The design and implementation of EHR systems extends beyond Canada to a number of international jurisdictions. Countries around the world are engaged in projects to develop infrastructure for national health information.  Both New Zealand and Denmark have experienced successes in implementing integrated electronic solutions in the healthcare context. 


A.  New Zealand

In 1992, the New Zealand government initiated three strategies that set the stage for the development of its EHR infrastructure.[55]  These strategies included the creation of a national health identifier database, the development of a health information privacy code, and an agreement with private sector organizations to develop and deliver information services to the sector.[56]  This strategic coordination showed tremendous foresight, as the establishment of private sector agreements and privacy codes at the outset of a strategy provided a solid foundation for the development of eHealth projects. 

Six years later, the New Zealand government granted general practitioner (GP) offices a one-off grant of approximately $NZ 5000 to purchase computers, and mandated that electronic billing be compulsory.[57]  This initiative was remarkably successful. Within two years of its onset, more than 95% of GPs used a computerized billing and appointment system, and more than 50% utilized this system for capturing clinical information during patient consultations.  Today, as electronic billing is now compulsory, 100% of general practitioners have a computerized system.  In addition, 75% of general practitioners take advantage of the system’s clinical functionality.[58] 

Currently, HealthLink, a privately-owned company, is the sole provider of all healthcare related electronic services in New Zealand.[59]  The services utilized by HealthLink to communicate with GPs are government-funded.  Any additional services provided by HealthLink are paid for by the healthcare providers that utilize them such as laboratories, hospitals and general practitioners.[60]  In recent years, however, the New Zealand government appears to be discouraging this monopoly by supporting the formation of competing services.[61]


B.   Denmark

The automation of physician offices in Denmark commenced in a similar fashion to New Zealand.  As early as the mid-1980’s, Danish primary care physicians received a small financial subsidy to send floppy disks of their medical claims to the public health insurance body.[62]  This process stimulated the purchase of a single administrative computer for use in physician’s offices, and created the early infrastructure necessary to facilitate the use of computers for clinical purposes.[63]  By 1990, the MedCom project was launched which connected two primary care physicians on one system with a hospital system and laboratory system.   Two years later, lab results and discharge letters were being transmitted electronically to a number of primary care physician practices, and the emergence of electronic medical records (EMRs) became a reality.  In addition, paper prescriptions were replaced by electronic prescription transmission from primary care physicians to pharmacies.[64] 

Unlike New Zealand’s for-profit HealthLink, MedCom is the Danish non-profit equivalent.  The mission of MedCom is to contribute to the development, testing, dissemination and quality assurance of electronic communication and information in the healthcare sector in order to enable coherent treatment, nursing and care.[65]  In carrying out its mission, MedCom develops messaging software, as well as core infrastructure and services used to securely exchange healthcare messages.[66]


C.  Health System Integrators

Both MedCom and HealthLink are examples of health system integrators (HSIs), a specialized information technology company that has expertise in integrating supporting messaging, online communications and security systems.[67]  There are several benefits to an HSI model in the delivery of electronic solutions in the healthcare context.  Health system integrators provide unambiguous interest in increasing the use and value of eHealth services across the sector. Also, HSIs must adhere to an explicit contractual commitment to standards and external governance as established by government.  They are required to support the use of all national data-communications standards, to interconnect with other HSIs and to defer to a national governance framework.[68]  The enforcement of these standards is essential to the efficient and effective operation of the health system.  In New Zealand, should HSIs fail to meet a range of government-imposed and monitored safety and security standards, accreditation is withdrawn.[69]

As described earlier, Canada Health Infoway has attempted to act in a similar capacity to health system integrators, however, to a certain extent has been unsuccessful.   The enforcement of standards has not been achieved as conformance testing and processes to address policy breaches are not in place.  Furthermore, although Canada Health Infoway has the mandate of coordinating the national EHR strategy, healthcare delivery is within provincial jurisdiction.  Infoway for instance is not responsible for ensuring that privacy laws or any other provincial policies/ regulations are adhered to.  The key distinction, therefore, is that Canada’s eHealth strategy is not under the power and influence of a single unifying body.  The fragmented jurisdictional model currently in place has fuelled the isolated and disjointed development of EHR initiatives in Canada. 



The effective and efficient uptake of electronic health solutions in Denmark and New Zealand is markedly different from the slow progress in Ontario.  What characteristics of the eHealth strategies in these two countries do you feel have contributed most to this success? 

New Zealand and Denmark have selected a sole-provider model to govern eHealth services.  What are the advantages and disadvantages of such an approach? 


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