5. Oulu’s Self Care Service, Finland

In 2011, the City of Oulu, Finland, scaled-up its digital patient-provider portal – the Self Care Service (SCS) – to all residents. This section details SCS’s objectives, services, access and partnering organisation.

SCS’s objectives are four-fold and in general aim to address the challenges caused by an ageing population and rising rates of multimorbidity:

  • Improve access to healthcare services through digital means

  • Improve patient outcomes and safety by encouraging people to take care of their health, enhancing patient safety, and enabling the City of Oulu’s chronic care model

  • Empower people to take care of their own health thereby improving disease prevention and chronic disease management

  • Reduce pressure on healthcare services by a) allowing patients to handle tasks independently thereby freeing up primary care professional resources and b) improving access to primary care thereby reducing demand on secondary/tertiary services.

SCS is a voluntary digital patient-provider portal focused on primary care and to a lesser extent social care. SCS has three interfaces: 1) a citizen interface; 2) a primary care professional interface (for general practitioners (GPs) and nurses); and 3) maintenance interface (Lupiañez-Villanueva, Sachinopoulou and Thebe, 2015[1]). SCS services offered as part of the citizen interface are detailed in Box 5.1.

With the patient’s consent, data collected through the citizen interface is linked to information within national EHRs, which are widely used across Finland. This ensures primary care professionals have ready access to all patient data. Patients can separately access their EHR via a national website (omakanta.fi).

The primary care professional interface connects professionals with patients. It provides professionals with tailored guidelines and care pathways based on individual patient information such as laboratory results. Further, primary care professionals can use the interface to contact social care when a patient has need of their services (Lupiañez-Villanueva, Sachinopoulou and Thebe, 2015[1]).

SCS is a public private partnership between the City of Oulu and CSAM, an eHealth company targeting Nordic countries. Specifically, SCS utilises CSAM S7 technology (for further details, see the following link: https://www.csamhealth.com/solutions/connected-healthcare/csam-s7/).

This section analyses Oulu’s SCS against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence-base and Extent of coverage (see Box 5.2 for a high-level assessment of SCS). Further details on the OECD Framework can be found in Annex A.

The objectives of Oulu’s SCS are to 1) improve access to healthcare, 2) improve patient outcomes and safety, 3) empower people and 4) reduce pressure on healthcare services. The remainder of this section explores SCS’s performance against the first three objectives, while objective 4 is explored under “Efficiency”.

Between 2012 and 2020, the number of SCS users increased from 21 252 to 71 157 (a 235% increase) (Figure 5.1). (Details on the breakdown of SCS users – e.g. by gender and age – are explored under the criterion “Extent of Coverage”). The average number of logins per user also increased from 5.6 logins per year to 10 over the same period.

Other findings related to healthcare access from SCS patients are summarised below:

  • COVID-19 tests: between August 2020 and March 2021, 61 843 COVID-19 test results were uploaded onto SCS

  • Messages to health professionals: since 2012, health professionals have received over 400 000 messages through the portal. Patients who use the messaging feature, on average, send between 1-3 messages per year.

  • ePrescriptions: over 18 000 prescriptions were renewed online between 2012 and 2016. In 2017, Kanta, the national digital service for health and social care, overtook responsibility for this service.

Data from SCS and national EHRs can be linked, therefore, it is possible for future studies to assess what impact SCS has on health outcomes and health expenditure. Given this information is not readily available, the following paragraph summarises the literature on the impact patient-provider portals have on psychological, behavioural and clinical outcomes.

In 2019, Han et al. (2019[3]) published results from a systematic review on the impact of patient portals on psychological, behavioural and clinical outcomes. Findings from the review concluded patient portals have a significant, positive impact on medication adherence and access to preventative services (e.g. papsmear tests and cervical cancer screening). On patient safety, there is moderate quality evidence indicating portals improve safety by allowing patients to request correction of errors, in particular, medication errors (Antonio, Petrovskaya and Lau, 2020[4]). Conversely, the impact of patient portals on psychological outcomes (e.g. healthy eating) and clinical outcomes (e.g. blood pressure, glycemic, cholesterol and weight control) is mixed. Regarding clinical outcomes, findings from Han et al. (2019[3]) align with recent systematic and umbrella reviews which conclude there is insufficient or low-strength evidence to support the positive impact of patient portals on clinical outcomes (Ammenwerth et al., 2019[2]; Antonio, Petrovskaya and Lau, 2020[4]).

Patient portals play a key role in delivering patient-centred care as they allow users to engage in shared decision-making and encourage patient self-management. Information on patient empowerment and Oulu’s SCS is not available. In the broader literature, there is evidence supporting the hypothesis that patient portals “empower patients in shared decision making” and “encourage engagement in self-care and self-management” (Antonio, Petrovskaya and Lau, 2020[4]).

An analysis undertaken by SCS administrators estimated that between 2012 and 2016, the service led to cost savings of EUR 5.12 million. The calculation is based on the assumption that SCS reduces the time taken to deliver services and that each minute saved reduces costs by EUR 0.5.

Evidence on patient portal efficiency gains within the broader literature are summarised in Box 5.3.

Oulu is available free of charge to all citizens of Oulu who have access to the internet and a bank account or mobile phone. By not charging a fee, individuals from lower socio-economic status backgrounds are more likely to access the service. SCS also takes into account the needs of certain disadvantaged groups by providing services in a format that enhances usability for those with a disability. For example, the video platform has an easy to use function for people with chronic illnesses or a disability.

SCS is currently available in Finnish, the official language of the country, however, there are plans to expand to other languages, namely English, Arabic, Dari and Somali.

Despite processes to ensure disadvantaged population groups have access to SCS, like any digital health intervention, there is a risk that groups with the greatest need for the service have the lowest level of access. An umbrella review of patient portals in 2020 found patient portal users were more likely to have a higher income and education level, similarly those with lower health literacy and numeracy skills were less likely to be portal users (Antonio, Petrovskaya and Lau, 2020[4]). These findings align with OECD data for Finland which showed that 86% of people in the highest income quartile had used the internet to search for health related information in the past three months compared to 65% in the lowest income quartile (nevertheless, both of these figures are markedly higher than the EU average of 63% and 45%, respectively).

As outlined under the “Intervention description”, SCS has four key objectives. Evidence from SCS is available for two of these objectives – “improve access” and “reduce pressure on healthcare services”. For the remaining two objectives – “improve patient outcomes and safety” and “empower people” – evidence was drawn from the broader literature on patient-provider portals.

The evidence-based criterion explores the quality of evidence used for each of these objectives, which includes systematic and umbrella reviews (see Box 5.4). For this reason, the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project was not used as it is more suitable when assessing singular studies.

The proportion of eligible Oulu citizens who logged into SCS has grown markedly since 2012 – from 11% to 34% (Figure 5.2). This is higher than the mean adoption rate of 23% estimated within a 2017 systematic review and meta-analysis of patient portals (Fraccaro et al., 2017[7]).

The majority of SCS users are women (60%), further a significant proportion are aged 65 years and over (22%) (Figure 5.3). Given people aged 65 years and over in Oulu comprise 16% of the population, these results indicate the older population are comfortable using digital technology to access healthcare (Statistics Finland, 2020[9]).

Finland has prioritised building a digitally literate health workforce. Digital health literacy is a core competency for health professionals working in Finland. For example, every university in Finland plans to provide nurses and medical students with streamlined digital health education – MEDigi. The aim of MEDigi is to harmonise and digitise national teaching to ensure medical graduates have the appropriate digital skills. Results from a recent eHealth survey in Europe reflect this commitment with Finland recording the third highest eHealth adoption rate amongst GPs (European Commission, 2018[10]).1

A digitally literate health workforce has led to a high uptake of SCS amongst professionals. As of 2020, over 600 primary care professionals use SCS,2 most of which are either doctors or nurses. Between 2012 and 2020, the number doctors and nurses registered with SCS increased by 173% and 62%, respectively.

Successful patient-provider portals are integrated with patient data (e.g. EHRs), provide clinical decision support tools, and offer secure messaging and ePrescriptions, all of which are features of Oulu’s SCS (Shaw, Hines and Kielly-Carroll, 2018[11]). Nevertheless, policy options to enhance the performance of Oulu’s SCS are available to SCS administrators and policy makers.

Higher levels of population health and digital health literacy (HL) will help SCS achieve its objectives. HL refers to an “individual’s knowledge, motivation and skills to access, understand, evaluate and apply health information” (OECD, 2018[12]). When people are health literate they are more likely to act on health information they receive, take greater responsibility for their own health, as well as engage in shared decision-making. Several interventions to boost HL levels exist in Finland including health education courses taught in schools, as well courses that teach participants basic skills on how to manage challenges associated with poor health (Evivo international programme) (OECD, 2018[12]). Relevant policy makers should continue efforts to boost HL drawing upon OECD’s four-pronged policy approach (see Box 5.5).

Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore, policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.

Execute plans to increase the number of languages available on SCS. In the City of Oulu, the proportion of people speaking a foreign language grew by 3.2 percentage points between 2000 and 2019 (1.2% to 4.4%) (Statistics Finland, 2019[13]). To ensure SCS is accessible by all residents, plans to expand the number of languages available on the service are encouraged – i.e. Arabic, Dari and Somali. These languages are frequently spoken by refugees (e.g. from Afghanistan and Somalia) who typically experience worse health outcomes and therefore have the most to gain from better access to care.

Support adoption of SCS among disadvantaged population groups. Certain disadvantaged population groups are less likely to access and therefore benefit from digital health interventions, such as patient-provider portals. Therefore, uptake of SCS among disadvantaged population groups should be a key priority. In Estonia, for example, patients with lower levels of digital literacy can receive training on how to use digital tools. Further, as part of its eHealth strategy, Estonia prioritises interventions that improve the skills needed to self-manage and self-educate using online solutions (OECD, 2019[14]).

Undertake an in-depth study into the impact of SCS on patient outcomes, and healthcare utilisation and costs. SCS is tethered to Finland’s national EHR, which is one of the most advanced among OECD and EU countries (Oderkirk, 2017[15]). Administrators of Oulu’s SCS are encouraged to capitalise on this advantage by evaluating the impact of SCS on healthcare outcomes and utilisation, and thus costs. Indicators of interest are summarised in Box 5.6, which could be compared between SCS users and non-users, for example, using propensity score matching (an econometric technique that creates an artificial control group by matching each SCS user with a non-user based on available characteristics).

Encourage health professionals to promote SCS to patients. There are high levels of public trust in the health workforce; therefore, health professionals can play an important role in boosting uptake of SCS amongst patients. A way of encouraging adoption of digital tools is to make them available in provider settings and have “professionals demonstrate and support their use” (OECD, 2019[14]).

Promote SCS using a targeted approach. The more useful an intervention is perceived to be, the higher the uptake. The usefulness of SCS will differ across population groups: for example, being able to upload medical information from home is of high use to multimorbid patients, but of less concern to younger populations who may perceive online appointment bookings as SCS’s key feature. For this reason, promotional activities should target different population groups.

Ensure SCS remains a trusted and non-burdensome tool for health professionals. Uptake of SCS among health professionals in Oulu is high. To maintain high levels of engagement, it is important that update and amendments to SCS (OECD, 2019[14]):

  • Are evidence-based in order to maintain trust among health professionals and patients

  • Include input and feedback from health professionals and patients, who are the end-users

  • Do not negatively affect usability and continue to be integrated into current practice (i.e. the portal does not increase the workload of health professionals).

    Improve access to children and teenagers. As specified by Oulu SCS administrators, better access for children and teenagers is needed – i.e. either with direct access or via their parents. This requires an update to current legislation and technical solutions to ensure privacy and safe access.

    Boost population HL so that patients understand information presented and thus the usefulness of the service. Policy options to enhance HL are explored under “Enhancing effectiveness”.

This section explores the transferability of SCS and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publicly available data; and 3) additional considerations for policy makers interested in transferring SCS.

Oulu’s SCS originally started as a pilot programme at one of Oulu’s technology health centre in 2008. Following the success of the pilot, the programme was scaled-up across the whole of Oulu in 2011 and later transferred to the municipalities of Oulunkaari and Raahe (with some necessary adaptions).

SCS has not been transferred to another country, however, patient portals are common in OECD and EU countries – for example, based on a 2016 EHR survey, 12 (out of 15) OECD countries reported they have or are in the process of implementing an ICT system that gives people access to their own health data (OECD, 2019[14]).

The following section outlines the methodological framework to assess transferability and results from the assessment.

Details on the methodological framework to assess transferability can be found in Annex A.

Several indicators to assess the transferability of SCS were identified (see Table 5.1). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data.

The majority of countries with available data have developed a national eHealth policy and/or a national health information system policy indicating there is political support for digital health interventions, such as patient-provider portals (see Table 5.2). These policies are supported by government funding with 26 out of 35 countries (with available data) stating a “very high” (>75%) proportion of funding for eHealth comes from public sources.

Implementing a patient-provider portal, however, may require additional resources (time, financial, expertise) when compared to Finland, given the country is a digital health leader. For example:

  • Finland recorded the highest proportion of people seeking healthcare online (76% versus the OECD/EU average of 54%) and the second highest eHealth adoption rate amongst GPs (2.64 composite score compared to the 2.1 average amongst European countries with available data)

  • Between 25-50% of tertiary institutions and associations offer health professionals ICT training, both during training and as part of continuing education (i.e. a “Medium” proportion of institutions)

  • 100% of primary care physician offices use electronic healthcare records compared to an average of 79% among countries with available data

  • Finland has an ICT development index value of 8.1, which was one of the highest amongst examined countries.

Results from the transferability assessment indicate Nordic countries such as Denmark, Iceland and Sweden are suitable candidates for this intervention. This finding aligns with feedback from Oulu SCS administrators who stated that “Nordic Countries, most of which follow similar social and health strategies and have similar infrastructure and population characteristics (web use, technologically-experienced users even in older age groups) would be good candidates for adopting such a service” (Lupiañez-Villanueva, Sachinopoulou and Thebe, 2015[1]).

To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 5.1. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.

Key findings from each of the clusters are below with further details in Figure 5.4 and Table 5.3:

  • Countries in cluster one have population, political, and economic arrangements in place to transfer Oulu’s SCS, and are therefore good transfer candidates. Finland, which operates SCS, falls into this cluster.

  • A high proportion of funding for eHealth programs comes from the government for countries in cluster two, indicating SCS is likely to be affordable in the long-run. Further, these countries have sector specific arrangements in place that support SCS such as a digitally health literate workforce. However, prior to transferring SCS, these countries should undertake further analysis to ensure SCS aligns with overarching political priorities, which is necessary for long-term sustainability.

  • Countries in cluster are encouraged to undertake further analysis to ensure the right conditions are in place to support the transfer of SCS, in particular, to ensure the intervention is affordable in the long term.

Data from publicly available dataset is not sufficient to assess the transferability of Oulu’s SCS. Therefore, Box 5.7 outlines several new indicators policy makers should consider before transferring SCS (or a similar patient-provider portal).

SCS services are available 24/7 and3 free-of-charge to the residents of Oulu. To access SCS via a computer or mobile, users can login with their bank account details or a mobile code. Primary care professionals can access the SCS system by signing in using their organisation’s patient record system or via their ID card. Similar to citizens, primary care professionals are not obliged to use SCS as part of their service.

SCS is a patient-provider portal designed to improve primary care. In 2011, the City of Oulu, Finland, expanded its patient-provider portal, SCS, to all residents. SCS is a tool used in primary care, which offers patients a range of online services such as online appointments, ePrescriptions, and messaging with health professionals. SCS provides primary care professionals with tailored guidelines and care pathways based on patient data obtained from their EHR, which is tethered to the portal. The objectives of SCS are to improve access to care; improve patient outcomes, safety and empowerment; and reduce pressure on the health system.

SCS improves access to care and is estimated to have reduced costs by over EUR 5 million. Between 2012 and 2020, the number of SCS users increased by 235%, with the average person logging into the service 10 times per year. Over the same period, users have sent over 400 000 messages to health professionals and received over 18 000 online prescriptions. SCS proved to be a key resource during the COVID-19 pandemic, with over 60 000 test results uploaded to the system (as of March 2021). Over years 2012-16, SCS is estimated to have saved EUR 5.12 million based on the assumption that SCS reduces the time taken to deliver services.

The design of SCS considers the needs of disadvantaged population groups, yet access barriers remain. SCS is available free-of-charge to residents of Oulu thereby improving access to individuals with a low SES. Further, SCS includes design features that improve usability for people with a disability. Nonetheless, like all digital health interventions, those most in need may experience access barriers, for example, due poor internet access.

Over one-third of the Oulu’s population access SCS. Thirty-four percent of Oulu residents use SCS, which is above the mean patient portal adoption rate of 23% estimated in a recent systematic review and meta-analysis. For this reason, SCS performs particularly well against the “Extent of coverage” best practice criterion. Adoption is also high amongst health professionals, which is attributable to the country’s focus on building a digitally literate health workforce.

SCS is a global leader in the area of patient portals, yet there are opportunities to enhance its performance. To enhance effectiveness, boosting levels of population HL and digital HL will help patients better understand the information uploaded to SCS, act on that information and take greater responsibility for their own health. To reduce health inequalities, SCS administrators should prioritise plans to expand the number of languages available, in particular those spoken by refugees in the country. To enhance the evidence base, researchers should take advantage of Finland’s rich data source and evaluate the impact of SCS on patient outcomes and utilisation of healthcare services. To enhance the extent of coverage, several options are available including efforts to encourage professionals to promote SCS to their patients.

Results from the transferability assessment indicate Nordic countries are suitable candidates for SCS. Based on publicly available indicators, countries most suited to transfer SCS (or a similar patient portal) are located in Europe’s Nordic region. Nonetheless, there is clear political will to implement patient portals as evidenced by a recent OECD survey showing 80% of countries have or have plans to make individual patient data available via a portal.

Next steps for policy makers and funding agencies interested in SCS are provided in Box 5.8.


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← 1. eHealth adoption was measured using a composite indicator reflecting use of electronic health records, telehealth, personal health records and health information exchange.

← 2. In addition to digital health literacy training provided to all health professionals in Finland, those working in the City of Oulu receive 1 to 2 hour training session on how to use SCS.

← 3. Online interaction with primary care professionals is only available during office hours.

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