Board certified physicians in health informatics a European precedent for professional recognition.

OBJECTIVE: To document the official recognition of a new specialty in health informatics in one European country, because a similar legal process may lead to professional equivalence for physicians in all member countries of the European Union and elsewhere. METHOD: In Belgium, a Ministerial Decree in 2001 established criteria for the certification of Physician Specialist in Health Data Management. Such recognition of a new competence is a natural complement to a University Master's degree and can have a major influence on the salary scale and on professional recognition and development in public and private sectors. RESULTS: Teaching and training programmes in Belgium were adapted according to the Decree. Ninety-seven physicians were certified in the French community and 72 in the Flemish community between 2002 and 2009, with a prerequisite of this title for engagement in several official and private positions, and a salary increase. DISCUSSION: In other countries, recognition of a specific competence in health informatics remains, at best, a voluntary registration process and University programs vary widely. The implications of this Decree, with recognition of Physician Specialist in Health Data Management as a special competence, rather than a medical specialty, are discussed. The extension of such recognition to health professions other than physicians is not yet envisaged. CONCLUSION: Although the title "Physician Specialist in Health Data Management" may appear rather old fashioned, recognition of this competence in a European Union country is a first step to help its diffusion to other countries.

Health data quality improvement by comparing administrative medical data and billing data.

OBJECTIVE: The increasing use of medical administrative databases in hospital financing means more attention is being paid to their quality. The object of this study is to compare diagnoses found in the medical database to treatments mentioned in the billing database and to identify hospital stays with discrepancies. METHOD: The analysis is performed for the diagnoses of heart failure, hypertension, and pneumonia. Data were extracted from the 2000 National Medical Minimum Basic Data Set (MBDS) database and from the 2000 National bill summary database. The in-hospital stays were split into four analysis groups: patients with the selected disease and a corresponding treatment, patients with the selected disease but without a corresponding treatment, patients with a treatment, without the selected disease, but with another pathology requiring the same treatment, and patients with a treatment, without the selected disease and without any other pathology requiring the same treatment. RESULTS: The proportion of in-hospital stays with the disease in the medical database but without a corresponding treatment mentioned in the billing database was 1.1% for heart failure, 12.0% for hypertension, and 5.1% for pneumonia. Under-reporting (patient with a treatment but without any corresponding disease) concerned a high proportion of stays for heart failure and for hypertension (29.6% and 26.8%, respectively). CONCLUSIONS: This database comparison identified hospital stays with discrepancies between the medical database and the billing database. This method allows a better focus on the medical MBDS to be reviewed but must be completed by a thorough analysis of the medical chart. An extension of this methodology to other pathology would be useful to assess the quality of administrative data.

[The advancement, progress and challenges in medical informatics in Belgium]. / Etat d'avancement, progrès et défis de l'informatique médicale en Belgique.

The development of medical informatics has been as quick in Belgium as in neighbouring countries. It followed the worldwide diffusion of new information technologies, mainly in hospitals, in laboratories, for medical imaging and, more recently, for the EPR (electronic patient record), the e-prescription and bioinformatics. Today, 78 % of general practitioners have access to an EPR and 100 % of acute care hospitals use computers. The Federal Government developed a policy in order to obtain more coherence in information systems and an economy of scale in the (nineteen) eighties, by introducing a reform of health care financing based on diagnoses documented by hospital inpatients record summaries, exhaustive since 1990. During the last years, software quality criteria, called labels, have been introduced in general practice, and "BeHealth", a Federal health network with a secure access platform and authentified medical data, has been developed as a pilot project. Challenges of health telematics in Belgium are related to a profound change in doctor-patient relationship. a shift in organizing medical practice and risks linked to socio-economic interests. These cannot have a primacy over patient interests. Informatics and medicine are not incompatible. The human character of doctor-patient relationship has to be preserved.

Norms for telematics in health care: priorities in Belgium.

A Commission has been established by Royal Decree in order to make recommendations to Ministers of Social Affairs and Public Health in matters related to standards in telematics for the health care sector in Belgium. The present strategic plan has three priorities: (1) To obtain coherent information systems allowing uniform data transfer between hospital and ambulatory care, using quality labels supported financially and taking in account long-term archiving. (2) To develop secure and standardised communication systems using electronic signature and standard messages in XML. The implementation of health professionals and patient identifiers is in progress. (3) To reinforce collaboration between health care services by using a health network prototype linked both to general practitioners and hospital institutions.

Electronic signature and certification models in health care.

Recently, Belgian legislation has enabled the practical use of electronic signatures. Several implementation options are still open and different models for deployment on a wide scale are possible. This document describes two models that can be applied to the healthcare domain and summarises the recommendations as issued by the Belgian Health Telematics Standards Committee

WHO views on perspectives in health informatics.

The wider use of telematics in public health and patient care will be a very important strategy for Member States, and one that can help bring expert knowledge to new areas and institutions in a cost-effective and rapid manner. However, such a strategy should take into account a number of elements that are given below. Health telematics systems and services should be dictated by health need s and by clinical and public health standards, not be technology-driven. The values and principles of Health for All (HFA), notably equity, sustainability, participation and accountability, should apply fully to the development of health telematics. Health telematics requires new skills from the relevant decision-makers , operators and users, calling for a mix of participatory education, skills training, continuing professional education and lifelong learning. Given the fast rate of technological obsolescence and changing price-performance ratios, countries will benefit from closer collaboration on the development of technological standards, compatibility, open architecture, competitive prices and pilot applications. Managing health information developments in an effective and rational way at the level of the European Region will require the major organizations active in this field to enter into more formal agreements of cooperation than is the case today; most importantly, this will involve World Health Organization (WHO), the European Commission and Organization for Economic Co-operation and Development (OECD).

Long term preservation of electronic health records. Recommendations in a large teaching hospital in Belgium.

Health records should be readily accessed by authorised persons for diagnosis, treatment and legal security purposes during patient's lifetime and thereafter for research and training purposes. Technology makes difficult the preservation of digital material, because of rapid changes in information media, hardware and software evolution, and because of the multiplicity of its location as well as the complexity of its environment. A committee in a large teaching hospital in Belgium, recommends two complementary approaches: (1) After a patient departure, all his health information should be managed by a unique organisation that would update regularly accesses to all data bases concerned by this patient. Health archives should be formatted using XML (Extensible Mark up Language) software family, and set on supports such as DVD-ROM, to be upgraded or updated when needed. This archive media is fast but not safe. (2) Computer output microfilm (COM) and scanners for non electronic data to be preserved appears to be also needed, as it is storage safe for at least 250 years and readable directly by eye. This archive media is safe but not fast.

Education and training possibilities in Europe for chaining ambulatory and hospital inpatients care.

Although there is a trend to the development of the electronic patient record, the need for uniform classification systems to document diagnoses and procedures is still there. In the European Union, some research projects or concerted actions promote the concept of episodes of care, meaning that the clinical status of a patient might be followed by different health professionals in various health care settings (ambulatory care, emergency, inpatient, long term care) through medical record summaries. An inventory of teaching and training tools related to information systems that classify diagnoses in various health care settings has been made during the year 1998. Its results show that casemix tools are mainly used for hospital inpatients, much less for outpatients and almost never yet to link episodes of care. Computerised training tools exist in several countries for coding as well as for grouping patients but this area appears still too knew in the field of education because of a lack of European health policy to use uniform data sets in order to measure the degree of efficiency as well as the quality of health care delivery systems in the European union country members.

Ethics and biomedical information.

Ethical rules are similar for physicians in most countries that follow the Hippocratic oath. They have no formal legal force, but can be used as a reference to provide answers to solve individual cases. It appears erroneous to believe that privacy is about information. It is about relationship. In medicine, there is a contract between a patient and a physician, where health care personnel has to respect secrecy, while integrity and availability of information should be obtained for continuity of care. These somewhat contradictory objectives have to be applied very carefully to computerised biomedical information. Ethical principles have to be made clear to everyone, and society should take the necessary steps to organise their enforcement. Several examples are given in the delivery of health care, telediagnosis, patient follow-up. clinical research as well as possible breakthroughs that could jeopardise privacy, using biomedical information.

Blood transfusion practice in Belgium. As assessed by a national survey.

In April 1995 the Ministry of Public Health invited all Belgian hospitals to participate to a survey on the use of blood transfusion. The questionnaire presented two parts, the first one devoted to products transfused and the second one to the transfusion organisation in the hospital. 71 hospitals answered: 7 university and 64 general hospitals. All hospitals reported the use of red cells, 31 of them still used whole blood. Surgical departments transfused the greatest absolute amount of units, but the highest intensity (units/bed/year) was observed in intensive care units. 52 hospitals mentioned the use of autologous predeposit. The highest consumption of platelets occurred in medicine but intensive care showed the highest intensity of platelet transfusion. In 41 hospitals platelets were obtained by cytapheresis. The number of plasma units transfused was highly correlated with the quantities of packed red cells and whole blood transfused. Ten hospitals didn't report the use of any blood conservation technique. Returning unused units to the blood bank was allowed in 80% of the hospitals, their return to the transfusion center was permitted in 65% of the hospitals. A transfusion committee existed in only 11 hospitals. Transfusion should be improved by a better education of all physicians and nurses involved with transfusion and by improving standardisation, by better documentation, better reporting and information of all health care workers involved.

"The Electronic Wardenî management of the data security access in a heterogeneous university hospital environment in Belgium.

A very flexible software system called "Electronic Warden" has been developed. It is based on a "client/server" architecture. It controls and manages the access right of the complex and heterogeneous data computer system at St Luc Hospital in Brussels. The electronic warden is independent of the other software applications of the hospital and is connected to them through API'S. The physical access is managed with the use of smart card and allows the electronic signature. The management of the users and their accesses to the data is run in a centralised or a decentralised way which allows a lot of flexibility.

Cost-effectiveness of preoperative examinations.

Preoperative medical evaluation is needed to assess individual patients risks of perioperative morbidity and mortality. The content of the preoperative examination remains the object of discussion. Although a well documented preoperative assessment of a patient's health status might allow to optimise his condition before surgery and to plan the most appropriate perioperative management, leading to an improvement of perioperative outcome as well as a reduction in costs, data to support this claim are still most often indirect. A large number of patients remain asymptomatic, with normal tests, which raises questions about the appropriateness to request a battery of tests on every candidate to surgery. Patients risks should be assessed mainly by history and physical examination, which might reduce drastically preoperative indication of laboratory tests: age, operation site, preoperative diseases and emergent surgery are important factors to consider. A risk estimate is presented, as well as recommendations for a preoperative health assessment, by categories of patients, following a screening pathway. Costs have been estimated in various alternatives. They have been evaluated to be above 2 billion BEF per year in Belgium for 563,485 surgical cases, and could most likely be reduced by about 60% in a near future.

Security of the electronic health record.

The Electronic Health Record (EHR) raises new challenges for security. Only authorized persons having a "right to know" can have access to identifiable patient data. Differences between the paper record and the EHR are first described. Several solutions in order to assure confidentiality, integrity and accessibility to patient information are then proposed.

Control and use of health information: a doctor's perspective.

The electronic health record offers all advantages of computer based memories. It is accessible over networks, highly structured and allows exchange of information both within the institution and across its borders. However, it has potential disadvantages among which a great risk for confidentiality, integrity and availability of information about identifiable patients exists. The present paper discusses advantages and disadvantages of the electronic health record as well as methods in order to control and use appropriately identifiable patient data. Personal data protection requires a legislation, a code of conduct, information contracts, an organisation under the responsibility of a physician, technical tools for health security, risk analysis methods, standards for development and implementation of computer systems as well as training and teaching sessions.

The need for security--a clinical view.

Systems which process patient health data of any kind are considered to be medical information systems. Some data can be categorized as non-personal, non-identifiable, or non-patient-based such as knowledge bases. Others are considered as highly sensitive because of the 'need to know' to deliver health care to patient. Access is not only justifiable for doctors and nurses, but, for specific purposes to administrative personnel and public health organisations. Of special concern are registers on sexually transmitted diseases, mental health and genetic diseases. In future, patients might gain more autonomy and also have access to some parts of their own record. Telematics allows them to update a data base and to consult a knowledge base. Clearly, physicians in charge of the cases have a responsibility that has been recognised by law in all Western countries. Access to patient's data should take into account this responsibility. Although most health professionals would still believe that confidentiality is the main issue, it appears that data integrity and availability are as important in the context of the 'paperless' electronic record. Information should be complete and correct, to be only accessed by authorized persons. The health care environment is characterised by an open nature of clinics that leaves them vulnerable to theft, damage and unauthorized access. Disclosure of information may affect the patient's social standing as well as their general health. The health professions lack sufficiently well-defined organisational structure, culture and perceptions to support security.

Development of standards and data quality control.

Health care expenses represent 6 to 10% of the Gross National Product in most European countries. This budget exceeds by far those devoted to Defence or Education. The rising cost of health care concerns all governments. In each country of the European Community, measures were and will further be taken in order to increase efficiency in the delivery of health care. Recent advances in information technology offer new opportunities to collect, process and exchange data to document health practices. In Belgium the Ministry of Public Health collects uniform medical summaries for all acute care hospital inpatients, while detailed health care activities are documented for each patient through a very precise billing system. The use of Minimal Clinical Data and Minimal Nursing Data Sets in hospitals became mandatory four years ago. The fundaments for any data collection is reliability, no matter what the preconceived aim was.

Structure for classification and coding of surgical procedures.

PT002s of TC251 of CEN has been established in order to identify structural elements for classification and coding of surgical procedures. This project team identified 10 types of characteristics that could describe any surgical procedure. These characteristics were grouped in three classes: objects (topography/e.g. body system and body site, pathology, side, material); actions (procedure, extent, numeral) and methods (instrument, material, topography). Syntax rules are proposed as well as references to existing lexicons. This structure is mainly addressed to developers of classifications of procedures. It allows retrieval of monoaxial classifications through a multiaxial representation, logical rules for updating, as well as a method to compare existing classification systems. It is still in development and discussion.

Hospital comparisons using a Euro Health Data Base for resource management and strategic planning.

A European approach for resource management and strategic planning has been implemented in the HOSCOM project of AIM by defining information standards needed across countries, as well as a methodology to measure resources and costs at the institutional and interinstitutional level. A Euro Health Data Base (EHDB) has been obtained in order to test data availability and comparability as well as to validate models through macrocomparisons using case-mix (DRG's, refined grouping, disease staging) and microcomparisons based on three diseases (cardiac valve replacement, diabetes mellitus and hip fracture). The EHDB's presently based on 274 164 medical record summaries sampled from 7 countries allowed us to build prototypes (using Clipper, Prolog and SQL) in order to export uniform aggregates in the different countries, with standard software tools for statistical comparisons. It showed the present feasibility of using case-mix based on the European Minimum Basic Data Set (MBDS) and the difficulty of obtaining uniform data on resources and costs other than length of stay across countries. Medical data confidentiality was assured but not yet population-based representativity. Given the present state of the EHDB, problems have been clearly identified in order to be solved by international research and development projects in the near future.

The European challenge in health information systems.

The challenge for Europe in the field of information and communication technologies applied to health care is that of "integration, modularity and security" of health information systems in order to obtain greater efficiency of health care, to assure quality of care and to promote industrial competitiveness.