Regional Service CardHealth & Social Care Information System(CRS-SISS Program)

29 October 2010

Nicola Contardi

Lombardia Informatica

Summary• Lombardy Region

• The Healthcare Network of Lombardia

• Lombardy’s Region Healthcare Information System evolution

• The CRS-SISS Program• The underlying philosophy• Goals and main streams• Services and Architecture• Project principles • Smart Cards Technology• The “Pillars”: Regional Registry, Electronic Health Record (EHR),

Reception Processes Improvement• The Electronic Health Record (EHR)• Main results in 2010• Open issues

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Lombardy Region

• Is one of the twenty Italian Regions• About 16% of Italy’s citizens• Is one of the most populated Regions of Europe (more

populated than 14 EU member States)• Its GNP is about 20% of Italy’s GNP

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The Healthcare Network of Lombardia

• 9.500.000 Citizens

• 150.000 Health & Social Care Operators

• 7.700 General Practitioners and Pediatricians

• 2.500 Pharmacies

• 15 Local Healthcare Units

• 34 Public Healthcare Services Suppliers (29 Public Hospital and 5 Public Medical Research Institutes)

• Over 2500 Private Healthcare Services Suppliers

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• Lombardy, like every Italian Region, is directly responsible for HC service provision

REGIONE LOMBARDIA

PHARMACIES

HEALTH & SOCIAL ASSISTANCE

GENERAL PRACTITIONERS

LOCAL HEALTH CARE UNITS

CI TI ZENS

HOSPITALS

REGIONE LOMBARDIA

PHARMACIES

HEALTH & SOCIAL ASSISTANCE

GENERAL PRACTITIONERS

LOCAL HEALTH CARE UNITS

CI TI ZENS

HOSPITALS

Lombardia Informatica

• Lombardia Informatica is a public-owned service company which was constituted in December 1981 as an initiative of the Lombardy Regional Government.

• The company designs and develops ICT Systems for the regional government and is responsible for management of the latter’s already-existing systems.

• Lombardia Informatica has around 500 employees and a revenue of about €240.000.000 (2009).

• Lombardy Region has entrusted Lombardia Informatica with the management and overall responsibility for the CRS-SISS project (Regional Service Card Health & Social Care Information System).

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Lombardy’s Region Healthcare Information System evolution

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1978 Collection and filing of hospitalizations

Collection and filing of outpatient visits data1997

1985 Collection and filing of pharmaceutical acquisitions

1982 Regional personal data Registry of Citizens and General Practitioners

CRS-SISS

Project requirements definition and feasabilty analysis

CRS-SISS

On site pilot project inthe Lecco District(300.000 citizens)

1999 2000 -2001 2002

CRS-SISS

Project Financingand beginning of the expansion to all Districts

2008

CRS-SISS

Healthcare Private Sector

2004 2005

CRS-SISS

2 millioncitizens

CRS-SISS

All Lombardy’s citizens(9,5 million)

Healthcare DataHealthcare Data

Administrative DataAdministrative Data

General Practiotioner

Practitioner

ASL

Healthcare Local Unit

Pharmacy

Hospital

Healthcare DataHealthcare Data

Administrative DataAdministrative Data

General Practiotioner

Practitioner

ASLASL

Healthcare Local Unit

Pharmacy

Hospital

Data WareHouseCluster of Patients

Electronic Health RecordVision per single Patient

Data WareHouseCluster of Patients

Electronic Health RecordVision per single Patient

The underlying philosophy

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SISS is a Regional Healthcare Information Network; the Citizen is its centre.All the data are gathered, organized and reported on the basis of the citizen’s clinical treatment within the Regional Healthcare Network.

SISS implements a work-flow based on thetypical healthcare processes:• Pharmaceutical• Outpatient examinations• Hospitalization• Emergency• …

CRS-SISS - Goals

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•Improve Services for Citizens: reducing the “distance” between Citizen and HC Service Providers by simplifying procedures and shortening waiting time (e-booking, access HER, e-precription)

•Improve quality of prescription, diagnosis and care (appropriateness) processes by Citizens’ clinical data sharing, through EHR, among qualified HC Professionals, securing Citizens’ Privacy Rights

• Improve Governance of Social and HC System managing costs: enhancing planning and controlling instruments (DataWarehouse, Business Intelligence)

•Improve internal process efficiency of HC Service Providers by a generalized diffusion of new technologies (digital signature, electronic filing, electronic prescription) to dematerialize documents

SISS

Planning and Governance of HC expenditures

Efficiency and Simplification Social and HC

Internal Processes

Assure continuity and quality of care

For Citizens and HC Professionals

For Administrations

(Regional Government and HC Providers)

•The prerequisite of the Project was the distribution of the personal Smart Card.

•The main objectives of the CRS-SISS Program are to unify and to protect, within a co-ordinated system, all the information related to the citizens’ state of health.

Reduce the gap between Citizen and HC ServicesProviders

CRS-SISS Main Streams

• creation of new services at regional level for Citizens and HC Professionals (Electronic Health Record)

• creation of a large technological infrastructure

• implementation of an integrated regional information system

• central data base and clinical data repository (administrative data, service codes, Patient Record,…)

• solutions for clinical management of patients

• application integration of Organization’s Information Systems through an integration middleware

Healthcare Extranet as main instrument of innovation

and integration frameworkamong all actors:

Develop HC Organizations’ (Hospitals, HC Local Units, …)Internal Information Systems,

promoting features such as:

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CRS-SISS Services

• Citizen Identification: Regional General Registry and Citizen Card• e-Prescriptions Management to enable a truly digital use of prescriptions

during their life cycle• Electronic Health Record (EHR): shares clinical data among HC

Professionals (events, prescriptions, reports, care profile, …), enables on-line access for Citizens

• Booking and Payment Services for Citizens by Internet, GP, Pharmacies, Regional Call Center, to improve citizen’s access to HC services

• Business Intelligence and DataWarehouse to make analyses and forecasts of epidemiological trends and to manage and forecast regional healthcare expenditure trends

• Digitalization of all medical and administrative documents in order to improve efficiency and effectiveness of processes

• Accounting information flow management: incremental records of administrative data in order to ensure on-line updating of Business Intelligence and Data Warehousing Systems

• Electronic signature, mailing system, encryption functionality

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CRS-SISS - Architecture

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General Practitioner, Pediatrician

Level 2 Healthcare Extranet

Hospital, Operators, Chemists, …

Provider Provider

HealthcareSocial Services

Level 1Central Repository

Level 3Operators and Organisations

Integration Management Unit

Citizens

SERVICES

Lombardy Region Central Systems

CRS-SISS Project Principles

• Web technologies• Evolution and integration, not replacement, of existing applications• Strict enforcement of personal data protection (privacy): high

security technologies• Process reengineering to improve efficiency• Extensive deployment of digital signature and electronic documents

(dematerialization)• Smart cards• Make available to existing applications a common infrastructure

for integration • Integrate, not substitute, existing functionalities• Preserve the current user interface as is• Minimize enhancements to operator's behaviour

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Smart Cards Technology• Identification and authentication• Data storage required for emergency care

(Netlink standard)• Access to Public Administration services• Certification of the “presence” of the

Citizen (through electronic signature of documents)

• Identification and authentication• Authorization access to the System

(according to operator’s profile)• Electronic Signature

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Citizen Card

Operator Card

CRS-SISS “Pillars”

• Regional General Registry

• Electronic Health Record (EHR)

• Reception processes improvement (booking and payment Services)

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Electronic Health Record (EHR): 2 level architecture

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Hospital

Hospital

ASLASLASL

Healthcare Local Unit

Events Link

EHR

ClinicalDoc

PS

HospitalClinical

Doc

ClinicalDoc

• Health documents• Healthcare Local Unit

• Patient Summary• Vaccine File

• Hospitals• Test results• Health Documents• Therapeutical plans• …

Electronic Health Record (1)

Electronic Health Record (EHR): main features

• Based on a “patient centric” structure, is the fundamental support for the care of the citizen

• Gathers and organizes summary information from organizations and citizens for medical care purposes

• Allows the sharing of medical documents between all the actors involved into the care processes of the citizen

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Electronic Health Record (2)

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Electronic Health Record (EHR): How does it work ?

GPPediatricians

HospitalDiagnostic Test Medical Specialist

Electronic Patient Record (EHR)

Patient health conditions

Exams resultsMaterial

Healthcare

Occurrences

Medical

Reports

Ospedale

Specialista

Diagnostic Test

Hospital

2: Results

Exam

Medical Specialist

Diagnostic Test

1: Test

2: Admission

8: Discharge

4: Investigation

5: Results

6: Consultation

7: Advice

Electronic Health Record (3)

Electronic Health record (EHR): functions

• Give an integrated view of the sanitary history of a specific citizen to the doctor who is treating him/her in a specific healthcare episode, with respect to all the privacy aspects.

• Give consultation functions able to increase the efficacy and efficiency of the clinical intervention.

• Make clinical reports available to the citizen on-line, reducing need for citizen to retrieve physically results and, thus, queues

• Simplify the activities of clinical operatives, allowing information exchange, import/export of documents (e.g. for admission, GP change, …)

• Interface decision support systems to allow secondary usage of information (health policy, administration, education, research, statistics, …)

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Electronic Health Record (4)

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• “Personal zone” for the citizen in his EHR

• Asyncronous Electronic Document consultation

• Diagnostic &Therapuetic plans

• Admissions clinical documents management

• Extensive use of structured documents

• Image mangement

Electronic Health Record - Main evolutions (5)

CRS-SISS – Main Results in 2010*

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• Over 9 millions of CRS smartcards delivered

• 96% General Practitioners and Pediatricians in the Network

• 100% Pharmacies in the Network

• 75 millions prescriptions

• 14 millions of Clinical Electronic Documents (most referrals)

• 5,8 millions of “active” EHR

• 1,2 millions of EHR consultations from GPs

• All Healthcare Local Units and Public Hospitals of the Region have integrated their applications to the network

• Private Hospitals started integration in the Network

• Pathology Networks: Oncology, Rare Diseases, Epilepsy, Emathology, Acute Myocardial Infarction, Nephrology, Emergency, Hearing, Stroke, Sudden Infant Death Syndrome

• Available on line services for citizens: access to EHR, booking, choice and revocation of GP, …

* Projection to the end of 2010

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• Customer-orientation

A system also for the healthy

A user-interface even more user-friendly

Simple functions in a little time-to-market

Simple bi-directional services for citizens

• An open world

The citizen may take a care where he prefers

Privacy: how much of his record the citizen may choose to share ?

Open Issues: EHR for the Regional System

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• EHR for e-Health government

Developing systems more and more citizen-data centric

Try to modify some Regional rules in order to exploit system capabilities

• More earned value for professionals

To improve the collaboration among the private professional, the general

practioner and the citizen

Focus on mobile services

Active involvement of all the stakeholders

Open Issues: EHR for the Regional System

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• Interoperability at a regional and european level

• Applications more oriented to the Inetrnet world

• Re-use

• Creation of an eco-system of parterns cooperating in developing

the overall system

Open Issues: EHR for the Regional System

Lombardia Informatica S.p.a.

Thank youNicola Contardi

nicola.contardi@lispa.it

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