eHealth: some challenges Frank Robben General manager eHealth-platform Sint-Pieterssteenweg 375 B-1040 Brussels Website eHealth-platform: Personal website:

2 21/09/2012 Some evolutions in healthcare More chronic care on top of merely acute care Remote care (monitoring, assistance, consultation, diagnosis, operation,...) Mobile care Multidisciplinary, transmural and integrated care Patient-oriented care and patient empowerment

3 21/09/2012 Some evolutions in healthcare Rapidly evolving knowledge => need for reliable, coordinated knowledge management and accessibility Threat of excessively time-consuming administrative processes Reliable support for healthcare policy and research requires reliable, integrated and anonymous information Cross-border mobility

4 21/09/2012 Those evolutions require... Collaboration between all actors in healthcare, not necessarily based on centralized data storage Efficient and safe electronic communication between all actors in healthcare High quality electronic patient records, across specialties Technical and semantic interoperability

5 21/09/2012 Those evolutions require... Optimized processes Guarantees for information security privacy protection respect for the professional secrecy of healthcare providers Trust of all stakeholders in the preservation of the necessary autonomy and the security of the system

6 21/09/2012 Electronic communication also stimulates.. Quality of care and patient safety prevention of erroneous care and drugs negative drug interaction drug contraindications (e.g. allergies, diseases, …) prevention of errors in administering care and drugs availability of trustworthy databases containing information about best care practices and decision support tools Qualitative support of healthcare policy and healthcare research based on reliable, integrated and anonymized information

7 21/09/2012 The Belgian approach At first creation of an adequate governance and consultative structure about eHealth and then further implementation under control of the governance and consultative structure Stimulation of multidisciplinary and high quality electronic patient records If the patient wishes so, gradual referencing to places where his/her personal health data are available

8 21/09/2012 The Belgian approach Common patient identifier Well elaborated legal and ethical framework patient rights privacy protection professional secrecy Respect for local, regional or national healthcare organisation structures and initiatives never use ICT to impose change to organisational structures

9 21/09/2012 The Belgian approach 2008: eHealth-platform creation a new parapublic institution, instituted by law governed by representatives of the stakeholders (healthcare providers, healthcare institutions, patients, sickness funds, relevant government institutions, …) based on the experience in the social sector

10 21/09/2012 The Belgian approach eHealth platform: an interoperable technical platform for safe and reliable electronic information exchange based on a service oriented architecture with common basic services using technical and semantic interoperability standards

11 21/09/2012 Basic services eHealth-platform Network Basic architecture Patients, health care providers and health care institutions AuthSAuthSAuthS Data providers Users Portal eHealth- platform Portal eHealth- platform Portal Health Portal Health VAS Software health care institution Software health care institution VAS MyCareNet VAS Software health care provider Software health care provider VAS Site RIZIV Site RIZIV VAS AuthSAuthSAuthS

12 21/09/2012 The Belgian approach eHealth-platform common basic services (provided for free): 1.Process orchestration 2.Integrated portal 3.User and access management 4.Logging 5.Encryption 6.Timestamping 7.Coding and anomyzation 8.eHealthBox 9.Reference directory 10.Consultation of the National Register and of the Crossroads Bank Registers

13 21/09/2012 eHealth-platform basic services 1.Process orchestration: allows a flexible and harmonious integration of the different processes linked to the implementation of several basic services into one and the same application 2.Integrated portal: a web window offering a variety of online services to health care actors in order to help them provide the best possible healthcare. The integrated portal provides all useful information on the services that are offered by the eHealth-platform, its tasks, its standards, etc. It contains, among others, the documents users need to configure the right settings in order for them to have access to the available online services.

14 21/09/2012 eHealth-platform basic services 3.User and access management: allows to guarantee that only authorized health care providers/ health care institutions have access to personal data to which they are authorized to have access access rules are defined by law, by authorizations of the Health Section of the Sectoral Committee (established within the Privacy Commission) each application defines its own accessibility rules when a user authenticates its identity (using the electronic identity card or the token), the generic verification model of the tool is set in motion: it consults the rules established for the application, verifies if the users comply with these rules and provides access or not to the application.

15 21/09/2012 eHealth-platform basic services 4.Logging: management of a register of access to the data management system: all read, write and delete accesses are registered and have probative value in case of a complaint 5.Encryption: transport 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 key. Two 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) 6.Timestamping: makes it possible to assign a date that is accurate to the second to a health care document and allows, in this way, to ensure the validity of its content throughout time by appending an eHealth signature

16 21/09/2012 eHealth-platform basic services 7.Coding and anonymization: makes it possible to hide the identity of the individuals behind a code so that useful data of these individuals can be used without infringement of their privacy + makes data anonymization possible by replacing detailed data with generalized data. These encoded or anonymized data preserve their usefulness, but don’t allow the direct or indirect identification of the person 8.Consultation of the National Register and of the Crossroads Bank Registers: gives authorized health care actors access to the National Register and to the Crossroads Bank Registers under strict conditions

17 21/09/2012 eHealth-platform basic services 9.eHealthBox: a secured electronic mailbox for the exchange of medical data 10.Reference repertory: indicates which types of data are stored by which health care actors for which patients with the consent of the concerned patient

18 21/09/2012 More than 40 value-added electronic services for healthcare actors have been implemented within 3 years by several partners, always using the basic services of the eHealth-platform eHealth-platform core business focused on electronics data's exchanges systems projects such as: communication system of electronic patient records between care providers electronic prescription disease en therapy registries Evidence Based Medicine verification and registration of medical record software packages semantic interoperability ….. Achievements/Projects

19 21/09/2012 The priority: multidisciplinary data sharing Sending snapshot of the data (do not remain up-to-date) sender chooses recipient sender is responsible for sending the data to recipients who are entitled to have access to these data Sharing evolutive data the sender does not know in advance who will consult the data (eg doctor on duty) organizational measures are required to limit access to the data to those who are entitled to have access

20 21/09/2012 Informed consent/therapeutic relationship  Informed consent inform patient about the system patient may give his authorization and decide “to get into the system” healthcare providers and patient decide together which information can be shared  Therapeutic relationship only healthcare providers who have a therapeutic relationship with the patient (1) have access to the information they need in order to fulfil their job (2) -(1) proof of the therapeutic relationship determines access to the right patient -(2) role determines which data can be accessed

21 21/09/2012 eHealthBox Sending of messages to ‘healthcare actors’ based on Social identification number NIHDI-number CBE-number through webapplication or integrated in the medical file with (or without) encryption based on eHealth certificates/ eHealth keys other functionalities: receipt-, publication-, reading confirmation r eply & forward consultation of multiple mailboxes p riority level auto-delete -…

22 21/09/2012 Multidisciplinary data sharing  Data from hospitals sharing of documents stored by hospitals the “hub and metahub system”  extramural data sharing of structured data stored by extramural healthcare providers the “extramural vault”  Coupled and interoperable standards informed consent therapeutic relationship …

23 21/09/2012 Exchange of patient data: now Remote files unknown

24 21/09/2012 Exchange of patient data: future A C B 1: Where can we find data? 3: Fetch data from hub A 3: Fetch data from hub C Meta- Hub 4: All data available 2: In hub A and C

25 21/09/2012

26 21/09/2012 Extramural health care providers A C B Meta- Hub VitaLink Intermed

27 21/09/2012 Reference directory Developed through a trapped system reference to the care provider(s) or care institution(s) where one or more electronic documents are available for a patient is, with the informed consent of the patient, stored in a local or regional reference directory (a so-called "hub") the reference directory managed by the eHealth-platform (the so- called "metahub") only contains references to the hub(s) where references for a patient are stored Development through a trapped system respects the organisation of regional and local networks between care providers and/or care institutions avoids the possibility that health information about the patient can be deduced from the information stored in the reference directory managed by the eHealth-platform

28 21/09/2012 Reference directory Publication of the reference in a hub and the metahub requires the informed consent of the patient concerned Access to information to which reference is made in a hub requires a therapeutic relationship between the requesting care provider and the patient concerned A guidance committee has been created within the Consultation Committee of the eHealth-platform

29 21/09/2012 Extramural health care vaults  Content : synthetic data emanating from local information systems of different (types of) first-line health care providers (Sumehr) health care programs and health care plans journals (reference to) the vaccination status  Allows a granular access control by means of software developped in a coordinated way (registered software)  Can interact with the information systems of the different types of health care providers by means of open standards and computerized business processes  With an operational management by bodies with representatives of the different types of first-line health care providers, hospitals and patient organizations

GPPharmacistHomecare Specialist Patient Therapeutic relationships NISS Software As A service MetaHUB eHealth kadaster eHealth box Own software Software As A service Software As A service Own Software Hospital HUB Informed consent by the patient …

32 21/09/2012 Key 1Key 2 In DB : Result : Without keys

33 21/09/2012 With key 1 Key 1 Key 2 In DB : B8i!(mà}z1&ajt Result :

34 21/09/2012 With key 2 Key 1 Key 2 In DB : K9l#'ç9gnh3lk Result :

35 21/09/2012 With both keys Key 1Key 2 In DB : Clear data Result :

you ! Any questions ?