Identity Conference: modernization of health processes in Belgium

14/05/2014

Frank RobbenGeneral manager of the eHealth platformQuai de Willebroeck 38B-1000 BrusselsE-mail: Frank.Robben@ehealth.fgov.beWebsite eHealth platform https://www.ehealth.fgov.bePersonal website: www.frankrobben.be

Some evolutions in health care

•more chronic care instead of merely acute care•remote care (monitoring, assistance, consultation, diagnosis, operation, ...), and home care•multidisciplinary, transmural and integrated care•patient-oriented care and patient empowerment•rapidly evolving knowledge => need for reliable and coordinated management and access to knowledge•threat of excessively time-consuming administrative processes•thorough support of health care policy and research requires thorough, integrated and anonymised information•cross-border mobility•need for cost control

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These evolutions require...

• collaboration between all actors in health care• efficient and safe electronic communication between all actors in

health care• high-quality electronic patient files, across specialties• care pathways• optimised administrative processes• technical and semantic interoperability• guarantees concerning

– information security– privacy protection– respect for the professional secrecy of health care providers

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Overall objectives of the eHealth platform

• how?– through a well-organised, mutual electronic service and information

exchange between all actors in health care– by providing the necessary guarantees with regard to information security,

privacy protection and professional secrecy

• what?– optimisation of health care quality and continuity – optimisation of patient safety– reduction of administrative burden for all actors in health care– thorough support of health care policy and research

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eHealth platform In practice

The patient consults his doctor

Administrative advantages

Possibility to register therapeutic relationships and informed consent

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Medical advantage

s

eHealth platform In practice

Laboratory results

Look up medical history through the

SumEHR

Medication schedule

Online advice and guidelines

Electronic medical referral form

Electronic prescriptions

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Adminis-trative

advantages

eHealth platform In practice

Tarification,billing

Create and send

certificates

Update SumEHR, medication schedule, ...

Send a report to the GMF owner

Registrations

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Basic servicesBasic serviceseHealtheHealth platform platform

Network

Basic architecture

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Patients, health care providersPatients, health care providersand health care institutionsand health care institutions

VASVAS VASVASVASVASSuppliers

Users

Overall Overall objectives of objectives of the the eHealtheHealth

platformplatform

Health portalHealth portalAVSAVSAVSAVSAVSAVSAVSAVS Software Software

health care health care institutioninstitutionAVSAVSAVSAVSAVSAVSAVSAVS

MyCareNetMyCareNetAVSAVSAVSAVSAVSAVSAVSAVS

Software Software health care health care

providerproviderAVSAVSAVSAVSAVSAVSAVSAVSSite NIHDISite NIHDIAVSAVSAVSAVSAVSAVSAVSAVS

VASVASVASVASVASVAS

8

10 basic services

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1. integrated user and access management2. orchestration of electronic subprocesses3. portal environment (https://www.ehealth.fgov.be)4. logging management5. system for end-to-end encryption6. personal electronic mailbox for each health care provider (eHealthBox)7. timestamping8. coding and anonymisation9. consultation of the National Register and of the Crossroads Bank

Registers10. reference directory (metahub)

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6.1. integrated user and access management: makes it possible to guarantee that only authorised health care providers/ health care institutions have access to personal data to which they are authorised to have access

• access rules are defined by, among other things, the law and authorisations issued by the Health Section of the Sectoral Committee (established within the Privacy Commission)

• each application defines its own access rules • when a user authenticates his identity (using the electronic identity card

or token), the generic verification model of the tool is set in motion: it consults the rules established for the application, verifies if the user does indeed meet these rules and accordingly grants or restricts access to the application

10 basic services

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Integrated user and access management

• identification and authentication of physical and legal persons

• management & verification of characteristics (e.a. a capacity, a function, professional qualification) of persons

• management & verification of mandates between physical or legal persons

• management & verification of authorisations

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Integrated user and access management

Kids-ID: on demand for children below the age of twelve

Foreigners card: for both EU and non-EU citizens with residence in Belgium

Electronic identity card (eID): statutory electronic identity card for Belgians over the age of twelve

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Electronic identity card (eID)

authenticate identity

read data

digital signatures

+

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Electronic identity card (eID)

1. Install eID software

2. Connect the card reader with the computer

3. Consult your data

Integrated user and access management

UserPolicy

Application(PEP)

Application

PolicyDecision (PDP)

Policy Administration

(PAP)

Policy Information(PIP)

Policy Information(PIP)

Policy Repository Authentic Source Authentic Source

Administrator

Action on application

Action on application ALLOWED

Action on applicationDECLINED

Fetch Policies

InformationQuestion/Answer

InformationQuestion/Answer

Decision answer

Decision request

Authorisation management

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6.2. orchestration of electronic subprocesses: allows for the flexible and harmonious integration of the different processes that are linked to the implementation of several basic services into one, single application

6.3. portal environment: a web window offering a variety of online services to health care actors in order to help them provide the best possible health care; the portal environment provides all useful information on the services that are offered by the eHealth platform, its tasks, its standards, etc. It contains, among other things, the documents users need to configure the right settings in order for them to have access to the available online services

10 basic services

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6.4. logging management: management of a register of access to the information management system: all read, write and delete accesses are registered and have probative value in case of a complaint

6.5. system for end-to-end encryption: transfer of complete and unmodified data from one point to another by making them indecipherable (encryption), provided that these data have not been decrypted with a keyTwo methods:• In the case of a known recipient: use of an asymmetric encryption

system (2 keys)• In the case of an unknown recipient: use of symmetric encryption

(the information is encrypted and stored outside the eHealth platform; the decryption key can only be obtained through the eHealth platform)

10 basic services

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6.6. timestamping: makes it possible to assign a time and date, accurate to the second, to a health care document and thereby makes it possible to permanently ensure the validity of its content by appending an eHealth signature

6.7. coding and anonymisation: makes it possible to hide the identity of individuals behind a code, so that the useful data of these individuals can be used without infringing on their privacy + makes data anonymisation possible by replacing patients’ detailed characteristics with generalised characteristics. These encoded or anonymised data preserve their usefulness, but without allowing the direct or indirect identification of the person

10 basic services

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6.8. consultation of the National Register and Crossroads Bank Registers:

authorised health care actors access the National Register and the Crossroads Bank Registers under strict conditions

6.9. eHealthBox: a secured electronic mailbox for the exchange of medical data

6.10. reference directory: indicates which types of data are stored, by which health care

actors and for which patients, with the consent of said patients

10 basic services

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Value-added services

65 value-added services in production 40 value-added services under study

Some examples of value-added services:• registration in and consultation of the Cancer registry, the registry of hip and knee

prostheses (Orthopride), the registries of care provided for heart implants (Qermid), the shared electronic arthritis file, including electronic processes for the reimbursement of anti-TNF medication (Safe)

• PROCARE RX allows radiologists to upload and send anonymous X-rays and information to experts for review or a second opinion

• reports on MUG interventions• Resident Assessment Instrument (BelRAI)• electronic medical card for people without documents (eCarmed)• consultation of living wills regarding euthanasia• electronic registration and consultation of the medical evaluation of disabled people• electronic birth registration – eBirth

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Cornerstone: Multidisciplinary data sharing

1. data transmission

– snapshot of the data

– sender chooses recipient

– sender is responsible for sending the data only to recipients who are entitled to have access to these data

2. data sharing

– evolutive data

– the source does not know in advance who will consult the data (e.g. on-call GP)

– necessity of clarifying which people are entitled to have access to the data

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Data transfer: eHealthBox:

• sending of messages to "actors in health care"– based on

• national Register number• NIHDI number• CBE number

– through web application or integrated into the medical file– with (or without) encryption based on eHealth certificates/ eHealth keys– other functionalities

• receipt, publication and reading confirmation• reply & forward• check multiple mailboxes• priority level• auto delete

– an average of 1.6 million messages sent per month to the eHealthBox (multiple recipients)

– an average of 2.4 million messages downloaded per month through the eHealthBox

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Multidisciplinary data sharing

1. data from hospitals

– sharing of documents between hospitals and doctors– “hubs and metahub system”

2. extramural data

– sharing of structured data between first-line health care providers and other extramural health care providers

– “extramural vaults”

3. coupled and interoperable

– standards– informed consent– therapeutic relationship/ health care relationship

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Hubs & Metahub system: Creation of the "hubs"

5 hubs

3 technical implementations

98 % of Belgian hospitals (have signed the 2012 protocol)

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Hub-metahub: currently

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Hub-metahub: in future

A

CB

1: Where can we find data?

3. Retrieve data from hub A

3: Retrieve data from hub C

4:All data available

2: In hub A and C

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Extramural data 1/2

• supporting the development of data exchange platforms for all sorts of extramural health care providers (GPs, dentists, pharmacists, physiotherapists, home nurses, dietitians, psychologists, ...)

– in cooperation with Communities (first-line health care conference in Flanders, the Intermed initiative in Wallonia)

– for the disclosure of data via the hub/metahub system between local information systems of extramural health care providers and between these systems and the information systems of health care/welfare organizations

– for the interaction with extramural vaults awaiting development

– by reusing the basic services of the eHealth platform and by making use of several achievements of the developed data sharing platform between hospitals and GPs/doctors

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Extramural data 2/2

A

C

B

Inter-Med

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Data sharing

• Each actor keeps their own file up to date

• However, they can decide to share parts of the file with other actors

• Examples:

• medication schedule

• SUMEHR

• parameters

• journal

• …

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Access for health care providers

• having a "health care relationship"

• depending on their role

No access for

• IT administrators, hoster,..

• eHealth platform

• authorities

without the active cooperation of the owner of the 2nd key

VaultGovernance Archiving Management

Vault data

Authentication ... Authorisation

Data quality

EncryptionDecryption Authentication

Vault connector

Treshold decryptieTrus

ted

3rd

part

y

2 1.

Vaul

t cor

e

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Informed consent & therapeutic relationship

• content of informed consent

– for registration in the reference directory (as required by the eHealth law)– for the electronic exchange of health data between health care providers

within the framework of patient health care, as long as the following conditions are met:

• approval by the Sectoral Committee• therapeutic relationship required• only relevant data• the patient decides, in consultation with the health care provider, which data will be

shared • health care providers may be excluded by name • possibility of a posteriori verification of the granted access • consent may be revoked at any given time

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• registration of informed consent– patient is informed about the system– specific procedure approved by the Board of Directors and the Sectoral

Committee– consent can be registered through eHealth consent

• either by the concerned person themselves• or by a doctor, a pharmacist, a hospital or a health insurance fund

– https://www.ehealth.fgov.be/fr/prestataires-de-soins/services-en-ligne/ehealthconsent

• therapeutic relationship– only health care providers who have a therapeutic relationship with the

patient (1) can access the information they need to perform their task (2)• (1) proof of therapeutic relationship determines which patient the health care

provider has access to • (2) role determines which type of data the health care provider has access to

Informed consent & therapeutic relationship

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Health care computerizationPlan 2013-2018 / Overview

• at the end of 2012, organization of a Round table regarding the development of health care computerisation

• participation of about 300 people from the sector

• tangible, 5-year action plan for eHealth established – Roadmap

• the action plan is based on 5 pillars: – to develop data exchange by health care providers on the basis of a joint architecture – to increase patient awareness of eHealth– to develop a reference terminology – to achieve administrative simplification and efficiency – to implement a flexible and transparent governance structure in which all competent

authorities and stakeholders are involved

• this action plan constitutes a clear framework for 20 concrete and measurable objectives for the next five years

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THANK YOU!

Questions?

Frank.Robben@ehealth.fgov.be

@FrRobben

https://www.ehealth.fgov.behttp://www.ksz.fgov.be/http://www.frankrobben.be