The wider perspective
In this issue, we have the opportunity to examine the ways in which four
countries with differing healthcare systems are in pursuit of the same
objective: an electronic healthcare record that is accessible wherever a
patient may present. Richard Alvarez, President and Chief Executive
Officer of Canada Health Infoway, describes work in the Dominion. Dr David
Brailer, National Co-ordinator for Health Information Technology, examines
the approach being taken in the United States. Ellen Maat, Head of
Healthcare ICT in the Dutch Ministry of Health Welfare and Sport, sets out
the work in progress in the Netherlands. And Richard Granger, Chief
Executive, NHS Connecting for Health and Director General of NHS IT,
explains the approach in the largest of the UK’s four home countries.
Physically, the three countries could not be more different. Canada, with
an area of 3.8m square miles, has a population of 33m. The United States, by
contrast, with a similar area has a population of 298.5m. The Netherlands,
with a landmass of only 16,000 square miles, has a population of 16.5m.
England, with an area of 50,000 square miles, has a population of 50.5m.
With this range of geographical circumstance, the approach to healthcare
(not to its actual delivery) cannot but be different. Different too are the
approaches to the way forward in the delivery of healthcare. In Canada,
healthcare, which has only been universally accessible since 1968, is the
responsibility of the provinces.
Financial responsibility is shared between the 10 provinces and the
Federal Government, with funds raised from taxation and health insurance.
The United States aims to achieve a market-driven healthcare system,
organised around the consumer, and actuated by choice.
In the Netherlands, central government aims to work with providers to
build an appropriate infrastructure through legislation, general direction
and co-ordination. Financially, it is in a time of transition: from January
of this year, funding has moved from a two-tier public–private base to a
single basic insurance premium for all, costing individuals between 1,000
and 1,300 euros a year.
Of the four countries, only England has a system funded totally from
general taxation, with an organisation subject to much central control.
Despite these very considerable differences, all four countries are
nonetheless aiming — for some common and some differing reasons — to create
the same thing: an electronic medical record available wherever the patient
may be. Given the diverse nature of funding, of organisation and even of
ethos between the four countries, it is not surprising that, despite the
common aim, the approach to creating communal medical records should also
differ. The major significant differences lie in how to create nationwide
interoperability.
The Canadian approach aims to accelerate the development of electronic
health-information systems with compatible standards and communications
technologies on a pan-Canadian basis; to build on existing initiatives; and
to pursue collaborative relationships to that end.
In the USA, with a market-based health economy, the aim is for the
Federal Government to collaborate with the private sector on the development
and evolution of the necessary standards and infrastructure on a voluntary
basis. In limiting regulatory action, the infrastructure is expected to
evolve alongside technological capacity.
In the Netherlands, central government sees its role as a provider of a
national infrastructure and the initial funding, but with healthcare
providers responsible for financing, implementing and running local systems.
The approach is to be phased, but with the installed base of existing
healthcare systems taken into account.
The approach in England attempts centrally provided major systems, to
which the variety of existing systems are essentially subordinate and are to
be supplanted by single standard solutions. The involvement of users —
always a problem in the NHS — is through a series of professional panels.
Two unifying themes underlie the different approaches: centralisation
versus decentralisation; ‘forced’ growth versus organic growth. Total
reliance on central funding is a major determinant in the English approach,
though that does not recognise the degree to which provider organisations in
the field are able to determine their own priorities.
The USA demonstrates the opposite end of the spectrum, with its
determination that, with a minimum of Federal intervention, market forces
and provider collaboration should create the necessary framework.
In Canada and the Netherlands where funding sources are mixed, the
decentralised approach is evident, and with it a different approach to
commitment by participants. Decentralisation also plays a significant role
in the approach to existing systems: it builds far more on those systems and
thus relies more on organic growth. The centralised approach, however, must
by its very nature place more reliance on ‘forced’ growth, with its
concomitant problems.
There is considerable benefit to be gained by looking at other approaches
to major computing strategies. This issue shows, as one might expect, that
similar aims can be pursued in different ways, and that in that diversity
there may well be things to learn. Michael Fairey |
