1. E-Health Programs of Regione Lombardia Fulvio Barbarito Lombardia Informatica 13 February 2008

2. 1  Lombardy Region  The Healthcare Network of Lombardia  Lombardy’s Region Healthcare Information System evolution  E-Health in the world: who is doing what where?  The CRS-SISS Programme –The underlying philosophy –Goals and main streams –Electronic Health Record (EHR): Architecture and main characteristics –Services and Architecture –Project principles –Smart Cards Technology –Main results in December 2007 –The Gartner five Technical Challenges and four People Challenges –The financing model Summary

3. 2 Lombardy Region Is one of the twenty Italy’s Regions About 16% of Italy’s citizens Is one of the more populated Regions of Europe (more populated than 14 EU member States) The number of inhabitants per Km 2 is 6 times Bulgaria’s one Its GNP is about 20% of Italy’s GNP

4. 3 The Healthcare Network of Lombardia 9.500.000 Citizens 150.000 Health & Social Care Operators 8.500 General Practitioners and Pediatricians 2.500 Pharmacies 15 Local Healthcare Units 34 Public Healthcare Services Suppliers (29 Public Hospital and 5 Public Scientific Services) Over 2500 Private Healthcare Services Suppliers As every Italian Region is directly responsible for Healthcare services provision

5. 4 Lombardy’s Region Healthcare Information System evolution 1978 Collection and filing of hospitalizations Collection and filing of outpatient visits data 1997 1985 Collection and filing of pharmaceutical acquisitions 1982 Regional personal data directory of Citizens and General Practitioners CRS-SISS Project’s requirements definition and feasibilty analysis CRS-SISS On site pilot project in Lecco’s District (300.000 citizens) 19992000 -20012002 CRS-SISS Project Financing and beginning of the expansion to all Districts 2008 CRS-SISS Healthcare Private Sector 20042005 CRS-SISS 2 millions citizens CRS-SISS All Lombardy’s citizens (9,5 millions)

6. 5 E-Health in the world: who is doing what where? Denmark: MedCom, portal, national databases (in use) Italy (Lombardy): CRS-SISS Health Portal (in use) Scotland: Emergency Care Record (in use) England: NHS National Programme for IT (in use) Sweden: Stockholm County Council (in use); Carelink (in design) Spain (Balearic Islands): Patient summary (in use) France: Dossier Medical Personnel (in design) Finland: Patient summary (in design) Netherlands: NICTIZ Out of Hours and Medication Records (in design) Germany: Health card (in preparation) Europe Regional Health Information Organizations (RHIOs) Four National Health Information Network (NHIN) pilot projects Canada Health Infoway United States /Canada Asia-Pacific region Australia, NZ, Singapore, Hong Kong… Today, the CRS-SISS Project, is one of the leading project in terms of implementation stage and completness of features

7. 6 SISS is a Regional Healthcare Information Network, the Citizen is its centre. All the data are gathered, organized and reported on the basis of the citizen’s clinical treatment within the Regional Healthcare Network. SISS implements a wok-flow based on the typical healthcare processes: Pharmaceutical Outpatient examinations Medical examinations Emergency … The underlying philosophy

8. 7 CRS-SISS goals Improve Services for Citizens: reducing the “distance” between Citizen and HC Services Providers by simplifying procedures and shortening waiting time Improve quality of prescription, diagnosis and care (appropriateness) processes by Citizens’ clinical data sharing, through EHR, among qualified HC Professionals, securing Citizens’ Privacy Rights Improve Governance of Social and HC System managing costs: enhancing planning and controlling instruments (DataWarehouse, Business Intelligence) Improve internal processes efficiency of HC Services Providers by a generalized diffusion of new technologies (digital signature, electronic filing, electronic prescription) to dematerialize documents Reduce the gap between Citizen and HC Services Providers SISS Planning and Governance of HC expenditures Efficiency and Simplification Social and HC Internal Processes Assure continuity and quality of care For Citizens and HC Professionals For Administrations (Regional Government and HC Providers) The main objectives of the CRS-SISS program are to unify and to protect within a co- ordinate system the information about the lombard citizen state of health and to distribute a CRS Card in order to obtain:

9. 8 CRS-SISS main streams creation of new services at regional level for Citizens and HC Professionals (Electronic Health Record) creation of a large technological infrastructure implementation of an integrated regional information system central data base and clinical data repository (administrative data, service codes, …) solutions for clinical management of patients application integration of Organization’s Information Systems through an integration middleware Healthcare Extranet as main instrument of innovation and integration framework among all actors: Develop HC Organizations’ Information Systems, promoting features such as:

10. 9 Electronic Health Record (EHR): Architecture Health documents HLU: Patient Summary, Vaccine file Hospitals: Referrals, Health Documents, Therapeutical plans, …

11. 10  It gathers and organizes synthesis information (documents) for care aim.  It allows the sharing of the medical information to all the actors who are responsible for the care of the citizens.  It has a patient centric structure.  It has a temporal horizon of along period  It is the fundamental support for the care of the citizen.  It collaborates datawarehouse which supports the uses of the information with institutional-administrative aims (government of the healthcare system, epidemiological analysis, searches)  It’s open to the citizen.  It contains specialized Pathology Network Data (Oncology, Epileptic,…). Electronic Health Record (EHR): Main characteristics

12. 11 CRS-SISS Services Citizen Identification Electronic Prescriptions Management Electronic Health Record (EHR): -share clinical data: events, prescriptions, referrals, care profile, … -on line access for Citizens and HC Professionals Clinical information exchange among HC Professionals Support to GP’s electronic patient dossier Booking Services (for Citizens by internet, GP, Pharmacies, Regional Call Center) Accounting information flow management Electronic signature, mailing system, encryption functionality

13. 12 CRS-SISS Architecture Services 2 LEVEL Healthcare Extranet Hospital, Operators, Chemists, … Provider Lombardy Region Central System 1 LEVEL Central Repository 3 LEVEL Operators & Organizations General Practitioner, Pediatrician Integrate Management Unit Citizens

14. 13 Project principles  Web technologies  Evolution and integration, not replacement, of existing applications  Strict enforcement of personal data protection (privacy): high security technologies  Process reengineering to improve efficiency  Large deployment of digital signature and electronic documents (dematerialization)  Smart cards

15. 14 Smart Cards Technology Citizen Card Operator Card Identification and authentication Storage of information needed for emergency care (Netlink standard) Access to Public Administration services Certification of the “presence” of the Citizen (through electronic signature of documents) Identification and authentication Authorization to gain access to the System (according to operator’s profile) Electronic Signature

16. 15  About 9 millions CRS delivered  More than 80% General Practitioners and Pediatricians in the Network.  100% Pharmacies in the Network  About 60 millions transactions during 2007  All Healthcare Local Units and Public Hospitals of the Region have integrated their applications to the network  More than half Public Hospitals are generating events, referrals and clinical documents, signed electronically, into EHR to share data with other operators  Oncology Lombardia Network and Rare Disease Network available  Available on line the service of choice and revocation of GP and pediatricians Main Results in December 2007

17. 16 The Gartner five Technical Challenges  1. Achieving semantic interoperability –You will always have a mixture of structured and unstructured data  2. Implementing standards –HL7 v.3, HL7 CDA, CEN EHRcom, SNOMED, IHE, Continua  3. Deciding between federated and centralised data architectures –Hybrid solutions are emerging  4. Integrating legacy systems –Healthcare is an extremely complex environment  5. Improving quality of data –Lives are at stake

18. 17 The Gartner four People Challenges  1. Engage clinicians –Involve them in decision-making –Ensure the systems benefit them  2. Engage citizens –They trust clinicians, not the government! –Their top concerns are privacy and security of data  3. Manage vendors –Balance risk and reward –Supervise consortia carefully  4. Ensure effective governance –Leadership, political engagement, funding –Balance between top-down and bottom-up decisionmaking

19. 18 Currunt usage: Total system Prescriptions

20. 19 Currunt usage: Total system Transactions

21. 20  Lombardia Informatica S.p.A.: is Lombardia Region’s operative Business into the ICT field. It is responsible for Project Management.  LISIT S.p.A.: is the special purpose entity created by Lombardia Informatica to implement the Project with three Private Partners: Awarded by a Public Auction. They own 44% of LISIT’s equity and participate to the Project implementation. Project Financing Model The financing model

22. 21 Thank you 13 February 2008 Fulvio Barbarito Lombardia Informatica