System and Information Architecture: A view from Belgium

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1 1 Directorate-General for the Organization of Health Care Institutions System and Information Architecture: A view from Belgium 1st International Meeting on the Electronic Health Record Lisbon 26 November 2010 Luc Nicolas Health Telematics Unit

2 2 E-health: a project cycle?

3 3 Does it look like that?

4 4 Or rather like that? Wassily Kadinsky: Harmonie tranquille

5 5 E-health: a project cycle?

6 6 Key facts about the Belgian healthcare system: Healthcare Expenditure as % of GDP: 10.2% (OECD 2007) WHO Ranking of Healthcare systems: rank 21 Public sector healthcare expenditure as % of total healthcare expenditure: 75.1% (OECD 2007) Euro Health Consumer Index: rank 11 Belgians do have excellent access to healthcare services, and are one of the nations in Europe where patients have real freedom of choice where to seek care. However, medical results are not good enough to propel Belgium into the top 10 of Europe Dr. Arne Björnberg Euro Health Consumer Index Director

7 7 Organisation: Political/administrative unit responsible for primary healthcare Consumer Choice Financing Organisational and regulatory: the Federal Ministry of Health. Regarding preventive care (also part of primary care): the regional health authorities. Financially: the National Health Insurance Institute. Free choice and free access to primary care as well as to specialised and hospital care. There is a financial incentive to select one general practitioner as holder of your global medical record. Free compulsive social security system, mandatory to all inhabitants. Largely funded by contributions of the citizens with some taxed-based state contribution for the elderly and social vulnerable persons. Public or private providers Self employed primary care providers solely. No publicly employed primary care providers at all. Gatekeeping function of the GP Integrating health: initiatives for coordination Free access to specialists and hospitals. Limited financial incentive for the patient when referred to the specialist. Public hospitals (large minority) are financially supported by the local authorities of patient's residence. Deficits of those hospitals are covered by patient's local authorities. Limited initiatives for local coordination between primary care and hospital care.

8 Total healthcare spent per capita

9 Number of physicians

10 10

11 11 DATA DIGITALIZATION % Digitalized Data in General Hospitals (2008) General Hospitals «Paperfull» More than 50% of Belgian Hospitals less than 50% digitalized data

12 12 PROBLEM DEFINITION

13 : All started with a recommendation

14

15 15 The legacy Content (Ambulatory care) Network (Hospitals) Communication and Incentives Incentive of 800 /Y for each HCP using a labelled EHR: 20 millions + /Y

16 16 ACTH + ALTEM + ANATEM + MEDITEL + UMT + (ATMB)

17 17 E-Gov

18 INFRASTRUCTURE TOP DOWN NETWORKS PUSH PULL Central DATA BANKS SERVICES BOTTOM UP INFOSTRUCTURE

19 19 KEY PRINCIPLES : How to create «trust» Subsidiarity : Investment should take place at the most appropriate level giving priority to users needs, perceptions and cost-efficiency. Mutualisation : Available ressources are pooled together and distributed according to needs under the control of an agreed governance process. Transparency : All information is available and transparent for all. Decisions are always documented. Ownership: Health profesionals (and GPs in particular) are highly involved at all stages and own the system..

20 : Change of strategy SHIFTING TOWARDS A system to system policy -Centralised EHR versus federated EHR? -> Web services -Patient ID: Unique or different? -Security and legal certainty. S3 (Serveur des Soins de santé) is «given» as «food for thought» to local telematics associations.

21 2008 : CREATION OF THE EHEALTH PLATFORM

22 22 PRINCIPLES ADOPTED at FEDERAL LEVEL No central storage of personal healthcare data: Exchange from system to system is the main rule. Only central location service (with patient consent). Unrestricted application of law (privacy, secrecy, patients rights, free choice) with Special attention to information security and privacy protection Respect for and support of * existing local or regional initiatives * private initiatives regarding electronic service to healthcare actors Use of the ehealth platform is optional, not mandatory Platform is managed by the representatives of the various healthcare actors Federating rules (Consent, exclusions, therapeutic relationship )

23 23 Users Basic Architecture Patients, healthcare providers Health Portal VAS VAS VAS VAS RIZIV-INAMI site VAS VAS VAS VAS and institutions ehealth platform Portal MyCareNet VAS VAS VAS VAS Healthcare institution software VAS VAS VAS VAS Care provider software VAS VAS VAS VAS Network Basic services ehealth platform ADS ADS ADS ADS ADS ADS Suppliers

24 24 E_Health platform: Basic Services operational Coordination of electronic processes Web portal ( Integrated user and access management Logging management System for end-to-end encryption for communication of data to a recipient known at the time of the encryption for communication of data to a recipient not known at the time of the encryption Personal electronic mailbox for each healthcare supplier with limited features Electronic time stamping Coding and anonymisation Reference directory (meta-hub)

25 Authentic Data Sources NATIONAL REGISTER and SOCIAL SECURITY REGISTERS CADASTER OF HEALTH PROFESSIONALS (Including agreement attributes) MANDATES DATA SOURCE HOSPITALS PHARMACEUTICAL PRODUCTS PATIENT RIGHTS (Health Insurance) BEST PRACTICES

26 ADS Proposed evolution

27 27 Exchange of patient data: now Remote files unknown

28 28 Exchange of patient data: Coming soon A 4: All data available Meta- Hub B C

29 29 25/6/

30 What? : INTERREG IV STRAND A The Euregio Meuse-Rhin platform Creation of areas of access organised for cross border health care Interhospital co-operation agreements Evaluation of the cover for the elderly Emergency services cross border Franco-Belgian Health Observatory Accessibility to information for patients and professionals via a website

31 INTERREG IV - STRAND A Cross Border co-operation Eligible regions

32 FRATEM & RSW : Looking back and forward SPF SANTE PUBLIQUE, SECURITE DE LA CHAINE ALIMENTAIRE ET ENVIRONNEMENT 32

33 : 5 «Informal» associations Coming From. 2000: 5 associations with non profit status. More «Global» and local-regional platform Enlarging to other (Non Hospital based ) stakeholders A shared secured internet messaging system Development costs Better levergae with industry Forum of exchange: Health telematics Formal status for legal and contracting certainty and visibility. CREDO: ANSWERING TO NEEDS IN A LOCAL CONTEXT, with LOCAL ACTORS in a shared common history.

34 : Federating to create an operational regional network.

35 35 7 YEARS PLAN 6 WORK GROUPS INVOLVING 100 STAKEHOLDERS: Creating trust Problem definition Agenda Policy adoption Implementation 2006: Technical and functional specifications approved 3 phases Creation of FRATEM asbl Pooled resources: /Y/Hosp Federal and regional limited support Basic federal services Authentic sources Privacy security Certification of systems Roll out : Opt in

36 36 IMPORTANT MILESTONES: February 2009 Privacy agreement approved by the National Order of Doctors. ->Establishment of surveillance and piloting comitees. 2010: External audit of security system: bluecrypt Creation of a function of mediator. Full opt in both for patients and health professionals. Designing a specific but phased integrated plan for integration of primary care actors with support of all circles of general parctice: -> Smooth links with Industry (Co-Gen: plug-in) -> Gradual Development of specific platform. DUPLICATION and FERTILISATION Helping other networks to be set up (Brussels) Helping to establish common rules and norms (With E-Health platform). Integrating the meta-hub in the picture Developing new functionalities (PACS,..)

37 37 Where are we now? Architecture based on Mutual Trust and web-services but.need of flexibility. Different standard used within hub(kmehr web-sevrices/ihe) Key services such as E-Prescription also developed with stakeholders. Limited Inclusion of «other stakeholders» (Nurses, kines, social workers) Discussion on patient access to data only starting. Co-existence of «shared EHR» under «Hub coverage». Encouraging industry to invest in web-based applications for individual HCP Different visions co-exist for ambulatory care platforms (HUBS_-Central regional- Per HCP- Private)-> Need for stocking validation criteria).

38 And.MOBILITY! Not later Now. -> Keep it simple first (and even after). -> Push Industry to adapt! -> Integrate with users (other) needs.

39 39 Where are we now? Federal strategy: -> Focusing on essentials (basic services, norms-rules-law and DB) and administrative simplification. -> Defining Semantic interoperability strategy. -> Looking at PET -> Integrating EPSOS -> Seeking cost-efficiency (No duplication of investment). -> Pushing innovative models (eg: Home hospitalisation). Need to be adressed asap: Training strategy. Global Evaluation strategy. Funding: Looking for overall «routine financing plan» (Stop ad hoc financing). Towards «Meaningfull Use»? Link with reimbursement?

40 TIME FOR MEDICAL (SMOOTH -CULTURAL) REVOLUTION? 简 单

41 The medical terminology revolution 3000 IDEOGRAMS: YOU READ A PAPER IDEOGRAMS: YOU READ A BOOK concepts: You deal with 85%+ of diagnostics and symptoms concepts: You deal with 90% of diagnostic, symptoms and interventions

42 Medical semantic interoperability Clinical expressions Highest granularity Data entry Fast Intuitive

43 Medical semantic interoperability Terminology server Controlled Medical Vocabulary Link to classifications, languages Intuitive data entry Context sensitive pick lists Syntactic search Semantic search (NLP) Webservice, API Enabler, alerter Rules vs Patient Record

44 Semantic search SPF SANTE PUBLIQUE, SECURITE DE LA CHAINE ALIMENTAIRE ET ENVIRONNEMENT text typed by doctor/nurse Natural Language Processor Terms CMV

45 Start up Belgian CMV Terminology Dutch, French Link Snomed, ICD-9-CM, ICD-10 (CM?), ICPC, LOINC, ICNP Snomed CT Cross maps Translation Ontology

46 Terminology management system Terms Speech communities Relationships Classifications Pick lists Work flow, clinical pathways Rules Webservice, API Local applications Enabler, Alerter

47 Terminology management system Import existing tables and updates Updates classifications and links Snomed? ICD-9-CM Management update requests New terms Edit, archive

48 Terminology management system Web based Shared Ownership National Regional Local

49

50 TIME LINE: From Now to 120,00% 100,00% 80,00% 60,00% 40,00% 20,00% 0,00% HUBS "life" Sumehr E-prescription EHR (% diagnoctic coded)) PHR (patient access) E-HOSP Min criteria

51 A few lessons learnt - Think global- Think E-Gov! - Make it generic: Reuse and adapt! - Do not get married with one (specific) technology - Invest in empowering PEOPLE who will help to establish trust in the system. - Provide universal key basic services - Invest in early stage in SOURCES (Collaborative) - Flexible Support to development of services - Select carefully use cases and targets (thin analysis of users profile). - Requestioning subsidiarity (EU) - Humans will remain humans: Do not change them into machines!

52 «PEOPLE DON T REACT TO REALITY THEY REACT TO THEIR PERCEPTIONS OF REALITY»

53 53 Thanks for your kind attention! Useful links:

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