Dr. Marzio Della Santa, MPH, Project Leader
Dr. Giuliana Corà, Scientific Collaborator
Dr. Ignazio Cassis, MPH, Cantonal Doctor
Department of Health and Social Affairs,
Republic and Canton of Tessin, Bellinzona (Switzerland)
Email: [email protected]
Health is one of the principal preoccupations of the Swiss population. Although the operation of the health system largely satisfies the great majority of our citizens and politicians, the evolution of healthcare costs is threatening the integrity of the system. It is therefore necessary to find an equilibrium between effectiveness, efficiency and equality. The effectiveness is understood as the capacity of the system to produce the expected results, efficiency as the optimal allocation of available resources (the balance between costs and the results obtained), and equality as the right to access to healthcare for everyone and the recognition of the specific needs of each person (justice).
The Swiss healthcare system is a complex and multifunctional mechanism. It is composed of a multitude of players with various specialities and specific interests, ideally complementary, but sometimes conflictual. In certain cases, personal reasons do not permit healthcare players to pursue the objective of stability of the system which corresponds to the public interest. For that reason, the parliament decided in 2003 to carry out a project aimed at ‘creating ideal conditions to favour the correct utilisation of the healthcare strucutres and services’.
New technologies for managing information, by nature neutral against the balanceof power between the healthcare players, were identified from the start as constituting the best way to achieve this objective. Given the complexity and the fragmentation of the healthcare system in our country, it appears essential to make the exchange of information between players more efficient, which will also allow an improvement in efficiency, greater security of personal information (privacy), and better quality of care.
‘Rete Sanitaria’ (‘Healthcare Network’): A Non-Linear Process
After an initial study phase, a concept conceived around the concept of electronic health (cyberhealth, e-Health) was chosen. It is laid out in three phases, conceived to initiate and continue a pragmatic process of reform towards a modern health system:
- The objective of the first phase is to make patients, professionals and politicians aware of the potential solutions which the use of cyberhealth tools offer in managing patients.
- In the second phase, the ‘Rete sanitaria’ is dedicated to satisfying the prinicipal functionalities required by the various participants. These were worked out in phase 1 of the project, dedicated to the discovering the possibilities offered by electronic health services.
- The third and last phase involves the transformation of the role of the state. This represents the main catalyst of the process of reform and is involved in the partnership on the same level as its counterparts.
The First Step: The Pilot of the Health Card
The pilot phase of the electronic health card is the main action of the first phase, the aim of which is to break down the psychological barriers and to facilitate the introduction of more evolved electronic health services and with a high addedvalue for professionals and patients. In effect, every new technology requires a certain time to be correctly mastered and exploited, and the health card is no exception. The IT competency of most people working in the health field is still often limited. Experience shows that the development of an electronic patient file takes a long time, on average 10 to 15 years until the final implementation. It must be said that a smart card for patients does not represent a real innovation. In fact, these have already in regular use in Switzerland in the banking and transport sector.
The test phase, limited to the urban zone of the principal town of Tessin, Lugano, was organised in such a way as to take account of the local context. It started in 2004 and was extended until June 2006: around 800 volunteer patients and 600 health workers working in 40 pharmacies, 33 surgeries, six hospitals, an ambulanceservice and a home healthcare service.
This phase included a blue card for patients, which, according to international standards, offers the possibility to record important medical information(allergies, vaccinations, medical therapy, list of principal health problems) and a green card for professionals, which identifies the health profesionals, and allows them to access and modify private data (always with the permission of the patient).
The software used for managing health card data assists the doctor in prescribing a drug.
Results of the Health card Pilot
The aim of phase 1 was to make patients, healthcare professionals and politicians aware of the electronic health solutions in order to respond to the demands of the healthcare system. An observation mechanism was put in place during the twenty months of testing: the behaviour of patients and professionals during the use of the health card was observed and analysed.
This made it possible to verify that the patients - in particular the elderly and chronic patients – are generally in favour of registering their medical data on the card and prefer to facilitate the access to data, for example by registering it on the freely readable part of the card, rather than protecting it by a PIN code which, in case of necessity, can hinder the action of a healthcare professional.
The receptiveness of the patient often depends on the attitude of the doctor: if he/she is in favour of electronic management, the patient very often holds the same view. Doctors also play a central role in the promotion of electronic health.
Health professionals have an attitude of resistance when faced with sharing information on their patients, even if they have the consent of the patient. This resistance is partially due to respecting a medical secret, but the principal reason seems to be linked to the fear of transparency in front of colleagues, insurers and the patient.
Concerning the use of the card inside hospitals, it was established that the support of the hospital managers and administrators is important, but on its own insufficient to induce doctors to use it. Better integration into work processes, as well as the improvement of its possibilities thanks to on-line services are the fundamental conditions for a real intra-hospital implementation of the electronic card.
Despite the fact that the pilot phase posed some problems, such as the quite modest use of the health card and a certain prudence dictated by the rapid evolution of the national context, the ‘cultural’ change (the psychological evolution when faced with something new) which Rete sanitaria wanted to target seems to be irreversibly under way. The demands of the healthcare professionals are the proof: after initial resistance, they are asking for an acceleration to a more functional level.
The initial fears and concerns seem largely to have been overcome. On that basis the Rete sanitaria initiative, whilst maintaining the structure for the use of the health cards already distributed while waiting for the future national insurance card (foreseen for 01 January 2009), is oriented towards the experimentation of three networked clinical services: access to radiological images, notification of entry and exit of the hospitalisation with a brief exit report, and access to laboratory results. A new strategy for 2008-2012 has just been submitted to the government of the canton; it is in line with the Swiss strategy of of cyberhealth .
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