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01 May 2023 | Policy Analysis
New Health System Reform Strategy for Slovenia
2.6. Health information systems
Health system performance has strengthened in the last 30 years, primarily in inpatient care where it is used to systematically measure performance at the regional, national as well as international levels. The information generated has a clear influence on national health policy goals, but performance assessment based on enhanced information still needs to be introduced in primary health care and could be designed to enable individual providers to continuously monitor their own performance and benchmark it against peers.
Slovenia’s health information system is based on strict legislation on personal data protection. Most registries and databases are covered by the Health Databases Act (2000, updates in 2015, 2018 and 2020). In December 2019, WHO reviewed Slovenia’s system and affirmed the overall high quality as well as the achievement of desired standards.
Since the 1990s, the NIJZ and ZZZS are the principal controllers and processors of large health data repositories, and they represent the two entry points for data reporting. NIJZ maintains patient and service registries, ranging from births and deaths, causes of mortality to vaccinations, hospitalizations, outpatient services and the health system workforce.
NIJZ is an authorized producer of official national statistics, coordinated by the National Statistical Office (Statistični urad Republika Slovenija – SURS) and is the reporting point for data to international organizations. It disseminates health statistics as open data at its own data portal (NIJZ, 2021a). ZZZS collects data on the financial management of the health system. There are several other institutions managing different disease registries. The Institute of Oncology is the operator and processor of the Cancer Registry (Europe’s oldest), two cancer screening programmes registries and numerous clinical registries. University Clinic Golnik manages the Tuberculosis Registry and Valdoltra Orthopaedic Hospital the Arthroplasty Registry.
Survey data are increasingly important in Slovenia, with NIJZ conducting large-scale surveys such as the European Health Interview Survey and topic-specific surveys. Other institutions that collect health survey data include the SURS and several university institutes. Several survey methodologies have been developed and, when applicable, web-assisted interviewing is widely used. Since 2019, NIJZ also gathers data on the patient experience in outpatient and inpatient hospital settings nationally.
Over the past two decades, several attempts have been made to modernize Slovenia’s health data collection. Efforts to develop a uniform and standardized health information system have leveraged e-Health solutions and standard classification sets, leading to new streamlined data collection systems at NIJZ, ZZZS and the Institute of Oncology. A national e-Health (e-Zdravje) project (2010–2015) implemented new applications to improve service quality and capture additional data. These include the CRPD, zVEM patient portal, e-prescriptions, appointments and triage, and teleradiology and telemonitoring for stroke patients (see section 4.1.3). This project also introduced a “uniform information model” involving standardized classifications and data standards, code lists and definitions of selected variables, and using the CRPD as an interoperable “backbone”.
Together this has led to a reduction in the administrative burden on health care providers as well as clarity on reporting paths and increased potential for linkage and availability of health data. Provided certain conditions are met, there is also clear legal and operational framework to connect the data from these sources – namely, NIJZ, ZZZS and the Institute of Oncology – via personal identity numbers, which allow these data to be linked (in adherence with privacy and data protection standards) with those of other databases and registries within and outside the health system, for example, the central Population Registry.
However, despite progress, important issues remain. Though substantial information is collected, some areas of the health system are underrepresented, including LTC and health system management; data for other areas are underutilized by the decision-makers; and data collection should correspond better to population and system needs. Further, data quality in certain sectors poses a challenge, particularly outpatient care and service delivery. Additionally, due to a lack of systematic data linkage, data cannot be connected across institutions or sectors (i.e. on sociodemographics, spatial/pollution, care utilization, employment), preventing research that focuses on health, health services and their determinants. Finally, effective health-related communication publicly and politically, especially data-driven insights, is also a challenge with only a small proportion of the data available directly utilized by policy-makers to shape policies to improve the health system operation.
The Prime Minister(PM)’s 22-member Advisory Board for the health system reform process has been meeting weekly to advance reform efforts. (See the policy analysis of 3 February 2023: “Whole-system Health Reform preparation formally launched in Slovenia”.) It has several subgroups, including medical faculties, primary care, financing of healthcare, health system governance, emergency medical services, and absenteeism. By the end of April 2023, it had prepared the following recommendations:
- Medical education – increase future admissions by at least 20%; enhance training capacity in regional hospitals and establish a possible third medical faculty.
- Absenteeism – address the current impasse, in which many patients experience a status between long-term sickness absence and disability.
- Primary care – clarify the status of patients not able to register with a GP of choice; incentivize junior doctors to choose primary care; revise completely the existing capitation formula, which has been applied since 2017 for workforce calculation, despite not being designed for this.
- Pharmacies – strengthen the role of pharmacies in local communities, potentially adding preventative services.
Additionally, three legal acts are under public discussion:
- Separate law for the Health Insurance Institute of Slovenia (HIIS): A separate law on the HIIS would reform the status, set-up and management of HIIS. HIIS would be registered as an insurance company, not a public institution. Rather than three management bodies – the CEO, the Management Board and the 45-member Assembly (25 insured representatives, 20 employers representatives) – the CEO and Board of three members – General CEO, vice-chair for compulsory health insurance and vice-chair for long-term insurance – would merge. The Assembly would also decrease to 11 members, representing the insured (6), employers (2), government (2), and employees of the HIIS (1).
- Law on digitalisation of the health information system: A special independent agency would be set up to oversee and implement the entire e-health and national reporting infrastructure. This would be managed by a special company and financed from a fixed percentage of the total health insurance budget. This is initially set at 3% and increased to 4.5% after three years; altogether, almost 10 times more money would be dedicated to e-health and digitalisation than currently, though there are some doubts to the feasibility of the funding source. Further, all national registries and data collection would transfer to five basic registries. It is unclear how these would be managed content-wise or by what methodology since the new agency would primarily oversee IT infrastructure. Nor is it clear how the complex international reporting obligations to Eurostat (legally binding), WHO and OECD would be fulfilled under this new system.
- Abolishment of complementary health insurance (CoHI) and corresponding amendments to the Health Care and Health Insurance Act (HCHIA): Triggered by a large increase in premiums by one CoHI company of almost 30% from 1 May 2023, the PM announced the future abolishment of CoHI. The proposal includes a freeze on premiums until September 2023 by which time the necessary amendments to the HCHIA should be adopted. This means that the present system of expansive CoHI would cease to exist by January 2024 at the latest. While this change may be an opportunity to (re)define the basic benefits basket and establish co-insurance for services not covered, it is unclear when and how this will occur.
References
- Law on the Health Insurance Institute of Slovenia, Draft law: https://e-uprava.gov.si/si/drzava-in-druzba/e-demokracija/predlogi-predpisov/predlog-predpisa.html?id=15438
- Law on the Health Information System: https://e-uprava.gov.si/si/drzava-in-druzba/e-demokracija/predlogi-predpisov/predlog-predpisa.html?id=15432