The document discusses some challenges facing eHealth, including more chronic care needs, remote care, mobile care, and integrated care. It also notes needs for reliable knowledge management, efficient processes, and information security and privacy protections. The Belgian approach to addressing these challenges involves creating a governance structure and technical platform to enable secure electronic information exchange between healthcare actors while respecting privacy.

1. eHealth: some challenges
Frank Robben
General manager eHealth-platform
Sint-Pieterssteenweg 375
B-1040 Brussels
E-mail: Frank.Robben@ehealth.fgov.be
Website eHealth-platform: https://www.ehealth.fgov.be
Personal website: www.law.kuleuven.be/icri/frobben

2. 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
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3. Some evolutions in healthcare
• 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
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4. 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
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5. Those evolutions require ...
• 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
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6. 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 healthcare policy and healthcare
research based on reliable, integrated and
anonymized information
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7. The Belgian approach
• 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
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8. The Belgian approach
• Common patient identifier
• Well elaborated legal and ethical framework
• patient rights
• privacy protection
• professional secrecy
• Respect for local, regional or national healthcare
organisation structures and initiatives
• never use ICT to impose change to organisational structures
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9. The Belgian approach
• 2008: eHealth-platform creation
• a new parapublic institution, instituted by law
• governed by representatives of the stakeholders (healthcare
providers, healthcare institutions, patients, sickness funds,
relevant government institutions, …)
• based on the experience in the social sector
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10. The Belgian approach
• eHealth platform: an interoperable technical platform
for safe and reliable electronic information exchange
• based on a service oriented architecture
• with common basic services
• using technical and semantic interoperability standards
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11. Basic architecture
Patients, health care providers
Software health
Portal Health and health care institutions care provider
VAS
VAS VAS
VAS
VAS
VAS Software health VAS
VAS
Site RIZIV care institution
VAS
VAS Portal MyCareNet VAS
VAS
VAS
VAS eHealth- VAS
VAS
platform VAS
VAS
VAS
VAS
Users
Basic services
Network
eHealth-platform
AuthS AuthS AuthS AuthS AuthS AuthS
Data providers
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12. The Belgian approach
• eHealth-platform common basic services (provided for
free):
1. Process orchestration
2. Integrated portal
3. User and access management
4. Logging
5. Encryption
6. Timestamping
7. Coding and anomyzation
8. eHealthBox
9. Reference directory
10. Consultation of the National Register and of the Crossroads
Bank Registers
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13. eHealth-platform basic services
1. Process orchestration: allows a flexible and harmonious
integration of the different processes linked to the implementation of
several basic services into one and the same application
2. Integrated portal: a web window offering a variety of online
services to health care actors in order to help them provide the best
possible healthcare. The integrated portal provides all useful
information on the services that are offered by the eHealth-platform,
its tasks, its standards, etc. It contains, among others, the
documents users need to configure the right settings in order for
them to have access to the available online services.
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14. eHealth-platform basic services
3. User and access management: allows to guarantee that only
authorized health care providers/ health care institutions have
access to personal data to which they are authorized to have
access
• access rules are defined by law, by authorizations of the Health
Section of the Sectoral Committee (established within the Privacy
Commission)
• each application defines its own accessibility rules
• when a user authenticates its identity (using the electronic identity
card or the token), the generic verification model of the tool is set in
motion: it consults the rules established for the application, verifies
if the users comply with these rules and provides access or not to
the application.
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15. eHealth-platform basic services
4. Logging: management of a register of access to the data management
system: all read, write and delete accesses are registered and have
probative value in case of a complaint
5. Encryption: transport of complete and unmodified data from one point to
another by making them indecipherable (encryption) provided that these
data have not been decrypted with a key. Two methods:
- in the case of a known recipient: use of an asymmetric encryption
system (2 keys)
- in the case of an unknown recipient: use of symmetric encryption
(the information is encrypted and stored outside the eHealth-
platform, the decryption key can only be obtained through the
eHealth-platform)
6. Timestamping: makes it possible to assign a date that is accurate to the
second to a health care document and allows, in this way, to ensure the
validity of its content throughout time by appending an eHealth signature
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16. eHealth-platform basic services
7. Coding and anonymization: makes it possible to hide the identity
of the individuals behind a code so that useful data of these
individuals can be used without infringement of their privacy +
makes data anonymization possible by replacing detailed data with
generalized data. These encoded or anonymized data preserve
their usefulness, but don’t allow the direct or indirect identification of
the person
8. Consultation of the National Register and of the Crossroads
Bank Registers: gives authorized health care actors access to the
National Register and to the Crossroads Bank Registers under strict
conditions
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17. eHealth-platform basic services
9. eHealthBox: a secured electronic mailbox for the exchange of
medical data
10. Reference repertory: indicates which types of data are stored by
which health care actors for which patients with the consent of the
concerned patient
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18. Achievements/Projects
• More than 40 value-added electronic services for
healthcare actors have been implemented within 3 years
by several partners, always using the basic services of
the eHealth-platform
• eHealth-platform core business focused on electronics
data's exchanges systems projects such as:
• communication system of electronic patient records between care
providers
• electronic prescription
• disease en therapy registries
• Evidence Based Medicine
• verification and registration of medical record software packages
• semantic interoperability
• …..
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19. The priority: multidisciplinary data sharing
• Sending
• snapshot of the data (do not remain up-to-date)
• sender chooses recipient
• sender is responsible for sending the data to recipients who are
entitled to have access to these data
• Sharing
• evolutive data
• the sender does not know in advance who will consult the data
(eg doctor on duty)
• organizational measures are required to limit access to the data
to those who are entitled to have access
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20. Informed consent/therapeutic relationship
 Informed consent
• inform patient about the system
• patient may give his authorization and decide “to get into the
system”
• healthcare providers and patient decide together which
information can be shared
 Therapeutic relationship
• only healthcare providers who have a therapeutic relationship
with the patient (1) have access to the information they need in
order to fulfil their job (2)
- (1) proof of the therapeutic relationship determines access to the right patient
- (2) role determines which data can be accessed
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21. eHealthBox
• Sending of messages to ‘healthcare actors’
• based on
• Social identification number
• NIHDI-number
• CBE-number
• through webapplication or integrated in the medical file
• with (or without) encryption based on eHealth certificates/
eHealth keys
• other functionalities:
• receipt-, publication-, reading confirmation
• reply & forward
• consultation of multiple mailboxes
• priority level
• auto-delete
- …
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22. Multidisciplinary data sharing
 Data from hospitals
• sharing of documents stored by hospitals
• the “hub and metahub system”
 extramural data
• sharing of structured data stored by extramural healthcare
providers
• the “extramural vault”
 Coupled and interoperable
• standards
• informed consent
• therapeutic relationship
• …
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23. Exchange of patient data: now
Remote files
unknown
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24. Exchange of patient data: future
A
Meta-
Hub
4:
All data
available
C
B
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25. 21/09/2012 25

26. Extramural health care providers
VitaLink
A
Meta-
Intermed Hub
C
B
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27. Reference directory
• Developed through a trapped system
• reference to the care provider(s) or care institution(s) where one
or more electronic documents are available for a patient is, with
the informed consent of the patient, stored in a local or regional
reference directory (a so-called "hub")
• the reference directory managed by the eHealth-platform (the so-
called "metahub") only contains references to the hub(s) where
references for a patient are stored
• Development through a trapped system
• respects the organisation of regional and local networks between
care providers and/or care institutions
• avoids the possibility that health information about the patient
can be deduced from the information stored in the reference
directory managed by the eHealth-platform
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28. Reference directory
• Publication of the reference in a hub and the metahub
requires the informed consent of the patient concerned
• Access to information to which reference is made in a
hub requires a therapeutic relationship between the
requesting care provider and the patient concerned
• A guidance committee has been created within the
Consultation Committee of the eHealth-platform
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29. Extramural health care vaults
 Content :
• synthetic data emanating from local information systems of
different (types of) first-line health care providers (Sumehr)
• health care programs and health care plans
• journals
• (reference to) the vaccination status
 Allows a granular access control by means of software
developped in a coordinated way (registered software)
 Can interact with the information systems of the different
types of health care providers by means of open
standards and computerized business processes
 With an operational management by bodies with
representatives of the different types of first-line health
care providers, hospitals and patient organizations
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30. Patient Informed
consent
Therapeutic relationships by the
patient
GP Pharmacist … Homecare Specialist
Software
Own
As A Software
service As A MetaHUB
Software
service
Own
Software
As A
software
service
Hospital
HUB
NISS
eHealth
kadaster
eHealth
box

32. Without keys
In DB : X!ilqshnf2@0à
Key 1 Key 2
Result : X!ilqshnf2@0à
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33. With key 1
In DB : X!ilqshnf2@0à
Key 1 Key 2
Result : B8i!(mà}z1&ajt
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34. With key 2
In DB : X!ilqshnf2@0à
Key 1 Key 2
Result : K9l#'ç9gnh3lk
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35. With both keys
In DB : X!ilqshnf2@0à
Key 1 Key 2
Result : Clear data
21/09/2012 35

36. Th@nk you !
www.ehealth.fgov.be