Review: The Use of Health Information Technology in Seven Nations

The paper reviewed here is ‘The Use of Health Information Technology in Seven Nations’ by Jha and colleagues. The authors examine the uptake of electronic health records (EHR) in 7 industrialised nations – the Uk, Netherlands, Australia, New Zealand, Germany, Canada, United States and conclude in the abstract that they

found that many have achieved high levels of ambulatory EHR adoption but lagged with respect to inaptient EHR and HIE (Health Information Exchange)

The authors suggest in the introduction that there has not been uptake of EHR in all parts of the US (although the article was published in 2008) and they were interested to see how the uptake of EHR compared to other industrialised nations. This was done with a view to identifying methods of improving uptake of EHR in the US.

In the methodology, the authors describe some of the terms in more detail. Thus they describe the HIE as the transfer of clinical information from one organisation to another. Interestingly the definition of EHR that they use includes decision support tools. The authors are quite rigorous in their approach to identifying relevant information – they conduct a literature search using established medical databases such as Medline, others using search engines such as google and also make contact with recognised experts in each of the six non-US nations in the study. I couldn’t find any reference however to the keywords that were used in the medline search which would be useful for replication purposes. The authors note that there has been a recent paper providing the information they need on the US explaining why the US is excluded from the above searches.

In the results section the authors note that due to the definition of EHR that they use there were few studies that fulfilled the criteria for identifying the relevant information. The only studies that included this information examined ‘ambulatory care’ which I understand to refer to care which doesn’t require inpatient admission. The authors were able to identify relevant studies in four of the countries and needed to utilise expert opinions for the other countries. There was sufficient information on the US however. They give figures for the US and I think that 10% of single practioner practices use EHR while up to 50% use EHR in larger practices (although they had used the term HER which I suspect is a typing mistake). While the figures for Canada for EHR came out at about 20% the figures for the UK revealed uptake of about 89% in General Practices. In the Netherlands this was figure was 98% for GP’s. Figures of 79% for GP’s in Australia and 92% of primary care providers in New Zealand were documented.

In the US they identified figures in hospitals of about 5-15% although commenting that the reliability of the data was relatively low. For other countries there was data on features such as electronic prescribing but little commentary on EHR. Thus there appeared to be a consistent pattern from the available data of higher uptake of EHR in primary rather than secondary care.

In terms of health exchange information networks they identify Infoway in Canada which focuses on uptake of EHR and HIE strategies, non-profit regional health information organisations in the US and the Switchpoint in the Netherlands amongst others. The authors cite pay-for-performance as one of the factors influencing the uptake of EHR in their study. They also note that the US has a number of measures of performance but these have not in general been linked to incentives.

The authors present their data in a number of tables and their discussion extends to electronic prescribing along with a number of other recommendations. The paper is informative, the methodology clearly stated and the researchers have identified relevant contact figures for further information in a number of the nations under study. The multiple data sources is a particular strength of the study. I found in particular the comments about clearly identifying performance measures to be particularly interesting. The use of electronic health records in itself does not necessarily imply that there is a high quality of healthcare as there are many other factors which determine the quality of a service most obvious amongst which are the healthcare practitioners themselves. However it might be expected that electronic health record systems would improve efficiency of workflow, information retrieval and contribute effectively towards decision-making. This is a useful comparison of national services which could serve as a template for future comparisons.



Jha A K, Doolan D, Grandt D, Scott T and Bates D W. The use of health information technology in seven nations. International Journal of Medical Informatics. 77. 2008. 848-854.


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