Van Cauwenberge Joris - Verhoyen Gregory E-Health in The Netherlands Van Cauwenberge Joris Verhoyen Gregory Course: Medical Informatics Prof. M. Nyssen and Prof. F. Questier Academic year 2013-2014 1 1. 2. 3. 4. 5. Intro: The Netherlands compared to Belgium Nation-wide EHR E-prescription E-consultation Conclusions Van Cauwenberge Joris - Verhoyen Gregory Contents 2 Van Cauwenberge Joris - Verhoyen Gregory INTRO: THE NETHERLANDS COMPARED TO BELGIUM 3 Van Cauwenberge Joris - Verhoyen Gregory EU – study (2010) 4 • Already a few years • Standards (IHTSDO) • HL7, Snomed CT, ICD9, ICD10, EN/ISO 13606 • Telemedicine • Patient-to-doctor • Doctor-to-doctor • E-prescription • Started 2014 • Standards (IHTSDO) • KMEHR, SUMEHR, ATC, ICPC2, ICD-10, ICD-9-CM • Telemedicine • Tele-monitoring • Elderly • Chronic diseases • Mobile monitoring Van Cauwenberge Joris - Verhoyen Gregory • E-prescription 5 • Citizen service number (CSN/BSN) • DigID (not obligated) • UZI-register for healthcare professionals • Identification • eID Van Cauwenberge Joris - Verhoyen Gregory • Identification 6 Van Cauwenberge Joris - Verhoyen Gregory NATION-WIDE ELECTRONIC HEALTH RECORDS 7 Development towards nation-wide EHR 2005 first ideas for nation-wide EHR ministry of Health, Welfare and Sports (VWS) takes leading role 2009 2012 Approval EHR-law Push-through nationby Dutch House of wide EHR without Representatives governmental support. Foundation VZVZ ... 2002 foundation of NICTIZ Start Aorta-project 2008 2011 Van Cauwenberge Joris - Verhoyen Gregory 1997 2013 Obligation Citizens EHR-law rejected National exchange Service Number unanimously by EHR Regional (CSN/BSN) in healthSenate exchange EHR care (except for hospitals) 8 For Who? What can be exchanged? GP’s, specialists and Electronic Medication Record pharmacists that have a (EMR) therapeutical relation with Summary of GP’s records : the patient o allergies, patients can request to o health problems look into their data and set o ... authorisation. Juvinile health records Future: maternal facilities physiotherapists ... In development: Lab results prescriptions Van Cauwenberge Joris - Verhoyen Gregory Nation-wide EHR 9 Aorta and the LSP Responsability of: • NICTIZ (standards) • VZVZ (technical) Goals: 1. Facilitating the exchange of medical data. 2. Make it possible for the patient to consult his/her medical records. Providers of care ? Patient Qualified Patient Portals Qualified Client offices Qualified Healthcare Information system (QHIS) National Switching Point (LSP) UZI/BIG registry PKIO Van Cauwenberge Joris - Verhoyen Gregory Aorta = The national, standardized infrastructure for exchanging and consulting medical records. Basic services DigID 10 National Healthcare information hub SBV-Z (CSN) Architecture LSP National Healthcare information hub Metadata : locations of medical records. Registers all consultations and adaptations. Act Reference Registry (Verwijsindex) Identification and authentication UZI/BIG registry PKIO Van Cauwenberge Joris - Verhoyen Gregory decentralized storage of medical records (by law) Basic services Audit Log Access Contral (Authorisation) Many additional components ... DigID SBV-Z (CSN) 11 Standards Terminology Snomed CT, ISO 9999, LOINC, ATC, ... Text HL7 v3 Transport SOAP and HTTP Security HTTPS Qualified patient portal QHIS Van Cauwenberge Joris - Verhoyen Gregory Exchange of messages client office Two parts that need to be qualified; 1. Software on its own (by private providers) 2. Data communication network (DCN) that uses a private TCP/IP 12 UZI – card = Smartcard for registered physicians, assistants or “businesses” Public/private key infrastructure (UZI-register) : secure connection to LSP (TLS) Sign documents DigID DigID low Login name and password. DigID middle login name, password and sms Based on CSN, yet without public/private key infrastructure insufficient for access! Future prospects : the eNIK. (started 2004 ...) Van Cauwenberge Joris - Verhoyen Gregory Identification & authentication 13 Therapeutic relation obligated, yet technically not necessary! Opting-out Intelligent audit log Opting-in (each time) Authorisation-protocols : who can see what Uses BIG-registry www.ikgeeftoestemming.nl Possibility to exclude or include medical personnel Van Cauwenberge Joris - Verhoyen Gregory Authorisation 14 security andprivacy Costs: € 30 million/ year (NICTIZ) no governmental support HL7 v3 well-standardized technically OK Current use of the LSP for exchange of information (5th of may 2014) Absolute number % of population GP – practices 3312 81% GP – posts 1687 85% Pharmacists 111 90% Hospitals 28 31% Van Cauwenberge Joris - Verhoyen Gregory Summary nation-wide EHR 15 Patient-data 3 614 090 unique CSN’s 21,5 % Van Cauwenberge Joris - Verhoyen Gregory E-PRESCRIPTION 16 E-prescription Year Medication-related acute avoidable hospitalization 2005 4.6% 20% 2008 3.9% 18% 7000 to 8000 cases in the Netherlands • Medication monitoring • Responsible care • Interactions medication • Allergies • Incorrect dosage • Double medication • Contra-indications and other patient characteristics Van Cauwenberge Joris - Verhoyen Gregory • Safety 17 • In 2008 already 62% electronic prescriptions • The only way of prescribing from January 1, 2015 • Possible to use different software platforms • Only qualified ICT-suppliers • “EMD plus” program • EHR and EVS software platforms have different suppliers Van Cauwenberge Joris - Verhoyen Gregory E-prescription • Extra work physician to include records in both the systems 18 E-prescription • Authenticity – integrity Electronic prescribing Digital signature prescriber Transmission receiving Service provider • Exchange prescriptions • With AORTA • Without AORTA Process prescription pharmacy Store prescription Van Cauwenberge Joris - Verhoyen Gregory • Digital signature with UZI-pas (obligated july 2007) via LSP directly to pharmacy • HL7v3 standard • Digital signature implemented 19 Van Cauwenberge Joris - Verhoyen Gregory E-CONSULTATION 20 E-consultation • Time • Physician: 11 minutes • Patient: half day • Content poorly remembered • E-consultation • • • • • More flexible More efficient for both doctor and patient Possible to reread content Safe New ICT-applications Van Cauwenberge Joris - Verhoyen Gregory • Normal consultation 21 Van Cauwenberge Joris - Verhoyen Gregory E-consultation 22 • Results www.webspreekuur.nl • • • • • 86% satisfied Consultation time from 11 to 4 minutes Safe Almost no waiting time Low cost Van Cauwenberge Joris - Verhoyen Gregory E-consultation 23 Van Cauwenberge Joris - Verhoyen Gregory CONCLUSIONS 24 difficulties for standardisation. decentralisation. privacy and safety concerns. fewer progression the last years compared to e.g. Belgium. Van Cauwenberge Joris - Verhoyen Gregory Technically, the dutch E-health is quite advanced. Yet legislation lags, and governmental issues persist, causing: 25 • Ministry of Health, welfare and sports: http://www.rijksoverheid.nl/ministeries/vws/organisatie • Nictiz: https://www.nictiz.nl/ • Vzvz: https://www.vzvz.nl/ • EU-studies: http://www.ehealth-strategies.eu/ (2010) Van Cauwenberge Joris - Verhoyen Gregory References • WHO: http://www.who.int/en/ 26 Van Cauwenberge Joris - Verhoyen Gregory Thank you for your attention! 27
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