Information management in the Belgian social and health care sector

Frank RobbenGeneral Manager CBSS and eHealth platformCEO SmalsSint-Pieterssteenweg 375B-1040 BrusselsWebsite CBSS: http://www.ksz.fgov.beeHealth platform portal: https://www.ehealth.fgov.bePersonal website: www.law.kuleuven.be/icri/frobben

Information management in the Belgian social and health care sector

http://www.ksz.fgov.be/

https://www.ehealth.fgov.be/



http://www.law.kuleuven.be/icri/frobben

June 20th, 2011 2

Structure of the presentation

about me stakeholders of the Belgian social and health care sector divisions of tasks with regard to eGovernment/eHealth in the social and

health care sector implementation order used by the CBSS in the social sector (start up

1991) achievements in the social sector advantages in the social sector and international recognition creation of the eHealth platform (start up 2008) principles implemented in the health care sector achievements in the health care sector advantages in the health care sector critical success factors Smals, an organisation specialised in information technology and related

competencies

June 20th, 2011 3

About me

°1961 studied law, ICT, ICT audit, business administration and personal

coaching in Leuven, Antwerp, Tübingen, Munich and Boston 1986-1988: advisor to the Belgian Minister of Social Affairs 1988-1991: advisor to the Belgian Prime Minister 1990-now: co-founder Interdisciplinary Center for Law and ICT at

KULeuven 1991-now: member of the Belgian Privacy Commission 1991-now: founder and general manager Crossroads Bank for

Social Security 2000-2001: founder and president of Fedict and co-developer of the

Belgian electronic identity card 2004-now: general manager Smals 2008-now: founder and general manager eHealth-platform see www.law.kuleuven.be/icri/frobben






June 20th, 2011 4

Stakeholders

stakeholders of the Belgian social sector - > 11,000,000 citizens

- > 220,000 employers

- about 3,000 public and private institutions (actors) at several levels (federal, regional, local)

stakeholders of the Belgian health care sector - > 11,000,000 citizens

- > 100.000 care providers (medical practitioners, dentists, clinical laboratories, pharmacists, physiotherapists, home nurses, …)

- > 300 care institutions (hospitals, residential care homes, …)

- health insurance funds

- government institutions

June 20th, 2011 5

Division of tasks

same division of tasks in both sectors no central data storage but secured exchange of data Crossroads Bank for Social Security (CBSS) in the social sector and eHealth

platform in the health sector act as service integrators- common vision- driving force for change and change management- solid ICT architecture and performant basic ICT services- in charge of a highly protected ICT-cooperation platform, with a reference

directory for• access control• routing• in some situations, automatic communication of alterations

- process optimization, lateral way of thinking- standards

• quality• information security• technical and semantic interoperability

- cross-actor program and project management- training and coaching

June 20th, 2011 6

Division of tasks

actors (or their ICT service providers)

- development of value-added services for internal purposes (for themselves and their co-workers) and external purposes (for the citizens, companies, …)

- information management according to agreed division of tasks

Smals, an association specialised in information technology and related competencies, owned by the public actors in the social and health sector

- hires ICT-specialists at normal market conditions and puts them at the disposal of its members

- elaborates shared ICT-services for its members (e.g. data centers, monitoring and supervision of applications, portal environments, …)

- executes (common) projects for its members

- has a research and development center for its members (recent European patent application for electronic (health) vault)

6

June 20th, 2011 7

Implementation order used in the social sector

common vision on information management and information security

demonstration of feasibility

political and public support, support of the social partners, support of the social security institutions

basic legislation- creating an institution as a driving force (CBSS has been created in

1991) and a control committee on information security and privacy protection

- translating the common vision on information management and information security

integration of unique identification key in all information systems

June 20th, 2011 8

Common vision on information management

information is being modelled in such a way that the model fits in as closely as possible with the real world, in order to allow multifunctional use of information

information is collected from citizens and companies only once by the social sector as a whole, via a channel chosen by the citizens and the companies, preferably from application to application, and with the possibility of quality control by the supplier before the transmission of the information

the collected information is validated once according to established task sharing criteria, by the actor that is most entitled to it or by the actor which has the greatest interest in correctly validating it

a task sharing model is established indicating which actor stores which information as an authentic source, manages the information and maintains it at the disposal of the authorized users

June 20th, 2011 9


information can be flexibly assembled according to ever changing legal concepts

every actor has to report probable errors of information to the actor that is designated to validate the information

every actor that has to validate information according to the agreed task sharing model, has to examine the reported probable errors, to correct them when necessary and to communicate the correct information to every known interested actor

once collected and validated, information is stored, managed and exchanged electronically to avoid transcribing and re-entering it manually

electronic information exchange can be initiated by

- the actor that disposes of information

- the actor that needs information

- the CBSS that manages the interoperability framework

June 20th, 2011 10


electronic information exchanges take place on the base of a functional and technical interoperability framework that evolves permanently but gradually according to open market standards, and is independent from the methods of information exchange

available information is used for

- the automatic granting of benefits

- prefilling when collecting information

June 20th, 2011 11

Common vision on information security

security, availability, integrity and confidentiality of information is ensured by integrated structural, institutional, organizational, HR, technical and other security measures according to agreed policies

personal information is only used for purposes compatible with the purposes of the collection of the information

personal information is only accessible to authorized actors and users according to business needs, legislative or policy requirements

the access authorization to personal information is granted by an independent Sectoral Committee of the Privacy Commission, designated by Parliament, after having checked whether the access conditions are met

the access authorizations are public

June 20th, 2011 12

Common vision on information security

every actual electronic exchange of personal information has to pass an independent trusted third party (basically the CBSS) and is preventively checked on compliance with the existing access authorizations by that trusted third party

every actual electronic exchange of personal information is logged, to be able to trace possible abuse afterwards

every time information is used to take a decision, the information used is communicated to the person concerned together with the decision

every person has right to access and correct his/her own personal data

every actor in the social sector disposes of an information security officer with an advisory, stimulating, documentary and control task

June 20th, 2011 13

Implementation order used in the social sector

implementation of the ICT architecture and the basic ICT services

controlled access to databases with authentic data

re-engineering of processes between actors in the social sector at all government levels

re-engineering of processes between actors in the social sector and companies

re-engineering of processes between actors in the social sector and citizens

always combined with the necessary legislative changes

June 20th, 2011 14

Achievements in the social sector

a network between all 3,000 social sector actors with a secure connection to the internet, the federal MAN, regional extranets, extranets between local authorities and the Belgian interbanking network

a unique identification key- for every citizen, electronically readable from an electronic social

security card and an electronic identity card

- for every company

- for every establishment of a company

an agreed division of tasks between the actors within and outside the social sector with regard to collection, validation and management of information and with regard to electronic storage of information in authentic sources

June 20th, 2011 15


Crossroads Bankfor

Social Security

citizen and company

ASI

interPInetwork

NIC:sickness

fundnetwork

other social sector actors

NOSS

NOSS-

PLPS

FPS SS

HVZ

NISSE

RKW

PDOS

FAO

FOD

RJVOSSORVP

SIGEDIS

RIZIV

NEO

FPSELSD

June 20th, 2011 16


225 electronic services for mutual information exchange amongst actors in the social sector, defined after process optimization

- nearly all direct or indirect (via citizens or companies) paper-based information exchange between actors in the social sector has been abolished

- in 2010, 700 million electronic messages were exchanged amongst actors in the social sector, which saved as many paper exchanges

electronic services for citizens

- maximal automatic granting of benefits based on electronic information exchange between actors in the social sector

- 13 electronic services via an integrated portal

- about 30 new electronic services are foreseen

June 20th, 2011 17


42 electronic services for employers, either based on the electronic exchange of structured messages or via an integrated portal site

- 50 social security declaration forms for employers have been abolished

- in the remaining 30 (electronic) declaration forms the number of headings has on average been reduced to a third of the previous number

- declarations are limited to 4 events

• immediate declaration of recruitment (only electronically)

• immediate declaration of discharge (only electronically)

• quarterly declaration of salary and working time (only electronically)

• occurrence of a social risk (electronically or on paper)

- in 2010, 25 million electronic declarations were made by all 220,000 employers, 98 % of which from application to application

June 20th, 2011 18


an integrated portal site containing

- electronic transactions for citizens, employers and professionals

- simulation environments

- information about the entire social security system

- harmonized instructions and information model relating to all electronic transactions

- a personal page for each citizen, each company and each professional

an integrated multimodal contact centre supported by a customer relationship management tool

a data warehouse containing statistical information with regard to the labour market and all branches of social security

June 20th, 2011 19

Useful tool: the reference directory

reference directory

- directory of available services/information

• which information/services are available at any actor depending on the capacity in which a person/company is registered at each actor

- directory of authorized users and applications

• list of users and applications

• definition of authentication means and rules

• definition of authorization profiles: which kind of information/service can be accessed, in what situation and for what period of time depending on in which capacity the person/company is registered with the actor that accesses the information/service

- directory of data subjects

• which persons/companies have personal files at which actors for which periods of time, and in which capacity they are registered

- subscription table

• which users/applications want to automatically receive what information/services in which situations for which persons/companies in which capacity

June 20th, 2011 20

1234567890

Useful tool: the social security card

nameChristian namedate of birthsexsocial security numberperiod of validity of the cardcard number

sickness fundsickness fund registration numberinsurance periodinsurance statussocial exemption status

other data to be added in the future, if useful

key 1

key 2

June 20th, 2011 21

Useful tool: the electronic identity card

June 20th, 2011 22

Uselful tool: the electronic identity card

identification of the holder- name

- Christian names

- nationality

- date and place of birth

- sex

- identification number of the National Register

- main residence

- manual signature

electronic authentication of the identity of the holder (private key and certificate)

possibility for the holder to sign electronically (private key and certificate)

no encryption certificate no electronic purse no biometric data

June 20th, 2011 23

Advantages

gains in efficiency

- in terms of cost: services are delivered at a lower total cost

• due to

– a unique information collection using a common information model and administrative instructions

– a lesser need to re-encoding of information by stimulating electronic information exchange

– a drastic reduction of the number of contacts between actors in the social sector on the one hand and companies or citizens on the other

– a functional task sharing concerning information management, information validation and application development

– a minimal administrative burden

• according to a study of the Belgian Planning Bureau, rationalization of the information exchange processes between the employers and the social sector implies an annual saving of administrative costs of about 1.7 billion € a year for the companies

June 20th, 2011 24

Advantages

gains in efficiency

- in terms of quantity: more services are delivered

• services are available at any time, from anywhere and from several devices

• services are delivered in an integrated way according to the logic of the customer

- in terms of speed: the services are delivered in less time

• benefits can be allocated quicker because information is available faster

• waiting and travel time is reduced

• companies and citizens can directly interact with the competent actors in the social sector with real time feedback

June 20th, 2011 25

Advantages

gains in effectiveness: better social protection

- in terms of quality: same services at same total cost in same time, but to a higher quality standard

- in terms of type of services: new types of services, e.g.

• push system: automated granting of benefits

• active search of non-take-up using data warehousing techniques

• controlled management of own personal information

• personalized simulation environments

better support of social policy

more efficient combating of fraud

June 20th, 2011 26

United Nations Public Service Award 2006

June 20th, 2011 27

European Public Service Award 2007

June 20th, 2011 28

Creation of the eHealth platform in 2008

in 2008, based on the experience in the social sector, a new parapublic institution, the eHealth-platform, has been created by law having as an overall objective

- what ?

• to optimize healthcare quality and continuity

• to optimize patient safety

• to simplify administrative formalities for all healthcare actors

• to reliably support healthcare policy and research

- how ?

• trough a well-organised, mutual electronic service and information exchange between all healthcare actors

• with the necessary guarantees in the area of information security, privacy protection and professional secrecy

the eHealth-platform is governed by representatives of the stakeholders (health care providers, health care institutions, patients, sickness funds, relevant government institutions, …)

June 20th, 2011 29

Some evolutions in healthcare

more chronic care on top of merely acute care

remote care (monitoring, assistance, consultation, diagnosis, operation, ...)

mobile care

multidisciplinary, transmural and integrated care

patient-oriented care and patient empowerment

rapidly evolving knowledge => need for reliable, coordinated knowledge management and accessibility

threat of excessively time-consuming administrative processes

reliable support for healthcare policy and research requires reliable, integrated and anonymous information

cross-border mobility

June 20th, 2011 30

Those evolutions require ...

collaboration between all actors in healthcare, not necessarily based on centralized data storage

efficient and safe electronic communication between all actors in healthcare

high quality electronic patient records, across specialties

technical and semantic interoperability

optimized processes

guarantees for

- information security

- privacy protection

- respect for the professional secrecy of healthcare providers

trust of all stakeholders in the preservation of the necessary autonomy and the security of the system

June 20th, 2011 31

Electronic communication also stimulates …

quality of care and patient safety

- prevention of erroneous care and drugs

• negative drug interaction

• drug contraindications (e.g. allergies, diseases, …)

- prevention of errors in administering care and drugs

- availability of trustworthy databases containing information about best care practices and decision support tools

qualitative support of health care policy and health care research based on reliable, integrated and anonymized information

June 20th, 2011 32

Principles implemented in the health care sector

at first creation of an adequate governance and consultative structure about eHealth and then further implementation under control of the governance and consultative structure

stimulation of multidisciplinary and high quality electronic patient records

if the patient wishes so, gradual referencing to places where his/her personal health data are available

common patient identifier well elaborated legal and ethical framework

- patient rights

- privacy protection

- professional secrecy

respect for local, regional or national health care organisation structures and initiatives- never use ICT to impose change to organisational structures !

June 20th, 2011 33


interoperable technical platform for safe and reliable electronic information exchange

- based on a service oriented architecture

- with common basic services provided for free such as

• process orchestration

• integrated portal

• user and access management (ao proof of consent of patient and of therapeutic relationship between user and patient)

• logging

• reference directory

• encryption

• eHealth-box

• time stamping

• coding and anomyzation

• eHealth vault

- using technical and semantic interoperability standards

June 20th, 2011 34


medical practitioner

eHealth platformbasic services

othercare

provider

pharmacist

FAMHP

RIZIV FPS

PH

citizen

prescription server

hospital

hospital

hospital

hospital

hospital

hospital

healthinsurance

fund

health insurance

fund

health insurance

fund

NIC

Communities

hub

hub

othercare

institution

June 20th, 2011 35


special attention to information security and privacy protection

- end-to-end encryption of exchanged personal health data

- very thorough preventive access control

- personal health data can only be exchanged with permission provided legally, by the Privacy Commission or by the patient

- logging of electronic services performed (who, what, about whom, when – not exchanged personal health data !)

- information safety policies and advisors in health care institutions

long-term vision combined with quick wins

concrete collaboration programs and projects with added value, e.g.

- multidisciplinary electronic summary patient record

- electronic exchange of (structured) information between health care providers

- electronic health care prescription

- simplification of administrative processes

- electronic consultation of health care insurance status

- …

June 20th, 2011 36

Achievements in the health care sector

9 basic services are in production

27 value-added electronic services for health care actors have been implemented within 2 years by several partners, always using the basic services of the eHealth-platform

choice for a unique patient identifier and the use of an electronic identity card were very useful

initial fear of health care providers and patients has turned into enthusiasm to collaborate

June 20th, 2011 37

Achievements / Projects

numerous projects

- communication system of electronic patient records between care providers

• hospitals: hubs & metahub

• extra muros care providers: extra-muros vault

- electronic prescription

• in-hospital: legal value through time-stamping and identification/authentication

• ambulatory: recip-e project

• handling of reimbursement requests (chapter 4)

- disease en therapy registries

• cancer registry, other diseases

• implant registries: orthopride (hip- and knee replacements), Qermid (cardiac devices)

- Evidence Based Medicine

• distribution of guidelines and advice, inclusion in software packages

- verification and registration of medical record software packages

- semantic interoperability

- …

June 20th, 2011 38

Hospitals

A

CB

1: Where can we find data?

3: Fetch data from hub A

3: Fetch data from hub C

Meta- Hub

2: In hub A and C

Hub

>110 general hospitals will join a hub in 2010-

2011

GP Pharmacist Homecare Specialist

Patient

Therapeutic relationships

NISS

SoftwareAs Aservice

MetaHUB

eHealthkadastereHealth

box

Own

software

SoftwareAs Aservice

SoftwareAs Aservice

Own

Software

HospitalHUB

Informedconsentby thepatient

…

June 20th, 2011 42

X!ilqshnf2@0à

Key 1Key 1 Key 2Key 2

In DB :

X!ilqshnf2@0àResult :

Without keys

June 20th, 2011 43

With key 1

X!ilqshnf2@0à


In DB :

B8i!(mà}z1&ajtResult :

June 20th, 2011 44

With key 2

X!ilqshnf2@0à


In DB :

K9l#'ç9gnh3lkResult :

June 20th, 2011 45

With both keys

X!ilqshnf2@0à


In DB :

Clear dataResult :

June 20th, 2011 46

Towards a network of service integrators

InternetInternet

Extranetregion or

community

Extranetregion or

community

FEDMANFEDMAN

Servicesrepository

FPS

FPS

FPS

ASS

ASS

Servicesrepository

Extranetsocialsector

ASS

RPS

RPS

Servicesrepository

VPN, …

VPN, …

Pharmacist Hospital

Serviceintegrator(eHealth)

Servicesrespository

Serviceintegrator(FEDICT)

Serviceintegrator(CBSS)

Serviceintegrator

(Corve, Easi-Wal, CIRB, …)

Doctor

June 20th, 2011 47

Advantages

gains in efficiency

- in terms of cost: health care services are delivered at a lower total cost

• due to

– avoiding unnecessary multiple medical examinations

– avoiding errors causing health care

– a minimal administrative burden for health care providers and patients, enabling health care providers to spend the maximum available time on healthcare

- in terms of quantity: more services are delivered

• relevant information is available at any time, from anywhere and from several devices

• services are delivered in a more integrated way: one connection to an electronic platform suffices for the use of several applications

June 20th, 2011 48

Advantages

gains in efficiency

- in terms of speed: the services are delivered in less time

• health care can be allocated quicker because relevant information is available faster

• waiting and travel time is reduced

• health care providers (and patients) can interact directly with real time feedback

June 20th, 2011 49

Advantages

gains in effectiveness: better health care provision and patient safety

- in terms of quality: same services at same total cost in same time, but to a higher quality standard

• support of multidisciplinary and transmural cooperation

• easier referrals between healthcare providers / institutions

• customized valorization of knowledge

• improved support in the practice of the health care provider

• more transparancy to and empowerment of the patient

- in terms of type of services: new types of services, e.g.

• remote care

• mobile care

better support of health policy and research

more efficient combating of fraud

June 20th, 2011 5050

Critical success factors

common vision oriented towards gain of efficiency and effectiveness and added value for all users (citizens, companies, care providers and care institutions, actors in the social sector, …)

- starting from health care and social protection objectives irrespective of government levels and actors

- translated into objectives for each government level and each group of actors, according to the division of tasks and responsabilities

- with derived objectives with regard to information management and information security for all actors involved

• basic principles for everyone, preferably fixed within enforceable legal framework

• objectives per group of actors and per actor

- translated into operational programs and projects

• balanced mix of long-term and quick wins

• multidisciplinary approach (BPR, change management, legal aspect, technical aspect, …)

June 20th, 2011 5151


cooperative governance

- directed by organs (management organs, consultative organs) in which all relevant actors are represented

- oriented towards

• clients

• willingness to cooperate and division of tasks

• trust based on transparency and respect

• buy in and commitment

• use of expertise and knowledge

• coordinated program and project management

June 20th, 2011 52


solid architecture

- information architecture

• data modelling

• semantic interoperability

• authentic sources complying with quality, availability and performance requirements

- process architecture

• chains of values developed under the coordination of service integrators

• various aspects

– information gathering

– validation of information

– information management

– information supply

– communication of supposed errors

52

June 20th, 2011 53


solid architecture

- technical architecture (SOA - service oriented architecture)

• modular => flexible

• reusable services => cheaper and faster time to market

• scalable

• oriented towards cooperation between actors

53

June 20th, 2011 54

What is Smals?

it is a non commercial organisation, owned and governed by public social security/eHealth agencies

specialised in information technology and related competencies

very focused: provides services exclusively to these agencies

exists as long as the actual social security system

1800 ICT professionals

June 20th, 2011 55

Services provided by Smals

ICT consultancy – long term missions- need for government agencies to be accountable for the Information

Technology function and hence need for skilled ICT staff

- legal system for recruitment of public agents less suitable for recruitment of IT specialists

- public sector system lacks the flexibility to handle fast pace evolutions in ICT salaries

- public sector salaries are experience based, not competence based, competencies acquired in private sector are not enough valued in public sector system

shared services- 3 data centers

- portals, inter organizational secured network …

projects + Research and Development

June 20th, 2011 56

Smals: an enabling organisation

modernization programs with a high degree of information technology involved are prone to failure

Smals has been able throughout the years to drastically reduce this risk

as a matter of fact though there have been issues and problems to be managed, no high profile failures were registered during several decennia

cooperation between government agencies and Smals form a specific model

June 20th, 2011 57

Smals reduces contract management

in traditional contract management for ICT projects

- red tape in (government) contract procedures requires carefull, specialized and labor intensive management

- it is difficult, expensive and time consuming to make a complete "description of work" (DOW)

- client and contractor rarely have the same understanding of the DOW, often leading to conflictual situations

- the DOW in many cases is already outdated at the moment of delivery; for the above mentioned reasons there is little or no room for flexibility

in the Smals model the client and the contractor are, by their structure, both accountable for the financial health of the project. There is less need for an elaborate DOW, little incentive for conflict and there is more flexibility should the need arise

June 20th, 2011 58

A "business also" competence pool

modernization programs are (almost) never "technology only" programs. The technicians need to know the business and its environment

a complex information system can easily be compared with a big factory, a large ship or plane or other big facilities: without a crew that understands the system as a whole as well as the details, the system cannot be kept running

Smals people are focused on the business of social security and e-Health and know the details of the system. This leads to less "starter errors", less coordination and control and getting faster up speed in projects

June 20th, 2011 59

Multi-agency projects

social security agencies also have their own internal ICT department, most of who's technicians are also provided by Smals

modernization and technology can be leveraged by cooperation between agencies. Smals facilitates common projects, due to their knowledge of the different environments, the experience of multi-agency projects and the possibility to concentrate project management and budget allocation

June 20th, 2011 60

Risk management

data stay local (guaranteed)

no risk of your vendor being acquired by another company

independent management but possibility to take measures if the need should occur

Smals cannot phase out services for purely commercial reasons

no risk of bankruptcy due to shared financial responsabilities

June 20th, 2011 61

Technology watch and innovation

scale allows for investment in state of the art infrastructures

commitment of government agencies to technology watch and innovation

R&D activities shared with the technicians of all members

innovative solutions: requirements for data protection in E Health could not be met by market solutions, a novel and performing (patented) approach has been developed

June 20th, 2011 62

Interdependent engineering

an architecture is interdependent if one part cannot be created independently of the other part

interdependent architectures optimize performance in terms of functionality and reliability

new programs with new functionalities require the performance delivered by interdependent engineering

organizations in these situations must be integrated, they must control the design and the delivery of every critical component

government agencies need to control these critical resources in order to optimize chances for program success

June 20th, 2011 63

There remain challenges though …

there is no fixed price but project budgets should be predictable, how to achieve commitment and ownership from the organization and the people?

lack of market correction mechanisms threatens cost competitiveness, need for cost benchmarking against the (ICT) market in general

complement internal Smals skills with skills drawn from the general ICT market, obtain a good mix of skills

idiosyncratic financial structure requires specific precautions e.g.- risk margin on projects

- risk provisions

- advance payment as a rule (in public procurement advance payments are an exception)

June 20th, 2011 64

Governance aims to meet these challenges

elaborate end-to-end project management practices (chain management)

describe (SLA), follow up (monitoring), report, discuss with user organization and continuously improve EVERY service

human resources management is critical: elaborate job descriptions, introduce competence management, recruit and retain, offer career development

score cards and Key Performance Indicators

continuous communication with the member organizations, tools developed to support this communication (e.g. overall budget and progress status)

June 20th, 2011 65

More information

social security portal

- https://www.socialsecurity.be

website Crossroads Bank for Social Security

- http://www.ksz.fgov.be/

Belgian eHealth platform portal

- https://www.ehealth.fgov.be

personal website Frank Robben

- http://www.law.kuleuven.ac.be/icri/frobben

https://www.socialsecurity.be/

https://www.socialsecurity.be/






http://www.law.kuleuven.ac.be/icri/frobben

http://www.law.kuleuven.ac.be/icri/frobben

20 juni 201166 04/19/2366

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Information management in the Belgian social and health care sector

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