This study investigates the required implementation of the System of Choice in the Swedish County Council of Västerbotten. The System of Choice is a national law with the objective to improve efficiency within primary care in Sweden. This was done by opening the market for more competition and giving the citizens the right to choose where to seek care. The reform was a big change for the organisation of health provision, which had up until the reform been characterized by monopolistic behaviour by county councils as dominant firms. At the time of this study it had been three years since the beginning of Health Choice, which is the name for the reform in Västerbotten. The aim of this research was to find out if the way in which Västerbotten County Council has chosen to shape Health Choice has led to the fulfilment of the objective of increased competition and thus higher motivation to perform quality care. This has been done by examining the development of the Health Choice and its reimbursement system through the eyes of the primary care providers. The study has further looked at the reasons underlying the result and ways to improve it. This area is not new ground for research. The organisation of health care is a popular topic all over the world since the population is growing and becoming older, thus putting increased pressure on the provision of health care (WHO, 2010, p. VI). Research has however showed that the optimal organisation of a reimbursement system for the primary care largely depends upon local conditions (Anell, 2005, p. 61). Since there is little previous in-depth information about the outcome of the Health Choice, the approach of this study has been inductive. Due to this exploratory and explanatory nature of the study a qualitative approach was applied. The data-collection has been done through 14 semi-structured interviews of about an hour each. To be able to catch the effects of the reimbursement system 11 of the interviews were conducted with health centre directors, representing both private and public providers as well as the different regions within the county council. The three other interviews were held with representatives from the county council and the supporting department for the Primary Care Group. The interviews generated transcribed text of 250 pages. This material was sifted and processed using the template analysis approach. The result shows that the county council‟s attitude to the Health Choice has negatively affected how it has been implemented. Too little resources have been spent on the purchasing department that is responsible for the development of the Health Choice and its reimbursement system. These factors have led to an organisation of Health Choice that discourages private providers to enter the primary care market in Västerbotten and there has thus only been a small increase in competition. A complex system with low continuity, lack of information and focus on the wrong things have led to the value of the reimbursement system as a motivational tool for increasing cost effectiveness and quality of care to be low.

Telemedizin ist der Einsatz von Telekommunikation und Informatik, um medizinische Dienstleistungen zu erbringen oder zu unterstützen, wenn die Teilnehmer räumlich getrennt sind. Die einzelnen telemedizinischen Anwendungen sind im Vordringen begriffen. Telemedizin ist allerdings kein eigenes Fachgebiet, sondern eine Methode, herkömmliche medizinische Maßnahmen zu unterstützen und zu verbessern. Da die Teilnehmer telemedizinischer Anwendungen nicht am selben Ort und zur selben Zeit agieren müssen, ist Telemedizin prädestiniert für die Überwindung der Sektorierung des Gesundheitssystems. Telemedizin kann insbesondere Rationalisierungsreserven mobilisieren und medizinische Dienstleistungen effektiver und effizienter gestalten. Ungeachtet dessen gibt es fünf Problemfelder, die beobachtet und weiter entwickelt werden müssen, um Telemedizin auch für die Zukunft möglich zu machen: Die unterschiedlichen Kommunikationsstandards müssen harmonisiert werden, damit der Datenfluß zwischen den Teilnehmer optimiert werden kann. Krankenkassen und Leistungserbringer müssen gemeinsam eine solide Basis für die Finanzierung derjenigen telemedizinischen Dienstleistungen etablieren, die dem Stand der wissenschaftlichen Erkenntnis entsprechen. Telemedizin mit Auslandsbeteiligung zieht in der Regel haftungsrechtliche Kollisionen nach sich, die von den Teilnehmern durch eine Rechtswahl- und eine Gerichsstandsvereinbarung vermieden werden können. Die sozialrechtlichen Möglichkeiten, insbesondere solche, Praxisnetze zu bilden, müssen noch in Einklang mit den berufsrechtlichen Vorgaben gebracht werden, da diese einer überörtlichen Leistungserbringergemeinschaft und einer entsprechenden Information des Patienten zum Teil noch im Weg stehen.Die durch die Telemedizin neu entstehenden Möglichkeiten der Kommunikation müssen durch zusätzliche Maßnahmen für Datenschutz und Datensicherheit flankiert werden. Insbesondere bei Datenübertragungen ins Ausland sollten sich die Teilnehmer durch eine gesonderte Einwilligung des Patienten in diesen Datenfluß absichern. / Telemedicine is the use of information and telecommunication technologies to provide and support health care when distance separates the participants. The single uses of telemedicine are growing in quality and quantity. Telemedicine, however, is not a medical field of its own, but a tool that can be used in most fields of medicine to enhance and support communication procedures. Since the participants must not act at the same time and at the same venue, telemedicine is bound to overcome the sectoral boundaries in a health system, which is separated in an outpatient and an inpatient world. Telemedicine can help to mobilise the health systems rationalisation potential and make procedures more effective and more efficient. There still are five tasks that have to be observed and to be solved, to make telemedicine possible in the future: Harmonisation of communicational standards must progress to optimise communication between the participants. Health insurance funds and medical persons must cooperate to insure a solid basis of financing for telemedicinal procedures that are state of the art. Participants of cross-border telemedicine must be aware of colliding laws and are well advised to agree upon the law to be applied and the court in charge. The professional law for doctors in Germany must be reconciled with the managed care concepts of practice networks that are legally permissible in terms of social law. Data protection and data security must be ensured under the new conditions of telemedicine. Especially cross-border data flow should be based on the informed consent of the patient involved