the French PHR/EHRCreation, usage and lessons learnt with a national e-health record

François Macary

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Building e-health services for the improvement of care coordination is a long term endeavor

"In some industries, it takes 10 or 20 years to go from an idea to something being real. Health care is certainly one of those areas. We should shoot for the things that are really, really important, so 10 or 20 years from now we have those things done."

Larry Page, CEO Google (September 18th, 2013)

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Evolution of the French regulatory framework

IT & Freedom Law (1978, modified in 2004)• Controls storage & processing of personal data• Creates CNIL (an independent agency controlling IT with regards to freedom)

Patient rights Law (2002)• Reinforcement of patient rights, including access to medical record• Protection of health personal data• Empowerment of health data hosts

National Personal Health Record (DMP) Law (2004)• DMP: goals, design principles• Requirements for a National Patient Identifier

"Hospital, Patients, Health, Territories" Law (2009)• DMP stated as optional for the patients• Legal framework for telemedicine• Regionalization (Regional Health Agencies)• Creation of ASIP Santé

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ASIP SantéAgency of shared health information systems

A public agency under authority of Ministry of Health Created in 2009 Board with Ministry of Health and the main healthcare insurance bodies

Major missions: Foster the development of shared information systems in the fields of

health and social care, for a better coordination and quality of care.

Build and run national e-health services (e.g.; the DMP)

Define, promote and homologate profiles of standards contributing to interoperability, security and usage of healthcare IT and e-health.

Produce and deliver healthcare providers' smart cards

Handle the national PKI

Manage the national directory of care providers

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Birth and growth of the DMP

• 2006 – 2008: Regional experimentations– Regional experimental projects leveraging various architectures and

technologies (incompatible with one another)

• 2009: ASIP Santé prepares the national solution:– RFP for a national system, selection of the consortium– Production of the national interoperability framework, 90% based on established

IHE profiles

• 2010: Build of the national system

• January 2011: DMP service goes live (HCP web portal)

• S1 2011: DMP-compatibility certification of health IT products

• S2 2011: Opening of Patient web portal, and first IT systems connected to the DMP

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DMP architecture

Patient smart card Patient Identifier

HCP smart card: Identification & authentication + digital signature

HCP access via their DMP-compatible solutionNational Interoperability FrameworkIHE profiles: XDS, XUA, DSG, ATNA, CT

National certiffied health data hostService Level AgreementDMP Content = Electronic documents:

(CDA, LOINC, ICD-10, SNOMED…)IHE content profiles: PCC, XD-LAB, APSR, …

Patient access(Web access, OTP)

HCP & Hospital DirectoriesPKI

Registration Authorities

HCPcouncils

Health Regional Agencies

Patient Portal

HCP Portal

DMP

HCP access via web browser

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The double intent of DMP

ossier

édical

ersonnel

D

M

P artagé

Personal Health Record

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DMP: a clinical document repository dedicated to coordination/continuity of care

It is both a PHR (personal) and an EHR (shared)

• Citizens are free to decide whether they want to open a record on DMP or not.

• The creation of the record is done by a care provider with the patient.

• From that point the patients have access to their own record, can manage the visibility of its content, can authorize HCPs to access it, can feed their own content.

• Once authorized by the patient, health care providers can use the DMP patient record.

• The goal being care coordination, most content fed in the DMP are reports and syntheses from episodes of care.

• HCP can turn some sensitive content temporarily invisible to the patient

PHR

EHR

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The DMP web access: www.dmp.gouv.fr

Patient Portal

HCP Portal

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System and process laid on public funding (health insurance body)

• Usage of the DMP is free for the patient and for the healthcare providers

• The DMP-compatibility certification process is free for health IT vendors, as well as the support they get from ASIP Santé along this process

• Implementation of DMP-compatibility in health IT products, and their deployment are driven by the market.

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The DMP-compatibility certificationA process run by ASIP Santé

Capability of a HCP software solution (hospital or ambulatory) to interact consistently with the DMP

Create and administrate a patient record in the DMP

Query and retrieve content from a patient record

Feed a patient record with new or updated content

HL7 v3 "patient registry" messages

Cross Enterprise Document Sharing (IHE XDS) profile+ IHE Content profiles templating clinical documents

User assertion carrying the HCP traits and certificates out of their smart card (IHE XUA)Mutual authentication of systems and channel encryption (IHE ATNA)

Consistent time (IHE CT)

3 profiles: ……….. Create Read Write

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Success of DMP-compatibility certification

• 222 IT vendors on the mailing list

• 121 IT vendors have subscribed the contract

• 66 IT vendors have at least one certified DMP-compatible product

• 123 IT products certified DMP-compatible

Figures as of October 20

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Success of DMP-compatibility certification

EAI : Enterprise Application Integration

FAH : SaaS solutions

GAM : Patient administrative management solutions (ADT)

LGC : ambulatory physician solutions

SIH : Hospital medical record solutions

SGL : Laboratory information systems

SIR : Radiology & imaging systems (RIS/PACS)

TLM : telemedicine systems

BIN : Interactive kiosk (for creation of patient record)

products certified / #profiles #products certified / profiles

Figures as of October 20

Create

Read

Write

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Creation of patient records in the DMP Figures as of October 24

395,000 existing records containing 850,000 documents altogether ambulatory HCP (mainly physicians) > 5,100Hospitals = 370

Creation on HCP Web portal

Creation by HCP solution

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Conclusions: A contrasted uptake

• Strong uptake by health IT vendors

– DMP has significantly raised the bar of standardized interoperability, functional relevance, data structuring on the French Health IT market (particularly for EHR-S, which were the first target).

– DMP strongly integrated in the care provider's solution

• However, the deployment of solutions is driven by market rules, therefore slow

• Hence a slow uptake by health IT providers

• No public marketing campaign undertaken yet. Thus the majority of citizens have hardly heard of DMP at this point.

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Some of the lessons learned

Change is systemic and needs to involve the complete ecosystem : Ministry, Health insurance bodies, Regional Health Agencies, HCP unions and councils, hospitals, patient associations, vendors.

Strong political and financial decision & support on the long term are critical;

Stake holders alignment and commitment at national, regional and local level are needed;

Time management is the key to install confidence: the project took years (from law adjustments to implementation, to run) and will need more years to grow

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Perspectives

• Healthcare Minister announced a DMP stage 2, extending the effort with a focus on chronic diseases

• In parallel ASIP Santé is now building a national messaging service "MSSanté" for the exchange of healthcare information between HCPs.

• Both services (DMP for sharing and MSSanté for exchange) stand on the common trust infrastructure (PKI, smart cards, HCP and hospital directories extended to support the email addresses and mailbox parameters)

• The growth of standardized interoperability and health data structuring will not stop. The current incentive program for modernizing HIS will require more interoperable solutions.

François Macary

THANK YOU!