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DataWatch

Health Care Spending And Use Of Information Technology In OECD Countries

Abstract

 
In 2003, the United States had fewer practicing physicians, practicing nurses, and acute care bed days per capita than the median country in the Organization for Economic Cooperation and Development (OECD). Nevertheless, U.S. health spending per capita was almost two and a half times the per capita health spending of the median OECD country. One proposal for both lowering health spending and improving quality is the adoption of health information technology (HIT). The United States lags as much as a dozen years behind other industrialized countries in HIT adoption—countries where national governments have played major roles in establishing the rule, and health insurers have paid most of the costs.

Health spending and GDP. Health economists have long recognized that health spending per capita is positively correlated with GDP per capita.³ If one takes as a benchmark a simple regression equation of health spending per capita (in purchasing power parities, or PPPs) on GDP per capita (in PPPs) over the OECD countries and excludes the United States and Luxembourg as outliers, assuming that GDP per capita were the only determinant of national health spending per capita, then U.S. health spending per capita would have been only $3,673 in 2003, or $1,962 less than it is now.⁴

Drivers of higher U.S. spending. Possible explanatory factors for the higher level of U.S. health spending include service use, administrative complexity, population age, threat of malpractice litigation, defensive medicine, and lack of waiting lists.⁵ We continue to find in using 2003 data, however, that the most compelling explanation remains, "It’s the Prices, Stupid."⁶ As we show in this paper, the United States has fewer hospital beds and physicians to treat patients and uses fewer impatient hospital days than the median OECD country. Yet in 2003 the United States continued to pay much higher prices in three key health care components: physician visits, hospital stays, and pharmaceuticals.⁷

HIT and spending control. In previous work we examined various explanations for the higher U.S. spending. In this paper we turn our attention to one proposed method of controlling health spending: the adoption of health information technology (HIT). Richard Hillestad and colleagues suggest that the electronic health record (EHR) could produce efficiency and safety savings of $142 billion in U.S. physician offices and $371 billion in U.S. hospitals over the next fifteen years.⁸ Others have questioned the validity of these estimates because the savings have not been demonstrated.⁹ As we show here, other countries have accepted the idea that HIT will lower health spending and improve outcomes; they are at least four to thirteen years ahead of the United States in initiating national HIT programs.¹⁰ The centerpiece of most of these programs is the EHR, but HIT also encompasses a wide range of services including telehealth, electronic ordering systems, decision support tools, networks, and infrastructure.¹¹ U.S. physicians have been adopting computers, personal digital assistants (PDAs), the Internet, and Web sites at rates comparable to those of physicians in other countries.¹²

Comparison Of Health Care Spending, Resources, And Use

Top Comparison Of Health Care... Health Information Technology Barriers To HIT Adoption Who Pays, And Who... NOTES

 
Annual growth in health care spending. The median growth rate for the United States (3.4 percent) for 1993–2003 is exactly the same as the median growth rate for all thirty countries in the OECD (Exhibit 1). The United States had two distinct periods of health spending during this period. Between 1993 and 1998, with the advent of managed care, it was able to hold health spending growth below the OECD median. However, from 1998 to 2003, after the bite of managed care had weakened, average annual growth was 4.6 percent, compared with the OECD median of 4.1 percent.

The OECD categorizes health spending into four categories: outpatient, inpatient, pharmaceuticals and other medical goods, and other health expenditures (Exhibit 1). These are much different from the categories used in the National Health Expenditure Accounts maintained by the CMS.¹³ U.S. outpatient spending per capita is almost four times the OECD median and nearly double the second-most-costly country (Sweden). In contrast, U.S. per capita spending on inpatient hospital services in 2003 was not the highest; Switzerland and Norway spent more. The trend in outpatient and inpatient spending over the past two decades suggests that U.S. policies to move as many services as possible out of the inpatient setting have been successful. The United States spent the most per capita on pharmaceuticals and other medical goods, although France and Canada were reasonably close. However, these latter countries pay much less for most pharmaceuticals, so it is likely that they are consuming more of them.

Resources and usage patterns. The higher level of U.S. health spending does not necessarily provide more resources or health care use. On several key indicators, the United States actually appears to provide fewer health care resources than many other OECD countries. For example, in 2003, the United States had fewer physicians, nurses, and hospital beds per capita than the median OECD country had, and one of the lowest numbers of acute care bed days per capita (only Turkey and Mexico had fewer) (Exhibit 2).

Health Information Technology

Top Comparison Of Health Care... Health Information Technology Barriers To HIT Adoption Who Pays, And Who... NOTES

 
In previous papers we have examined factors that could explain the reasons for higher U.S. spending. Here we examine the adoption of one technology that has the potential of both lowering spending and improving quality.

HIT in the United States. As noted, the United States lags behind several industrialized countries in the HIT area. Rigorous studies on the cost effects of fully wired health systems are lacking, even in countries that are leading the way and have moved in this direction partly for cost reasons. Thus, we do not mean to suggest that the U.S. status in this regard has a direct relationship to its relative performance in the area of health care costs. However, to the extent that HIT systems are cost-saving in the long run, the lack of an integrated, national IT system for health in the future could exacerbate the position of the United States relative to countries that are HIT leaders.

In April 2004, President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONCHIT) to promote HIT.¹⁴ In fiscal year 2005, the president budgeted $50 million in new funds to support ONCHIT’s efforts, but Congress did not pass the appropriation.¹⁵ As a result, ONCHIT relied on funds earmarked for patient safety along with other miscellaneous funds directed from the Agency for Healthcare Research and Quality (AHRQ) to operate in FY 2004 and FY 2005.

At the beginning of 2006, the most prominent HIT legislation under discussion is the Wired for Health Care Quality Act, S. 1418.¹⁶ It passed the Senate and was referred to a House committee 6 January 2006. It would codify the creation of ONCHIT, establish a collaborative to adopt HIT standards, and authorize grant programs to encourage HIT adoption. The bill would authorize $125 million in FY 2006, $155 million in FY 2007, and "such sums as necessary" for 2008 through 2010. This represents only a small proportion of the resources that will be needed to create a fully operational HIT system. A recent study estimated that capital investments of $156 billion over a five-year period, with an additional $48 billion in operating costs, will be needed to achieve a national HIT network.¹⁷

HIT programs abroad. Several countries established federal committees similar to ONCHIT as many as a dozen years ago, to foster the adoption of HIT. Each of these countries has experienced difficulties implementing its HIT system, and the adoption process has been criticized by both providers and the public in those countries. As it tries to play catch-up, the United States could learn from these successes and failures.

Germany was the first country to start developing a national HIT network (1993) and also has the first expected completion date (2006). Germany is updating its smart-card technology to use advanced security features to protect the stored personal medical data.¹⁸ In 1997, Canada established the Advisory Council on Health Infrastructure and in 2001 launched Canada Health Infoway, a nonprofit organization. Canada Health Infoway expects to have EHRs for half of the population by the end of 2009. The United Kingdom has established the National Programme for IT (NPfIT), the most expensive and perhaps the most comprehensive HIT system in development worldwide. The program anticipates creating an integrated care record service, an electronic appointment system, and an electronic prescription transmission system and will build infrastructure and networks that will be accessible to all of the major health care providers by 2014. Norway and Australia have also established major HIT initiatives, and both countries have at least a six-year head start on the United States.

Providers included in HIT systems. As currently envisioned, the United States has fewer categories of providers using EHRs than some other countries have. If the Wired for Health Care Quality Act is enacted, a wide range of providers will be required to use EHRs in the United States. The list includes hospitals, physicians, group practices, skilled nursing facilities, home health facilities, federally qualified health centers, health care clinics, Indian Health Service (IHS) clinics, rural health clinics, pharmacists, and laboratories (Exhibit 3). However, some countries also include optometrists, physical therapists, and dentists in their HIT networks.

Ways to increase physicians’ participation. Because of the importance of involving physicians, countries have adopted various approaches to increase physicians’ participation. For example, Norway encouraged adoption through federal contributions to regional projects proposed by specific providers. Conferences and seminars were also conducted to inform and educate providers to ease the transition to an electronic system.

England and Australia both encouraged implementation by identifying early adopters and using them to convince their colleagues of HIT’s potential value.²² The two countries also designed campaigns that addressed physicians’ questions. For example, the HealthConnect campaign in Australia focused on clearly outlining the legal issues of participation, creating an easy step-by-step registration process, and defining and addressing the capabilities providers need to effectively participate.

Barriers To HIT Adoption

Top Comparison Of Health Care... Health Information Technology Barriers To HIT Adoption Who Pays, And Who... NOTES

 
One reason that countries abroad did not experience the same level of fragmentation in HIT adoption that the United States has experienced is that they have relatively simple health insurance contract payment structures, with standard nomenclatures that are easily operated electronically.²³ Australia, Canada, Germany, Norway, and the United Kingdom all began with fragmented and incremental processes, but over time, they realized the need for national HIT standards.²⁴ These countries found that national efforts have the advantage of ensuring uniform privacy and confidentiality standards, guiding efficient development and implementation of technology, and providing grants and incentive programs to encourage HIT adoption.

Lack of interoperability. Some countries have found that one danger of a fragmented approach to HIT implementation is a lack of interoperability among various HIT systems. This is particularly important for the management of people with multiple chronic conditions, whose care is often managed by multiple providers.²⁵

Germany and Norway have built their HIT programs using the standards of interoperability and privacy set by the eEurope 2002 and eEurope 2005 Action Plans.²⁶ Their visions were to prepare their HIT systems for future levels of interconnectivity in electronic commerce, particularly for pharmaceuticals.²⁷ A longer-term goal is to allow all clinicians in Europe to be able to access health records from all countries.

In June 2005, the U.S. Department of Health and Human Services (HHS) formed the American Health Information Community to develop common standards and interoperability while ensuring privacy and confidentiality. At the request of HHS, Health Level Seven (HL7) interoperability standards are being adopted for clinical and administrative data on various computer systems to communicate while preserving meaning.²⁸ Canada, Germany, the United Kingdom, and to a limited extent Norway and Australia have adopted HL7 standards to promote interconnectivity. In addition, HHS signed a licensed agreement to standardize the Systemized Nomenclature of Medical and Clinical Terminology (SNOMED CT).

Germany’s upgrade of its smart-card technology moves it toward the goal of portability.²⁹ The technology allows authorized health professionals to access a centralized database holding patient data within a secure network managed using public key infrastructure (PKI) technology.³⁰ The provider signs legally valid electronic documents to store data within a chip on the smart card and then encrypts the data to allow their secure transmission.³¹ The new smart health card allows physicians to access networked databases that provide patients’ complete medical histories.

Privacy and confidentiality concerns. The public’s perception of the security of their personal health records is critical to HIT adoption. The U.S. Health Insurance Portability and Accountability Act (HIPAA) of 1996 has provisions establishing the privacy of health information, mandating steps toward the creation of standards for coding and the electronic transmission of medical claims. However, 70 percent of the U.S. population remains concerned that sensitive personal information could be leaked because of weak security.³²

Each country engaged in HIT has developed or is in the process of developing privacy and confidentiality standards. Germany’s health initiative divides information into two parts: an administrative part that is obligatory (for example, copayment status and paperless transmission prescriptions) and a medical part that is voluntary (for example, drug usage, current diagnoses, and previous surgeries). Germany’s regulations allow patients to decide whether or not to release their medical part and which specific medical information to make available to whom.³³ Norway recently adopted laws regarding health professionals’ handling of confidential and electronic health information, and laws enforcing the integrity and security of EHRs.³⁴ Canada developed a Pan-Canadian Health Information Privacy and Confidentiality Framework to suggest a set of core provisions for the collection, use, and disclosure of personal health information in both the publicly and privately funded sectors.³⁵ However, not all of the provinces have adopted the full framework.

Direct and indirect costs. The cost of HIT adoption is a major concern in all of the countries. This is also the most difficult component to compare because of the various scopes and types of programs and funding mechanisms. In addition, cost estimates are often revised as a project progresses.

Rainu Kaushal and colleagues estimate that to establish a national HIT network in the United States within five years, the largest costs will be $103 billion in capital costs and $53 billion in interoperability costs.³⁶ U.S. hospitals are expected to incur the highest functionality costs ($51 billion), followed by skilled nursing facilities ($31 billion) and office practices ($18 billion). Kaushal and colleagues advise public and private insurers to revise their payment policies to promote HIT adoption.

Australia’s HealthConnect found that the largest costs over the first five years were for infrastructure deployment, change-management programs, and system integration.³⁷ Ongoing costs were shared among jurisdictions and private-sector partners.³⁸ Nevertheless, Australia does not envision a substantial role for the private sector as an investor in the first few years.³⁹ With an undefined completion date, Australia is aware that further efforts and funds will be necessary to fully establish a national HIT program.

The Canadian government shares costs with provinces and territories through a matching-funds program to support implementation. Canada funds up to 80 percent of ground-breaking projects because of the high risk and high initial investment.⁴⁰ The funding is scaled downward to 20 percent as the project becomes less risky. Canada funds only those programs that also meet federally agreed-upon standards.

Often, initial estimates of the total cost for HIT implementation have been too low. For example, the Canadian government originally provided funds of $420 million to Canada Health Infoway but now expects to spend to $1.2 billion. The original plan included only funds for researching solutions for IT use in health and did not incorporate the implementation phase. When the decision was made to implement, each of the provinces signed on to receive funds from the Canadian government.

The United Kingdom originally announced in 2002 that the NPfIT program would cost $4.3 billion over three years but later more than doubled its estimate and time frame to $10.8 billion over ten years.⁴¹ The National Health Service (NHS) hopes to achieve a steady-state annual funding level of 4 percent of its total budget to go toward HIT programs, up from the current 1.5 percent.⁴² The head of NPfIT, Richard Granger, insists that the money will come from already committed funds for HIT programs and that no extra money needs to be allocated, assuming that the overall NHS budget grows as projected.⁴³

The Australian government has more than doubled its current investment in the development of EHRs. Although the current total spending level is less than $100 million, $1.1 billion in HIT-related projects are "on the drawing board."⁴⁴ Hospitals in Australia are struggling with operational issues that are forcing the federal government to keep funding minimal for HealthConnect until these issues are resolved. In addition, Australia works in partnership with states and territories, which will be investing sizable funds in HealthConnect. Norway and Germany have remained close to their original budgets.

Who Pays, And Who Benefits?

Top Comparison Of Health Care... Health Information Technology Barriers To HIT Adoption Who Pays, And Who... NOTES

 
In all of the countries, the cost of implementing an HIT program is borne by the government or health insurers, or both. It is recognized in these countries that the benefits and cost savings accrue primarily to patients and insurers, not to providers. Economists recognize that use of IT in health care has a strong public-goods component, which means that a particular stakeholder often does not reap the full social benefits produced by new HIT investment. Consequently, according to economic theory, the private sector will underinvest in IT relative to its social benefits, which leads economists to recommend that public subsidies be used for the development of HIT systems, even though they will be used by private stakeholders. Also, the value of a particular HIT system installed by one stakeholder tends to increase with the number of other HIT systems installed elsewhere with which that stakeholder’s HIT system can communicate. For these reasons, many industrialized countries have subsidized the application of HIT with public funds, albeit it on the condition that those HIT systems can interconnect. The United States has begun to do so in recent years as well, although so far on a much more modest scale.

THE UNITED STATES STILL HAS THE HIGHEST LEVEL of health spending in the world—currently almost two and a half times the level in the median OECD country. One suggestion for lowering health spending and improving health outcomes is the adoption of HIT. However, in all countries, we found no evidence that the savings from these initiatives have been rigorously evaluated. Nevertheless, many industrialized countries are proceeding to implement HIT because they are convinced that it both saves costs and improves quality.

A comparison with other industrialized countries suggests that the United States is beginning the implementation process as much as a dozen years behind these countries. The United States might be able to shorten the implementation phase if it can learn from these countries’ experiences.

Editor's Notes

 
Jerry Anderson (ganderso{at}jhsph.edu) is a professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Bianca Frogner is a doctoral candidate there. Roger Johns is a professor in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins School of Medicine and currently a Robert Wood Johnson health policy fellow working in the office of Sen. Orrin Hatch (R-UT). Uwe Reinhardt is the James Madison Professor of Political Economy at the Woodrow Wilson School of Public and International Affairs, Princeton University, in Princeton, New Jersey.

This research was supported by a grant from the Commonwealth Fund. The authors thank Christian Hyde from the National Health Service’s Connecting for Health in the United Kingdom, Mark Giles from HealthConnect in Australia, Tim Hunt from Health Canada, Cindy Hoffman from Canada Health Infoway, Kristian Skauli and Alfred Ehrenclou from the Directorate for Health Affairs in Norway, and Truls Frogner for corroborating data sources and providing comments on a draft.

NOTES

Top Comparison Of Health Care... Health Information Technology Barriers To HIT Adoption Who Pays, And Who... NOTES

 

1. Spending is measured in purchasing power parities (PPPs), which adjust for cost-of-living differences between countries by comparing the price of an economywide market basket of goods.
2. C. Borger et al., "Health Spending Projections through 2015: Changes on the Horizon," Health Affairs 25 (2006): w61–w73 (published online 22 February 2006; 10.1377/hlthaff.25.w61).[Abstract/Free Full Text]
3. J.P. Newhouse, "Medical-Care Expenditure: A Cross-National Survey," Journal of Human Resources 12, no. 1 (1977): 115–125.[CrossRef][Web of Science][Medline]
4. The regression equation is as follows: Health Spending per Capita = 0.0019 x (GDP per capita)1.3738. This simple bivariate equation has an R² of 0.9083. The equation suggests that a 10 percent increase in GDP per capita is associated with a 14.0 percent increase in per capita health spending. Inclusion of added variables in the equation might alter its estimated coefficients. Generally, other studies found that even when other variables are included, health spending rises at a greater proportion than increases in GDP. The regression equation including the United States and Luxembourg was as follows: Health Spending per Capita = 0.0043 x (GDP per capita)1.2943, R² = 0.85.
5. G.F. Anderson et al., "Health Spending in the United States and the Rest of the Industrialized World," Health Affairs 24, no. 4 (2005): 903–914[Abstract/Free Full Text]; U.E. Reinhardt., P.S. Hussey, and G.F. Anderson, "U.S. Health Care Spending in an International Context," Health Affairs 23, no. 3 (2004): 10–25[Abstract/Free Full Text]; G.F. Anderson et al., "It’s the Prices, Stupid: Why the United States Is So Different from Other Countries," Health Affairs 22, no. 3 (2003): 89–105[Abstract/Free Full Text]; and U.E. Reinhardt, P.S. Hussey, and G.F. Anderson, "Cross-National Comparisons of Health Systems Using OECD Data, 1999," Health Affairs 21, no. 3 (2002): 169–181.[Abstract/Free Full Text]
6. Anderson et al., "It’s the Prices, Stupid."
7. See, for example, G.F. Anderson et al., "Doughnut Holes and Price Controls," Health Affairs 23 (2004): w396–w404 (published online 21 July 2004; 10.1377/hlthaff.w4.396).[Abstract/Free Full Text]
8. R. Hillestad et al., "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs," Health Affairs 24, no. 5 (2005): 1103–1117.[Abstract/Free Full Text]
9. J. Walker, "Electronic Medical Records and Health Care Transformation," Health Affairs 24, no. 5 (2005): 1118–1120.[Abstract/Free Full Text]
10. H. Taylor and R. Leitman, "European Physicians, Especially in Sweden, Netherlands, and Denmark Lead U.S. in Use of Electronic Medical Records," Health Care News 2, no. 18 (2002): Table 1.
11. U.S. Government Accountability Office, Health Information Technology: HHS Is Taking Steps to Develop a National Strategy, Pub. no. GAO-05-628 (Washington: GAO, May 2005).
12. Taylor and Leitman, "European Physicians."
13. The CMS National Health Expenditure Accounts separate spending by provider of services; the OECD categorizes health spending data by use of services.
14. White House, "Executive Order: Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator," 27 April 2004, http://www.whitehouse.gov/news/releases/2004/04/20040427-4.html (accessed 7 February 2006).
15. During the 108th Congress, an additional $50 million was earmarked to the AHRQ health care IT programs for a total of $100 million. "E-Health Initiative, IT-Related Appropriations, and Legislation in the 108th Congress (2003–2004)," http://www.ehealthinitiative.org/assets/documents/108thlegFNL.doc (accessed 19 July 2005).
16. Other bills on the floor include S. 1355 and S. 1227.
17. R. Kaushal et al., "The Costs of a National Health Information Network," Annals of Internal Medicine 143, no. 3 (2005): 165–173.[Abstract/Free Full Text]
18. Smart cards are plastic cards, similar in size and shape to a credit card, with an embedded computer chip to store and process data. The card is accessible according to conditions dictated by hardware and software.
19. R.H. Miller and I. Sim, "Physicians’ Use of Electronic Medical Records: Barriers and Solutions," Health Affairs 23, no. 2 (2004): 116–126.[Abstract/Free Full Text]
20. G.F. Anderson, "Medicare and Chronic Conditions," New England Journal of Medicine 353, no. 3 (2005): 305–309.[Free Full Text]
21. Hillestad et al., "Can Electronic Medical Record Systems Transform Health Care?"
22. NHS Connecting for Health, Better Information Better Health: NHS National Programme for IT Annual Report 2004–2005, http://www.connectingforhealth.nhs.uk/publications/annual_report_0405.pdf (accessed 7 February 2006); and Australian Government Department of Health and Ageing, The Health Connect Implementation Approach, 26 November 2004, http://www.healthconnect.gov.au/pdf/ia_jan2005.pdf (accessed 19 July 2005).
23. U.E. Reinhardt, "Does the Aging of the Population Really Drive the Demand for Health Care?" Health Affairs 22, no. 6 (2003): 27–39.[Abstract/Free Full Text]
24. NHS Confederation, "The National Strategy for IT in the NHS," Briefing no. 88, August 2003, http://www.dh.gov.uk/assetRoot/04/07/13/99/04071399.pdf (accessed 25 March 2006); Norwegian Ministry of Social Affairs and Norwegian Ministry of Health, "Te@mwork 2007: Electronic Cooperation in the Health and Social Sector," 16 September 2004, http://www.shdir.no/vp/multimedia/archive/00001/IS-0036_Te_m_Work__se_1999a.pdf (accessed 28 January 2006); Australian Government Department of Health and Ageing, "HealthConnect: An Overview," December 2004, http://www.healthconnect.gov.au/pdf/overviewDec04.pdf (accessed 28 January 2006); and B. Assadi, Information and Communications Technologies in the Canadian Health System: An Analysis of Federally-Funded ICT-Related Projects, June 2003, http://www.hc-sc.gc.ca/ohih-bsi/pubs/2003_analproj/rpt_e.html (accessed 19 July 2005).
25. Anderson, "Medicare and Chronic Conditions."
26. See Commission of the European Communities, eEurope 2005: An Information Society for All, 28 May 2002, http://europa.eu.int/information_society/eeurope/2002/news_library/documents/eeurope2005/eeurope2005_en.pdf (accessed 19 July 2005).
27. G. Dietzel and C. Riepe, "Modernizing Healthcare in Germany by Introducing the eHealthcard," Swiss Medical Informatics no. 52 (2004): 18–22, http://www.dimdi.de/static/de/ehealth/literatur/sim52-18-22-germany.pdf (accessed 6 February 2006).
28. See the Health Level Seven home page, http://www.hl7.org.
29. Giesecke and Devrient GmbH, "Card-Enabled e-Health Networks in Germany," March 2005, http://www.gi-de.com/portal/page?_pageid=44,96105&_dad=portal&_schema=PORTAL (accessed 19 July 2005).
30. A. Bhatti, "Healthcare Smart Cards—The Movement from Concept to Reality," Business Briefings, 2004, http://www.bbriefings.com/pdf/950/bhatti.pdf (accessed 19 July 2005).
31. Giesecke and Devrient GmbH, "Card-Enabled e-Health Networks in Germany."
32. Harris Interactive, "Health Information Privacy (HIPAA) Notices Have Improved Public’s Confidence That Their Medical Information Is Being Handled Properly," 24 February 2005, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=894 (accessed 19 July 2005).
33. Germany Federal Ministry of Health and Social Security, "Information on the Electronic Health Card," June 2005, http://www.die-gesundheitsreform.de/presse/publikationen/pdf/flyer_elektronische_gesundheitskarte_en.pdf (accessed 26 January 2006).
34. Team Nord, Health and Social Sectors with an "e": A Study of the Nordic Countries, 10 April 2005, http://www.kith.no/upload/1750/eHealthNordic.pdf (accessed 26 January 2006).
35. Assadi, "Information and Communications Technologies."
36. Kaushal et al., "The Costs of a National Health Information Network."
37. Australian Government Department of Health and Ageing, Health Connect Interim Research Report: Volume 1, Overview and Findings, August 2003, http://www.healthconnect.gov.au/pdf/v1.pdf (accessed 6 February 2006).
38. Ibid.
39. Ibid.
40. D. Bisch, "eProgress: After a Slow Start, Canada Health Infoway Is Making Some Headway on the Road to a Pan-Canadian EHR," Canadian Healthcare Manager (December 2003): 39–40.
41. NHS Connecting for Health, A Guide to the National Programme for Information Technology, April 2005, http://www.connectingforhealth.nhs.uk/all_images_and_docs/npfit_brochure_apr_05_final.pdf (accessed 26 January 2006).
42. Christian Hyde, Directorate of Communication and Stakeholder Engagements, NHS Connecting for Health, personal communication, 6 July 2005.
43. T. Collins, "There Is No Cash Shortfall, IT Chief Tells NHS Trusts," ComputerWeekly.org, 2004, http://www.computerweekly.com/Article134343.htm (accessed 11 September 2005).
44. K. Dearne, "Project Flatline," Australian IT, 6 September 2005.

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