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Contents lists available at ScienceDirect

Health Policy
journal homepage: www.elsevier.com/locate/healthpol

E-health in Switzerland: The laborious adoption of the federal law on

electronic health records (EHR) and health information exchange
(HIE) networks
Carlo De Pietro , Igor Francetic
SUPSI DEASS Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Via Violino 11,
CH-6928 Manno, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Within the framework of a broader e-health strategy launched a decade ago, in 2015 Switzerland passed
Received 6 December 2016 a new federal law on patients electronic health records (EHR). The reform requires hospitals to adopt
Received in revised form interoperable EHRs to facilitate data sharing and cooperation among healthcare providers, ultimately
28 September 2017
contributing to improvements in quality of care and efciency in the health system. Adoption is volun-
Accepted 3 November 2017
tary for ambulatories and private practices, that may however be pushed towards EHRs by patients. The
latter have complete discretion in the choice of the health information to share. Moreover, careful atten-
Keywords:
tion is given to data security issues. Despite good intentions, the high institutional and organisational
Electronic health data
e-health
fragmentation of the Swiss healthcare system, as well as the lack of full agreement with stakeholders on
Switzerland some critical points of the reform, slowed the process of adoption of the law. In particular, pilot projects
Policy development made clear that the participation of ambulatories is doomed to be low unless appropriate incentives are
Care coordination put in place. Moreover, most stakeholders point at the strategy proposed to nance technical implemen-
tation and management of EHRs as a major drawback. After two years of intense preparatory work, the
law entered into force in April 2017.
2017 The Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Purpose of the policy
In June 2015 the two chambers of the Swiss Federal Parliament
passed a law [1] that requires hospitals and nursing homes to adopt
interoperable patients electronic health records (EHRs) compati-
ble with national standards, i.e. with technical rules that facilitate
sharing of standardised data and the development of health infor-
mation exchange (HIE) networks. The federal law is in effect since
April 2017. Hospitals and nursing homes have respectively three
and ve years to adopt such compatible EHR systems, whilst other
healthcare providers will be encouraged to voluntarily adopt inter-
operable EHRs and contribute to their development.
EHRs can be dened as repository of patient data stored in a
digital format [2] containing past, current and possibly prospective
data about patient, his/her health and clinical status. EHR systems
Open Access for this article is made possible by a collaboration between Health
Policy and The European Observatory on Health Systems and Policies.
Corresponding author at: SUPSI DEASS, Via Violino 11, CH-6928 Manno,
Switzerland.
E-mail addresses: carlo.depietro@supsi.ch (C. De Pietro), igor.francetic@supsi.ch
(I. Francetic).
can potentially bring great benets to the health system, mainly in
terms of greater efciency and better quality of care through better
information availability [2,3]. HIE networks are dened as the pro-
cess of sharing patient-level electronic health information between
different organizations [4]. HIE networks allow effective sharing
and interoperability of EHR data among communities, providers
and actors, unleashing their full potential. Nevertheless, besides
a generalized gap between quality goals and achieved objectives
[5], successful adoption of EHRs in industrialized countries was
hindered by different factors. These include concerns with secu-
rity, service continuity and privacy [6,7] coupled with the inherent
policy legislative complexity of such matters [2,8] as well as gener-
alized lack of acceptance by providers, above all physicians [9,10].
The broad goal of the eHealth strategy for Switzerland, launched
by the Federal Government in 2007, is to help patients access and
share with selected providers their own health information. More
specically, the law aims at improving cooperation and integration
among healthcare providers, increasing transparency of health ser-
vices as well as maintaining the Swiss health system up to date with
ICT developments.

https://doi.org/10.1016/j.healthpol.2017.11.005
0168-8510/ 2017 The Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Please cite this article in press as: De Pietro C, Francetic I. E-health in Switzerland: The laborious adoption of the
federal law on electronic health records (EHR) and health information exchange (HIE) networks. Health Policy (2017),
https://doi.org/10.1016/j.healthpol.2017.11.005
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2. Relevance
In other countries and setups, EHRs showed modest positive
effects on different measures of quality of care [1114] and con-
rmed the potential positive impact on health information systems
and patient data management procedures [1517]. On the other
hand, the prospected efciency and cost-saving effects were so far
debated [18,19], rather pointing to increased workload in the short
run [20,21]. Despite the often limited evidence available and the
call for more evaluations [5], EHR initiatives are spreading in most
industrialized countries, although there are many challenges on
their way to a complete implementation [2,22,23].
The Swiss health system has good or excellent performances
with regards to nearly all relevant OECD health status and quality of
care indicators [24,25]. On the other hand, the economic efciency
of the health system is low, with Switzerland consistently ranking
among the most expensive countries in the world [25]. An impor-
tant barrier to efciency gains is represented by the high degree
of fragmentation that characterizes the Swiss health system [26].
Fragmentation exists both at the institutional level, with 26 Can-
tons regulating the health system and a limited stance for national
policies, and at the organisational levels, with many independent
healthcare providers serving the same population and the strict
separation between the health insurance companies and the health
services providers [26,27]. Institutional and provider fragmenta-
tion entails limited sharing of data and results in poor transparency
of the system [22,27], potentially representing a threat to health
care safety as well. In the own words of the Federal Government,
Today service providers are operating with too little coordination,
and too little use is being made of modern information technologies
(e-health). This leads to inefciency and duplication [28]. In the
current situation, the new federal law requiring compatible EHRs
represents a potentially powerful tool to tackle the two challenges
mentioned above.
Compared to other countries, Switzerland can be seen as a
late adopter of EHRs and HIE networks. According to 2015 data,
Switzerland ranks among the last OECD countries (ahead of Turkey,
close to Ireland and Japan) in terms of key health data availabil-
ity, maturity and use [24]. A major determinant for this situation
is certainly the institutional and organizational fragmentation that
characterizes the Swiss health system. Moreover, many of the chal-
lenges in the development of EHRs in Switzerland were already
highlighted in a 2013 OECD report [27]. The complex interaction
of legal, organizational and technical conditions of the reform con-
tribute, in our opinion, to increasing the interest of the Swiss EHR
policy process. Our contribution adds a number of updates and
insights about the strategies implemented to overcome these chal-
lenges and move towards a successful introduction of EHRs and
HIEs in Switzerland by 2020.
3. Health policy processes
The new federal law and its entry into force are the result of a
long preliminary work, both technical and political, promoted by
the Federal Government. Box 1 lists the main milestones of this
process.
In 2006, the Federal Government revised the strategy for an
information society in Switzerland, originally written in 1998. A
new chapter titled Health and the health service was incorpo-
rated into the strategy. The primary focus of the Government in
this chapter was electronic communication with and between the
authorities (e-government) and the use of information and com-
munication technologies (ICT) in the health system (eHealth) [29].
Within this framework, the Federal Ofce of Public Health devel-
oped a specic eHealth strategy for Switzerland, released in 2007.
Please cite this article in press as: De Pietro C, Francetic I. E-health in Switzerland: The laborious adoption of the
federal law on electronic health records (EHR) and health information exchange (HIE) networks. Health Policy (2017),
https://doi.org/10.1016/j.healthpol.2017.11.005
Box 1: The eHealth policy process in Switzerland
2006 The Federal Council adds a new chapter titled Health and
the health service to the Strategy for an information society in
Switzerland.
2007 The Federal Office of Public Health publishes the eHealth
strategy for Switzerland.
2008 The Confederation and Cantons establish a coordination
organism called eHealth Suisse.
2013 The Federal Council approves the Health 2020 strategy,
and to make greater use of e-health is recognised as objec-
tive for the priority area Safeguard and increase the quality of
healthcare provision.
The Federal Council proposes to the Parliament a federal law
defining the development and adoption of interoperable EHR
systems by hospitals and other health providers.
2015 The Parliament adopts the federal law, limiting the obliga-
tion to hospitals and nursing homes. GPs and other healthcare
providers will join EHR communities voluntarily [1].
2017 The Federal Council passes three implementation decrees
[3840] and the federal law [1], enters into force.
2018 Expected certification of first EHR communities and first
exchanges of health data within and between communities.
2020 Deadline for adoption of interoperable EHRs by hospitals.
2022 Deadline for adoption of interoperable EHRs by nursing
homes.
The Confederation and Cantons decided to establish a coordina-
tion body called eHealth Suisse, co-nanced by the Confederation
itself and the Swiss Conference of the Cantonal Health boards
(GDK/CDS). The new body started to operate in 2008 with the main
task of promoting interoperability of EHR solutions in all its dimen-
sions, this means at the technical, organisational, political and legal
level [30]. Thereafter, several local projects developed following
the national strategy, most of them supported or originated by
Cantonal Governments.
In 2013 the Federal Government approved the Health 2020 strat-
egy [28], setting the Swiss health policy priorities over 4 areas and
36 objectives. To make a greater use of e-health was recognised
as one of the three objectives for the priority area Safeguard and
increase the quality of healthcare provision (see Box 2). In the same
year, the Government asked the Parliament to pass the new federal
law and allocated 30 million Swiss francs to support the develop-
ment of e-health initiatives during three years after the entry into
force of the law, thus between 2017 and 2020.
A few Cantons already promoted e-health initiatives before the
establishment of eHealth Suisse, achieving mild or poor results
(with formal decisions to stop the initiatives or lack of diffu-
sion/adoption by health providers). Failures can be attributed,
above all, to lack of incentives or legal obligations paired with
fragmentation of actors in the health system (public and private
hospitals, private practices, other providers, private insurers, can-
tonal authorities) [31].
After 2008, eHealth Suisse has been effective in coordinating and
spreading ideas and experiences, as well as setting the ground for
cantonal and local experiences. Important advances were made in
(i) dening a common glossary; (ii) clarifying the legal bases and
requirements of the initiative (technical implications of patients
privacy, health data storage) [32]; (iii) setting IT standards for inter-
operability [33].
The role of insurers, a major owner of patient health information,
deserves special consideration. The Swiss eHealth strategy does not
include insurers among the actors involved in the development of
EHR and excludes explicitly insurance companies from the range of
actors allowed to access patients data. The choice reects the fear
that insurers could take advantage of EHRs directly and indirectly,
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Box 2: Objective 3.2: Make greater use of e-health
E-Health tools can improve the quality of healthcare provi-
sion and patient safety by giving all healthcare professionals
access to relevant information and patients records at all loca-
tions and times. In this way e-health contributes to greater
efficiency by avoiding duplication of diagnostic procedures.
Great attention must be paid to protecting personal data when
implementing e-health. E-Health can intensify the coordina-
tion between all stakeholders in the treatment process. This
benefits patients, particularly those with complex chronic dis-
eases. These improvements in quality will also reduce costs
in the medium and longer term. E-Health is an important ele-
ment in moving forward healthcare reforms designed to have
an impact on quality and costs.
The major measures relating to e-health are:
Introduce and actively promote e-medication, giving doc-
tors, pharmacies and hospitals electronic access to informa-
tion about patients medication. Increase patient safety by
reducing errors.
Introduce and actively promote the electronic patient dossier
in order to increase the quality of healthcare provision and
patient safety and to support treatment processes and col-
laboration between service providers.
Provide digital support for treatment processes such as
hospital discharge processes or integrated management pro-
cesses throughout a treatment plan using the electronic
patient dossier to provide the necessary data.
for cream skimming and premium discrimination (for example
in voluntary supplementary insurance).
Medical doctors and other health professionals, while support-
ing EHR in principle, do not favour the current implementation
process. In particular, they criticized the burden of legal and tech-
nical requirements, the lack of detailed procedures for day-to-day
operations and the unclear nancial consequences linked to the
implementation of such new systems in private practices. Ulti-
mately, they ask for higher involvement and a general delay in
the process [34]. Besides the ofcial position, the mild reception
of EHRs by MDs is also explained by (i) values and views of the
doctor-patient relationship, (ii) the lack of appropriate incentives
to share their patients health records and (iii) a large share of old
GP practices that still rely on paper records.
The difculties in spreading interoperable EHR in ambulatory
setting are well represented by a project recently promoted by
a southern Canton (Ticino). The pilot phase of the project lasted
18 months and was promoted for oncology patients. Despite the
encouraging results from a technical point of view, the project
struggled to recruit private oncologists, who did not perceive util-
ity in joining the program [35]. Moreover, most doctors asked to
inhibit patients to access their health records on the grounds of
potential problems in the doctor-patient relationship.
More positive results emerged from a relevant experience pro-
moted by a western Canton (Genve), aimed at developing EHR and
HIE for the population living in a limited cluster of municipalities,
instead of a single pathology area [31]. In this case, access to infor-
mation by patients gave leverage to the adoption of the EHR system,
building on an information campaign targeting directly patients
(invited to ask their doctors to be enrolled in the EHR system). In
the case of Genve, the pilot project was later rolled out to the whole
Canton.
Other Cantons (for example Vaud, Zrich and St. Gallen) piloted
EHR data sharing communities among large public and university
hospitals, with encouraging results in terms of participation of pri-
vate practices (Table 1). The national coordination body, eHealth
Please cite this article in press as: De Pietro C, Francetic I. E-health in Switzerland: The laborious adoption of the
federal law on electronic health records (EHR) and health information exchange (HIE) networks. Health Policy (2017),
https://doi.org/10.1016/j.healthpol.2017.11.005
3
Suisse, continuously supports and evaluates similar pilot studies
across the country [31].
Healthcare providers have generally shown a positive attitude
towards the principles of e-health, understanding its role within
the larger ICT trend and grasping the potential in terms of better
coordination and higher quality of care. However, when asked to
adopt EHRs, providers especially the private ones were reluctant
and explicitly stated the need for public nancial support for imple-
mentation in case of mandatory adoption. Patients organizations,
whilst favouring the initiative, expressed concerns with data own-
ership and security [36]. Despite not being affected by the reform,
health insurers also praised the initiative but warned about poten-
tial problems that may arise from the proposed nancing model for
the implementation and management of EHRs by providers [37].
The parliamentary debate about the law reects the lack of con-
sensus around EHRs. In fact, compared to the initial version sent to
the Parliament, the law was amended prescribing the obligation to
adopt EHRs only for hospitals and nursing homes, excluding other
healthcare providers [1].
4. Content of the reform
The federal law and the related decrees set the rules for the use
of information contained in the patients EHRs, as well the measures
for promoting their diffusion and adoption [1,3840]. The explicit
goals of EHRs are to improve the quality of care, patients safety, ef-
ciency of the healthcare system and promote health literacy among
the population.
The EHR envisaged by the current law allows storage and
retrieval of relevant health data produced by healthcare providers
or by the patient himself.
The setup of an interoperable EHR requires the written con-
sent by the patient, which can withdraw from the system at any
time. The patient can access his health records, while all health-
care providers require explicit authorisation by the patient, along
dened safety and access levels. To access EHR records, a secure and
veried electronic ID is required for both patients and providers.
In case of emergencies, or when the patient cannot express his
will, healthcare providers can access the EHR. The patient will
be informed later about the exceptional access. The patient will
also decide which data to share with other health actors (e.g. only
MRI results and pharmaceutical records). Insurance companies and
other actors not qualifying as healthcare providers are excluded
from access. Moreover, the law excludes all secondary use of EHR
data (e.g. scientic research), requiring specic request procedures
to EHR communities, federal and cantonal authorities [41].
The new federal law introduced the necessary legal basis for
electronic sharing of patient data. Due to the Swiss political feder-
alism, each Canton has his own health, data protection and hospital
laws. Cantons need therefore to amend their legislations in order
to comply with the federal rules [41].
EHR systems are promoted and managed by so-called commu-
nities, private legal bodies built around population groups (i.e. the
whole population residing in a specic area or a Canton). Communi-
ties can be funded by groups of hospitals, GPs, pharmacies or other
existing networks of healthcare providers [41]. EHR communities
need to be certied by external bodies in order to guarantee com-
pliance with technical, legal, nancial and organizational standards
dened by the federal law and the related decrees, ensuring inter-
operability and functioning HIEs. IT data integration rules are set in
accordance with international standards, to allow future interna-
tional integration of HIEs (e.g. with a European exchange) [40]. EHR
communities are responsible for data accessibility and record keep-
ing related to data access [1], for data protection purposes. Access
to data across communities will be granted by common operational
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Table 1
Overview of EHR pilot projects in four Swiss Cantons.

Canton

Fribourg Genve St. Gallen Ticino

Geographic area Central-West West North-East South
Language(s) French and German French German Italian

Content of EHR and HIE
Role of patients
Lessons and implications
Administrative and
pharmaceutical data
available to pharmacies
and GPs
Indirectly involved through
GPs
The pilot was successful in
enrolling patients and was
well perceived and
supported by GPs
Administrative, imaging,
medical and clinical data
Directly involved and
encouraged to join, with
access to data
Project later rolled out in
the whole Canton
Direct involvement of
patients proved to be a
successful lever on GPs to
join the community
Administrative, imaging,
medical and clinical data
Not involved, beyond
informed consent, no
access to data
The pivotal role of hospitals
was successful in attracting
GPs, in line with the actual
content of the law
Administrative, medical,
and clinical data in
oncology setting
Not involved, beyond
informed consent, no
access to data
Low adherence among
oncology private practices
due to concerns about data
sharing with patients

Source: Authors own elaboration based on GDK/CDS (2017).

Fig. 1. Example of EHR communities and data ows.

Source: authors own elaboration.

standards and communication protocols. However, the patients
authorization will be required for any enquiry outside the original
patients community (e.g. if the patient lives in Geneva and visits a
public emergency department while on vacation in Ticino).
Finally, it is worth repeating that the law requires hospitals to
adopt interoperable EHR systems and join a community by 2020
(by 2022 for nursing homes). On the other hand, joining EHR com-
munities will be voluntary for other healthcare providers, including
GPs and outpatient services, as shown in Fig. 1.
The law allows federal nancial support to develop EHR com-
munities for the period 20172020. To that end, the Federal
Government allocated a 30 million Swiss francs budget. Federal
funds can cover IT needs, accreditation, etc. and are disbursed in
the form of matching funds, requiring at least the same investment
from Cantons or other actors involved in the process [1]. Finally,
the law states that Federal Government is responsible for the pro-
motion of EHRs, the information to all relevant actors as well as the
coordination among Cantons and key actors [1].
The federal law approved in May 2015 boosted the develop-
ment of e-health in Switzerland, yet its results will be incomplete
compared to the goals of the initial eHealth strategy for Switzerland
dened in 2007. At that time, objective A6 stated: By the end
of 2012, it will be possible to transfer medical data electronically
between the players in the health system; the procedure will be
structured, seamless and will ensure that no data are lost. All hospi-
tals providing acute, non-psychiatric care, all integrated healthcare
networks and the majority of doctors in private practice will be
using the electronic version of treatment-relevant information
from the patients personal medical records while objective A7
prescribed that: By the end of 2015 everyone in Switzerland will
be able to grant service providers of their choice electronic access
to treatment-relevant information (electronic patient record) any-
where and at any time [29].
5. Conclusion
The development of interoperable EHRs in Switzerland was
slowed by several factors so far.
First, whilst the health system is seeing a relevant surge of fed-
eral regulation, Cantons maintain a pivotal role in organising and
often providing healthcare services. The establishment of a national

Please cite this article in press as: De Pietro C, Francetic I. E-health in Switzerland: The laborious adoption of the
federal law on electronic health records (EHR) and health information exchange (HIE) networks. Health Policy (2017),
https://doi.org/10.1016/j.healthpol.2017.11.005
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coordination body (eHealth Suisse) was a successful attempt to
addresses this issue, integrating the two levels of government.
A second factor that hinders the development of HIE networks is
the fragmentation of healthcare provision, with a plurality of public
and private actors and a key role played by GPs in private practices,
that are not forced to adopt EHRs. The different e-health initiatives
need thus to be negotiated among a high number of actors and
bodies, with different goals and priorities.
Institutional and organisational fragmentation explains at least
partially the approach adopted by the Federal Government, pro-
moting interoperable bottom-up initiatives organised around the
so-called EHR communities, instead of pushing for a national stan-
dardised programme. On the ip side, local initiatives can lack
the sufcient political, nancial, and technical resources to suc-
ceed. For this reasons, several initiatives are currently in place to
develop inter-cantonal communities, whilst some small Cantons
simply plan to join communities established in larger neighbour-
ing Cantons [31]. Analogously to similar e-health initiatives in other
countries, the pilot projects run so far conrm the struggle in per-
suading healthcare providers to adopt EHRs until the system does
not contain enough useful information and enrolled providers. Put
it another way, e-health projects are characterised by a snow-ball
effect, with the adoption of the ICT solution becoming more and
more valuable as utilization increases. To that end, the intermedi-
ate phase between the launch of the EHR systems and the actual
benets for healthcare providers remains critical.
Another limiting factor for EHR development is the lack of spe-
cic nancial incentives for implementation, as the federal law
on health insurance does not contemplate any reimbursement
for providers adopting EHRs [27]. The absence of insurers among
EHRs promoters is primarily explained by the concerns associated
to their access to health data. However, insurers are the actors
that could also benet most efciency gains from the adoption of
EHRs and play a major role in health care nancing. The federal
law supported several pilot projects developed between 2015 and
2018, while for the period 20172020 the Federal Government will
nance a maximum of 50% of development costs of each commu-
nity, with a cap of 500 000 Swiss francs in form of matching funds
[39].
Unfortunately, little evidence about impacts of EHR and HIE net-
works is available from the projects so far completed, in particular
with regards to efciency, productivity and nancial implications.
The federal law includes a specic norm to tackle this issue [1],
stating that the Federal Government is responsible for gather-
ing relevant data from the providers within the community for
monitoring and evaluation purposes. Suggested efciency and pro-
ductivity indicators include case-mix adjusted cost, work relative
value per provider full-time equivalent (FTE), diagnostic proce-
dures per case and medications ordered in emergency department
setting. Financial indicators may include net income per work rel-
ative value unit (RVU), net income per physician FTE or practice
expense per work RVU. As of today, Switzerland is well behind
other countries in terms of EHR adoption and data linkage [22]. In
addition to efciency and productivity gains, improvements in this
area may also be benecial for quality of care through better safety
and appropriateness at point of care (diagnosis, prescriptions),
improved continuity of care for chronic diseases and long-term care
as well as improved monitoring opportunities [5,17,19].
Finally, the need to protect patients privacy can hinder the
adoption of e-health and requires specic attention. In the Swiss
case, this aspect was taken into account both at legal and technical
levels.
To overcome the obstacles mentioned above, well known from
the experiences of EHRs and HIE networks in other countries [2],
Switzerland has chosen two main tools: (i) a federal obligation for
the main providers i.e. the hospitals and nursing homes and (ii)
Please cite this article in press as: De Pietro C, Francetic I. E-health in Switzerland: The laborious adoption of the
federal law on electronic health records (EHR) and health information exchange (HIE) networks. Health Policy (2017),
https://doi.org/10.1016/j.healthpol.2017.11.005
5
the denition of specic technical, security and organizational rules
for interoperability, leaving to Cantons or providers networks the
responsibility to develop the EHRs and the communities. This
approach, which takes into account pragmatically the pluralism of
the Swiss health system, the political difculties to extend the obli-
gation to the outpatient settings, as well as the focus on patients
rights, could inspire and give specic suggestions to other countries
with decentralized health systems struggling with the introduction
of EHR and HIE systems.
Conict of interest
The authors have no relevant interests to declare.
Acknowledgements
The authors would like to thank Mr. Carlos Garcia (e-health
Ticino) for his insightful comments to an earlier version of the
paper.
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