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  DECLARATION ON E-HEALTH

   Summary
Academy of Medical Sciences of Croatia has published this "Declaration on eHealth" in order to alert all stakeholders (patients, health professionals, institutions, government bodies, suppliers) to use the immense potential of information and communication technologies and solutions for improving health care in Croatia. The Declaration draws attention to the areas of infrastructure, such as: education, regulation and standardization, medical and health informatics as a profession, the obligation of institutions, government bodies and suppliers. In addition to answering the question "what?", Declaration addresses the most important question "how?". Actual situation is characterized by fragmentation in computerization of the healthcare system, and unconnected projects and solutions. The Declaration proposes the realization of a common concept of computerization of healthcare system and health as such through the establishment of a central body at national level (agency, office, institute) where the expertise, decision making and financing of health information projects at the national level will be focused. This central body needs to function on the principles of professionalism, independence and transparency. The purpose of the proposal the Declaration has offered is to improve the management of Information Technology in the healthcare system. This will avoid containment within institutions, enable provision of purposeful use of financial resources and experts, and achieve cooperation, which would result in information supporting the healthcare system closer to the optimum.

   Preamble
Modern information and communication technologies enter into all spheres of human life and existence, including medicine and health, because it is a technology that facilitates access to information and allows their use in order to expand knowledge and provide arguments for responsible decision making. At the same time, there are examples of misuse and even abuse of the technology, which is why there is a need to introduce order into their use. To avoid mistakes and misuse of information and communication technologies in medicine and health care, it is necessary to assess the possibilities of such technologies, set up a framework, adopt standards for information infrastructure, quality and safety and define an appropriate education.
Medicine and health are very sensitive areas in terms of human life and work, and any inappropriate use or misuse of medical information can lead to undesirable outcomes.
The fact is that Croatia is working on the computerization of the health system. Primary health care is computerized mainly in the part that refers to storing patient data in digital format and data exchange with the Croatian Health Insurance Institute. Components that will allow primary care physicians to use the information infrastructure and information systems for their continuous education and longlife learning, routine consultation (telemedicine) with colleagues and specialists, to search and fill the national databases, to communicate directly with patients through information and communication technology (ICT) , does not yet exist even in the plans, so there will be a huge, organized upcoming activity. Hospitals and polyclinics have their own ideas and are continually working to develop their own information systems to meet their information needs. Public Health Institutes (and others) develop subsystems that are based on data coming from health care institutions stored in the medical records of their patients. However, sending these data requires additional work of a physician or other health care personnel in the preparation of reports based on data from medical records which often result in delays, and sometimes with incomplete data. Therefore, healthrelated statistical reports are late. Furthermore, medical documentation is typically fragmented (part of the patient data is in primary care, some in hospitals, a large part of the medical information patients keep at home). It also makes the access to patients' data difficult or impossible which could create problems in direct medical work.
Regarding the process of computerization of the health care system it can be noticed that it does not run smoothly. Health professionals, as users of health information systems, are generally not involved in its development and, finally, they are not satisfied with applications they obtain, Often it is not clear how they might take part in the improvement of the system, to whom they could suggest the improvement and how to do it how to painlessly replace the software that does not satisfy them.
For all these reasons the Committee for ehealth of the Croatian Academy of Medical Sciences proposed declaration defining the scope of application of modern technology, educational framework for health and IT professionals, and basis that will allow raising the quality of ehealth, and, consequently the quality of health care system.


Content

  E-Health
  Health Data and Information are an Issue of Public Interest
  Quality Assurance and Improvement of Health Care
  Defining the Medical and Health Informatics as an Activity within the Health System  
  Establishment of an Umbrella Institution for Medical Informatics

  Involvement of Medical Professionals in Professional Teams of Medical Informatics
  Legal Regulation of Computerization of Health Care System
  Change Management
  EHealth Issue in Education of Health Professionals
  Health / Medical Topics in Education of ICT Professionals
  Education for Change Management
  Communication among Healthcare Institutions and Healthcare Institutions with Health Care Users
  Integration of Health Information
  Health Statistics as an Issue of Public Interest
  Health Registries
  Standards and Standardization
  Certification of Software and Other Solutions
  Obligations of the Manufacturer of Software for Health
  Obligation to Comply with European Initiatives in EHealth
  Abbreviations

 

E-Health

E-Health is the common name for the development, implementation and evaluation of information and communication technology (ICT) in the healthcare system for the needs of health professionals (routine or professional work, continuous education and lifelong learning, evaluation of professional work and research ) and for all citizens (for their own health: information on the health system functioning and reliable health information on the Internet).
There are different terms talking about the application of ICT in health and medicine (biomedical, medical and health informatics, health portals, medical advice on the Internet, information for patients, computerization of health care, internetization of health system, telemedicine). It is useful to create an umbrella term that includes all the above it is EHealth.

Health Information is an Issue of Public Interest

The decisionmaking related to efficiency and management of the healthcare system should be supported by health information being collected in daily work in health institutions. Valid healthcare system is an issue of public interest for both the state and the society.
The amount of information in the healthcare system cannot be processed without the modern ICT. The decision making should be supported by facts, by available, accurate, current,, and timely information. The public interest in the need of data and information must respect equally important principle that information in medicine and health is protected in terms of universal human rights and international and national legal provisions on data protection in the health care system, and also keep the ethical principles in the handling of medical and health data. The public money should fund only those projects of computerization of health care that are explicitly and clearly designed so that their ultimate sense, as well as concrete practical goals are aiming at the direct, immediate benefit of the citizens which they can easily see, feel and use. Improvement of the system, or any process that does not directly provide practical benefits to the citizens, should not be reason enough to use public money. Such projects should be transformed.
In the private health institutions part of the data is of public interest and must be available and involved in the production of public information of interest for the state and the society in general.

Ensuring and improving the quality of health care

Investing in ehealth will ensure and enhance the quality of healthcare. The development of ICT in the health care system is a tool for the further development of quality health care for the population based on solidarity, accessibility, comprehensiveness, efficiency and fairness. Without investment in health ICT we can not deliver sustainable and quality health care. Investments must be appropriate (with the amount based on the experience of developed countries) and in line with the results that these investments should give.

Defining the Medical and Health Informatics ( MHI) in the health system

Activities of medical and health informatics (HIPs) in health care facilities and the standard of a professional team of medical informatics should be legally defined. These different types of experts are necessary for the planning, development and management of information and communication technologies in health care facilities. The composition and extent of the team depends on the level of health care that is performed and the degree of computerization, which was reached in the units of the health system. Following the example of other medical professions it is necessary to develop a legal framework to define the activity of HIPs. Plans for development of ICT in the health care system must include a clearly defined need for personnel of ICT systems. It is necessary to identify the good practice of balanced development and management of certain functionalities of the system by their own ICT personnel and the involvement of external experts. Resolving the status issue of ICT professionals in the health system will contribute to the positive selection of personnel.

Establishment of an umbrella institution for Medical Informatics

Strategies, construction and supervision of health information system should be entrusted to the body the umbrella institution (institute, agency, office, etc.), which operates on a national level. All laid out in this Declaration can not occur spontaneously and in cooperation with the current entities in the health sector and beyond. It is necessary to establish a body responsible for building the national health information system which will have control over it. Such an institution must be an umbrella institution, that is beside it no one can do anything with public money, it must be independent and it must have a significant budget for the central development of health information (in accordance with relative standards in developed countries).

Involvement of medical professionals in professional teams of Medical Informatics

Inclusion of medical professionals of different profiles into teams of HIPs will improve and facilitate the development and management of ICT in the health care system. Understanding the needs of the healthcare system, medical technology and the possibilities of ICT is essential for the successful development and management of the information systems (IS) in medicine. Establishing a system of subspecialization of HIPs and the definition of professional status will encourage the entry of medical professionals in this field.

Legal regulation of computerization of health care system

The entire area of ehealth should be fully supported by harmonized legislation. Some of the existing regulations and laws related to health are not mutually consistent. Existing laws and regulations should be adjusted or supplemented. Surely we need centrally regulated form and content of medical records, including electronic health records, and policy and regulation of information security. Legislation should regulate the position of the central institution described in section 5

Change Management

The introduction of ICT in the work of any individual or organization means a change in working modes. Changes should be managed. At the top of the pyramid in any project of computerization should be a project of change management (organization of work, education). Out of it derive tasks for all other projects and activities.

 

   EDUCATION


Ehealth issues in the education of health professionals

The educational curriculum of every health profession must include topics on ehealth. For efficient use of modern ICT in medicine or health profession (doctor, nurse, medical technician, etc.) it is necessary to know the principles and possibilities of ICT, and acquire skills for its use. One should avoid formal, factual and superficial teaching and insist on understanding and putting technology in the context of everyday activities in the health care system and encourage health professionals to actively and independently consider strengths and weaknesses of the application of specific technologies and procedures.

Health / medical topics in the educational curriculum of ICT professionals

It is necessary to determine the educational profile profession of a Medical / Health IT Specialists , that is to introduce health and medical topics in the educational curriculum of ICT professionals who want to deal with ehealth professionally. The fact is that the collaboration of health professionals and IT specialists will be more effective if both parties have certain common knowledge. This implies that health care professionals should master certain skills and knowledge in the field of HIPs, and IT specialists specific IT knowledge and skills related to medical and health issues.

Education for Change Management

Users of the system that is based (or will be based) on ICT should be incorporated into the design of the system, its testing, continuous monitoring and evaluation, and primarily in education. The purpose of the system, the method of its construction, the results and any other pertinent information must be timely and well communicated to all stakeholders. Computerization projects should not be taken so that system users are the last who learn about it and meet it only when it is completed. The correct way would be to involve future users of the system already at the beginning of its creation, during the development of the trial, and upon completion they should participate in its evaluation and education. These are the principles of change management. Therefore, strategists, planners, IT specialists and health workers need to acquire basic understanding and implementing of change management in order to successfully participate, plan and implement it. In addition, change management should be regulated organizationally, which means it should determine how users communicate with the manufacturers of the system.

 

   COMMUNICATION


Communication of healthcare institutions with each other and with users of health care system

Citizens must have the ability to communicate, with all units of the health system. The communication should be adapted to them and useful. Health professionals and health institutions are required to communicate with each other. All participants of the health system (users, service providers) should be allowed to use the modern methods of electronic communication. Ministry of Health and Social Care, Clinical Hospitals, Croatian Health Insurance Institute (CHII) and other health insurances, Croatian Institute of Public Health (CIPH) and other institutes should set an example in introducing new methods of communication. It is, therefore, beneficial that the health institution has updated its website (Web). These websites should contain all the information which maybe
beneficial to the user of the health care (eg. where is the diagnostic unit or clinic, working hours, who works there, how to contact them etc.), but also information on who will educate him/her on health, how to achieve it and maintain it (the reliability of such information should be confirmed by certified HONcode). Health care providers need to proactively implement technologies that enable the direct exchange of information among agencies without the encumbrance of health care users and the direct, twoway communication with users of health care, thus increasing the quality, speed and ease of service provided, while reducing costs and errors.

 

   QUALITY OF E HEALTH


Integration of health information

Health Information System (HIS) must integrate all the information circulating in the health system and with a high degree of security and protection ensure the availability of data to authorized entities. Each user of health care should have its own unique electronic health record (EHR) that is fed at various segments of health care (family physicians practice, specialist practice, hospital, laboratory, diagnostic unit and elsewhere). It is not necessarily to keep it physically in one place, but it must be possible to connect parts of the records whenever necessary, as required by the authorized person (a doctor during the delivery of health services for the patient) and with the consent of the patient. Each user of health care must have a complete and easy access to information about who has used the patient's data, when and which data and under which law or authority.

Health statistics as an issue of public interest

Data on the health status of health care user and health services provided in health institutions are the basis for the preparation of periodic statistical reports used by Croatian Public Health Institute and the network of county public health institutes and other institutes and agencies. The purpose of health statistics is diagnosing the health of the population and the functioning of health system, and the basis for public health interventions in the population and the organization / reorganization of the health system. Direct retrieval (extraction) of data from the patient's EHR (information on treatment, prevention, medical procedures, etc.) enables health statistical reports to be current and without delay. Using the data in all parts of the health system and the cooperation of the above mentioned institutions and agencies with all the structures in the health sector will help to improve the quality of work. Indices of the quality of work are measuring instruments of such activities. Data should be retrieved and used anonymously, ie so that the identity of health care user, whose data is processed, can not be determined. Part of the health statistical information should be available to users outside the health system.

Health Registries

Health registers need to be filled on the basis of data in the EHR . Death information is retrieved from the Registries of the dead and should also be entered into the EHR and thus become useful for the purposes of health registers. Direct retrieval (extraction) of data from the patient's EHR, will enable updated and completed registries.

Standards and Standardization

Standardization is a prerequisite for the proper functioning of the system. Here we refer to standards setting in the educational system (for all levels of education) in science and research (the appropriate definition of scientific fields and branches) and in daily practice (eg, daily medical and health practice, in the construction and use of
health information systems , etc.). "Standard is a document adopted by consensus, approved by the competent authority, which for common and repeated use, provides rules, guidelines or characteristics for activities or their results, and ensures the best level of organization in the given circumstances" (Law on Standardization). Under standards we should also understand medical guidelines (eg Guidelines for the treatment of hypertension, etc. issued by international professional bodies) as well as recommendations of other international bodies and organizations (eg, recommendations for training in biomedical and health informatics, or the Code of Ethics for Medical Informatics promulgated by the International Medical Informatics Association (IMIA)). Regarding standardization of health information systems it is necessary to follow the European (CEN, CENELEC, etc.) and international standards (ISO, HL7, etc.) and standards adopted by Croatia (Croatian Standards Institute CSI).

Certification of software and other solutions

Before using any product it must pass the certification process verification of functionality, security of data and information systems and interoperability.. For this purpose it is necessary to set the primary criteria which a product must meet, establish a body that will implement the certification process, define the period for which the certificate will be valid as well as the conditions for a potential recertification of products. When it comes to the ZIS, EHR, etc., the body that conducts certification must include a variety of professions: (1) users / health professionals, (2) Medical Informatics and ICT professionals, (3) lawyers and (4) a variety of professions and individuals potentially interested for considered problems.

Obligations of the manufacturer of software solutions for healthcare system

All programming decisions should be consistent (compatible). This means that the development of software solutions must provide direct interoperability with other software or retrieval (extraction) of data in a standard format that any software solution can accept. Establishment of criteria that a software solution should meet, taking into account international standards and certification that any software solution must pass on its way to acceptance for use in practice, will increase the liability of manufacturers and freedom of users (health professionals) in the selection or replacement of software solutions.

Obligation to comply with European initiatives in ehealth

Construction of EHR systems must be compatible with European initiatives in ehealth.
European Institute for Health Records (EuroRec) has initiated a project for standardizing the quality of EHR systems in the European Union. Given the fact that Croatia does not have its own National Center ProRec included into EuroRec network, the Croatian Society of Medical Informatics (CSMI) has been involved as a partner in this project Establishment of the CroatianProRec center could make a direct connection to the European efforts in the area of Ehealth and its involvement in European and EuroAtlantic projects of the European Commission, coordinated by EuroRec.

Abbreviations

 

CEN

European Committee for Standardization - European Organization for Standardization (http://www.cen.eu/cen/NTS/What/Pages/default.aspx )

EuroRec

European Institute for Health Records - an independent nonprofit organization in Europe to promote the use of high quality EHR
( http://www.eurorec.org/whoarewe/introduction.cfm )

EHR

Electronic Health Record

CSMI

Croatian Society of Medical Informatics ( http://www.hdmi.hr )

HL7

Health Level Seven International - an international organization of production and exchange of communication standards in healthcare, also a group of such norms (http://www.hl7.org)

HONcode

Code of Conduct devoted to medical and health Web sites - a certificate on the reliability of health information on the Internet (http://www.hon.ch)

CIPH

Croatian Institute of Public Health (http://www.hzjz.hr)

CSI

Croatian Standards Institute (http://www.hzn.hr)

Health
Insurance


Croatian Health Insurance Institute (http://www.hzzo-net.hr/)

ICT

Information and Communication Technology

IMIA

International Medical Informatics Association - International Association for Medical Informatics (http://www.imia.org)

IS

Information System

ISO

International Organization for Standardization - International Organization for Standardization (http://www.iso.org/iso/home.html)

MHI

Medical and Health Informatics

HIS

Health information system

Acta Medica Croatica
 
Pliva
 
Ljetopis AMZH 2013.-2014.
 
Socijalna psihijatrija
 
Croatian medical journal