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WISSENSCHAFT
WISSENSCHAFT
VON EU-NACHBARN LERNEN
HEALTH INSURANCE
CARD IN SLOVENIA
Von Stefan Lummer
Über ein Jahrzehnt dauert inzwischen das Gezerre der Selbstverwaltung
von Kassen, Ärzten und Apothekern um die elektronische Gesundheitskarte. Mit magerem Ergebnis. In derselben Zeit hat ein junger EU-Staat
die Karte als sicheren Schlüssel für den online-Datenaustausch für sein
Gesundheitssystem auf die Beine gestellt. Wir wollten wissen, wie das
geht.
© Petrol / Getty Images
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» Warum ist der Impfpass nicht als
App auf dem Smartphone? «
IT gehört zu den „Hot Health Topics“. Das war die zentrale
Botschaft der conhIT 2015 Mitte April in Berlin, Europas
wichtigster Fachmesse für Gesundheits-IT. Aber sind wir
in Deutschland schon soweit, die Möglichkeiten zu nutzen? Ein wunderbar böser Spott der CDU Bundestagsabgeordneten Dr. Katja Leikert gegen die BZgA-Kampagne
„Deutschland sucht den Impfpass“ legt den Finger in die
Wunde: „Warum suchen wir ihn überhaupt? Warum ist er
nicht als App auf dem Smartphone?“, fragte Leikert auf der
conhIT. Deutschland nutzt ein gelbes Papierbuch, während
Maschinenbauer ihre Anlagen so planen, dass sie mit Hilfe
des Internets kommunizieren können. Industrie 4.0 heißt
das und in Bregenz am Bodensee hat Professor Bertolt
Meyer von der TU Chemnitz mit Experten der Betrieblichen Gesundheitsförderung aus Österreich, der Schweiz
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und Deutschland über Megatrends zur gesunden Arbeitswelt im Zeitalter der Mensch-Roboter-Koordination in der
industriellen Produktion gesprochen. Die Vernetzung von
IT-Systemen entlang der Behandlungskette – daran haben
die IT-Entwickler in den vergangenen Jahren intensiv gearbeitet, dafür gibt es Lösungen. Der Entwurf des geplanten E-Health-Gesetzes fordert auch den intersektoralen
Austausch von Patientendaten. Aber die Sektorengrenzen
in der Versorgung will die Bundesregierung erst mit Hilfe
des Innovationsfonds einreißen lassen. Die bittere Wahrheit ist: die IT-Hersteller sind der Realität in Deutschland
einen Schritt voraus, es fehlt es an den notwendigen Strukturen, um das Potenzial der smarten Systeme vollständig
auszuschöpfen.
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„Demografie und Digitalisierung werden die Gesundheitspolitik unter erheblichen Veränderungsdruck setzen“,
schreibt Axel Ekkernkamp, Ärztlicher Direktor und Geschäftsführer des Unfallkrankenhauses Berlin im April in
einem Leitartikel in der Süddeutschen Zeitung über die
beiden wegweisenden Megatrends in unserem Gesundheitssystem. Doch um die Chancen der Digitalisierung zu
nutzen, brauchen wir zuerst die Einsicht, dass andere Länder den Ton angeben weil sie bereits Milliarden in Gesundheits-IT investieren.
Die Keimzelle der elektronischen Gesundheitskarte hat
Ulla Schmidt als Bundesgesundheitsministerin vor unendlichen 14 Jahren in das deutsche Gesundheitssystem
geimpft. Ein Arzneimittelpass auf einer Chipkarte, damals
befeuert durch einen Arzneimittelskandal: unsachgemäßer
Gebrauch eines CSE-Hemmers hatte zu schweren Nebenwirkungen geführt. Im Jahr 2015 ist ein Medikationsplan
für Patienten, die mehr als fünf Arzneien verordnet bekommen, Teil des E-Health-Gesetzentwurfes. Das ist gut für
Patienten, denn so eine Übersicht verbessert die Versorgungssicherheit. Aber der Arzt erstellt diesen Medikationsplan auf Papier.
Über ein Jahrzehnt nachdem die Politik die Selbstverwaltung der Kassen, Ärzte, Zahnärzte, Krankenhäuser und
Apotheker beauftragt hat, eine Infrastruktur zu sicheren
Übermittlung von Gesundheitsdaten aufzubauen, dauert
jetzt in Deutschland das Gezerre um die elektronische Gesundheitskarte. Eine Milliarde Euro sind ausgegeben, fünf
Geschäftsführer verschlissen und mit Hermann Gröhe hat
der vierte Minister das Thema auf dem Tisch. Die neue Fotokarte der Krankenkassen kann allerdings nichts mehr als
die bisherigen Chipkarten. Die Politik sieht sich zum Eingreifen genötigt. Der Entwurf des E-Health-Gesetzes sieht
verschiedene Schritte vor, wie die Internetanbindung der
Gesundheitskarte vorangetrieben werden soll. Minister
Gröhe hatte öffentlich angekündigt, Ärzte und Kassen bei
weiteren Verzögerungen zu bestrafen.
Doch das Thema wird abseits der Entscheidungsgremien
angetrieben von IT-Konzernen und Nutzern. So schaffen
sich etwa die IT-Giganten IBM und Apple mit sehr hohen
Investitionen eigene Plattformen: Das iPhone und demnächst die Apple Watch mit „körperbezogenem Interface“
werden für ihre Nutzer medizinische Daten aufzeichnen,
wie Herzfrequenz, Kalorienverbrauch, Cholesterinwerte.
IBM entwickelt dazu eine App, die solche Daten über einen
Online-Datenspeicher einsammelt. Noch bevor in naher Zukunft eine Generation junger Ärzte in die Praxen kommt,
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die sich selbst als „Digital Natives“ bezeichnen, weil sie
das Internet in die Wiege gelegt bekommen haben, werden
ihre Altersgenossen bereits eine Art digitale Patientenakte
für sich angelegt haben, weil die Verwendung von FitnessTrackern sehr verbreitet ist. Gesundheit ist für diese Generation kein individueller Zustand mehr, sie wird zum sozialen Netzwerk-Ereignis. Und die Datensätze dazu sammelt
eine IBM-Firma in Boston/USA ein. Kostbarer Rohstoff für
forschende Medizin, Gesundheitsunternehmen, Versicherungen aber auch Arbeitgeber, die sich für die Gesundheit ihrer Belegschaften interessieren. Welche Regeln die
Bundesregierung in die neue EU Datenschutzverordnung
unterbringen kann, ist beinahe unerheblich, denn über den
Standort Boston für jene Health Cloud gilt US-Recht über
die Herausgabe von Daten an amerikanische Behörden.
Datenschützer in Deutschland sind ohnehin alarmiert: Führende Anbieter von sogenannten „Fitness-Trackern“ wie
Jawbone oder Fitbit haben Deutschland als Markt bereits
entdeckt und wollen Apps auch Personalabteilungen von
Firmen anbieten. 2016 will eine private Versicherung ihren
Kunden spezielle Tarife für eine kontrollierbare und kontrollierte Lebensweise anbieten.
Axel Wehmeier, Sprecher der Geschäftsführung Deutsche
Telekom Healthcare and Security Solutions GmbH hat für
uns in der ersten Ausgabe 2015 dieses Magazins drei
Stufen beschrieben, „um der offenen Internetwelt ein für
Patienten qualitätsgesichertes E-Health-Konzept entgegenzusetzen“ und um deutsche Gesundheits-IT weltweit zu
einem Exportschlager zu machen.
E-Health kann die Versorgung stärken und Patienten die
Möglichkeit geben, in ihrem häuslichen Umfeld besser versorgt zu werden. Eine Perspektive für ein Flächenland wie
Mecklenburg-Vorpommern, wo ebenso wie im Schwarzwald und in der Eifel jetzt schon abzulesen ist, was es
bedeutet, dass wir im demografischen Wandel älter und
weniger werden. Eine Perspektive aber auch für Senioren
in den Ballungszentren, falls wir so Bauen lernen, dass die
Wohnungen mit ihren älter werdenden Bewohnern altersgerecht werden können. „Aging in Place“ – so lautet das
Versprechen, zu dem auch E-Health beitragen kann.
In diesem Umfeld der aktuellen Debatte lenken wir den
Blick in dieser Ausgabe auf ein junges EU-Mitglied, das
uns auf dem Weg zur elektronischen Gesundheitskarte mit
pragmatischen Lösungen locker überholt hat: Boris Kramberger, hat als Verantwortlicher des Health insurance Institute of Slovenia die elektronische Gesundheitskarte als
sicheren Schlüssel für den online-Datenaustausch etabliert.
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© Georgijevic / E+ / Getty Images
WISSENSCHAFT
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Health Insurance
Card in Slovenia
ZUSAMMENFASSUNG
Von Boris Kramberger, Senior Adviser, Department for Analysis
and Development, Health Insurance Institute of Slovenia
Slowenien ist mit seinen 2 Millionen Einwohnern seit 1991 eines der jüngeren EU Mitglieder. Es gibt jedoch eine lange Tradition der Krankenkassen: In Ljubljana – damals das Laibach der Habsburger Monarchie – wurde 1896 eine Krankenkasse gegründet. Eine funktionierende elektronische Gesundheitskarte gibt es bei unseren europäischen Nachbarn
bereits seit dem Jahr 2000. Zunächst konzipiert, um den Datentransfer zwischen der Krankenversicherung und den Leistungserbringern im Gesundheitswesen zu sichern. Ein Update im Jahr 2010 brachte einen Rollenwechsel: Nunmehr ist die Karte wirklich smart, sie
funktioniert als Schlüssel für den direkten digitalen Datenaustausch und ist zertifiziert.Das
Hauptziel des neuen Systems war, die alten offline-Systeme abzuschaffen und mittels eines sicheren Schlüssels für Krankenversicherung und Gesundheitsberufe den Zugang zum
online-Datenaustausch zu ermöglichen. Boris Kramberger erklärt, wie das System etabliert
werden konnte, das administrative Prozesse im Gesundheitssystem erheblich vereinfacht.
© Georgijevic / E+ / Getty Images
INTRODUCTION
HEALTH PROTECTION SYSTEM
In Slovenia, a health insurance card system was introduced nationwide in 2000 and updated in all regions by the end of 2010. Today, the health insurance smart card is not just a
medium to transfer data between health insurance administrators, health care providers
and other health care players. It has taken on the role of a certified key for direct electronic
data exchange in the online system that has been established in parallel.
Today, different users have reliable, secure, constant (24/7/365) and rapid online access to
comprehensive administrative data on insured persons (including certain health and medical data) from databases in the backend application systems of the Health Insurance Institute of Slovenia and voluntary health insurance providers. The use of the online system is
obligatory for all health care providers included in the public health care system, primarily
to obtain data for recording and accounting of services.
In future this solid and secure infrastructure will facilitate more demanding applications for
direct exchange of medical data between health care providers and other players in a more
integrated national health care information system.
With a population of around 2 million people, Slovenia is one of the smaller countries
within the EU. Having gained independence in 1991, it is also among the youngest. However, health protection systems based on social health insurance have a long tradition.
The first “krankenkasse” in Ljubljana was established back in 1896. After the health care
reforms in 1992, compulsory health insurance (CHI) was re-established. It is provided by a
sole provider – the Health Insurance Institute of Slovenia (HIIS), which is a public legal entity, typically self-governed by representatives of employees’ (and other insured persons)
and employers’ associations.
Everyone with permanent residency in Slovenia is covered under the unique CHI scheme,
either as a mandatory member or as (family) dependants. The system is funded through
CHI contributions from employees/employers (the active population) and others who are
obliged to make contributions (the self-employed, farmers, pensioners etc.). In formal
terms, the entire population is insured.
The CHI system ensures universal health care benefits. But the extent of coverage defined
by the law is strongly characterised by specific co-payments and a cost-sharing system.
Namely, with the exception of certain vulnerable groups and certain diagnosis/treatment
procedures which have full coverage under the CHI, the majority of the insured have relatively high risks of co-payments. Since the law envisaged (complementary) voluntary
health insurance (VHI) for co-payments, almost all members of the population at risk of
co-payments (over 14 million people – 72% of the population) have entered different VHI
schemes. For the time being, VHI is provided by three competitive insurers.
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© Georgijevic / E+ / Getty Images
In the year 2014, total health care expenditure in Slovenia was around 33 billion euros,
representing a little less than 90% of GDP or 2,003 PPP euros per capita. Public spending
(besides CHI as major public finances, there are certain national and local budget funds for
national preventive programmes and capital investments) reached 6.4% of GDP or 1,432
PPP euros per capita (72% of all sources). Private sources gathered mainly through VHI
and direct payments were at the level of 25% of GDP or 571 PPP euros per capita representing around 28% of all sources for health care services in Slovenia.
Since the establishment of HIIS, implementation of information and communication technologies to support key CHI processes (inclusion of insured persons, payment of contributions, allocating resources to providers, accounting methods for services performed,
ensuring access to health care services, etc.) has been a matter of strategic importance.
New health insurance card and online system
The Slovene health insurance card system was introduced on a national scale in the year
2000. The new system provided insured persons with smart cards. It set up data links
between the health care service providers, HIIS and VHI providers. Cards were issued free
of charge to all users. This first generation of card (image 1) was a patient identification
document containing electronic data on insured persons’ CHI and VHI status. It contained
certain health care and medical data (records on insured persons’ chosen physicians, medications and medical aids issued and declarations for donation of organs and tissues for
transplants). All health care professionals (i.e. doctors, nurses, pharmacists etc.) were
given personal health professional cards which enabled access to the data on insured
persons’ cards. Insured persons updated their data (CHI and VHI validity) on cards through
the network of widely accessible self-service terminals, which also served as health promotion and health care information kiosks. The system functioned well and brought several benefits to users and above all higher operational efficiency and a reduction in the
volume of administrative tasks.
The reasons for the update of the card system were of a technical and business nature:
the ageing of technical components (the cards, self-service terminals and readers), new
trends in information and communication technology, demands for greater scope, more
accurate, qualitative and updated data from health care providers, etc. The underlying aim
of the new system was to migrate from the offline system and promote direct electronic
data exchange between various players in the healthcare system in a new online system,
where health insurance and professional cards are used as secure keys to access data
from HIIS/CHI and VHI backend databases. This type of system was a reasonable way of
simplifying the process of insurance identification and the insurance status validity control
for insured persons at all entry points in the health care system, promising the full benefits
of unique, accurate and qualitative data from backend IT applications and improving security through modern security solutions including digital subscription.
The project for the health insurance card renovation and online system introduction was
managed and coordinated by HIIS. Due to its national character, the project was supervised by the Ministry of Health and representatives of health care providers. Among the
partners were VHI providers’ and IT provider experts. The project was implemented from
2008 to 2010. In 2009 a pilot implementation of the updated system was run in one small
region of Slovenia. National implementation followed gradually, region by region. All health
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care providers (1,850 providers – 220 public institutes and 1,630 private providers) were
switched over to the new online system by the end of 2010.
Technically, the new health insurance card does not differ very much from the first generation card. This is why there was no need to replace all of the health insurance cards at
once. They were to be replaced in a “natural” way (when needed: lost or damaged cards,
at the wish of the owner, etc.). By the end of the national implementation in 2010, only
140,000 health insurance cards (out of 2 million) had been replaced. There were no major
changes in the insurance cards’ functionality either: they were utilised for insurance identification and validity control and the use of certain health care and medical data. But the
role of the health insurance card changed significantly. The card is now a key way to access remote data and is no longer just a data carrier. Access to data in the network is only
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The update of the health insurance card system and the introduction of the new online system has brought important advantages for different players in the health care system. For
insured persons, the online system means further simplification of procedures in which
accurate and reliable data from backend applications contribute to better efficiency and
quality of health care services. The health insurance card and online system have simplified a number of procedures, and, in particular, are user-friendly for the insured persons, as
they ease administrative barriers in the implementation of health insurance rights. Future
e-services for insured persons offering different certificates and approvals for service utilisation (including cross-border health) will further improve this situation.
possible with a health insurance card, which provides the owner with a digital certificate to
access his or her (personal) data.
All health professional cards contain digital certificates to enable secure e-communication.
Both cards, i.e. health insurance and health professional cards (image 2), are used at the
same time (using readers – image 3) to access data in the online system: health insurance
cards to access the data of insured persons; health professional cards for user identification and authentication. Among professional cards, physicians’ health professional cards
contain a qualified certificate to enable a digital signature. All health professional cards
(over 30,000) were replaced by the end of 2010.
The new system simplifies administrative procedures for health care providers. The biggest advantage for them is faster, easier and secure e-communication, not just with insurance providers, but between providers, too. The new information infrastructure has
brought important new solutions, allowing for secure exchange of data and communication via the internet. This is the basis for the further improvement of efficiency and quality
of health care services.
For HIIS and VHI providers, besides improving, simplifying and automating administrative
procedures connected with the recording and accounting of health care services, the new
system also provides a firm foundation for the rapid development of electronic communications with providers and other players in the health care system. It is worth mentioning
that in 2013, HIIS developed and introduced a special new application called “Expenditures” through which all detailed data on health care services provided and medical products
(medications and medical aids) issued are collected electronically from health care providers for recording and accounting purposes. More than 500 automated controls for proper
billing were developed with this application. In addition, a special analytical system (based
on data warehouses) for deeper analysis of this huge amount of electronically collected
data on health care services expenditure (costing) is also under development.
The data, stored in the backend applications and databases of HIIS, are protected against
unauthorised access by being accessible only via digital certificates or the digital signature
of the health insurance card holders and health professional card holders. This ensures a
high level of security in the online system, the significance of which is growing along with
the progressive extension of the data set and e-services provided.
At the present time, electronic services offered by the online system facilitate insured persons’ identification, their CHI and VHI status or validity, data on their personal physicians,
data on medications and medical aids issued to persons by pharmacies and medical aid
suppliers and the person’s willingness to be an organ donor. The new online system with
its secure infrastructure also enables other types of electronic data exchange between
different players in the health care system.
Since 2011, two important web electronic services for insured persons and health care
providers have been developed by HIIS. A portal for insured persons facilitates access
(with any nationally qualified digital certificate) to different personal health insurance data,
including data referring to one’s recent utilisation of health care facilities (along with the
costs of the services). A web solution has been prepared in two versions: simple (basic
access to data) and advanced (secure access using a digital certificate). Use of the portal
has been growing since its introduction in 2011.HIIS has also been continually extending
the portal with new services for insured persons.
Basic insurance data are accessible by mobile phones, too. For example, insured persons
can verify their data on insurance validity via automated SMS response (the identification
key is their health insurance number).
Health care providers connect to the online system through the internet. Use of the online
system is obligatory for providers. A special portal for providers has been developed where they can collect electronic data from the HIIS backend information system for administrative purposes (for recording and accounting of services) and other data connected with
their performance activities.
The online system is a reliable and secure infrastructure and is very promising for the
further development of direct electronic data exchange between different health care players. A national e-prescription project has already been tested in a pilot project and will
be rolled out in the near future. In the next phases, online collection/exchange of data on
patient medical records, referrals, waiting lists and online certified approvals of certain
procedures (expensive services, cross-border treatments, etc.) are planned.
Conclusions
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Finally, it is worth stressing again that probably the biggest advantage of the new health
card and online system is the new, solid and secure infrastructure with good prospects for
future development of e-services/e-communication between different players in the health
care system. How these prospects will be realised depends on the resources available –
and, in particular, on the willingness and knowledge of the players involved, to ensure they
can take full advantage of the infrastructure for greater and measureable efficiency and
quality in the health care system.
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