1. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 1 Arsenàl.IT Veneto’s Research Centre for Innovation in e-Health AER EHe@lth Network Trieste June10 th, 2009 Mauro Rizzato Chief Administrative Officer Arsenàl.IT

2. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 2 Contents   Veneto Region’s approach to cross- border patients   HEALTH OPTIMUM   NETC@RDS   N2N

3. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 3 Contents   Veneto Region’s approach to cross- border patients

4. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 4 Background   EU's internal market rules are designed to facilitate the free movement of people. One of the consequences of the free circulation of individuals is the increased mobility of patients seeking healthcare in countries other than their own for a variety of reasons.   Patient mobility is a common phenomenon particularly in border regions and is only one of the four possible types of cross-border healthcare, all of which are relevant.

5. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 5 n.Typology of Cross-border patient 1citizens who, while on holiday, need to use healthcare services in the country they are visiting. Use of European Economic Area (EEA) to facilitate the process, based on the E111 form, conferring the right to treatment during a temporary visit. 2citizens who retire to a different country/region and wish to use the healthcare system of the country where they are currently living 3people sharing close cultural or linguistic links with the region where care is provided. In regions where a natural community is divided by a national frontier, people look for treatment close to home – which happens to be on the other side of the border. This is often the case where a town that has developed over centuries is divided by a river that forms a country border. When access to cross-border care is relaxed, for instance within the framework of cooperative agreements, these patients are likely to be the first ones to take advantage of the new possibilities. 4patients who cross a border to receive healthcare or to buy health goods. This is often because of perceived advantages related to quality, accessibility or price, specifically out-of-pocket payments borne by patients. Examples include patients going abroad to avoid long waiting lists in their home country and patients seeking treatments that are cheaper, typically moving from old to new Member States. 5patients who are sent abroad by their own health system to overcome capacity restrictions at home. It concerns mainly smaller countries or regions with a low population density where the domestic health system cannot reasonably provide a comprehensive range of health care services for its population. Healthcare provided in this category is, in general, actively managed by public authorities, seeking to ensure continuity of care, coverage of extra expenses and appropriate selection of providers abroad. Some patients cross borders within the framework of cooperative agreements in order to share facilities, especially in relation to capital-intensive or highly-specialised services. Analysis

6. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 6 Region area   Cross-bording can be between:   EU Member states (Usually)   International   EU regions   Local area organizations (i.e. provinces) with authonomous administrative core

7. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 7 Veneto Region’s approach   Tools   Organisational Interoperability   Clinical Interoperability   Open administrative systems   IT standards E-HEALTH

8. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 8 Veneto Region’s approach   Steps   Validation of e-Health services   Deployment of services   Technical network creation   Clinicians consensus building in cross- border patient management   Privacy management   Administration management

9. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 9 e-Health Project Initiatives E-Government services TERREGOV Paperless handling of health documents TeleMed-ESCAPE Web-based booking of health services IESS e-Learning for health Growing-Together Satellite-based Second Opinion services Near-To-Needs Interoperability of health smart cards NETC@ARDS Neurosurgical Tele- counselling HEALTH OPTIMUM Patient Summary & e-Prescription Open e-Health Initiative … …

10. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 10 Contents   HEALTH OPTIMUM

11. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 11 Health Optimum Initial Deployment RR. Giampieretti / Arsenàl.IT / Veneto Region – Vienna, April 11, 2008Copyright © 2008 Arsenàl.IT – Tutti i diritti riservati HEALTHcare delivery OPTIMisation throUgh teleMedicine

12. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 12 The HO model: clinical areas  Neurosurgery  Neuroradiology  Oral Anticoagulation Therapy  Neurology  Dermatology  Radiology  Oftalmology  Oncology  Haematology  Diabetology  Cardiology  Endocrinology   Trombolysis   Dialisys   Coronary Arteriography   Hortopaedics   Alcool rehabilitation   Homecare   Oral and maxillo-facial surgery   General Surgery   Plastic surgery 21 clinical areas where services were successfull tested

13. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 13 HEALTH OPTIMUM in VENETO Neurosurgical tele-counselling Telelaboratory STROKE Management TAO Management

14. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 14 Neurosurgical tele-counselling 79% of un-useful travel avoided

15. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 15 Neurosurgical Tele- counselling roll-out 36 peripheral hospitals without neurosurgery/neuroradiology units are going to be linked to 7 neurosurgical centres Emergency22 Intensive Care14 Neurology13 Radiology4 Medicine1 tot. 54

16. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 16 Telelaboratory

17. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 17 Tele-laboratory roll- out Units 61 Elderly Homes 10 Local Districts 7 GP 2 tot. 80 80 peripheral sites are going to be linked to hospital LIS systems

18. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 18 The technical and organisational model has been defined; the technical infrastructure is almost the same used for neurosurgical telecounselling, more speed has to be guaranteed the group of the involved neurologists defined the clinical form; a working group is already defining a shared clinical protocol. STROKE management

19. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 19 The technical and organisational responsibles have been designated; the architecture proposed has been accepted and shared with Directions; the budget has been defined, written communication has been sent and the funds have been allocated; the technical architecture is going to be more precisely detailed; the integration among systems according to standard HL7 messages is being studied OAT Management

20. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 20 XDS framework in Veneto Provincia Belluno Provincia Vicenza Provincia Treviso Provincia Venezia Provincia Rovigo Provincia Verona Provincia Padova Governance system Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway Sistemi Aziendali Sistema di Teleconsulto Indice Provinciale Gateway

21. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 21 N2N assett Application to neurochirurgical telecounsuelling Tele-oncology Shared clinical FORM  semantic interoperability between Italy and Romania Timisoara Connection

22. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 22 HO: European volumes  5.000 telecounselling  38.000 laboratory tests  800 tele-referrals  52.000 radiological images  2.000 videoconferences  More than 4.000.000 exchanged clinical data

23. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 23 HO: interoperability aspects Technical architectures developed according to international standards Sharing of clinical and organizational paths The path developed during the HEALTH OPTIMUM project had often been recognized and adopted on a larger scale.

24. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 24 Conclusion  The HEALTH OPTIMUM model showed its validity, linking specialists and health operators in different clinical areas e and different geographical, health and legal contexts.  This innovative model may be easily replied also in other countries and contexts, not only in the healthcare field.

25. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 25 Contents   NETC@RDS

26. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 26 Netc@rds – Smart Card and Network Solutions for the Electronification of the European Health Insurance Card Slides from: Central Research Institute of Ambulatory Health Care in Germany (ZI), Herbert-Lewin-Platz 2, 10623 Berlin; email: rtavakolian@kbv.de; Tel.: +49-30-4005-2418

27. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 27  Pan-European initiatives to foster mobility & skills inside the E.U with common rules for social protection  Since June 2004: common EU Health Insurance Card (EHIC) – ensures access to health care when abroad inside the EU & the EEA  Announced decision on long-term course – 2008+ to introduce will progressively replace the eye-readable EHIC  But in 27 Member States + other EFTA countries – different health systems and care entitlement, different levels of IT infrastructure -  NETC@RDS challenge : to demonstrate potential of same service for all EU/EFTA citizens based on different but interoperable national/regional IT infrastructures Context & Challenges

28. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 28 Project at a Glance  Consortium of 28 partners from 16 EU/EFTA countries : Austria, Bulgaria, Czech Republic, Finland, France, Germany, Greece, Hungary, Italy, Liechtenstein, Norway, Poland, Romania, Slovak Republic, Slovenia  Partners : statutory health insurance institutions, technical or economical organisations, hospitals, health practitioners associations.  Budget : 20 M€ co-funded by the EC DG INFSO e-TEN Programme (30% of eligible costs)  Time table:  Phase A1 Market Analysis & Technical Requirements (2002 – 2003)  Phase A2-A3 Validation of the Service (2004 – 2006)  Phase B Initial Deployment (2007 – 2009)  Phase C Full Deployment of the Service (2010+)  Common objective for phases A, B & C:  A stepwise approach on the way towards introduction of the e-EHIC

29. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 29 Proposed definition An electronic European Health Insurance Card (e-EHIC) is a digital process with the result of a trustworthy data set for entitlement at the healthcare provider It can be used for associated inter-state back office e-billing reconciliations as well Thus, the introduction of a new specific health insurance smart card is not necessary whilst the e-EHIC trustworthy dataset can be obtained either by scanning the eye- readable EHIC or by reading national/regional health smart cards then by checking data on-line Basic Concepts

30. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 30 Objectives of Netc@rds Online verification of insurance data to prevent fraud and misuse Fostering mobility of European citizens Simplification of procedures for involved institutions: - - Health insurance providers - - Healthcare providers - - Interstate clearance bodies Integration of electronic data sets for EHIC into national cards Contribution to interoperability of eHealth in Europe

31. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 31 Work items of Netc@rds 1. Status survey and analysis on EHIC handling 2. Technical proposal based on the NETC@RDS-cases Proposal for electronic data storage on chip cards Suggestions on interoperable infrastructure components Demonstrator setup of a verification network Automated optical data capture of conventional EHIC Post-processing interface of EHIC data (XML Output file) 3. Strategic proposal for eEHIC introduction

32. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 32 Case 4: dataset captured from eye- readable medium (EHIC, paper) Home Country Member-State Member State of Temporary Stay Case 2: dataset captured from chip card & server Case 3: dataset captured from server Case 1: dataset captured from chip card health insurance data server Netc@rds dataset Netc@rds-Cases1-4

33. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 33 National portal EHIC database Smart card database Smart card & EHIC database NETC@RDS pan-european infrastructure

34. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 34 Slovenia Austria Germany France Italian Regions Eye-readable EHIC Cards Accepted by NETC@RDS

35. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 35 Summary   Online verification of entitlements rights   Replacement of paper forms   Contribution to interoperability   Interoperable dataset to foster electronic post-processing   Cost-effective extension to new card schemes   Simplified access to foreign healthcare systems   Fostering mobility of European citizens   Fastening Administrative reimbursement for patient mobility   German-Italy (i.e. tourism flow): timing for reimbursemen  4years  <6month

36. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 36 Contents   N2N

37. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 37 CONTEXT  Protocol intent between Veneto Region and Timis Region  Twinning between Treviso and Timisoara Municipalities  Considerable presence of Italian enterprises in Timis Region

38. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 38 ACTORS INVOLVED  European Space Agency  Treviso ULSS9 healthcare authority – Veneto Region  Timisoara Spitalul Clinic Judetean de Urgenta

39. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 39 OBJECTIVES  Analyse the potential of a satellite platform in healthcare  Promote the integration and sustainability of ICT in daily healthcare provision and medical/nursing training. Provide specialist healthcare thanks to the help of qualified personnel who are connected remotely; Act as a star centre for network connections with local Romanian Centres of Excellence;

40. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 40 PROJECT ARCHITECTURE  Satellite connection between Treviso and Timisoara hospitals to provide the following services: ♦ telecounselling ♦ telelaboratory ♦ e-learning ♦ epidemiology

41. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 41 Project architecture

42. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 42 E-LEARNING  In order to enhance cooperation between the two hospitals: ♦ videoconference sessions between specialists to discuss clinical cases or to share experiences ♦ e-learning sessions for nurses

43. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 43 EPIDEMIOLOGY  Service to collect data on hospital acquired infections  Data analysis and comparison for statistical studies at international level  Study of an early warning alert system via satellite, for epidemiological emergencies

44. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 44 ADVANTAGES  Realization of an electronic registry, ELETTRONIC HEALTH RECORD, cointaing the clinical history of the patient, which can be easily consulted by the authorized physicians, both from Timisoara and from Treviso  Epidemiological studies for the prevention and the treatment of the infectious diseases Easy deployment of the model overcome of geographical barriers

45. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 45 RESULTS Telecounselling requests performed Videoconferences between the cardiology staffs E-learning course for nurses

46. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 46 RESULTS

47. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 47 Conclusions   Existing experiences shows that technical interoperability is possible   Administrative, clinical and cultural must be achieved   Interregional policy must be defined

48. M. Rizzato / Arsenàl.IT / Veneto Region – Trieste, June 10, 2009 Copyright © 2009 Arsenàl.IT – All Rights Reserved 48 Thank you for your attention. Mauro Rizzato Chief Administrative Officer Arsenàl.IT mrizzato@consorzioarsenal.it