Electronic medical records Country: France Partner Institute: Institut de Recherche et Documentation en Economie de la Santé (IRDES), Paris Survey no: (8)2006 Author(s): Chantal Cases, Philippe Le Fur Health Policy Issues: New Technology Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract As part of its latest reform package, the current government aims to introduce electronic medical records for patients. The objective is to improve the co-ordination and quality of care and to better use health care resources. But the implementation seems to be more challenging than expected. 2. Purpose of health policy or idea Better co-ordination of care One of the major objectives of the Health Insurance Reform Act passed in August 2004 is to rationalise health care consumption through a better co-ordination of care (see "sickness fund reform, survey no (5) 2005). In particular, to keep the same level of reimbursement as before, the patients have to choose a "preferred doctor" (médecin traitant) and to accept to be referred by him/her for any specialist care. In parallel, the reform requires the introduction of electronic personal medical records (dossier médical personnel, DMP) in order to keep track of all patient contacts with the health care system. The DMP will include medical data both from health professionals and hospitals and will be accessible through the internet. The electronic files will be hosted by selected internet providers approved by the government. Patients control medical records The patients will have entire control over their personal medical records. They will be able to add/change some personal information and decide who is authorised to have access to their medical record. Moreover, patients will have the right to withhold some medical information from certain health professionals if they wish. For example, a patient could decide to hide that s/he has cancer from his/her dentist, so when the dentist enters into his/her medical file this information would not appear on the record without him realising that there is some hidden information. There will be two keys to access to electronic medical records: a new electronic health insurance card (VITALE 2), which should be implemented between 2006 and 2010, and an e-card for health professionals to use jointly. Since 1998, a personal e-card - the card VITALE - has been introduced in France for all insured persons over 16 years. Currently the card Vitale contains only identity information for the insured person, and eventually for his/her children under 16, and is used to facilitate the reimbursement of care by reducing paper work. Health professionals and pharmacists use this card to transmit medical bills directly to the health insurance funds. At the moment about - 1 -
85% of the general practitioners and almost all of the pharmacies use the card Vitale for transmitting electronic reimbursement forms. The new card, Vitale 2, is designed to contain medical information (e.g. diagnoses, medication prescribed, allergies, etc.). The content of medical information to be shared will be defined by a decree after the French data protection watchdog, the Commission nationale informatique et libertés (CNIL) has agreed on it. The data will be stocked in a 32KB chip (4KB for VITALE 1), and the card will contain a photo of the insured person in order to avoid frauds. The data security will be improved as it could be used for electronic signature. Main objectives The main goals of this policy are: to ensure a better coordination and continuity of care ; to improve care quality and safety by preventing inappropriate care; to simplify information sharing between patients and health professionals while respecting the rules of medical confidentiality; to spend less money and to better allocate resources by avoiding unnecessary examinations or procedures. Type of incentives As the philosophy of the health insurance reform is to rely on financial incentives and consumer choice, the use of medical electronic records will be optional, but better reimbursement will be ensured if the patient accepts using the medical record. The level of co-payment for those who refuse to use medical records is not defined yet. Health professionals on the other hand will have to use electronic records in order to keep their agreement with the statutory health insurance fund. Groups affected Patients, health care providers (ambulatory doctors, hospitals, laboratories, etc), health insurers 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral 4. Political and economic background Increasingly, it is recognised in France that the lack of co-ordination between health care providers generates both quality problems (e.g. physicians ignoring the prescriptions of each other, lack of follow up after hospitalisation, - 2 -
insufficient guidance for patients with chronic diseases) and that it is a cause of inefficiency (e.g. duplication of procedures, patients shopping around for doctors ). The idea of creating health records for better care coordination is not a novelty. For children under 16 years old a "health record book" (carnet de santé) has been used for more than 40 years. In 1996, the "Juppé edict" made the health book mandatory for the adult population as well. So in 1996 more than 40 million insured persons received a health record book to be presented in every consultation. The physicians were asked to write down in it medical information about consultations, tests carried out, hospitalization, vaccination, etc. But no sanction was planned in the edict in case of non respect, neither for the patient nor for the physician. This measure remained ineffective: the use of health books never became a common practice. The patients were rather resistant to the idea of showing their health books when they consulted physicians and the physicians (as they were not consulted at all before the implementation) were considering this exercise as useless. In the late 90s, the idea of an electronic medical record appeared with the intention of developing an e-card which contains medical information. But its implementation was regularly postponed. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea In August 2004 the Health Insurance Reform Act formally decided the creation of electronic health records (articles 3 to 5). The Act on Patients' Rights and Quality of Care (2002) previously defined the rights of patients to access to their medical records and the conditions of use of medical electronic data. A decree in 2006 defined the conditions for an approval of Internet providers to host the data. Three more decrees have to be published before 2007: to define the electronic health record contents and the access rights for health professionals; to specify the confidentiality rules for hospitals and health professionals; to define the codes identifying the patients in the electronic record. A public consortium (groupement d'intérêt public) was set up in 2005 to carry out contracting and implementation of the personal electronic medical records (DMP). Between 2005 and 2006, the consortium had three successive general managers, which indicates the political difficulties encountered to advance the project. The consortium is also responsible for the initial pilot phase, which started in June 2006 after more than a year delay. The experiment involves 17 sites and five software companies. The goal is to create electronic records for 30, 000 voluntary patients with the help of 1,500 health professionals and 100 hospitals. By the end of September 2006, about 13,700 records have been created. But the question of how these records will be identified is not resolved yet. The first (and simplest) proposition is to use the existing social security numbers or another national ID number for identifying medical records. But the patient associations and the general public opinion are very sensitive to the possibility of linking medical data with administrative information. The second proposition is to create a new specific "health number" which cannot be linked to the social security number (estimated cost between 10 to 30 per patient). While the CNIL, French data protection watchdog, seems to be more favourable of the second option, it postponed the decision on this issue several times. The full implementation of electronic medical records is announced for July 2007, whereas many observers have doubts about the likelihood of this time schedule. The Health Ministry estimates the total cost of the operation at 1 billion euros from 2006 to 2010. - 3 -
Initiators of idea/main actors Government Approach of idea The approach of the idea is described as: new: Stakeholder positions In the early days of the Health Insurance Reform Act, a large majority of the physicians' and patients' representatives appeared in favour of the idea of creating personal electronic medical records. Nevertheless, they are increasingly aware of the many expected difficulties about data security and defining patients' and physicians' responsibility in its management. Not surprisingly, the positions of the patient and physician associations vary. In particular, the recent decision of allowing patients to mask some information about their health from some professionals who provide care for them, without indicating that some information is hidden, is a problem for physicians. They claim that to provide an appropriate treatment they need to have access to the whole medical history of a patient or at least to be warned that some information is missing in the file. Furthermore there are problems as to the organization of the data transfer from health professionals towards the electronic personal records. Physicians fear that entering information for the personal medical records will be too time consuming. At the same time, no financial measure had been proposed for helping them with their computer and software investments. That is why some physicians have threatened to boycott the pilot phase. More generally it appears that the physician associations see the DMP as a means to put pressure on the government in the approaching annual tariff negotiation between physicians the sickness fund. Opinions also differ as to the feasibility of introducing electronic records in such a short time span. Indeed, the initial provisional cost was largely underestimated, and the initial time schedule rapidly appeared unrealistic for such an ambitious and complex project: the first pilot trials, planned for the first half of 2005, began only in mid 2006, that is hardly one year before the announced date for the generalisation. Despite all the difficulties, mid 2007 is kept as the target by the health department, but it is already clear that the electronic medical records will only be available for a limited number of volunteers by then. Actors and positions Description of actors and their positions Government Ministry of health very supportive strongly opposed Health insurance fund very supportive strongly opposed Physican associations very supportive strongly opposed Patient associations very supportive strongly opposed Influences in policy making and legislation See above Legislative outcome Actors and influence Description of actors and their influence Government - 4 -
Ministry of health very strong none Health insurance fund very strong none Physican associations very strong none Patient associations very strong none Positions and Influences at a glance 6. Expected outcome The expected advantages of the electronic personal medical record are the following: for the patient: the electronic personal medical records intend to reinforce co-ordination of care and therapeutic security. It could help the patient to be more active in his/her own treatment and simplify his treatment while respecting medical confidentiality; for health professionals: currently medical information concerning a patient is spread over various places. The electronic personal medical records would allow health professionals to access simply and "in real time" information from other professionals. In order to protect patient interests, the personal medical records will not be accessible by the company doctors (médecin du travail) nor by the private insurance organizations ( mutuelles). - 5 -
for the government: electronic medical records are also seen as a tool for reducing health expenditures. According to the Health Ministry, 15% of all medical examinations are redundant which generate about 1.5 billion excess costs; and around 128 000 inpatient stays a year would be the result of inappropriate drug prescriptions. The electronic medical records are also seen as a lever to enforce the development of computerization in ambulatory care, as well as in hospitals. But, the data security and management (who should have how much right and responsibility in managing data) will be clearly the key issues to be resolved for ensuring the success of electronic medical records. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high 7. References Sources of Information www.d-m-p.org www.sante.gouv.fr/htm/actu/carte_vitale2/present.htm Author/s and/or contributors to this survey Chantal Cases, Philippe Le Fur Suggested citation for this online article Chantal Cases, Philippe Le Fur. "Electronic medical records". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/fr/a8/3-6 -