Architecture for Digital Government: A Single Patient Record or a Unified Citizen Record?
Debating the different models for storing citizen records, that utilize a decentralized vs a centralized approach.
In the digital age, governments worldwide are grappling with an unprecedented challenge: how to effectively manage the vast and growing troves of citizen data.
From healthcare to taxation, social services to law enforcement, the information collected about individuals is scattered across multiple systems and domains, often siloed, fragmented, and inefficiently utilized.
Two competing visions have emerged to address this issue: the Single Patient Record (SPR), primarily focused on consolidating healthcare data, and the Unified Citizen Record (UCR), an ambitious proposal to integrate all citizen data into a single, comprehensive profile.
Each approach raises profound questions about privacy, efficiency, security, and the role of government in the lives of its citizens. Which path forward best balances the needs of individuals and the state?
The Case for a Single Patient Record
The Single Patient Record is a concept born out of the healthcare sector’s need for interoperability. Healthcare systems often rely on disparate databases—hospitals, clinics, pharmacies, and insurers each maintain their own records, leading to inefficiencies, errors, and delays in care. An SPR aims to consolidate all health-related data for an individual—medical history, prescriptions, test results, and more—into a single, accessible record.
The benefits are clear. A unified health record could streamline care delivery, reduce redundant tests, and improve patient outcomes. For example, during an emergency, a doctor with instant access to a patient’s full medical history could make faster, more informed decisions. Studies estimate that interoperable health records could save billions annually by reducing administrative costs and medical errors. Countries like Estonia have already implemented elements of this model, with their e-Health system allowing citizens to access their medical data through a secure digital identity.
However, the SPR is inherently limited in scope. It addresses only one domain—healthcare—while ignoring the broader spectrum of citizen interactions with the state. A myopic focus on healthcare data risks perpetuating the same siloed approach governments are trying to move away from.
Moreover, even within healthcare, challenges abound: ensuring data security, standardizing formats across jurisdictions, and protecting patient privacy are no small feats. High-profile data breaches, like the 2017 Equifax hack or the 2021 Irish Health Service Executive ransomware attack, underscore the risks of centralized systems. If a single breach could expose sensitive medical data, public trust in such systems could erode quickly.
Challenges and Issues
The challenges with this approach are described in this article and this webinar, by Joe McDonald.
In his article, Professor Joe McDonald, a former NHS consultant psychiatrist and founder of the Great North Care Record, argues that the push for a Single Patient Record (SPR) in the NHS is misguided and likely to fail due to its scale and complexity.
He suggests that the focus on creating a centralized record overlooks the real issue: integration of existing digitized records. McDonald points out that most NHS records are already digital, and the challenge lies in enabling seamless data sharing across organizations.
He highlights successful examples, like Shropshire Community Health Trust and Midlands Partnership University Trust, which use intelligent care platforms to integrate critical information from separate systems, allowing hospital and community staff to access vital data. McDonald advocates for a “Neighbourhood Integrated Care System” to advance shared care records, emphasizing interoperability over a monolithic SPR.
He critiques the NHS’s lack of institutional memory in policy decisions, which contributes to repeated failures in large-scale IT projects. Commenters agree, noting that poor data quality and lack of understanding from project leaders could doom even integrated systems if underlying issues persist.
The Vision of a Unified Citizen Record
Enter the Unified Citizen Record, a far more ambitious proposition.
A Unified Citizen Record (UCR) could revolutionize how governments manage citizen data by integrating information across domains like health, taxes, and social services. A decentralized model using digital wallets offers a citizen-centric alternative to centralized systems, balancing efficiency with privacy.
Instead of a single government database, data is distributed across secure nodes, with individuals controlling access through digital wallets—secure applications storing cryptographic credentials like digital IDs or verified attributes. Citizens can selectively share data, such as tax records for benefits or medical history for healthcare, using technologies like zero-knowledge proofs to reveal only what’s necessary without exposing their entire profile.
Writing on Linkedin Frank Macha explores this scenario, an approach that leverages blockchain or distributed ledger technology to ensure data integrity and auditability, as seen in Estonia’s KSI Blockchain for e-governance. Decentralized Identifiers (DIDs) enable pseudonymous interactions, while standards like W3C’s Verifiable Credentials ensure interoperability across systems.
Digital wallets, similar to those used for cryptocurrency, empower citizens to manage their data, reducing risks of mass breaches or surveillance inherent in centralized systems. For example, India’s Aadhaar could evolve toward decentralization, letting citizens control access to their biometric data.
The benefits are significant: enhanced privacy through user control, improved security by eliminating single points of failure, and streamlined services as agencies access verified data instantly.
However, challenges include technical complexity in integrating legacy systems, the digital divide excluding those without smartphones or literacy, and the need for robust governance to prevent fraud. Legal frameworks must evolve to ensure consent and data minimization, aligning with regulations like GDPR.
A phased approach—starting with pilot programs in healthcare, fostering public-private partnerships, and prioritizing citizen education—can pave the way. By embracing global standards and inclusive design, a decentralized UCR via digital wallets could redefine trust, offering a secure, equitable way to manage citizen data in the digital age.
