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Publishedby:

MinistryofHealth,WelfareandSport

Addressforvisitors:

Parnassusplein5

2511VXTheHague

TheNetherlands

Correspondenceaddress:

PObox20350

2500EJTheHague

TheNetherlands

Telephone+31(0)703407911

Telefax+31(0)703407834

Internet:

www.minvws.nl

May2006

ICT in Dutch Healthcare:An International Perspective

� ICTinDutchHealthcare:AnInternationalPerspective � ICTinDutchHealthcare:AnInternationalPerspective

Contents

1 Summary 5

2 Introduction 7

2.1 ThehealthcaresystemintheNetherlands 7

2.2 Aimoftheroadmap 8

3 Healthcare and ICT in the Netherlands 9

3.1 ElectronicHealthRecord 9

3.2 AORTAbasicinfrastructure 11

3.3 EMD/WDHimplementationprogramme 14

3.4 Otheraspects 15

3.5 Conditions 16

3.5.1 Legislativeframework 16

3.5.2 Funding 17

3.5.3 Coordination 17

4 EU eHealth Action Plan 19

4.1 Introduction 19

4.2 Astrategyforcommonchallenges 19

4.3 Pilotprojects 22

4.4 Monitoring 23

Appendix1:HealthIndicators-TheNetherlands 25

Appendix2:Nationalexpenditureonhealth-TheNetherlands 26

Appendix3:HealthcareProfessionals2003-TheNetherlands 28


1 Summary

TheDutchgovernmentisworkingwithplayersinthehealthcaresectortodevelop

anationwidesystemforsecureandreliableelectronicexchangeofmedicaldata.

Manyinitiativeshavealsobeenlaunchedintheinternationaldomaintoimprovethe

deploymentofICTinhealthcare.Thisroadmapisaworkingdocumentwhichpresents

theDutchpositiononICTinhealthcareinaninternationalperspective.

ICTsupplierscanuseDutchdesignsforICTarchitectureinthehealthcaresectorand

theaccompanyingspecificationsasabasisforintegratingtherequiredfunctionsin

thesystemsofhealthcareprovidersandhealthinsurers,thusenablinghealthcare

professionalstoexchangedigitalinformationonanationalscale.Theroadmapdiscusses

theconstituentsofthebasicinfrastructureandtheapplications.

ForidentificationandauthenticationwedistinguishbetweentheCitizenServiceNumber

(BSN)foridentifyingpatients,theUniqueHealthcareProfessionalIdentification(UZI)for

identifyinghealthcareproviders,andtheUniqueHealthInsurerIdentification(UZOVI)for

identifyinghealthinsurers.

InJanuary2006aNationalSwitchPoint(LSP)wasbuiltwithareferenceindexfor

routing,identification,authentication,authorizationandlogging.TheNationalSwitch

Pointactsasasortof‘trafficcontroltower’throughwhichhealthcareproviderscan

requestrecentpatientdatafromthesystemsofhospitals,pharmaciesandGPs.

HealthcareinstitutionscanlogontotheNationalSwitchPointviathenetworksof

commercialproviders–CareServiceProviders–ofcommunication,applicationand

contentservices.Thedatainlocalsystemsneedtobesystematicallystoredandsecured

andmeetthecriteriaforaWell-ManagedHealthcareSystem(GBZ)

TheDutchgovernmenthasoptedfortheincrementaldevelopmentofanElectronic

HealthRecord(EPD).Thisconsistsofacollectionofapplicationswhichareconnected

tothenationalinfrastructure.ThespearheadsaretheintroductionofanElectronic

MedicationRecord(EMD)andanElectronicGeneralPractitioner’sRecord(WDH),but

manyotherhealthcareapplicationsarealsobeingdeveloped.

Thecomponentsofthebasicinfrastructureandthefirsttwoapplicationscometogether

intheEMD/WDHimplementationprogramme.Toensureasmoothtransitionseveral

regionshavebeenselectedas‘pilots’andtheimplementationprocesshasbeensplit

intothreephases,startingwithaProofofConceptinwhichalltheconstituentsofthe

chainaretestedincombinationunderlaboratoryconditions.Thiswillbefollowedby

implementationinthereferenceenvironmentsandthenintheotherpilotregions.


TheimplementationofanationwideElectronicHealthRecordintheNetherlandsis

basedontheassumptionthatprimaryresponsibilityforthequalityofthecareandthe

useoftheICTsystemsrestswiththeproviders.Thegovernment’sroleistopavetheway

bypassinglegislation,creatingtherightinvestmentclimate,andcoordinatingtheoverall

process.

Section3addressestheactivitiesbeingcarriedoutintheNetherlandsinrelationtothe

EUeHealthActionPlanof2004.

2 Introduction

Healthcareisprovidedbyhumans–and,aseverybodyknows,humansarenotinfallible

andsometimesmakemistakes.Technologyhasalottoofferinsupportofhumaneffort.

OneareawhereICTcanplayacrucialroleistheexchangeofmedicaldata.Ifhealthcare

providersweretohaveaccesstoaccurateandrecentdata,theywouldbeinafarbetter

positiontoprovidetherequisitecare.

TheMinistryofHealth,WelfareandSportisworkingwiththeNationalITInstitutefor

Healthcare(NICTIZ)1andtheCentralInformationPointforHealthcareProfessions(CIBG)2

onthedevelopmentofanationwidesystemfortheelectronicexchangeofmedicaldata.

ThissystemisknownastheElectronicHealthRecord(EPD).

However,thepromotionofICTinhealthcare(eHealthcare)doesnotstopatthe

geographicalbordersoftheNetherlands.Manyinitiativeshavealsobeenlaunchedinthe

internationaldomain,aimedatimprovingtheaffordability,accessibilityandqualityof

healthcarethroughthedeploymentofICT.Another–related–trendisincreasingmobility

amongpatientsandprofessionals.Furtherobjectivesarebeingpursuedatpoliticallevel

togiveshapeandformtotrans-bordermobilityand(preventive)medicine.

2.1 The healthcare system in the Netherlands

ThehealthcaresystemintheNetherlandsconsistsofthreecompartments.Thefirstcovers

long-termcareandtheso-called‘uninsurable’medicalrisks.Thecareinthiscompartment

islargelyprovidedandfundedbythestateviatheExceptionalMedicalExpensesAct

(AWBZ).

Thesecondcoversshort-termmedicalcare(cure)whichshouldbeuniversallyaccessible.

Thecareinthiscompartmentisprovidedandfundedbythestateandtheinsurers.

Thethirdcoversthecarethatisnotincludedinthefirstorsecondcompartmentandfor

whicheveryonecanvoluntarilyinsurethemselves;typicalexamplesaredentaltreatment

andalternativemedicine.

TheageingpopulationwillintensifythepressureontheDutchhealthcaresystem.More

andmorepeoplewilldevelopchronicconditionssuchasdiabetes,cardio-vascular

diseaseandbronchialcomplaints.Theaccessibility,affordabilityandqualityofthecare

mustcontinuetobeguaranteed.Itisforthisreasonthatanumberofchangeswere

introducedin2006.

1 TheNICTIZisaneutralandindependentorganizationwhichwasfoundedin2002byvariousplayersinthe

healthcaresector.Itisresponsibleforthedesignandconstructionofthenationwidebasicinfrastructureandforthe

developmentofstandardsforanElectronicHealthRecord.Formoreinformationseewww.nictiz.nl

2 TheCIBG(www.cibg.nl)consistsofninedifferentunitsandisanexecutivearmoftheMinistryofHealth,Welfare

&Sport.Theregistrationofdataandtheprovisionofinformationareamongitsmostimportanttasks.Eachunit

specializesinaspecificsegmentofthecaremarket.


Thesechanges,whicharedesignedtopreparethesystemforthefutureandtomake

thehealthcaremoreeffective,efficientandcustomer-focused,necessitateabetter

distributionofresponsibilityamongthekeyplayers.Thepatient/clientoccupiesacentral

roleinthecurrenthealthcaresystemintheNetherlands,withmoreopportunitiesbut

alsomoreresponsibility.Itisuptothepatient/clienttobringaboutimprovementsto

thequality.Awell-informedpatientcansingleouttheproviderthatoffersthebestcare

forhiscondition.Thiswillspurhealthcareproviders(doctors,hospitalboards,etc.)to

raisetheirperformance.Medicalinsurerswillbearmoreresponsibilityformatchingthe

demandsoftheconsumerwiththeofferingsoftheproviders.Itisthegovernment’sjob

tooverseequality,accessibilityandaffordability.

TheDutchhealthcaresystemtakestheformofaninsurancesystemwhichisrunby

privateproviderswithapublicremit.Thisset-upalsoappliestotheICTpolicyandrole

allocationinthehealthcaresector.Thegovernment,inthiscasetheMinistryofHealth,

Welfare&Sport,wantstopromotetheuseofICTinhealthcarewiththeultimateaimof

improvingaffordability,accessibilityandquality.Itwilldosobycreatingaclimatewhich

isconducivetooptimalandsecureuseofICT.Thehealthcareprovidersbearprimary

responsibilityforthequalityofthecareandtheuseofICTsystems.

2.2 Aim of the roadmap

Internationalcooperationmeansthat,ifwecanshareourdatahereintheNetherlands,

thenEuropeaninteroperabilitymustalsobeachievable.TheNetherlandsfavoursa

pragmaticapproach:memberstatesshouldpreparethemselvesfortrans-Europe

exchangeofmedicaldatainthefutureandreachsomeformofagreement.

TheaimofthisroadmapistopresenttheDutchstandpointonICTinhealthcareinan

internationalperspective.ItbeginsbydescribingthecurrentsituationintheNetherlands

andthenoutlinestheexpectedsituationafter2006.Itexplainsthedecisionstodeploy

ICTintheDutchhealthcaresystemandpositionstheminrelationtopolicyanddecisions

inEurope.Finally,itsetstheDutchgovernment’stimetableforICTinhealthcareinan

internationalperspective.

Thisroadmapisintendedprimarilyforpolicymakersandpolicyexecutivesinthe

Netherlandsandabroad.Itprovidesasnapshotimageofnationaldevelopmentsin

relationtotheeHealthprogrammeoftheEUandwillbepresentedattheHighLevel

eHealthconferenceinMalaga(10-12May2006).Thetimetableisbasedonthenational

focusanddevelopments.Partsoftheroadmap,however,needtobefurtherfleshedout

nationallyandinternationally.Discussionsareneededatvariouslevelsforthispurpose.

3 Healthcare and ICT in the Netherlands

ThissectionexplainsthehealthcareandICTsituationintheNetherlands.Thefirstpart

willaddresstheapplicationsoftheElectronicHealthRecord(EPD).Thesecondwill

discussthevariouscomponentsofthenationalbasicinfrastructure.Thethirddeals

withtheimplementationprogrammefortheElectronicMedicationRecord(EMD)and

theElectronicGeneralPractitioner’sRecord(WDH,paragraph3.3)inwhichthesetwo

functionswillbetestedtogetherforthefirsttime.Attentionwillalsobepaidtoother

ICTdevelopmentsinthehealthcaresector,suchasconsultationsbye-mail.Thefinal

paragraphwilldiscusstheinstrumentswhichtheDutchgovernmentcanemployto

realizeallofthis.

3.1 Electronic Health Record

TheNetherlandshasitssightssetonanationaltransmuralElectronicHealthRecord

(EPD):asecureenvironmentinwhichclient/patientdatawhicharestoredindifferent

systemscanberetrieved,exchangedandcogentlyshowntoauthorizedhealthcare

providerstosupportthehealthcareprocesses.

This‘virtual’EPDconsistsofacollectionofapplicationswhichareconnectedtothe

nationalAORTAinfrastructure.ThespearheadsaretheintroductionofanElectronic

MedicationRecord(EMD)andanElectronicGeneralPractitioner’sRecord(WDH),but

manymorecareapplicationsarebeingdeveloped.TheNetherlandsismovingtowards

afully-fledgedEPD.

A Electronic Medication Record (EMD)

TheElectronicMedicationRecordgiveshealthcareprovidersinsightintothemedication

historyofspecificpatientsviatheirowninformationsystem.Thisinformationstaysat

thesource(informationsystemofahospital,pharmacy,GPpracticeetc.)butisavailable

toprovidersandprescribersofmedication:publicpharmacies,hospitalpharmacies,

GPpractices,locumposts,hospitals,mentalhealthinstitutionsandresidentialcareand

nursinghomes.

ResearchbytheDutchpharmaceuticalassociation,theWetenschappelijkInstituut

NederlandseApothekers,hasrevealedthatanestimated90,000patientsareadmitted

tohospitaleveryyearasaresultofmedicationerrorsthatcouldhavebeenavoided.

Thiscostsaround300millioneurosayearandaccountsforapproximately2.5%of

hospitalizationnationwide.Ifhealthcareprovidershaveelectronicaccesstoallthe

medicationdataoftheirpatient,alotofsufferingandinconveniencecanbeavoidedand

alargepartofthissumcanbesaved.

B Electronic General Practitioner’s Record (WDH)

TheGPshortage,anageingpopulation,anageingprofessionalgroup,plusthefactthat

mostnewlyqualifiedGPsprefertoworkpart-timehaveprecipitatedtheemergenceof

10 ICTinDutchHealthcare:AnInternationalPerspective 11 ICTinDutchHealthcare:AnInternationalPerspective

LocumPostsinrecentyears.AtthemomenttheGPswhostandinfortheircolleagues

atLocumPostsintheeveningsandweekendshavehardlyanyaccesstothemedical

historyofthepatients.Insomecasesthispreventsthelocumfrommakinganadequate

diagnosis.ItisnotalwayspossibletogettherequiredinformationfromtheregularGP.

Whatismore,manypatientsareunabletoprovidecrucialinformationandsometimes

cannotevenrecallthenameofthemedicationtheyaretaking.

AnElectronicGeneralPractitioner’sRecordwillprovidethelocumwithasummaryofthe

patient’shistory.TherecordswillremainwiththeregularGPandwillonlybeaccessible

toalocum.Informationgainedduringtheconsultationisautomaticallyrelayedtothe

regularGPintheformofalocumreport.Theinformationappearsonthescreenofthe

GP,whochecksitandaddsittotherecordswithaclickonthebutton.

C Extension of applications

Thefirststepshavealreadybeentaken.MostoftheICTagendaforthecomingperiod

isstilltobedetermined.Theintroductionofnewapplicationswillbeprioritizedonthe

basisofthetechnologicalpossibilitiesandthewishesofthepatients,thehealthcare

providersandtheinsurers.Inthenextfewyears,various‘chapters’willbeaddedtothe

EPD,whichwillbeextendedtootherprofessionalgroupsanddomains(welfare,juvenile

careetc.).Thisstep-by-stepapproachshouldeventuallyleadtoanumbrellacollection

ofexchangeabledataforalltheplayers.Atalleventsthefollowinginitiativeswillbe

launchedinthenearfuture:

• FurtherdevelopmentoftheEPDcomponents:

• ExtendtheEMDbyaddingelectronicprescriptionfunctionsforhealthcare

providers;

• ExtendtheEMDtootherprofessionalgroups;

• ExtendtheWDHtoAccident&Emergency;

• Developthecomponentsforanelectronicdiabetesfile(aroundthecomplex

chainofhealthcareproviders),startingwithaself-managementtoolwhichgives

patientsaccesstotheirowndiabetesdata;

• DevelopanElectronicChild’sRecord(EKD).From1January2007everychildbornin

theNetherlandswillhavehis/herownEKD,containinginformationonthechild,the

familysituationandtheenvironment.Therecordswillbeadministeredbydoctors

andnursesinthejuvenilecaresector.Variousorganizationswillbeabletoadd

observationstotherecordwithoutconsultingit.Thisway,theprivacyofthechildis

protectedwhilejuvenilecareworkerscanidentifyproblemssoonerandtakequicker

action.

• UpsizeproveneHealthapplicationsbymeansofvariousprogrammes(e.g.the

NationwideProgrammeforSocialSectorsandICT).3

3 TorealizebreakthroughsinupsizingtheICTapplicationsandservicestheDutchgovernmentwillhavetotake

theleadinresolvingstickingpoints.ResponsibilityhasbeendelegatedtotheNationwideProgrammeforSocial

SectorsandICT(2005-2009)whichcoversfourdomains(mobility,education,safetyandhealthcare).

• Createconditionswherebypatientsgetelectronicaccesstotheirownrecord.Atthe

momentpolicymakersarethinkingintermsofanelectronicNationalIdentityCardas

ameansofpatientaccess.

The choices in the Netherlands:

• IncrementaldevelopmentofanElectronicHealthRecord.Newapplicationswill

beregularlyaddedtotheEPDintheyearsahead.

• GeneralPractitioner’sRecordasaninitialapplicationofanEPD.

• ElectronicMedicationRecordasaninitialapplicationofanEPD.

3.2 AORTA basic infrastructureInrecentyearstheDutchgovernment,theNationalICTInstituteforCare(NICTIZ)and

healthcareprofessionalshavetogetherlaidthefoundationfornationwideelectronic

communicationinthehealthcaresector.ICTsupplierscanuseDutchdesignsforICT

architectureinthehealthcaresectorandtheaccompanyingspecificationsasabasisfor

integratingtherequiredfunctionsinthesystemsofhealthcareprovidersandinsurers,

therebyenablingelectronicexchangeofinformationonanationalscale.Thesystems

ofthehealthcareprovidersandinsurersneedtobemodifiedsothattheycanbelinked

tothebasicinfrastructureandinordertorealizethedesiredlevelofsecurityand

accessibility.Thenationalbasicinfrastructureforhealthcareconsistsofanumberof

componentsandisdueforrealizationin2006.

A National registration systems for identification and authentication of patients,

healthcare providers, insurers and other care agencies

Nationalelectronicinformation-exchangeinvolvesthelinkingofdata.Toensurethat

dataisregisteredconsistentlyandthatpatients,healthcareprovidersandinsurers

communicatingatadistanceareproperlyidentified,uniquenationalidentification

numberswillbeapplied,namely:

1 TheCitizenServiceNumber(BSN)forpatientidentification.

Theintroductionofthisnumberatallgovernmentorganizationswillberegulated

bylaw.Separatelegislationwillbedrawnupfortheuseofthisnumberinthecare

sector.

2 UniqueHealthcareProfessionalIdentification(UZI)fortheidentificationofcare

providers.

Aregisterofcareprovidershasbeensetup,whichalsoseestotheissuingofUZI

passesandUZIcertificatesforidentifyingandauthenticatingcareproviders.Thefirst

passeswereissuedatthestartof2006.

3 UniqueHealthInsurerIdentification(UZOVI)fortheidentificationofhealthinsurers.

Aregisterofhealthinsurerswillalsobesetupandcertificateswillbeissuedto

confirmidentitieswhendataiselectronicallyexchanged.Thecertificateswillbe

issuedfromJanuary2007.

1� ICTinDutchHealthcare:AnInternationalPerspective 1� ICTinDutchHealthcare:AnInternationalPerspective

B A National Switch Point (LSP) with a reference index for routing, identification,

authentication, authorization and logging

On31January2006theNationalSwitchPoint(LSP)forthehealthcaresectorwas

established.Thisisanimportantstep,astheNationalSwitchPointisthe‘trafficcontrol

tower’behindthesecureelectronicexchangeofup-to-datepatientdatathroughoutthe

Netherlands.Inthesummerof2006theNationalSwitchPointwillbetestedwithICT

suppliersinthehealthcaresector.Afterwardsthehealthcareproviderscanbeconnected

toit.Thisisexplainedfurtherinsection3.3.

TheconstructionoftheNationalSwitchPointwascommissionedbyNICTIZ.Aftera

Europeantenderingprocedurethecontractwasawardedon8November2005.Actual

realizationtooklessthanthreemonths.

WiththeNationalSwitchPointasthetrafficcontroltower,healthcareprofessionalsall

overthecountrycanretrieveup-to-datepatientinformationfromthesystemsofhospitals,

pharmaciesandGPs.TheprimaryadvantageoftheNationalSwitchPointisthatcare

institutionsandsuppliersofICTapplicationsforthehealthcaresectorhaveonepointof

contactforspecificservices:

• TheNationalSwitchPointmanagesa‘nationalreferenceindex’whichcanswiftlytrack

patientdatawhenahealthcareproviderrequestsspecificinformation.Thepatientdata

arenotstoredatacentralpoint.Thereferenceindexkeepstrackofwhichpatientdata

arestoredinwhichinformationsysteminthecountry.

AtthesametimetheNationalSwitchPointconfirmsthatinformationissuppliedonly

tohealthcareproviderswiththerequisiteauthorization.Theswitchpointchecksthe

provideragainstthenationalUZIregister.Theprovidermustprovehisidentitywitha

UZIpass.

• TheNationalSwitchPointalsoconfirmswiththeaidoftheCitizenServiceNumberthat

thecorrectpatientdataarebeingsupplied.Thegovernmentisresponsibleforissuing

andcontrollingthisnationalpatientidentificationnumber.

• Finally,theNationalSwitchPointascertainswhichinformationthehealthcareprovider

mayaccess(authorization)andkeepsarecordoftheproviderandtheconsulteddata

(logging),sothattheauthorizationregulationscanbemonitored.

C Care Service Providers for communication and services between local environments

and the central LSP environment.

So,topromotesafeandfastcommunicationbetweencareorganizationsacrossthecountry

aNationalSwitchPoint(LSP)hasbeenestablished.Careorganizationscanconnectwiththe

LSPviathenetworkconnectionsofcommercialprovidersofcommunication,application

andcontentservices.Inthelongrunthese‘CareServiceProviders’willrequirecertification.

Intheinterim,asystemhasbeendevisedwherebymarketplayerscanbeauditedon

thebasisofaqualificationscheme.AsuccessfulauditcombinedwithasuccessfulLSP

acceptancetestleadstorecognitionasaCareServiceProvider.

D Information systems of care organizations

Careorganizationsneedtoasktheirsuppliertomodifytheirinformationsystemssothat

thedataisavailable24/7andcanbeaccessedbyauthorizedusers.Thismeansthatthe

datamustbestoredandsecuredinastructuredsystemandthatthelocalsystemscan

connectwiththeNationalSwitchPoint.Healthcareinformationsystemsneedtosatisfy

theGBZstandardsforwell-managedhealthcaresystems,wherebytheyalsomeetthe

internationalsecurityguidelines.Inaddition,careorganizations,healthcareproviders,

andlocalhealthcareinformationsystemsmustbeidentifiablewithauniquenationally

applicablenumber.

E Security and Authorization

Playersinthehealthcaresectorandpatientsmustbeconfidentthatthedatatransport

andstorageandaccesstopatientinformationisadequatelysecured.Awholearrayof

instrumentshasbeendevelopedforthispurpose.Accesscanbesecuredasfollows:

beforeaccesstocertaininformationisgranted,theidentityoftheapplicantisascertained

(identification)andconfirmed(authentication).Therightsoftheapplicanttoconsultthe

informationarethencheckedout(authorization).Messagesareencryptedtoensurethat

theinformationcannotbeinterceptedduringtransport.

Tooptimizesecurityallorganizationalandtechnicalaspectsneedtobeproperly

regulated.TheinfrastructureisPublicKeyInfrastructure(PKI),asystemoforganizational

andtechnicalrules,includingauthentication(Istheapplicantreallywhoheclaimstobe?),

dataencryptionandanelectronicsignature.PKIisthemostcommonlyusedsecurity

standard.Onesingleagencyconfirmstheaccessentitlementofthehealthcareprovider,

institutionorcomputersystemandissuesanelectroniccertificate.Thiscertificateisthen

usedtodeterminetheaccessrightsandregistertheidentityofthesender.

F Message standards

Informationexchangebetweenhealthcareprofessionalsrequiresmessagestandardsat

variouslevels.Messagesatapplicationlevelaredefinedfromoneinformationmodel

basedontheinternationalHL7version3standard.TheDutchhavedecidedtostandardize

on‘HL7version3’messagesbecausethisisaninternationalstandardwiththepotential

todevelopwithonestandardfromanationale-medicationrecordtoanationalElectronic

HealthRecord.ThespecificationshavebeenworkedoutindialoguewithHL7Nederland

andarebeingincorporatedintheinternationalHL7standard.

Ashealthcareinformationservicescoverabroadspectrumithasbeendecidedtogear

furtherdevelopmenttothegenericinfrastructuralfacilitieswhichwillattheveryleast

beneededtorealizethee-medicationrecord.Itiswithinthiscontextthatthebasic

infrastructurespecificationshavebeendrawnup.Thesewillthenbeextendedand

optimized.


Choices in the Netherlands:

• Allmedicaldatatoremaininlocalrepositories;exchangevia

aNationalSwitchPoint.

• Nationalregistersforidentificationandauthentication.

• Nopatientsmartcardwithwhichthehealthcareprovidercanaccesspatientdata.

• MessagestandardizationbasedonHL7v3.

• SecurityviaNENnorm7510(ISO799).

3.3 EMD/WDH implementation programme

IntheEMD/WDHimplementationprogrammethecomponentsofthebasicinfrastructure

andthefirsttwoapplicationscometogether.Thedifferentcomponentswillhaveto

operateinconcertinatestenvironment.FiveEMDandsixWDHpilotregionshavebeen

selectedforthistrialandwillreceiveactiveassistancewiththeintroductionofoneor

bothapplications.Together,thesepilotregionscover1,000healthcareprovidersand

some2millionfiles.Formoreinformationsendane-mailtoinfo@invoering-epd.nl

Care provider Number

GPs 724

Publicpharmacies 286

Hospitals 7

Locumposts 34

Total 1051

Besidesthepilottrial,thereareotherwaysinwhichhealthcareprovidersareclosely

involvedintheintroductionoftheEMDandtheWDH.Fourworkgroupshavebeen

formedtodefinethefunctionalneedsandwishesofthehealthcareprovidersinthe

programme.TheseworkgroupsarefocusingoneverydayaspectsoftheEMDandthe

WDH,suchasthetechnicalrequirementsofthehealthcareandadministrativeprocesses

atpharmacies,GPpracticesandhospitals,andonmeetingtheGBZstandards.

Toensureoptimalcareandattentiontheimplementationprocesshasbeensplitinto

threephases:

1 Proof of Concept (PoC)

TheimplementationoftheElectronicMedicationRecordandtheElectronicGeneral

Practitioner’sRecordbeginswitha‘ProofofConcept’(PoC)phase.InthePoCallthe

constituentsofthechain(LSP,(LSP,SBV-z(sectoralmessageservicesincare),theCitizen

ServiceNumber,theUZIregister,theUZIpassandtheICTsystemsofthehealthcare

providers)aretestedinconcertunderlaboratoryconditions.Thiswillshowwhetherthe

nationalfacilitiesareworkingeffectivelyandwhetherthetestedhealthcaresystemsare

operatingcorrectlyandsafelyintandemwiththenationalfacilities.Oncethisphasehas

beensuccessfullycompletedthesystemsofthesupplierscanbeimplementedinthe

environmentsofthehealthcareproviders.

2 Pilot in pilot reference environment

InthesecondphasetheresultsfromtheProofofConceptareintroducedinthe

healthcaresectoroftwoofthepilotregions(thereferenceenvironments):oneEMD

andoneWDHregion.ThispilotcanonlyproceediftheProofofConceptphasehasbeen

completedandapprovedandtheGBZcriteriahavebeenmet.

Previousexperienceofthistesthasshownthatthesystemsmayneedmodification.

Thesystemsthendefinitivelybecomeoperationalintherespectiveregion.

3 Pilot in other pilot regions

Afterthepilotshavebeensuccessfullycompletedinthereferenceenvironmentsand

anyflawsinthesystemhavebeenredressed,theimplementationintheotherpilot

regionscanstart.

Iftheseprovesuccessfulthenationalroll-outbeginsearlyin2007.

3.4 Other aspects

NowthatthebasicinfrastructureandtheapplicationsforEPDarebeingimplemented,

themanyhealthcareandbusinessapplicationsviaInternetwhicharedevelopedinthe

Netherlandswillgetasafeandreliablebasisfordataexchange.

Healthcareapplicationswillespeciallybenefitfromthenewbasicinfrastructure.Take,

forexample,e-mailconsultations,Internetapplicationsinthementalhealthsector,

Noord-Holland Noord

Rijnland & Midden-Holland

Rijnmond

AmsterdamHarderwijk

UtrechtNijmegen

Twente

Drenthe

Friesland

WDH

EMD


tele-dermatologicalconsultationsand‘screen-to-screencare’innursing.In2004the

DutchgovernmentlaunchedtheDeclaratiecasusprogramme,aprojecttoimprove

billinginthecaresector(everyyeartheinsurersreceivemillionsofmedicalbillsfrom

thousandsofcareproviders).

ThoughtheneedtodeployICTtohelpsafeguardaffordableandaccessiblehealthcareis

beyonddispute,manyofthetele-medicineapplicationsarehavingdifficultybecoming

apart(bothorganizationalandfinancial)ofthemainstreamhealthcareprocess.Their

effectivenesswillhavetobeprovenbeforetheycanbeintegratedinthecurrentfunding

systemand–ifnecessary–connectedtothenationalinfrastructure.Anadditional

obstacleisthatthecostsandbenefitsofinvestmentandoperationareusuallyspread

acrossdifferentplayers.However,thepotentialprofitsfromtele-medicineandthe

potentialforbroadapplicationarebecomingmorediscernibleallthetime.

TheDutchgovernmenthaslaunchedvariousprogrammestoupsizespecificICT

projectsorprojectsinwhichICTplaysarole,suchasSnellerBeter(FasterBetter),Zorg

voorBeter(GettingBetter)andtheNationwideActionPlanforSocialSectors

andICT(2005-2009).

3.5 Conditions

PrimaryresponsibilityforthequalityofhealthcareandtheuseofICTsystemsrests

withthehealthcareproviders.Itisthegovernment’stasktopavethewayandfacilitate

andstimulatetheuseofICTinhealthcarebypassinglegislation,creatingaconducive

financialclimateandcoordinatingtheprocess,allwithaviewtoimprovingaccessibility,

affordabilityandquality.

3.5.1 Legislative framework

Theprovisionofresponsiblecareandtheuseofmoderntoolsinpresent-dayhealthcare

fallsundertheQualityofHealthcareInstitutionsAct(KwaliteitswetZorginstellingen).The

MedicalTreatmentAct(WetGeneeskundigeBehandelovereenkomst)requireshealthcare

providerstokeeprecordsandthePersonalDataProtectionAct(WetBescherming

Persoonsgegevens)setsprivacycriteriafortheprocessingofpersonaldata.Thecurrent

legislation,whichappliesto‘paper’records,offersanadequatelegislativeframework

foranEPD.Thelegislativeframeworkwill,however,havetobeamendedtocover

informationsearcheswiththeCitizenServiceNumber(BSN)andtoencourageall

healthcareproviderstomakeuseofElectronicHealthRecords:

A. Legislation on the use of the Citizen Service Number (BSN) in healthcare

Thislegislationregulatestheuseofanationalidentificationnumberinthehealthcare

sectorinawaythatenablesmedicaldatatobeuniquelylinkedtoonepatientacross

multipleinformationsystems.TheBillisawaitingdebatebytheDutchParliament.

HealthcareworkersandorganizationswillbeobligedtoentertheBSNintheirrecords,

confirmthatitbelongstothepersoninquestion,andtouseitintheelectronicexchange

ofdata.

B. Legislation on the Electronic Health Record (EPD)

Theaimofthislegislationistoaddressissues,suchassecurity,dataquality,

authorizationandaccess(bythepatientamongstothers),standardizationandtheactual

useoftheEPD.

LegislationforthenationwideElectronicHealthRecordshouldregulateattheveryleast:

• (mandatory)connectionofhealthcareproviderswiththeNationalSwitchPoint;

• electronicavailabilityofpatientdataviatheNationalSwitchPoint;

• secureandreliableinformationexchangeviatheNationalSwitchPoint.

Initially,thelegalobligationwillapplyonlytohealthcareproviderswhoarerequiredto

testtheoperationoftheEMDandtheWDH.Ifnecessary,thelegislationcanbeextended

tootherprovidersandotherpartsoftheElectronicHealthRecord.

3.5.2 Funding

Thenationalfacilitiesfortheinfrastructurewillbefundedbythestate–atleastinthe

earlyyears.ThisconsistsofthedevelopmentandmanagementoftheNationalSwitch

Pointandtheregistersofcareprovidersandhealthinsurers.Thegovernmentwillalso

fundthefirstissueoftheUZIpassandthecard-reader.

Further,thegovernmentwillcontributefinanciallytotheimplementationoftheEMD/

WDHinthepilotregions,wherebytheICTsupplierswhowishtoparticipateinthe

frontrunnerprojectwillgetthechancetoadapttheirsystems.Thelocaluserswillpay

forimplementationatlocallevel–connectingthesystemwiththeNationalSwitchPoint

–andthedataexchange.

TheannualbudgetforICT–currentlyintendedforallcomponentsofthebasic

infrastructureandtheEMD/WDHimplementationprogramme–amountstoover

€ 35million.

3.5.3 Coordination

Mostofthecentralfacilitiesfortheprogrammeareready,sotheemphasishasshifted

fromdesignandconstructiontoactualimplementationofthefirsttwoapplicationsin

concertwiththecentralfacilities.Asthisrequiresacentralpointofcontact,theMinistry

ofHealth,Welfare&Sportisresponsibleforcoordinatingtheprocessfrom1January

2006.Hence,aseparateimplementationorganizationhasbeensetupwithintheministry

forthispurpose.Itstaskistwofold:firsttosupportandfacilitatetheintroductionofthe

ElectronicMedicationRecordandtheElectronicGeneralPractitioner’sRecordinthepilot

region;andsecond,tocoordinatetheentireoperation.


4 EU eHealth Action Plan

4.1 Introduction

TheeHealthActionPlanispartoftheEuropeanUnion’se-Europestrategy,whichaimsto

bringthebenefitsoftheinformationsocietywithinreachofallEuropeancitizens.

TheprimaryobjectiveoftheeHealthActionPlanistoenabletheEUtoutilizethefull

potentialofon-linehealthcaresystemsandserviceswithinaEuropeanspacefor

eHealth.

Threespearheadshavebeendefined:

• Developastrategyforcommonchallengesandcreateaframeworkconduciveto

eHealth;

• Organizepilotprojectstokick-starteHealth;

• Disseminatebestpracticesandevaluatetheprogress.

TheeHealthworkgrouphasprioritizedthefollowingelementsintheActionPlan:

• Patientsummary

• Identityofcitizens/patientsandhealthcareprofessionals

• Emergencydataset

OntheadviceoftheworkgroupaStakeholdersGrouphasbeenformedtofleshout

theseissues.

4.2 A strategy for common challenges

A Healthcare institutions have an important job to do

TheActionPlanproposesthateachmemberstatedevelopsanationalorregional

roadmapbymid-2006atthelatest.Thisroadmapmustcontainacontinuousagendaand

befinalizedintheautumnof2006.

Situation in the Netherlands:

• TheDutchgovernmentwillpresentitseHealthroadmapatthe‘HighLevel

eHealthconference’inMalagaatthestartofMay2006.

B Interoperability of the healthcare information systems

Interoperablehealthcareinformationsystemsmustensureunambiguousidentification

ofpatientsandtransparentexchangeofhealthcaredatathroughoutEurope.

TheActionPlanthereforeproposesthatthememberstatesformulateacollective

strategyforpatientidentificationbytheendof2006andreachagreementon

interoperabilitystandardsformessagescontainingmedicaldataandelectronicmedical

�0 ICTinDutchHealthcare:AnInternationalPerspective �1 ICTinDutchHealthcare:AnInternationalPerspective

files.Thestrategymustalsotakeaccountofbestpractices,relevantstandardization

activitiesandrecentdevelopmentsin,forexample,theEuropeaninsurancecardand

identitymanagementforEuropeancitizens.


• Identification:inFebruary2006theDutchorganizedaEuropeanExpertMeeting

onHealthIDManagement.TheresultsareduetobeannouncedinMay2006.

Atthesametime,theDutchwillmakethenationalsolutionforpatientsand

healthcareprovidersaccessibleforinternationalharmonization.

• Interoperabilityformessagetraffic:theDutchhaveoptedtostandardize

messagesviaHL7version3,asthisisaninternationalstandardwhichoffers

potentialfordevelopingfurtherwithonestandardfromanationalEMD/WDH

toanationalElectronicHealthRecord.

• Standardization:thisisessentialinordertorealizetheeHealthobjectives

inEurope.TheDutchregardtherecommendationsoftheCEN/ISS‘eHealth

StandardizationFocusGroup’(14March2005)asthebasisforacollective

strategyonstandardization.

• Europeaninsurancecard:theEuropeaninsurancecardwasintroducedinthe

Netherlandson1January2006.Thecardisnotyetconnectedtoanelectronic

functionality.TheDutchgovernmentisnotinfavourofconnectingthiselectronic

cardtopatientidentity,nordoesitseethecardasakeyforaccessingor

supplyingmedicaldata.

C Mobility of patients and healthcare professionals

PatientsandhealthcareworkersarebecomingevermoremobilewithintheEU.

TheEUhasalreadyadoptedastatementonpatientmobilityandstartedprojectsto

improveinformationservicesinthisdomain.Informationonthemobilityofpatients

andhealthcareprofessionalswillbeimprovedbytheactivitiesoftheworkgroupon

healthcaresystems.


• TheDutchgovernmentisworkingonanationwideElectronicHealthRecord

whichwillmakehealthcareinformationavailabletoauthorizedusersregardless

oftimeorplace.

• TheDutchareplayinganactiveroleintheEuropeandebateonthemobilityof

patientsanddoctorswithintheEU.Besidesitsinterestinstandardizationfor

futureideals,theDutchsupportpragmaticsolutionsforbottlenecks.

D Modernization of infrastructure and technology

TheActionPlanrequiresthememberstatestosupporttheconstructionofeHealth

informationnetworksin2004-2008onthebasisoffixedandwirelessmobileand

broadbandinfrastructureandgridtechnology.


• TheNationwideActionPlanforSocialSectorsandICT(2005-2009)isalsogeared

toapplicationswhichneedbroadband(utilizationofbroadband).

• ThereisahighlevelofbroadbandcoverageintheNetherlands.InarecentOESO

studytheNetherlandsscoredhighinbroadbandpenetration,withover

25subscriptionsper100inhabitants.

E Conformity tests and accreditation for an eHealthcare market

NumerousEuropeancountrieshavealreadyembracedtheaccreditationofelectronic

healthcaresystems,whicharenowservingasmodelsforotherregions.

Bymid-2006atthelatesttheCommissionmustcompilealistofbestEuropeanpractices

asaguidelineforthememberstates.Bytheendof2007thememberstatesmustthen

organizeconformitytestsandaccreditationonthebasisofsuccessfulbestpractices.


• In2006thebasicinfrastructureisduefortestinginpilotenvironments.

• In2007certificationschemeswillbereadyforthelocalinformationsystems(GBZ/

well-managedhealthcaresystems)forconnectiontotheNationalSwitchPoint.

F Investment incentives

Eachdevelopmentormodernizationofthesystemsrequiresinvestment.Accordingly,

thememberstates–inlinewiththeActionPlan–mustdevelopajointstrategybythe

endof2006tosupportandstimulateinvestmentineHealth.


• Upsizing:TheDutchgovernmentisencouragingtheupsizingofdevelopments

inICTsystemsandservicesviaaNationwideActionPlanfortheSocialSectors

andICT.

• Attheendof2006theDutchwillexchangeinformationwithothercountrieson

defrayingthecostsofeHealth.

G Judicial and regulatory aspects

UndertheActionPlantheEuropeanCommissionmusttakejointactionwiththemember

statesbytheendof2009to:

• establishareferenceforastandardizedEuropeanqualificationforeHealthservicesin

aclinicalandadministrativesetting;

�� ICTinDutchHealthcare:AnInternationalPerspective �� ICTinDutchHealthcare:AnInternationalPerspective

• createaframeworkformorelegalsecurityinrelationtoproductandserviceliability

ineHealthwithinthecontextoftheexistinglegislationonproductliability;

• improvetheinformationforpatients,healthinsurancesystemsandhealthcare

providersonhowtoreclaimthecostsofeHealthservices;

• promoteeHealthtoreduceindustrialaccidentsandoccupationalillnessesandto

findwaysofpreventingnewrisksintheworkplace.

4.3 Pilot projects

ManypilotprojectsoneHealtharealreadyunderwayintheEuropeanUnionorwillstart

verysoon.

H Information for citizens and governments on health education and

prevention of illness

AspartofitspublichealthprogrammetheEuropeanCommissionhasbeenworkingona

publichealthportalsitefortheentireEU,scheduledtobeoperationalattheendof2005.

Thissiteofferscitizensonepointofaccesstoinformationonpublichealthandalsoon

healthandsafetyintheworkplace.

TheECisalsoimprovingtheICTinstrumentssothatearlywarning,detection,and

surveillanceofthreatstopublichealthcanbesteppedup.


• In2005aportalwassetupintheNetherlandsofferingcomparativeandhealth

informationtomembersofthepublic.Thisportalcontainsinformationon

hospitals,healthinsurance,medication,patientinterestandmedicalissues

(www.kiesbeter.nl).In2006and2007theportalistobefurtherextendedwith

informationon,amongstothers,GPs,physiotherapists,residentialcareand

nursinghomes,homecare,mentalhealthcareandcareforthehandicapped.

• ItwillbeharmonizedwiththeEUportalsitein2006.

I The development of integrated healthcare information networks

Atpresent,alotofworkandenergyisbeinginvestedintheinterconnectionofhealthcare

informationnetworks.Bytheendof2008mostEuropeanhealthcareorganizationsand

regions(municipalities,provincesetc.)mustbeabletoofferon-lineservicessuchas

tele-consultations(secondmedicalopinion),electronicprescriptions,electronicreferralto

specializedservices,tele-monitoringandtele-care(monitoringthepatientathome).


• TheNetherlandswillactivelylookintotheinitiativesofothermemberstates

tointegratedomotica,telemedicineandstandardizationconcerningElectronic

HealthRecords.

J Encouraging the use of cards in the healthcare sector

Therearetwotypesofcardthatcanbeusedinthehealthcaresector:thehealthcare

pass,whichcontainsusefulinformationforemergencies,suchasbloodgroup,

medicalconditionsandtreatment;andtheEuropeanhealthinsurancecard,whichwas

launchedon1January2004andreplacesallthepapersthatpeopleusedtoneedto

getemergencymedicalcareduringastayabroad.Thememberstatesareorganizing

campaignstoencouragepeopletousethesecards.Ithasalsobeenagreedthatthe

principleoftheelectronichealthinsurancecardwillbeapprovedby2008.


• OntheissueofpatientaccesstotheirownmedicalrecordstheDutchare

focusingontheelectronicnationalidentitycardwhichwillbeintroducedin2007.

• PatientswillnotbeabletousetheEuropeaninsurancecard,introducedon

1January2006,toaccesstheirownrecords.TheNetherlandsisplayingan

activeroleinthedebateontheelectronicinsurancecardwhichtheEUplans

tointroducein2008.

4.4 Monitoring

K Dissemination of best practices

eHealthcaremustbesupportedbythelarge-scaledisseminationofbestpractices.The

keyissuesaretheeffectsonaccesstohealthcare,thequalityofhealthcare,anevaluation

ofcostsavingsandproductivitygains,andmodelsforastrategytoaddressliabilityfor

tele-medicalservices,reimbursementproceduresandaccreditationofeHealthproducts

andservices.

Thedisseminationofbestpracticesneedstobesafeguardedbyregularhigh-level

conferenceswhichenjoythesupportoftheEuropeanCommission.Meantime,the

Commissionmustintroduceaneffectivesystemfordisseminatingbestpracticesbythe

endof2005.


• TheNetherlandswillactivelyshareitsbestpracticeswithothermemberstates.

AnEnglishoverviewwillbeavailableatthestartof2007.

L Evaluation

TheEuropeanCommissionhasundertakentopublishabiennialevaluationinthecourse

of2004-2010ontheprogressintheintroductionofeHealthcare.


• TheNetherlandswillactivelycontributetobiennialevaluationbytheEC.


Appendix 1

Health indicators - The NetherlandsSource:www.who.org

Population EstimatesIndicator Value

Totalpopulation(000),2003 16,149.0

Annualpopulationgrowthrate(%),1993to2003 0.6



Totalfertilityrate,2003 1.7

Health IndicatorsIndicator Value

Life expectancy at birth (years) 2003

Totalpopulation 79

Males 76

Females 81

Child mortality (probability of dying under age 5 years) (per 1000) 2003

Males 6

Females 5

Adult mortality (probability of dying between 15 and 59) (per 1000) 2003

Males 93

Females 66

Healthy life expectancy at birth (years) 2002

Totalpopulation 71.2

Males 69.7

Females 72.6

Healthy life expectancy at age 60 (years) 2002

Malesatage60 15.5

Femalesatage60 18.4

Expectation of lost healthy years at birth due to poor health (years) 2002

Males 6.3

Females 8.5

Percentage of total life expectancy lost due to poor health (%) 2002

Males 8.3

Females 10.4


Appendix 2

National expenditure on health - The NetherlandsSource:www.who.org

A Proposed ratios and levels 1998 1999 2000 2001 2002 2003 2004

I. Expenditure ratios

Totalexpenditureonhealth(THE)%GDP 8.2 8.4 8.3 8.7 9.3 9.8 9.8

Generalgovernmentexpenditureonhealth(GGHE)%THE 64.1 62.7 63.1 62.8 62.5 62.4 61.2

Privateexpenditureonhealth(PvtHE)%THE 35.9 37.3 36.9 37.2 37.5 37.6 38.8

GGHE%Generalgovernmentexpenditure 11.2 11.2 11.5 11.5 12 12.4 12.3

Socialsecurityexpenditureonhealth%GGHE 93.9 93.8 93.9 93.8 93.8 93 93.3

Netout-of-pocketspendingonhealth(OOPs)%PvtHE 23.6 24.1 24.3 23.4 21.4 20.8 20

Privateprepaidplansexpenditureonhealth%PvtHE 45.6 44.5 43 43.6 45.6 45.7 46.4

Externallyfundedexpenditureonhealth%THE 0 0 0 0 0 0 0

II. Per capita levels

THEpercapitaatexchangerate(US$) 2067 2102 1916 2067 2411 3088 3471

GGHEpercapitaatexchangerate(US$) 1326 1318 1209 1298 1506 1926 2123

THEpercapitaatinternationaldollarrate 2044 2124 2270 2517 2777 2987 3056

GGHEpercapitaatinternationaldollarrate 1311 1332 1432 1581 1735 1863 1869

B Values underlying ratios and levels

Health System Expenditure & Financing (million NCU)

I.MeasuredFinancingAgents

Totalexpenditureonhealth(THE) 29221 31236 33261 37150 41264 44589 45754

Generalgovernmentexpenditureonhealth(GGHE) 18744 19589 20981 23333 25773 27815 27981

…ofwhichSocialsecurityexpenditureonhealth 17604 18367 19696 21881 24165 25856 26095

Privateexpenditureonhealth(PvtHE) 10477 11649 12280 13817 15491 16774 17773

…ofwhichNetout-of-pocketspendingonhealth 2469 2807 2987 3232 3310 3496 3548

...ofwhichPrivateprepaidplansexpenditureonhealth 4778 5186 5280 6029 7070 7673 8255

II.MeasuredFinancingSources

Externallyfundedexpenditureonhealth 0 0 0 0 0 0 0

III.MacroVariables

Grossdomesticproduct(GDP)(millionNCU) 354194 374070 402291 429345 445160 454276 466310

Generalgovernmentexpenditure(millionNCU) 167216 175554 182228 203063 214960 224231 227535

Exchangerate(NCUperUS$) 0.9 0.94 1.09 1.12 1.06 0.89 0.81

Internationaldollarrate(NCUperinternationaldollar) 0.91 0.93 0.92 0.92 0.92 0.92 0.92

Totalpopulation(inthousands) 15707 15812 15926 16046 16149 16225 16275

�� ICTinDutchHealthcare:AnInternationalPerspective

Appendix 3

Healthcare professionals - The Netherlands

Health care professionals Number in 2003 Density per year

Physicians 50854 3.15

Nurses 221783 13.73

Midwives 1940 0.12

Dentists 7759 0.48

Pharmacists 3134 0.19

Publishedby:

MinistryofHealth,WelfareandSport

Addressforvisitors:

Parnassusplein5

2511VXTheHague

TheNetherlands

Correspondenceaddress:

PObox20350

2500EJTheHague

TheNetherlands

Telephone+31(0)703407911

Telefax+31(0)703407834

Internet:

www.minvws.nl

May2006

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