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Va Jornada FòrumCIS

    National and Regional Integration
         of medical information


         CRS-SISS Project
 IT for innovation of HealthCare system


           Luciano Bresciani – Claudio Beretta
              Ministry of Health - Lombardy Region

                 ForumCIS, 22 February 2007 - Barcelona   1
Agenda

1. Lombardy HealthCare system.
2. Why the CRS-SISS.
3. CRS-SISS project overview.
4. Current situation of the project.
5. Economical sustainability of the project.
6. Some observations and lessons learnt
   from the project experience.

              ForumCIS, 22 February 2007 - Barcelona   2
National Italian Health System
                                                                Public Budget
                                                                          *
  All Italian citizens and foreign                            93.5 Billion euro
  workers are insured.                                          (6,3% of GDP)
  Regions are in charge of the
  Health System management.
  Italian government is in charge of
  the overall coordination of the
  Health System.
  All health care treatments
  (excluding dental) are covered by the
  National Health system.
  Compulsory contribution through
  taxes.
  The Health System directly pays
  for all services admitted.                              Private HealthCare
                                                                           *
                                                                 expenditure
* 2006 data
                     ForumCIS, 22 February 2007 - Barcelona       (2,1% of GPD)   3
Lombardy Health System

   9.300.000 Citizens
   160.000 Healthcare employees
   7.900 GPs and Pediatricians
   2.540 Pharmacies
   15 Local Health Authorities
   212 Public and Private Hospitals
   983 Public and Private Medical Ambulatories
   770 Ageing People Shelters
   15,5 Billion euro budget for public healthcare (5,1% of GDP)
   70% of Healthcare services provided by public providers

* 2006 data
                     ForumCIS, 22 February 2007 - Barcelona       4
Why the CRS–SISS ?
            Health expenditure increase
     1.45
                                                                      89,0
      1.4
                                                                      13,7
     1.35
      1.3
     1.25                                                                             Lombardy
      1.2                                                                             Italy
     1.15
      1.1
     1.05
            62,7   10,0
        1
            1999      2000     2001        2002        2003       2004


                                                              Public         Private          Total
ICT expenditure in Hospitals per year (K€)                170.000 90.000 260.000
            Lombardy data, year 2006                           1,5%            2,4%           1,8%

                             ForumCIS, 22 February 2007 - Barcelona                                   5
What we tend to have
 Full capacity to share information and documents:
 amongst hospitals and between specialists and
 GPs.
 Capacity to rationalize administrative processes
 and make the information technologies “mission
 critical” in healthcare sector.
 Identify an interoperability standard used in the
 hospitals and by all healthcare professionals and
 make compatible, possibly uniform, the informatics
 structure of Hospital Information Systems.
 Capacity to promote some “networks of pathology”
 for main clinical areas.
                ForumCIS, 22 February 2007 - Barcelona   6
CRS–SISS overview
The core of the project is an ‘Healthcare
Extranet’, which links professionals, social
services, organizations and citizens, tracking all
the events in the process of patient care and
providing value added services.


The project is based on smart
card technologies, granting
access to the Network to both
citizens and operators by their
personal smart cards.


                 ForumCIS, 22 February 2007 - Barcelona   7
Smart Cards features


               Identification and authentication.
               Access to all Public Administration services.
               Certification of the “presence” of the Citizen
  Citizen      (through electronic signature of documents).



               Identification and authentication.
               Access authorization to the System.
               Electronic Signature.
Professional


                      ForumCIS, 22 February 2007 - Barcelona    8
Objectives&Functionalities

                 Information sharing and exchange amongst healthcare
     Citizens

                 operators and professionals to improve quality of
                 healthcare provision (consultation referrals, prescription
                 process, etc.).
                 Improvement of services provided to Citizens through an
                 easy and secure access to the Healthcare System.
Administration




                 Information availability at analytical level to monitor
                 healthcare quality and expenditure during the
   Public




                 process of care for a better planning at Regional level
                 (management, budget control, expenditure).
                 Simplification of administrative processes (through
                 electronic prescription and electronic signature).


                               ForumCIS, 22 February 2007 - Barcelona         9
Two joint implementations

 CRS (“Regional        Services     Card”): the
 personal smart card allow every citizen to
 access all public administration services and
 enabling to access to private services.

 SISS (“Health Care Information System”): the
 regional network connect all healthcare and
 social providers in Lombardy and provide e-
 Health services for ensuring continuous care.

               ForumCIS, 22 February 2007 - Barcelona   10
SISS major services
 Prescription management
   Electronic prescription: drugs and services coding,
   control, digital signature, storage, display.
 Healthcare document management
   Outpatient examination report, Letter of Discharge,
   Emergency Form: digital signature, notification,
   display, import in professional’s EPR.
   Issuing and maintenance of report are in charge of
   the health care company providing the service.
 Outpatient booking service
   Through Unique Regional Call Center or through a
   software used by GPs and Chemistries.
   Unique Booking System for all healthcare
   providers involved by contract in the Regional
   System.
                ForumCIS, 22 February 2007 - Barcelona   11
Document Management
Regional DataBase
  Maintenance of event index.
  Maintenance of Prescription Index.
  Maintenance of citizen and professional register.
  Maintenance of access grant through Single-Sign-On.
  Maintenance of coding tables.
  Management of GPs communication.

Hospital Doc. Repository
  Document management.
  Maintain the database of signed documents.
  Communicates to the Hospital Gate for allowing the
  SISS to access documents.
  Can be used also by the Hospital software (e.g.
  EPR).
                ForumCIS, 22 February 2007 - Barcelona   12
Network Infrastructure
                                  Citizens


                                                                       Pharmacies
                                                                          GPs

  Lombardy Region                                     Provider
   Central System        Health Care                           HTTPS

                          Extranet
                                Provider


                            HTTPS

                    Hospitals




                                Operators
                                                           Citizens

                      ForumCIS, 22 February 2007 - Barcelona                        13
Network Providers
 they are the intermediaries between users and the
 regional trust that are in charge for the project
 implementation;
 they are selected and certified by the Region Lombardy;
 they provide the access to the SISS Network and to
 Internet;
 they install the “front end” software and the “SISS
 programs” on the operator’s Work Stations;
 they supply the first level “Help Desk” and the “on site”
 technical support for the SISS;

 they are chosen on the market and paid by Hospitals,
 GPs and Pharmacists.
                  ForumCIS, 22 February 2007 - Barcelona   14
Project results                                      I
      Smart Cards distribution
                 (August 2006)

        • Operator Smart Card,
          53.000 distributed (90% of public)




        • Citizen Smart Card,
          9.200.000 distributed (98,9%)

            ForumCIS, 22 February 2007 - Barcelona       15
Project results                                       II
   CRS-SISS services implementation
               (December 2006)
                                    9.200.000 Citizens
                                    53.000 Healthcare Professionals
                                    5.400 GPs and Pediatricians (69%)
                                    2.380 Pharmacies (95%)
                                    15 Local Healthcare Authorities
                                    175 Public Healthcare Structures
                                    4 private Healthcare Structures
                                    (private extension starts in 2007)
   Started   Starting
             1 Pubblic
               Hospital
                                        Actual extension to
             in Milano 2                  public HC structures
             ForumCIS, 22 February 2007 - Barcelona                      16
Project results                                                                                                    III
                                                  SISS Transactions 2005/2006                                per month.
SISS Transactions




                    5.000.000
                    4.000.000
                    3.000.000
                    2.000.000
                    1.000.000
                           0
                                Genuary

                                          March

                                                    May

                                                           July

                                                                   September

                                                                               November

                                                                                          Genuary

                                                                                                     March

                                                                                                             May

                                                                                                                    July

                                                                                                                           September

                                                                                                                                       November
                                                   Transactions per                                 year
                           2004: 5.364.000            - 2005: 17.413.000 - 2006: 40.200.000
                                                     ForumCIS, 22 February 2007 - Barcelona                                                       17
European cooperation

 The CRS is compliant with
 Decisions n°189, 190, 191 of
 European Administrative
 Commission, 18 June 2003:

 NetLink file system and
 authentication;

 Further cooperation in EU funded
 initiatives for smartcard
 interoperability in Europe:
    Netc@rds for eEHIC (eTEN)
    INCO-HEALTH (INTERREG IIIC).




                     ForumCIS, 22 February 2007 - Barcelona   18
Project Costs

There are not investments of the Lombardy Region:
 the Region pays a fixed fee for the service.

   Fee of service all inclusive is
         10.33 € (8.61 + VAT)
            per citizen / year
        (€ 96,000,000 per year).
                ForumCIS, 22 February 2007 - Barcelona   19
Involved Companies
                                                                                           Contractor
                                                                                       Payment of the service



     Call Center for the citizens                                         8.61 Euro per year / Activated Card

          Lombardia Call
          Lombardia Call                                 100% Regione
     100% Lombardia Informatica
     100% Lombardia Informatica                               Lombardia
                                                                                        Contract Holder
   7 year supply value: ~ 5 million Euro
                                                                                        Project Management



                                                                          8.09 Euro per year / Activated Card
      Supply and consulting
      Partners: Telecom Italia
      Partners: Telecom Italia
                Finsiel
                Finsiel
                                                                   LISIT
                Lutech
                                                                                         Realization of
                Lutech                                    56% Lombardia Informatica
                                                          56% Lombardia Informatica
                                                          44% Partner (Telecom,
                                                          44% Partner (Telecom,
                                                                                          the project
   7 year supply value: ~ 350 million Euro
                                                                 Finsiel, Lutech)
                                                                 Finsiel, Lutech)

Note: Values not including VAT
                                       ForumCIS, 22 February 2007 - Barcelona                                   20
Comments
                and
lessons learnt


  ForumCIS, 22 February 2007 - Barcelona   21
CRS-SISS achievements
  Cost saving for public Healthcare system

   The CRS-SISS creates an infrastructure which
          can save 40 million € per year
                                                      Reports or      Saving        Saving
               Type of saving
                                                     prescriptions (person-year)     (K€)
Provider and connection costs                                                        - 6.500
Report management                                     48.000.000           880       70.000
Report printing and distribution (inpatients)         12.000.000             50       7.200
Administrative simplification                                            1.760       61.000
Management of pharmacies                              62.000.000                      8.500
reimbursement
                 TOTAL                                                             140.200

 2006 data
                             ForumCIS, 22 February 2007 - Barcelona                            22
CRS-SISS achievements
        Time saving for the citizens
  Healthcare services supplied through ICT allow
  reduction of time spent by citizens to get them
                                                                              Total Saving
          Part of process                      Events         Unit saving
                                                                               (K hours)
Booking (including travel)                  23.000.000                60             23.000
Reception                                   30.000.000                 1                 500
Payment                                     18.000.000                10               3.000
Report issuing (including travel)           28.000.000                30             14.000

            TOTAL                                                                  40.500

  Average saving per citizen: 7,4              hours per year
                About 5,5 million Lombardy citizens use healthcare services

                             ForumCIS, 22 February 2007 - Barcelona                            23
Future developments
            CRS-SISS as HealthCare Tool
      The CRS-SISS system can support the
     healthcare processes and must be used to
            Help physician into HealthCare processes;
            Help to share diagnostic and therapeutic guidelines
            for making clinical protocols;
            Help to control and to monitor the protocols usage;

       The savings from the right knowledge of the clinical
       history of the patient are estimated to be about 5% of
                   yearly HealthCare Expenditure *
                 (about 725 million euros per year for Lombardy ).

*Jan Walker and oth.: “The 2005 Of Health Care Information Exchange And Interoperability”
 Health Affairs, January, 19
                             Value

                                   ForumCIS, 22 February 2007 - Barcelona                   24
Lessons learnt
 The cost of developing the entire informatics system is
 a small part of the total investments: we spent for that
 about 70 mil €;
 The main economical effort is to upgrade the Hospital
 Information System: we have already spent for that 250
 million €;
 The security infrastructure cost is smaller then the
 “Privacy” respect: we spend 200.000 € for security and
 20 million € per year for “Privacy”;
 The training cost is less that we could wait;
 At present, the health professionals accept
 Regional Healthcare Information System and they
 are using it more and more.
                  ForumCIS, 22 February 2007 - Barcelona    25
www.crs.lombardia.it

      Thank you
claudio_beretta@regione.lombardia.it

Direzione Generale Sanità
   Regione Lombardia
via Pola 9 – 20124 Milano - ITALY
       ForumCIS, 22 February 2007 - Barcelona   26

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LOMBARY CRS-SISS Project: ICT for Innovation of Healthcare System.

  • 1. Va Jornada FòrumCIS National and Regional Integration of medical information CRS-SISS Project IT for innovation of HealthCare system Luciano Bresciani – Claudio Beretta Ministry of Health - Lombardy Region ForumCIS, 22 February 2007 - Barcelona 1
  • 2. Agenda 1. Lombardy HealthCare system. 2. Why the CRS-SISS. 3. CRS-SISS project overview. 4. Current situation of the project. 5. Economical sustainability of the project. 6. Some observations and lessons learnt from the project experience. ForumCIS, 22 February 2007 - Barcelona 2
  • 3. National Italian Health System Public Budget * All Italian citizens and foreign 93.5 Billion euro workers are insured. (6,3% of GDP) Regions are in charge of the Health System management. Italian government is in charge of the overall coordination of the Health System. All health care treatments (excluding dental) are covered by the National Health system. Compulsory contribution through taxes. The Health System directly pays for all services admitted. Private HealthCare * expenditure * 2006 data ForumCIS, 22 February 2007 - Barcelona (2,1% of GPD) 3
  • 4. Lombardy Health System 9.300.000 Citizens 160.000 Healthcare employees 7.900 GPs and Pediatricians 2.540 Pharmacies 15 Local Health Authorities 212 Public and Private Hospitals 983 Public and Private Medical Ambulatories 770 Ageing People Shelters 15,5 Billion euro budget for public healthcare (5,1% of GDP) 70% of Healthcare services provided by public providers * 2006 data ForumCIS, 22 February 2007 - Barcelona 4
  • 5. Why the CRS–SISS ? Health expenditure increase 1.45 89,0 1.4 13,7 1.35 1.3 1.25 Lombardy 1.2 Italy 1.15 1.1 1.05 62,7 10,0 1 1999 2000 2001 2002 2003 2004 Public Private Total ICT expenditure in Hospitals per year (K€) 170.000 90.000 260.000 Lombardy data, year 2006 1,5% 2,4% 1,8% ForumCIS, 22 February 2007 - Barcelona 5
  • 6. What we tend to have Full capacity to share information and documents: amongst hospitals and between specialists and GPs. Capacity to rationalize administrative processes and make the information technologies “mission critical” in healthcare sector. Identify an interoperability standard used in the hospitals and by all healthcare professionals and make compatible, possibly uniform, the informatics structure of Hospital Information Systems. Capacity to promote some “networks of pathology” for main clinical areas. ForumCIS, 22 February 2007 - Barcelona 6
  • 7. CRS–SISS overview The core of the project is an ‘Healthcare Extranet’, which links professionals, social services, organizations and citizens, tracking all the events in the process of patient care and providing value added services. The project is based on smart card technologies, granting access to the Network to both citizens and operators by their personal smart cards. ForumCIS, 22 February 2007 - Barcelona 7
  • 8. Smart Cards features Identification and authentication. Access to all Public Administration services. Certification of the “presence” of the Citizen Citizen (through electronic signature of documents). Identification and authentication. Access authorization to the System. Electronic Signature. Professional ForumCIS, 22 February 2007 - Barcelona 8
  • 9. Objectives&Functionalities Information sharing and exchange amongst healthcare Citizens operators and professionals to improve quality of healthcare provision (consultation referrals, prescription process, etc.). Improvement of services provided to Citizens through an easy and secure access to the Healthcare System. Administration Information availability at analytical level to monitor healthcare quality and expenditure during the Public process of care for a better planning at Regional level (management, budget control, expenditure). Simplification of administrative processes (through electronic prescription and electronic signature). ForumCIS, 22 February 2007 - Barcelona 9
  • 10. Two joint implementations CRS (“Regional Services Card”): the personal smart card allow every citizen to access all public administration services and enabling to access to private services. SISS (“Health Care Information System”): the regional network connect all healthcare and social providers in Lombardy and provide e- Health services for ensuring continuous care. ForumCIS, 22 February 2007 - Barcelona 10
  • 11. SISS major services Prescription management Electronic prescription: drugs and services coding, control, digital signature, storage, display. Healthcare document management Outpatient examination report, Letter of Discharge, Emergency Form: digital signature, notification, display, import in professional’s EPR. Issuing and maintenance of report are in charge of the health care company providing the service. Outpatient booking service Through Unique Regional Call Center or through a software used by GPs and Chemistries. Unique Booking System for all healthcare providers involved by contract in the Regional System. ForumCIS, 22 February 2007 - Barcelona 11
  • 12. Document Management Regional DataBase Maintenance of event index. Maintenance of Prescription Index. Maintenance of citizen and professional register. Maintenance of access grant through Single-Sign-On. Maintenance of coding tables. Management of GPs communication. Hospital Doc. Repository Document management. Maintain the database of signed documents. Communicates to the Hospital Gate for allowing the SISS to access documents. Can be used also by the Hospital software (e.g. EPR). ForumCIS, 22 February 2007 - Barcelona 12
  • 13. Network Infrastructure Citizens Pharmacies GPs Lombardy Region Provider Central System Health Care HTTPS Extranet Provider HTTPS Hospitals Operators Citizens ForumCIS, 22 February 2007 - Barcelona 13
  • 14. Network Providers they are the intermediaries between users and the regional trust that are in charge for the project implementation; they are selected and certified by the Region Lombardy; they provide the access to the SISS Network and to Internet; they install the “front end” software and the “SISS programs” on the operator’s Work Stations; they supply the first level “Help Desk” and the “on site” technical support for the SISS; they are chosen on the market and paid by Hospitals, GPs and Pharmacists. ForumCIS, 22 February 2007 - Barcelona 14
  • 15. Project results I Smart Cards distribution (August 2006) • Operator Smart Card, 53.000 distributed (90% of public) • Citizen Smart Card, 9.200.000 distributed (98,9%) ForumCIS, 22 February 2007 - Barcelona 15
  • 16. Project results II CRS-SISS services implementation (December 2006) 9.200.000 Citizens 53.000 Healthcare Professionals 5.400 GPs and Pediatricians (69%) 2.380 Pharmacies (95%) 15 Local Healthcare Authorities 175 Public Healthcare Structures 4 private Healthcare Structures (private extension starts in 2007) Started Starting 1 Pubblic Hospital Actual extension to in Milano 2 public HC structures ForumCIS, 22 February 2007 - Barcelona 16
  • 17. Project results III SISS Transactions 2005/2006 per month. SISS Transactions 5.000.000 4.000.000 3.000.000 2.000.000 1.000.000 0 Genuary March May July September November Genuary March May July September November Transactions per year 2004: 5.364.000 - 2005: 17.413.000 - 2006: 40.200.000 ForumCIS, 22 February 2007 - Barcelona 17
  • 18. European cooperation The CRS is compliant with Decisions n°189, 190, 191 of European Administrative Commission, 18 June 2003: NetLink file system and authentication; Further cooperation in EU funded initiatives for smartcard interoperability in Europe: Netc@rds for eEHIC (eTEN) INCO-HEALTH (INTERREG IIIC). ForumCIS, 22 February 2007 - Barcelona 18
  • 19. Project Costs There are not investments of the Lombardy Region: the Region pays a fixed fee for the service. Fee of service all inclusive is 10.33 € (8.61 + VAT) per citizen / year (€ 96,000,000 per year). ForumCIS, 22 February 2007 - Barcelona 19
  • 20. Involved Companies Contractor Payment of the service Call Center for the citizens 8.61 Euro per year / Activated Card Lombardia Call Lombardia Call 100% Regione 100% Lombardia Informatica 100% Lombardia Informatica Lombardia Contract Holder 7 year supply value: ~ 5 million Euro Project Management 8.09 Euro per year / Activated Card Supply and consulting Partners: Telecom Italia Partners: Telecom Italia Finsiel Finsiel LISIT Lutech Realization of Lutech 56% Lombardia Informatica 56% Lombardia Informatica 44% Partner (Telecom, 44% Partner (Telecom, the project 7 year supply value: ~ 350 million Euro Finsiel, Lutech) Finsiel, Lutech) Note: Values not including VAT ForumCIS, 22 February 2007 - Barcelona 20
  • 21. Comments and lessons learnt ForumCIS, 22 February 2007 - Barcelona 21
  • 22. CRS-SISS achievements Cost saving for public Healthcare system The CRS-SISS creates an infrastructure which can save 40 million € per year Reports or Saving Saving Type of saving prescriptions (person-year) (K€) Provider and connection costs - 6.500 Report management 48.000.000 880 70.000 Report printing and distribution (inpatients) 12.000.000 50 7.200 Administrative simplification 1.760 61.000 Management of pharmacies 62.000.000 8.500 reimbursement TOTAL 140.200 2006 data ForumCIS, 22 February 2007 - Barcelona 22
  • 23. CRS-SISS achievements Time saving for the citizens Healthcare services supplied through ICT allow reduction of time spent by citizens to get them Total Saving Part of process Events Unit saving (K hours) Booking (including travel) 23.000.000 60 23.000 Reception 30.000.000 1 500 Payment 18.000.000 10 3.000 Report issuing (including travel) 28.000.000 30 14.000 TOTAL 40.500 Average saving per citizen: 7,4 hours per year About 5,5 million Lombardy citizens use healthcare services ForumCIS, 22 February 2007 - Barcelona 23
  • 24. Future developments CRS-SISS as HealthCare Tool The CRS-SISS system can support the healthcare processes and must be used to Help physician into HealthCare processes; Help to share diagnostic and therapeutic guidelines for making clinical protocols; Help to control and to monitor the protocols usage; The savings from the right knowledge of the clinical history of the patient are estimated to be about 5% of yearly HealthCare Expenditure * (about 725 million euros per year for Lombardy ). *Jan Walker and oth.: “The 2005 Of Health Care Information Exchange And Interoperability” Health Affairs, January, 19 Value ForumCIS, 22 February 2007 - Barcelona 24
  • 25. Lessons learnt The cost of developing the entire informatics system is a small part of the total investments: we spent for that about 70 mil €; The main economical effort is to upgrade the Hospital Information System: we have already spent for that 250 million €; The security infrastructure cost is smaller then the “Privacy” respect: we spend 200.000 € for security and 20 million € per year for “Privacy”; The training cost is less that we could wait; At present, the health professionals accept Regional Healthcare Information System and they are using it more and more. ForumCIS, 22 February 2007 - Barcelona 25
  • 26. www.crs.lombardia.it Thank you claudio_beretta@regione.lombardia.it Direzione Generale Sanità Regione Lombardia via Pola 9 – 20124 Milano - ITALY ForumCIS, 22 February 2007 - Barcelona 26