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Schweizerische Gesellschaft für Medizinische Informatik Société suisse d’informatique médicale Società svizzera d’informatica medicale Swiss Society for Medical Informatics
Swiss Medical Informatics National Strategies for the Integration of ICT into Healthcare
Schwabe AG Verlag · Basel
Swiss Medical Informatics National Strategies for the Integration of ICT
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Table of contents
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Editorial: Switzerland in need of an eHealth strategy (Martin D. Denz)
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Integration of Informatic and Communication Technologies (ICT) in the EU national health systems: status and trends (Jean-Claude Healy)
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Integrated clinical information systems: an essential resource – an opportunity for International cooperation (Angelo Rossi Mori)
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Development of National strategies for integration of ICT into healthcare in England (Peter Drury)
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Modernizing healthcare in Germany by introducing the eHealthcard (Gottfried T. W. Dietzel, C. Riepe)
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Progress Report on European Healthcare IT (Murray Bywater, VĂŠronique Lessens)
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Swiss Medical Informatics Editorial
Switzerland in need of an eHealth strategy
Martin D. Denz Swiss Medical Association
E-Mail martin.denz@hin.ch
Against all our expectations, the use of information and communication technologies (ICT) in Swiss healthcare is still oriented towards the continuation of traditional business models. Instead of striving for complexity management and harvesting results of knowledge management for the benefit of all the stakeholders in healthcare, efforts are focused on “cream skimming” at the end of the value chain. Resources are invested into retrospective cost analysis of the expenses incurred already, and are thus unavailable for clinical decision support at the point of care delivery, giving away all chances of a bottom-up steering and optimizing of medical processes and risk management.
After the eHype collapse, service oriented industries with typically high information intensity and need for process optimization, discreetly and rapidly began to merge „e“ with their traditional business models, thus generating real added value. However, in healthcare which represents the biggest industry in western countries, the use of obsolete technology prevails as well in supportive processes as particularly in medical core processes. Discontinuity of processes, redundancy and lack of coordination do generate unacceptable risks and costs from an economic point of view as well as from a medical and ethical one.
FMH Correspondence: Martin D. Denz President of the Swiss Society for Medical Informatics Head eHealth Unit FMH Swiss Medical Association FMH Elfenstrasse 18, CH-3000 Bern
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„eHealth“ is synonymous with the integration of ICT into healthcare. As a strategic concept, it targets to the impact of ICT on the communication and organisation of healthcare systems. eHealth applies experiences and solutions from other industries to develop enhanced business processes. The aim of eHealth lies in the improvement of efficiency and quality, the fundamental approach is change management in health-
care by use of up-to-date instruments. The upcoming change will also contribute to the development of health professionals‘ culture. This challenge may be perceived as a threat or as an opportunity.
The prerequisite for any successful change, in healthcare too, is the development of a strategy. Discussions about the use of technology in healthcare only make sense if a shared vision about the shape of this future healthcare system has been attained. Technology is nothing more than a means to this end. Thus, we should withstand seductive but futile technology driven approaches, being able to appraise ICT as a carrier who may convey varying objectives according to the social, cultural and political context within different healthcare systems. The fate of any strategy lies in the expressed commitment by top decision makers. Their unambiguous commitment is crucial, including courageous investment and allocation of resources.
With the present edition of Swiss Medical Informatics, the Swiss Society for Medical Informatics gives a contribution to gain insight into national strategies within the EU. As Switzerland could learn from eHealth strategies in the EU, the reverse process may also be conceivable. In view of the challenges due to enlarging Europe, the Swiss model of developing a national eHealth strategy on its background of federalistic heterogeneity and organisational diversities may be a source of helpful mutual exchange. The Swiss Society for Medical Informatics will encourage any cross-border and transboundary collaboration.
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Swiss Medical Informatics Integration of Informatic and Communication Technologies (ICT) in the EU national health systems
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Integration of Informatic and Communication Technologies (ICT) in the EU national health systems: status and trends J. C Healy DG INFSO C4 eHealth, European Commission, Brussels
Since the last 15 years the European Union, as a component of the successive framework research programs, supported Research and Development (R&D) activities in the domain of ICT for health. In total around 500 M Euros were allocated and more than 500 cost-shared projects funded. Gradually the paradigms moved from the “computer for doctors” during the second half of the 80’s, towards “networks for Healthcare professionals” during the 90s, followed by ICT for solving the “demands of the users” during the second half of the 90’s and more recently (2000) ICT as response to the “societal health challenges”. Today the various ICT products, systems and services in line with health matters are commonly named eHealth products. What are the results of these initiatives and what about the impacts of the eHealth solutions on the various nationals or regional healthcare delivery systems? By definition the ICT and eHealth solutions are “diffuse” technologies and accordingly, the impact must be assessed in different ways.
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Each product exhibited during the conference had been positively evaluated according the so-called AQE. This methodology, developed during the last few years, tries to overcome the different facets of the impact of eHealth solutions and assesses the impact on “access to care” (for convincing the decision makers), the impact on the “quality of care” (for convincing the HC professionals) and finally the “economy of care” (for the financial aspects). The overall impact cannot be just focused on a single aspect but must integrate the three and the final decision for potential large-scale implementation must integrate the three components of the AQE model for solving the local priorities. The overall assessment can be synthesized as the following: •
For the professionals: 10 years ago, many HC professionals were sceptical and sometimes opposed to the use of ICT for health. Today more than 78% of the general practitioners are using Internet in order to continue the education (72%), for the transfer of medical data (46%) or for telemedicine services (12%) (eurobarometer 15). Of course large discrepancies exist between the member states, and the health professionals connected to the Internet moves from less than 20% in Greece up to more than 95% in Sweden and in the UK.
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For the patients and citizens: with more than 150000 health related websites, the final users have a very wide choice for getting information on symptoms, diseases, drugs, etc. in the respect of the quality criteria for health related websites
The direct impact: the eHealth products, systems and services and their implementation During the first eHealth ministerial conference held in Brussels on 22/23 May 2003, the state of the art was described in the “Case for eHealth” document produced by Mrs. Denise Silber and in the Exhibition guide. The typology of the products had been classified as follows :
Correspondence: Prof. J. C Healy DG INFSO C4 eHealth European Commission B-1000 Brussels e-mail: Jean-claude.healy@cec.eu.int
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national and regional eHealth networks;
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eHealth systems and services for health professionals;
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telemedicine and homecare applications;
empowering citizens in management of health and well being.
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proposed by the EU Commission in 2001. •
For the managers and the decision makers, the intranets are now the backbones both of the hospitals and of the regional networks for the transfers of the lab test results, for the transfer of the medical files and the images in the respect of the data protection regulations, valid in the European Union (Directive 95/46).
But in short we can say the following: the eHealth solutions are the products of the new health industry, the eHealth industry. This new industry, after the pharmaceutical industry and the medical imaging industry, is the third health industry. The Deloitte and Touche studies demonstrated that this industry will represent 5% of the healthcare expenditure by 2010. In 1995 ICT for health in the hospitals represented roughly 0.7% of the total expenditure. In 2003, this amount is between 2 and 3%. These numbers are credible if we consider that the healthcare system is a service industry in which 80% of the costs are human costs and in which the integration of the ICT is expected the more efficient for the improvement of the productivity. It is classical to allocate between 10 and 15% of the total cost to the ICT in the service industry. All these elements demonstrate an attitude completely opposite to the attitude of the last 10 years. In the classical and conservative healthcare delivery system, the total daily integration of any new efficient drug or new powerful image technology, request commonly … 17 years. In the European Union, the doubling of the HC professionals Internet connections within the last 4 years illustrates the facts: eHealth technologies are no longer questionable and, even more, are an essential component. This fact is now comforted by the recent initiative of the WHO HQ to design an “eHealth” essentials worldwide strategy. This approach duplicates exactly the one previously designed for the essential drugs or for the essential medical instruments.
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The indirect impact: the impact of eHealth on the national health strategies and the reengineering of the systems The introduction of any technology in the health sciences induced fundamental changes: the molecules and drugs renovated the diagnostic and the treatment procedures, the medical images revised completely the diagnostic methods. The technologies are no longer some additional gadgets which comfort the existing systems but more importantly the instruments for the renovation of the systems, including the role of the different actors, recruitment, hierarchy, procedures, etc. During the last 20 years the introduction of ICT in the manufactures systems and in the business areas induced complete revision of the old habits and finally substantial gain of productivity. Accordingly, the application of ICT in the health domains is expected to generate, with a short term point of view, substantial gains of productivity and with a mid long term point of view renovation of the systems. In the various EU existing healthcare delivery systems, the crucial point is the gains of productivity expected by the decision makers for facing the increase of the demand. A first round of implementation is supported according this rationale. More or less, as demonstrated during the 1st eHealth conference, all the EU member states have already strategic plans. We can mention in particular: •
in France and Germany the use of health cards for automatic financial transfers;
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in Belgium and in many other countries the automatic exchanges of lab test results;
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in the UK the famous NHS direct for the citizens and the patients;
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in the Nordic countries such as Finland and Sweden the common use of the telemedicine services for remote area access or for second medical opinion;
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the regional networks are efficiently implemented in many places including in Slovenia for
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avoiding duplication of the data entry and efforts; •
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the e-Prescription: e-Procurement gradually implemented in the Danish health information network merging together 100% of the hospitals, pharmacy emergency doctors, 90% of GPs and laboratories and demonstrated to save 52 minutes a day of the HC professionals concerned and finally 22.5 M euro a month; etc.
Finally, after the embryonic phase based on academic research (1990), after the baby phase based on some champions activities (1998), today (2004) the eHealth is clearly a major component of the healthcare system. But, more important, the current rapid implementations of the eHealth solutions are only the instruments for the renovation of the systems themselves. The new health systems must be conceived. Of course, it is sensitive, difficult and requests time. Nevertheless the major trends are the following: •
the new systems will be health systems and no longer essentially based on healthcare systems: the education, the prevention, the direct commitment of the users will be promoted;
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the new systems will focus on individuals, as citizens, not just as patients (“citizen centered model”);
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the new systems will be based on the networks (physical, technical, human, etc.) in the respect of the different specificities, proximity, etc. and not just based on the hospitals acting as black hole;
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the management of the health information will play the crucial role today allocated to the images or laboratory techniques (knowledge-based model);
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the sources of health knowledge whatever the scales (nanoscale level such as genomics or molecules, microscopic scale level such as cells and tissues including neuroinformatics and macroscopic scale with the alphanumerical data and medical images) will be merged both for prevention purposes (risk management) and for action purposes (personalised diagnostic, treatment and follow-up).
All these diverse applications have in common: •
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The necessity to develop some political and financial incentives for a mid-term investment, a step by step approach for the education and the commitment of the users, to guarantee the evolution and the future integration of new applications and not to be outdated in the near future. In this context the bottlenecks are no longer the technologies (the existing IC technologies, not the old ones, are rapid, robust, secure, easy to use and not so expensive), but frequently the lack of political incentives and investment. The EU Communication (2004) “Towards European eHealth area. Action plan” tries to push the decision-makers to go ahead and proposes a lot of benchmarked initiatives. As a part of these initiatives, we can mention: dissemination of the best practices positively evaluated, support to the bi- or multi-regional approaches of the eHealth solutions for reducing the investment cost and guaranteeing the continuity, use of the structural funds and other EU resources for urgent investment, etc. The industrialists (some large companies but more and more small and medium enterprises) are ready to go ahead and to actively contribute to the standards for the securisation of the interoperability.
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This is the urgent challenge: what could be the next health systems? No unique solution can be envisaged, but large-scale regional solutions may be implemented in the respect of the diversity of the languages, of the habits and of the culture.
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All the researchers are concerned and not just the ICT specialists. The human sciences will be crucial for the improvement of the man machine interfaces, for the user acceptance, for the integration of sensitive health and medical data, etc.
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On the reverse, the healthcare professionals and the authorities are simultaneously invited to urgently conceive the next 20 years knowledge-based and citizen-centred health systems in the respect of the multicultural and multilingual approaches. Finally, let’s remember Mercator: if the earth is spherical, we have to integrate this fact into the maps: the famous Mercator’s projection is still in use and efficient. In the Global Information Society, the health system will not stay alone and we have to immediately integrate this fact into our new maps for action in the health areas.
Conclusion Perceived as instruments for the requested changes of the health systems, the eHealth solutions must be quickly implemented. The majority of the EU member states are now convinced. No alternative exists in the developed countries.
Die Mitgliedschaft bei der SGMI beinhaltet folgende Dienstleistungen: • das Abonnement der Zeitschrift «Swiss Medical Informatics» (Publikationsorgan der SGMI) • reduzierte Gebühren an der Jahresversammlung der SGMI • das «Yearbook of Medical Informatics» der IMIA
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Swiss Medical Informatics Integrated clinical information systems
Integrated clinical information systems: an essential resource – an opportunity for International cooperation Angelo Rossi Mori Istituto Tecnologie Biomediche, CNR, Roma
By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. The future of Information and Communication Technology (ICT) in healthcare is citizen-oriented. The transition from the previous facility-centred approach turns into an unprecedented political challenge. In fact, it implies the simultaneous deployment of ICT in large communities and the integration of clinical, organizational and economic information. The analysis of the ongoing transition processes in the most reactive countries shows that it takes several years to go through the following unavoidable phases: (i) diffuse awareness that innovative ICT solutions can improve quality of care and optimize resources, (ii) debate to reach a common vision across stakeholders and production of a White Book, (iii) definition of a long-term roadmap with short-term milestones, (iv) creation of an eHealth agency to support the coordination of ICT professionals and the dissemination of know-how, (v) launch an acceleration program with significant (federal) financial resources. The close cooperation among jurisdictions within a country and the international cooperation – throughout all the phases of this process – can produce faster and more robust solutions, at minor cost. Introduction
Correspondence: Angelo Rossi Mori Istituto Tecnologie Biomediche CNR Via G.B. Morgagni, 30/E I-00161 Roma e-mail: angelo@itbm.rm.cnr.it
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The next generation of ICT solutions in healthcare faces an unprecedented challenge, for the amount of resources simultaneously involved, the geographical scale and the need of integration of many heterogeneous information systems. It becomes a key political issue.
The deployment of the next generation of ICT solutions is a key political issue “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care”, said President Bush in his State of the Union Address of January 2004 [1]. A few days later, he affirmed that “moving American medicine into the information age” is a step that Congress can take this year [2]. The English government already took this step. In the last few months it signed contracts for 8 billions euro over ten years, to gradually deploy a lifelong Electronic Health Record (EHR) that will be safely accessible anytime and anywhere [3]. To achieve this goal, the National Program for Information Technology (NPfIT) will double ICT spending in the next three years, from the present 2% of the health budget to about 4%. In Canada, the central and regional governments in 2001 created Infoway, Inc. to accelerate the introduction of ICT in the health sector and in 2003 they provided an additional budget of 400 million euro. The President of Infoway declared: “Whereas in the U.S. health-care spending on information technology (IT) is around 5.5% of operating budgets, in Canada we invest only 1.8% of health care operating budgets for IT. The gap is even wider when we compare the health-care industry with other information-intensive sectors, such as banking and government, where IT spending ranges from 9–13% of operating budgets” [4]. Other highly reactive countries (in Europe as well in Australia) entered the same process, with strategic plans for the introduction of the EHR solutions and the related infrastructures, mostly deployed at regional level.
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An epochal change of perspective, refocussed the citizen’s needs
Towards a theory on the evolution of ICT and healthcare
The approach to ICT in healthcare was driven until now by the economic and managerial needs of each healthcare facility and by the clinical requirements of the individual healthcare professionals.
The diffusion of international standards specific for ICT applications in the health sector (e.g. DICOM [8], HL7 [9], ISO [10], CEN [11]), with pragmatic approaches for their effective usage (e.g. IHE [12]), is a prerequisite to reach the required levels of integration, at least from a technical point of view.
The focal point of the ongoing epochal shift are instead the needs of the citizen/patient (tab. 1). Table 1 ICT as a service for citizens. The deployment of modern ICT solutions can enable a citizen to: •
reduce waste of time for administrative procedures;
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take advantage of an effective continuity of care, thanks to an information system that facilitates collaboration among all the health professionals caring for him/her;
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access the up-to-date information about healthcare facilities;
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access – through the Internet and in his/her language – authoritative multimedia knowledge (on diseases, drugs and procedures) and the guidelines to express a more appropriate demand for care (see for example NHS Direct on-line [5]);
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manage in a secure way his/her personal clinical information (see for example “My Health Space” in NHS Direct [6]). This conversion requires the diffusion of clinical information systems [7], and the integration of clinical, organizational and managerial information within each healthcare facility. Moreover it requires the simultaneous deployment of coherent ICT solutions for all the facilities in communities of increasing coverage that, for several functions, will expand beyond the regional and national dimensions. Data warehouses for top management and for public health – timely fed by reliable information extracted from the care process and interpreted according to reference care pathways – will enable to consider the appropriateness of resources and the quality of care with respect to the specificity of individual patients.
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However, the process of change cannot be managed anymore through separate and independent decisions of individual healthcare facilities. From “technical awareness” to “political awareness”: agencies and acceleration programs In fact, according to the experiences observed in various countries, the “technical awareness” is not adequate to face the level of the challenge. It seems however to be a precondition to trigger the “political awareness”, and thus to enter a phase of public interventions to facilitate the close cooperation among all the involved stakeholders (i.e. national and regional authorities, standard developing organizations, hospitals and health trusts, health maintenance organizations, health insurances and third party payers, providers of software, services, telecom, security and hardware, together with the communities of health professionals, health informatics professionals and citizens). The political awareness progressively brings to strategic plans and then to the creation of permanent collaborative eHealth agencies at regional and national level [e.g. 13, 14, 15, 16, 17, 18]. These eHealth agencies perform a set of structural tasks according to an explicit roadmap: •
to manage the task forces that produce strategic and technical material;
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to organize meetings and portals to build consensus and disseminate know-how;
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to produce surveys and to monitor the deployment of the strategies in regions and pilot sites.
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The success of the coordination initiatives is making evident that large benefits will come by increasing the speed of nation-wide infrastructures and from a close synergy among the different jurisdictions, to drive a balanced and accelerated process of change management. Recently a few countries [e.g. 19, 20, 21] and the largest health maintenance organization in the US [22 ] entered a further phase: the EHR Acceleration Programs, providing additional resources that can exceed the billion of euro per year. The eras in the evolution of ICT in healthcare The combined evolution of organizational models for healthcare provision and of ICT solutions corresponds to a sequence of particular steps in health information systems, within and across organisations, up to a regional, national and international scale.
In the new period, the “neohitic period”, platforms and common services are developed to integrate subsystems within the hospital or to harmonise views for continuity of care within networks for particular pathologies. The deployment of ICT is managed at the level of a whole hospital or a local community.
During the prototaxic era, the evolution across the periods is left to spontaneous local initiatives, with a myriad of decision makers following different priorities according to their local contexts. For that reason, many local situations at different evolutionary stages (or even in the “pre-hitic period”, i.e. paper and pencil) may coexist within the same country.
For explanation purposes, this evolution is schematized here into 3 main eras (the first one is divided into three periods). Each step involves an optimal percentage of spending in ICT with respect to the healthcare budget (see fig.1). The steps in this evolution determine the approaches to ICT standards and the focus of research and development efforts, as well the innovation transfer modalities.
Several countries and Regional Authorities are realizing that nowadays the evolution should be suitably controlled, as described above. Therefore they are now entering in the “modern era” of eHealth, which implies regional integration and strategic federal initiatives to synchronize and accelerate the local processes. Moreover, there is a need for specific resources and infrastructures deployed at Regional and National level. Information systems should be patient-centred.
Firstly, information systems in the “prototaxic era” were mostly provider-centred. This is the era of the preliminary (proto-) organization (-taxon) on ICT solutions, when individual hospitals and local trusts were bringing information technology into the healthcare sector. This era can be divided into three periods:
Finally, we can expect that in future we will see a “utopian era”, to bring the healthcare sector into the Information Society, within a global systemic vision of ICT across all the economic sectors, including in particular social and health sectors and comprehensive e-government actions. The information systems will be fully citizen-centred.
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In the ancient period of Health Information Technology, the “paleoHITic period”, a number of hospital wards and services autonomously decided to implement each single application. In the intermediate period, the “mesohitic period”, communication between applications is pursued, by a first generation of international standards (HL7 [9], CEN [11]). The decisions typically involve several units within a hospital.
An opportunity for cooperation among jurisdictions To enter the modern era, each jurisdiction should activate a collaborative process of change management, with a proper blend of regulations, incentives, education and an appropriate amount of human and financial resources.
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Eras and periods in the evolution of ICT solutions in healthcare (with an estimate about the possible ideal spending on ICT over the healthcare budget) [23].
Each jurisdiction should develop a comprehensive vision on ICT solutions, customized to its actual context. This vision is the framework for a roadmap with long-term objectives, reached through an explicit sequence of partial milestones, and for the decisions of hospitals and local trusts. The unprecedented challenge requires a cooperation among Regions and countries In several countries, regions are already cooperating to define their role with respect to hospitals and local trusts, i.e. to promote not only the deployment of a technological infrastructure (e.g. by the e-government actions not specific for healthcare), but also of an information infrastructure (usually termed as “Infostructure”). The latter area deals with the logistic, methodological and conceptual support to ICT professionals and to decision makers, to exchange knowhow and best practices, to develop reference material and to increase the confidence on innovative ICT solutions and on new organizational models supported by ICT [23]. Quoting again the President of Infoway [3]: “Infoway’s value-added is our collaborative approach. By working in partnership with health-care providers and by developing interoperable solutions – usable and reusable by all health jurisdictions in Canada – Infoway ensures that each dollar invested provides maximum return and impact. Our analysis shows that if jurisdictions were to implement EHR in isolation, the estimated one-time costs climb to $3.8 billion. How-
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ever, with Infoway’s collaborative approach, the cost is estimated at $2.2 billion – a potential saving of $1.6 billion”. The distribution of tasks and the exchange of know-how across jurisdictions in the same country, and international cooperation, are crucial goals [24–26]. They are effective even in presence of significant differences in the organization of the healthcare systems and in the criteria for financing and reimbursing of care facilities. In fact, medicine is universal and basic functionalities involved in the care process obey to common principles. A demonstration of this axiom is the success of HL7 – the most widespread standard developing organization on ICT for health – that is currently involving about 30 National affiliates in the usage and in the further development of the standard. How to activate “unaware” countries Several “reactive” countries already started with their acceleration programs. On the contrary, in many “unaware” countries the enormous potentiality of modern ICT in healthcare is not yet adequately recognized. In countries like Italy there are many skilled people and optimal experiences, however they are too isolated to express together a proactive “willingness” at the country level, i.e. they are not able to impose in the country the debate with opinion leaders that will bring to eHealth agencies and acceleration programs.
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The lesson learned from the reactive countries could be transferred to the unaware countries, to learn how to trigger the passage to the modern era (tab. 2). For example, in Italy the spending on ICT is around 0.5% of operating budgets. Nevertheless, ICT is nowadays a mandatory component of a modern healthcare enterprise. Decision makers are not yet aware of the heavy costs of not using properly the modern ICT solutions. Hospitals and local trusts should be guided to overcome the budget limitations and to increase in a few years and in an optimal way the ICT spending towards some 5%. Decision-makers must be assisted to understand the opportunities coming from advanced ICT solutions, to adapt them to their own context, to develop a precise road-
Table 2 Some potential short-term actions to trigger a process of change management in “unaware” countries. • each hospital or local trust should recognize the crucial role of a Chief Information Officer (CIO) directly linked to the Chief Executive Officer and should make an aggressive plan for the enrolment of a suitable number of ICT professionals; •
each hospital or local trust should require, in the next contracts, the provision of certified applications (e.g. through IHE) and the usage of open standards (e.g. DICOM, HL7), according to National implementation guidelines and profiles;
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the eHealth community should produce a White Book on the opportunities for ICT in healthcare, with an appropriate debate to reach consensus on a common vision across all the potential stakeholders;
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the responsible of each National, Regional, local project should make easily available to the community a structured description of the project, its goals, its expected deliverables, its contribution to the overall vision, together with the collection of promotion and technical material already produced, in order to be able to compare the lessons learned from each project and harmonize their different solutions;
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each jurisdiction should set up a permanent Reference Centre, to transfer know how to and from ICT professionals, supported by a web-based virtual community and documentation centre [24, 27]. Appropriate resources should be devoted to look for cooperation with Reference Centres of other jurisdictions;
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the community of health professionals should begin to collect and compare the definitions of the structured content of the components of the Electronic Health Records, in relation to specific tasks and contexts (e.g. including diagnostic reports, discharge letters, disease registries, etc), in order to improve their coherence [28].
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map with limited initial actions to harvest immediately the economical effects and the improvements in quality. With the current spending, in the Italian local trusts and hospitals there are perhaps 3000 ICT professionals, i.e. a very low amount if compared to the 20000 professionals in the NHS in England (i.e. in a healthcare system similar to the Italian one), presumed to raise by another 7000 in the next three years. In turn, the market on the whole has difficulty to maintain a decent level of innovation and quality. It is a delicate issue to divert skilled professionals (in the public sector as well in the industry) from their daily activities, to deal with policies and investment on future. Therefore the most crucial action should be to create the context to optimize the benefits from the involvement of most competent professionals, i.e. to set up the framework for cooperation to transfer know-how and build a common infostructure. A Reference Centre with a permanent staff of full-time mediators should be set up in each jurisdiction, to select and transfer know-how to and from eHealth professionals, with appropriate resources to establish an international network among Reference Centres. Most countries should gain knowledge of the potential approaches how to increase awareness, how to build the community of eHealth professionals, and how to introduce the culture of standards. But the most crucial investment should be in the education. Within the hospitals, the current role of “technology manager” should evolve into the role of a “Chief Information Officer”, with a proper responsibility near the Chief Executive Officer. A large number of ICT professionals should be educated into the peculiarities of healthcare, and many new jobs for these eHealth professionals should be created, specially in hospital and local trusts. On the other side, the healthcare professionals should develop the skills on the innovative management of information with the support of ICT.
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Conclusions Information and Communication Technology (ICT) is ready to support the integrated management of clinical, organizational and economic data, with a dramatic improvement in the quality and appropriateness of care provision, as well in the effectiveness of clinical governance and managerial decision making, eventually based on accurate and timely data coming from the actual care processes. The effects on public health surveillance and control can propagate up to Regional and National Authorities. National and Regional Authorities – each within its own scope – may facilitate harmonization of local subsystems and their integration, by promoting the implementation of a technological infrastructure, of an informative infrastructure (infostructure) and of basic common services. It is an opportunity for cooperation at European level. We need to create a common vision and a robust context all over Europe, for the healthcare organizations on one side and for the industry on the other, encouraging the National and Regional customizations
according to well established criteria and/or guidelines for the implementation of the standards. Indirectly this infostructure will provide a large benefit to the industry too, as the substrate to support the expansion of the European market. In fact, the international convergence towards a common understanding of the framework and a robust methodology will in turn facilitate the development of new commercial services (indexes, registries, data warehouses, servers) and a proper diffusion of innovative commercial applications. The challenge is huge. Let’s learn together how to face it.
Acknowledgments The ideas presented here were developed through discussions with many colleagues linked to the following projects and organizations: CEN, Ehtel, HL7, Mobidis, Osiris, Prorec, Widenet. The documents on ehealth strategies are being collected and analysed by the OSIRIS Project, co-financed by the Italian Ministry of Health.
References
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1
George W. Bush. State of the Union Address, January 20, 2004. www.whitehouse.gov/news/ releases/2004/01/20040120-7.html.
2
George W. Bush. The President’s Address to the Nation, January 24, 2004. www.whitehouse.gov/ news/releases/2004/01/20040124.html.
3
“Senate Committee Endorses Infoway Strategy”. Press release 2002. www.infoway-inforoute.ca/ news-events/index.php?loc=20021028&lang=en.
4
NHS Care Records Service. Press release, 26 January 2004. www.doh.gov.uk/ipu/programme/ pressrelease26-01-04.pdf.
5
NHS Direct Online. Home page. www.nhsdirect.nhs.uk/.
6
NHS. Welcome to your NHS HealthSpace. https://www.healthspace.nhs.uk/.
7
Brian Raymond and Cynthia Dold. Kaiser Permanente Institute for Health Policy. “Clinical Information Systems: achieving the Vision”. 2002. www.kaiserpermanente.org/medicine/ihp/pdfs/raymond_feb_2002.pdf.
8
NEMA (National Electrical Manufacturers Association) and ACR (American College of Radiology). Digital Imaging and Communications in Medicine (DICOM). http://medical.nema.org.
9
Health Level Seven. ANSI-HL7. see www.hl7.org
10
International Standard Organization. Technical Committee on Health Informatics ISO/TC215. http: //secure.cihi.ca/en/infostand_ihisd_isowg1_e.html.
11
European Standard Committee. Technical Committee on Health Informatics CEN/TC251. www.centc251.org.
12
Integrating the Healthcare Enterprise (IHE). www.rsna.org/IHE (International Committee) or www.ihe-europe.org (European Committee)
13
Canadian Advisory Committee on Health Infostructure (ACHI). Tactical plan for a pan-canadian Health Infostructure. 2001 Update. www.hc-sc.gc.ca/ohih-bsi/pubs/2001_plan/plan_e.html.
14
Canadian Institute for Health Informatics (CIHI). Roadmap Initiative: lauching the process, year 3 in review. 2002. http://secure.cihi.ca/cihiweb/en/downloads/profile_roadmap_e_year3_review.pdf.
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Swiss Medical Informatics Integrated clinical information systems
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Marius Fieschi. Les données du patient partagées: la culture du partage et de la qualité des informations pour améliorer la qualité des soins. 2003. Rapport au ministre de la santé de la famille et des personnes handicapées. www.sante.gouv.fr/htm/actu/fieschi/sommaire.htm.
16
UK NHS Information Authority. Strategic Plan for 2002–2005. 2002. www.nhsia.nhs.uk/pdocs/board/Strategic_Plan_Summary_Final_Version.pdf.
17
Australian National Health Information Management Advisory Council. Health on Line – a Health information Action Plan for Australia. Second edition. 2001. www.health.gov.au/healthonline/docs/actplan2.pdf.
18
La Junta ha invertido ya 160 millones de euros para aplicar las nuevas tecnologías a la sanidad. Press release, 2003. www.andaluciajunta.es/SP/AJ/CDA/ModulosComunes/MaquetasDePaginas/AJ-vMaqCanalNot-00/0,17657,214288_214389_39558,00.html.
19
Canada Health Infoway Inc. Presentation of Business Plan. 2002. www.canadahealthinfoway.ca/pdf/CHIPresentation-BussPlan.pdf.
20
US National Committee on Vital Health Statistics. Information for Health. National Health Information Infrastructure (NHII). 2001. http://ncvhs.hhs.gov/nhiilayo.pdf.
21
National Programme for IT in the NHS (NpfIT). www.doh.gov.uk/ipu/programme/index.htm.
22
Rhonda l. Rundle. HMO Kaiser Plans to Put Its Medical Records Online. The Wall Street Journal. 2003. www.stdsys.com/kaiser_permanente.htm.
23
Angelo Rossi Mori, Fabrizio Consorti. A reference framework for the development of e-health – Bringing the Information Systems into the Health Systems, Bringing the Health System into the Information Society. 2002. www.e-osiris.it/data/docs/it252_reference-framework-16.doc.
24
OSIRIS Project to build an e-community on health ICT in Italy. www.e-osiris.it.
25
European Health Telematics Association (EHTEL) for the promotion of ICT solutions in healthcare across Europe. www.ehtel.org.
26
EUROREC European Institute for the Promotion of the Electronic Health Record. www.eurorec.net/ main.htm.
27
Italian National Research Council, Institute of Biomedical Technology. A collection of documents on National and Regional strategies on e-health from several countries. Interim release. May 2003. www.eosiris.it/e-library/databaseOnStrategies.htm.
28
Angelo Rossi Mori, Fabrizio Consorti. The prototype for an inventory of clinical data sets. 2003. The description of the activity and the inventory are available at www.prorec.it/registry.htm.
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Swiss Medical Informatics Development of National strategies for integration of ICT into healthcare in England
Development of National strategies for integration of ICT into healthcare in England Peter Drury
Summary
Information Policy Unit, Department of Health
This article traces how the strategies for integrating Information and Communication Technologies (ICT) into healthcare in England have evolved over the last 20 years or so. Since 1992 the direction of travel for IM&T has been guided by the principle of person-based systems that enable the integration of care around the patient, with good quality information for management (primarily) as a by-product. This way forward has been reaffirmed by Government and NHS-wide developments in citizen and patient-centred policies. Until 2001/2 progress in the NHS was based on local IM&T implementations guided by national strategy, standards and infrastructure. But this approach was not delivering what the NHS needed. Since then a national programme to deliver IT services has begun to accelerate progress in achieving integrated care.
effective healthcare and improved population health” [1]. The Information for Health strategy of 1998 was also a “national strategy for local implementation”. But it was accompanied by the announcement of a £1 billion investment programme. It also had widespread support from the clinical and management communities in the NHS. Delivery was predicated on the ability of health authorities to develop “local implementation strategies” that reflected local priorities so that they could achieve in their local information systems the vision set out in Information for Health. Although the strategy was funded with money to support local implementation, the funding went into local baseline budgets allocated to NHS organizations – albeit that it was “hypothecated” and then “ring fenced” for use on IT. In practice, however, the pressures of balancing the budgets and hitting other targets meant that in many NHS organizations the funds were spent on other priorities.
The 1990s
Correspondence: Dr Peter Drury Department of Health Information Policy Unit 1N07 Quarry House Quarry Hill UK-Leeds LS2 7UE Tel. +44 1132 54 62 56 e-mail: peter.drury@doh.gsi.gov.uk
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The early 1990s were a period in which the Zeitgeist of the market economy encouraged “a thousand flowers to bloom”. There were many suppliers of systems to general practitioners and hospitals. Many were “home grown” by enthusiasts. The 1992 strategy for NHS information systems gave a national lead in terms of policy, standards, guidelines, and disseminating good practice. But it was for managers, clinicians and IM&T staff locally to interpret and incorporate national policies into local strategies to maximize the opportunities from the central lead, and to make sound local procurement decisions which supported the strategy and complied with national standards. One verdict on this strategy was that “while it did deliver some important national infrastructure, it was over-concerned with management information, and failed to address the real needs of the NHS for information to help clinicians and managers deliver more
2000 to mid-2002 Until 2000 there was no framework for ICT across the public services in England. However, a strategic direction for the modernisation of public services was given in “e-Government: A strategic framework for public services in the Information Age” [2]. It proposed that the public sector must embrace new ways of citizen-centric thinking and new ways of doing business (e.g. using intermediaries). The intent is to give people information about and transactions with the services they want, when they wanted them and with the minimum cost and bureaucracy. And to do this the e-government interoperability framework of standards (such as e-gif ) was established [3]. The strategic direction for the modernisation of the NHS, as set out in the NHS plan published in 2000, reflects the e-Gov-
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ernment strategy. “Step by step over the next ten years the NHS must be redesigned to be patient-centred – to offer a personalised service” [4]. While the structure of the NHS evolves [5] shifting power closer to the “frontline”, and national standards for care are established [6], citizens need to have more choice and knowledge about services available, performance criteria, health conditions and treatment options. To support the delivery of the NHS plan, reflect the e-Government strategy and to update “Information for Health”, in 2001 a document was published entitled “Building the Information Core: Implementing the NHS Plan” [7]. This described how the integration of health services, both internally and externally in the context of e-Government, would be supported by the development of a modern ICT infrastructure capable of supporting a wide range of applications, knowledge management, and electronic records. During 2001, however, it was becoming clear that relying on “local implementation” to deliver the national health ICT strategy was not working. Many in the NHS were asking the Centre to take a stronger lead in delivery and arguing that whilst local ownership of solutions remained important, it was more important to have some robust national solutions in place which could be tailored locally. Particularly from a local perspective, the complexities of the IT procurement process were daunting, although the benefits of framework agreements in a national procurement strategy were acknowledged. Nevertheless, the NHS was clearly “punching below its weight” in getting value for money from IT procurements. At the same time, however, the Government was beginning the process of “shifting the balance of power” and decentralizing control. So a shift towards more central control of IT was counter-culture. Nevertheless, the inability of the NHS to take a long-term view of the need to invest in IT – difficult when there is frequent structural change in organizations and a high turnover of managers – was clearly threatening delivery of IT, and thereby the modernisation of the NHS. At the end of 2001, an important conference was held at which the then Secretary
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of State, the Rt. Hon Alan Milburn, and the NHS Chief Executive, Sir Nigel Crisp, affirmed the need for all to understand that Information and IT had to be part of the “mainstream” of modernisation. It was vital to invest in IT if the NHS is to become more patient-focused and patients receive integrated care [8]. In February 2002 a meeting with the Prime Minister secured that most vital ingredient in any corporate IT development namely support from the very top. The meeting endorsed the need for a dramatic increase in funding, a shift towards a centrally driven, standardized, performance-managed implementation. In April 2002, a report by Derek Wanless for HM Treasury entitled “Securing our Future Health” was published. It confirmed that “national, integrated ICT systems across the health service can lay the basis for the delivery of significant quality improvements and cost savings over the next 20 years. Without a major advance in the effective use of ICT the health service will find it increasingly difficult to deliver the efficient, high quality service which the public demand. This is a major priority which will have a crucial impact on the health service over future years” (paragraph 6.22) [9]. Wanless too argued for significantly greater investment of resource in IT. Mid-2002 to date In May 2002, the policy document promised at the February meeting with the Prime Minister and entitled “Delivering 21st Century IT” was announced [10]. Additional central funding IT was announced in late 2002 – £400 million for 2003/04, £700 million in 2004/05 and £1.2 billion in 2005/06. This funding was additional to local investment, currently running at about £850 million a year from baseline allocations. In order to protect the central funding, stronger controls will be introduced for its allocation. A further indication of the seriousness and determination behind delivering this national agenda for NHS IT was the decision to appoint a Director General of IT. An individual with the necessary expertise, experience and drive could only be found in the private sector and the UK Government had to be prepared to extend its salary structure to secure the best person.
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The Director General (Richard Granger) arrived in October 2002 and established the National Programme for IT (NPfIT). The National Programme is focussed, in its first phase on four key deliverables: appointment booking, an integrated NHS care records service, prescribing and an underpinning IT infrastructure with sufficient connectivity and broadband capacity to support the critical national applications and local systems that will be richer and richer in subsequent phases. The outcomes from this investment in the four key elements of NPfIT will be as follows: a summary patient record to assist out of hours and emergency care; improved patient-centred care through high quality integrated clinical systems for healthcare professionals. This will be available at the point of care and supply patient summaries, prescribing summaries, test and specialist referrals and results, digital images and assessment and care planning when and where required. Other systems will monitor admissions, lengths of stay and discharges to transform hospital bed management. Next, there will be improved choice and convenience for patients through electronic appointment booking and the electronic transfer of prescriptions. Electronic booking will reduce the waiting times for hospital appointments, the number of Did Not Attends and provide reassurance that care is progressing. The electronic transfer of prescriptions in the community will provide better value for money, improve patient safety and deliver the modern service that patients and the public expect. An infrastructure will be established with key national applications to support automated, technology-assisted care that will in turn support more local services for instant access, day surgery or intermediate care. Additionally, there will be investment in a modern high capacity broadband network that will support all of the NHS’ messaging and electronic transfer requirements. And finally, the largest corporate e-mail and directory service in the world will provide NHS staff with rapid electronic communications and access to online information and services. This will accelerate the flow of information around the NHS and thereby assist in the improvement of patient care.
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The procurement process for NHS IT has been transformed. The current National Programme is one of the world’s largest IT procurement programmes and has a challenging timetable for all parties to meet. Rapid procurement enables the speedy production of benefits to patients and has the added advantage of limiting the cost of bidding for suppliers. The process involved advertisement in the Official Journal of the European Community, the issuing of an Output Based Specification, evaluation of suppliers’ responses and negotiating contractual arrangements. The National Programme will deliver an integrated service to the NHS through the recently completed appointment of local and national service providers. National applications include the data spine for the Integrated Care Records Service and the national electronic booking service and these will be delivered by National Application Service Providers (NASPs). There will be a single National Infrastructure Service Provider (NISP) which will be responsible for the provision of networking and supporting services for the NHS that will underpin the National Programme for IT. For the local provision of IT systems and services, England has been divided into five geographic clusters, London, the South and the South East, the West Midlands and North West, the East Midlands and East of England and finally the North East, Yorkshire and Humber. A Local Service Provider (LSP) will have responsibility for delivering a full range of IT services in each of the clusters. They will ensure that national applications can be delivered locally to meet both national standards and local business needs. A Design Authority has been established to define the business and technical architecture for IT applications and systems and also the standards needed to ensure that suppliers develop software and systems that are compatible and capable of sharing information. It will draw on NHS, UK eGovernment, European and international IM&T standards as appropriate.
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Swiss Medical Informatics Development of National strategies for integration of ICT into healthcare in England
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The Way Ahead The delivery in the UK of broadband, digital TV and increasing use of mobile computing is likely to reinforce the existing direction of travel. This use of new media is focused on delivering an infrastructure that will allow citizens, patients, and those caring for them to make progressively better informed decisions at all stages of any care pathway (whether it is formalized as one or not), anywhere and at anytime. Building on the lessons learnt from local implementations from 1992 to 2002, the means of delivery is now shifting towards the “industrial strength” solutions needed to deliver integrated care to the required quality. But national installation of IT solutions needs NHS staff who are ready, willing and able to use it if the benefits are to be realized. Improving the management of information remains at least as great a challenge as delivering the necessary IT. And a way must be found of accelerating this agenda if the 21st century IT is to underpin the modernisation of the NHS as effectively as it could. References
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1
Information for Health. An Information Strategy for the Modern NHS. Department of Health. September 1998. www.doh.gov.uk/ipu/strategy/index.htm.
2
e-Government: A Strategic Framework for public services in the Information Age. Cabinet Office. London 2000. www.e-envoy.gov.uk/ukonline/strategy.htm.
3
The most up to date, interoperability-related, listings are held on www.govtalk.gov.uk – current subsections include: Gateway, e-GIF, XML Schema, Metadata, GCL, and e-Services Framework.
4
The NHS Plan. Department of Health, 2000. www.nhs.uk/nationalplan/.
5
Shifting the Balance of Power. Department of Health, 2001. www.doh.gov.uk/ shiftingthebalance/.
6
National Service Frameworks. Department of Health. www.doh.gov.uk/nsf/nsfhome.htm.
7
Building the Information Core: Implementing the NHS Plan. Department of Health, 2001. www.doh.gov.uk/nhsexipu/strategy/update.
8
Chief Executive Bulletin. 21 December 2001 – 3 January 2002. Issue 98. www.doh.gov.uk/ cebulletin3january.htm.
9
Wanless D. Securing our Future Health: Taking a long-term View HM Treasury April 2002. www.hm-treasury.gov.uk/Consultations_and_Legislation/wanless/consult_wanless_final.cfm.
10
Delivering 21st Century IT. www.doh.gov.uk/ipu/whatnew/deliveringit/nhsitimpplan.pdf.
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Swiss Medical Informatics Modernizing healthcare in Germany by introducing the eHealthcard
Modernizing healthcare in Germany by introducing the eHealthcard The Action Programme Information Society Germany 2006 and the Healthcare Reform Gottfried T. W. Dietzel, C. Riepe Federal Ministry for Health and Social Security, Bonn-Berlin
Germany has a healthcare system using sophisticated technologies. But the sectororiented service structures and pillars of our healthcare system are also reflected in the area of ICT. In the German healthcare system every institution in itself is an isolated solution, partially in line with the latest scientific research, but singular. As a rule, the limits of information technology are reached where the economic and business capacities of one’s own institution are exhausted. Therefore the existing solutions regularly have to cope with the problem of incompatibility, only in exceptional cases there is a well functioning interoperability. Consequently, the essential advantage of telematics, which is in particular the use of synergistic benefits, is given away. Also the advantages offered by disease management programmes which do not focus on the structures of services but on persons, could still be consolidated by digital documentation covering and connecting a broad range of institutions. Therefore both the infrastructural conditions for the use of telematics have to be improved and also important key applications such as the electronic prescription have to be boosted. By introducing the new electronic health card, the nationwide use of health telematics in Germany can be promoted. The activities of the Federal Government and the legislation initiated within the scope of the Act on the Modernization of the Statutory Health Insurance (Health Reform 2003) serve these improvements. The Federal Government is striving for a nationwide and cross-institutional networked use of information technologies.
Correspondence: Gottfried T. W. Dietzel Federal Ministry for Health and Social Security D-10000 Berlin
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The resolution unanimously adopted at the 75th Conference of Health Ministers in 2002 showed that nowadays the stakeholders consider telematics to be generally indispensable. For the first time the provision of quality-assured health information e.g. by establishing health information portals for
the general public is formulated as a public function of the Federal Government and the Laender. The Working Group of the Federal Government and the Laender on Telematics in Health Care has been commissioned to develop, in co-operation with the Federal Ministry of Health and Social Security, a national strategy for the nationwide and interoperable use of health telematics applications, connected with a binding plan describing the steps of implementation. This is a joint task of the Federal Government, the Federal Laender and the selfgoverning bodies in the healthcare system (Selbstverwaltung). To this end, the basis of the Federal Government’s work will be the agreement reached with the central organisations in the healthcare system on a joint action for the further development of telematics. In their declaration of 3rd May 2002 the Federal Ministry of Health (and Social Security) and the central associations of self-administration committed themselves “to develop a new infrastructure for telematics on the basis of a general framework architecture, to improve and/or introduce the electronic communication (electronic prescription, electronic discharge letter by the physician) and to introduce the former health insurance card as an electronic health card in the future”. The stakeholders agreed that they wanted to find joint solutions to further details, functionalities, standardization, and financing because of the common benefit to be expected. For this purpose a Steering Group on Telematics has been established where all stakeholders involved are represented, ranging from the Federal Government Commissioner for Matters related to Disabled Persons via the Data Protection Commissioner, the self-governing bodies, the patients’ representatives up to scientists. Its tasks include the formation of political consensus and the
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development of a national strategy for the use of health telematics. These measures are accompanied by activities of the Action Forum on Health Telematics and of the German industry, and furthermore by research and pilot projects of the Federal Ministries of Education and Research and of Health and Social Security which will develop and test approaches to solutions in specified problem areas. This includes the prerequisites for qualityassured health information portals for the general public on the Internet. A particular important measure is the funding of the fundamental project of IT architecture: “bIT4health – better IT for better health”. The German activities are connected with the European agreements to establish infrastructures for health telematics (eEurope 2002 and eEurope2005 Action Plans). •
The objective is the standardization of a communication infrastructure based on a harmonized framework of IT architecture promoting competition. The electronic health card has an important role as a flagship project in building up an infrastructure for telematics.
•
In 2006, 80 millions of electronic health cards, giving also access to medical data, are to be distributed to persons insured under the statutory and private health insurance scheme.
•
The use of the electronic health card is linked with an electronic health professional card (HPC). A corresponding initiative has been launched by the Laender for this purpose – parallel to the activities of the German Medical Association. By the year 2006 about 300,000 HPCs with a digital signature could be distributed.
•
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As of 2006 it will be feasible to electronically deal with about 750 million prescriptions every year. Since the electronic prescription offers the opportunity of connecting the drug documentation with drug information systems, the side effects and undesirable interactions
of pharmaceutical products can be considerably reduced. In conjunction with the drug documentation the electronic prescription will lead to an improved supply of pharmaceutical products and to annual savings amounting to more than 1 billion euro. •
The electronic prescription is also meant to support the electronic commerce with pharmaceutical products in Germany and other states of the European Economic Area, which will become possible as of 1st January 2004.
•
The electronic health card is the lead-in to the electronic patient record.
•
The distribution is connected with the introduction of the European health insurance card (carried on the reverse side substitute for the European health insurance certificate E-111. In a first step, the card will be issued in an “eye-readable format” but offering the possibility of integrating electronic data sets. By the year 2008 decisions are foreseen on the transition to an electronic health card. The decisions reached in Seville and the eEurope 2005 Action Plan envisage the extension to further functionalities, e.g. the storage of emergency medical data and the accessibility of electronic patient records.).
Infrastructure and framework architecture of telematics The systems which are used also have to be capable of communicating electronically. A prerequisite for this is the concept of a general structural framework of telematics and an adequately integrated security infrastructure. “bIT4health – better IT for better health” – this was the approach by the Federal Ministry of Health and Social Security when the task of providing support for the introduction of the electronic health card was launched. Its objective is the lasting standardization of an information structure,
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based on a harmonized sustainable architecture of telematics. The results should be generally valid and should be neither affecting competition nor depend on the respective product. A migration concept is being developed for the procedures and components so far. In this way the ability to plan sustainable and to achieve added values is assured for all stakeholders. The foundations have already been laid by European projects as e.g. TrustHealth and PICNIC as well as by recommendations on telematics by the German industry. Groundwork was also done by Teletrust e.V., the working groups of “BundOnline” and the Action Forum on Health Telematics. The existing activities have to be closely interlinked with one another. All decisions within this project should be made in transparency and be discussed with the authoritative partners of industry and the self-governing bodies. The final agreement on a framework architecture for telematics in the German healthcare system is to be reached within the Steering Group and according to § 291a SBG V. Electronic health card In his policy statement of 14th March 2003 – accompanying the “agenda 2010” – the Federal Chancellor Gerhard Schröder acknowledged “that we have not fully exhausted the potential inherent in a modernization of communication technology in the health service”. In this connection he announced that in addition to the electronic patient record, an electronic health card is to be introduced by 1st January 2006. Now that the Act on the Modernization of the Statutory Health Insurance has been adopted by the Bundestag and the Bundesrat, the legal basis for realizing this project definitely exists. Electronic health cards and HPCs will become the electronic keys for the crossinstitutional co-operation of the stakeholders in healthcare, interlinking more than 80 million patients with about 270,000 physicians, 77,000 dentists, 2000 hospitals, 22,000 pharmacies and more than 300 health insurance funds. In its function as a second generation patient chip card, the electronic health card
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is going to replace the now available electronic health insurance card. Its technology and functions will be extended and it shall be offered to the insured persons for use as a health card. For this purpose it is necessary to arrange the health card as a microprocessor card which is suitable for electronic identification, encryption and digital signature. In this way the best possible reliability and security of the data can be guaranteed. As a rule, the use of the new card as a health card shall be voluntary. This means that every insured person will receive a new electronic health card with its administrative functions, but it will be left to his/her discretion whether he/she wants to make use of the additional functions, i.e. the medicinal part, or not. The use of the administrative part of the electronic prescription shall become obligatory. The electronic health card has a particular significance for enhancing links between the patients’ data which are distributed and documented at different places. In its function as a link between the electronic prescription and the electronic patient record it does not only improve the emergency medical treatment and/or the drug and therapy safety. New applications of telematics are being developed and/or may occur. The electronic health card is a communications interface between the various bodies responsible within the German healthcare system – in the patients’ hands. Holding their cards and on the basis of their authorization they are deciding themselves on whether and which additional information is stored and who may be given the right to access. The implementation of their already existing rights to have access to the documentation themselves and to receive hard-copy printouts and/or copies of it, will be facilitated. In connection with their personal signature card bearing a qualified signature, they may also handle their personal data or data made available to them by their physicians in a particular personal folder. For data protection controls every access is recorded and the last 50 ones are stored. One of the essential preconditions for the acceptance of the card is a convincing data security concept. During the last legislative term the amendment of the Digital SignaSMI 2004; No 52
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ture Act provided an important prerequisite for a secure communication within the healthcare system. Apart from a few controlled exceptions, the use of the electronic health card shall, as a rule, only be possible in connection with a health professional card (HPC) bearing a qualified digital signature. Electronic patient record The electronic health card serves as the basis and thus also as a lead-in to other applications of telematics, as e.g. the electronic patient record. Within an infrastructure of telematics and on a medium-term basis, the electronic patient record is an important patientrelated information link for the various bodies responsible for healthcare in the outpatient, in-patient, rehabilitation and nursing care sector. It provides for the informational basis for integrated healthcare and disease management programmes. Thus far there are only isolated solutions and proprietary offers – both at national and also at European level. At European level, however, the concepts are currently being driven by the initiative “EUREC” (European Medical Record) with the participation of the German industry and by the work of the Action Forum on Health Telematics. Yet, important aspects of data protection have to be settled. The rights of access to patients’ data being stored in various places but virtually integrated in the electronic patient record have to be defined. To this end, new IT solutions are being developed which have to be extended. In this connection the civil liberties of the patients to the protection of their data have to be balanced with their right of the best possible treatment. In this context the introduction of the voluntary concept of the electronic health card is a pragmatic intermediary step emphasizing the patients’ rights with regard to control over and release of their medical data. Electronic prescription In today’s processes the prescription undergoes several expensive discontinuities of media. The largest part of the about 750
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million prescriptions per year is issued by PC, then, however, they are printed for the patients. Later on the pharmacies pass the paper prints to their data processing centres for scanning and for the purpose of reimbursement by digital processing and from there they are sent to the health insurance funds. The electronic prescription improves both, the writing and issuing of the doctor’s prescription and also the subsequent processing and accounting procedures. To this extent the electronic prescription is an example of best practice of a telematics application which pays its way economically, even in the short term. The interaction of drug documentation and drug information systems decisively improves the quality of treatment. Undesired side-effects can be avoided more easily and personal incompatibilities can be taken into consideration. At the same time a more efficient and rapid communication between physicians, pharmacies and health insurance funds becomes possible – without discontinuities of media. By inclusion of all stakeholders of healthcare, the electronic prescription is therefore attributed a key role in the introduction of information and communication technologies in healthcare. Evaluation, transparency In view of the increasing relevance of IT applications in healthcare, adequate framework conditions for introducing further applications of telematics have to be developed and stipulated. Prior to the selection of concrete telematics applications and systems they have to be evaluated on a technical, economic and medical background (HTA). Surveys on procedures applied in practice or still being developed have to be elaborated and assessed systematically (determination and selection of best practices). As a basis on the way to this end, the “TELA” database is currently being established in co-operation with the Federal Laender and harmonized with the corresponding European activities of the eEurope 2002 Action Plan. It shall be made available to the general public and accompany the development of evaluation procedures for telematics applications.
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Patient empowerment With the increasing use of the Internet the patients can be given opportunities of information connected with a rapid, simple and low-cost access to medical knowledge, in the interest of an improved health promotion and preventive healthcare. At the same time, however, the risks of health information imparted via the Web are growing, since to a large degree its quality and reliability are beyond any regulatory influence. Top quality information as well as dubious publications, useful pieces of advice as well as dangerous recommendations can be found there. At the same time the Web technology serves as a basis for new forms of commercial offers (e-commerce) and new possibilities for the arrangement of product-related advertising (interactivity, linking, combination of advertising messages with reliable health information).
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were elaborated, AFGIS participated as a non-governmental organization on behalf of the Federal Republic of Germany. The transparency criteria adopted by AFGIS correspond to the European quality criteria recommended for health-related Web sites. Therefore the Federal Government continues to support the application of this model scheme in the appropriate EU committees. Moreover, there are endeavours to develop and test the conditions and structures for a public health portal of the Federal Government operationalizing the criteria of AFGIS for a central public health portal. In this way IT is now ready to serve as the major tool for the modernization of the German Healthcare System, improving quality and efficiency at the same time, within a new eHealth environment.
Well-established methods of quality controlled publication are working to an only very limited extent on the Internet. The more important are those procedures of quality assurance which develop efficient quality seals for the orientation of Web users. In the interest of the patients, the origin of recommendations has to be transparent on the one hand, and their medical reliability has to be ensured on the other hand. The “eEurope 2002� Action Plan has created a European framework by elaborating a key set of common quality criteria. At the same time the Federal Government initiated the Action Forum for Health Information Systems (AFGIS) where in the meantime more than 150 suppliers of health information services, bodies responsible for health education as well as institutions and organizations in the fields of consumer and patient protection as well as of quality assurance have joined to build up a quality network. In this way reliable health information on various topics is available to both, the health professions and also to the patients. The standards and structures for quality assurance and quality control which have been developed in the AFGIS working groups receive considerable attention at an international level, too. When the EU quality criteria for health-related Web sites
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Swiss Medical Informatics Progress Report on European Healthcare IT
Progress Report on European Healthcare IT
Murray Bywater, Véronique Lessens Health Information Network Europe (HINE)*
Research studies conducted in 2003 for Health Information Network Europe (HINE)* revealed a number of major concerns relating to healthcare IT policy areas in Europe. These included: •
discrete and outmoded government policies;
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little enthusiasm for providing central IT funding;
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predominance of ageing legacy systems in hospitals;
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little provision for integrated shared infrastructure;
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lack of large scale competitive service suppliers;
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problems with access, control and distribution of data.
Despite this, there are many signs that the healthcare IT market is at a critical flexing point with a period of substantial change expected over the coming years. This paper discusses the current situation for healthcare IT in Europe and the immediate prospects for change.
based demand for improved healthcare services. Healthcare is one of the last great “unreconstructed” industry sectors in the Western World. Despite deploying amazing leading edge technologies in medical practice, basic service delivery concepts have remained effectively unchanged for 1000 years. Healthcare business process differs fundamentally from other service industries. It is significantly more complex – and less amenable to a conventional systems approach. Personal health data is unusually voluminous, difficult to collect and changes over time. As medical technology has advanced, the process “components” that make up the full continuum of care have increased in number and sophistication. Despite heroic efforts to cost justify higher expenditure, typical European investment levels in healthcare IT have remained static at around 1% of total revenue. Now, in the USA and Europe, a new set of common political imperatives is driving demands for additional funding to establish effective healthcare IT infrastructures: •
pressure to secure acceptable levels of patient safety;
European healthcare IT facing period of unprecedented expansion
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expectation of “consumer-type” access to health services;
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need for radical improvements in service productivity;
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impact of increasing complexity of healthcare processes.
Murray Bywater HINE - Director mbywater@deloitte.com
Over 25 years, healthcare has fallen progressively behind other service sectors in terms of relative levels of IT investment. Deployment of IT in many sectors has delivered major transformational change together with significant improvements in the personal productivity of service providers. These changes are reflected in many facets of modern society, and provoke the question: “Why has this not happened in healthcare?”
Véronique Lessens HINE - Manager vlessens@deloitte.com
The answer lies partly in the nature of healthcare business processes themselves and partly in the delayed impact of consumer-
* HINE provides strategic market support to assist planning and investment decisions for senior management regarding European Healthcare IT and associated eHealth sectors. Correspondence: Deloitte – HINE Berkenlaan 8b B-1831 Diegem Tel. +32 2 800 28 28 e-mail: mail@hineurope.com website: www.hineurope.com
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These developments will generate unprecedented expansion in healthcare IT, with European eHealth expenditure predicted to approach 50 billion per annum by the end of this decade.
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Increasing clinical complexity driving need for IT support To compound the problem, medical practice is growing exponentially more complex – with no sign of slowing. Coping with these changes presents a big challenge to individual clinicians (assimilating huge amounts of essential information) and healthcare enterprises (integrating interdependent services of many different healthcare professionals). These challenges are typified by point of care IT support for electronic prescribing (EP). EP is considered a good measure of “gold standard� healthcare IT in the acute hospital sector. Current USA emphasis on reducing avoidable medication errors has generated a boom market for Computerised Physician Order Entry (CPOE) that will be replicated in European markets.
Forecast healthcare ICTexpenditure growth. Source: HINE, 2003.
Demographic time bomb ticking for healthcare services Increased life expectancy and lower birth rates have changed the balance between working (young) and retired (old) people. As average ages of the population increase, more and more elderly people are expected to survive for significant periods (tens of years) with medical conditions that require multiple medication and healthcare interventions. Latest population forecasts indicate that the number of retired and chronically sick people in Europe will exceed the working population by 2020. Apart from the potential cost of dealing with this increase in demand for healthcare services, there is an even more serious problem in terms of lack of people (at whatever cost) to deliver services in the way to which we have become accustomed. These problems manifest themselves not only in failure of health provider systems to meet growing demand, but also in increasing consumer dissatisfaction with the quality and effectiveness of the sub-optimal services now being delivered.
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Prescribing processes in the USA are different from those in Europe. US clinicians enter prescriptions as notes in the patient record and then pharmacists transcribe these into the Medication Administration Record (MAR). Specific medication orders are supplied in individual packaging for each dose rather than as a bulk pack for distribution from ward stocks. In this respect, both legal status and supply processes are different. There is a potential opportunity to break these processes down into a more configurable approach where the same software components are appropriate for worldwide prescribing needs. Medico-legal issues impacting European healthcare market With widespread adoption of classic consumer attitudes towards healthcare delivery, there has been a rapid growth in European medical litigation. Given the alarming increase in adverse medical incidents (medication errors already result in deaths on a scale approaching that attributable to motor accidents), the rise in litigation levels is hardly surprising. Other industries would be neither prepared, nor allowed, to accept this level of malfunction in critical and potentially life threatening circumstances. Industries such as air travel, motor manufacture and food distribution have had to learn how to cope
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with management of quality and risk to acceptable and sustainable levels in the face of rapidly growing mass markets. European Governments are now becoming aware of the scale of this problem in healthcare, and more effective deployment of IT support is seen as an essential ingredient for improving patient safety. Use of electronic communication of orders for tests and procedures, in conjunction with standard order sets, profiles of care and clinical governance protocols not only reduces the risk of adverse medical incidents but also improves productivity and supply chain efficiency. Legal precedent indicates that courts are prepared to accept electronic data from order communication systems as evidence of compliance with best practice. Clinicians are also becoming aware of the potential personal benefits of practising in an institution where clinical governance and operational best practice are built into corporate computer systems. Radical improvements being demanded in healthcare productivity Experience in other comparable service industry sectors indicates that effective deployment of IT support at the point of care is a key requirement in order to achieve really big increases in productivity. For these service industries, commodity networking and communication technologies, together with growth of the Internet and associated technologies, have revolutionised service delivery and enabled transformational change. If similar pressures for change and productivity improvement in healthcare delivery are to be met, a step change in the level of IT investment and the delivery capability of industry is required during the next decade. Current emphasis on discrete IT solutions at the point of care addresses a perceived need for more “better” clinical systems. But this has led to replication and support of existing processes, rather than utilising full strategic capabilities of IT for enabling transformational change. It has proved consistently difficult to cost justify IT investment at the current sub-optimal level and there is clear evidence that substantially higher investment is required to generate significant
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returns in terms of greater productivity and better value for money as reflected in scale, scope and quality of healthcare services. However, the current structure of healthcare IT markets in the Europe has given cause for concern on several different fronts: •
lack of large scale well financed suppliers of healthcare enterprise systems;
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problems with growth and profitability for innovative small-scale suppliers of specialist clinical systems;
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difficulties for major technology vendors in working though specialist healthcare solution IT suppliers as distribution channels;
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challenge to identify appropriate funding sources for shared ICT infrastructure at regional or national level;
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reluctance of healthcare users to deploy high level strategic and change management support;
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failure to engage necessary resources for large-scale technical integration and project management.
While traditional healthcare IT suppliers are struggling with integration at the healthcare enterprise level, European Governments are now working directly with technology suppliers to focus on integration between different enterprises within healthcare communities at regional, national or even international level. Progressive globalisation of IT and telecommunications industries – and also pharmaceutical and medical device suppliers – is helping drive demand for larger scale integration. Electronic patient records (EPR) represent a pivotal application enabling patient information to be shared between different authorised users – including patients themselves. Governments taking action to develop eHealth ifrastructures The need for urgent action to stimulate IT investment in healthcare is now focused
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clearly on the role of Government in dealing with provision of universal access to shared Healthcare IT infrastructure. The political imperatives are clear – and beginning to be recognised on a worldwide scale. Because of its political structure, Europe is uniquely positioned to take a strategic lead in this important aspect of the eHealth market. In addition to active programmes for promotion of specific telehealth applications, Europe also has unique industry strengths in telecommunications, biotechnology and diagnostic devices.
To meet these challenges, European Governments need clarity and confidence in areas of:
But healthcare is rapidly becoming a global industry, and Europe can no longer expect to act in isolation from other leading markets, notably the USA. The challenge, therefore, is to engage effectively with European and global industry representatives to ensure that Europe is properly equipped to take maximum advantage from emerging eHealth technologies and solutions. This involves high-level collaboration with leading industrial organisations that have the financial and technological strength to tackle intransigent structural and cultural problems in healthcare delivery.
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strategic future vision for eHealth;
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plans for modernising care delivery;
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identification of operational benefits;
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incentives for transformational change;
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understanding of infrastructure needs;
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effective partnerships with industry;
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awareness of global market trends;
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acceptance of need for market diversity;
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cross-agency policy collaboration;
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willingness to invest adequate funds.
However, time is not on our side if the demographic challenge is going to be met. Complex healthcare systems will require 10 years for effective implementation – and 2020 is only 15 years away. Now is the time for action, and the immediate need is to identify practical short-term steps that will make a positive contribution towards longterm transitional strategies – and then provide the political leadership to ensure they are put into effect.
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Swiss Medical Informatics Impressum
nächste Ausgabe: Juni 2004 prochaine édition: juin 2004
Events
Die nächste Ausgabe des Swiss Medical Informatics erscheint im Juni 2004 und behandelt folgendes Thema: • „Mobile Medicine“
La prochaine édition du Swiss Medical Informatics paraîtra en juin 2004 et traitera le sujet suivant: • „Mobile Medicine“
MEDINFO 2004 7-11/9/2004, San Francisco, USA www.medinfo2004.org
AMIA 2004 10-13/11/2004, Minneapolis, USA www.amianet.org/annual/next/ overview.html
GMDS 2004 A Joint Conference of the Medical Informatics Associations of Austria, Germany and Switzerland 26-30/9/2004, Innsbruck, Austria www.gmds2004.de
Impressum Publikationsorgan der Schweizerischen Gesellschaft für Medizininformatik Organe de publication de la société suisse d‘informatique médicale Herausgeber / Editeur SGMI, Schweizerische Gesellschaft für Medizininformatik c/o VSAO Dählhölzliweg 3 Postfach 229 CH-3000 Bern 6 Tel. 031 350 44 99 Fax 031 350 44 98 e-mail: admin@sgmi-ssim.ch Internet: http://www.sgmi-ssim.ch/ Vorstand der SGMI / Comité de la SSIM Martin Denz, Antoine Geissbühler, Felix Heer, Christian Lovis, Eusebio Passaretti, Benno Sauter, Judith Wagner, Ulrich Woermann, Chefredaktor / Rédacteur en chef Rolf Grütter Redaktion / Rédaction Rolf Grütter, Christian Lovis, Ulrich Woermann Editor for SMI 52 Martin D. Denz
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Redaktionsadresse / Adresse de rédaction Rolf Grütter Institut für Medien- und Kommunikationsmanagement Universität St. Gallen Blumenbergplatz 9 9000 St. Gallen e-mail: rolf.gruetter@unisg.ch Layout / Mise en page Jürg Hirsiger Abteilung für Unterrichtsmedien AUM Universität Bern Inselspital 38 3010 Bern Autorenrichtlinien / Directives pour les auteurs http://www.sgmi-ssim.ch/smi/index.htm Verlag / Editions Schwabe AG Steinentorstrasse 13 4010 Basel Betreuung im Verlag: Dr. Markus Trutmann Tel. 061 467 85 55 Fax 061 467 85 56 e-mail: mtrutmann@emh.ch
„eHealth 2005“ München 19. - 21. April 2005 http://atg.gvg-koeln.de
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