View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Trepo - Institutional Repository of Tampere University SCIENTIFIC PAPERS Half of the Finnish population accessed their own data: comprehensive access to personal health information online is a corner-stone of digital revolution in Finnish health and social care Vesa Jormanainen1, MD, MSc, Kimmo Parhiala1, MSocSc, Anu Niemi1, MD, Marina Erhola1, MD, MQI, PhD, Ilmo Keskimäki,1,2, MD, PhD, Minna Kaila3,4, MD, PhD 1 Finnish National Institute for Health and Welfare (THL), Helsinki, Finland; 2 University of Tampere, Tampere, Fin- land; 3 University of Helsinki, Helsinki, Finland; 4 Helsinki University Hospital, Helsinki, Finland Vesa Jormanainen, Chief Specialist, Social and Health Systems Research, Finnish National Institute for Health and Welfare (THL), P.O. Box 30, FI-00271 Helsinki, FINLAND. Email: [email protected] Abstract In Finland, the implementation of the national Kanta services’ second phase was carried out step by step from May 2010 to December 2017. My Kanta Pages, launched in 2010, is an online service where citizens can browse their own health information recorded in the Prescription Centre and the Patient Data Repository regardless of whether the healthcare services they had used were public or private. It is the patient accessible national electronic health records in Finland (PAEHR). The study objective was to investigate the use of the national PAEHR by using indicator data from 2010 to 2018. Cumulatively 2.8 million (M) persons (51% of the Finnish population, and 63% of the adults at least 18 year old) had accessed the PAEHR 23.2M times (49.2M sign-ins) by 31 December 2018. Altogether, 6.0M e-prescription renewal request were sent to healthcare via the PAEHR by 31 December 2018. Patient Data Management Service was implemented as part of the Patient Data Repository. By 31 December 2018, the Patient Data Management Service had records of 6.3M information notices, 3.3M consents and 93,732 refusals (consent restrictions). In addi- tion, the Patient Data Management Service had records of 467,055 organ donation testaments and 93,484 living wills. Half of the Finnish population in general, and two out of three adults had used the national PAEHR by 31 Decem- ber 2018. Since nine years after its launch, the adults’ use of the Finnish national PAEHR is still increasing and is approaching 50% annual use. Keywords: access to information, patient internet portal, electronic health records, information system 6.11.2019 FinJeHeW 2019;11(4) 298 SCIENTIFIC PAPERS Introduction A nationally shared, widely accessible PAEHR system has powerful symbolic meaning; it may or may not be Many European health systems have recognized the perceived as improving quality and safety of care. Al- transformative potential of digital health services for ternatively a PAEHR can be seen as a threat to patient improving care delivery and reducing costs [1]. From confidentiality or the traditional role of the physician or 2006 to 2010, European Union member states reported the nurse [15]. Online e-services in healthcare and so- considerable increase in national e-health activities but cial welfare services are usually PAEHRs that are owned still, patients had rarely access to their own medication by healthcare organizations [16,17]. However, introduc- profiles or were able to reorder certain repeat medica- tion of a PAEHR alone does not guarantee its wide use tions themselves, e.g. via the web [2]. In 2019 Finland, among patients with a diagnosis [18,19]. In 2007, e- Sweden, the Netherlands, and Denmark scored highest services that the adult (at least 18 year old) Finns who according to the Digital Economy and Society Index of responded in a population survey wished for, such as the European Commission [3], followed by the United access to laboratory test information, appointment Kingdom, Luxembourg, Ireland, Estonia and Belgium. scheduling or repeated prescription renewal, were in short and there was no possibility to view electronic Patients are offered access to their own health data on medical records (EMR) or EHR [20]. In 2014 among a national level only in a few countries, such as Austral- respondents in a population survey, the most asked ia, Canada, Denmark, Estonia, Finland, France, Iceland, online services were still an access to laboratory and New Zealand, Norway, Scotland, Singapore and Sweden medical imaging results, patient records, prescription [4]. Easy access to personal health information has long data and prescription renewal [21]. In contrast, the been on the wish lists of patients and their advocates, follow-up survey respondents in 2017 had already used and modern health information technology, internet multiple such online services which they also consid- and secure patient accessible electronic health records ered useful in general [22]. (PAEHR) may dramatically increase possibilities for patients’ access to their own data [5–8]. There is also a geographical aspect of information and communication technologies: telephone and internet Access to health records improves quality of care, may be well suited for health education in rural areas shared care management, with patients using their [23,24], but not necessarily for everyone [25]. Living in records to improve interactions with healthcare provid- a rural versus urban area may have implications on ers, decision-making about their health [7,9–12]. Access technology adoption. In Sweden, older adults living in to PAEHR is likely to save time for patients and practices rural areas use internet less than their urban counter- in primary healthcare [13]. In a year-long quasi- parts [26]. experimental trial among 105 primary care practitioners and their 13,564 patients, the patients accessed their Kaiser Permanente, a non-profit healthcare organiza- visit notes frequently, a large majority reported clinical- tion in the USA, began offering online healthcare ser- ly relevant benefits and minimal concerns, and virtually vices in 1996 [27]. Functionalities, such as prescription all patients wanted the practice to continue [5,6]. Con- refill, online appointment transactions, facility directory cerns of professionals about privacy were unrealized and health encyclopaedia visits consistently rank among and those about workload increase were only partly the six most visited and used features. Sweden became corroborated according to a systematic review [12]. one of the first countries to use e-prescriptions in 1983, Physicians’ experiences with the usability of currently and patients as well as physicians generally have ex- used electronic health record (EHR) systems and chang- pressed satisfaction with the e-health system [8,28–31]. es in their perceptions did not improve between 2010 Electronic patient journals have been available for pa- and 2017 [14]. tients since 2012 but each region decides what infor- mation is shown. Denmark is an early adopter of health information technology [2] and, launched the Danish 6.11.2019 FinJeHeW 2019;11(4) 299 SCIENTIFIC PAPERS national PAEHR sundhed.dk in 2003 [4] and the E- Kanta services is the name of the Finnish national digital Journal national repository of record information from data system services that form a unique service entity all public hospitals in 2007 [32]. based on legislation effective since July 2007 [34]. The current main services are described in Figure 1. Since Finland also has a long history of using information the Finnish national PAEHR does not have a stand-alone technology in healthcare [33,34]. The issuing of e- data of its own, information from community pharma- prescriptions was made obligatory in public healthcare cies (medicine dispensations) and e-prescriptions regis- in 2013 and in private healthcare in 2015. Since January tered in healthcare are shown in the PAEHR together 2017, all healthcare providers are obliged to use the e- with health data registered to the Patient Data Reposi- prescription system [35]. Community pharmacy cus- tory. The Prescription Centre is in mandatory use na- tomers are familiar and very satisfied with the national tionwide since January 2017 whereas the Patient Data service [36,37], and general practitioners report that e- Repository is in use in Mainland Finland excluding the prescribing has improved their patient medication Åland Islands. management [38,39]. Finnish health professionals have positive expectations about the PAEHR [40]. User groups Kanta services Healthcare service providers Public primary healthcare organizations Prescription centre Pharmaceutical database Public hospital districts Prescriptions Dispensations Medicinal products details Prices Private healthcare providers Renewals Reservations Substitution rules Reimbursement rules Pharmacies Patient data repository Health records Imaging infrastructure Archive of old patient data Encounter data Imaging data Old health records Kelain Structured health records Healthcare professionals E-prescription service layer messaging Physicians (web-based) Dentists Data management service Kanta Consent data* Will expressions** Summary service*** Information notices Living wills Problems Vaccinations Risks Consents Organ donation wills Procedures Imaging studies Citizens My Kanta Pages Consent restrictions Lab results Physiological findings * In Consent data section, information about the fact that the patient has been informed of the nationwide data system services (information notices) is recorded. A person can read the information