Norms in Telematics for Health Care : Priorities in Belgium
2. Priorities in Belgium
A strategic plan was already elaborated in 1999.
It has been re-actualised in 2002. The main objective of the Commission is to promote the electronic exchange of health data by the promotion of standards and an appropriate organization, as well as to develop the use of the electronic patient record in hospitals and in ambulatory care. The aim of this standardisation is to obtain a coherence in health information systems by using norms in harmony with national and international standards in order to facilitate exchanges among health care professionals, between health care establishments and authorities, to encourage industrial developments and to improve quality of care.
Priorities are devoted to three domains: (1) To obtain a first level of norms for local information systems in ambulatory and hospital care. (2) To
standardize and make secure information communication by standardized messages and secure identifiers for health care professionals and patients. (3) To create a health network in order to reinforce collaboration inside the health care sector. These three aspects will be described thereafter.
2.1 Local standards for local information systems.
The Commission opted for yearly quality labels in order to improve information systems already available.
Quality criteria were first used for electronic patient records softwares in general practice. A total amount of 4.7 million € has been devoted to this objective in 2002 in Belgium. A total of 300 criteria were first proposed and reduced to 100 major criteria, then to 35 selective criteria.
Twenty softwares were tested in April 2002.
They could modify their earlier software version in order to attain the criteria. 17 of them will benefit from the Governmental support (743 € by general practitioner). Financial support will be annual.
A second initiative was the legal recognition of a new specialty for physicians in health data
management. Educational programmes in 2 years are offered by universities, including public health and computer sciences components.
In supplement, the function of a medical and hospital organization has been recommended by the Commission. This organization should establish a hospital information plan and assure the coordination of the electronic patient record.
It is aimed also to collect medical record summaries, to provide a feedback and to analyse data of different types.
At present, quality labels are also considered for hospital information systems but not yet ready.
Finally, the Commission prepares a project to obtain the long-term preservation of patient records. They have to be kept during 30 years in Belgium. It is proposed that some documents could be destroyed after 20 years but that a summary should be preserved by an appropriate organization assuring the migration of electronic supports and long term archiving. XML format is recommended on all supports (electronic and microfilms).
2.2. Standard and secure
communication for health
information
80 The development of standard messaging between health care professionals appeared to be more urgent than to recommend already structured medical records. The present messaging format is in XML with selective choices in HL7 and CEN-TC 251 standards (2).
Among messages, let’s quote electronic prescription, laboratory data, medical record summaries, final reports, request from general practitioners, ...
Electronic certificates have been proposed to be used for health care professional signatures as well as for encrypting electronic communication of data (3,4). Each Belgian citizen will have an electronic ID card beginning in 2003. Specific attributes could be given to physicians and other health care professionals provided their qualification is certified. A personal key infrastructure and a trusted third party will allow to link a private and a public key.
A main debate today concerns the opportunity and the implementation of a patient identifier.
There is a national register with a unique identifier by citizen in Belgium. The significance of this number (based on date of birth) and its
linkage to multiple data bases (tax return, legal, ...) makes its choice controversial for health care needs. It is now proposed to obtain for each patient a derived number, from a unique numbering system, strictly anonymous, for three different objectives: a first for health care purposes, another for research and various studies and a third for administrative purposes.
The strategic plan of the Commission proposes also to develop a model in order to collect electronic data for epidemiologic studies.
2.3 To create a health network
Prototypes already exist in several cities. It is proposed to link them and to obtain a federal prototype that should meet deontologic and juridic recommendations. It is proposed to link this health network to the electronic record of the general practitioner as well as to hospital information systems.
3. Discussion
During the three years of its existence, the Federal Commission “Norms in telematics for health care” has developed a strategic plan that has led already to several recommendations that are in process to be implemented in legal texts and financial incentives. Its work is intensive
and requires numerous meetings of specialised committees. Several studies financed by the State are also regularly followed by the Commission. Its influence depends very much on the confidence of the Ministers in relation to issued advices.
Up to now, the Government has recognised the role of the Commission by asking questions relevant to the health care sector. The Commission played its role also by initiating recommendations in priority areas for the development of health information systems. The constant follow up of international standards, especially those issued by the CEN-TC 251 and ISO-TC 215 is also a condition of success. The combination of quality labels for electronic patient records in general practice and financial incentives appears rather unique in the development of standards up to now.
There are however several obstacles to the development of standardization in the country.
First, there are difficulties to finance information systems mainly in small institutions. Physicians are reluctant to use their fees for computerised applications while administrators don’t estimate to have enough funding by days of stay. There
are also incoherent views between organizations that do not always understand correctly what is behind a standard, for example, for the patient numbering system. One should take into account also reactions of defence by certain groups that promote their own interests. Finally, there is always a delay in the development of standards at the international level before they become applicable by the industrial sector. Further thinking is also expected about the patient citizen role in e-health information access and use.
References
1. Ministry of Social Affairs, Public Health and Environment. 3 May 1999. Royal Decree on Telematics Standards for the Healthcare Sector. Moniteur Belge, 30.07.1999, pp. 28464-69; pp. 28501-502.
2. CEN/TC 251. Medical Informatics, ENV 13606-4 on message standard – 1999.
3. Directive 1999/93/EC of the European Parliament and of the council of 13 December 1999 on a Community framework for electronic signatures, Official Journal of the European Communities, 19.1.2000.
82 4. F. De Meyer, G.J.E. De Moor, F.H. Roger
France. Electronic signature and certification models in health care. Medinfo 2001, V. Patel et al (eds), IOS Press, Amsterdam, 2001, pp 1252-56.