Today I had the pleasure of having lunch with an informatics professor from the University of Wien and got an inside look into health IT in Austria. The highlight of our conversation was a discussion regarding ELGA – Austria’s national health information network.
Timeline: ELGA is an Austrian government funded initiative that is being roll-out in phases. While it is “live” now, ELGA is only just beginning to onboard some of the major Austrian provinces public hospitals who will come online in sometime in 2015. By mid-2016, all hospitals will be on-boarded and the process on on-boarding ambulatory practices and pharmacies will begin. Private hospitals and practices will follow in 2017, if they desire. In 2022, they will onboard dentists.
Architecture: ELGA is based on a federated architecture wherein no patient data is stored outside of the host EHR (hospital, physician practice etc.). Austria has a national health ID card (it’s a smart card) that is issued to all citizens. This smart card is the “patient identifier thus addressing master patient indexing (MPI). Patient information is queried via a physician portal. Patients also have their own portal view and gain access via their smart card.
Data Exchange: Unlike most U.S. public HIE efforts, ELGA is not trying to distribute an entire patient record. Instead, ELGA will only be able to query and present discharge summaries, radiology reports, lab reports and medications. Other data elements such as a patient’s problem list will not be a part of ELGA data package in the initial roll-out. However, draft implementation guides for ophthalmologic reports and reports of infectious diseases are being balloted IHE XDS is the query standard, HL 7 CDA the format and use standards such as LOINC and SNOMED.
Privacy & Security: ELGA is an opt-out system wherein a patient has to formally request that their records not be available through ELGA. And one thing I’ve come to understand living here – Austrians take their privacy very seriously (they are appalled at what they see occurring in US – eg NSA). Access to ELGA and a patient’s record is strictly limited to the attending physician and the patient. Physician use the patient’s smart card and must have justifiable need to gain access to data. Other physicians, government agencies, payers (they are part of government), employers, etc. – no one can access a patient’s data.
And since it is based on a federated architecture, no patient medical data is centrally stored anywhere. While this puts a real crimp on an ability to perform any type of analytics, it does provide an added level of security that hybrid and centralized architectures cannot match.
Not Without Its Challenges and Shortcomings
ELGA has some nice things going for it such as relatively straight-forward data package, a highly-refined data consent model (citizens can opt-out entirely, restrict access to specific records, restrict access of specific physicians), security built into the architecture and a reasonable roll-out schedule.
But as in the U.S., ELGA and the Austrian government face some political challenges. The government has yet to provide policy guidance as to who will pay for connecting to ELGA – i.e., does the provider have to pay for connecting to ELGA or will the government. The professor told me that there are likely more than 50 different ambulatory EHRs in use in Austria and that adoption hovers in the mid-90th percentile. There is also no clear policy guidance regarding physician liability. So while hospitals by and large support ELGA, support from private practice physicians is lacking. This has lead to some advertisements in local publications sponsored by physician groups decrying ELGA stating that it is not safe, not secure and that citizen’s health data will be exposed.
The most glaring shortcoming of ELGA is its lack of any sort of data repository for clinical analytics. It appears that the Austrian government knew that Austrian culture regarding privacy would never allow such to happen. There may also be the issue that as a single payer system, the government can determine quite a lot regarding the health of its citizens from claims data. Granted, it may not be as richly detailed as clinical data, but it is useable and there is no political risk.
ELGA is not perfect, but I have yet to find an HIE that is. Some of the issues ELGA faces are not dissimilar to those in other countries, including the U.S. Based on this one afternoon lunch, there is quite a bit we can learn from one another’s experience. Yes, each will have their own peculiar nuances, but there is still plenty there to share.