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1. 1. Health information technology can drive improvements in quality and efficiency in health care...33 1. 2. Reducing operating costs of clinical services...
5. 2. Countries have adopted a range of different approaches to monitor ICT adoption...116 5. 3. Common information needs are reflected in a core set of widely
used indicators...119 5. 4. Improving comparability of data on ICT in health: What options?..
122 References...124 TABLE OF CONTENTS †7 IMPROVING HEALTH SECTOR EFFICIENCY: THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES  OECD 2010
Box 1. 4. Report on the costs and benefits of health information technologies in the United states (US Congressional Budget Office...
Box 2. 4. Open source health ICTS...64 Box 2. 5. The progressive introduction of interoperability provides a
Box 5. 4. Improving comparability of data on ICT in health: working towards an OECD â€oemodel surveyâ€?..
Table 5. 3. Overview of main data collections reported by countries...118 ABBREVIATIONS †9
CAD Canadian dollar CCHIT Certification Commission for Healthcare Information Technology CDM Chronic disease management CITL Center for Information technology Leadership
CHF Congestive heart failure COPD Chronic obstructive pulmonary disease CPOE Computerised Physician Order Entry EDI Electronic data interchange EFT Electronic funds transfer
ehi e-Health Initiative EHR Electronic health record EMR Electronic medical records EU European union FFS Fee-for-service
IM/IT Information management and Information technology 10 †ABBREVIATIONS IMPROVING HEALTH SECTOR EFFICIENCY: THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES  OECD 2010
NEHEN New england Healthcare Electronic Data Interchange Network NEHTA National e-Health Transition Authority NGO Non-governmental organisation
PACS Picture Archiving and Communication systems PHCTF Primary Health care Transition Fund PIN Pharmaceutical Information Network PIP Australian Practice Incentive Programme
PITO Physician Information technology Office POC Proof of concept POSP Physician Office System Programme QMAS Quality Management and Analysis System
and exchange of health data are likely to foster better care co-ordination, and the more efficient use of resources
information, online access to clinical guidelines or drug databases monitoring the effects of disease and therapies on the patient over time, and
guidelines and the use of a web-based chronic disease management â€oetoolkit†the province of British columbia achieved significant improvements in
CAD 4 400 (Canadian dollars) to CAD 3 966 per patient Reducing operating costs of clinical services
data processing, and by reducing multiple handling of documents. Experience in other sectors shows that these functional improvements can have a positive
Communication systems (PACS), which are considered an indispensable part of the drive towards a fully functional EHR and for the delivery of
Data from 22 sites in British columbia show that report 14 †EXECUTIVE SUMMARY IMPROVING HEALTH SECTOR EFFICIENCY:
the New england Healthcare Electronic Data Interchange Network NEHEN), a consortium of providers and payers established in 1997
the two major technologies used in electronic payment, electronic data interchange (EDI) and electronic funds transfer (EFT),
In Australia, for example, electronic claiming over the internet has been available since 2002 when Medicare Online was introduced.
their health information systems. Electronic data collection and processing can provide data in an accessible form that facilitates
reporting on different quality metrics, benchmarking and 16 †EXECUTIVE SUMMARY IMPROVING HEALTH SECTOR EFFICIENCY:
THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES Â OECD 2010 identification of quality improvement opportunities.
subset of data necessary for quality reporting and expanded the measurement of outcomes at GP practice level
clinical records and data storage, as well as a multiplicity of schemes introduced to facilitate interconnection and communication between
electronic data collection and reporting on quality improvement activities There is a growing body of practical experience across OECD countries that
number of information technology products, â€oelinkages†remain a serious problem. EHR systems must be interoperable, clinical information must still
systems or between versions of the same software. It must also be gathered consistently if it is to permit effective secondary analysis of health data
Electronic capture of data through EHRS can facilitate clinical research, as well as improve evidence-based care delivery
The development of standards to enable interoperability continues to be a political and logistical challenge and a barrier to seamless exchange of
Under pressure, vendors and users as well as international standards organisations, have started also to collaborate more openly in the development and progression of standards
patient data among different providers in a network raises the question of who should be allowed access to the file
creating a coordinated information system for patient care. Some of the case study countries require that patients be informed at the time of data
collection of all the purposes for which their data may be used. Others operate on the basis of an implied consent model for disclosure of health
information for treatment purposes, coupled with the individual's right to object to disclosure (opt out
In Canada, well-intentioned privacy laws have created barriers to data access. In British columbia, an unintended consequence of this commitment
government cannot access critical health data and carry out the necessary associative studies to improve services for citizens
for example, to implement a locally developed web-based electronic messaging and patient management system in Western australia which cut
These methodological difficulties are exacerbated further by data limitations, definitional problems and the lack of appropriate sets of indicators
there is little or no available data which would allow measurement. Despite a plethora of anecdotal information
Failure to collect the data necessary to evaluate the impact of ICTS is one of the core challenges to achieving widespread adoption of
high-performing ICT initiatives Notwithstanding the difficulties entailed, the case studies cast no doubt on the potential ability of countries to make major progress toward key policy
provide a secure, high-speed wireless communications network for over 97 %of the region†s rural private physician†s offices through a CAD 1. 2 million
USD 1. 14 million) grant from the federal Primary Health care Transition Fund. In Australia, the Great Southern â€oemanaged Health Network†developed
a secure web-based electronic messaging system that is being now rolled out in the most remote areas of the region with start-up funding of
a key factor in winning user acceptance Although there are limits to the generalisation of results, the case studies
data from the patient†s primary care record can facilitate greater efficiency and safety as well as contribute to future research
1. Data refer to 2006 2. Data refer to 2005 Source: OECD Health Data 2009, June 2009
26 †INTRODUCTION IMPROVING HEALTH SECTOR EFFICIENCY: THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES  OECD 2010
From 1990 through 2009, an increasing share of the gross domestic product (GDP) of OECD countries has been devoted to the provision of
data have remained unacceptably high despite the many calls for reforms. In 2007, an OECD survey reported that medical records of individual patients
exchange of health data are likely to foster better care, and the more efficient use of resources.
physicians are still using their computers mainly for billing or other administrative tasks Despite the promise they hold out, the implementation of ICTS in clinical
Bates, D. 2002), â€oethe Quality Case for Information technology in Healthcareâ€, BMC Medical Informatics and Decision making, Vol. 2
No. 7 Gandhi, T. K. et al. 2000), â€oemedication Errors and Potential Adverse Drug Events among Outpatientsâ€, Journal of General Internal medicine
OECD (2009), OECD Health Data 2009 †Statistics and Indicators for 30 countries, online and on CD-ROM, OECD Publishing, Paris. See
1. 1. Health information technology can drive improvements in quality and efficiency in health care A large body of literature has emerged recently that addresses the
information system that can prevent errors from occurring in the first place and which makes it easy for health care professionals to acquire and share
guidelines or drug databases and clinical decision support tools. These features were key requirements in the secure electronic messaging and
and use of online medicines databases (e-MIMS •Access to online treatment guidelines •Easily accessible information for reconciling the medications prescribed to a
compared with baseline data, the proportion of people with diabetes who had Hba1c, blood pressure and lipid tests complying with guidelines from
an average of CAD 4 400 (Canadian dollars) to CAD 3 966 per patient. In Canada, a relatively modest investment in IT has led to a major rapid change
Implementation involved the development of an interim, web-based information system for three chronic conditions: diabetes, congestive heart failure and major
depressive disorder. The interim system was developed later to provide the chronic disease management (CDM) toolkit The CDM toolkit incorporates clinical practice guidelines in flowsheets,
Communication systems (PACS) which allows the digital capture viewing, storage and transmission of medical images was viewed
and communication systems PACS is a computer system that replaces conventional x-ray film, and greatly improves access to patient information by making it possible for referring clinicians to review their
patient's images on PCS from their own offices. Hitherto, in rural areas information such as lab test results and discharge summaries has taken sometimes days
PACS also benefits radiologists who also have improved access to patient data and no longer have to forward information to other health care facilities
referring physicians deemed to be high users of the system. The survey was completed by 78 radiologists (43.1%response rate) and 181 referring physicians (17.6%response rate
system, was conducted on data extracted for 22 sites in British columbia. The analysis showed that report turnaround time decreased following the implementation of PACS by 41%(mean
All sites Rural sites Sites without on-site radiologist %decrease Source: Northern Health Authority (British columbia 1. 2. Reducing operating costs of clinical services
time with data processing, reduction in multiple handling of documents etc Experience in other sectors shows that this can have a positive effect on
They related this gain to easier access to patient data, faster communication, and the availability of higher quality and more complete data
Similarly, pharmacists in Sweden reported that processing prescriptions had become quicker and easier through the use of e-prescriptions and that they
Box 1. 4. Report on the costs and benefits of health information technologies in the United states (US Congressional Budget Office
estimating the value of health information technologies (ITS. The questions of primary concern to the CBO were:
by the RAND Corporation and the Center for Information technology Leadership (CITL *The RAND study, a modelling exercise based on a broad literature survey of evidence
return to their practices to consult patient data or clinical notes. These time gains may lead to improved quality of life, decision making, and higher quality
processing through the New england Healthcare Electronic Data Interchange Network (NEHEN), a consortium of providers and payers
the two major technologies used in electronic payment, electronic data interchange (EDI) and electronic funds transfer (EFT),
In Australia, electronic claiming over the internet has been available since 2002 when Medicare Online was introduced.
Although data was limited, in Western australia, physicians reported faster communication, fewer telephone calls, and savings in mail handling, stamps, and paper
difficult for them to evaluate acute stroke patients on site when needed. In addition emergency room physicians typically do not have the requisite experience to make decisions
about thrombolytic therapy without the backup of a vascular neurologist The regional health authority†s (Ib-Salut) drive to modernise health care IT began in
records to make critical patient data available not only at the point of care, but to all essential
and Communication system is used to allow the rapid sharing of essential radiological imagery to make the confirmatory diagnosis of the stroke and its
and data transmission to enable Son Dureta neurologists to be â€oevirtually†present at the bedside of a stroke patient anywhere in
Case studies show that automated data collection and processing can provide richer data in an accessible form that facilitates benchmarking and
identification of quality improvement opportunities. It can also enhance CHAPTER 1. GENERATING VALUE FROM HEALTH ICTS †45
other data sources necessary to expand measurement of outcomes. The MAEHC€ s effort to extract health care quality data from the community
level database, which is an agreed upon subset of data stored in physicians†EHRS, offers an opportunity to engage providers effectively and increase
alignment between incentives programmes (Box 1. 6 Health authorities and payers can now have a more timely view of how
the health system is performing, enabling them to make more relevant decisions about which areas call for clinical improvement, how best to
Only good quality data can enable valid conclusions to be drawn, which in turn enable changes to be made for the better.
and collection and analysis of quality of care data have traditionally followed divergent paths. Although more and more patient data are held on computer
systems, traditionally, quality data is collected and analysed retrospectively on the basis of insurance claims. Structured electronic data sources can,
however, provide useful, and in principle, more accurate and granular complementary information. Improving quality of care
measurement has been a key goal of the Massachusetts e-Health Collaborative (MAEHC since its inception.
Most of the data today is sent directly to a central quality data warehouse, from HIES via EHRS deployed in physician†s practices, together with data from their billing system
The shorter-term end product has been the production and distribution of EHR clinical performance feedback reports to participating providers,
health care quality data directly from HIES has opened a live window on the performance of the local health system and provided a shorter feedback loop for clinicians who can adjust
as service delivery data can now be captured in real-time 46 †CHAPTER 1. GENERATING VALUE FROM HEALTH ICTS
Computer-Based Intervention to Reduce Utilization of Redundant Laboratory Testsâ€, American Journal of Medicine, Vol. 106
Informatics Association, Vol. 8, pp. 299-308 Bates, D. et al. 2003), â€oepatient Safety: Improving Safety with Information
Information technology on Quality, Efficiency and Costs of Medical Careâ€, Annals of Internal medicine, Vol. 144, pp.
Information systems, Vol. 16, No. 4, pp. 41-67 Garg A x. et al. 2005), â€oeeffects of Computerized Clinical Decision Support
/106. PDF Harpole, L. H r. Khorasani et al. 1997), â€oeautomated Evidence-based Critiquing of Orders for Abdominal Radiographs:
and Appropriatenessâ€, Journal of the American Medical Informatics Association, Vol. 4, pp. 511-521 Hillestad, R.,J. Bigelow et al.
to Support Public Healthâ€, Journal of Biomedical Informatics, Vol. 40 pp. 398-409 Linder, J. A. et al.
Interoperabilityâ€, Center for Information technology Leadership HIMSS), Washington, D c Pricewaterhouse Coopers (2007), The Economics of IT and Hospital
Medical Informatics Association, Vol. 13, pp. 40-51 Shekelle, P. and C. L. Goldzweig (2009), â€oecosts and Benefits of Health
Information technology: An Updated Systematic Reviewâ€, The Health Foundation, London Starfield, B. 1994), â€oeis Primary Care Essential?
Supplement Web Exclusives, pp. W5-97-107 Stroetmann, K. A t. Jones, A. Dobrev and V. N. Stroetmann (2006
and Interoperabilityâ€, Health Affairs, Supplement Web Exclusives pp. W5-10-18 CHAPTER 2. WHAT PREVENTS COUNTRIES FROM IMPROVING EFFICIENCY THROUGH ICTS?
clinical records and data storage, as well as a multiplicity of schemes introduced to facilitate interconnection and communication between
conclusions about which health information technology functionalities are most likely to achieve certain health benefits †and the assessment of costs
and who benefits from health information technology implementation in any health care organisation †except those, such as
one site and in one budget, while a large share of the cost commitments appear at another site and in another budget.
In addition, there are no incentives, and may even be disincentives for care providers to be the first to
software/hardware, and patient management systems provided over the web via an application service provider (ASP
In the United states, the MAEHC has performed traditional in-office implementations of EHRS in each of the physician†s practices located in the
MAEHC reports hardware and software costs of approximately USD 30 700, plus another USD 12 100 for support
In Canada, the Physician Information technology Office (PITO programme established by the B c. Government in 2006 to â€oeco-ordinate
facilitate and support information technology planning and implementation for physicians†has adopted a different approach based on the ASP model
and certified a panel of five vendors from which primary care physicians must purchase their EMR
hardware and software start-up costs of approximately USD 15 500 plus an annual fee of almost USD 4 000 the first year, rising to almost USD 6 000
selected, the EMRS funded by PITO include all of the core elements of a fully functional EHR, with the exception of three of the main functions
One the basis of advice from an expert panel, in 2008 Desroches and colleagues defined
clinical and demographic data, viewing and managing results of laboratory tests and imaging managing order entry (including electronic prescriptions),
Health information and data: five functions Basic system Fully functional system Patient demographics x X
Hardware 22 800 6 364 Software & implementaion 17 200 9 091 Annual support/License 5 600 3 709 (1st year
/5 836 (2nd year & beyond Source: MAEHC and PITO (the PITO programme is only available to physicians in
eventual major upgrades or system replacement. Physicians in all six of our case studies repeatedly referred to cost,
outside of the traditional office visit, such as phone consultations or using electronic media to communicate with patients.
e-mail, working with data from new sources, and facilitating 58 †CHAPTER 2. WHAT PREVENTS COUNTRIES FROM IMPROVING EFFICIENCY THROUGH ICTS
between CAD 255 and 415 per month. At higher prices, interest dropped off dramatically Improved efficiency, better access to medical information and faster chronic patient data
charting and health trend analysis all act as drivers of physician interest Figure 2. 1. Willingness to pay
Low=CAD 255 Med=CAD 415 High=CAD 575 Low=CAD 415 Med=CAD 575
High=CAD 690 Low=CAD 7 200 Med=CAD 11 200 High=CAD 15 200
Source: Keshavjee et al. 1998 2. 4. Cross-system link-ups remain a serious problem While health care organisations are equipped increasingly with
ICT products and systems, linking them remains a serious problem Information systems in separate health care business entities must be able to
exchange clinical information on patients, i e. be interoperable, if value is to be attained as a result of introducing ICT in clinical settings.
Consistent CHAPTER 2. WHAT PREVENTS COUNTRIES FROM IMPROVING EFFICIENCY THROUGH ICTS? †61 IMPROVING HEALTH SECTOR EFFICIENCY:
THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES Â OECD 2010 implementation of standards and appropriate organisational changes are
necessary to facilitate this process Different computer systems are said to be interoperable when they can exchange data with and use data from other systems.
Simply converting data from a paper format to a digital format is not enough to ensure
interoperability. Interoperability depends primarily on all the computer systems that need to exchange information being able to communicate.
The rules that specify how to send information back and forth need to be defined This obviously involves technology issues,
but it also includes other kinds of issues, such as legal and business rules that need to be coordinated between
organisations in order for them to feel comfortable exchanging confidential patient data (Chaudhry, 2005 At present, both health care delivery and the ICT that supports it are
fragmented. The current health care delivery system is composed of a patchwork of care and services where patients interact with providers in a
variety of settings (e g. GP practice, specialist office, and clinical laboratory that are linked rarely up
and this now makes it difficult to achieve adequate electronic data exchange among different patient management and/or other clinical data systems
and quality of data that can be conveyed. While users have complained long about the situation,
few appear to be willing to pay more for what many feel should somehow be a standard
exchange of patient information between existing health care information systems were tested for their compatibility. At that time, a major concern for public authorities was the
These EMR software platforms were largely incompatible with each other, and were not interoperable. They had to be modified to
a greater or lesser extent to enable smooth data transfer into the planned national database
Under pressure, vendors and users as well as international standards organisations have started nonetheless to collaborate more openly in the
some level of success. The open standards1 of DICOM for digital images and HL7 for clinical messaging are slowly becoming universally available, and
were developed through a voluntary industry and user-driven process. In both cases, health professionals and technology manufacturers collaborated in
the development of open source health care software with several initial successes. Open source software is developed with an open code that is made
available, at no cost, in the public domain to download and change as needed and again share with the community.
health records systems, open source could provide a possible reference point 1. The term â€oeopen standard†as used here refers to the nature of the standard†s
availability for use by all interested stakeholders (users, vendors; and the high level of access to its specifications for ready promulgation in a variety of hardware
and software. It does not necessarily imply freely available or royalty-free. The term â€oeopen standard†is coupled sometimes with â€oeopen source†with the idea that
a standard is not truly open if it does not have a complete free/open source
reference implementation available 64 †CHAPTER 2. WHAT PREVENTS COUNTRIES FROM IMPROVING EFFICIENCY THROUGH ICTS
for compatible information systems and ensure broader interoperability Making open source software such as EHRS available as an option for
physicians offers significantly lower upfront costs. This, however, does not mean free software for everyone, nor it necessarily implies higher guarantees
of reliability and quality than commercial products. The success of any open source software depends on the community of developers who participates in
its development (California Health care Foundation, 2006. Recently, a growing chorus of policy makers have been advocating government support
for more open source development of EHRS (see Box 2. 4 Even when standards are available,
Box 2. 4. Open source health ICTS Examples of open source software that have been developed and are being widely
deployed, include EMR software such as OSCAR, Freemed, Vista and other software such as Medline, Epi-X and others.
To this effect, a 2002 NHS Information Authority paper on â€oeopen Source Software and the NHS€ concluded:
â€oeopen source health care applications would provide healthy competition to the existing closed source commercial market, encouraging
More recently in the United states, the success of the open source Vista EHR software developed by the US Veterans Administration,
implementations of open source technologies for their own use. In another sign of increasing support for open source software, the Certification Commission for Healthcare Information
Technology (CCHIT) has created recently three separate pathways to electronic health records certification. The first is still the traditional route for most commercial products but
the other two pathways were created with open source developers in mind, making their software potentially eligible under incentive programmes with funding guidelines calling for
such certification CHAPTER 2. WHAT PREVENTS COUNTRIES FROM IMPROVING EFFICIENCY THROUGH ICTS? †65 IMPROVING HEALTH SECTOR EFFICIENCY:
information has been developed by the Center for Information technology Leadership CITL). ) This provides a functional taxonomy based on three factors in data exchange:
the amount of human involvement, the sophistication of the ICT, and the adoption of standards
interoperability or below, the data can be used by humans, but for the most part cannot be used by machines to provide automated decision support, active guidance, or pattern
1 Non-electronic data †no use of ICT to share information. The most commonly used manual process for sharing
abstract data from paper sources Examples: postal mail, phone 2 Machine transportable data †transmission of nonstandard information via basic ICT;
information within the document cannot be manipulated electronically. Clinicians can access the information, but no computerised
data processing or logic can be applied Examples: PC-based exchange of scanned documents or manual faxing, pictures, portable document format
PDF 3 Machine-organisable data †transmission of structured messages containing non-standardised data; requires
multiple interfaces that can translate incoming data from the each of the sending organisation†s vocabulary to
the receiving organisation†s vocabulary; usually results in imperfect translations because the vocabularies used have incompatible levels of detail.
Data content is indexed down to single fields, however human translation is required to convert actual data in each field from the vocabulary of the sending organisation to that of the
receiving organisation Examples: secure e-mail of free text, or PC-based exchange of files in incompatible/proprietary file formats
HL-7 messages 4 Machine-interpretable data †transmission of structured messages containing standardised and coded data;
the ideal situation in which all systems exchange information using the same formats and vocabularies.
All systems exchange data using the same messaging, format, and content standards, removing the need for multiple
customised interfaces. All content can be extracted and converted electronically in each field and no longer requires human intervention
Examples: automated exchange of coded results from an external lab into a provider†s EMR, automated
exchange of a patient†s â€oeproblem list†Source: Center for Information technology Leadership; Walker et al. 2005
2. 6. Privacy and security are crucial How health care organisations handle their digital information environment affects the uptake of health ICTS.
Sharing sensitive patient data in a large and heterogeneous environment through the use of web-based
applications raises a series of privacy and security issues. For treatment purposes, an individual†s health information will need to be accessed by a
variety of health providers: physicians, nurses, radiologists, medical students, or others who are involved in the patient†s care.
obvious to users, and must be high on the list of information that patients are
As a recent Microsoft survey revealed, a large majority of the US public wants electronic access to their personal health information †both for
access is likely to increase the quality of the care they receive (Microsoft Corporation, 2009.
Benefits of Health Information technology, AHRQ, Rockville Maryland Ash, J. S. and D. W. Bates (2005), â€oefactors and Forces Affecting EHR
American Medical Informatics Association, Vol. 12, No. 1, pp. 8-12 Brennan, J.,E. Fennessy and D. Moran (2000), â€oethe Financing of Primary
California Health care Foundation (2006), Open source Software: A Primer for Health care Leaders, ihealth Reports Center for Democracy & Technology (2008), â€oecomprehensive Privacy and
Chaudhry, B. 2005), â€oehealth Information technology (HIT) Adoption †Standards and Interoperabilityâ€, RAND Health Working Paper
Leadership Needed to Define and Implement Information technology Standardsâ€, GAO-05-1054t, GAO, Washington, D c 70 †CHAPTER 2. WHAT PREVENTS COUNTRIES FROM IMPROVING EFFICIENCY THROUGH ICTS
Institute of Medicine (1997), The Computer-Based Patient Record: An Essential Technology for Health care, National Academy Press
Microsoft Corporation/Kelton Research (2009), â€oehealth Engagement Survey 2009â€, Microsoft corp.,, Redmond, WA. available at www. microsoft. com/presspass/presskits/industries/healthandlifesciences
/docs/MSHEALTHENGAGEMENTSURVEY2009. ppt OECD (2007), â€oeimproved Health System Performance through Better Care Coordinationâ€, OECD Health Working papers No. 30, Directorate for
Employment, Labour and Social affairs, OECD Publishing www. oecd. org/els/health/workingpapers Rosen, B. 1989), â€oeprofessional Reimbursement and Professional Behavior
the American Medical Informatics Association, Vol. 14, No. 1 pp. 110-117 Smith, C. 2002), â€oeopen Source Software and the NHS:
White paper National Health Service Information Authorityâ€, available at http://pascal. case. unibz. it/retrieve/2888/5. pdf,
accessed January 2010 Taylor, R.,A. Bower et al. 2005), â€oepromoting Health Information Technology: Is there a Case for More-Aggressive Government
and Interoperabilityâ€, Health Affairs, Supplement Web Exclusives pp. W5-10-18 Wang, S. J.,B. Middleton et al.
market stimuli to persuade users to change their behaviour. They also may involve using disincentives,
email): ) which offers direct payment for new categories of care or services related to the use of ICTS (e g. use of emails or
telemedicine •Withholding payments from providers: which amounts to financial â€oepenalties†following poor compliance, for example, part of the
Data used to calculate clinical quality indicators are extracted from the individual GP clinical IT systems
Information technology (IM/IT. It encourages the adoption of new technology as it becomes available, to assist practices to improve both their
encourages incremental compliance by software suppliers with the National e-Health Transition Authority (NEHTA) standards and specifications, with
computers for clinical purposes. Most practices had computer software and hardware to perform administrative and clinical functions, and most (78.3
%had speed a high Internet connection. Over half these practices (55.6%)had received a PIP payment for information technology/information
management, and nearly a third (31.5%)had received payments through another incentives programme intended to stimulate broadband uptake
Broadband for Health. An earlier study by Nielsen in October 1997 had found that only 31.0%of practices had computers, most
of which were being used for administrative purposes only. This evidence depicts a rapid uptake of computers to access crucial patient information at point of care
and to support clinical decision in general practice over about half a decade from implementation of PIP
These incentive programmes, which were administered generally with the support of Divisions of General Practices, have also been largely
responsible for the significant levels of adoption of computers and patient management systems by GPS in rural Western australia.
80%of WA practices were using computers for clinical care and not just for practice administration (Figure 3. 1). This number has been growing since
databases Practice administration Electronic data availability & exchange Electronic diagnosis & treatment 2003-04 2004-05
2005-06 %Practices Source: Primary Healthcare Research and Information Service (www. phcris. org. au The Physician Information technology Office in British
Columbia, Canada In British columbia (Canada) the Physician Information technology Office (PITO) was established in 2006 as a voluntary programme to assist
physicians with the adoption and use of EMRS PITO provides reimbursement of 70%of the cost of adoption and use of
A total of CAD 108 million was committed for 2006-12 to be disbursed gradually over the duration of the programme.
The hardware reimbursement levels were established based on real costs incurred by a representative group of practices, large and small in
sessions, training and support (e g. by providing help with data entry. The â€oebasket†of incentives, described below,
had a significant effect on user acceptance. Direct and indirect monetary incentives have expedited the chronic disease management (CDM
web-based software developed by the B c. Health Ministry with a Health Canada†s Primary Health care Transition Fund grant.
MOA time is compensated at CAD 20/hour as an expense to the GP Direct payments to spur use of the CDM Toolkit
since the inception of the programme in 2003, received a onetime payment of CAD 7 500
The complex care e-mail/telephone follow-up management fee To encourage the use of â€oee-visitsâ€, from 1 january 2008, a complex care e-mail
/telephone follow up management fee at a rate of CAD 15 (payable up to a maximum of four
two-way telephone or e-mail communication with the patient or the patient†s medical representative to follow-up case
push for provider adoption of interoperable health information technology through the â€oehealth Information technology for Economic and Clinical
Health Act†provisions within the American Recovery and Reinvestment Act of 2009 (ARRA. ARRA provides financial incentives through the Medicaid
and the ability to submit data on 2. These programmes provide health coverage for eligible individuals and families
whose patient panels consist of at least a minimum threshold of low-income individuals and families who
fail to become meaningful users, whether or not they avail themselves of the purchase-support incentive
costs associated with in-office installation of EHR software/hardware which are more significant than those incurred for an ASP-based EMR by
USD 1. 10 CAD 86 †CHAPTER 3. ALIGNING INCENTIVES WITH HEALTH SYSTEM PRIORITIES IMPROVING HEALTH SECTOR EFFICIENCY:
and robust data have been obtained. This conundrum is addressed later in the report Box 3. 3. Delayed benefit realisation
actually negative at CAD 1. 5 billion, having reached a positive cash flow by year seven and
CAD 20 billion This is further supported by a 2007 study by Pricewaterhouse Coopers of nearly
Case study Users Individual patients Society Payer E-Messaging Western Australia Neutral /Favourable physicians allied health
The user base has been steadily growing. In 2009 the network had over 5 700 users registered in the system from across 30 Australian regions.
In addition, in 2009 the GSHMN entered into partnership with private sector GSHMN charges GPS and Specialists AUD 750 (USD 696) per user
per year for the use of the full clinical patient management functionality Allied Health and GPS just using the messaging functionality pay AUD 250
USD 232) per user per year. An additional fee of AUD 200 (USD 185 per user per year is charged for the license,
and the use of the clinical databases. Physicians†costs are more than offset by the Australian
Government e-Health incentives for GP practices. Given the steadily increasing user-base, the sustainability and costing model put forward seem
to have met the necessary objectives 92 †CHAPTER 3. ALIGNING INCENTIVES WITH HEALTH SYSTEM PRIORITIES
their data to be shared in ways that clinicians and payers find valuable. The business model also depends on incentives that adequately reward physicians
for their participation in quality improvement activities which require data collection and reporting. Payers and purchasers willingness to differentially
leaders, and 3) participation in other relevant activities, such as clinical data exchange (e g. Medsinfo) or Computerised Physician Order Entry (CPOE â€
Medical data repositories Accurate patient medical data Very favourable Other stakeholder co-operation Source: Adapted from Deloitte Center for Health Solutions (2006
94 †CHAPTER 3. ALIGNING INCENTIVES WITH HEALTH SYSTEM PRIORITIES IMPROVING HEALTH SECTOR EFFICIENCY: THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES  OECD 2010
o exchanges. pdf E-Health Initiative (ehi)( 2009), Migrating Toward Meaningful Use: The State of Health Information Exchange
www. ehealthinitiative. org/assets/Documents/2009surveyreportfinal. pdf Gans, D. et al. 2005), â€oemedical Groups†Adoption of Electronic Health
Information technology: The Massachusetts e-Health Collaborative Experienceâ€, Journal of the American Medical Informatics Association Vol. 16, pp. 132-139
Keshavjee, K. et al. 2006), â€oebest Practices in EMR Implementation A Systematic Reviewâ€, AMIA 2006 Symposium Proceedings, p. 982
Use of Computers for Prescribing and Electronic Health Records Results from a National Surveyâ€, Medical Journal of Australia
Meetingâ€, Powerpoint presentation at AHRQ Annual Meeting, Bethesda Maryland CHAPTER 4. ENABLING A SECURE EXCHANGE OF INFORMATION †97
number of information technology products, achieving system-wide secure exchange of health information remains a serious problem
number of information technology products, many of these systems cannot talk to each other, and health information exchange remains a serious
simplest clinical data exchange (Box 4. 1)( Goroll et al. 2009 In Canada, the focus has similarly been on developing common
adoption of information technology 3. European commission Recommendation of 2 july 2008 on cross-border interoperability of electronic health record systems, Brussels, COM (2008) 3282
From its inception MAEHC has had in place a Data Exchange Standards Workgroup The goal of the Workgroup was to establish interoperability standards that systems must
meet that will allow for adequate data exchange to achieve the goals of clinical data sharing and access,
as well as meeting software and hardware compatibility requirements. However though the MAEHC had done an extensive job researching the vendors and making final
Achieving interoperability of health information technology solutions requires detailed negotiations between the vendors involved. This must also be
EHR product suitability, quality, interoperability, and data portability can often be very difficult to judge,
increases the confidence of users that the purchased systems will indeed provide required capabilities (e g. ensuring security and confidentiality
The Certification Commission for Healthcare Information technology (CCHIT) is an independent, not-for-profit organisation that certifies health IT products.
at vendor facility with jurors and proctors observing via simultaneous Web conference/audio conference. Each vendor sets up a test environment that replicates the live environment of its
Certification Commission for Healthcare Information technology 2009 www. CCHIT. org, accessed 12,july 2009 Although numerous products have already been certified in these
•Certification addresses the full range of products †open source, self -developed, modular, and other vendor.
open source developers, often don't understand why they need to go through the expense of detailed certification processes and possibly
5. http://healthit. hhs. gov/portal/server. pt/gateway/PTARGS 0 11113 881027 0 0 18/CA SUMMARY 071409. pdf, accessed January 2010
104 †CHAPTER 4. ENABLING A SECURE EXCHANGE OF INFORMATION IMPROVING HEALTH SECTOR EFFICIENCY: THE ROLE OF INFORMATION AND COMMUNICATION TECHNOLOGIES  OECD 2010
certified EHRS are neither user friendly nor designed to meet ARRA€ s ambitious goal of improving quality and efficiency in the health care system
ensure is a baseline of core functionalities and specifications that could be used to achieve interoperability.
http://healthit. hhs. gov/portal/server. pt? open=512&objid=1269&&pageid=1650 1&mode=2&in hi userid=11113&cached=true, accessed January 2010
Through a combination of funding, information technology services and change management services, POSP has helped nearly half of Alberta†s
practicing physicians to incorporate information technology into their practices Some of the initiatives that POSP supports include
•Developing solutions to move patient data from one physician office system to another •Reducing the risk of data loss in physician offices caused by human, hardware or
software failure •Working with stakeholders to update the Vendor Conformance and Usability Requirements (VCUR) for physician's offices.
These requirements are reviewed regularly to ensure they continue to reflect the needs of all stakeholders
and access to patient health data, and on patient consent. Interpretation of privacy and security requirements are still often
sharing data becomes more difficult because stakeholders may have differing views of what can be shared and with whom.
In Canada, well-intentioned privacy laws have created barriers to data access. In British columbia, an unintended consequence of this commitment
government cannot access critical health data and carry out the necessary associative studies to improve services for citizens
To overcome some of the obstacles to the secondary use of data, in May 2006 the B c. Government passed Bill 29
developed web-based electronic messaging and patient management system in Western australia which cut across several jurisdictions.
the importance of consulting users and identifying key concerns to improve the implementation process. The MAEHC case study interviews indicated
the opt-in approach to consent, patients declare what data they are willing to share.
option at the point of care to prohibit a clinician from looking up data. Both
that wanted to share patient data, rather than on the patients themselves since no data could be shared without written permission from the patient
From the MAEHC perspective, the consent form would educate individuals about how health information is exchanged,
while determining the extent of data sharing that most patients would be willing to accept. The risk that large numbers of patients
clinical data to be copied or â€oeuploaded†to the HIE community database. As such, patient recruitment became a preeminent concern for the HIE enterprise,
if it was to be viable. To address this concern the MAEHC adopted a â€oeturning consent to demand†strategy investing
The MAEHC has focused on the core messages that appealed to all of the focus groups convenience and data security.
Informatics Association, Vol. 14, pp. 48-55 G. W. School of Public health and Health Services (2009), â€oepatient Privacy
in the Era of Health Information technology: Overview of the Issues†G. W. School of Public health and Health Services, Washington, D c
Information technology: The Massachusetts e-Health Collaborative Experienceâ€, Journal of the American Medical Informatics Association Vol. 16, pp. 132-139
Healthcare Information and Management Systems Society (HIMSS)( 2008 Electronic Health Records: A Global Perspective, HIMSS, Chicago
2007), â€oeadoption of Information technology in Primary Care Physician Offices in Alberta and Demark, Part 2:
how to improve the availability and comparability of data on health ICTS at OECD level
the efficiency of health care systems, there is little or no available data that could allow any quantitative estimation.
collected shows that the currently available national and international data on health ICTS is often not comparable for a whole range of statistical
patient data. Consequently, policy makers, developers and managers have thus far been concerned primarily with addressing the many challenges
system that ranged from an estimated CAD 133 in Canada as of 2009 to CAD 570 per
1. OECD Health Data 2009; 2. 2007; 3. 2008; 4. 2006; 5. Source: HHS, FY 2010
2009, exchange rate CAD 1. 10; 8. Source: Department of health and Ageing, Australia; 9 2009-10, exchange rate AUD 1. 19;
OECD Population Data, 2007; 11. Through March 2010, exchange rate CAD 1. 10; 12. NAO, through December 2015, exchange rate GBP 0. 61
13.2007 CHAPTER 5. USING BENCHMARKING TO SUPPORT CONTINUOUS IMPROVEMENT †115 IMPROVING HEALTH SECTOR EFFICIENCY:
Access is related to the availability of equipment and internet connections. Availability, relates to the question of how many different
â€oeintention to adopt†addresses the propensity of users to adopt these applications in their clinical work,
on â€oepurpose of use and user satisfaction†reflects the intensity of ICT-related activities and can inform specific policy and institutional questions
•Secondary use of data for monitoring public health 5. 2. Countries have adopted a range of different approaches to
monitor ICT adoption Analysis of surveys from nine OECD countries (Australia, Canada, Czech Republic, France, Finland, New zealand, Norway, Sweden, and United states
and at EU level shows that the major types of data collections are •Stand-alone surveys of health care providers (businesses or
•Use of administrative data 7. An example of how this model can be applied to health ICT is Finland, where the
sector, most OECD countries have not yet set out to collect national data on health ICT adoption on any systematic basis. In addition, most surveys are
the OECD study also use routine administrative data to monitor ICT adoption. This approach may represent a low cost alternative way for
The downside is compiled that data from such sources are constrained by the fact that in most cases administrative data collection
has been designed for other purposes than monitoring ICT use and impact Activity by OECD countries national statistics offices to monitor
ICT use in the health sector has been limited generally. 8 With few exceptions (namely Canada and the United states), current surveys on ICT
the survey can be designed to meet the specific needs of the user, in this case, health care policy makers.
The main drawback is that the data is generally not comparable with other data sets that might be available for the
same country or across countries for statistical reasons, including the use of different sampling techniques, definitions and the scope of the surveys.
different data sources in terms of: a) relevance, i e. how well the data reflects the information priorities of policy makers;
b) feasibility, i e. how easily data can be gathered (cost and time; c) prevalence, i e. whether the
type of data collection is used frequently or not; d) extent of comparability Table 5. 3. Overview of main data collections reported by countries
Data collections Relevance Feasibility Prevalence Comparability National statistics surveys of ICT use Low Low Low High
Use of administrative data Medium High low Low Surveys of the population Medium Low Low Low
Stand-alone surveys of health care providers businesses or personnel High Medium High low Source: OECD The OECD study also reviewed how countries define ICTS in their
surveys. With the exception of the term â€oeelectronic health record†and â€oeelectronic medical recordâ€, there was very little or no overlap in the lists
5. 3. Common information needs are reflected in a core set of widely used indicators The OECD analysis clearly shows that the way countries are currently
data, within and across countries, or to link survey data to other data sources Nonetheless, it is possible to identify a core set of indicators widely
used in these surveys. These indicators were assessed against a set of criteria listed in Box 5. 2 and assigned to three broad priority groups of
policy objectives Box 5. 2. Criteria for the selection of indicators •Be relevant to actual or anticipated policies
•Measure something of obvious value to users and decision makers •Be clearly definable, simple to understand
relevant data to address the adoption and use gap. A number of surveys have adopted a â€oepurpose of use†approach in their questions on the use of EMRS
demographic data, viewing and managing results of laboratory tests and imaging, managing order entry (including electronic prescriptions),
data transfer across settings. The efficient application of e-health solutions is predicated on the seamless sharing of patient information across the health
Inter-provider data sharing is a challenge that is only just beginning to be tackled in many OECD countries,
instance, user satisfaction, is important to address key policy questions such as the need to provide any additional financial incentives or technical support
new information technologies and may be used with other types of quantitative indicators to explain differences in the intensity of use of new
5. 4. Improving comparability of data on ICT in health: What options Evidence-based policy analysis for health ICTS appears still a distant
ideal, and the necessary data cannot be gathered from existing national statistics or data collections There is clearly much work to be done to gather relevant information for
a) improving the quality of existing data and indicators; b) improving the linkages between policy and indicators;
c) developing indicators for unmet information needs. However, in addition to producing better data, it is important to improve the comparability of data and consequently the
methodologies used to collect and analyse this data. Data should be more easily accessible to the relevant users †not only policy makers, but also health care
providers, and analysts and researchers, who serve as important intermediaries in processing the information for evaluation and policy analysis
The creation, initial testing and subsequent use of an indicator entail high fixed costs (initial tests, survey design and implementation), and these
are hard for a small group of initiators to bear. This means that OECD countries have a lot to gain from pooling their efforts and sharing the
burden of developing and testing indicators in this sector. Risk, delay and cost can all be minimised by learning from good international practices
international guidelines to improve the availability and comparability of data on health ICTS. In the model survey approach an agreed set of indicators
Box 5. 4. Improving comparability of data on ICT in health working towards an OECD â€oemodel surveyâ€
way to improve the availability and comparability of data for a core set of indicators on
use of core modules allows measurement on an internationally comparable basis, additional modules and new indicators within existing modules can be added to respond to evolving or
efforts to improve the comparability of health ICT data internationally. These features are reviewed below
•Link of indicators to user needs: the model survey reflects common elements of national ICT usage that in turn are guided by national policy priorities
While the use of core modules allows the measurement on an internationally comparable basis, additional modules and new indicators
Information technology for Improving Quality of Care in Primary Care Settings, AHRQ, Rockville, Maryland Anderson, G. F.,B. K. Frogner, R. A. Johns and U. E. Reinhardt (2006
â€oehealth Care Spending and Use of Information technology in OECD Countriesâ€, Health Affairs, Vol. 25, No. 3, pp. 819-831
â€, Journal of the American Medical Informatics Association, Vol. 11, No. 2, pp. 100-103
generation of healthcare%5b1%5d. pdf, accessed 28 september 2009 Department of health and human services (2009), â€oepublic-Private Initiativesâ€, HHS, Washington, D c.,http://healthit. hhs. gov
/portal/server. pt? open=512&objid=1149&mode=2, accessed 9 june 2009 George, D. and N. Austin-Bishop (2003), â€oeerror Rates for Computerized
Journal of the American Medical Informatics Association, Vol. 12 pp. 377-382 CHAPTER 5. USING BENCHMARKING TO SUPPORT CONTINUOUS IMPROVEMENT †125
in Ambulatory Settings, Center for Information technology Leadership Boston, MA Kilbridge, P.,E. Welebob and D. Classen (2001), â€oeoverview of the
www. leapfroggroup. org/CPOE/CPOE%20evaluation. pdf Koppel, R. et al. 2005), â€oerole of Computerized Physician Order Entry
OECD (2009), OECD Health Data 2009 †Statistics and Indicators for 30 countries, online and on CD-ROM, OECD Publishing, Paris. See
promising potentialâ€, Powerpoint presentation to OECD Expert Meeting on ICT in the Health Sector, Paris
Debate over Medicare Reformâ€, Health Affairs, Supplement Web Exclusives, pp. W96-W114 ANNEX A. COUNTRY CASE STUDIES †127
The GSMHN is delivering web-based patient management systems and secure electronic messaging solutions to clinicians in the vast rural expanse of Western australia.
Centre for Software Practice (UWA Centre) provided dedicated technical support under a not-for-profit partnership agreement
A 2001 study found that 86%of Australian general practices had at least one computer and projections indicated that within two years,
most practices had the computer software and hardware to perform administrative and clinical functions, and most (78.3%)had speed a high internet connection.
Furthermore GSGPN survey results from 2006 indicated over 80%of Western australia practices using computers for both clinical and administrative functions
Background and benefits The Great Southern Managed Health Network (GSMHN) was established in 2007 as a not-for-profit association between the Great
Southern General Practice Network (GSGPN) and the University of Western Australia (UWA) Centre for Software Practice
The goals of the project were to achieve •Secure messaging and increased collaboration between health
•Improved patient data capture •Improved medication reconciliation A wide variety of benefits and impacts of electronic messaging have
professionals, which related this effect to easier access to patient data (they were able to access information about their patients that was previously
unavailable, at least routinely), faster communication, higher quality of data and more complete information. GSMHN allowed health providers to
managed for over three decades population health data in Western australia on behalf of the Department of health. It was acknowledged that the
UWA Centre for Software Practice had been a critical, if not major factor in the successful implementation of the project, both for the enthusiastic
extensive expertise in software development 132 †ANNEX A. COUNTRY CASE STUDIES IMPROVING HEALTH SECTOR EFFICIENCY:
capability to access web-based clinical decision support tools such as the chronic disease management (CDM) Toolkit
2. Information technology 3. Privacy legislation 4. Guidelines development 5. Implementation of new service delivery models
To encourage the adoption and use of information technologies, the B c. Government adopted a mix of financial incentives and strategies:
training and support (e g. by providing help with data entry reimbursement for complex care e-mail/telephone follow-up, direct payments to spur use of the
CDM Toolkit, reimbursement of 70%of the cost of adoption and use of an eligible electronic
The CDM â€oeself-evaluation†toolkit is based a web software developed by the B c. Health Ministry.
provides an excellent entry to the world of information technology and getting a first glimpse of
which included the deployment and use of information technologies. These efforts, including those aimed at addressing care gaps and the rapidly
Physician Connect began in 2004 with a CAD 1. 2 million Primary Health care Transition Fund (PHTCF) grant.
the NHA€ s information systems to enable quick and secure retrieval of laboratory results, and spur adoption of EMRS
capability to access web-based clinical decision support tools such as the CDM toolkit. By tracking patient care processes using best practice
services for people with complications is approximately CAD 776 million each year. By 2016, direct health care costs to treat patients with diabetes in
CAD 1. 38 billion In addressing the challenges posed, the Physician Connect effort has created a value proposition for all key stakeholders.
of data within and across health authorities while maintaining their autonomy is an ongoing concern †along with a need to deal more
physicians was that sharing identifiable patient data among different providers raised the questions of who should be allowed access to the file
implementation of electronic health records (EHRS) and clinical data exchange capabilities in three Massachusetts communities.
as needed electronic exchange of their clinical data between clinical sites (however, no permission is sought to have stored data in the practice's EHR;
and the benefits of HIE participation were touted to encourage patient participation rather than making security
coupled with practice management software to link all clinical and administrative practice functions in one seamless health
surrounding patient privacy and data sharing agreements •Built a novel health care quality data infrastructure to collect
organise, and analyse, health care system performance Results to date have shown over 95%physician adoption rate of EHRS
Health Information technology within the US Department of health and Human Services (US DHHS) is providing leadership for the development
overarching health information technology modernisation effort guided by the Plan Estratã gic de Sistemes d†Informaciã (PESI) which included the development of a health
system-wide EHR, radiology information system (RIS)/ picture archiving and communication system (PACS), pharmacy information system, and others.
The guiding vision of the plan to deliver equal access to health services regardless of patient location and providing continuity
and data for neurologists at Son Dureta to â€oevirtually†examine stroke patients Results on outcomes show that efficacy
and timesavings are the features most appreciated by users today Determinants of success Apoteket†s monopoly position and state-ownership
a move away from mainframe computing to desktop PCS. Combined with continued research and live implementations throughout the
patient data, pictures, medical applications and services for which the Internet is not acceptable. Subsequently, in 2001 when the first large scale e-prescription implementation
In addition, patients have ready Web access to their entire medication lists as prescribed and can be printed easily in preparation for
•New legislation allowing national databases, independent of reimbursement form, but with high degree of patient consent and
list-resulting in low physician use of the national database •Clinical decision support has not been developed and implemented
and security measures to allow access to certain national databases e g. National Pharmacy Register •Progress in hospital deployment has been limited due to competing
data items in their medical record by withholding authorisation or by requesting the masking or concealing of specific information at the local level
electronic signature to a prescription, a letter of referral or a contract. The government has ANNEX A. COUNTRY CASE STUDIES †149
health care information system were tested ICT suppliers were invited to take part in the POC and were reimbursed financially for
sites since 2007. The WDH provides the out-of-hours GP and allied health professionals with a summary of the patient†s history which can assist
package to promote the purchase of computers and the use of electronic medical records. This package included an extra per capita fee for each
if the GP used a computer. Together, these incentives represented an EUR 8. 000 average increase in a physician†s
information system tested and approved by professional associations 2) implement a patient management system within two years from the
purchase of a computer; and, 3) participate in data collection and reporting In addition, until 2008, physicians could also receive an additional 25 cent
quarterly/patient if participating in electronic claims processing. The incentives programme was terminated in 2006. Physicians can, however
traditional in-office installation of software/hardware and installation through an external application service provider (ASP.
The national information system is based on a central â€oelocator service†the Landelijk Schakelpunt or National Switch Point (LSP), which went live
Under this system, clinical data will be maintained locally, i e. in the databases of the health care provider or regional databases and will be
accessed through the central search engine which can locate and extract the data from local databases.
The LSP cannot store patient histories, and doctors†systems will not be able to store records retrieved by LSP.
To retrieve data, LSP keeps an index of specific patient information kept by each healthcare practitioner.
It also maintains a log of who accesses what information, and when. Doctors can only see information pertinent to their
specifically on surveys or data collections that are considered useful from a policy perspective and the most common indicators used today
Given the dearth of data, the workshop concluded that implementation of case studies would be the most promising approach
A group of OECD experts in health information technology was established to help guide the work, the development of a framework for the
sourceoecd is the OECD online library of books, periodicals and statistical databases For more information about this award-winning service and free trials, ask your librarian,
Health information technology can drive improvements in quality and efficiency in health care Reducing operating costs of clinical services
Countries have adopted a range of different approaches to monitor ICT adoption Common information needs are reflected in a core set of widely used indicators
Improving comparability of data on ICT in health: What options References Annex A. Country case studies
Annex B. Project background and methodology
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