How FRANCE will cope with the new expectations of the citizens regarding

e-health and Patient Record

Michèle THONNET

Mission pour l ’Informatisation du Système de Santé (MISS)

Barcelona February 2007

Agenda Agenda Health & ICTcharacteristics of the french systempolicy, strategy and reform (1996-2006)goal, projects and objectivesroll out and current situationePMR (DMP)lessons learnedwe are part of Europe … and of the world

Reforming the H system : a Reforming the H system : a necessity necessity ageing populationchronic diseases evolutioncitizen demands & needs transfoincreasing costs of research, equipments, examinations, treatmentpandemia expansionlack or shortage of HCPmobility of citizens & patients, …economic model

ICT : ICT : necessarynecessary but not but not sufficientsufficient

medical informaticstelematics telemedicinee-Healthp-health connected health e-inclusion

the most visible target the eHR ...

Visible part : an iceberg ? Visible part : an iceberg ?

techno. is attractive, speaking about is usualbut cultural changes are key– more difficult to envisage– need more time and continuous efforts– change professional exercice, patient view– reorganise the actors relationships & positions– destabilize the present « system »

team work needs exchange & sharing info….the ePMR :only a good enabler & trigger tool

The French health system

Some characteristics

France France and health and health systemsystem

540 000 Km2 60 M inhabitants

life expectancy : 75,2 M 82,7 W

Global Expenditure per capita 2000 €

1,7 M jobs in Healthcare

A complex system

A multitude of actors– health insurance (compulsory complementary )– 300 000 professionals (120 000 doctors), 23 000

pharmacies , 4 000 laboratories

– 4000 hospitals, 1,1 million employees (50 000 doctors)

…with a very large autonomy

11-- A systemA system that deserves its that deserves its appreciative appreciative rating ...rating ...

The first in the world according to WHO (2000)…

… but with important internal inequalities

– social

– geographical

22-- aa high costhigh cost

The national expenditure of health– 148 billion €uros, 8.8% of GDP

one of most expensive among thedeveloped countriesA growth regularly stronger than the GDP

+ 5,2 % in 2001, ...Presumptions of inefficiencies– adequacy of the offer compared to the needs

Public policies for e-health in France

Objectives of theObjectives of the authoritiesauthorities

GovernmentGovernment’’s guideliness guidelines

To develop the assets of a policy for (public) health

By improving the overall effectiveness

policy followed by the introduction of the ICT is a variation of that

The main goalThe main goal

Make use of ICT and Internet torationalize the healthcare system– for a healthier population

• => to improve the level and quality of care • => by controlling the costs

Three Three types oftypes of projectsprojects

a first stage : SESAM-Vitale : (Administration)– administrative simplification for refunding health

expenses

a « corner stone » project to improve the doctor-patient relationship : (Medical)– electronic health record (EHR)

public health issue : (Information)– to manage the consequences of the availability of the

information to public (education, protection)

Four main objectivesFour main objectives

To facilitate the continuity and the coordination of the health care :

– electronic health records :protected access and transmission

– telemedicine

To improve access to knowledge :

– online state of the art for the professionals ( KB, EBM)

– quality of e-health sites

Four main objectives (2)Four main objectives (2)

better know the reasons for recourse andevaluate the expenditure

– piloting information systems (reorga H System)

better and quicker refunding

– administrative simplification : SESAM-Vitale

A A continuous voluntarist strategycontinuous voluntarist strategy

important investments

an impact on the whole population

– 55 million smart cards handed over

The rollThe roll--out out scenarioscenario

Starting point administrative simplification with SESAM-Vitale, (infrastructure needed)

… but investments need to serve the othermore general goals

Structural role of technical tools : HCP cards, Insurance cards (Vitale), Internet standards, RSS,...

Public policies for e-health in France : about TRUST

Confidence requirement is key

Health isHealth is not anot a product like othersproduct like others

SecuringSecuring datadata confidentialityconfidentiality

A A specific statusspecific status for for healthhealth informationinformation

The European Legislation 24 October 1995 (art 8)

– prohibits any data processing without the consent of the person– except for the data absolutely necessary to the health professional– or those related to the management of health services, required by

people exercing under professional secrecy

The french Medical Privacy Act (4 february 2002)

– transmission of personal information is authorized only between health professionals treating their mutual patients, and only with their priorconsent (article L1110-4)

Confidentiality requirementsConfidentiality requirements

To secure release and circulation of invoices(SESAM-Vitale)

– authentification of the transmitter– signature of the person receiving benefits and the

recipient

choice of cards supports

Soon significant volume of information will circulate

necessity to invest in confidentiality

Confidentiality requirementsConfidentiality requirements

Two key issues to deal with, for the French Government

– legislative : the Act of March 4th, 2002

– technical : smartcards, PKI, secured standardised network

Internet sites on e-health– support self-regulation between bodies involved (users,

professionals, economic actors)the project « e-health quality »

A A technical federatortechnical federator : infrastructure : infrastructure

to exchange and share :The choice of Internet standard technologies, but protected

for / with the HCP :The Health Professional Card(CPS) – (identify), authenticate, sign, coding

for / the citizen :The recipient insurance card :– carte Vitale

Health Professional Card Health Professional Card (CPS)(CPS)

CPS– an large roll-out ...

• over 485 000 cards rolled-out– a central role in the security of the system

• authenticate the holder of the card :– identity HCP, qualifications, conditions of exercise– « Sésame » to reach to protected informations

• electronic signature

• protecting and coding messages

The The health insurance cardhealth insurance card

The Vitale card

– easier• identify the holder :

– 55 million cards handed out to the citizens

Public policies for e-health in France

The The currentcurrent situationsituation

SESAMSESAM--VitaleVitale

An increasing use :

– >80 million electronic invoices issued every month

– more than 65% of invoices

– 180 000 Professionals using the system

– a smooth and steady implementation

The The electronic electronic Patient Patient MedicalMedical Record Record ePMRePMR . . . DMP. . . DMP

An effective way to manage patient’s continuity of health care…

… but which must offer all theguarantees of privacy

TheThe rolerole of the of the AuthoritiesAuthorities

To support the development of the consensus

finalities, contents, control of the uses

To encourage experiments

To build up the legislative framework

To develop incentives, if necessary

Role and vision of the Government

ThreeThree important innovations in theimportant innovations in thelawlaw for thefor the patient's rightspatient's rights

An important reform of the Health Insurance

The ePMR (DMP)

The new The new law law : : three three important innovations important innovations

11-- Direct Direct accessaccess to to personalpersonal medicalmedicalinformations (article L1111informations (article L1111--7)7)

2 2 Securing Securing confidentialityconfidentiality (article L1110(article L1110--4)4)

3 3 RegulateRegulate by by lawlaw the the storagestorage ofof personalpersonalEHREHR (article L1111(article L1111-- 8)8)

To enhance their developmentThe objective:

support the development of ePMR, used & shared

– information is produced by health professionals

– reviewed on line with strict conditions on the rights of access (ICT team) – of which the use (and contents?) are controled by the patient

– which are stored securely under very strict conditions byaccredited third party outside the premise of the MD (authorities)

13 13 August August 2004 2004 Act Act DMP (DMP (ePMRePMR,...),...)

Coordination dossier ( 2007- implementation start)– no replacment of the GP dossier

Strongly linked to the « patient act »– strict security policy & mechanisms– patient control on the access

• authorised access for HCP habilited• direct access to medical data by patient

– mandatory labelisation of the storage places, which are not allowed to accesss to medical data

Four question marks ????Four question marks ????

Optimal level of confidentiality

Identification of the patient

Control of the access by the patients

Technical options

The objectives of the The objectives of the ePMR ePMR (DMP)(DMP)• to offer over 2007:

–the same ePMR for all, under the control of the patient

–an ePMR compliant to the law(s): improvmentof the care ‘ circuit ’, avoiding iatrogeny & redondency of examination

–with simplicity of access and usage• to allow the patient to choose his accredited

medical storage « harbour »• to support the HC professionnals in order to

populate the ePMR

Principle Principle 1 : 1 : increase increase the the existing existing value value & & build upon experimentationbuild upon experimentation

Continuity of the approach– to build upon the outcomes of the experimentat.– to offer the same ePMR for all, useful & used– to associate all the actors to the management of

the project (including industry)

Structuration via a universal service- simplicity of access, identification, managt- Interoperability, evolutivity

The The key factors key factors of of successsuccess

• To join forces of all the concerned actors– Appropriation & usage of the developed tools– Convergence with the existing systems– Call for projects proposals

• Cooperation with the industry– build up tools for populating easily the ePMR

(services sub contracting to the market players) • concertations with the software editors for HCP• opening to the medical storage harbour when

generalized • Cost containment

The The approach approach ::

Offer & open an ePMR to each one who ask– create the infrastructure able to support this

Exploit all the established features from the experimentations– specifications & content, security & ergonomics issues– capitalise on the proposed organisational changes

Avoid the ‘ blank page ’ syndrome– « recovery » of the ePMR used for the experimentations– mechanisms to (automatically) populate the ePMR

Programme control & Programme control & masteringmastering• Involvment strategy• Confirmation of the objectives

– compliant to the law(s) - simplicity– ergonomy - utility

• Master, control the follow-up of the interoperability

• Visibility on costs & budget• Respect of the announced planning• Reinforcement of the resources of the

structure in charge of (GIP DMP)

Iden

tifi c

atio

nA

nnua

ires

Authentific

ationTables desdroits

Services de confiance uniques

ArchitecturePortail

3SVA 3

Assistance 3

Hébergeur deDMPagréé

3

Portail4

SVA 4

Assistance 4

Hébergeur deDMPagréé

4

Portail2

SVA 2

Assistance 2

Hébergeur deDMPagréé

2

Portail5

SVA 5

Assistance 5

Hébergeur deDMPagréé

5

Producteurs de données

Aiguillage

donnéesmédicalement

utilesdétenues parl ’assurance

maladie

SIHRése

au

Assistancetéléphonique

Portailunique

Hébergeur

de DMP de

référence

Accueils du portail : patient PS hébergeur

Serviceuniversel

DCC LGC(PS)

2006 2006 experimentationsexperimentations::13 13 regionsregions, 17 sites, 17 sites

How to How to cope with cope with ee--healthhealth

Some lessons learned

What happened so What happened so far ?far ?

Objectives & goals– unsatisfactory situation

designing a strategy : eee---Health Health Health for for for HealthHealthHealth– reform supported by politicans– need some legal framework

strongly linked to other policy regulations(health & not health) taking into account all stakeholders

The The lessons learned so lessons learned so farfaralways more time than expected– resistance to change, « daily routine »– early adopters are not representative

always more expensive– unexpected « borderline effects »

critical mass point is not easy to reach– to be careful on incentives

do not underestimate – the existing environment– conditions & consequences of generalisation

How to How to increase increase the chances of the chances of successsuccess

Define clear objectives

– with explicit milestones to measure progress– based on consensual indicators

Involvment of all stakeholders

– early pre - consultation / concertation

The The accompagnying measuresaccompagnying measures

Rearrangment of existing measures

– to maximise integration of the new elements– take advantage to reorganise & optimise

(hospitals/clinics, specialists,GP, homecare)

Anticipate the needed changes– on medical care, on personal behaviour– on the HC system, on reimbursement, ...

A A way way to to progressprogress

design an iterative process– existing adopted roadmap & context evolution

do not forget to nominate A pilotA pilotA pilot– strong coordination & clear decisions

be precise in respective roles & responsabilities

ClearClear objectives in anobjectives in an evolvingevolving worldworld

Integrate the regional & national evolutions

avoid to focus too much on technical issues

anticipate– negative consequences of a new system or

– changing in the existing forces balance

We We are part of Europe & of the worldare part of Europe & of the world

Take into account the evolution of the other EU M.S. and other countries

… to support citizen & patient mobility… to be « compliant » with other systems… to anticipate their potential impact on national (& regional ) HC system

Keep European and Keep European and open on the worldopen on the world

improve & facilitate the the use ofuse of european & international standards

give no long term agreement to proprietary products

be present on international arena to anticipate changes

The The keykey basic componentsbasic components

Will & cooperation of all actors (citizen, govt, patient, HCP, hosp., insurer, industry,daily used added value servicesstandardised shared mutual services on– security (id, authent, certif, PKI,e-signature,…)– access (ergonomic, perf., available, direct. LDAP)– modelling (RIM : HL7 V3) processes– transformation (syntaxic format XML, CDA-XDS)– terminology (semantic : ICD, MeSH, MedDRA, LOINC,

SNOMED, GALEN, GO, FMA,...)

International collaboration : EUInternational collaboration : EUHealth is a national prerogative but collaboration is a key issue patient mobilityvolontarist coope. on INTEROPERABILITYconsensual defined priorities at EU level :– non ambiguous ID (patient, HCP, hospital,

service)– patient record summary (minimum data set)– secure data exchange flows

• emergency data set / e-prescription

Thank you Thank you for attentionfor attention

Think globally

Act locally

michele.thonnet@sante.gouv.fr