1. How FRANCE will cope with the new
expectations of the citizens regarding
e-health and Patient Record
Michèle THONNET
Mission pour l ’Informatisation du Système de Santé (MISS)
Barcelona February 2007

2. Agenda
Health & ICT
characteristics of the french system
policy, strategy and reform (1996-2006)
goal, projects and objectives
roll out and current situation
ePMR (DMP)
lessons learned
we are part of Europe … and of the world

3. Reforming the H system : a necessity
ageing population
chronic diseases evolution
citizen demands & needs transfo
increasing costs of research,
equipments, examinations, treatment
pandemia expansion
lack or shortage of HCP
mobility of citizens & patients, …
economic model

4. ICT : necessary but not sufficient
medical informatics
telematics
telemedicine
e-Health
p-health
connected health
e-inclusion
the most visible target the eHR ...

5. Visible part : an iceberg ?
techno. is attractive, speaking about is usual
but cultural changes are key
– more difficult to envisage
– need more time and continuous efforts
– change professional exercice, patient view
– reorganise the actors relationships & positions
– destabilize the present « system »
team work needs exchange & sharing info….
the ePMR :only a good enabler & trigger tool

6. The French health system
Some characteristics

10. France and health system
540 000 Km2 60 M inhabitants
life expectancy : 75,2 M 82,7 W
Global Expenditure per capita 2000 €
1,7 M jobs in Healthcare

11. A complex system
A multitude of actors
– health insurance (compulsory complementary )
– 300 000 professionals (120 000 doctors), 23 000
pharmacies ,
4 000 laboratories
– 4000 hospitals, 1,1 million employees (50 000
doctors)
…with a very large autonomy

12. 1- A system that deserves its
appreciative rating ...
The first in the world according to WHO
(2000)…
… but with important internal inequalities
– social
– geographical

13. 2- a high cost
The national expenditure of health
– 148 billion €uros, 8.8% of GDP
one of most expensive among the
developed countries
A growth regularly stronger than the GDP
+ 5,2 % in 2001, ...
Presumptions of inefficiencies
– adequacy of the offer compared to the needs

14. Public policies for e-health in France
Objectives of the authorities

15. Government’s guidelines
To develop the assets of a policy for
(public) health
By improving the overall effectiveness
policy followed by the introduction of the
ICT is a variation of that

16. The main goal
Make use of ICT and Internet to
rationalize the healthcare system
– for a healthier population
• => to improve the level and quality of care
• => by controlling the costs

17. Three types of projects
a first stage : SESAM-Vitale : (Administration)
– administrative simplification for refunding health
expenses
a « corner stone » project to improve the
doctor-patient relationship : (Medical)
– electronic health record (EHR)
public health issue : (Information)
– to manage the consequences of the availability of the
information to public (education, protection)

18. Four main objectives
To facilitate the continuity and the
coordination of the health care :
– electronic health records :protected access and transmission
– telemedicine
To improve access to knowledge :
– online state of the art for the professionals ( KB, EBM)
– quality of e-health sites

19. Four main objectives (2)
better know the reasons for recourse and
evaluate the expenditure
– piloting information systems (reorga H System)
better and quicker refunding
– administrative simplification : SESAM-Vitale

20. A continuous voluntarist strategy
important investments
an impact on the whole population
– 55 million smart cards handed over

21. The roll-out scenario
Starting point
administrative simplification
with SESAM-Vitale, (infrastructure needed)
… but investments need to serve the other
more general goals
Structural role of technical tools : HCP cards,
Insurance cards (Vitale), Internet standards, RSS,...

22. Public policies for e-health in
France : about TRUST
Confidence requirement is key
Health is not a product like others
Securing data confidentiality

23. A specific status for health information
The European Legislation 24 October 1995 (art 8)
– prohibits any data processing without the consent of the person
– except for the data absolutely necessary to the health professional
– or those related to the management of health services, required by
people exercing under professional secrecy
The french Medical Privacy Act (4 february 2002)
– transmission of personal information is authorized only between health
professionals treating their mutual patients, and only with their prior
consent (article L1110-4)

24. Confidentiality requirements
To secure release and circulation of invoices
(SESAM-Vitale)
– authentification of the transmitter
– signature of the person receiving benefits and the
recipient
choice of cards supports
Soon significant volume of information will
circulate
necessity to invest in confidentiality

25. Confidentiality requirements
Two key issues to deal with, for the French
Government
– legislative : the Act of March 4th, 2002
– technical : smartcards, PKI, secured standardised network
Internet sites on e-health
– support self-regulation between bodies involved (users,
professionals, economic actors)
the project « e-health quality »

26. A technical federator : infrastructure
to exchange and share :The choice of Internet
standard technologies, but protected
for / with the HCP :The Health Professional Card
(CPS)
– (identify), authenticate, sign, coding
for / the citizen :The recipient insurance card :
– carte Vitale

27. Health Professional Card (CPS)
CPS
– an large roll-out ...
• over 485 000 cards rolled-out
– a central role in the security of the system
• authenticate the holder of the card :
– identity HCP, qualifications, conditions of exercise
– « Sésame » to reach to protected informations
• electronic signature
• protecting and coding messages

28. The health insurance card
The Vitale card
– easier
• identify the holder :
– 55 million cards handed out to the citizens

29. Public policies for e-health in
France
The current situation

30. SESAM-Vitale
An increasing use :
– >80 million electronic invoices issued every
month
– more than 65% of invoices
– 180 000 Professionals using the system
– a smooth and steady implementation

31. The electronic Patient Medical Record
ePMR . . . DMP
An effective way to manage patient’s
continuity of health care…
… but which must offer all the
guarantees of privacy

32. The role of the Authorities
To support the development of the
consensus
finalities, contents, control of the uses
To encourage experiments
To build up the legislative framework
To develop incentives, if necessary

33. Role and vision of the
Government
Three important innovations in the
law for the patient's rights
An important reform of the Health
Insurance
The ePMR (DMP)

34. The new law : three important innovations
The new law : three important innovations
1- Direct access to personal medical
informations (article L1111-7)
2 Securing confidentiality (article L1110-4)
3 Regulate by law the storage of personal
EHR (article L1111- 8)

35. To enhance their development
The objective:
support the development of ePMR, used & shared
– information is produced by health professionals
– reviewed on line with strict conditions on the rights of access
(ICT team)
– of which the use (and contents?) are controled by the patient
– which are stored securely under very strict conditions by
accredited third party outside the premise of the MD
(authorities)

36. 13 August 2004 Act DMP (ePMR,...)
Coordination dossier ( 2007- implementation start)
– no replacment of the GP dossier
Strongly linked to the « patient act »
– strict security policy & mechanisms
– patient control on the access
• authorised access for HCP habilited
• direct access to medical data by patient
– mandatory labelisation of the storage places,
which are not allowed to accesss to medical data

37. Four question marks ????
Optimal level of confidentiality
Identification of the patient
Control of the access by the patients
Technical options

39. The objectives of the ePMR (DMP)
• to offer over 2007:
–the same ePMR for all, under the control of
the patient
–an ePMR compliant to the law(s): improvment
of the care ‘ circuit ’, avoiding iatrogeny &
redondency of examination
–with simplicity of access and usage
• to allow the patient to choose his accredited
medical storage « harbour »
• to support the HC professionnals in order to
populate the ePMR

40. Principle 1 : increase the existing value
& build upon experimentation
Continuity of the approach
– to build upon the outcomes of the experimentat.
– to offer the same ePMR for all, useful & used
– to associate all the actors to the management of
the project (including industry)
Structuration via a universal service
- simplicity of access, identification, managt
- Interoperability, evolutivity

41. The key factors of success
• To join forces of all the concerned actors
– Appropriation & usage of the developed tools
– Convergence with the existing systems
– Call for projects proposals
• Cooperation with the industry
– build up tools for populating easily the ePMR
(services sub contracting to the market players)
• concertations with the software editors for HCP
• opening to the medical storage harbour when
generalized
• Cost containment

42. The approach :
Offer & open an ePMR to each one who ask
– create the infrastructure able to support this
Exploit all the established features from the
experimentations
– specifications & content, security & ergonomics issues
– capitalise on the proposed organisational changes
Avoid the ‘ blank page ’ syndrome
– « recovery » of the ePMR used for the experimentations
– mechanisms to (automatically) populate the ePMR

43. Programme control & mastering
• Involvment strategy
• Confirmation of the objectives
– compliant to the law(s) - simplicity
– ergonomy - utility
• Master, control the follow-up of the
interoperability
• Visibility on costs & budget
• Respect of the announced planning
• Reinforcement of the resources of the
structure in charge of (GIP DMP)

44. Architecture
Portail Portail
Accueils du portail :
Portail Portail
patient PS hébergeur
Identification
2 3 4 5
Héberg
SVA 2 SVA 3 Héberg
Héberge
Portail
Héberg Héberg
Annuaires
ur SVA 4 SVA 5
eur de eur de eur de eur de
DMP unique DMP
de DMP
droits
Tables des
ation
Authentific
DMP DMP
Service agréé agréé
de
agréé agréé
référenc
2 3 4 5
universel e
Aiguillage
Services
Assist Assist de confiance uniques
Assist Assist
ance 2 ance 3 Assistance ance 4 ance 5
téléphonique Rése
SIH DCC LGC au
données
(PS)
médicalement
Producteurs de données utiles
détenues par
l ’assurance
maladie

45. 2006 experimentations:
13 regions, 17 sites

46. How to cope with e-health
Some lessons learned

47. What happened so far ?
Objectives & goals
– unsatisfactory situation
designing a strategy : e-Health for Health
– reform supported by politicans
– need some legal framework
strongly linked to other policy regulations
(health & not health)
taking into account all stakeholders

48. The lessons learned so far
always more time than expected
– resistance to change, « daily routine »
– early adopters are not representative
always more expensive
– unexpected « borderline effects »
critical mass point is not easy to reach
– to be careful on incentives
do not underestimate
– the existing environment
– conditions & consequences of generalisation

49. How to increase the chances of success
Define clear objectives
– with explicit milestones to measure progress
– based on consensual indicators
Involvment of all stakeholders
– early pre - consultation / concertation

50. The accompagnying measures
Rearrangment of existing measures
– to maximise integration of the new elements
– take advantage to reorganise & optimise
(hospitals/clinics, specialists,GP, homecare)
Anticipate the needed changes
– on medical care, on personal behaviour
– on the HC system, on reimbursement, ...

51. A way to progress
design an iterative process
– existing adopted roadmap & context evolution
do not forget to nominate A pilot
– strong coordination & clear decisions
be precise in respective roles &
responsabilities

52. Clear objectives in an evolving world
Integrate the regional & national evolutions
avoid to focus too much on technical issues
anticipate
– negative consequences of a new system or
– changing in the existing forces balance

53. We are part of Europe & of the world
Take into account the evolution of the
other EU M.S. and other countries
… to support citizen & patient mobility
… to be « compliant » with other systems
… to anticipate their potential impact on
national (& regional ) HC system

54. Keep European and open on the world
improve & facilitate the use of european &
international standards
give no long term agreement to
proprietary products
be present on international arena to
anticipate changes

55. The key basic components
Will & cooperation of all actors (citizen, govt,
patient, HCP, hosp., insurer, industry,
daily used added value services
standardised shared mutual services on
– security (id, authent, certif, PKI,e-signature,…)
– access (ergonomic, perf., available, direct. LDAP)
– modelling (RIM : HL7 V3) processes
– transformation (syntaxic format XML, CDA-XDS)
– terminology (semantic : ICD, MeSH, MedDRA, LOINC,
SNOMED, GALEN, GO, FMA,...)

56. International collaboration : EU
Health is a national prerogative
but collaboration is a key issue patient mobility
volontarist coope. on INTEROPERABILITY
consensual defined priorities at EU level :
– non ambiguous ID (patient, HCP, hospital,
service)
– patient record summary (minimum data set)
– secure data exchange flows
• emergency data set / e-prescription

57. Thank you for attention
Think globally
Act locally
michele.thonnet@sante.gouv.fr