The context for supply and demand of public online services in Sweden

Sweden is a centralised state. This means that Sweden has a strong national level and a strong government with centrally managed authorities/agencies. This in turn means that it is the central state/government authorities that have the responsibility for almost all of the services taken up in this study.

Apart from the central government, Sweden is administratively divided in 19 counties (län) run by county councils. The county councils' main responsibility is health care matters. There are also two regions and one municipality, which have the same responsibilities as the County councils. The country has 290 local authorities/municipalities in charge of various questions such as schooling, housing and local taxes. Sweden is among the European countries with the lowest density of population.

Sweden's long-successful economic formula of a high-tech capitalism interlarded with substantial welfare elements was challenged in the 1990s by high unemployment and in 2000-02 by the global economic downturn. Fiscal discipline over the past several years has allowed the country to endure economic fluctuations. The Eurostat 2004 Survey shows that Sweden has returned to a level of unemployment which is considerably below the EU15 average. The country also has a high GDP (in Power Purchasing Parity) compared to the weighted EU25 average.

Key figures about Sweden[1]

	Sweden	Ø EU15	Ø EU25
Old age dependency ratio	26.4	25.5	24.5
Population density	21.6	119.8	116.3
GDP per head	117.0	108.6	100.0
GDP growth - 5 year average	2.49%	1.85%	1.92%
Unemployment rate	6.3%	8.1%	9.0%
Inequality index	24	30	29

Sweden has achieved an enviable standard of living. It has a modern distribution system, excellent internal and external communications, and a skilled labour force. Three out of four Swedes use the Internet and 12% of households have access to broadband connections. These facts confirm Sweden's status as one of the world's leading information societies, as stated by IDC in its 2004 assessment.

Information Society indicators[2]

	Sweden	Ø EU15	Ø EU25
Individuals regularly using the Internet	75%	41%	38%
Broadband penetration	12.1%	7.6%	6.5%
Price for Internet use basket	58.25	49.57	48.35
ICT expenditure as percentage of GDP	3.7%	3.2%	2.6%
Digital Divide Index	65.2	53.0	50.1

eHealth in Sweden

The dominating supplier of health care services in Sweden is the County Councils. Today, there are 18 county councils and two regions and one municipality functioning as county councils, which are the main suppliers of health care services in Sweden.

These actors have all of them eHealth portals on the internet containing practical advice for self-care. Typically, these web sites contain a dictionary of symptoms and illnesses coupled with tips on how to treat them on your own or if the potential patient should see a doctor about it. At the county council web pages there is also information about how to live a healthier life, quit smoking and similar issues in order to improve the health of the public. This type of information is also available at the web page of the pharmacy www.apoteket.se

All these sites also contain information about where to go in case you are ill, phone numbers and other contact information to all the health care institutions within the county council. Very often, these pages also have links to private alternatives within the health care sector. (These services are available at all the county council web pages, see for example www.lul.se)

The primary health care clinics offer telephone advice by a nurse and sometimes telephone advice from the family doctor during telephone hours.

In all county councils patients can call a telephone service line to get health care advices from a nurse, after telephone hours of the health care clinics. This service is available 24/7, (for example Sjukvårdsupplysningen, health care advice centre) The Federation of County Councils is working on a project in order to connect all these telephone service lines and give them the same telephone number all over the country.

There is no data gathered centrally on the extent of eServices in the health care system. A search at the web pages of the county councils shows that all county councils but two (that is 19 out of 21) have web-based services in at least some of their primary care clinics. eServices that are offered in all of these counties include: booking or cancelling an appointment; renewal of a prescription and submitting views upon the health care clinic. As far as the web search can tell, all county councils but two have eServices in at least some of their primary care clinics. These relate to prescription renewal and booking or cancelling appointments. Direct online consultation seems to be rather unusual.

There is a pilot stage eService in the county of Östergötland where the patients can access their medical file online (www.lio.se).

All primary care clinics (that is family doctors and GPs) within the jurisdiction of the county councils have a web page accessible from the web pages of the county councils. (See for example www.ltdalarna.se ) The web pages contain contact information and opening hours.

The county councils' web websites have contact information to all their health care clinics that is also to the specialists. However, the web site search shows that it is less common for specialists/ specialist clinics to have online bookings of appointments and prescription renewals even though this is available in a few county councils (see for example www.lio.se). This is probably due to that the primary source of health care is the primary care clinics and many specialist clinics require a letter of referral in order to see a patient.

Apoteket (The Pharmacy) is a monopoly held by the government in Sweden, i.e. there are no private pharmacies in Sweden. All selling of medicine by other actors than the Apoteket is illegal. Apoteket is found at www.apoteket.se At this web site you can buy medicine and other products from the pharmacy, provided that these do not require a prescription. There is also a pilot stage test of selling medicine that requires prescriptions in which you have your prescription available online. Advice about illnesses, health care and other health issues, such as dieting and exercising, are also available at the web site. The web site also contains links to related sites.

Internet Use for Searching Health Information[4]

At the county council web pages there is also information about how to live a healthier life i.e. by eating healthier, how to quite smoking and similar issues in order to improve the health of the public. This type of information is also available at the web page of the pharmacy www.apoteket.se

Infomedica (www.infomedica.se) has information about healthy living, illnesses, treatments and hospital/health care contacts. It has also a service that enables you to ask questions to a doctor.

www.fass.se is a site with information about illnesses, and medication. At this site you can use a search engine to find information about medicines. The Swedish Association of the Pharmaceutical Industry provides this site and its information about medication is commonly used by the pharmacies.

Karolinska Institutet is one of the most prestigious medical universities in Sweden, known for its cancer research. On the web page of the institute, www.ki.se , information about cancer and how to avoid it and tests judging the risk for getting cancer is available.

The county council web pages also contain information about all the different kinds of health care services (hospitals, primary care, child welfare centres, psychiatric clinics etc.) run by the county council. These sites have very often links to, or contact information about private care alternatives as well. Furthermore the county council web pages have information about the costs, the rights of the patients and what kind of treatment the patients have the right to demand.

Vårdguiden (www.vardguiden.se ) is a site within the jurisdiction of the county council in Stockholm that has been awarded for its clear structure and complete information about health care services within Stockholm county council. Information about illnesses and healthy living is also available on this site.

The web service Infomedica (www.infomedica.se ) has a service called "ask the doctor". You can send a question and a specialist will answer it within a week (approximately). Special priority is given to matters concerning second opinions about serious matters, matters where anonymity is extra important, matters concerning issues with a wide range of people interested in the answer, and questions concerning prioritised areas in the health care system. When the question is being sent, the sender gets a control number that serves as a log in id that is required when checking the answer. The answers are being gathered in a database that is searchable for the public directly online, but all private information that can be used to identify the person asking the question is taken away.

General Practitioners with Websites[5]

Main drivers for the implementation of eHealth Services in Sweden are following:

• The step towards making the health care system available 24/7 is not far away. For example, all health care clinics within the county councils have the medical records and information about the patients on computer files. Thus, the health care system is already computerized. Making the services e-based can be said to be the next logical step.
• It is also relatively easy to transfer information about patients in Sweden between different health care clinics. This is because all Swedish citizens have a personal number, which is used to unambiguously confirm the identity the patients. Thus, the ID-system for the patients is identically in all clinics.
• Computer literacy and availability are well advanced in Sweden. 50% of the Swedish citizens use the Internet every day [6]. Thus, large parts of the Swedish population have extensive experience in using the Internet and also possess the means to access it easily. This logically facilitates the uptake of eHealth by citizens.

User orientation in eHealth services

Since there are no reliable data gathered about the extent of eHealth services in the country, assessment of the extent to which supply matches (potential) demand of eServices is hardly possible. However, a few points can be made.

Information about health services and health related matters is easily accessible for everyone through the web sites of the county councils and infomedica, the county councils common information site. There are simple eServices at almost all primary care clinics, such as booking or changing appointments, renewal of prescriptions and asking questions, but there are few online services to specialist clinics. In the Swedish health care system the 'normal' procedure is to first contact the primary care clinic for consultation, and if this is not enough the patient gets a letter of referral to a specialist. Thus, a large part of the patients can access their health care clinic online. However, there are very few advanced eServices as concerns eHealth, such as real online consultations or having the patients medical records accessible online, which would make the communication between different doctors treating the same patient (for example in case a patient needs many specialists) more efficient. The development of this kind of service would benefit chronically ill people that need many contacts with the health care system.

In sum, simple services, such as information and booking of appointments are rather well developed and to a large extent available to all patients, but more complicated services that would benefit the people who are most ill are not very well developed. However, this is in part due to legal complications.

Main barriers for the implementation of eHealth Services[7] are to be found in the form of legal, cultural and economy-related factors.

With regard to legal barriers, as in the case of other eGovernment services, some of the laws about the handling of information are older than the information technology of today. The question is if these laws are applicable at the new handling of information and if they are - how are they to be interpreted? Since the health care institutions have to follow the laws, old (and therefore unclear) laws are a barrier[8]. This is also taken up by the Swedish Agency for Public Management. They state that agencies tend to be reluctant to use eServices for fear that they might accidentally violate the laws. Thus it is important that the interpretation of the laws is made very clear[9].

Satisfaction with National Healthcare System[10]

This can be illustrated by the following example from the county council in Uppsala. The county council started an eService called the Personal Health Account, in which both the patient and the health care system (the patients own doctors) could access all important information about the patient in order to make the communication between different instances in the health care system more efficient and to give the patient a greater insight into his/her own medical condition. However, this was stopped by the Swedish Data Inspection Board (datainspektionen) because the eService did not follow the law about health care registers §8. This paragraph states that the information in the health care registers must be 'accessible only for persons who need the information to be able to carry out their work'. Since this does not include the patient itself, the eService did not follow the law and was stopped. Since the law is old, no consideration of eServices and patient accessibility was taken when it was written.

A committee is now working on how to modernize the law and make it more up to date. Probably, the law will be changed in the near future which will make it possible to develop more complex eServices [11].

With regard to cultural barriers, since the patients' possibility to access their own medical records is a rather new phenomenon, some doctors are reluctant to making the patients medical record available to them. In the case of advanced eServices, as the one described above, this will however be a necessity. Thus, there is to some extent some opposition against eServices.

Economy-related barriers come into play because of the fact that the health care system usually cannot charge patients extra for using eServices. This means that eServices need to be financed in other ways. eServices are expensive to develop and therefore may have to be considered as a means of reducing the costs of healthcare provision. This means that services that a large part of the patients can use and will use frequently will be developed faster than other services. Some services can be used by a large share of the patients, such as register for a family doctor - however, most people register for a doctor once every decade, which means that the service is not used very frequently and will therefore be expensive to develop. Therefore, the economy is to some extent a barrier for developing further eServices.

eUser - the Project

The eUser study is funded by the European Commission's IST (Information Society Technology) programme. eUser is a major research and support project which has set out to provide solid evidence as to users' real needs regarding eGovernment, eHealth and eLearning offers, as well as providing data about their attitudes and the uptake levels of current public online services. The project supports the IST programme to achieve its key objectives of putting the user and his/her needs at the centre of IST developments. It provides empirical information on key public eServices domains -eGovernment, eHealth, eLearning - identified as priorities by the European Council, and assesses the demand/supply match in these fields.

The eUser Approach

To achieve its objectives, eUser addresses both generic user-related issues and domain-specific topics, and develops a globally accessible repository of evidence-based knowledge, methods and best practice examples. It pursues an extensive programme of active knowledge translation, transfer and dissemination supported by sophisticated online knowledge dissemination tools. The knowledge base will consolidate both existing knowledge and approaches, and novel data generated by the project through representative population surveys (demand side) in old and new Member States, and through comparative analyses of readiness to address user aspects of public eServices in each Member State (supply side).

The project is designed in two phases. Phase I - the preparatory phase - has developed a conceptual framework that systematically identifies and cross-references user issues and service characteristics in relation to online public services. An EU-wide population survey regarding the needs, experiences and requirements of both current and potential users of online public services has been carried out in early 2005. Concerning the supply side, information from national public sector environments has been collected, about the degree to which the European public sector pays sufficient attention to user-orientation of online services. Good practice examples regarding user-appropriate online public service provisions are being identified and described.

All these results build the basis and provide content for the eUser interactive online knowledge base and support service which is being set up as an online observatory on user issues. This constitutes the basis for active support services on user-centred topics which are being made available inside and outside the IST programme.

eUser Country Briefs

This document has been prepared by Lone Jensen of the Danish Technological Institute, based on information provided by the Swedish National Correspondent (Anna Ullsten, Intersecta AB), as well as secondary data sources such as Eurostat and other Commission Services.Altogether 25 eUser Country Briefs are available in a common format, one for each member of the enlarged European Union. You can access and download these documents in PDF format (for free) from our website.

More information

Check our results and achievements on: www.euser-eu.org. If you wish to be provided with more details, or to receive news and updates, please contact us at: eUser@empirica.com or get in touch with any of the project partners listed below.

empirica Gesellschaft für Kommunikations- und Technologieforschung mbH (Project Co-ordinator) Oxfordstr. 2, 53111 Bonn, Germany, Tel.: +49 228 985 30 0, www.empirica.com

Danish Technological Institute Center for Competence and IT Kongsvang Allé 29, Aarhus, Denmark, Tel.: +45 72201417, www.teknologisk.dk

Foundation for Research and Technology - Hellas Institute of Computer Science P.O. Box 1385, Heraklion, Crete, GR - 71110 Greece, Tel: +30-2810-391741, www.ics.forth.gr

Work Research Centre Ltd. 1 Greenlea Drive, Terenure, Dublin 6W, Ireland, Tel.: +353 1 492 7042, www.wrc-research.ie

University of British Columbia, Vancouver, BC, Canada #105 - 2194 Health Sciences Mall, Vancouver, B.C., Canada, Tel.: +1 6 04 6 39 46 68 www.cme.med.ubc.ca

National Research Council Canada, Saint John, New Brunswick 127 Carleton Street, Saint John, New Brunswick, Canada, E2L 2Z6, Tel: +1 5 06 6 35 06 33, www.iit-iti.nrc-cnrc.gc.ca

Notes About the Data Sources Used in This Document

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