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uilt, which data will be available in the digital files,who will have access to what data, what policiesand procedures are governing the privacy and securityof the information, and how to ensure that thisinformation will not be used for surveillance andother private purposes. It is also necessary to definethe mechanisms of public oversight to ensureprocesses and agreements on the management ofthe information are implemented properly.With the understanding that this is a highlytechnical process, both from the information technologyperspective and from a medical point ofview, citizen participation in building EDUS hasbeen absent so far. The process has been definedas a specialised health and computing process, notas a process that has to do with citizen information.The analysis of EDUS must be performed fromdifferent perspectives, which are interrelated andindivisible:From the perspective of the right to healthAs indicated in the bill, the implementation of EDUSis an essential condition to improve the exercise ofthe right to health in Costa Rica:The application of this technology in the CCSSaims to reduce waiting lists in health care services,improve the quality of care and eliminateduplication of administrative procedures relatedto the data of the insured…The current fragmentation of health data canbe solved through the standardisation andintegration of information resulting from theintegration of programming languages, technologyplatforms and operating costs in a singlesystem. 3From discussions with stakeholders, several importantchallenges have been identified:• There is a great risk in seeing EDUS as the magicsolution to the fundamental problems of theCCSS. But as noted by the Comptroller Generalof the Republic, following the implementation ofthe information system, a complete reorganisationof the institution must be undertaken, sothat this public investment does not become anunnecessary expense.• There is resistance to change by a large groupof health care workers in general and doctors inparticular, who consider EDUS a system that canbe used to control their performance.3 Affirmative opinion prepared by the Commission on Science,Technology and Education of the Legislative Assembly (2010-2014),July 2011.• Cost and time represent a major risk to projectsuccess. Some of those consulted feel that thereis a lack of good analysis of what this means now,and what it will mean in the future for CCSS, andraise concerns that EDUS may unbalance CCSS’sbudget if a good projection is not made.• The success of EDUS will be determined byother national issues that are not under the controlof the CCSS, such as access to the internetthroughout the country.• The need to think about other models where theelectronic health record is administered by eachcitizen (as with personal bank accounts) hasbeen proposed.From the perspective of citizen oversightof the health care systemHaving a system such as EDUS would have a highvalue for the control and supervision of health services,as well as accountability and transparency inthe provision of universal service. A condition forthis to be possible is to have accessible, updatedand available information to enable citizens tolearn, evaluate and propose actions to strengthenthe universal health care system.At present there is no information on the functioningof the health care system available forpublic examination. Those interested in exercisingthis role as citizens must look at various files (oftenwith little information), request authorisationto access public information, and learn to analysecomplex and disconnected data.Until now, the development process of EDUShas not referred to the integration of informationmodules that allow citizen oversight. Civil societyhas not developed or proposed actions in thisregard and seems to be unaware of the positive impactthis can have on universal service and citizensurveillance.From the perspective of citizen surveillanceIn terms of citizen surveillance, it is important tomention that when the EDUS bill was discussed, theCommission on Technical Affairs of the LegislativeAssembly addressed the confidentiality of data forthe first time as a human rights issue that must beregulated. It indicated that the technological solutionchosen for the creation of the records shouldhave certain characteristics, including security:“The electronic record and the software solutionsthat interact with it must meet the criteria establishedfor this purpose in the scientific, ethical andadministrative technology field, in order to ensureintegrity, confidentiality and availability in the use,Table 1.Summary of discussions on EDUS with key stakeholdersRight to healthCitizen surveillanceProgressGreater control and monitoring of the provisionof health care servicesGreater efficiency in health care servicesWould strengthen universal serviceThere is a good data protection lawFavours an analysis of the health care system fordecision makingFacilitates accountability and transparencyRisksFacilitates the prioritisation of care according tohealth conditionsInformation should belong to the people, notthe health care system.To ensure universality it is essential thatall citizens have equal access to their electronicrecords, no matter where they aregeographically.Doctors are seeing electronic records as a wayto control their performance. There is resistanceto change.The financial cost of the project is very high andthe state does not have the resources to developit. It also has associated long-term coststhat are not contemplated.Implementation time is very short for the completesystem.Need for thorough reorganisation of CCSS.Technological solution is seen as the magicsolution.Source: Prepared by the authors.management, storage, maintenance and ownershipof the data included in the clinical record.” 4However, in conversations for the preparation ofthis report, the issue of data security from the pointof view of system functionality (user profiles relatedto access rights, for example) was emphasised, insteadof the issue of citizen surveillance, which isnot seen as an important issue in the developmentof EDUS. Nevertheless, you can think of citizen surveillancefrom two angles:4 Replacement text for Article 5 of the bill, proposed by theCommittee on Technical Issues of the Legislative Assembly, 2012.Allows greater control and oversight by citizensIt is an opportunity to have an open databaseavailable to the publicRegulation:Despite the good data protection law, the regulationsand accompanying implementation at national levelare weak.Technology policies, agreements and conditions forthe safeguarding of health data are unclear.There is no specific legal framework for healthrecords.Internal process:There are different views within the CCSS on what todo in terms of technological development in general,and specifically when it comes to EDUS.There is a need to update staff at CCSS on thegovernance of health technologies, security and dataprivacy, open government and citizen surveillance.Development process:The CCSS, which oversees the implementation ofEDUS, has emphasised the functional aspect of thesystem rather than the security and privacy of dataand the potential of citizens monitoring the data.Civil society, health actors and decision makers arenot informed about the development process of EDUS,nor have they discussed aspects of security, privacyand surveillance in these instances.• The provision of health data for surveillancefrom the private sector, whose interests are verydiverse, ranging from strengthening the privatehealth schemes that compete with universalpublic service, to designing advertising campaignsfor specific target audiences.• The availability of health data for surveillanceby the state, whose current and future interestsmay also be very different, starting with publicsafety to the repression of social and popularmovements.118 / Global Information Society Watch costa rica / 119