Activities since 2008

Swiss eHealth Strategy 1.0 until adoption of EPRA

In 2006, health and the healthcare system were added to the Federal Council’s strategy for an information society in Switzerland. This
resulted in the preparation of the Swiss eHealth Strategy for 2007–2015, which was adopted by the Federal Council in June 2007. This strategy comprised three action areas – “Electronic Patient Record”, “Online Services” and “Strategy Implementation” – and set out a number of objectives. The most important objective was the implementation by 2015 of a national Electronic Patient Record (EPR) managed primarily by patients themselves and from which, if required, key medical information can be accessed in electronic format anywhere and at any time. The primary objectives at healthcare system level were improved efficiency and safety, and optimised treatment quality for patients.

As one of the first operational measures under the eHealth Strategy, the Confederation and Cantons signed a framework agreement, under which eHealth Suisse was created as a national coordination centre on 1 January 2008. From that time, eHealth Suisse was responsible for implementation of the eHealth Strategy. Accordingly, eHealth Suisse’s broad-based project organisation started work during 2008 with representation from all relevant stakeholders (Swiss Medical Association and doctors, hospitals, Cantons, professional associations, industry and patient and consumer organisations). Responsibility at strategic level lay with eHealth Suisse’s steering committee, which was chaired by the Head of the Federal Department of Home Affairs (FDHA), while operational responsibility was assumed by the project management committee.

The project organisation was divided into six workstreams:

• Online services and empowerment
• Education and research
• Pilot trials and public-private partnership (subsequently: Development and networking)
• Standards and architecture
• Legal aspects
• Financing and incentive systems

One working group made up of stakeholders in the topic was deployed for each workstream. Between 2009 and 2014, these working groups developed recommendations, each of which went through a broad consultation process beforehand. The recommendations covered those topics that would have to be considered for the future interoperability of the national EPR in the broadest sense: not only technical considerations, but also political, legal, semantic and organisational matters.

The online services and empowerment workstream drew up recommendations on empowering patients to manage medical information (health literacy) and use the new IT tools (digital literacy). The workstream also produced a report describing several options for a public health portal. In January 2012, the Confederation and Cantons decided to forego the portal on resource grounds.

The aim of the education and research workstream was to examine the measures and modifications that would be necessary in educational offerings for healthcare professionals to accommodate modern-day information and communication technology requirements. The workstream also examined the integration of this content into the relevant teaching and study programmes.

The pilot trials and PPP (public-private partnership) workstream formulated recommendations for eHealth pilot trials and the conditions that have to be fulfilled for them to succeed. Pilot trialling was intended to generate insights for the future national Electronic Patient Record (EPR). A scheme developed by the workstream gave pilot projects the option of being evaluated by eHealth Suisse and of obtaining a label if found to be suitable.

The standards and architecture workstream examined and recommended standards in the broad sense (technical, content-related and
semantic) that are required to set up a national architecture for the EPR. This workstream laid the foundations for fundamental decisions that still underpin the EPR today – its distributed architecture, adoption of non-proprietary standards at technical level (IHE profiles) and high-granularity patient management of the EPR that promotes informational autonomy.

The legal aspects and financing and incentive systems workstreams identified a legal framework within which eHealth could established
despite competencies being split between the Confederation and Cantons. Thought was also given to the measures and incentives that could be used to fund and drive forward the EPR. The preliminary work done by the legal aspects workstream was used by the eHealth expert group deployed by the Federal Department of Home Affairs (FDHA) in December 2009. Its task was to establish which areas of eHealth the Confederation would be able to regulate under the existing constitutional provisions and which would become the responsibility of the Cantons. A preliminary draft of the Federal Act on the Electronic Patient Record (EPRA) was put out to consultation in 2011. In April 2012, the Federal Council commissioned the FDHA to produce a dispatch and draft act on the EPR. This dispatch and draft act were submitted to Parliament in May 2015. Parliament adopted EPRA in June 2015.

External link: Federal Council business

External link: EPRA bill 2010–2017

While this work was in progress, eHealth Suisse began to lay the technical foundations for the EPR in 2014/15 in the form of specifications, which it drew up in partnership with the Federal Office of Public Health (FOPH). These specifications provided the foundations for the Ordinance on EPRA, which was heard during the first half of 2016. The Ordinance took effect on 15 April 2017. At its heart is the certification process for communities and core communities as amalgamated service providers with an obligation to provide
EPRs.

In terms of semantics, SNOMED CT was adopted as the national reference terminology in 2016. Since then, eHealth Suisse has been operating the associated Release Center.

External link: SNOMED CT

From February 2009 to the end of 2018, eHealth Suisse was also actively involved in the European efforts to establish Europe-wide infrastructure intended to ensure secure exchange of patients’ medical data across national boundaries. A National Contact Point was set up and operated at Geneva University Hospital for this purpose as part of involvement in various EU projects. At the end of 2018, the European Commission (EC) dispensed with Switzerland’s contributions for political reasons.

Swiss eHealth Strategy 2.0 and first-time certification

The Federal Act on the Electronic Patient Record (EPRA) and the two associated Ordinances took effect on 15 April 2017. When Switzerland’s eHealth Strategy expired in 2015, it was clear that work towards a national EPR had made good progress, but more time was still needed because of the complexity involved and the highly federalised structure of the Swiss state. The Federal Council therefore adopted eHealth Strategy 2.0 in November 2018. This strategy is valid until 2024 and focuses on the introduction and dissemination
of the Electronic Patient Record. In pursuit of this goal, eHealth Suisse has been regularly publishing implementation guides and factsheets since 2016 to support the establishment and ongoing development of the certified communities and core communities as EPR providers under EPRA.

External link: Federal Act and Ordinances on the EPR

External link: Swiss eHealth Strategy (210 KB, 10/30/23)

Stakeholder development

Nine core communities and one community were set up following the introduction of EPRA. Seven core communities and one community completed certification between December 2020 and November 2022.

In autumn 2022, SwissPost acquired a majority holding in the operating company axsana AG. The infrastructure of the xsana platform was transferred from Swisscom’s technical solution to that operated by SwissPost. Since then, Swisscom has not provided any technical infrastructure for the EPR.

In spring 2023, axsana AG was renamed Post Sanela Health AG and the xsana brand was discontinued. The core community name – XAD – remains the same.

Certification process

The certification procedure is performed by KPMG AG, a company accredited by the Swiss Accreditation Service SAS to certify EPR communities, core communities and EPR identification tools. The certification process is time-intensive and complex, particularly because of the extremely high data protection requirements and the need to ensure data security given the nationwide networking of the EPR. Certification of the communities and core communities had to be performed carefully in the interests of patient protection and was more time-consuming.

The first cycle of first-time certifications concluded with the certification of the AD Swiss core community in November 2022. eHealth Suisse, the communities and core communities were able to begin interoperability testing in January 2023 to ensure seamless technical operation of the EPR throughout Switzerland during 2023.

To enable the technical EPR providers to prepare for certification under EPRA, eHealth Suisse organised the first EPR Projectathon in September 2017. This has been repeated each year since then to permit technical testing of new EPR functions.

EPR Projectathon

External link: EPR roll-out history (in German) (302 KB, 10/09/23)

Progressive connection of healthcare institutions

Rolling out the Electronic Patient Record (EPR) involves a complex interaction of legal, organisational and technical requirements and a large number of players. Under the Federal Act on the Electronic Patient Record (EPRA), which has been in force since 15 April 2017, acute care hospitals, rehabilitation centres and in-patient psychiatric clinics had to join a certified core community within three years. Birthing centres and nursing homes were required by law to join a core community by 15 April 2022. The complex certification process meant it was not possible to meet the implementation deadline of 15 April 2020.

The revision of the HIA to authorise service providers approved in June 2020 came into force on 1 January 2022. Since then, doctors and facilities that provide out-patient care by doctors have had to prove to the cantonal authorities that they are members of an EPR community when they apply for authorisation to provide services charged to compulsory health insurance (Art. 37 para. 3 HIA).

The Cantons are responsible for reviewing applications and decide what records have to be submitted.

All other healthcare institutions and healthcare professionals in the out-patient setting are free to choose whether or not they join an EPR community.