The eHealth platform: current situation and future perspectives

23/04/2014

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, ...), among others home care•multidisciplinary, transmural and integrated care•patient-oriented care and patient empowerment•rapidly evolving knowledge => need for reliable, coordinated knowledge management and accessibility•threat of excessively time-consuming administrative processes•a thorough support of health care policy and research requires thorough, integrated and anonymized information•cross-border mobility•need for cost control

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These evolutions require...

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

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

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

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Overall objectives of the eHealth platform

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

exchange between all actors in health care– providing the necessary guarantees as regards information security, the

protection of the private sphere and professional secrecy

• which?– optimization of health care quality and continuity – optimization of patient safety– simplification of administrative formalities for all actors in health care– thorough support of the health care policy

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eHealth platform In practice

The patient consults his doctor

Administrative advantages

Possibility to register therapeutic relationships and informed consents

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Medical advantage

s

eHealth platform In practice

Consult 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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Advantages of a

subscription

eHealth platform In practice

Tarification,billing

Create and send

certificates

Update SumEHR, medication schedule, ...

Send a report to the EMR 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 missions

1. development of a vision and a strategy with regard to eHealth

2. organization of the collaboration between other government agencies charged with coordinating electronic services

3. acting as a key driver for the necessary changes in order to carry out the vision and the strategy with regard to eHealth

4. establishing the functional and technical norms, standards, specifications and the basic ICT architecture

5. software registration in order to manage electronic patient files

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10 missions

6.creation, development and management of a cooperative platform for a safe electronic data exchange with the corresponding basic services

7.to come to an agreement on a task division and on quality standards and to verify if these standards are complied with

8.as an independent trusted third party (TTP), being in charge of the coding and anonymization of personal health data at the benefit of specific agencies as enumerated by law in order to support scientific research and policy

9.promoting and coordinating the development of programs and projects

10.managing and coordinating the ICT aspects of data exchange within the framework of electronic patient files and electronic medical prescriptions

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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 anonymization9. 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: 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, among others, 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 his 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 user does indeed meet these rules and provides access or not to the application

10 basic services

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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 a flexible and harmonious integration of the different processes that are linked to the implementation of several basic services into one and the same 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 others, 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 data 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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Encryption known recipient

eHealth platformHealth care actorperson or entity

Inte

rnet

Iden

tifica

tion

certi

ficat

e

Iden

tifica

tion

certi

ficat

e

Web serviceRegister key

Connector or other software togenerate key pair

Sendspublic key

Stores private keyin a secure way

Public keysrepository

1

2

2

Authenticates sender

Storespublic key

3

4

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Iden

tifica

tion

certi

ficat

e

Encryption known recipient

Internet

eHealth platform

Public keysrepository

Authenticates sender

Sendspublic key

2.

3

Message originator

Iden

tifica

tion

certi

ficat

e

Asks for public key

Encryptsmessage

4

1

Message recipient

Decrypts message5 Stored

privatekey

Identificationcertificate

Web serviceAsk public key

Send message

Any protocol

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Encryption unknown recipient

User 2Recipient

User 1Originator

Key Management

/ Depot

MessagesDepot

1 asks for key

2 sends keySymmetric key

Encrypted with public

key of user 1

3 sends encrypted message

Message encrypted with

symmetric key

Encrypted with public key of

Message depot

Message encrypted withsymmetric key

4 justifies right toobtain key

4 justifies right toobtain message

Symmetric key

Encrypted with public

key of user 2

5 receives key

5 receives message

Message encrypted with

symmetric keyEncrypted with public key of User

2

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6.6. 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

6.7. coding and anonymization makes it possible to hide the identity of individuals behind a code so that the useful data of these individuals can be used without infringement of their privacy + makes data anonymization possible by replacing their detailed characteristics with generalized characteristics. These encoded or anonymized data preserve their usefulness, but don’t allow the direct or indirect identification of the person

10 basic services

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Application of timestamping: the electronic prescription in hospitals

Prescription A1

Hashcode A2

Prescription B

Hashcode B

Timestamp bagElectronic

timestamping

4

Electronicsignature

5

Archive6

Archive63

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6.8. consultation of the National Register and of the Crossroads Bank Registers: authorized 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 for which patients with the consent of the concerned patients

10 basic services

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Value-added services

64 value-added services in production> 40 value-added services under study

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)

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Value-added services

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

• management of on-call GP and dentist shifts (Medega)

• reports on MUG interventions

• electronic communication to the owner of a global medical file (GMF) of the reports drawn up by on-call GPs

• Resident Assessment Instrument (BelRAI)

• electronic consultation of health insurance coverage of patients by nurses (nurse groups)

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Value-added services

• SARAI care portal of the Antwerp Hospital Network ('Ziekenhuisnetwerk Antwerpen'-ZNA) in support of

– the collaboration between GPs, specialists and health care teams within the health care programs of the NIHDI (diabetes and renal insufficiency)

– the contribution of GPs to the multidisciplinary oncology consultation

• electronic forwarding of third party invoice by nurses (nurse groups) to health insurance funds

• quality indicator for hospitals (QI dataserver)

• emergency services data registration of 2 participating hospitals (UREG)

• electronic medical card for people without documents (eCarmed)

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Value-added services

• platform for data exchange between the Flemish Agency for Care and Health and the services recognized by the Agency (VESTA)

• support of the electronic care prescription in 108 hospitals (77 % of the hospitals)

• consultation of living wills regarding euthanasia

• electronic registration and consultation of the medical evaluation of disabled people in the information system (Medic-e) of the FPS Social Security

• online registration system for private facilities within the sector of special youth care in Flanders

• 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)

– a need to clarify 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

• the national Register number• the NIHDI number• the CBE number

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

• receipt, publication and reading confirmation• reply & forward• consultation of 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– the “hubs and metahub system”

2. extramural data

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

– the “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 the Belgian hospitals (have signed the 2012

protocol)

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Hub–metahub: as is

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Hub–metahub: to be

A

CB

1: Where can we find data?

3. Fetch data from hub A

3: Fetch 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 the 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 an extramural vault that needs to be developed

– 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 his own file up to date.

• However, he 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 2 nd key

VaultGovernance Archiving Management

Vault data

Authentication ... Authorization

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 far as the following conditions are met:

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

shared • exclusion of health care providers by name is possible • a posteriori verification of the granted access • revocation of the consent at any given time is possible

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

Committee– the consent can be registered through eHealth consent

• either by the concerned person himself• either 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 to which patient the health care

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

Informed consent & therapeutic relationship

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eHealthConsent

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eHealthConsent

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eHealthConsent

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eHealthConsent

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Health care computerizationPlan 2013-2018 / Overview

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

• participation of about 300 people from the sector

• a tangible action plan for eHealth has been established for five years - Roadmap

• the action program is based on 5 pillars: – to develop data exchange by health care providers on the basis of a joint architecture – to increase patient involvement and patient knowledge on 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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Roadmap 2013-2018 (www.rtreh.be)

• each owner of an GMF manages an electronic file regarding the concerned patient, updates the relevant data in a SUMEHR and shares them through Vitalink/Intermed

• each hospital disposes of a structured electronic patient file

• hospital documents are shared and generalized through the hub/metahub system

• intramural and extramural laboratory results and reports in medical imaging are shared through the hub/metahub system or through Vitalink/Intermed

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Roadmap 2013-2018 (www.rtreh.be)

• data concerning the delivered medicines and the medication schedule are electronically shared

– shared pharmaceutical file as an authentic source for the delivered medicines

– Vitalink and Intermed as authentic sources for the medication schedule

• the electronic medicine prescription in the ambulatory sector is generalized and extended to other prescriptions (physiotherapy, nursing, laboratory researches, medical imaging)

• per health care profession the minimum content of an electronic patient file is defined

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Roadmap 2013-2018 (www.rtreh.be)

• generalized usage of the eHealthBox

• traceability of medical devices

• elaboration of a national terminology policy

• extension of the hub/metahub system to psychiatric hospitals and rest homes

• evolution of BelRAI as an evaluation tool

• social debate about the modularity or not of access rights to patient data

• patient organizes the access to his data

• adaptation of the regulation and financing as incentives for ICT usage

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Roadmap 2013-2018 (www.rtreh.be)

• inclusion of eHealth in the training of health care providers

• implementation of MyCarenet services (electronic billing of third-party payer, electronic consultation of insurability, electronic exchange between the hospital and the health insurance fund in case of a hospitalization, ...)

• inventory and consolidation of registers

• action plan for a further administrative simplification

• monitoring and execution of the action plan

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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