Problem: Rising burden of chronic disease; lack of standardization in care quality; disparities in access to health services; concentration of care in higher-level settings; inefficiencies in service delivery due to misaligned incentives and a lack of monitoring.
Solution highlights: An electronic Central Health Information System (CEZIH) was introduced by the government to connect stakeholders and provide real-time data on patients and providers; a strong government commitment and top-down leadership established the necessary conditions for the widespread adoption of e-health; data collected through the e-health system helped drive performance improvements; a new payment model for primary care providers was introduced and realigned financial incentives encouraged positive changes in clinical practice; ongoing trainings supported providers to uptake and capitalize on new technologies; a patient e-portal helped engage patients in their own care.
Description of practice
In the mid-1990s, health outcomes in Croatia ranked below EU averages and a growing burden of chronic disease was observed. A lack of quality control structures contributed to suboptimal health outcomes, plus access, quality and efficiency disparities in the delivery of health services. Furthermore, misaligned payment incentives contributed to the overprovision of care in secondary and tertiary settings, limiting focus on health promotion and disease prevention and driving up care costs.
Strengthening information flows for health services became a national priority for Croatia. In the early 2000s, the Ministry of Health initiated the development of an electronic Central Health Information System (CEZIH) to connect stakeholders and provide real-time data on patients and providers. Under managerial oversight from the Health Insurance Fund, CEZIH was introduced in 2007. Upon its launch, use of CEZIH by primary care providers was mandatory; incorporation of providers’ service payments into the system necessitated its timely uptake. The provision of ad hoc trainings and free software for providers also supported the adoption and widespread use of CEZIH. All 2300 general practice offices, as well as more than 2500 primary care offices, 1100 pharmacists, 100 primary care diagnostic labs and 800 outpatient specialists are now connected through CEZIH, allowing for greater coordination among providers and improved continuity of care. Numerous technological applications have been developed within CEZIH to improve efficiency, such as e-prescriptions, e-referrals and e-waiting lists. An e-citizens portal allows patients to interact with CEZIH and an additional portal for providers offers professional development and networking opportunities. Facilitated by CEZIH, a new payment model for primary care providers was introduced in 2013 to incentivize care improvements, promote the development of group practices and encourage service delivery in lower-level settings. Efforts to strengthen data collection for improved performance monitoring are ongoing. At present, significant progress has been made towards achieving the government’s vision of an open, connected and interactive e-health system. Further development of e-health is a current priority for the Ministry of Health, as detailed in the National Health Care Strategy 2012–2020. Integration of hospital providers into CEZIH is underway and an e-discharge application and electronic health records are currently being piloted.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
CEZIH was initiated in a top-down approach led by the Ministry of Health. The Ministry developed the necessary political and legislative framework to drive change through aligning incentive structures, making resources available and mandating the uptake of CEZIH. The Health Insurance Fund was appointed to manage implementation and coordinate necessary stakeholders; a new department for information technology was established within the Fund to develop applications for CEZIH.
The integration of information systems across primary care has been completed and CEZIH records all prescriptions, referrals, laboratory reports and visit summaries at the primary level. Digitalizing referral and prescription processes has resulted in greater efficiency and has generated cost savings estimated at €2 million. As the use of e-health continues to grow and develop, further quality and efficiency improvements are anticipated.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
Please click on the link below for more information about this practice.
- Tatjana Prenda Trupec
- Croatian Health Insurance Fund