Salud, desarrollo y aprendizaje: nociones generales.

4.1. Overview of relevant actors in the Dutch health care sector

The Dutch health sector consists of a lot of actors, such as hospitals, insurance companies, and research centres part of Dutch universities (Volksgezondheid en zorg, 2016). In this paragraph, the most relevant actors considering the electronic health record will be briefly discussed to give a clear overview.

According to the VZVZ’s website, within the health care sector a subdivision can be made resulting in three subsectors, namely:

 The IT sector, providing for the system behind the electronic health record;  The provision sector, consisting of doctors, general practitioners et cetera who

provider health care;

 The insurance sector, consisting of insurance companies.

The last sector actually does not work with the electronic health record, as the insurance sector is not allowed to look into electronic health records. Health insurance companies are obliged to provide base insurances, without knowing whether or not someone is being treated for a certain disease. However, insurance companies do take up a big part of the health care sector, as they compensate for medicines and treatments and they determine what is and is not insured.

The IT sector works closely together with the VZVZ as this sector enables the connection with the (digital) infrastructure of the health care sector, the LSP, meaning that they enable for organisation X to become part of the (digital) network of the health sector. Furthermore, the IT sector makes sure that organisations meet the required qualifications, thus, that the organisations are in fact allowed to become a part of the (digital) network (VZVZ, 2016d). The infrastructure consists of the LSP, which is a connection point consisting all of the health care systems and networks. The LSP enables the cooperation between different actors in the health care sector (VZVZ, 2016). Furthermore, the infrastructure consists of services providing routing, authorisation, authentication, and patient profiles for example (VZVZ, 2016d).

The provision sector, consisting of organisations such as hospital and general practitioners’ offices, is also important when it comes to the electronic health record, as these organisations work with the electronic health record on a daily basis. When analysing the implementation of the electronic health record, doctors and nurses play a crucial part in the success of the electronic health record. As mentioned before, when the system is perfect, but

36 doctors do not know how to use the system, it still is not a success (De Veer & Francke, 2009; Beeuwkes Buntin et al., 2011). Thus, it is not only important for the VZVZ to govern the IT sector and the provision sector separately, but it is also of importance that the cooperation between the sectors is governed in an adequate manner.

4.2. Electronic health record: What is it?

The electronic health record is a digital system that gives doctors, general practitioners and specialists insight in one’s personal medical file. The advantage of a digital system is that information can be more easily shared, resulting in an easier, more smoothened cooperation between different actors in the health care sector, such as a general practitioner and a doctor working in a hospital. Furthermore, the reason why the electronic health record is of importance as well is due to the fact that, when one’s doctor is for example not around, the doctor who replaces him or her can have access in one’s medical file. The general practitioner then knows what medicines one is using and thus will not prescribe a conflicting medicine. Consequently, one can state that the electronic health record is more safe as well (Het Informatiepunt BSN in de zorg en landelijk EPD, 2016).

4.3. History of the electronic health record

All health care organisations in The Netherlands, such as hospitals and general practitioners’ offices, keep up patient files to gather as much medical data of a person as possible. The goal among other things is to make sure one is not getting conflicting medicines that can lead to more severe health issues, or that one is receiving medicines while he or she is allergic to certain components of the medicine. Before the introduction of the electronic health records, all this data was collected by one organisation and the sharing of personal medical data and/or records hardly ever happened. One of the main reasons medical records were not shared a lot, was because of the system did not allow this to happen in a safe and easy way.

In 2008, Minister of Health Mrs. Edith Schippers wanted to change all of this by introducing the electronic health record (Vrijbit, 2013). Simply put, the electronic health record holds the digitalisation of already existing medical files. By doing so, the sharing of data between different health care actors was assumed to become more efficient (Van ‘t Noordende, 2010). Some organisations already worked with digital medical files long before Minster of Health Mrs. Schippers introduced the electronic health record, as the results of the expert survey show. However, this differed per organisation and the sharing of data was irrelevant at the time.

37 The introduction of the electronic heath record did not just happen all of the sudden. Before the parliamentary approval, a campaign was started to introduce the electronic health records in society. Letters were sent to inform citizens about the electronic health record. In this letter, benefits of the electronic health record were highlighted and people were given an option to object to the introduction of the electronic health record (Rijksoverheid, 2008). As a part of the introduction and implementation of the electronic health record in The Netherlands, two laws needed to be implemented as well. These laws both focused on the use of the social security number (in Dutch: BSN) in the health care sector. With the implementation of the electronic health record, the social security number would be shared between different health care actors. This, however, was not legal at the time. The two laws were implemented to make sure this would be legal and in 2009, it was (Vrijbit, 2010).

One year later, on June 2nd 2010, the Dutch Senate stopped the implementation of the electronic health record. It rejected the bill unanimously. The financial risks of the bill would be too high and the bill in itself was said to be unclear (NRC, 2010). With the support of minister Schippers, Nictiz decided to implement the electronic health record with the use of private actors (Pharmaceutisch Weekblad, 2011). Nictiz is an expertise centre focusing on ICT developments in the health care sector. The switch from public sector to private sector did not go unnoticed and on September 29, 2011 critical questions were asked in the House of Representatives, resulting in what was being said to be the definitive end of the electronic health record (Tweede Kamer der Staten-Generaal, 2011; Herderscheê, 2011). Furthermore, the Senate instructed Health Minister Schippers to stop her involvement in the development of the electronic health record. As a result, the Vereniging van Zorgaanbieders voor

Zorgcommunicatie (VZVZ) was established. This association consists of five organisations,

focusing on communication in a broad sense in the health care sector. The goal of the VZVZ is to save and develop the idea of the electronic health record. The association also manages the

Landelijk Schakelpunt (LSP), one of the most important parts of the infrastructure of the

electronic health record. In short, the LSP holds the health care systems and its networks. Thus, it holds the cooperation between different actors in the health care sector (VZVZ, 2016).

In November 2012, the majority of the House of Representatives still had insuperable objections against the development of the electronic health record in the private sector (Vrijbit, 2010). One of the biggest concerns was the developer of the supporting system of the electronic health record, the American company CSC. According to the American Patriot Act, American companies can be forced to share data. Because CSC developed the Dutch electronic health record system, many started to be concerned that the data in these electronic health records

38 might fall into the wrong hands. However, former director Edwin Velzel stated that the electronic health record falls under Dutch law, in specific under the law of the protection of personal data (in Dutch: Wet bescherming persoonsgegevens – Wbp). Furthermore, according to Velzel, CSC has declared to act according to Dutch law. Therefore, no data could be shared with the American government (Novum, 2012; Tweede Kamer der Staten-Generaal, 2012). Yet, suspicion remained because American law still could force companies to share data.

To gain more trust from society in the electronic health record, the design of the LSP has been adjusted by the VZVZ since April 2013 (VZVZ, 2013). The LSP has been divided into 44 regions based on partnerships between different health care organisations. The result of the new design is that personal medical information is not shared on a national level, but on a local level (VZVZ, 2016a). The underlying assumption is that, by designing the LSP on a local level, society will show higher levels of acceptance in entrusting the protection of their data in the electronic health record and therefore will be more willing to participate (VZVZ, 2013). However, the question rises if this actually changes something about the situation, or that it only changes the perception of citizens but the actual plan remains the same.

4.4. Mapping governance trends of the electronic health record

As described in the paragraph above, governance of the electronic health record has gone through some changes to become the system as it is now. The governance trends, including the changes it has made, will be described in this paragraph in light of the four key concepts 1) agencification, 2) responsibilization, 3) privatization, and 4) decentralization.

The electronic health record was at first meant to be governed by the government as a bill was introduced by Health Minister Schippers in 2008 (Vrijbit, 2013). However, the bill did not pass and through the help of private actors, Health Minister Schippers tried to pursue the developments of the electronic health record (Pharmaceutisch Weekblad, 2011). Once this was achieved and the VZVZ was established, the governance of the electronic health record was completely privatised and full responsibility lied in the hands of the VZVZ. As mentioned earlier, the government did not hold any formal responsibility the electronic health record. The shift from governing the electronic health record in the public sector to governing the electronic health record in the private sector holds the key concepts of privatization and responsibilization.

Once the private sector had complete control in governing the electronic health record, some changes needed to be made. At first, personal medical data could be shared on a national level. However, citizens whose data was stored in an electronic health record were not happy with this possibility (VZVZ, 2013; VZVZ, 2016a). Why should a doctor from the north of the

39 country be able to look into electronic health records of citizens living in the south of The Netherlands? The VZVZ decided to change its approach in order to gain more trust from society. Instead of being able to share and look into electronic health records on a national basis, the VZVZ decided to divide the country into approximately 40 regions and only within those regions, personal medical data could be shared and looked into by using the electronic health record (VZVZ, 2013). By doing so, the governance of the electronic health record became fragmented and decentralized, with its purpose to gain more trust.

The concept of agencification took form after the VZVZ continued developing the electronic health record. Agencification holds the shift from policies and tasks from the public sector to the private sector with multiple private agencies (see Table 1). As the overarching organisation of the VZVZ was established, multiple other organisations were needed to successfully continue the electronic health record’s developments. These organisations, such as IT companies which created the system behind the electronic health record, are the ‘task specific’ organisations, which is an indicator for the concept of agencification (see Table 1). On a structural basis, certain tasks are carried out by these companies, as the VZVZ as an overarching organisation is not able to do so.

Thus, in each phase of the governance of the electronic health records, the four key concepts play a crucial role. To provide a clear overview of the important changes in governing the electronic health record, Figure 2 shows a timeline with all the important events in the development process, influencing the governance of the electronic health record.

40 Introduction of the EHR by Health Minister Schippers 2008 88 Ratification of laws considering

the use of social security numbers 2009 Dutch Senate halted the implementation of the EHR unanimously 2010 Implementation of the EHR with the

use of private actors 2011 Critical questions by the House of Representatives about the EHR

Objections of HoR about developing EHR in private sector 2012 Decentralization of the EHR due to

concerns of government and

society

2013

Figure 2. Timeline of important events in developing the EHR.

41

CHAPTER V: FINDINGS

In this chapter, the findings of the expert survey will be analysed. Each question will be (shortly) described, as all questions contribute to answering the central research question. To analyse the findings relatively easy, the questions are divided into multiple sections in which the findings will be analysed. These sections are divided into paragraphs. Question 1 and 2 will be analysed in the first paragraph,

5.1. Respondents and the use of the electronic health record

In this paragraph, the first two questions will be analysed. At first the function of the respondents (N=13) will be analysed. The results can be found in Table 2.

Table 2

Overview of functions of respondents

Function Frequency Percentage

Coordinating clinician 2 15,4%

Psychologist 4 30,8%

PhD candidate 1 7,7%

Nurse 2 15,4%

Combination of multiple functions 4 30,8%

Total 13 100%

Note. Percentages are rounded up to one decimal behind the comma.

As Table 2 shows, most of the respondents are psychologists, or have multiple functions within the organisation (both N=4). As findings showed, some respondents are for example coordinating clinician as psychologist as well.

When analysing the second question, asking how long the organisation already works with an electronic health record, answers varied from less than a year to 10 years or longer. Of the 13 respondents, 3 linked their answer to the duration of how long they already worked for the company. Thus, when respondent X already works there for two years, the organisation works with electronic health records for at least two years. However, it remains unclear how long the organisation already works with the electronic health record. Furthermore, 3 of the 13 respondents did not link the duration of the use of the electronic health record to the time that they already worked for the company, but however said to be unsure about the answer that they

42 had given. In addition, answers also differed between respondents who seemed to know for sure how long the organisation had already worked with electronic health records. A total of six respondents thought that the organisation worked with electronic health records for 10 years or longer and four respondents thought it was seven or eight years.

5.2. Advantages and disadvantages of the electronic health record

Question 3 focused on both the perceived advantages and disadvantages of the electronic health record. A great variety of answers was given, which can be analysed in Table 3 and Table 4.

Table 3

Advantages of the use of electronic health records

Advantages Frequency Percentage

Clear registration of client’s profile and situation

6 19,4%

Contributing to and improving the multidisciplinary cooperation

2 6,5%

More efficient (as most people type faster than they write)

1 3,2%

Possibility of working from home

1

3,2%

Accessibility everywhere 5 16,1%

Possibility to share and look into records of colleagues (at the same time)

6 19,4%

Legibility 3 9,7%

Possibility of linking the agenda to the EHR and the system

43 Information can be easily

processed and found in the system

2 6,5%

Transparent 2 6,5%

Safe (in comparison to a paper health record)

1 3,2%

Transmissible 1 3,2%

Total 31 100%

Note. Percentages are rounded up to one decimal behind the comma.

A total of 31 advantages were given by the 13 respondents. As seen in Table 3, the advantages differ from technical advantages, advantages in accessibility and cooperation, but also advantages considering the user-friendliness. However, most respondents agreed that the clear registration of a patient’s situation and his or her profile is a great advantage (19,4%). The same goes for being able to look into electronic health records of colleagues’ patients (at the same time) (19,4%), which was mostly described as an advantage so that colleagues could learn from one another.

The disadvantages will be described in Table 4, and what is noticeable is that some disadvantages overlap with the advantages described in Table 3.

Table 4

Disadvantages of the use of electronic health records

Function Frequency Percentage

No disadvantages 2 9,1%

Less privacy of the client 4 18,2%

44 Administrative tasks are more

easily carried out in other systems such as Outlook

1 4,5%

Not user friendly when wanting to add documents such as letters

1 4,5%

Possibility of system failures 2 9,1%

Slow system 1 4,5%

Difficult to find older records and the history of treatments in the system

2 9,1%

Disparity in working with the system between different departments, resulting in messy EHRs

1 4,5%

Always needing a computer 1 4,5%

Lack of possibility to leave instructions behind in the system for colleagues

1 4,5%

Registering data costs relatively much time

1 4,5%

Codes 1 4,5%

45 Clients often do not know what is

written about them

1 4,5%

Total 22 100%

Note. Percentages are rounded up to one decimal behind the comma.

Where the advantages were widespread (see Table 3), this is even more so when analysing the disadvantages. A total of 22 disadvantages are given by 13 respondents. A lot of disadvantages were experienced by one respondent only. However, one disadvantage stands out with 18,2%, and that is that with the use of electronic health records, patients have less privacy as the records are more easily accessible for other doctors, psychologists, et cetera. The question then rises how data privacy is being regulated. Furthermore, what is interesting is that there are also some concerns about the security of the system, as two respondents state that a disadvantage of the system is that it is hackable, resulting in a risk of being able to violate patients’ privacy. Furthermore, two respondents state that it is a disadvantage that failures can occur in the system. In a way, employees become more dependent on the electronic health record’s system now that it is digitalised, because all data is stored in this electronical system. Thus, when an error occurs, one cannot look into or adjust information in medical files. So even though working with paper files has its own disadvantages, for example not being able to read