system does not require all data to be stored in a single location. It is quite possible to achieve the key objectives outlined earlier in this report without central storage or even aggregation. A unified and co‑ordinated approach to national data governance can enable smooth information exchange and use for a range of purposes without compromising privacy, security and ownership of data. In fact, in some ways data protection can be enhanced under a federated data structure.
Further, ensuring that data can be exchanged across national borders into Europe and beyond can amplify the benefits of data analytics and research in, for example, the context of public health, rare diseases, pharmacovigilance, and precision medicine (see next section). An information system that follows international data standards facilitates within-country and cross-border health care delivery and business opportunities for the Netherland’s research and technology sectors; and is better prepared to participate in and adapt to European regulations and initiatives.
Box 2.1. Data standards in health and health care
Data standards in health and health care describe the methods, protocols, terminologies, and specifications for the collection, exchange, storage, and retrieval of health data from many different sources including electronic medical records, insurance claims, laboratory test results, prescription medicine dispensing records, vaccination and public health records, population surveys and more.
Standardisation can be summarised as a three‑step process. The first step is to specify and define data elements. Examples of data elements are a lab test result, a particular medicine, and a patient’s name, age and allergies.
The next step is to associate data types with the data elements. Types include dates, time, counts, units (weights and measures) and codes that rely on formats and terminologies. For data to be exchanged and used for many purposes it is essential that the data types are universal and used consistently. A simple example is recording the time something occurred in a 24‑ or 12‑hour format.
Many data elements are defined by terminologies and their associated codes. For example, SNOMED CT or SNOMED Clinical Terms is a systematically organised computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. Standards for syntax are also required which specify how terms should be combined to be interpretable.
The third step is determining how to encode the data elements as an electronic message to exchange the data within the health information system. Message format standards include common encoding specifications, information models for defining relationships between data elements, and document architectures and clinical templates for structuring data as they are exchanged. A widely used standard for clinical record exchange is Health Level 7 (HL7).
Information models describe how elements and codes should be contextualised with additional information about data subjects. For example, the terminology and code for fever may be insufficient without also including information about the process for measuring the fever.
Document architectures are standards for classifying, capturing and revising clinical notes. Clinical templates impose constraints on an information model. For example, a message format for a laboratory test may have a clinical template that requires certain data elements to be included.
In addition to standards for data terminology and exchange, standards are also necessary for user interfaces, record linkage, and data privacy and security protections.
Standards should be accompanied by use cases.
A use case describes a particular instance of exchanging health data and includes the standardised data to be exchanged as well as the stakeholders involved and the legal framework supporting the data exchange.
Developing standards requires consideration of the data needs of all of the key stakeholders within the information system, including stakeholders requiring data for primary (direct care) and secondary (statistics and research) uses. Developing use cases alongside the development of data standards is a mechanism for ensuring that the standards will support the different uses of the data that will be needed.
Source: Institute of Medicine (2004[3]) “Health Care Data Standards”, in Patient Safety: Achieving a New Standard for Care, https://doi.org/10.17226/; Schulz S., Stegwee R., Chronaki C. (2018[4]), “Standards in Healthcare Data”, in Fundamentals of Clinical Data Science, https://doi.org/10.1007/978-3-319-99713-1_3.
The EU Health Data Space to help the region capitalise on the potential of health data
The considerable potential to advance health and welfare as well as providing commercial opportunities for European companies are the motivation to create an EU Health Data Space as part of the EU Digital Health Strategy (EC, 2021[5]). A new regulation is proposed to support Data Spaces in key economic sectors to create a single market for data, where data from public bodies, businesses and citizens can be used safely and fairly for the common good. An EU Health Data Space is proposed to “promote better exchange and access to different types of health data (electronic health records, genomics data, data from patient registries etc.), not only to support health care delivery (so-called primary use of data) but also for health research and health policy making purposes (so-called secondary use of data)” (EC, 2021a[6]).
Three pillars to support the Health Data Space are proposed:
1. Developing a health data governance framework for EU member states that provides guidance toward secure and privacy protective primary and secondary uses of health data that foster the accessibility and sharing of data. Such guidance would support greater harmonisation of the implementation of EU GDPR requirements in practice.
2. Data quality and interoperability including technical and semantic (terminology) interoperability between the different infrastructures and IT systems and ensuring health data in Europe are FAIR (Findable, Accessibly, Interoperable and Re‑Usable).
3. Technical infrastructure that builds upon and scales up EU infrastructure, including the eHealth Digital Service Infrastructure, the European Reference Networks and the Genomics Project.
The technical and semantic interoperability standards for the Health Data Space are expected to include international standards for data exchange and terminology and favour exchange standards that support protection of health data privacy and security. For example, a 2021 policy report of the Standing Committee of European Doctors which represents medical associations across Europe, calls for the Health Data Spaces to adopt the HL7 FHIR standard for data exchange and the SNOMED CT clinical terminology standard (CPME, 2021[7]).
In alignment with the EU Health Data Space, the European Medicines Agency (EMA) is developing the DARWIN (Data Analysis and Real-World Interrogation Network) (EMA, 2021[8]). DARWIN will be a co‑ordination centre to provide timely and reliable evidence on the use, safety and effectiveness of medicines for human use, including vaccines, from real world health care databases across the European Union (EU). The 2021 call for tender for DARWIN requires all bidders to implement a common data model (CDM).
New national bodies in France and Finland have characteristics and functions that are similar to the health data spaces envisaged by the EU. France introduced the Health Data Hub in 2019 and Finland launched FinData in 2020 to provide a unique entry point for secure and privacy-protective data linkage services and access to health microdata that are EU GDPR compliant (see next section for descriptions of FinData and the Health Data Hub).
Privacy by design and a national data governance framework are essential
A key component of a well-functioning health information system is data governance that avoids the over-use of consent to authorise data exchange, in favour of legal authorisation and requirements for an approach that protects privacy, ensures data security while enabling data to be exchanged and used for legitimate purposes. The OECD Council Recommendation on Health Data Governance sets out the elements for a national health data governance framework and fosters a ‘privacy-by-design’ approach that is consistent with emerging transnational requirements such as those set out in the EU General Data Protection Regulation (GDPR) (See Annex B).
Privacy-by-design involves designing IT systems in a way that pro‑actively anticipates and addresses risks to data privacy and security so they may be mitigated. In such approaches, the privacy of all individuals whose data is within the system is protected by default. The protection of individuals’ privacy and data security is embedded within the architecture and functionality of the IT system. At the same time, the IT system supports all uses and re‑uses of data that are in the public interest (Cavoukian, 2006[9]).
Privacy-by-design is important because health data are often personal and sensitive, particularly health micro-data where there is a data record for each individual. The EU Data Protection Regulation (GDPR) [Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016] places personal health data in a special category with the highest standards of protection.
The OECD Recommendation on Health Data Governance responds to the growing need for a consensus about the framework conditions within which health data can be appropriately governed to enable health data processing to take place both domestically and transnationally. Such health data governance frameworks require a whole of government approach; given that the public interests served span the domains of health, justice, industry, science, innovation and finance. The OECD Council Recommendation on Health Data Governance is compliant with the EU GDPR and encourages ‘privacy-by-design’.
The OECD Recommendation on Health Data Governance was adopted by the OECD Council on 13 December 2016 and was welcomed by OECD Health Ministers at their meeting in Paris on 17 January 2017. The Recommendation provides policy guidance to:
Encourage the availability and use of personal health information, to the extent that this enables significant improvements in health, health care quality and performance and, thereby, the development of healthy societies while, at the same time, continuing to promote and protect the fundamental values of privacy and individual liberties;
Promote the use of personal health data for public policy objectives, while maintaining public trust and confidence that any risks to privacy and security are minimised and appropriately managed; and
Support greater harmonisation among the health data governance frameworks of Adherents so that more countries can benefit from statistical and research uses of data in which there is a public interest, and so that more countries can participate in multi-country statistical and research projects, while protecting privacy and data security.
Governments adhering to the Recommendation will establish and implement a national health data governance framework to encourage the availability and use of personal health data to serve health-related public interest purposes while promoting the protection of privacy, personal health data and data security.
The Recommendation sets out 12 key elements of the development and implementation of national health data governance frameworks. The elements encourage greater cross-country harmonisation of data governance frameworks so that more countries can use health data for research, statistics and health care quality improvement.
The 2019/20 Survey of Health Data and Governance measured implementation of national health data governance frameworks and related regulations and policies. The 23 respondents to the 2019/20 survey were officials of national health ministries or national health data authorities.
A national health data governance framework can encourage the availability and use of personal health data to serve health-related public interest purposes while promoting the protection of privacy, personal health data and data security. Overall, 17 of 23 respondents reported that a national health data governance framework is established or is being established (Table 2.1).
Most respondents reported health data falling under a national health data privacy legislation; other data used in health studies falling under a national privacy legislation; and certain health datasets or health data programmes falling under other legislations governing ministries, data collections or registries. Some countries have legislations at different levels of government. Overall, 21 of 23 respondents reported that a national law or regulation exists that speaks to the protection of health information privacy and/or to the protection and use of electronic clinical records.
European Union (EU) member states implement the European Union (EU) Data Protection Regulation (GDPR) [Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016]. The GDPR places personal health data in a special category with the highest standards of protection. Compliance requires that personal health data are very well organised and portable. For example, organisations must have data systems that allow them to fulfil individuals’ rights to access their own personal data, to rectify or restrict their processing and to request data portability from one organisation to another; as well as to assure data are correctly categorised and demonstrate compliance with the regulation. In addition to national privacy laws compliant with the GDPR, most EU member states reported other national legislations with provisions specific to the protection of health data such as laws regarding patient rights, the collection and management of health information, the provision of medical care and health care organisations, electronic clinical record systems and health research.
Table 2.1. National health data governance elements
Note: Note: n.r.: not reported.
1. Mission of the Health Data Hub is to elaborate a citizens and patients charter in collaboration with patient associations.
Source: Oderkirk (2021[10]) “Survey results: National health data infrastructure and governance”, https://doi.org/10.1787/55d24b5d-en.
Six respondents reported that their health data governance framework is set out in law (Austria, the Czech Republic, Denmark, Finland, France, Germany). In Austria, there are elements of data governance within legislation governing health telematics, documentation and research organisation. In the Czech Republic, the National Health Information System and its governance are defined in the Act on Health Services. Finland’s health data governance framework is set out in legislation regarding digitisation and management of client and patient information as well as in regulations and guidelines of the health ministry (THL) (Box 2.2). Health data governance requirements, including GDPR requirements, are set out in federal and state laws in Germany.
Box 2.2. Finland – FinData
Findata is authorised by law to support the secondary uses of health and social data in Finland for projects that contribute to the public interest. Findata is the only authority that can issue permits for the secondary use of health and social data when the data is compiled from more than one data custodian. Findata provides for the secure linkage and research access to publicly funded datasets and registries including the data holdings of the Finnish Institute for Health and Welfare (THL), the Social Insurance Institution of Finland (Kela), the Population Register Centre, the Finnish Centre for Pensions and Statistics Finland. From 2021, Findata will expand to include data within the national EHR system (Kanta).
Findata is a centralised system issuing permits and a one‑stop shop for the secondary use of health and social care data in Finland. It grants data use permits when data are requested from multiple registries or from the private sector; collects, links and prepares the data; provides the data in a secure IT-environment for data users; offers electronic tools for data permit applications; offers a help desk for data users; and works in collaboration with the controllers of the data.
Findata is not a permanent data repository, but a hub in which the data flows. It exists to streamline and secure the secondary use of health and social care data for four main purposes: 1) enabling effective and safe processing and access to data; 2) enhancing data protection and security; 3) eliminating overlapping administrative burden; and 4) improving data quality.
The Act on the Secondary Use of Health and Social Data (enacted in May 2019) gives Findata the authority to grant secondary use for research within Finland. It is noteworthy that this is made possible due to Finland’s personal identification code that remains unchanged throughout an individual’s life and is the key to linking personal information from various registries.
As a rule, the data are always disclosed to Findata’s secure operating environment. However, the Act empowers Findata to make the data available in another environment as well, if it is necessary for the research purpose. These other environments will be audited for compliance with the regulation.
Source: Magazanik (forthcoming[11]), “Supporting Health Innovation With Fair Information Practice Principles: Key issues emerging from the OECD-Israel Workshop of 19‑20 January 2021”.
In France, principles of data governance are set out in an Act on the Modernisation of the Health Care System which unified the governance of administrative health data in the custody of three organisations and enabled dataset linkages and set out principles and procedures for data access. The 2019 Act on the Organisation and Transformation of the Health System broadened the definition of the national health data system to include additional datasets and their custodians and set out data sharing principles among these custodians. A Health Data Hub is defining the elements of shared data governance with stakeholders. The Health Data Hub (HDH) was launched in 2019 to support France in becoming a leader in Artificial Intelligence in health and to overcome barriers to the re‑use of health data for research (Box 2.3).
Box 2.3. France: Health Data Hub
The HDH is a public interest group that was authorised by law and funded by the government to expand upon the existing national health data system (SNDS) to encompass all existing databases concerning publicly funded health activities (e.g. hospital electronic health records warehouses, cohorts, and registries). HDH was built on the infrastructure of the SNDS, the French administrative health care database that covers 99% of the population. The HDH catalogue unifies a collection of pseudonymised databases which the HDH is authorised to make available for research.
HDH’s primary goal is to support research and innovation in health and health care by providing a unique entry point for secure and privacy-protective data linkage services and access to health microdata for research projects that contribute to the public interest, while respecting patient rights and ensuring transparency with civil society. The second goal was to design a state‑of-the‑art platform at the highest level of security, offering data storage, computing, risk mitigation and analysis capabilities. Finally, the third goal was to create a documented data catalogue built in a progressive manner to make priority data known to the scientific community.
The legal reform that launched the HDH aims to allow better visibility of common data assets for the entire ecosystem and to harmonise data access rules. Access to data is regulated and is carried out with respect for the rights of individuals. There is no obligation to process health data in France within the technological platform of the HDH and it is still possible to conduct research in other partnerships. HDH has so far launched 27 pilot projects, 9 of them COVID‑19 related, after HDH received a specific mandate to accommodate COVID‑19 related projects.
Permanent access to the HDH is granted to health authorities by decree of the French Ministry of Health. Other research requests for data are submitted to the “access team” that conducts a scientific and ethical assessment. If the request is found eligible, it is sent to the independent Scientific and Ethical Committee (CESREES). CESREES verifies that the purpose of the study is relevant and of public interest, that the data requested are in line with the study objective and that the proposed methodology is robust. If found positive, the project is submitted for authorisation of the French Data Protection Authority.
HDH consults with civil society by carrying out studies and consultations on the relationship that citizens have with health data and on their perceptions, needs and expectations. This knowledge is necessary to orient and adapt public communications, and to evaluate them and ensure they are clear. HDH also contributes to the implementation of a “health data culture” by providing educational tools to enable citizens to understand the data and to learn how to use them and how to carry out projects with them. (CNIL).
Source: Magazanik (forthcoming[11]), “Supporting Health Innovation With Fair Information Practice Principles: Key issues emerging from the OECD-Israel Workshop of 19‑20 January 2021”.
In the Netherlands, the Informatieberaad Zorg works on the development and sustainability of national health information and includes health care organisations and the Ministry of Health. The Council has four information system development goals: data to monitor the safety of prescription medicines; citizen access to their own medical data and the ability to link their own health and medical data; digitisation and exchange of data between health care professionals; and that data is recorded once and reused. A sub-group of the Council is the Community of Data Experts which advises the Council about the secondary use of health data for statistics, research and health and health care policy. Several laws include rules that make it mandatory to keep a medical record, to provide patients with digital access to their medical records and regarding system quality. A new framework law that passed the parliament in 2021 requires the electronic exchange of medical records among health care providers.
In Korea, the Ministry of Health established a health data governance framework in 2018 and set up a Healthcare Big Data Policy Deliberation Committee which is responsible for data development, use and dataset linkages. The COVID‑19 pandemic has inspired an expansion of health data under a “Digital New Deal” which allows for the expansion and linkage of national health insurance data with other relevant data and for the accessibility of data for global research (Box 2.4). Latvia developed a Health System Performance Assessment Framework in 2019 (including health care quality, patient safety and efficiency indicators). Within this framework, principles and procedures for data provision, data linkage, health data protection, and access to data for research are set out.
Box 2.4. Korea: Digital New Deal
In Korea, the National Health Insurance (NHI) Database was established many years ago and organisations have been required to submit data to the NHI Program to obtain reimbursement. Korea already has real-time data at the national level across the continuum of health care services from insurance claims and these data are routinely linked for statistics and research.
The COVID‑19 pandemic, however, has inspired an expansion of health data under a “Digital New Deal” that is being developed now. Under the New Deal, real-time insurance claims data can be linked with real-time clinical data. For example, Korea is developing the capability to monitor adverse events from the COVID‑19 vaccination in real time. The Ministry of Health and Welfare and Health Insurance and Review Assessment Agency (HIRA) have been authorised to share COVID‑19 data with the international community to find an effective response to COVID‑19.
In order to further promote health data sharing for research, Korea has prepared legislation to establish a national data lake that will allow public bodies and private companies to have access to health data. Korea aims to link additional repositories to this national initiative. Under this new law (anticipated in 2021), Korea plans to maintain the data lake after the pandemic ends so it may continue to support international researchers’ access to updated COVID‑19 patient data.
De‑identification techniques such as pseudonymisation are being used as a safeguard, and qualified organisations will perform data preparation. Engagement with the data lake is by application to qualified agencies.
Source: Magazanik (forthcoming[11]), “Supporting Health Innovation With Fair Information Practice Principles: Key issues emerging from the OECD-Israel Workshop of 19‑20 January 2021”.
The United States Department of Health and Human Services proposed in 2020 a new rule within the 21st Century Cures Act to support seamless and secure access, exchange and use of electronic health records (Box 2.5). The rule aims to increase innovation and competition by giving patients and their health care providers secure access to health information; allowing more choice in care and treatment. A provision in the rule requires that patients can electronically access all their electronic health information (both structured and unstructured data) at no cost and deters blocking authorised access to and exchange of data. It calls on the health care industry to adopt standardised application programming interfaces (APIs) to allow individuals to securely and easily access structured electronic clinical data using smartphone applications.
The Department of Health and Human Services and the Office of the National Co‑ordinator have also released a Trusted Exchange and Common Agreement (TEFCA) which sets out principles, terms and conditions for a common agreement to enable nationwide exchange of electronic health information across disparate health information networks. It aims to ensure that health information networks, health care providers, health plans, individuals and other stakeholders can have secure access to their electronic health information when and where it is needed.
Box 2.5. United States: New rule promoting access to data
In the United States, each state manages their own public health reporting programs, and these practices are regulated by state law. Each individual hospital system may have their own network – which can include thousands of payer systems. This fragmentation impedes patients’ access to their complete records, as well as the availability of health data for research. To address this, the Department of Health and Human Services (HHS) proposed a new rule within the 21st Century Cures Act to support the seamless and secure exchange and use of electronic health records. The rule asks the health care industry to utilise Application Programming Interfaces (APIs) and to adopt the HL7 Fast Healthcare Interoperability Resources (FHIR) standard for health data exchange. Further, a Trusted Exchange and Common Agreement (TEFCA) sets out principles, terms and conditions to enable the nationwide exchange of electronic health information across disparate health information networks.
Standardisation of the data sources is required for health data to be exchanged across all networks, not just the major networks like Medicare. The Office of the National Co‑ordinator of Health IT (ONC) plans to introduce a the United States Core Data for Interoperability Standard, that will be the content and vocabulary baseline for health data, beginning 24 months after the publication of the final rule. This standard includes new data classes and data elements, such as provenance, clinical notes, paediatric vital signs, addresses, email addresses and phone numbers. These data pieces were not universally exchanged before – but are essential for patient matching and identifying risk factors. Leveraging this data allows better demographic information to be available to health care providers so that they can evaluate patients’ risks and needs.
ONC has several pathways for public engagement and input into these data interoperability standards including a federal advisory committee made up of representatives from health care, health IT, and patient advocacy organisations. It publishes proposals for public comment and conducts targeted listening sessions with different groups. Finally, on the technical aspects, it works closely with the standards organisations which include public input and consensus- based balloting processes.
Generally, there isn’t financial support to all stakeholders to invest in this, but there is some support for states to implement these capabilities in their networks. For health care providers, there was previously a programme that provided incentive payments for adoption of an electronic health record system, but there has not been new funding approved by Congress to continue support. However, there are requirements for hospital systems that are paid under the Medicare (National) programme to adopt and use technology that is certified to certain standards and functionalities. ONC has added these new requirements to the existing programme requirements. There is also a programme that requires the payers (the plans that administer Medicare and Medicaid) to build Application Programming Interfaces (APIs, as well to allow the data they hold to also be accessible. And finally, ONC requires technology developers, through a certification programme, to make this technology available to their customers.
Source: Magazanik (forthcoming[11]), “Supporting Health Innovation With Fair Information Practice Principles: Key issues emerging from the OECD-Israel Workshop of 19‑20 January 2021”.
In Australia, governmental responsibility for national health datasets is shared between Federal and State/Territorial jurisdictions. At each level of government, there are a range of agencies with responsibility for specific datasets and there is no overarching health data governance framework. However, all jurisdictions have signed the 2020‑25 National Health Reform Agreement which includes an action to scale up a national approach to data governance arrangements, structures and processes, to facilitate clear and efficient mechanisms for sharing and developing data in a sustainable, purpose‑based and safe way. There is an Australian data governance framework for electronic clinical data exchanged as part of the My Health Record System. A Data Availability and Transparency Bill was introduced in 2020 to implement a scheme to authorise and regulate access to Australian Government data (Box 2.6).
Box 2.6. Australia: Data Availability and Transparency Reform including the new Dataplace
Varying legislative requirements across the Commonwealth, States and Territories, particularly for privacy and permitted uses of data, have historically made data sharing more complex. Challenges to effective and efficient sharing and use of data are not limited to legislation. Technical, data availability and data quality challenges have affected the application of data from both new and well-established data assets to respond to the needs of the health system and the different needs Commonwealth, State and Territory data users.
The Office of the National Data Commissioner (ONDC) in Australia has been tasked with developing a new data sharing and release framework, and overseeing the integrity of data sharing and release activities of Australian Government agencies. The ONDC released its first guidance in 2019 – the Best Practice Guide to Applying Data Sharing Principles – which provides general guidance to assist agencies in adopting international best practices in data sharing.
The Australian Government introduced the Data Availability and Transparency Bill 2020 (DAT Bill) into the Commonwealth Parliament in late 2020. Once passed, the Bill will establish a new scheme to safely share Australian Government data. To support the implementation of the new data sharing scheme, ONDC is establishing digital services (known as Dataplace) to manage: the accreditation process under the scheme; the submission of data requests to data custodians; and the negotiation, registration and management of data sharing agreements.
It is intended that Dataplace will eventually support the sharing of Australian Government data both under the new data sharing scheme and through other data sharing mechanisms.
The ONDC is also preparing to implement a Data Inventories Pilot Program to develop individual data inventories for Australian Government agencies using common standards and then to aggregate these inventories into an Australian Government Data Catalogue. The Pilot will initially cover about 20% of Australian Government entities. The Pilot will support greater transparency of government data holdings, facilitate data sharing and assist the Australian Government to respond quickly in emergencies.
An Intergovernmental Agreement on data sharing, agreed by the National Cabinet on 9 July 2021, committed the Commonwealth, State and Territory Governments to share public sector data (including health data) as a default position, where it can be done securely, safely, lawfully and ethically. The principles-based agreement recognises data as a shared national asset and aims to maximise the value of data to deliver outstanding policies and services for Australians. National effort will also be focussed on specific time‑limited national priority data areas, under the Intergovernmental Agreement’s National Data Sharing Work Program.
The 2020‑25 Addendum to the National Health Reform Agreement has committed to a series of national action to enhance health data to enable long term health reform and harness data and analytics to drive meaningful improvements in the health system. This includes: establishing a national approach to govern the creation, access and sharing of data from all Australian Governments and progressing mechanisms and interoperable systems for secure and comprehensive integration of data across patient journeys.
Source: OECD Questionnaire on Health data and governance changes during the COVID‑19 pandemic, 2021.
Ireland’s Department of Health is currently working on a national health information strategy. In this strategy, Ireland is planning a National Health Observatory which would be authorised by law and include the development of a national health data governance framework.
In Israel, responsibilities for national health data governance are shared between the Ministry of Health and the Israel Innovation Authority. Israel’s government has been working on designing a policy framework for secondary use of health data for research to enable collaborative data research initiatives. This framework is not yet finalised. As a result of the COVID‑19 pandemic, the government has been accelerating work toward data sharing and access (Box 2.7).
Box 2.7. Israel: COVID‑19 Data Lake
The Ministry of Health is working on an initiative to form a ‘Data Lake’ that will include Israel’s digital health data from hospitals as well as HMO’s and the Ministry of Health itself. On a national level, Israel has a rich and well computerised health data ecosystem consisting of 30 years of central public health care provided within HMOs serving 95% of patients. There is value in bringing all of this data together to accelerate COVID‑19 related research. The ‘Data Lake’ policy framework consists of IRB certificate mechanisms, transparency, de‑identification mechanisms, secure environment, user controls, opt-out mechanisms, and data use agreements.
The public interest in making the data available for research allows for an opt-out mechanism. Israel communicated with the public about the creation of the data lake via a text message to all persons. Strengthening the argument supporting the decision to offer an opt-out mechanism were previous decisions regarding the National Patient File (summary health record). The National Patient File requires all providers in Israel to use the same central system for data management, so that they can easily communicate with each other. There were discussions in the Ministry of Health to determine if this system should have an opt-in or opt-out structure. An opt-out structure was chosen because there was strong evidence that having all of the data available for patient care provides for more accurate findings and better health care services; and allows for more effective decisions to be made, which in turn allows costs to decrease and is in the public’s best interest.
The COVID‑19 Data Lake is only available for pure research with no collaboration with industry. There remain concerns that providing researchers access to the data lake may diminish public trust. In order to streamline the application process to the Data Lake, Israel is preparing one formal agreement for researchers that want to access the data, since this data is needed in a timely manner due to COVID‑19. Further, Israel is considering new technologies for privacy enhancement that support researchers’ ability to access complete records (raw data).
Source: Magazanik (forthcoming[11]), “Supporting Health Innovation With Fair Information Practice Principles: Key issues emerging from the OECD-Israel Workshop of 19‑20 January 2021”.
The Government of Canada, together with provinces and territories, is leading the development of a Pan-Canadian Health Data Strategy to improve Canada’s collection, sharing and use of health data while protecting privacy. An Expert Advisory Group (EAG) was established in December 2020 to provide advice and guidance as work on the Pan-Canadian Health Data Strategy evolves.
Slovenia began developing a national health data governance framework in 2019. Luxembourg is planning a National Health Observatory which will be authorised by law and will support the development of a national health data governance framework. Belgium reported an intention to increase co‑operation among several federal health administrations (Federal Public Service Health (FPS Health), RIZIV-INAMI, FAGG) regarding data policy.
The United Kingdom (Scotland) has an information governance framework for personal data, within which is a Public Benefit and Privacy Panel (PBPP) for health and social care data. The PBPP is a patient advocacy panel which scrutinises applications for access to NHS Scotland health data for secondary purposes with respect to the public benefit and privacy implications of proposed projects.
Legal or policy restrictions to public authorities extracting data from electronic health records
While many countries are extracting data from electronic clinical records to develop their key national datasets and for research (as will be discussed in the next section), 10 survey respondents in a 2019‑20 survey on health data governance reported barriers to doing so.
In Luxembourg, data extraction from electronic clinical records for secondary uses is only lawful with the prior written consent of patients. Similarly, in Canada, electronic medical records in primary health care are in the custody and control of care providers who have no obligation and sometimes, depending on the jurisdiction, no legal authority to share data with public authorities, without express consent. As in Canada, the federal structure of Germany leads to different legal frameworks at the state level (state data protection laws, state hospital laws) that govern whether data may be extracted for secondary purposes. In Australia, data extraction is restricted by a number of legislative, privacy, secrecy and confidentiality requirements and medical records can be disclosed with consent, or in specified circumstances where authorised by law.
In France, extracting data from the electronic health record or DMP (dossier médical partagé) for the purposes of sharing and linking data is legally prohibited. France reports the legal prohibition came about because the national health insurance fund (CNAM) provides operational management of the linked health care administrative database and patients’ associations sought a guarantee that clinical data within the DMP would not be accessible to the insurer. It is, however, legally possible to create a dataset of anonymised data from DMP records.
In Japan, there is no national electronic health record system within which data might be contributed by each medical institution. Further, medical institutions require patient consent for each research or statistical project where data would be extracted and shared from their electronic records.
In Korea, it is legally possible to extract data from electronic health records for secondary uses but the interpretation of the law is strict so doing so is difficult in practice. In Belgium there is no real policy about the extraction of data from electronic records for secondary uses. In Latvia, there is no experience yet with data extraction as the implementation of the national e‑health system has only started recently. In Ireland, most health records remain paper-based in acute care hospitals.
Concerns were further echoed by respondents to the 2021 EHR survey. In 2021, 15 respondents reported that problems with the quality of data within electronic clinical record system created a barrier to developing national health datasets from this data source. The most common concern was with unstructured (free text) data within EHRs that need to be structured following common terminology standards to be readily useable for statistics and research. Thirteen respondents also reported legal or policy barriers to public authorities extracting data from within EHRs to develop national health datasets.
Perhaps the most difficult barrier is in Switzerland, where the law which authorises the creation of electronic clinical records did not foresee the use of data from within this information system for national statistics or research and, as a result there is a total ban on utilising this information resource for any purpose within the public interest other than directly caring for an individual patient. Similarly, in Korea, the law authorising the Information Exchange Program only authorised the exchange of EHR records for direct patient care and there is no legal basis for the secondary use of EHR data.
In Sweden, whether data can be extracted from EHRs for a statistical purpose is limited to the legal authorisation of the specific use. Statistics and research uses that have not been already foreseen and legally authorised are restricted. Similarly, Finland’s law authorising the EHR system did not specify that health care quality monitoring could be undertaken with data from within the EHR system and are facing restrictions to this activity which is within the public interest. In Iceland, health data registries (datasets) are each authorised by a separate legislation. If a new registry (dataset) is needed, then it is necessary to pass a new legislation to authorise it. Similarly, Portugal reports a lack of legal authorisation to extract data for statistical purposes.
Japan and Turkey report concerns that the national data privacy law restricts their ability to extract data from within their EHR systems to build national datasets that are within the public interest. Canada reports the challenge of having different data protection laws within its 13 provinces and territories.
EU Members are also reporting challenges implementing the EU General Data Protection Regulation (GDPR). Italy reports that the GDPR provisions are complex and require the involvement of the data protection authority to develop effective solutions that support extraction of data from EHRs for statistical purposes. Similarly, Slovenia reports that the national legislation is very sophisticated and restrictive which limits their ability to extract data for statistical purposes.
In the Netherlands, problems have arisen following the introduction of the EU GDPR. Dutch health datasets are in the custody of various public sector organisations (such as the Dutch Hospital Data institute, and the Perined (child birth data) institute). Among the custodians of health data, there are different interpretations of the EU GDPR and some have determined that past data exchange arrangements are no longer legally permitted. To clarify that data exchange is lawful, some organisations and institutes are asking government for legislation authorising the exchange of electronic clinical data (see Chapter 3 for further discussion).
EMR interoperability is critical with success characterised by co‑ordination and leadership at the national level
Clinical data are a key component of any health information system looking to improve care quality as well as enabling research and innovation. This section outlines the current situation in OECD countries regarding the exchange and interoperability of electronic health records data, and the key elements of successful integration.
Exchange of clinical data at the national level
Most OECD countries, 21 of 27 countries surveyed in 2021, are exchanging electronic clinical records among physicians, medical specialists and hospitals for the direct care of patients. Sixteen countries report one country-wide EHR system is in place. Thirteen countries reported that a nationally standardised patient summary is exchanged among health care providers at a national level, and a broader array of patient data are exchanged among health care providers at the sub-national (state, regional) level. In three countries, Belgium, Canada and the Czech Republic, patient data is exchanged among health care providers only at the sub-national (regional, state) level.
A single authority to oversee EHR development and interoperability
In 2021, the OECD surveyed countries regarding the readiness of their electronic health record systems to contribute to national information and research. Twenty-three of 27 countries reported a national organisation with primary responsibility for national EHR infrastructure development. Twenty countries reported that their national organisation is responsible for setting national standards for both clinical terminology within EHRs and standards for data exchange (electronic messaging).
Table 2.2. National organisation responsible for EHR system and its role
Notes: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Canada Health was in a lead role for the development and implementation but it is managed by each jurisdiction.
2. EHR are regulated by the Ministry of Health.
3. Some aspects are co‑ordinated between a few authorities.
4. US Department of Health and Human Services adopts national standards and regulates the certification of EHR products. Governance of the exchange infrastructure is currently being defined.
5. ADHA specifies which messaging standards are required to allow other clinical systems and mobile applications to connect with the My Health Record System.
6. MoH recommends standards. Legislation is in preparation to create a legal mandate to enforce e‑Health related standards.
7. Norwegian Directorate for e‑health is responsible to set standards for clinical terminology and data exchange.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Fourteen countries reported in 2021 that the national organisation responsible for EHR infrastructure development had a multidisciplinary governing body with representation from various stakeholder groups. Multi-disciplinary governance supports the development of standards that meet the needs of different stakeholders in the health information system.
Table 2.3. National organisation has a multidisciplinary governing body
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Convergence towards specific standards is occurring
Global consensus regarding terminology standards for key clinical terms has not been reached yet. There are, however, a few international terminology standards that are used by a significant share of countries.
In 2021, 18 respondents reported using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD‑10) for diagnostic terms; 16 respondents reported the Anatomical Therapeutic Chemical (ATC) Classification System for medication terms; 13 respondents reported the Logical Observation Identifiers Names and Codes (LOINC) for laboratory test terms; and 10 respondents reported DICOM standards for medical image terms. These results for 2021 are a small improvement from 2016, as the number of respondents adopting the ICD‑10 diagnostic terms and ATC medication terms has grown by a few countries.
Twelve respondents reported adopting the Systematised Nomenclature of Medicine‑Clinical Terms (SNOMED CT) for at least one key term within their EHR. SNOMED CT is a comprehensive set of terminology standards covering key terms within EHR records. The cost of deployment; however, is a barrier to widespread adoption and the number of respondents is unchanged from 2016.
However, there remain key terms within clinical records where there is no consensus among countries about which international standard could apply. These include surgical procedures, vital signs, healthy behaviours, socio‑economic status, clinically relevant cultural and psychosocial characteristics, and patient reported outcomes and experiences. Further, there are often local standards that have been adopted or, in some cases, these elements are not coded to a terminology standard but recorded as free text.
The legacy of fragmented deployment of EHRs has resulted in 11 respondents reporting clinical terminology standards are inconsistent among different networks or regions within their country. While this remains a significant problem, it has improved from 2016 when 20 respondents reported this issue.
Twenty-one respondents in 2021 reported implementing policies or projects to improve the interoperability of data within electronic health record systems (EHRs). Seventeen respondents are adopting the HL7 Fast Healthcare Interoperability (Resource) standard and a further two respondents are considering adoption. The HL7 FHIR standard supports web-based applications in health care as they exist for other sectors such as for e‑commerce, banking, and travel booking; and utilises commonly used web development tools which allow for a larger pool of developers and faster development.
Twelve respondents are also adopting SMART on FHIR standards (or similar) and a further 4 respondents are considering adopting SMART on FHIR. Substitutable Medical Applications and Reusable Technologies (SMART) is a standard used on top of FHIR to develop web-browser and mobile/smartphone apps that can be connected to/interact with any EHR system. For example, an app to assist patients with managing their medications or an app for secure communication with a health care provider.
Fourteen respondents reported developing public application programming interfaces (APIs) and an additional respondent is considering adopting this standard. Application programming interfaces (APIs) allow data sharing among different EHR software and Health Information Technologies, overcoming blockages to data interoperability.
Table 2.4. Interoperability standards
Notes: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. May not be open (public).
2. In consideration for adoption.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Global collaboration towards common standards
Encouragingly, respondents reported participation in global collaborative work toward agreed international standards for clinical terminology and data exchange (electronic messaging). In 2021, 15 respondents reported participating in the Integrating the Healthcare Enterprise International collaboration and 10 respondents reported participating in the Global Digital Health Partnership.
There is extensive work underway within the European Union (EU) toward improving the accessibility, sharing and use of health data that, if successful, would have an influence on the evolution of global collaboration in the sharing, use and protection of health data. A key EU project is the eHealth Digital Service Infrastructure (eHDSI) for cross-border health data exchange under the Connecting Europe Facility (CEF) that is supporting EHR data exchange at the country level and the provision of core services at the EU level.
Another key project is the Joint Action Towards the European Health Data Space (TEHDAS). TEHDAS is developing European principles for the secondary use of health data, building upon successful development of health data hubs in a few countries, such as France and Finland, and aiming to develop health data governance and rules for cross-border data exchange, improve data quality and provide strong technical infrastructure and interoperability (EC, 2021[5]). The European Health Data Space has the potential to act as a powerful federator between national data hubs, promoting interoperability standards, best practices for data sharing across the European Union and setting a coherent governance framework.
Table 2.5. Global collaborations for exchange and terminology standards
Notes: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
The 2021 survey also asked respondents about the coding of health data to CDMs which facilitate within country statistical and research projects. In 2021, five respondents reported coding data within their EHR systems to a CDM. When the common data model is international in scope, such as the OMOP (Observational Medical Outcomes Partnership) CDM, such coding efforts support internationally comparable data for a wide array of research and statistical uses. There were some applications of the OMOP CDM reported by Australia and Israel in 2021. The Health Insurance Review and Assessment Agency (HIRA) in Korea coded linked health data to the OMOP CDM, including HIRA’s national insurance claims data, for the purposes of encouraging secure access to timely data for global COVID‑19 research as part of the OHDSI project. France is coding data within the Health Data Hub to the OMOP CDM as part of the EU EHDEN project which is affiliated with OHDSI.
Approaches to data storage and management vary
Surprisingly, given the mounting volume of data created, only 8 of 26 respondents in 2021 reported that EHR data are stored or processed using Cloud Computing services (Australia, Israel, Japan, Korea, Luxembourg, the Netherlands, Portugal and the United States). The majority of respondents are still managing EHR data on dedicated servers.
Essential to data security, integration and patient safety are unique identifiers. In 2021, 24 of 27 countries reported that they have a unique national number that identifies patients to build and electronic health record. Further, 23 countries reported having a unique national number that identifies health care providers or other authorised persons who are entering data into an electronic health record.
Fourteen respondents reported that clinical data are encrypted when they are exchanged to protect privacy and data security. Nine respondents reported that clinical data are exchanged using a dedicated, secure network. Security measures for these networks included a digital signature for ID (Denmark), digital signature with smartcard (Luxembourg, the Netherlands), multi-factor authentication (Canada, Italy, the Netherlands, Switzerland), digital certificates for ID verification (Japan, Lithuania), virtual safeboxes for data exchange (Israel), channel encryption (Italy), and IP security and Internet key exchange (Japan). A few respondents also noted data de‑identification and pseudonymisation (Italy) and even data anonymisation (Costa Rica).
Respondents reported methods they are using to secure EHR data from unauthorised access, hacking and malware. These include virus scanning, firewalls, controlled access, access logs, audit logs, automated log-out, timely software updates, network separation, auditing hardware and databases, physical security for networked hardware, staff training in data security including how to identify phishing schemes, malware and other malicious programs, penetration tests (ethical hacking), vulnerability scanning, national authorities supervising cybersecurity among data processors, and business continuity and disaster recovery planning.
Legislation requiring adoption of Electronic Health Record Systems that conform to national standards
In the 2021 survey, 17 respondents reported that there are laws or regulations requiring health care providers to meet standards for national electronic health record interoperability. Sixteen respondents reported that laws or regulations require electronic messaging standards and 16 also respondents reported that laws or regulations require terminology standards.
Table 2.6. Laws or regulations require standards for EHR interoperability
Notes: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Law recommends the use of EHRs.
2. For diagnosis.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Certification of electronic health record system software vendors
In the 2021 EHR survey, 16 respondents reported that they have a certification process for the vendors of electronic health record system software that requires vendors to conform to particular health information exchange (electronic messaging) standards. Thirteen respondents reported a certification process that requires adherence to national standards for clinical terminology and 13 reported certifying vendors for adherence to requirements or standards for national EHR interoperability.
While not a national certification of software vendors, reimbursement for medical expenditures requires that providers follow certain terminology and exchange requirements in Israel. In Luxembourg, there is a national labelling process for software vendors to access the national EHR system. In Italy, there are no national requirements for certification, but individual regions may impose requirements. In Slovenia, certification has been legally authorised, but it is not yet implemented due to resource constraints. However, to connect to the national EHR system in Slovenia, vendors must use nationally standardised APIs (Application Programming Interfaces).
Table 2.7. Certification requirements of vendors of EHR system software
Notes: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Optional.
2. Certification of communities using EHR software.
3. E‑prescription services are certified.
4. Certification is voluntary but required for reimbursement of medical claims from national insurance programmes (Medicare, Medicaid).
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Auditing clinical records for quality
Another mechanism to verify if health data meet national expectations for data quality is to conduct audits of clinical records. In the 2021 EHR survey, 13 respondents reported that the electronic records of physicians, medical specialists and hospitals are audited to verify quality. An additional three respondents indicated that at least one of these three groups are audited to verify quality. In most cases, it is a national authority that is responsible for undertaking quality audits. In Canada and Sweden, regional authorities conduct audits. In Switzerland, private sector organisations can be certified to then conduct audits as part of certifying the compliance of communities to national requirements including auditing clinical records for quality. Under law in the United States, health care providers are responsible for generating auditing reports on the quality of their clinical records and ensuring data quality.
Table 2.8. Auditing clinical records for quality
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Policy levers used by OECD countries to increase EHR interoperability and data use
In 2021, OECD countries reported several different policy levers supporting EHR interoperability and the increased use of data from within EHR systems for direct care, patient centred services, research, statistics, applications development and other uses within the public interest. This section reviews countries use of laws or regulations requiring data standards; certification of software vendors; and incentive payments.
In 2021, 13 countries reported implementing laws or regulations that require health care providers to adopt electronic health record systems that meet national standards for both clinical terminology and electronic messaging (data exchange).
Sixteen countries reported laws or regulations requiring health care providers to meet standards for national EHR interoperability. In Iceland, regulations require that health care providers can connect to the Icelandic HealthNet (national EHR network). In Italy, the law defines a national federated system with a mandatory, nationwide, interoperability. In Lithuania, data is structured and standardised by law and must be suitable to be forwarded smoothly to the ESPBI IS (central EHR system). In Luxembourg, connecting to the DSP (central EHR system) requires meeting legal requirements for data standardisation. In Slovenia, IHE XDS and OpenEHR standards are required with proprietary modifications that are set out in law. In Switzerland, certifying communities and software vendors are required to meet national standards including HL7 FHIR and IHE. In Portugal, by law, health care providers IT systems must conform to a catalogue of standards to exchange data.
Table 2.9. Laws or regulations requiring adoption and standardisation of electronic health records
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Law recommends the use of EHRs.
2. For diagnosis.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Another policy lever is requiring vendors of electronic health records systems to be certified to be in conformance with national data standards. Overall, 13 countries have a software vendor certification that requires vendors to meet national standards for both clinical terminology and electronic messaging.
Table 2.10. Certification requirements of EHR software vendors
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Optional.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Finally, 8 countries have incentive payments or penalties for health care providers to install EHR systems from a certified software vendor, 9 have these payments to health care providers to keep EHR systems up-to-date regarding changes to national standards over time and 11 have incentives or penalties to meet national requirements for EHR interoperability.
Table 2.11. Incentives or penalties to install EHR systems from a certified vendor, to keep standards up-to-date and to meet national interoperability requirements
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. National terminology referential bases are put in place and maintained by Agence eSanté.
2. Incentive for primary health care clinics to use the national patient portal.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Patient portal to their own medical records
In most countries, patients have access to and can interact with their own medical records within a secure Internet portal. ‘Access’ means patients can view information contained in their own record and ‘interact’ means that patients can amend information, upload data or interact with their health care provider. Thirteen countries reported that 100% of patients have access to their own medical records through an Internet portal and 12 reported that 100% of patients can interact with their portal. Eighteen countries reported that patients can view their own records from all of their current health care providers and containing their current medications, lab tests, and imaging results.
Table 2.12. Patient access to and interaction with their own EHR through a secure Internet portal
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Regional (state/province) level differences.
2. All patients can upload PDF files to the portal.
3. To some extent.
4. When providers upload files to the national system.
5. Two regions and certain hospitals.
6. Some private providers not included.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Secondary analysis of EHR system data
Most respondents are regularly extracting data from the EHR system for public health monitoring (16 countries). Such uses have been accelerating in response to the COVID‑19 pandemic. Further, countries have been increasingly depending upon data with EHR systems for their superior timeliness, enabling analysis of the pandemic situation and response in near real time. Ten countries reported regularly extracting EHR data to monitor the performance of the health system including, treatments, costs and health outcomes. Twelve countries regularly rely upon EHR data to monitor patient safety, including post-market surveillance of medications. Ten countries report that EHR data are extracted for health and medical research to improve patient care, health system efficiency or population health, such as long-term follow-up studies of patients experiencing different risk factors, health conditions and treatments. Five countries are regularly relying upon EHR data to facilitate and contribute to clinical trials, such as following clinical cohorts to measure health outcomes and health care encounters over time. Five countries also enable physicians to query the data to inform themselves about previous treatments and treatment outcomes when caring for patients.
Table 2.13. Regular secondary analysis of EHR system data
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Physicians can query their own data.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Development of artificial intelligence algorithms, machine learning and analytics
The Netherlands, Denmark and Israel are the three countries with the most applications of machine learning, artificial intelligence algorithm development and other more advanced analytics based on EHR data that were measured in the 2021 survey. Overall, 8 countries reported data mining to find or extract data from the EHR; 8 countries are using EHRs to develop messages and alerts for patient care or managerial decision-making; and 7 countries are using EHRs to develop predictive analytics trained on EHR data for patient care or managerial decision-making. Six countries report national projects to integrate or link EHR data with genomic, environmental, behavioural, economic or other data. Three countries are also using natural language processing to convert free text to standardised (coded) data.
Table 2.14. Machine learning, artificial intelligence and analytics with EHR system data
Note: n.r. Not Reported // n.a. Not Applicable // d.k. Unknown.
1. Physicians can query their own data.
2. In development as part of the creation of a data lake.
Source: OECD 2021 Survey of Electronic Health Record System Development, Use and Governance.
Summary of the situation across the OECD regarding the interoperability of EHR systems
In 2021, most OECD countries surveyed had: 1. established a national organisation that was responsible for setting national clinical terminology and electronic messaging (exchange) standards; 2. created a multidisciplinary governing body for the national organisation that represents key stakeholders; 3. use unique identification of patients and health care providers; 4. adopted international terminology standards for diagnoses, medications, laboratory tests and medical images; 5 adopted the HL7 FHIR standard for data exchange (electronic messaging); and participate in global collaborative projects to improve international data standards.
Most countries have one country-wide electronic health record system and are exchanging EHRs at the national level including data sharing among physician offices and hospitals about patients’ treatment, medication use, laboratory tests and images.
Most countries have a Patient Internet Portal where patients can access their own medical records from all of their current health care providers. Most are extracting data from their EHR system for public health monitoring. Many countries are also utilising EHRs for other secondary purposes including health system performance monitoring, patient safety surveillance and health and medical research. Some are also developing big data analytics including machine learning, artificial intelligence algorithms with EHRs.
Countries reported several levers to improve the spread and interoperability of their electronic clinical data.
Sixteen had a legal requirement for health care providers to meet national standards for EHR interoperability and 13 had a legal requirement for health care providers to adopt an electronic health record system (software) that conformed with national standards for both clinical terminology and electronic messaging (exchange).
Thirteen countries had a certification of eHR system (software) vendors that required them to adopt national standards for both clinical terminology and electronic messaging and 13 had a certification that required software vendors to meet requirements for national EHR interoperability.
Eleven countries had financial incentives (or penalties) for health care providers to install an EHR system that meets national standards and requirements for national EHR interoperability. Nine countries report incentives for health care providers to keep their EHR system up-to-date as clinical terminology and electronic messaging standards change over time; and 8 reported incentives for health care providers to install and EHR system from a certified software vendor.
References
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Note
← 1. In addition, the Youth Act, which regulates assistance provided to children, adolescents and their parents – which is a municipal responsibility. It covers developmental and parenting support for families, psychosocial and psychiatric problems, supplementing what families cannot do themselves.