Understanding Health Information Systems: For The Health Professions
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CHAPTER 13
HIS Around the Globe
“What kind of world do we want to live in?”
Tim Cook, CEO of Apple, cautioning all in a speech to European leaders, on the data industrial complex
(Nicas, 2018)
“We do not ride on the railroad; it rides upon us.”
Henry David Thoreau, lamenting the U.S. industrial complex in the 1800s (Lyndon, 1846)
LEARNING OBJECTIVES
By the end of this chapter, the student will be able to:
■ Describe uses, strategies, and impacts of Health Information Systems (HIS) in countries
internationally.
■ Explain the context in which these different approaches to HIS occur, including the overall
performance of health systems around the world.
■ Portray the relationship between cost, outcomes, and HIS in these countries.
■ Detail the highlights and lowlights of various countries’ HIS infrastructure and strategies.
■ Identify the strengths and weaknesses of HIS in various countries.
■ Provide examples of the uses of digital health solutions internationally.
■ Illuminate the ways that the structure of a health system affects HIS strategy and results.
■ Explain lessons learned from the experiences of different countries in the adoption of HIS.
▸ Introduction
The subject of HIS in other countries provides a vi
ant opportunity to learn what types of HIS and technology work
in other health system structures, providing a
view into the ways HIS can improve the sup-
port of clinical, administrative, analytical, and
population health management processes,
as well as cautions about the problems and
effects of those uses. It is not lost on students
of health care that the U.S. differentiates itself
in two conflicting ways: first, some of the most
excellent healthcare services are available in
the U.S.; second, that care is only accessible
on a regular basis to those with comprehen-
sive affordable health insurance or lots of cash,
leaving the underinsured and uninsured, and
371
in fact, many with high deductible plans at
isk. Additionally, U.S. health outcomes are last
among Organization for Economic Cooper-
ation and Development (OECD) nations and
lag at low standing compared to all nations in
important statistics such as maternal and infant
mortality (Martin & Montagne, XXXXXXXXXXWhile
progress is being made in many areas, medi-
cal e
ors comprise 10 percent of all deaths in
the U.S., serious public health problems have
eached crisis proportions, such as the opioid
epidemic, and we are far from stemming such
problems and failings of the system (Pearl,
2017). Certainly, the combination of health
system structure and HIS that support it are
important elements of those poor outcomes.
Research and Statistical
Foundation of Measuring Health
System and HIS Effectiveness
Government organizations, universities,
and global organizations such as the World
Health Organization (WHO), The Com-
monwealth Fund, Institute for Health
Care Improvement (IHI), the Health and
Medicine Division (HMD) of the National
Academies of Sciences, Engineering, and
Medicine, and many other respected organi-
zations are devoted to the development of new
knowledge, methods, insights, and informa-
tion related to healthcare quality, cost, pop-
ulation health, and other relevant topics that
can be put into action to influence the ways
health care is delivered and public health mea-
sures are tracking. The reach of these organi-
zations’ impact is far and wide and, in some
cases, ubiquitous. These organizations per-
form research—that is, inquiries, studies, and
eporting on all manner of health-related top-
ics. Of course, these organizations need data to
conduct these activities effectively. Thus, the
esearch, policy, and public health impact of
HIS depend on availability of high-quality data
from healthcare organizations, health surveil-
lance methods, and direct data collection
techniques. The source systems of these data
include the growing base of core HIS described
in the HIS and management layer of the HIS
model, which in this case, applies to HIS inter-
nationally. Without these HIS data sources,
esearch, policy, and public health organiza-
tions also conduct primary data collection or
find data through other means, which can be
difficult and limited in scope. It behooves the
cause of advancement of learning in health
care around the globe to connect consistent,
comprehensive data sources from primary
sites of healthcare delivery (that is, healthcare
and public health organizations) to these sec-
ondary uses of data for research, policy, and
public health purposes.
A Nation’s Healthcare Philosophy
and Structure Influences Its HIS
Strategy
In most developed nations, other than the
U.S., health care is supported by the gov-
ernment through a variety of programs and
mechanisms, but consistent in the principle
that health care is available as a right to all its
citizens. Private health insurance and care is
also typically available in these countries with
a national health service for those who wish
to pay for the privilege of on-demand health
care. Any discussion of HIS in these countries
should be done in the context of the over-
all structure of the countries’ health system.
Questions to consider when evaluating HIS
adoption and uses in other countries include:
1. Is access to health care universal or
selective?
2. Who has access to health care and
how are HIS and digital health
used to facilitate that access?
3. What role do HIS play in achieving
the results in health outcomes and
cost in that country?
4. What are the strengths and weak-
nesses of HIS in this particular
country?
372 Chapter 13 HIS Around the Globe
5. How widely are new digital health
technologies being used in these
countries?
6. What highlights and low-lights
have occu
ed in the adoption and
use of HIS and digital health in that
country?
7. What are some experiences and
examples of using digital health
such as eHealth, mHealth, and
telemedicine used internationally?
How are HIS and digital health used
to support and facilitate health care
in that country?
8. What are lessons learned from
these findings and scenarios that
can be shared with and adopted
in other countries? How does the
structure of a country’s health sys-
tem influence the ability to adopt
HIS and digital health?
▸ Adoption of HIS
in Many Countries
HIS investment and adoption abounds inter-
nationally, as technology ubiquitously infil-
trates and su
ounds our world. As would
e expected, countries invest and deploy
HIS and technology based on the traditions,
structures, and philosophical underpinnings
of their own health systems, economics, and
strategies for providing (or not providing) for
the health needs of their population. Coun-
tries vary according to the principles and
parameters of their commitment to their
populace, fueled by societal forces and mar-
kets, governed by public and private regula-
tions and law.
Common goals internationally revolve
around efforts to automate, streamline, and
innovate within each country’s unique health
system. Historically, in a 2008 study funded by
the Commonwealth Fund, HIS and technol-
ogy plans and projects in Australia, Canada,
Germany, the Netherlands, New Zealand, the
U.K., and the U.S. were examined. More than
90 percent of general practitioners in Austra-
lia, New Zealand, the Netherlands, and the
U.K. reportedly used electronic health records
(EHRs), whereas only 10–30 percent of prac-
titioners in ambulatory settings in the U.S.
and Canada used EHRs (Jha, Doolan, Grandt,
Scott, & Bates, XXXXXXXXXXThese adoption statistics
have changed remarkably since that time. A
striking finding of the earlier study is that only
10 percent of hospitals in the seven countries
studied met the criteria for major elements
of an EHR system, a measure comparable to
the distinctions drawn between “basic” and
“comprehensive” EHR systems in studies
of U.S. hospitals and ambulatory settings (Jha
et al., XXXXXXXXXXSince then, enormous but varied
investments of financial resources, time, effort,
and organizational energy have been made
country by country, and the results are largely
the same internationally as in the U.S.—HIS
adoption is slow and painstaking work.
Results vary widely from country to coun-
try, which is to be expected, given the vary-
ing resources, different political systems, and
competing priorities country by country. Still,
international comparisons provide an import-
ant natural experiment on what it takes to use
HIS to achieve desired economic and health
outcomes and provides interesting texture to
discussions about the effectiveness of various
health system structures and funding mecha-
nisms, as well as approaches to HIS strategy.
For instance, various versions of national
health systems exist, even if based on a simi-
lar construct of a single payer model—that
is, national health systems in which providers,
hospital systems, and the payer are all part
of the same unified health system, such as in
the U.K., tend to be better positioned to set
up standardized HIS and infrastructure, and
thus opportunity for effective population
health management programs. Numerous
countries internationally with single payer
health systems have viable opportunities to
pull together consistent efforts to implement
Adoption of HIS in Many Countries 373
nationwide to HIS initiatives and provide the
foundation to support cost-effective health
care for their population. In the U.S. system,
consisting of a combination of free market and
governmental programs, Kaiser Permanente
is an example of such a self-contained health
system that sets the benchmark for effective
population health management, even amid the
complicated U.S. health system.
Even so, developing a national HIS strat-
egy is still incredibly difficult work for many
easons. First, a cogent overall national health
system strategic plan must be created and
agreed upon, upon which to base the HIS Stra-
tegic Plan. Additionally, the required financial,
human, and infrastructural resources must
e determined and then allocated to support
the development, implementation, on-going
maintenance, and enhancement of expensive
EHR systems and HIS infrastructure, follow-
ing methods consistent with those described
in Chapter 4: HIS Strategy, Planning, and Gov-
ernance and