Page 2: Current status of the electronic patient dossier

Contents

Although there has been an EPD obligation for hospitals since 2020. Since 2022, this has also applied to medical practices, nursing homes and pharmacies licensed after 2022 – they all have to join an "EPR community". Healthcare professionals and institutions licensed before 2022 as well as outpatient service providers can use the EPR on a voluntary basis.

According to the Federal Office of Public Health (FOPH), 72,000 EPRs had been opened by patients as of August this year. (Population CH: 9 million). The majority of hospitals are now participating. However, only 18 percent of doctors' surgeries are connected to an EPR. Pharmacies and home care services also have some catching up to do.

As of August 2024, 82% of hospitals, 57% of nursing homes, 18% of doctors' surgeries, 10% of pharmacies and 7% of home care services have an EPR.

In most cases, several reasons are given for the slow pace of EPR introduction, such as the voluntary nature of the process to date. To open an EPR, you need a smartphone (or computer/tablet plus cell phone) with a cell phone number including an email account, a health insurance card and pension certificate (AHV), an "electronic identity" – i.e. eID app (SwissID, TrustID) and a biometric passport/identity card from Switzerland or the EU/EEA (exception: German ID card). If you need help with onboarding the EPD, which can be tricky for some, you can also apply for the EPD at an EPD opening point, such as a pharmacy.

Choosing an EPD provider

The first step is to choose an EPR provider. These are so-called communities in which healthcare professionals and their facilities are technically and organizationally networked. There are eight such communities. Interested parties can open their EPR in seven of them, which are called master communities. Both associations are certified and organized decentrally, i.e. they are present in one canton or in several or all of the 26 Swiss cantons – usually affiliated with the respective (language) region.

For example, anyone wishing to open an EPD with the largest parent company, the non-profit company Post Sanela Health, can now do so online throughout Switzerland. In twelve cantons, Post Sanela Health offers this free of charge. Otherwise, it costs 15 francs (16 euros). (Incidentally, the SwissID is also issued by a Swiss Post subsidiary).

The EPR, or more precisely its provider, was financed (from 2018 to 2022) not only by the opening fees, but rather by financial aid divided equally between the Confederation and the cantons. According to media reports, the introduction of the EPR has already cost CHF 100 million. More money has been available since October 1.

The federal government and the various EPR stakeholders held a hearing on the restructuring and further development of the EPR in the fall of 2023. This resulted, among other things, in transitional funding; due to the "financially critical phase" of the core communities according to the FOPH, CHF 30 million was approved by Parliament last spring. The financial aid came into force at the beginning of October 2024. The federal government can now provide an amount of CHF 30 per EPD opened, i.e. for a total of 1 million EPDs. However, – as before – the respective canton must contribute the same amount.

Fear of a "PDF graveyard"

The process of opening an EPD varies slightly depending on the provider. However, once everything has been completed, the EPR user can determine which authorized healthcare professionals are granted access rights. These, as well as the patient(s) themselves, can store documents in the EPR, such as their vaccination record. However, even eHealth Suisse, the competence and coordination center of the federal government and cantons, admits that the information stored in the EPR often has to be laboriously searched for. Consumer advocates also complain that it is time-consuming because it is not possible to search for explicit terms.

You first have to narrow down PDFs thematically, open and read everything, and then perhaps find the information. According to eHealth Suisse, healthcare professionals fear that the EPR will create a "PDF graveyard": institutions would upload documents en masse. Many documents must first be converted before uploading, in any case, to archivable PDF/A-1. Other possible file formats: TXT, CSV, XML; JPEG, PNG, TIFF; MP3, MP4, MPEG, GIF.

Work in progress

In addition, there have been various criticisms that the decentralized nature of the systems means that data exchange is not generally guaranteed. At the end of 2023, for example, the ORK, the Eastern Switzerland Intergovernmental Conference, to which seven cantons belong, called for a system at federal level to be specified and declared binding instead of the various parent communities. It even called for a pause in the EPD until all major problems had been solved. As it stands, the EPR would hardly be of any use; it has too many design flaws.

The health directors of the cantons (GDK) are also no longer interested in "cantonalism" and are in favor of controlling and financing the EPR from a single source. And not only inter-cantonal bodies such as the GDK and ORK, but also the Swiss Federal Audit Office (SFAO), the government's financial auditors, advise the FOPH to compare a centralized EPD with the current model and to opt for the better one.

Major objection to centralization

Many providers reduce the risk to data security, as sensitive data is not stored centrally by a single organization. The demand for centralization of the EPR system was also the subject of the consultation in summer and autumn 2023 and, according to the FOPH, should be examined for the total revision. As mentioned, this is due to take place by 2028.

Due to the various individual cantonal solutions, there is hardly any useful convergence, according to criticism - also due to outdated technology. Instead of structured and dynamic data (including blood pressure values), which could be automatically exchanged between service providers, the EPR currently only contains image and text files. The technical connection of the so-called primary systems in hospitals, doctors' surgeries etc. to the EPR platforms is also too complicated overall.

This, along with many other things, does not really make the benefits of the EPR compelling for many at present and does not make the situation any easier – even if a majority of the population generally views the EPR positively. Currently, however, the opinions of many observers and users of the EPR – up and down the country – still range from at best benevolent to even scathing. "A federalist patchwork of horrors from which many are making good money," one expert complained anonymously in the media.

Without benefits, doctors have no interest

Other healthcare professionals are also annoyed, such as Anna Winter, President of IG eHealth and Co-President of the "Alliance for Digital Transformation in Healthcare". In a specialist media article last year, she stated: "As long as doctors have no benefit, they won't be able to convince patients of the EPD". And major Swiss media, such as newspapers from the CH Media publishing group, have also noted a vicious circle: the EPR's lack of appeal results in its low penetration rate, and as long as this remains low, the EPR will have little traction - both with patients and with healthcare institutions.

More interoperability

But slowly, very slowly, the situation is improving. Little by little, EPR information and IT systems are being better standardized and structured so that, it is hoped, all computer and software systems will eventually be able to work together in a meaningful way. When asked by heise online, the FOPH replied that the systems have been interoperable between all German-speaking Swiss and with other (core) communities since summer 2024.

It remains difficult, because the important exchange formats for structured data communication (which are needed in addition to PDF and the other file formats mentioned) are anything but fully developed. For just two e-health applications, medication and vaccinations, there are two legally prescribed exchange formats (e-vaccination, e-medication) that are still being tested –, for example in the annual EPD IT test week "Projectathon". According to eHealth Suisse, formats for four other areas of application are being developed, all based on international technical and semantic standards such as FHIR from HL7.

eHealth Suisse is developing various recommendations and technical solutions to ensure end-to-end interoperability. For example, regarding the standards for primary systems – there is still some need for "deep integration" with the EPR. This refers to the IT systems in healthcare facilities for documenting and recording original data (such as practice, clinic or laboratory information systems). Their manufacturers offer eHealth Suisse assistance in integrating the systems into the EPD platform via technical interfaces (of which around a dozen are required) or also via "EPD connectors" which have already implemented the EPD standard interfaces.

(vza)