Information society in Czech healthcare ‘starting point’ to prognosis for the year 2013

Information society in Czech healthcare ‘starting point’ toprognosis for the year 2013

Jana Zvarova *, Vladimır Pribık

European Centre for Medical Informatics, Statistics and Epidemiology-Cardio, Institute of Computer Science, Academy of Sciences of the

Czech Republic, Pod Vodarenskou vezi 2, 182 07 Prague, Czech Republic

Abstract

A prognosis of how the information society in health care will look like in 2013 must start from the current state of

affairs at the given locality regarding healthcare management by public authorities including legislative, ICT

technological levels and accessibility of professional knowledge in individual fields of medicine. It is presumed that

after 10 years the influence of this ‘starting point’ will still persist and knowledge of the current state of affairs will be

needed to positively but also negatively differentiates the prognosis [Health Care in the Information Society: A

Prognosis for the Year 2013, in this issue] for individual localities, e.g. Germany versus neighbouring the Czech

Republic. The present article focuses on aims of Czech health care and the measures that are taken in Czech health care

that are carried out and which have been already initiated. Their significance towards the future prognosis according to

[Health Care in the Information Society: A Prognosis for the Year 2013, in this issue] is clear. The first measure is

legalisation of conditions, which allow health care administration only be carried out with electronic forms and the

protection of these sensitive personal data when they are placed in a centralised data depository where they are prepared

for physicians who use them while providing health care in health institutions. In the Czech Republic an information

system is developed called Internet Access to Health Patient Information (IHPI). The second measure is creating a

unified central system of health information together with methodologies for data collection, data standards and

protocols. In the Czech Republic there is the National Health Information System (NHIS) governed by the Institute for

Health Information and Statistics (IHIS CR). The NHIS enables care providers to get information about the health

state of citizens, about health institutions, about their activities and economics, it enables to regulate the provision of

health care, to define conceptions of state health politics and to administrate public health. The third measure is

legalisation of possibilities to establish centralised health care registers that are designated for recording and following

of patients with chosen socially serious diseases. These registers help with diagnosis and therapy and reveal

consequences of diseases for the patients. It helps to evaluate accessibility and quality of provided health care in the

country. An important goal of the use of health care registers and information systems is for educational purposes and

as causal expert systems for physicians. The National Health Registers have been introduced to the whole of the Czech

Republic; some of them are accessible on-line in a countrywide data network. The last part of the paper focuses on

research and education for developing the information society in Czech health care and on co-operation with EU

countries in selected projects and initiatives.

# 2002 Elsevier Science Ireland Ltd. All rights reserved.

* Corresponding author

E-mail address: [email protected] (J. Zvarova).

International Journal of Medical Informatics 66 (2002) 59�/68

www.elsevier.com/locate/ijmedinf

1386-5056/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.

PII: S 1 3 8 6 - 5 0 5 6 ( 0 2 ) 0 0 0 3 7 - 0

mailto:[email protected]

Keywords: Information society; Health care management; Governmental measures

1. Introduction

Haux article summarises positive and also

negative factors that influence the develop-

ment of the information society in the field of

health care up to the year 2013. The article

puts together a great amount of data about

the functioning of the current German health

care system and it states, in a sovereign way,

for each considered aspect the percentage of

increase after 10 years. The reader from the

neighbouring Czech Republic subconsciously

notices a certain insufficiency in the prepara-

tion of the Czech Republic to the year 2013.

The stated prognosis is generous for Ger-

many. However, a thorough examination of

the article makes it is clear that the success of

further development is for a great deal deter-

mined by the current situation of the health

system in each country and also by the

attitudes of citizens toward informatics, by

the level of health care management by public

authorities and also by the legislative level,

ICT technological levels and levels and acces-

sibility of professional knowledge in indivi-

dual fields of medicine. It has appeared that in

the current health system in the Czech Re-

public health institutions are poorly equipped

and offer a poor level of health services.

Moreover, the miserable economic circum-

stances of years ago have influenced the

development for many years. It is assumed

that during the period of the prognosis, i.e. 10

years, the influence of the ‘starting point’ will

still be apparent and this is the reason why it is

necessary to modify Haux’ prognosis. In the

paper [1], part 4, system aims and measures

are stated: to establish a system of patient

centred health records, to integrate decision

support with the process of healthcare and to

use patient data for research and healthcarereporting. The aim of following section is toinform the reader from these points of viewabout the situation in the Czech Republic andto support with evidence the surprisingly highthe readiness to solve information societytasks and to show that there is an opportunityto provide a good prognosis of the develop-ment of the information society until 2013.

2. The centralised system of health patientrecords

In the year 2001 the Czech Republiclegalised the use of the electronic form forstoring patient health conditions. Besides thepaper form the electronic form (without thepaper form) is now also accepted on conditionthat new information is confirmed with so aso-called guaranteed electronic signature.Also legislation is being prepared that neces-sitates the provision of a time stamp, indicat-ing the period the data has been recorded.Several certification authorities are created forenabling the guaranteed electronic signaturein health care sector including the provision ofthe time stamp. Concurrently a lot of othernecessary legislative, organisational and stan-dardisation measurements are being taken.Creation of conditions for managing of healthdocumentation continues on the basis ofamendment of the health law signed in theCzech Republic in the year 2001. It supportsfor the development of conditions that allow agradual introduction of the information so-ciety to the health system of the country.Patient health records are the most importantsource of health data that can be found in thedatabases of hospitals and in ambulatory

J. Zvarova, V. Pribık / International Journal of Medical Informatics 66 (2002) 59�/6860

information systems. In an anonymous andaggregate form they are used in the so-calledNational Health Information System (NHIS),the system that is the source of most healthdatabases and registers, health statistics andso on. The availability of electronic healthrecords (EHR) is the basic assumption of theestablished centralised systems of health re-cords and these centralised systems will pro-vide the main thrust to the changes that willlead to the prognosis for the year 2013.

A Czech law from the year 2000 requiredthe protection of sensitive personal data inhealth records and this protection becameanother obstacle in creating a centralisedsystem of health records, which is useful forphysicians when providing health care. Theonly alternative allowed by the law is toobtain the patient’s agreement with respectto storage and transmission of data to physi-cians. Also the Central Institute for Protectionof Personal Data has to be notified of the datastructure and of the data collection. Dataprotection of health records in the centralisedsystem is a complicated ICT issue. In theCzech Republic an attempt of private firms todesign an Internet access to health patientinformation (IHPI) into which physicians andpatients under exactly specified rules mayenter data. Some psychological problems stillhave to be tackled: overcoming not only thedistrust with respect to the security of thesystem of patients but also of some physicians,even though the security is very well techni-cally provided. The result of the countrywideeffort will shortly become a feasibility test ofthe thus created centralised system.

3. The NHIS

In the Czech Republic all health informa-tion has been unified together with themethodologies of data collection, data stan-

dards and protocols of the information systemcalled the NHIS, whose administrator becamethe Institute of Health Information and Sta-tistics of the Czech Republic (IHIS CR).

NHIS is the countrywide information sys-tem designated for:

. collection and processing of informationabout health conditions of citizens, abouthealth institutions, their activities and eco-nomics, with the aim to regulate the provi-sion of healthcare, to provide formulationof state health care policy, to supporthealth care management and to providedata for health statistics;

. managing national health registers;

. providing information, including providinginformation to international institutions.The extent is determined by the legal rulesabout the citizens health data protection;

. using information for health research.

Obtaining information from health institu-tions is regulated by the law on the statisticalsurvey or on basis of approved collection ofdefined data as health care sector duties.

The existence of NHIS is the basic condi-tion for developing the state health systemand it definitely has a positive impact on theprognosis for the Czech Republic for the year2013.

4. National health registers

In the year 2001, as a special part of NHIS,the establishment of centralised health regis-ters was legalised. These registers are estab-lished mainly for registration and monitoringof:

. patients with certain specific socially ser-ious diseases and pathological conditions.The data are used for diagnostic andtherapeutic purposes and for monitoring

J. Zvarova, V. Pribık / International Journal of Medical Informatics 66 (2002) 59�/68 61

the causes, development, and consequencesof these diseases and conditions;

. chosen blood donors.

Total evaluation of the accessibility and

quality of provided health care is now possi-ble. These health registers and information

systems can also be used for educationalpurposes and as casual expert systems for

physicians. The system of National HealthRegisters has been introduced in the Czech

Republic and this system can be used in acountrywide data network.

We present here a selection of currentlyexisting on-line accessible National Health

Registers communicating via the countrywidedata network:

. National Transplant Register (divided ac-cording to the kinds of transplant organs,waiting lists of candidates, receivers, anddonors).

. National Cardio-surgical Register (particu-larly courses of individual cardio-surgicaloperations are stored here with possibilitiesof statistical prediction and stratification).

. National Register of Cardiovascular Inter-ventions (particularly parameters of allPTCA interventions).

. National Register of Vascular Interven-tions (particularly registrations of all vas-cular operations).

. National Register of Articular Substitutes(particularly all operations of substitutionsof hip joints).

. National Oncological Register (report onincidence of all tumours).

. Others registers.

In the period of 2001 and 2002 a new very

advanced technology of web operation in theprotocol of https while using the public data

network Internet started to be used to accessto National Health Registers. This allows the

utilisation of already existing PC and Internet

equipment of users. The investment activitiesstill focus on central workstations for IHISCR as an administrator of the system that isequipped with powerful database servers.

5. Czech experience obtained from Europeanjoint research and education projects

The motivation to use electronic datastorage in medicine is based on the obviousdrawbacks of the paper medical record in-cluding illegible handwriting, poor organisa-tion of documents, missing data andambiguous data. Current developments inEHR focus on advanced features, includingstrategies for data entry and retrieval, multipleviews and transparent integration of diverseinformation sources of different platforms[2,3]. Moreover, the availability of an EHRis a must for using advanced decision support(including guideline support) in medicine andhealth care. The European project I4C of thefourth Framework Programme (1996�/1998)was carried out for the further advancementof cardiac care [4]. It focused on clinicalapplications and its main goals were tointegrate access to data wherever stored, tosupport evidence-based care by remote elec-tronic consultation and peer review and torecord more comprehensively and more con-sistently patient data, images, videos andbiosignals. With the support of the I4Cproject the multimedia open record for care(ORCA) was developed. It integrates struc-tured patient data entry including history,medication, symptoms and more with multi-media objects as ECG, angiography or la-boratory data. The project TripleC of thefourth Framework Programme transferredORCA to the Czech and Slovak languageenvironment and validated that the ORCAsystem could support the continuity of cardiac


care [5] in three hospitals (Prague, Bratislava

and Caslav).In the Czech Republic the ambulatory

health care is provided in two types of offices

from the point of view of information systems.

The first type of office is part of the larger

healthcare providers (e.g. policlinics, hospitals

or medical institutions) operating an informa-

tion system used by the whole organization

(e.g. the hospital information system). The

second type of the office is an independent

consulting room of a general practitioner or a

specialist with its own and independent in-

formation system. A successful implementa-

tion of EHR to the Czech health care

environment also depends on legal require-

ments of health care providers. Below the list

of obligatory standards for health care provi-

ders is given.

. A register provides a unique ten-digitnumber that is created from the date ofbirth, sex and other digits after the birth ofa newborn. All healthcare organisations,pharmacies, health insurance companies,government agencies and public authoritiesuse this unique number.

. An eight-digit number identifies a health-care provider.

. List of healthcare procedures (according tothe law 134/1998) contains a numericalclassification. It contains approximately5000 healthcare procedures with the follow-ing additional items: number of points forused for billing healthcare insurance com-panies and time limits for health careprocedures.

. To state the diagnosis in the healthcaredocumentation the ICD10 is used.

. The list of produced drugs paid fully orpartially by the General Insurance Com-pany of the Czech Republic is updated andpublished quarterly. Besides that there is anapproved list of drugs to be prescribed in

the Czech Republic. This list is stored in thenational system Automated Information

System of Drugs (AISLP).. It is obligatory to use in the Czech Republic

approved Data standard for patient data

transfer among health care informationsystems and the National list of 9000

laboratory items according to recommen-

dations by the International Union of Pureand Applied Chemistry (IUPAC) and In-

ternational Federation of Clinical Chemis-try (IFCC) to transfer the results of

laboratory measurements to physicians.. To transfer data among health insurance

companies and health care providers the

data interface include also code-lists andpatient records.

. To create documents by health care provi-ders there is the duty to use the Methodol-

ogy to supply and transfer documents of

the General Health Insurance Company ofthe Czech Republic, that is obligatory for

all health insurance companies.. An ambulatory office has to carry out

statistical services. They cover: (a) a yearly

speciality statement covering ambulatoryactivities, e.g. the number of examinations,

the number of patients, (b) a yearly eco-

nomic statement of health care providers,e.g. payments of health insurance compa-

nies, costs of activities, (c) a half-yearlystatement on employees and salaries ac-

cording to the law no. 1/1992, (d) reports to

the Register of health care organizationchange, and extinction.

. There is a yearly tax return form forhealthcare providers. It is obligatory to fill

in data about all the yearly activities.

Moreover, since the EHR serves as a tool

for data collection decision support programs

can use its data for automatic generation of

alerts, reminders and suggestions when stan-

dards of care (e.g. based on medical guide-


lines) are not achieved. In the joint researchproject Medical Guidelines Technology(MGT) of the fourth FP research focused onthe development of electronic medical guide-lines (EMG) and on making them availablefor physicians using Internet, especially withthe simultaneous use of EHR [6,7]. In addi-tion to increasing the level of informationavailable to healthcare professionals, the In-ternet also provides a vehicle for citizens tofind out more about their clinical situationand the interventions proposed by clinicians.This potential is increasing when more of thepublic gains efficient access to the Internet. In2013 we expect that the high exploitation ofmedical knowledge and of new informationand communication technologies will ensurethat no one is excluded from her/his justifiedhealth care needs. New tools based on theresearch in decision support and knowledgebased systems (including expert systems) willhave been widely implemented and will beable to handle the uncertainty. Some examplesof such systems [8] were developed in theCopernicus EU project Managing Uncer-tainty in Medicine (MUM). The Institute ofHealth Informatics and Statistics of the CzechRepublic was charged to establish the Registerof Medical Devices within the EU projectEUDAMED, in which all data generated inthe process of notification of medical technol-ogy devices on the national level are collectedin a common European database. EU-DAMED follows activities of the GermanInstitute for Medical Documentation andInformation (DIMDI). In the Czech Republican experimental application focused on elec-tronic health cards has been running inLitomerice with the support of the Phareprogramme. The aim of the application wasto verify the use of chip cards in healthcare [9].

However, the whole technological develop-ment will be used properly only in a societyeducated how to use these new tools. There-

fore, the appropriate education of healthpersonnel as well as of citizens is a basicrequirement for the successful development ofthe information society in health care. Thejoint education project EuroMISE of thePhare programme has opened the field ofinterdisciplinary education in medical infor-matics, statistics and epidemiology [10,11] andthe Information Technologies Education andTraining (IT-EDUCTRA) project of thefourth FP has developed a broad scale ofeducational materials and tools for the fieldand for examination using Internet [12,13].Based on the experience gathered in EUprojects the national research of the Euro-MISE Centre-Cardio is focused on specifictasks of EHR, EMG, data mining, decisionsupport and knowledge based systems and onthe practical application of new systems andtools in the Czech healthcare environment.The Ministry of Education of the CzechRepublic has supported the research with theproject LN00B107.

In the years 2000 and 2001 the Ministry ofEducation of the Czech Republic supportedthe project ‘Proposal for a National Programof Future Oriented Research and Develop-ment in the Czech Republic and its Imple-mentation’. It prepared in cooperation withmore then 500 experts the final document forfuture oriented research. The document fo-cused on all disciplines and applications (in-cluding healthcare) for information societydevelopment. The report also describes possi-ble developments of the information society inhealthcare in the Czech Republic.

The panel ‘Information Society’ of theproject consisted of 21 experts from Univer-sities, Academy of Sciences of the CzechRepublic, directors of industrial companiesas well as representatives of SMEs. The reportof the panel also contained the recommenda-tion to integrate the results of this panel withthe results of the other panels. We will present


here two research topics (RT) coming fromthe interaction of the ‘Information Society’panel with the panel ‘Medicine and Health-care’.

5.1. RT1: medical information and knowledge-based systems including personal systems

Research and development of informationand knowledge-based systems including per-sonal systems will lead to a global informationsociety that will bring a lot of changes tohealthcare.

Many people, mostly by means of Internet,can access information sources easier. Itprovides also access to information abouttheir health and to other information aboutdiseases, food, life style and medicine or tosystems of health care. It is expected that inthe future it will be possible to contact expertsvia teleconsultation in cases of emergency andthat patients will carry their personal EHRwith them. Internet/Web together with Intra-net networks offer an open and global schemeof cooperation. It is considered to use healthinformation systems directly from medicalinstitutions to get information about preven-tion and disease therapy, medical consulta-tions including remote consultation. Clinicalworkers gradually gain access to an immensenumber of international databases and knowl-edge bases that can be used for furthereducation or as virtual electronic libraries.They have easy access to medical guidelinesand to protocols, to medical practice based onthe health documentation and to researchresults.

For physicians and other health care work-ers the possibilities of mutual consultationregardless of a place or distance are opening.The results of research and development areconcentrated on gaining medical knowledgeand experience that can be used anywhere andanytime. Intensive development of telecom-

munications heads from basic vocally orientedservices through the expansion of fast net-works towards integrated multimedia servicesincluding voice, data and a fully fluctuantpicture. New services, e.g. video telephones,create other requirements to telecommunica-tion networks, as they need high-speed datatransfer and little delay to connect alreadyexisting services (vocal, TV broadcasts andlow-speed data transfers). Multimedia servicesenable the introduction of telerehabilitation,distance education or access to medical emer-gency services.

Interdisciplinary research and developmentwill focus on intelligently using data andknowledge saved in healthcare informationand knowledge systems (including personalsystems) and on new technologies in the fieldof telemetry and telemedicine. The main aimof the research will be to improve the qualityand to make more effective diagnostic andtherapeutic processes and prevention possible(e.g. by creating determinist and stochasticexpert systems, by statistical analyses ofextensive medical databases, by developmentof methods for choice of relevant informationfor decision making and management fromhealth information systems). New approachesto use medical knowledge from medical pub-lications and guidelines (design of EMG anddocumentation), to interpret data and knowl-edge in a satisfactory way and facilitate fastretrieval of information sources (classifica-tion, coding, terminology, Internet indexa-tion, retrieval of quality information) will beintroduced.

5.2. Description of the situation regarding RT1

in the Czech Republic

According to data from the year 1999 thereare around 23 000 medical institutions servingthe needs of more than ten million inhabitantsof the Czech Republic. At present there are


140 hospitals connected to Internet via hospi-

tal information systems. The Internet connec-

tion is usually used for sending e-mails and for

the transfer of health information while pro-

viding health care to a patient. Similarly,

standards of health informatics are quickly

developing. The centre for operation of health

registers became the Coordination Centre for

Health care sector. Other registers are mana-

ged by institutions such as the Institute of

Medical Information and Statistics of the

Czech Republic, the National Institute of

Public Health, by medical scientific institutes,

medical institutions and by large or specia-

lised hospitals.The factual aim of the program ‘Health

care on-line’ ‘The Action Realisation Plan of

the State Information Politics’ is to introduce

new information and communication technol-

ogies in Czech health care as it follows,

. To create standardised conditions for in-troduction of new information and com-munication technologies and to carry outcoordination activities during the establish-ment and operation of national registerswith the aim to guarantee an increase of thelevel of specialisation of medical institu-tions, to increase the quality of providedmedical care to citizens and to improve theorganization of the state medical system.

. To introduce the technology of telemedi-cine, especially concerning the transfer ofimage data. Bring it into operation withinbig hospitals with the aim to increase thelevel of diagnostics by means of guidanceevaluation of the results of examinations.

The scientific-research base of the Czech

Republic for performing interdisciplinary re-

search in the field of medical information and

knowledge systems is relatively well developed

in several institutions of the Academy of

Sciences of the Czech Republic, at universities

and in several research institutes in healthcare.International, mainly European, cooperationis under great development. The privatesphere, mostly small and medium softwareand high-tech firms, is very well prepared totransfer the research results into applicationswith high export ability. Education of specia-lists is sufficient, e.g. at universities of techni-cal orientation.

5.3. RT2: electronic documentation in medical,social security and governmental systems

Research in the application field of electro-nic documentation in systems of health care,social security and governmental systems,which could substitute for the traditionalpaper documentation, brings to the fore theinterest in information security: the credibil-ity, accessibility and integrity of computerdata. With the infiltration of informationtechnologies into healthcare, social securityand governmental systems, it becomes neces-sary to also introduce the corresponding legalsystems, if we want to prevent ill-consideredinformation technology applications that donot pay attention to the security of informa-tion.

It is easy to imagine that principles andorganisation of paper documentation will alsobe satisfied in the case of electronic documen-tation. Even though there are similar pro-blems in both cases, there are also strongdifferences among the media that requiremore attention to the security of the includedinformation. Medical documentation includesinformation about the physical or mentalhealth of patients but also information relat-ing to provision of health care by physiciansof medical institutions. Personal medical in-formation provided by a patient may beadded by family members, social workers orby other persons. Provision of health care isrecorded into special records including obser-


vations and opinions of physicians and othermedical workers. These data are not insertedinto medical records only by medical workerstreating a patient (physicians, nurses andworkers whose profession is connected withhealthcare), but also by experts providingauxiliary services (pathologists, radiogra-phers, pharmacists and others), by non-med-ical staff helping medical workers (secretariesand administrative workers) and even bypatients themselves. The variety of sourcesand the different ways of using data inmedical documentation leads to security pro-blems both in the traditional paper recordsand in the electronic records. It is expectedthat in the future it will be possible to contactvarious experts via teleconsultation in emer-gency cases and that patients will carry theirelectronic medical record with them. Theimpact of using unprotected systems in healthcare is far-reaching. Patients can be embar-rassed or socially isolated because of revela-tion of sensitive information about theirmental health, sexually transferred diseases,genetic disorders or drug addition. Theirhealth care can be disturbed by inaccurate ormissing data as a consequence of un-authorised editing, system failure or mistakesoriginated in the design of the program. TheEHR must be, therefore, being designed,introduced and used in such a way that thepossibility to harm a patient would be mini-mal.

5.4. Description of the situation regarding RT2in the Czech Republic

After the acceptance of state informationpolitics the government of the Czech Republichas entered the vision of creating an informa-tion society. Current developments in theCzech legislative field, especially with respectto two new laws, are very important (http://www.uoou.cz). The first one is law no. 101/

2000 Coll. regarding personal data securityand the second one is law no. 227/2000 Coll.Regarding the electronic signature. The re-cently accepted amendment of the law no. 20/1966 Coll. regarding public health care re-moves legislative confrontations with theforce of law no. 101/2000 Coll. Regardingpersonal data security when creating andmanaging the electronic health documenta-tion. The factual aim of the program ‘Health-care on-line’ is also to bring into consultingrooms and hospitals the possibility to use onlythe EHR and to prepare the introduction ofthe technology for using the guaranteedelectronic signature for personal data security.On 24th June 1998 the Czech Republic joinedthe Agreement on personal data security andon human dignity in connection with applica-tion of biology and medicine (the Agreementon biomedicine). The program ‘Healthcareon-line’ improves and solves new problemsof standardisation in the field of personal datasecurity and supports the fulfilment of theAgreement on biomedicine in organ trans-plantation.

6. Conclusion

The aim of the Czech initiatives in the wideand coherent development of the informationsociety in health care is in general context ofthe evolution towards a society based onknowledge and communication. The develop-ment of infrastructures, communication andinformation systems and services as well as thelegal framework for all the activities is anecessary assumption to integrate the Czecheconomy with the global economy and the EUeconomic and social space.

The prognosis of the development of theinformation society in health care in the year2013 is strongly determined by the ‘startingpoint’ of each country. The ‘starting’ point


http://www.uoou.cz

http://www.uoou.cz

can positively or negatively influence theprognosis of health care in the informationsociety for individual countries.

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Documents

Information society in Czech healthcare ‘starting point’ to prognosis for the year 2013