Dutch EHR plans put on hold

Plans for a national Electronic Health Record in the Netherlands have been put on hold after the Dutch Senate voted to make major changes to the national programme.

Until the EHR legislation is approved the Dutch EHR programme will no longer be mandatory. Care providers will now only be allowed to link to the national EHR on a strictly voluntary basis.

In addition, there will be no more financial incentives to encourage GPs, pharmacists and hospitals to link to the national EHR infrastructure.

In the proposed legislation individual providers who refuse to connect to the national infrastructure face potential €33,500 fines.

The proposed EHR legislation fell into disgrace, after too many amendments were introduced. Many Senators also felt that the wrong technological model had been adopted. The Dutch EHR system is based on a pull model that dynamically pulls together records from local source systems.

The Dutch EHR is based on an online medication list and a patient medical summary for GPs.

The rollout of these two core services will now continue on a strictly voluntary basis –without financial carrot/stick incentives from The Hague.

In addition the Department of Health (VWS) will not be allowed to add new functionality to the present EHR rollout.

Considerable delays are likely as the legislation will probably be returned to Parliament. This decision will be made in two months.

Indonesian born Dutch Labour MP, Ing Yoe Tan, who was a key mover in the legislative changes- expects a delay of at least one year.

Even this may prove optimistic. Following the June 2010 Dutch elections the Parliament has taken a more critical view of the long-running EHR project. There is growing resistance to many elements in the EHR legislation.

Many questions arose. Should technical details (like HL7v3) be part of legislation in a time of fast technological change? Is the national EHR unfair competition to regional systems, which are funded by private parties?

The delays and legislative changes are a big blow to Nictiz, the Dutch EHR coordinator. Nictiz started the national EHR roll-out in the end of 2002, on behalf of the Dutch government. Dissatisfied with the speed of implementation the Department of Health decided to take over that role. After three and a half years of work the results were rather minimal: only 100 care providers were connected to the national EHR Switch.

For the two initial EHR objectives some 6,500 care providers must be connected. But by the end of March 2010 only 11% had done so, largely due to a financial bonus, which will now be scrapped. The large majority continues to communicate through regional EHR’s, in which they have greater confidence.

Health Minister Ab Klink wanted to get rid of the regional EHRs, as they don’t meet all legal requirements (i.e. opt-in, data protection). But Klink and his predecessors also saw regional EHRs as a threat to their own EHR ambitions.

The Dutch EHR industry is in an ambivalent position. One EHR provider (Microbais) supported the national system almost from the start –also for strategic reasons. Support grew recently, as a long lasting deadlock did not allow anyone to invest in new developments.

Delays were rife. The Dutch EHR rollout originally was to be completed in 2004.

The national EHR was never popular with GPs and other care providers. Almost half a million Dutch citizens (out of a population of 16.5m) have opted to stay out of the national EHR.

In the Dutch healthcare system care providers pay their own ICT investments (and make their own software choices). A late 2009 report by M&I Partners calculated that Dutch care providers in 2008 spent about €1.7 billion on healthcare IT.

Specific figures on EHR expenditure by the government were not given, but are estimated to have been at about €100m in 2008.

The total amount of €1.8 billion is quite high as compared to the health IT spend of the English National Health Service, which in 2008/2009 spent approximately €2 billion.

The figures suggest that The Netherlands (with a population almost exactly one third of England) spends about 2.5 times as much per capita on healthcare IT.

Ton Smit is editor-in-chief Dutch health IT news service Qure.