1 Introduction
Healthcare is both complex and hierarchical, characterized by interrelated subsystems, and social, characterized by formal structures and elementary units [1‐5]. Most healthcare reforms are not properly followed-up, and their outcomes are rarely evaluated [6]. The demand for healthcare system and service reforms is compelling, and often there is little choice but to implement complex information and communication technology on a large, often nationwide scale [7, 8]. Clearly, there exist a need to carry out further research in order to describe implementation and adoption of nationwide healthcare information systems.
Health information exchange (HIE) is the electronic transfer of patient data and health information between healthcare providers or institutions regionally, nationally and internationally between different information systems [5, 9‐11]. HIE systems assist healthcare organizations in collecting, processing and disseminating electronic information internally and in their environment [12]. An electronic health record system (EHR) is an electronic collection of health-related data concerning one subject of care – the patient. It provides clinical data [13, 14] and a longitudinal record of information in computer processible form across practices and specialists in real time [15]. An EHR can include an organized web-based patient portal allowing patients independent access to their own data. However, only a small number of nationwide implementations of shared patient-accessible EHRs have been launched in OECD countries, including that of Finland [5, 16‐18].
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Health information systems (HIS) integrate the data collection, processing, reporting, and use of the information necessary for improving health service effectiveness and efficiency through better management. Comprehensive HIS implementation is risky [19‐21]. Implementing a new nationwide HIS is a megaproject: large-scale, complex and costly, taking many years to develop and build, involving multiple public and private stakeholders and impacting millions of people [20, 22, 23].
Finnish patient records became electronic in phases during the 1970s [24, 25]. Finland’s first large-scale health information development programme in healthcare and social welfare services was the Satakunta Macro Pilot regional programme, which ran in Western Finland in 1998–2001 [26]. In primary healthcare, the prevalence of electronic patient records was 50% in 1998, and 50% in municipal primary healthcare hospitals in 2002; by contrast, the figure was 100% by 2007 [27]. By 2007, all central and university hospitals had electronic patient records, electronic image repositories and laboratory systems in place [28]. In 15 June 2001, the Ministry of Social Affairs and Health (STM) proposed that the Social Insurance Institution of Finland (Kela) together with the Finnish Medicines Agency (Fimea) begin assessing the requirements for developing electronic prescriptions in Finland [29].
Large-scale implementation of nationwide HIS services is a rather novel research theme, the concepts and definitions of which are still to be established. Thus far, no comprehensive review of the empirical research literature has been performed for strategies for electronic health implementation [30].
The World Health Organization (WHO) has recently introduced the term ‘digital health’, which is the systematic application of information and communications technologies, computer science, and data to support informed decision-making by individuals, the health workforce, and data systems, to strengthen resilience to disease and improve health and wellness [31‐33]. The health system challenges can be grouped into nine overarching categories: information, availability, quality, acceptability, utilization, efficiency, cost, accountability, and equity [33]. Digital health application is the software, information and communications technology systems or health communication channels that deliver or execute the digital health intervention and health content.
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The follow-up data from May 2010 to December 2018 provided the first observations on the increasing availability of the nationwide Kanta Services in Finland [34]. However, there were no means to observe the services separately by public or private healthcare service organizations. This research aimed to extend the follow-up from January 2019 to December 2023, and thus, in order to cover a 14-year period (2010–2023) of healthcare data processing in the centralized electronic Prescription and Patient Data Repository Services. During the study period, two major events took place in Finland, e.g. the Covid-19 epidemic (starting March 2020) and the major re-organization of healthcare, social welfare and rescue services (starting January 2023). The objective of this research was to document if these major events had any impacts on healthcare organizations’ entries to and exits from two nationwide Kanta information services.
2 Material and Methods
2.1 Nationwide Kanta Services in Finland
The Kanta Services is the name of Finland’s nationwide centralized, shared, and integrated electronic data system services. The main national Kanta Services were introduced in phases in 2010–2018. The Kanta Services form a unique service concept and entity comprising My Kanta Pages, Prescription Services, a Pharmaceutical Database, a Patient Data Repository, the archiving of old patient data, a client-data archive for social welfare services, the sharing of medical certificates, the Kelain online prescription service and the Kanta client test service [34]. The Finnish national legislation on Kanta Services came into effect in 2007.
2.2 Material
The Finnish Institute for Health and Welfare (THL) maintains the official Social Welfare and Healthcare Organization Registry (SOTE-organisaatiorekisteri), which is accessible for everybody via internet. The registry is part of the national Code Server [https://koodistopalvelu.kanta.fi/codeserver/], and the Kanta Services. In this official registry, data on public and private organizations are compiled from social welfare and healthcare service providers and their service units. The registry data are used for registration and release of electronic prescriptions, patient and customer documents in the healthcare Kanta Services. The THL (specifications) and the social welfare and healthcare service providers (data) together are responsible to maintain the registry up-to-date and data correct. The Kela provides dates of the registered entries and exits in the registry.
2.3 Methods
Full registry data were extracted in an excel file format in 3 January 2024. The full registry contained originally 44 columns (variables) and 121 018 rows (organization issues). Officially registered dates of entries to and exits from the Prescription and Patient Data Repository Services were identified by public and private sector organizations, respectively. The registry only contained data on organizations, not on medication dispensing community pharmacies or prescribing professionals (e.g., physicians, dentists or nurses).
Outcomes were continuous registration of the services or registered exist from the services.
3 Results
3.1 Prescription Services
In total 252 entries to the nationwide Prescription Services among public healthcare service provider organizations took place in 2010–2023, out of which largest numbers around 2011–2013 with the highest peak number (n = 113) in 2012 (Table 1). In 2022–2023, numbers were higher than in previous years. In total 169 exits from the nationwide Prescription Services among public organizations took place in 2010–2023, out of which the largest numbers in 2016, 2019 and 2023 with the highest peak number (n = 118) in 2023. The number of organizations that had Prescription Services in production rose to 133 from 2010 to 2013 stabilizing to level 170–181 in 2014–2022. In 2023, 23 public organizations entered and 118 public organizations left the Prescription Services, and 83 organizations had the services in production.
In total 1,302 entries to the nationwide Prescription Services among private healthcare organizations took place 2010–2023, out of which largest numbers in 2014 and 2016–2017 with the highest peak numbers (Table 1). In 2014, there were also more entries than in other years. In total 384 exits in the nationwide Prescription Services among private healthcare service organizations in 2010–2023, out of which the highest number (n = 71) in 2019. The number of private organizations that had Prescription Services in production rose to 52 from 2012 to 2014 stabilizing to level 37–71 in 2015–2023. In 2023, 56 private organizations entered and 55 organizations left the Prescription Services, and 198 organizations had the services in production.
In 2010–2023, in total 1,530 organization entries and 553 exits took place in the nationwide Prescription Service, and 977 organizations had the Prescription Services in production in 2023.
Table 1.
Prescription Services: annual number of organization entries, exits and in production of nationwide electronic Prescription Services by public and private healthcare service organizations in 2010–2023 in Finland.
3.2 Patient Data Repository Services
In total 247 entries to the nationwide Patient Data Repository Services among public healthcare service organizations took place in 2011–2023, out of which largest numbers around 2014–2015 and 2023 with the highest peak number (n = 128) in 2014 (Table 2). In total 161 exits from the Patient Data Repository Services among public healthcare organizations took place in 2011–2023. The number of public sector organizations that had the services in production rose to 144 from 2011 to 2014 stabilizing to level 169–191 in 2015–2022. In 2023, 23 organizations entered to and 118 organizations left the Patient Data Repository Services, and 86 organizations had the services in production.
In total 1,733 entries to the nationwide Patient Data Repository Services among private healthcare organizations took place in 2010–2023, out of which largest numbers in 2014 and 2016–2017 with the highest peak numbers (Table 2). In 2014, there were also more entries than in other years. In total 384 exits from the Patient Data Repository Services among private healthcare service organizations took place in 2010–2023, out of which the highest number (n = 71) in 2019. The number of organizations that had Patient Data Repository Services in production rose to 812 from 2016 to 2018, and had an increasing trend thereafter. In 2023, 224 organizations entered to and 70 organizations left the Patient Data Repository Services, and 1,400 organizations had the services in production.
In 2011–2023, in total 1,980 organization entered to and 494 left the nationwide Patient Data Repository Services among private healthcare service organizations. Altogether 1,486 organizations had the nationwide Patient Data Repository Services in production in 2023.
In Patient Data Repository Services, the registered organizations provided altogether 7,692.1 follow-up years, out of which 2,372.8 years from the exit group and 5,557.9 years from the continuous group.
Table 2.
Patient Data Repository Services: annual number of organization entries, exits and in production of nationwide Patient Data Repository Services by public and private healthcare service organizations in 2010–2023 in Finland.
4 Discussion
Based on literature, the current research is a rather rare study reporting detailed data on national level implementation of two large-scale healthcare centralized services in a 14-year time span in Finland by using a unique official database that contained data on organization entry and exit dates by public or private healthcare service providers in 2010–2023 in Finland. In this study, we report the first time healthcare private sector organizations’ entries to and exits from two nationwide services in Finland.
We found profound dynamics among public and private healthcare organizations in the registry data. In the nationwide Prescription Services, 1530 healthcare organizations entered to and 553 left the national services, whereas 977 organizations had the national services in production in 2023. In Patient Data Repository Services, 1980 healthcare organization entered to and 494 left the national services, whereas 1486 organizations had the national services in production in 2023.
Permanent legislation may explain many of the number peaks observed in this research. For example in Prescription Services, the centralized Prescription Centre services were launched in mid-May 2010. The target date for pharmacies to adopt the Prescription services was set by end-March 2012, whereas it was by end-March 2013 for public primary healthcare providers. Private healthcare providers were divided in two phases based on their annual prescription volume: the target date was end-December 2014 for healthcare providers who had more than 5,000 prescriptions annually, whereas the target date was end-December 2016 for the rest of private healthcare service providers. These legally set target dates explain rather well the cumulative effects of the observations shown in Table 1. Similar observations in Patient Data Repository Services are found in Table 2. Especially in the Patient Data Repository Services, there were healthcare service organizations’ entries and exits before the services were launched in early-November 2013. These exists and entries were due to development (2011) and a ‘sliding’ to the services by common registries in 2012.
In Finland, the responsibility for organizing healthcare, social welfare and rescue services was transferred from municipalities and joint municipal authorities to wellbeing services counties on 1 January 2023 [35]. Today there are 21 wellbeing services counties. The region of Uusimaa is divided into four wellbeing services counties. The City of Helsinki continues to be responsible for organizing healthcare, social welfare and rescue services. The HUS Group is responsible for demanding specialized healthcare duties separately laid down by law. This major reform – the largest in Finland since the World War II – may well explain observed effects on healthcare service organizations in 2022–2023 in this research.
In this registry study, neither in the Prescription Services nor in the Patient Data Repository Services on healthcare service organizations’ service entry or exit time series revealed any specific effects due to Covid-19 epidemic in Finland.
Most of the literature on change, reforms and transformations in healthcare describes initiatives typically performed by a single healthcare organization or by one service alone [36]. Literature suggests that the success of a large-system transformation depends on local history, and, in particular, the role of the physicians appears to be crucial to healthcare transformations.
Transformational change (e.g. implementation of a nationwide HIS or infrastructure) involves significant and fundamental systemic change in an organization’s working methods, requiring changes in structure, culture and management [37, 38]. The transformational change of organizations is usually required for successful implementation of a large-scale HIS or HIE. However, successful transformational change programmes are rarely replicated in another setting [15]. Moreover, large-scale transformation health system processes usually involve possible tensions between bottom-up and top-down approaches [37].
The large investments required for HISs and HIEs have driven demand for effective monitoring of the resulting adoption, use and impact [39]. Longitudinal monitoring can provide valuable feedback on underlying policies and highlight the complex nature of monitoring and the assessment of implementation (and adoption). Establishing an evidence base for health information policies, trends and developments may involve utilizing transparent, published and continuous monitoring and assessments.
In a recent study in Denmark and Finland, implementations of a new commercial data system was analyzed by documents including user surveys, assessment reports, material from project partners, and research papers [40]. The Danish and Finnish implementations were still troubled five and three years, respectively, after the first go-live. In Denmark, the business case and implementation processes have been sharply criticized. The correction of usability problems and unstable system integrations have been slow, the time required to perform common clinical tasks has increased, and 32% of the users remain dissatisfied or very dissatisfied with the system. In Finland, the physicians’ and nurses’ experience improved technical performance but inferior usability and reduced work support compared to the EHR they used before the new already implemented data system. The consequences of using the new data system have become salient only after go-live. As a result, the implementing organizations and their users have predominantly found themselves in a reactive mode of fending off problems rather than a proactive mode of realizing benefits.
This research’s findings on dynamics in entry to and exit from the two nationwide services in Finland suggest that there exist a major administrative burden on public or private healthcare organizations as well as the Kela. For example from testing to production is a demanding phase since before starting production use, the information system provider must successfully complete joint testing and, possibly, deployment testing. In general, healthcare provider organizations are using a legally certified commercial information system that they already have implemented and adopted in the organization. In addition, both parties must accept and sign an agreement on issues of starting to use and actually using the appropriate nationwide Kanta Services and stating the responsibilities of the parties.
A major strength of the present study is access to comprehensive and detailed official national register data from public and private sector healthcare provider organizations. Due to this comprehensive data access, registered services’ entry and exit dates are up-to-date in real time. The unique material in this research consisted of dates from the official registry in 2010–2023. To the author’s knowledge, almost no previous studies exist on the implementation of two national HIS services conducted in a time-series fashion [34].
There are also limitations in the present study. The target registry – the official Social Welfare and Healthcare Organization Registry – contains information on organizations that use the nationwide Kanta Services, e.g. Prescription and Patient Data Repository Services, and their service entry and exit data. However, the registry data and information excludes private practitioners and individual professionals that contribute to information volume in the nationwide services. Information on professionals is confidential and is not directly accessible via internet. Furthermore, the registry does not include information on pharmacies whose information can be found in the official Pharmacy Register (Fimea Apteekkirekisteri) maintained by the Fimea.
The latest strategy for digitalization and information management in healthcare and social welfare in Finland vision is building a digital foundation for healthcare and social welfare [41]. Strategy timespan covers years 2024–2035. Citizens will be provided with better opportunities to independently take care of their wellbeing and health as individuals, service customers or as persons managing the affairs of their close family members. The flexibility and efficiency of healthcare and social welfare services will be enhanced through customer and service counselling and the introduction of advanced technology, while at the same time, the workload of the personnel will be reduced. Health and social services will be organized on the basis of effectiveness data and evidence (research findings or evaluated data) on higher quality basis and in a socially, economically and ecologically sustainable manner. A total of 13 sets of tasks are listed in the strategic roadmap.
In digitalization operating practices are developed and updated using information management as a basis [41]. It involves the changing of an organization’s processes and electrification of services in line with the advances of information and communications technology (ICT). Planned digitalization measures can only be successfully implemented if the change is planned and coordinated by the key actor instead of allowing the change to be driven by ICT. Information management means the definition of the contents and uses of information as well as the collection, organization and storage of information in such a manner that the information can be retrieved and used appropriately and in a controlled manner. In information management, ICT solutions are combined with an organization’s activities and the flow of information in the organization. Information management and ensuring interoperability are prerequisites for digitalization.
Acknowledgments
The contributions of the THL national Code Server process, the Kela (Kanta Services) and private and public healthcare organizations are acknowledged in preparing, development, specifications and maintenance of the official Social Welfare and Healthcare Organization Registry (SOTE-organisaatiorekisteri) in Finland.
Disclosure of Interests
The author has no competing interests to declare.
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