Dosarul Electronic al Pacientilor -o abordare strategica in domeniul serviciilor de sanatate-

1. Dosarul Electronic al Pacientilor -o abordare strategica in domeniul serviciilor de sanatate- Dan Ursuleanu Noiembrie 2008

2. Putina istorie… • Sistemul informational sanitar a incercat inca din anii 1920-1930 sa aplice principii cum ar fi: 1. informatia sa fie doar o singura data in sistem 2. fluxuri unice de date 3. date primare – date agregate 4. aplicarea teoriei sistemelor • De fapt informatia medicala a pacientului este de mai multe ori in sistem si fluxurile sunt dublate

3. …tot istorie • Evolutia tehnologiei informatiei a permis inca din anii 1990 ca la nivel local sa se poata asigura unicitatea informatiei pacientului, fluxuri unice de date, agregarea datelor primare… • Unde? In sistemele informatice integrate de spital • Cum? De la PC la retele locale si la Internet • Probleme: securitatea datelor, acces rapid, comunicatii sigure, training…

4. Context • Nevoi exprimate de populatie pentru servicii medicale accesibile, acceptabile, eficiente, eficace si echitabile • Presiune pe management pentru reducerea cheltuielilor si cresterea calitatii serviciilor • Cresterea ponderii bolilor cronice • Reformele in sanatate si metode de sustinere a reformelor • Control preventiv, eficient • Pacientul in centrul actiunilor de reforma • Declaratia Ministrilor Sanatatii – Bruxelles 2003 • Planul de actiune al UE pentru e-Sanatate – CE 2004

5. Definitii - EHR • Prima specificatie tehnica internationala publicata: “ISO/TS 18308: 2004 Health informatics – Requirements for an Electronic Health Record Architecture” • Electronic Health Record(EHR) • Electronic Medical Record (EMR) • Electronic Patient Record (EPR) • Computerized Patient Record(CPR) • Electronic Health Care Record (EHCR) • Virtual EHR • Personal Health Record (PHR) • Digital Medical Record (DMR)

6. Definitii - EHR • U.S. Institute of Medicine - 1991: “Un set de componente care formeaza un mecanism prin care inregistrarile pacientului sunt create, folosite, stocate si regasite … sistem accesibil furnizorilor de servicii medicale …care include persoane, date, reguli, proceduri, echipamente de procesare si stocare, comunicatii si facilitati de suport.”

7. Definitii - EHR • U.S. Institute of Medicine – 2003: “O colectie longitudinala de informatii electronice de sanatate pentru si despre persoane, unde informatia de sanatate este definita drept starea de sanatate si serviciile de sanatate primite; …acces electronic imediat numai persoanelor autorizate si populatiei; …ofera cunostinte si suport de decizie care cresc calitatea, siguranta si eficienta serviciilor de sanatate; …este un suport de livrare de procese eficiente de servicii de sanatate”

8. Definitii - EHR • CEN 13606 – 2000: “Un sistem pentru colectarea, regasirea si manipularea informatiilor in inregistrarile electronice de sanatate”

9. Ce au facut alte tari • Strategii …Resurse financiare • Legislatie specifica • Standarde • Proiecte EHR • Timp • Mentalitati • Efort …Rezultate!

10. HTB: Germany eHealth Card Programme • A pilot project for Knappshaft Insurance service providers and beneficiaries Solution: an Electronic Health Record Centralized record for the eHealth Card (eGK) programme • Data repository accessible to providers and patients: demographic data, ePrescription, co-payment status (EU) • Specification determined by the Act on Modernisation of the Statuary Health Insurance System • Proof of concept complete: 1 hospital, 100 patients, 20 users Partner: T-Systems Germany

11. HTB: Netherlands Gorinchem Region: • 280,000 people • 1 Hospital • 70 General Practitioners, 30 Pharmacies Solution: “Communication Platform” • Centralised EHR to improve continuity and quality of care • Software development is complete • Currently 10 GPs and 1 Pharmacy under acceptance testing, rollout to progress from June 2006 Partners: Rivas Zorggroep, Trias Zorgvesekeraar, Regionale Huisartsen Vereniging, Oracle Consulting Netherlands

12. HTB: Sweden Stockholm County: • 1.9 million people (20% of Sweden) • 25 municipalities • 26 different health record systems Solution: a regional Electronic Health Record • Centralised EHR built on Service Orientated Architecture with a common storage layer (Phase 1 – Lab Reporting) • Acceptance testing and proof-of-concept completed April 2006 • Current activity: integrating completed HTB storage layer with application and portal layers • Project Goal: “One person – one health record” Partner: WM-data

13. HTB: Spain Son Dureta Hospital: • Mallorca, Balearic Island • Regional referral Hospital • 800 beds Solution: a Clinical Web Portal Building the foundation of a regional Electronic Health Record • Order management, result viewer, access to clinical applications • Patient demographics, orders and results to be persisted to HTB • The portal and order management software is supplied by Orion • Acceptance testing to commence in June 2006 Partners: Orion Health and Fujitsu

14. HTB: Denmark Roskilde Hospital: • Roskilde Region, Denmark • University teaching hospital • Proof of concept implemented in an acute stroke ward Solution: “Clinical Suite” A Paperless clinical environment (EHR) for managing patient information: • One-week pilot completed in the Roskilde acute stroke ward • High clinician and nurse acceptance • Academic publications from analysis of the pilot are anticipated Partner: CSC-Scandihealth

15. HTB: Italy Lombardia Region: • Lombardia, Italy • Regional government Solution: “Clinical Suite” Managing patient information: • Regional Electronic Health Record • e-Prescribing

16. EHR – Cine? • Autoritati nationale de sanatate publica • Autoritati regionale/locale de sanatate publica • Servicii de sanatate private grupate • Consortii de servicii de sanatate locale • Retele de asistenta primara • Spitale, retele de spitale

17. EHR – Cum? • Legislatie specifica Ro si EU • Informarea populatiei/acordul cetatenilor • Conferinte de consens pe zona eticii si deontologiei medicale • Functionalitati de asistenta medicala : servicii de sanatate, suport de decizie, comunicatii • Functionalitati de sustinere a activitatilor asociate actelor medicale: administrative, finanaciare, cercetare medicala, promovarea sanatatii publice, analiza, cercetare • Functionalitati de infrastructura: securitate, managementul informatiilor, identificare unica, suport standarde, terminologii, interoperabilitate, fluxuri

18. EHR – Cum? • Aplicarea principiilor si recomandarilor principalelor organizatii internationale de standardizare, active in domeniul EHR: HL7, ISO/TC 215, CEN/TC 251, DICOM • Specificul organizarii sistemului de servicii de sanatate in Romania/prioritati regionale • Utilizarea experientei similare altor tari – sisteme pilot regionale • Relationarea altor functionalitati: e-Prescribing, tele-medicina, PACS, laborator, e-Learning,etc

19. EHR:De ce - cum? Solution Overview Customer value proposition • Secure, centralized electronic health record developed by IZIP and the General Health Insurance company in CZ Republic on Oracle Database and RAC available over the public network. • The EHR includes all relevant information compiled from regular GP visits, dental treatments, laboratory and imaging tests and hospital services, such as complicated surgery. • Citizens allowed to view their record and approve access by healthcare professionals. Only health professionals are able to update or insert data. Organisation 1 Key Benefits • Citizens have control over the information on their health history and access to it at the point care • Improved communication between Healthcare Providers, Insurers and citizens • Significant reduction in duplicate data entry and tests • Estimated productivity gain by healthcare professionals: 74% Organisation 2 Solution Overview • Electronic Health Card based access to centralised secure electronic health record. Essential health information available on card for quick access. • Data warehouse for analysis and reporting created from the transactional electronic health record. • Single window accessibility to healthcare services, appointment bookings, lab results and prescription management Key Benefits • Reduction in duplicated or unnecessary procedures • Improved patient safety, as allergy and other data is stored on the smartcard • Patients can choose where they want to be treated, as all hospitals have access to their health record

20. EHR:De ce - cum? Customer value proposition Solution Overview • Integrated standards based electronic health record framework over Oracle HTB for creating a single, up-to-date information record for the emergency department • Synchronised patient data from existing repositories using Oracle Partner Orion Health’s Rhapsody with HTB via HL7 v3.0 messages • Scalability of Oracle HTB to roll out electronic health records to all departments in Son Dureta and other regional hospitals, and support thousands of users simultaneously Organisation 3 Key Benefits • Improve the speed and quality of healthcare delivery by creating a single,universally accessible electronic health record for each patient • Cut developing costs by reuse of existing clinical systems Organisation 4 Solution Overview • Architecture for telematics applications including electronic health card, and a backend electronic health record (EHR) developed on Oracle HTB. • The EHR exposed as web services and accessible to patients through a user interface via Kiosks. • Implementation of enterprise processes, i.e. authentication, identity and access to EHR. Key Benefits • Support the modernisation of the Statutory Health Insurance System (GKV-Modernisierungsgesetz) • Reduction of healthcare costs

21. 1a Oracle Solution Project Management Change Management 3 Delivery Capabilities Facilities Manager (Oracle On-Demand) Systems Integrator Systems Integrator PLUSOracle Package Enabled Reengineering Method Core Applications Location/ Office Recruitment Configuration and Architecture Organisation Design Process Design EHR - Cum? Solutii, Parteneri si Capacitati de livrare 1 eHR-Conceptual components 2 Business Partners

22. EHR: Rezultate asteptate Obiective pentru beneficiari Implementing IT will prove to provide a wide range of benefits. Not all are easy to financially quantify. • Improve quality of care • Reduction in medical errors caused by inaccurate or unavailable patient information • Able to track access to healthcare information more easily. • Improved communication and coordination between healthcare stakeholders in care delivery • Improved legal and regulator compliance with controlled and auditable provider access • Notes, prescriptions, orders and other data is always readable. • Reduce Costs • Medical errors cost between $17 and $29 billion in US alone • Savings of approx. $500 billion in unneeded duplicative care • Reduced cost of recruitment by improved clinician satisfaction • Reduced transcription costs estimates monthly between $300-$1000 per physician • Reduction of office visit time by 13% for physicians and one minute for pre-exam • Increase Citizen Satisfaction Sources: HealthGrades, June 2004; DATAMONITOR, July 2006; College of Medicine, Florida State University, Feb. 2005

23. EHR: Sunt si obstacole? Key Inhibitors Source: DATAMONITOR Report, July 2006

24. EHR Solution Architecture

25. EHR - Circuitul informatiilor Information Generation network @ point of care Information collection (Aggregation) Information persistence and harmonisation Electronic Processing and Information dissemination Clinical views Data Transformation Hospitals Data transport platform Normalisation Information extracts Consistency check & validation Primary Care Semantic harmonisation Health Surveillance Information Quality Diagnostics Message exception handling Rules processing Patient Register Pharmacies Payer Views Patient views Document Repository Image repository Analytics Electronic Documents Scanned paper documents Electronic Data

26. EHR- Arhitectura Functionala

27. Oracle portal BPEL PM Enterprise Service Bus Wireless Gateway Clinician views Patient views Public health views User workflow Web Services Interface Oracle identity manager Single Sign on Authorisation management identity federation Authentication Policy management Session Management Stellent content management Oracle healthcare Transaction base Enterprise terminology services EMPIservices Role based access Clinical document repository DICOM Interface CDA Interface DICOM Repository Normalised clinical data repository (HL7 RIM) Query services Messaging Services Image repository ( Scanned paper) Hl7 V3 SOAP JCA In Memory JMS B2B Oracle Integration Adapters XSLT Mapper EHR - Solutia Oracle