EHTO Trends in Health Telematics in the European Union


	Updated: Dec 6, 96
SWEDEN

Sweden had 8.8 million inhabitants in 1995, with 18 percent aged 65 or over. The demographic transition to an aged population is accentuated more in Sweden than in any other country in the world. The Swedish health care system is decentralised and to a large extent publicly oriented. Close to 90 percent of the health care expenditure is publicly financed and most of the health care providers institutions are publicly owned.

The national government is responsible for ensuring that the health care system is efficiently developed and that it is in keeping with overall objectives, based on the goals and the constraints of the social welfare policy and macroeconomic factors. However, the responsibilities and financing for health care is to a large extent decentralised to the county council level. According to the Health and Medical Service Act of 1982, county councils are required to promote the health of residents in their areas. Their responsibility is also to offer equal access to good medical care to all their inhabitants. The Act requires county councils to plan the organisation of health care with reference to the aggregate needs of the county population.

Sweden is divided into 23 county council areas and three municipalities (City of Gothenburg, City of Malmo and the island of Gotland), which also have responsibilities as county councils. The populations of these 26 units ranged from some 60,000 to 1,7 million inhabitants (about 300,000 on average) in 1995.

There were altogether about 950 local health care centres and about 90 short-term care hospitals in Sweden in 1995. Private providers are responsible for a minor part of the health care production only. Of the short-term care beds, in 1994 only three percent were run by private providers. These institutions were chiefly providing long-term and psychiatric nursing home care.

The clinical department is a strong and rather independent organisational level in Swedish hospitals. Budgets are allocated to this level and hospital beds belong to individual clinical departments. An in-patient is administratively discharged from the hospital department and not from the hospitals as is the case in most other OECD-countries.

From a functional perspective a hospital could be divided into three different kinds of units (departments):

Clinical departments (e.g. general surgery)
Medical service departments (e.g. diagnostic radiology)
General service departments (e.g. catering service)

A general tendency is to create internal markets within hospitals. There should be no "free service" available to physicians. In this new situation service departments are financed by an income instead of a fixed budget. The income is generated by selling services to other departments. The clinical departments may still be financed in this model by fixed budgets. However, when this is the case, the traditional budget of clinical department will be expanded to include estimated costs for all hospital services needed by patients in the unit.

According to a recent survey 25 out of 26 county councils had at least one service unit financed mainly by selling services. Development along this line has been pronounced the most in general service departments.
Some county councils have implemented more profound changes in health care organisation, with the trend to make a division between purchasing and providing functions has continuing to evolve in many. The financial agreements for clinical departments vary from block contracts to per case reimbursement and fee-for-service arrangements. Per case payment based on DRGs was used to finance hospitals (at least to some extent) in seven county councils in 1992.
Legislation on quality assurance in health care has been introduced in Sweden. The act took effect on January 1st 1994 and each health care unit is required to have a programme. The unit level is defined as a clinical department in a hospital or an individual practitioner in primary care. The quality assurance process must according to the law be systematic, continuous and documented.

IT utilisation is different in primary care, in hospital care and in psychiatric care. In all areas management systems as personnel planning systems, salary systems, budgeting systems, bookkeeping systems, are widely used as well as systems related to laboratory work. Electronic communication systems between laboratories and hospitals, laboratories and clinics and laboratories and primary care centres are common.

Electronic health care record (EHCR) systems are widespread in the primary care sector, where more than 85% of the newly generated medical records are EHCRs. At hospitals and their clinics as well as in psychiatric care units less than 15% of the generated medical records are EHCRs. The use of IT in the health care sector is expected to increase very rapidly in the coming years.

Projects are carried out in order to find common logical structures as well as common technical structures for the EHCRs to facilitate exchange of data and to build a basic structure for overall epidemiological studies, for statistical purpose, as well as for health care assessment studies. To perform representative studies with high data and information quality, a well defined and controlled vocabulary is being developed.

Telemedicine is developing in some areas and many tests are carried out. The possibility of transforming telemedicine technology into savings is, by some, expected to occur when the effects from reshaping organisations and telemedicine synergetically can be integrated.

In Sweden a patient card is used as an identifier. This card is generally an embossed card with a magnetic strip. The card contains the mandatory "personal identification number" as the unique patient identifier. Some projects with different goals include tests of optical cards and smart cards.

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