Ehealth: introduction

Ronald Buyl (Vrije Universiteit Brussel)

Introduction...................................................................................................4
E-health.........................................................................................................5
1.1.Definitions......................................................................................................5
1.2.Impact and importance of e-health................................................................8
1.2.1.Economical benefits...............................................................................10
1.2.2.Health care benefits...............................................................................11
1.3.E-health initiatives in Europe........................................................................13
1.4.E-health initiatives in Belgium......................................................................17
2.Electronic Health Records (EHR)..............................................................24
2.1.Definition......................................................................................................24
2.2.Aspects of EHRs...........................................................................................26
2.2.1.Role of the patient in the EHR................................................................26
2.2.2.Core function of the EHR........................................................................27
2.2.3.Standards for classification and nomenclatures.....................................28
2.2.4.Data integrity and security.....................................................................31
2.2.5.Interoperability.......................................................................................31
 Introduction
Within the context of this work the terms e-health (also ehealth or electronic
health) and EHR (electronic health record) will be frequently used. For these
concepts, many, sometimes confusing definitions exist. Obviously it is very
important that the reader gets a clear understanding of what is meant by the
concepts e-health and EHR within the scope of this work. In this first chapter
the different aspects of the terms e-health and EHR are highlighted, thereby
defining the environment and context in which this work has been
performed.

In a first part of this chapter, e-health is handled in detail. We will discuss the
development of e-health definitions in detail and emphasize on the
particularities of the different propositions. In a next part the impact, both
economically and concerning the delivery of care will be dealt with.
Additionally the current status of the work that is performed in Europe in this
domain with a highlight on to the situation in Belgium is presented {see note
1 on literature search}.

{note 1} The literature search for this part of the chapter was performed in
different steps . First by a “Medline (Pubmed)” search, using the keywords:
e-health (102), ehealth (74 hits), electronic health (320), with the following
limits (abstract available, published the last 5 years, English, word in title).
We emphasize that until today, no Medical Subject Heading (MeSH)
taxonomy exists. These articles were checked manually. In a second step,
the reference lists of important recent reviews were used to find other
interesting articles. Finally, reports of European projects (via projects
websites) as well as conference proceedings were used as valid information
sources for information concerning e-health.
In a second part of this chapter, the general concepts of the EHR are
detailed. Again we will start by defining the concept and we will elaborate
briefly on the EHR initiatives in Europe and Belgium. Special attention is
given in this part to some crucial aspects, such as interoperability and
codification standards {see note 2 on literature search}.

{note 2} The literature search for this part of the chapter included again
different levels. First a “Medline (Pubmed)” search was performed, using the
following limits (abstract available, published the last 5 years, English). The
Mesh keywords “Medical Records” (+1400) and "Medical Records Systems,
Computerized" (+500) led to too many hits. These mesh keywords were
combined in a second stage with “Physicians, Family” (Mesh) and “Physical
Therapy (Specialty)”. Further combinations with non mesh keywords (with
additional limits such as “title word”) were performed. Additionally,
pertinent information was drawn from the reference lists, cited in the
review articles, found in the previous search as well as reports from different
projects, via the projects websites.
E-health
1.1. Definitions

What is e-health? Many have already tried to answer this question. Gunther
Eysenbach, editor of the Journal of medical internet research stated in his
2001 editorial titled “What is e-health?”: “The term e-health was barely in
use before 1999, but now this term seems to serve as a general "buzzword,"
used to characterize not only "Internet medicine", but also virtually
everything related to computers and medicine [1]. The situation has only
become more confusing since then. In 2005 a review was published by
Pagliari and colleagues [2] that included 36 different definitions for the term
e-health. The authors state that the term is not immediately discernable
from that of the wider (medical) health informatics field.

This is, amongst others (as stated earlier no correct keyword, such as Mesh),
a very important reason for the confusion and lack of appreciation regarding
the research domain. Therefore terms such as “medical informatics”, “health
informatics”, “telehealth” and “telecare” are all domains that have a large
overlap with what is generally considered as e-health. This characteristic of
the e-health domain makes unambiguous and well structured (literature)
searches extremely difficult. They usually result in too broad and unspecific
conclusions.

The list of Pagliari (2005) [2] was even extended by Oh et al. (2005). In their
review article bearing again the same title “What is eHealth?” an exhaustive
overview of all possible definitions used to describe the terms ehealth, e-
health or electronic health is presented [3]. In total these authors came up
with 51 unique definitions, but conclude that possibly more exist. The
definitions range from very short: “Internet technologies applied to health care
industry” [4], “E-health is all that’s digital or electronic in the health care industry”
[5] or even “Internet related health care activities” [6] to extremely large
definitions as “The most broad term is ehealth, with refers to the use of electronic
technologies in health, health care and public health. (...) The various functions of
ehealth [are]: (...) reference (electronic publishing, catalogues, databases); self-
help/self-care (online health information, support groups, health risk assessment,
personal health records), Plan/provider convenience services (online scheduling,
test and lab results, benefit summaries), Consultation and referral (doctor-patient or
doctor-doctor consultation via telemedicine systems, remote readings of digital
image and pathology samples), E-health commerce (sales of health related product
and services) [and] Public health services (automated data collection, data
warehouses, online access to population survey data and registries, advance
detection and warning systems for public health threats). (...) This chapter uses the
term ehealth to refer to the broadest possible range of interactive technologies
applied to health and health care.” [7].

Other definitions are very specific, and focus on a particular aspect (e.g.
Economical): “E-health – the application of e-commerce to health care and
pharmaceuticals” or sub-domain of e-health (e.g. telehealth or telecare): “E-
health is the process of providing health care via electronic means, in particular
over the Internet. It can include teaching, monitoring (e.g. physiologic data), and
interaction with health care providers, as well as interaction with other patients
afflicted with the same conditions” [8].

In the context of this work, the goal is not to come up with yet another
definition for the term e-health. Neither will we criticize or make remarks on
one of the definitions used by other researchers or institutions, because they
all contain valuable aspects of the large concept of e-health. We clearly
want to emphasize the broad scope of the domain, and we realize that the
content of the definitions is significantly biased by the stakeholders’
perspective on the field. Social insurance companies will have a totally
different view of e-health than commercial software vendors. Hospitals will
have a completely different vision on the concept than independent nursing
practitioners. A summary-overview of the most important aspects of the
numerous definitions discussed in the 2005 review of Oh et al. can be found
in the next paragraph.

Analysis of the definitions

From the 51 unique definitions two universal themes health (49/51) and (46/51) can be
identified. Six other less general aspects were used in different definitions: commerce,
activities technology, stakeholders, outcomes, place, and perspectives. In 11 definitions, e-
health was referred to in terms of commerce, suggesting that e-health is “health care's
component of business over the Internet”, the “application of e-commerce to health care
and pharmaceuticals” or as “new business models using technology”. Others associated e-
health with activities such as managing, educating, arranging, connecting, obtaining,
providing, redefining, supporting, using, assisting and accessing. The stakeholders most
often mentioned were health care providers (physicians, health care providers, health care
professionals, health workers, managers, and caregivers). The public is mentioned as public,
patients, consumers, non-professionals, and citizens. Governments, employers, and payers
are also listed as potentially benefiting from e-Health. While most of the definitions
concentrated on the process of care, about one quarter of them focused on the outcomes to
be expected. These definitions mentioned improving and increasing the cost-effectiveness of
health care and making processes more efficient. Others suggested that e-health could
solve problems related to access to care, cost, quality, and portability of health care
services. While the actual word place was not used in any of the definitions, some authors
referred to the concepts of distance, geography, and location. One definition describes the
impact of e-health as local, regional, and worldwide. Another describes e-health as taking
place both at the local site and at a distance. A third suggests that distance and place no
longer remain barriers, as e-health is “to provide and support health care wherever the
participants are located”. Finally, other definitions suggest that e-health represents a new
perspective on health care. One author describes e-health as a “state-of-mind, a way of
thinking, an attitude, and a commitment for networked, global thinking”. Another source
describes e-health as a “consumer-centered model of health where stakeholders
collaborate” (summarized from Oh, 2005 [3])

Because e-health is such a broad concept involving many aspects, some

authors have tried to come up with a very global, all covering definition.
From these efforts the following one (already dating back to 2001) from
Eysenbach is still perceived as a very good overall statement of what is
covered by the term e-health: “e-health is an emerging field in the intersection
of medical informatics, public health and business, referring to health services and
information delivered or enhanced through the Internet and related technologies. In
a broader sense, the term characterizes not only a technical development, but also
a state-of-mind, a way of thinking, an attitude, and a commitment for networked,
global thinking, to improve health care locally, regionally, and worldwide by using
information and communication technology” [1].

For us, academic researchers the content of e-health is also very well
described in an article by Jones, R and colleagues, again titled ‘What is
eHealth?’ In this article, using, processing, sharing and controlling information
(data) are considered the key aspects in e-health. All other aspects relate
more to “how the results of this research should be implemented and carried out”
or to “how the improvement in health care can be measured” [9]. The latter are
more important to other stakeholders like end-users, commercial (software)
companies, governmental organizations, social security.

We emphasize that e-health and the e-health applications as described in

this work are looked at from a researchers’ perspective, but with the
contribution of as many stakeholders as possible.

Although from an e-health-research perspective we are more interested in

the flow and the management of the data, we realize that these latter
aspects also deserve the necessary attention, because in the end it are the
software vendors who will build the systems, the government who will certify
and control the systems and the health care workers who will use the
systems. All the stakeholders start to realize that an interdisciplinary
collaboration in e-health research with mutual awareness and respect for
each others’ methods and contextual drivers will eventually result in better
technologies [10]. This is particularly the case between the software
developers and the health services and academic researchers.

In our research we have always tried to incorporate the ideas and beliefs of
the whole field, by means of user committees and focus groups. This did not
always prove to be the most efficient and fastest way of working, but finally
resulted in technologies where all stakeholders could agree upon and that
are already used in the field.

1.2. Impact and importance of e-health.

Is e-health worth it? Why bother to make the switch from paper-based to
electronic communication and data storage to digital applications in health
care? Are all initiatives in e-health research really necessary? Does e-health
save money? Or even more importantly: does e-health save lives? The
answer to these questions is not straightforward, but the different examples
in this paragraph illustrate that e-health really is worthwhile if the
technologies and methods are applied in a carefully planned way. E-health is,
as discussed in detail in the previous paragraph, a very complex domain. It
consists not only of different professional approaches, uses numerous
technical building blocks, but also has to deal with the legal framework and
the “goodwill” of the end-users. The complexity and wide variety of e-health
applications makes it almost impossible to measure the impact of e-health
on the modern health care systems, but in this paragraph we will try to give
some answers, based on some real-life examples.

Health care systems are a fundamental part of the social infrastructure of a

country. For many years, information and communication technologies (ICT)
have been expected to contribute to the development of our health care
systems. Unfortunately, e-health or health information technologies have
mostly realm for just a few enthusiasts. Recently however, the results of the
European e-health IMPACT study have shown that - given the right approach,
context and implementation process – ICT –based solutions can indeed
improve the quality, accessibility and efficiency of health care. These
benefits include both economical and health care-professional benefits on
individual as well as societal level [11].
Especially the lack of reliable evidence of the economic impact of using ICT
in delivering high quality health care has been a key barrier to the more
widespread diffusion of e-health solutions. But particularly that impact,
although potentially enormous, is very difficult to measure because
evaluations often have only a single perspective (such as financial) or the
view of only one stakeholder.

Moreover, privacy issues and dependency on technology lead to

conservative attitudes in favor of the “paper-based” handling of medical
documents.

The “Aho” report (January 2006 [12]) explicitly acknowledged the importance
of ICT in tackling specific challenges within the health care sector, and thus
identified e-health as an example of a key area where a market for
innovation can operate and public policy can have a significant role.
Consequently, the European Union (EU) commission proposed “the Lead
Market” initiative on e-health aiming at the creation of markets with high
economic and social value, in which European countries could develop a
globally leading role. [13] “The Lead Market” initiative was about identifying
example areas with the greatest potential to the European economy. It was
not about artificially creating markets for research results, but creating an
environment that enables industry and academic institutions to develop
innovative products and services. For the EU commission the e-health
market can be defined as comprising the following four inter-related major
categories of applications:

1. Clinical information systems

a. For health professionals within care institutions

b. For primary care workers

2. Telemedicine and home care

3. Integrated regional/national health care networks

4. Secondary usage non-clinical systems

a. Health education

b. Systems for research and data collection

c. Support systems
E-health is becoming a mainstream element of national health system
priorities. This is shown by the fact that virtually all EU member states
feature by now e-health strategies in dedicated documents or as a part of
wider e-Services. Most of these documents have been published since 2003.
However, some countries such as Denmark, as will be discussed in the next
paragraph already adopted initial e-health policies during the 1990’s.

1.2.1. Economical benefits

The health sector in the European Union employs almost 10% of the total
workforce and corresponds to almost 9% of the gross domestic product
(GDP) (in 2006). Health spending is rising faster than the GDP and is
estimated to reach 16% of the GDP by 2010 in OECD1 countries. The e-health
industry in the EU was estimated to be worth close to € 21 billion in 2006.
This figure covers the four previously mentioned areas in the e-health
market, including ICT infrastructure belonging to the health delivery system.
The major part (almost 80%) of this figure represents generic ICT
infrastructure (networks, communication, hardware, software,…). So e-health
cost a lot of money. But is there also a return of investment? All market
players and observers agree the e-health in Europe is set for an explosive
growth, driven by the need to face health related challenges [14].

One example that clearly illustrates the possible economical benefit from e-health is
Medcom, the Danish Health Data Network [11]. In Europe this is one of the oldest
health care networks, with a start already dating back to the early 1980’s. Medcom
as it exists now is the results of different projects based on new information and
communication technologies in health care, lead by the Danish centre for Health
Telematics, that was founded in the 1990’s. The focus of the projects lies in the
electronic data interchange (EDI) which is used for the messaging process of
electronic data, including referrals, prescriptions, request reports, discharge letters,
notifications and reimbursements.
The economic results of the project are summarized and shown in Figure 1 below
and they clearly demonstrate a financial benefit for the introduction of this e-health
technology.
Some more detailed results are:
• First year of annual net benefit, i.e. when annual benefits exceed
annual costs: 1997, year 3
• Estimated annual net benefit for the year 2008: approximately € 80
million
• First year of cumulative net benefit: 1999, year 5

1
OECD: Organisation for Economic Co-operation and Development (30member countries
worldwide)
 • Estimated cumulative benefit by 2008: approximately € 1.4 billion
• Cumulative investment costs, including operating expenditure, by
2008: approximately € 725 million
• Estimated productivity gain, measured in decrease in cost per
message transaction: 97%
• Distribution of benefits to 2008: Citizens – 2%; HPOs – 98%

Figure 1: Present Values (PV) of the estimated annual costs and benefits for Medcom, Danish
Health Data Network. 1994-2008, in € 000s. (from e-health IMPACT study, 2006. The data
after 2006 are estimated number based on the virtual health economy concept of the
IMPACT study [11])

No overall figures are available of the possible economical benefit of e-health

in Europe. Recent studies have shown that the benefits for health care
delivery as discussed in the next part can have an indirect positive benefit
on the financial picture of e-health. However sound management and well
organized spending of the available resources is needed.

1.2.2. Health care benefits

Many aspects of how e-health can contribute to the improvement of the

health care process have been described in literature. Some examples that
are often cited include the use of clinical decision support systems that will
help the clinician in making the correct diagnosis and choosing the best
therapy for the patient [15-18] and the use of telemonitoring and telecare
systems, that provide clinical aid to patients living at a great distance from
the regular point of care (hospital, GP, nursing office,…) [18-20]. But many
more examples ranging from better record keeping with electronic health
records [21-24] to electronic prescriptions of medication and care [25-27] are
often mentioned.
To describe the impact of e-health on the citizens’ health, Eysenbach [1]
identified 10 features, or the 10 e’s, that collectively distinguish e-health
programs and each can be looked at as a measure for their health care
benefit: efficiency (reducing excess care and costs), enhancing quality
(facilitating choice of high-quality providers), evidence-based (scientifically
proven), empowerment (access to knowledge bases and electronic records),
encouragement (shared decision making), education (access to training for
providers and high-quality information for consumers), enabling
(standardized information exchange), extending (global access), ethics
(professional practice and privacy issues), and equity (must reduce digital
divide).

The EU IMPACT study (2006) [11] defines benefit categories along the lines
of the following quality aspects:
• Informed patients and health care providers
• Sharing of information designed to streamline health care processes
• Timeliness (scheduling and providing health care at the right time)
• Safety
• Effectiveness
• Access
• Efficiency

But the real question for health care benefits is: “do these technologies
actually improve the patients’ health-level?” Are there lives being saved?
Does e-health really have an impact on the patients’ health status?

Example:
A study from an e-prescription system from the North-Atlantic region in the US
showed that in 2007, more than 525,000 prescriptions were written electronically.
In addition, nearly 23,000 medication history requests were made, allowing the
physician to review all of the patient’s medications. Reviews of the complete
medication history resulted in prescription changes due to allergy warnings (9
percent), drug-drug interaction warnings (34 percent), duplicate therapy warnings
(36 percent), dose warnings (13 percent) and formulary non-compliance warnings
(22 percent) [28].

This example not only shows economic benefits when using this e-health
technology, but the results confirm that using an e-prescribing system
clearly has a beneficial influence on the patients’ health status. Numerous
allergic reactions and drug-drug interactions would not have been spotted
without the e-prescribing technology.
Although this component of e-health, namely the real effect on the patients’
health status is very difficult to measure, it will become one of the key
aspects in the acceptance and development of e-health systems in the near
future. This is an aspect that not only addresses the patients directly but is
also the primary concern for the health care providers. Therefore it will be
necessary to strictly define the assessment rules and come up with an
inimitable set of criteria on an international (European) level that will be used
to evaluate the efficiency and effectiveness of the e-health systems
regarding the patients’ health status.

1.3. E-health initiatives in Europe

It would take a series of encyclopedia to describe all the recent e-health

initiatives that have started in Europe. Over the past years, the number of e-
health projects has increased rapidly. Web of Science©2 is currently
reporting 20 journals in the field of Medical informatics. Moreover the online
“Journal of Medical Internet research”, founded in 1999 has become the
leading journal in the field in just 10 years time, mainly due to the increasing
pressure to publish state of the art research in a very innovative field where
technologies and applications change rapidly.

E-health initiatives range from very small to very large, from local or regional
to national or even international, although there are not yet many large-
scale national e-health procedures in routine operation. Most undertakings
are at the stage of development, pilots or in larger test phase. Few initiatives
already have gone through a fully functional roll-out. Only the three
Scandinavian countries have already implemented fully operational national
ICT infrastructures. Most EU countries have their e-health infrastructure in
the process of development and schedule the implementation phase in the
years to come.

The EU ERA report provides a detailed report on the priorities and strategies
of the European countries until 2007, and their plans for the future [14]. In
Table 1 you find a summary-overview of the 32 European countries that were
covered by this study. Six major e-health themes were selected:
Infrastructure, electronic health records, interoperability, patients and health
2
Web of Science ©, more info on:
http://www.thomsonreuters.com/products_services/scientific/Web_of_Science
professional mobility, legal and regulatory framework and evaluation and
impact analysis.

Table 1: Overview of e-health initiatives in EU countries until 2007. (Summarized from ERA report EU
Commission, i2010 countries are countries that are not EU-member states, but involved in the EU
policy framework for the information society and media i2010)

a. Infrastructure

As a fully operational telecommunications infrastructure (preferably

broad-band) is a prerequisite for regional or national e-health
solutions, all EU countries have invested in such networks.
Therefore all countries score a plus on this item. This however does
not imply that all EU countries have dedicated network
infrastructures connecting health service providers and other
relevant stakeholders. In most case we are just talking about basic
 infrastructure like broadband connections or basic technical or
semantical interoperability3. Scandinavian countries are amongst
the most advanced here. Since 2002, for example, all hospitals and
primary care centers in Sweden are connected via Sjunet [29]. It is
a federated telecommunications network which also links together
pharmacies and several other health care enterprises and regional
administrations. Most EU countries are planning to extend their
telecommunications infrastructure in near future.

b. Electronic Health Records (EHR)

Electronic health record is a rather fuzzy term, as will be discussed

in detail further on in this chapter. EHRs can range from
summarized to complete (well structured) health records. Most EU
countries already have some form of long-term summarized
records, accessible regionally or even nationally. The EHRs can be
organized within a national health program, as in the MedCom
health infrastructure in Denmark [30], can be hospital based [31-33,
43] or even managed by the primary care sector, as a collaboration
between commercial software providers and national health
institutes, as in Belgium [21, 22, 40, 42].

Next to the national initiatives also European projects exist that

endorse the use of well organized EHRs. OpenEHR for instance is an
organization that has as goal to come up with an economically
viable construction of maintainable and adaptable health computing
systems and patient-centric electronic health records. [34-35].
Another initiative, EuroRec is an independent not-for-profit
organization, promoting the use of high quality Electronic Health
Record systems (EHRs) in Europe. EuroRec is organized as a
permanent network of National ProRec centers and provides
services to industry (the medical software developers and vendors),
health care providers (the buyers), policy makers and patients.

3
Semantical interoperability: is the ability of two or more computer systems to exchange
information and have the meaning of that information automatically interpreted by the
receiving system accurately enough to produce useful results, as defined by the end users
of both systems. Will be explained in more detail in paragraph 2.2.5
c. Interoperability

Data exchange and interoperability are concepts that are closely

linked to the EHRs discussed in the previous paragraph. Despite this
relationship, not many EU countries have put interoperability high
on their agenda. This is surprising because interoperability is one of
the key issues in the EU Action Plan. Only about a third of the
member states mention interoperability in their action plan. A few,
for example Denmark, with the MedCom initiative have already
developed a platform based on technical standards and
interoperability for e-messages, called the Danish Health Data
Network [30]. Also on a transnational level initiatives have taken
place. RIDE is a roadmap project, supported by the sixth framework
of the EU commission, for research and development on
interoperability of e-health systems leading to recommendations for
actions and to preparatory actions at the European level, with
Special Emphasis on Semantic Interoperability [36].

d. Patient and health professional mobility

As with interoperability, patient and health professional mobility is

not a key issue in most EU countries e-health policy, although it is a
central point of e-health action plan of the EU. In most case mobility
must be viewed in the context of electronic identity or health cards
or web-based access to health information or other services.
Slovenia’s health policy explicitly states patient mobility as a
priority topic. This country has also been dealing with the issue of
an electronic health insurance card for many years now [37-39].

Besides this, in various European Union regions a wide variety of

cross-border schemes allowing citizens to obtain health care in
another EU member state have been developed. Moreover, in the
early 2000’s public health insurance funds in Germany, the
Netherlands and Belgium together with the hospitals of the touristic
regions along the North Sea coast, introduced a service that
supports immediate access to health care for traveling citizens,
which instantaneously informs participating hospitals about the
 insurance status of the patient. Moreover it guarantees
reimbursement within a week thanks to electronic transfer of
administrative data. [14].

e. Legal and regulatory framework

Legal and regulatory frameworks are crucial building blocks for fully
functional e-health infrastructures. Not only for health care
providers but also for citizens are medical data very sensitive
information that should be handled with care. Especially when the
data are available via the network and possibly visible to and
accessible by numerous persons. Citizens are very anxious to know
what is happening with their health information. But many e-health
applications such as EHRs, eHealth platforms, health grids involve
new legal challenges [44]. Therefore in EU countries where
legislation is already implemented or at least under serious
discussion, the introduction of e-health systems will prove to
progress more efficiently.

Alongside legislation and general regulations on data protection,

confidentiality and telecommunications, legislation on digital
signature and medical device liability is widely spread. Several
countries already have legislation in place for different aspects of e-
health, like for example Belgium, with the new eHealth platform
[45], or are on the verge of reviewing their existing legislation in
respect to new developments in the e-health domain.

1.4. E-health initiatives in Belgium

Belgium is a federal constitutional monarchy, where executive and

legislative power is divided between the federal government, three regions
(Flanders, Wallonia and Brussels) and three communities (Flemish-, French-
and German speaking). Because the communities are responsible for
personal matters, comprising health and welfare, Belgium’s e-health policy is
subject to several ministries. Due to that large number of participants,
Belgium sees clear advantage and need for a concerted official e-health
roadmap, mainly supported by the Ministry of Health (FOD Volksgezondheid,
Veiligheid van de Voedselketen en Leefmillieu4).

In Belgium the first e-health initiatives originated from this Ministry of Health
(Dr. J.P. Dercq, Dr. M. Bangels, Director Dr. C. De Coster and colleagues). By
law (Royal Decree of May 3rd 1999) the Telematics commission was created
to coordinate research and deployment actions in the e-health field. In 2008
major changes took place: the e-Health Platform was created (law on e-
Health, Aug. 2008) and the focus of initiatives shifted from the Ministry of
Health to the social security administration (RIZIV / INAMI).

Currently many regional and national e-health initiatives exist in Belgium. In

the next part we will briefly summarize a few of the most important ones,
emphasizing that this list is far from complete.

a. Local and regional initiatives between hospitals

Flow projects (Facilities, Legal implementation, Organizations, Wisdom):

national health care network(s), built around the shared electronic health
record between geographically spread hospitals. Pertinent health data are
available via the sites selected by the mobile patients, who can freely decide
where they get treatment in the health care system. Currently three major
initiatives exist:

• Flow alpha: Réseau Santé Wallon, between several Walloon hospitals.

[46]

• Flow beta: Abrumet (BHIP: Brussels Health Information Platform),

between several hospitals in the Brussels region. [47]

• Flow gamma: GZO (Gents Ziekenhuis Overleg), between several

hospitals in the region of Gent. [48]

Besides these projects, more local projects attempt to connect physicians

and other healthcare providers to large hospitals. For example in Leuven
LISA (Leuvense Internet Samenwerking Artsen) [49].
4
FOD Volksgezondheid, Veiligheid van de Voedselketen en leefmillieu:
https://portal.health.fgov.be
 b. Carenet – My-Carenet [50]

This project is putting in operation a safe electronic exchange of financial

and administrative information between health care institutions and health
care providers on one hand, and mutual health insurance institutions on the
other hand. Carenet has the following three main goals:

• Improve the quality of the invoice data used in a third-party payer

environment

• Decrease the administrative workload, by reducing the amount of

manual and in particular repeated data input

• Cost savings on printing and sending.

c. IBBT projects

IBBT (Interdisciplinary Institute for Broadband Technology) is an independent

research institute founded and funded by the Flemish government to
stimulate ICT innovation. The IBBT team offers companies and organizations
active support in research and development. It brings together companies,
authorities, and non-profit organizations to join forces in the context of
research projects. Both technical and non-technical issues are addressed
within each of these projects. The mission of IBBT is the creation of highly
competent human capital in different aspects of ICT through multi-
disciplinary demand-driven research. IBBT carries out this multi-disciplinary
research for the Flemish business community and the Flemish government.
This includes all technological, legal and social dimensions of the
development and exploitation of broadband services.

A few of the projects of the IBBT are:

• eHIP (e-health Information Platforms 1 Sep 2005 - 29 Feb 2008) is a

regional information platform for the health care sector. It offers
authorized care personnel safe and reliable access to confidential clinical
patient information. The system is always accessible at every workplace.
E-HIP is designed to promote co-operation between the information
islands of today. The final objective is an adequate health care, which is
supported by an integrated regional IT infrastructure that is available to
all care personnel, including family doctors, hospitals, specialists, health
centers, etc. [51]
• Share4Health (1 May 2008 - 30 Apr 2010): The focus of this project is a
common patient centric, community centric health care IT platform that is
used by hospitals, general practitioners and pharmacists and that
 addresses the needs of the next generation clinical applications, which
focus on collaboration and decision support. Furthermore it relies on the
advances and the innovations that come with Web2.0. [52]

d. Kmehr (Kind messages for electronic health records)

This project that already dates back to the early 2000’s defines an XML
implementation for health related electronic messages. Kmehr-bis (Belgian
Implemantation Standard) is currently considered as the standard for
exchanging health related electronic messages, which are used in many of
the above described e-health initiatives. Amongst these messages are
discharge letters, medical prescriptions and lab-results. More detailed
information on Kmehr can be found in the next chapters. [53]

e. Recip-e [27]

The Recip-e project involves the creation of an electronic prescription system

for Belgium, corresponding to the theoretical model realized previously,
fitting into the Belgian health system and aiming to obtain a consensus from
all involved parties: physicians, pharmacists, authorities and the patients.
The in depth analysis of the pilot study resulted in a detailed requirements
set, specifying the implementation features and taking into account the
features that will enable ´painless´ roll-out. A realistic estimation was
already made of the efforts required and a clear pathway is drawn, to come
to an operational system, from which all involved parties will benefit,
especially the patient, who becomes more knowledgeable about the status of
his prescriptions and who will get more protection against errors

f. Belgian eHealth platform [54-55]

Although all these regional or even national initiatives exist, there still
remains a need for coordination of all these projects, without losing the
original approach and dynamics of the individual programs. Therefore the
eHealth platform5 (formerly Be health) was created based on a shared
basic vision and strategy concerning e-health between all the actors in the
Belgian health care domain. Another important goal of e-health is to create
of platform for technical and semantical interoperability, for quality and

5
eHealth platform: we will use BOLD formatting when referring to the Belgian eHealth
platform. Normal formatting will be used when referring to the general e-health term.
security standards applicable in the whole country. In this model the
eHealth platform has special attention to:

• the protection of the “privacy” of the patient

• the “professional secrecy” of the health care provider

• regulations about information security

• coherence of all the parts of the proposed model

Some other crucial aspects of the eHealth platform model:

• no central repository for medical / personal health data

• secure data exchange between all health care providers

• if a patient wishes, partial redirection to the places where his /her

heath data is available

• application of current legislation about e-health, and “privacy” of the

patient

• respect and support for existing e-health initiatives

• the utilization of the eHealth platform is offered, not forced

• the eHealth platform is not performing any research regarding

health care in its own right and does not have access to medical data,
themselves

Schematically, the use of the eHealth platform and its services is

presented in figure 2. The model consists of three layers. Maybe the most
important aspect of the eHealth platform is the provision of free basic ICT
services (BS) that can support the local and regional e-health initiatives,
which can be found in the middle layer. These basic services are made
available to institutions that can use these services in order to generate
added value services (AVS).

The basic services are:

• portal-site environment (https://www.ehealth.fgov.be)

• integrated user / access management
• management of logins
 • personal electronic mailbox for every health care provider
• time stamping
• coding and anonymisation
• upkeeping of KMEHR, software certification
o system for end-to-end encryption
o coordination of electronic partial processes

The top layer consists of the added value services. These added value
services are put available for patients and / or health care workers. Examples
of these added value services are as described above: My-Carenet, Flow
projects, the site of the ministry of Health (FOD Volksgezond, veiligheid van
de voedselketen en leefmillieu) and many others as will be described in next
chapters.

The bottom layer stands for validated authentic sources (VAS). These are
basic database that are used by the eHealth platform. The manager of the
database is responsible for the availability and the (organization of the)
quality of the data that is provided. Examples of these databases are the
registry of health care providers (“Kadaster van zorgverleners”) managed by
the Ministry of Helath (FOD Volksgezond, veiligheid van de voedselketen en
leefmillieu), that contains information on diploma and specialty of the health
care providers, identified using his social security number (INSZ6). Another
database is managed by the RIZIV7 and contains information about the
recognition of the health care providers.

The introduction of the eHealth platform has many advantages, not only
for the government, but also for the health care providers as well as for the
patients at large.

Government:
• better policy support
• maximum spending of available budget on care thanks to more efficient handling of
administrative formalities
• singe implementation of-re-usable (basic)services
Health care provider:
• less administrative formalities, more time for care
• better professional support
• one affiliation to the electronic platform suffices for many applications
• support for local and regional cooperation
Patient:
6
INSZ: Identificatie nummber voor sociale zekerheid.
7
RIZIV: Rijksinstituut voor Ziekte- en Invaliditeitsverzekering (http://www.riziv.fgov.be)
 • improved quality of the health care and security for the patient
• in some cases, faster delivery of care
• better transparency

Figure 2: Schematical representation of the eHealth platform. AVS stands for Added Value Service,
BS means Basic Service, and VAS is Validated Authentic Source (schematically from e-health
presentation of F. Robben, 2008)
2. Electronic Health Records (EHR)
2.1. Definition

Electronic health records are a major focus for current research in the field of
health informatics and e-health [56, 57]. Most research has been performed
on the possibilities of the current technologies and the underlying
architecture. The EHR is considered to be one of the cornerstones of e-health
as recently confirmed by CEN’s focus group on E-health [58]. In 2006 the EU
commission reports: “achieving a European health record is not yet an
overarching goal, but collaboration on developing individual countries' health
records or basic patient summaries as a first step towards more
comprehensive records appears to be an aim of increasing interest to many
of the Member States”[11]. This last example clearly demonstrates the need
for well organized EHRs. But before one can dream of an EHR at a European
level, we need to agree on what we define as an EHR. And EHR is a rather
“fuzzy term”, as mentioned in the EU report.

As with e-health there exists a wide variety of definitions [59-64]. The list is
more exhaustive in comparison with the e-health definition, due to the
different health care disciplines that all try to define their own EHR. Big
differences exist between primary care and hospital settings or between
family physicians and specialist. Also other health care providers as nurses,
pharmacists, physiotherapists and paramedics use their own domain specific
definition for the EHR.

Despite this wide variety, some very general and standardized definitions are
available, which was not the case for e-health. In 2004, the International
Organization for Standardization (ISO) defined the electronic health record
[65]. According to this definition, the EHR means “a repository of patient data
in digital form, stored and exchanged securely, and accessible by multiple
authorized users. It contains retrospective, concurrent, and prospective information
and its primary purpose is to support continuing, efficient and quality integrated
health care”. This definition, although not very detailed, is very clear and it
describes and contains all the core concepts that are needed to build a well
organized EHR. An adapted version of this definition is also being used by the
openEHR8 project, an open standard specification that describes the
management and storage, retrieval and exchange of health data in EHRs.

8
OpenEHRM www.openehr.org : The openEHR Foundation is a not-for-profit company. Its
founding shareholders are University College London, UK and Ocean Informatics pty,
Australia.
They define the EHR as “repository of information regarding the health status of a
subject of care in computer processable form, stored and transmitted securely, and
accessible by multiple authorized users. It has a standardized or commonly agreed
logical information model which is independent of EHR systems. Its primary purpose
is the support of continuing, efficient and quality integrated health care and it
contains information which is retrospective, concurrent, and prospective” [34, 35].

Many more definitions exist, but in the scope of this work, we do not wish to
give a large overview of all possibilities. For our research work, the definition
of ISO, includes all the necessary elements that are needed in an EHR. We
emphasize the fact that not only EHR is used as a term to describe the
electronic storage of clinical (patient) data. According to the health care
domain, different types of EHRs exist and they are defined using different
concepts. ISO also gives a number of other terms that are frequently used in
the relevant literature, to describe different types of EHRs. This is clearly
illustrated in table 2, which contains the data from a review article from 2008
(from Häyrinen and colleagues [64]), concerning the definitions on EHRs

As already mentioned above, some organizations deal with the topic of EHR.
On an international level, the openEHR-project [34, 35] is one example,
another on a European level is Eurorec [66]. In Europe, 15 countries
including Belgium (7 other applicant countries) each have their own ProRec-
centre, an initiative supported EU commission. These centers provide
services to industry (the developers and vendors), health care providers (the
buyers), policy makers and patients, mainly concerning EHRs. EuroRec is
organized as a permanent network of National ProRec. The EUROREC
Institute (EuroRec) is an independent not-for-profit organization, promoting
in Europe the use of high quality Electronic Health Record systems (EHRs).
One of its main ambitions is to support, as the European authorized
certification body, EHRs certification developments, testing and assessment
by defining functional and other criteria. The topic of certification and quality
labeling will be further discussed in chapter 2.
Table 2: Overview of the types of definitions used for describing EHRs (from Häyrinen et al., 2008 [64])

2.2. Aspects of EHRs

When developing EHR systems many aspects have to be taken into account.
What is the patients’ role in the EHR (1). What is the core function of the EHR
(2). Which are the standards, codes, nomenclatures and vocabularies that
are going to be used (3). What about data integrity and security (4). Are
these EHRs interoperable with other systems and is data exchange possible
(5) [64]. These aspects can be found in the definitions that are mentioned
above and they are pertinent to our research that will be discussed in the
next chapters.

2.2.1. Role of the patient in the EHR

The patient plays a central role in the EHR. Not only is he the subject of the
EHR, but the patient can also play an active role in the management of the
EHR. Should the patient be responsible – or at least partially - for managing
his own EHR? Nowadays, using secure web technologies, many options are
available and the topic forms a very pertinent discussion. Many voices speak
in favor, but equally as many are against [72-76]. It is not the goal within this
work to further extend on this discussion, moreover that in Belgium the
general practitioner (GP) is keeper of the medical record of the patient9. The
fact that the GP is the manager of the patients’ medical record, and
therefore also the EHR, is a key concept of this work which will be elaborated
in more detail in chapter 4, where interoperability between EHRs for GP and
EHR for physiotherapists is discussed. Patient empowerment is ever
increasing, the patient is considered more and more as a partner in the
health care team. Further debate on the patients’ role in assigning
authorization rights to parts of a shared patient record are going on, as this
work is being published. Therefore it is impossible to go into detail, but this
item also remains a key aspect for the future development of EHR systems.
[73, 74]

2.2.2. Core function of the EHR

As already mentioned above, different types of EHRs exist depending on the

speciality of the health care provider. Most EHRs include a part of
administrative patient data such as names, addresses, gender etc. Besides
this, the core functionality and structure of the EHR is often determined by
the way the health care provider organizes his work. Early classifications for
the structure of EHRs that are mentioned in literature are time-oriented
problem-oriented and source-oriented EHRs. Nowadays EHRs combine all
three elements. In the time-oriented electronic medical record, the data are
presented in chronological order. In the problem-oriented medical record
(POMR), notes are taken for each problem assigned to the patient, and each
problem is described according to the subjective information, objective
information, assessments and plan (SOAP). In the source-oriented record, the
content of the record is arranged according to the method by which the
information was obtained, such as notes of visits, X-ray reports and blood
tests. Within each section, the data are reported in chronological order [75-
76].

9
The general medical record of the patient (in Dutch: “Globaal medisch dossier”) is
managed by the family physician in Belgium
Not only the way EHRs are structured is differentiated, also the content
differs according to the health care domain and the scope of the EHR. It is
clear that nurses are interested in keeping other health care data than
physiotherapists, and hospitals store other data than GPs. Many initiatives to
build a solid EHR exist. Unfortunately they are often organized using the
point of view of a specific health care domain, without the broader vision of
the whole sector. These structural disparities between EHRs for different
health care providers, is an important issue when discussing the topic of
interoperability. This topic will be further elaborated in chapter 4, regarding
the exchange of data between electronic medical records and electronic
physiotherapy records. These systems have a completely different approach
for dealing with a health care problem.

Another aspect when dealing with the content of the EHR is the concept of a
minimal needed set of health care data. In different countries these
minimalistic EHRs are already being put into practice, but they differ a lot in
functionality. Some are stored within the hospital information systems,
others like the Sumehr10 in Belgium are kept by the GPs EHR. Other
initiatives even want to store the data on the patients’ health insurance card
[77] Even non-official projects exist, where commercial software companies
encourage patients to store there “minimal” patient record on a memory-
stick or similar devices that they always carry with them.

Next to the medical minimal datasets, there also exist minimal datasets used
in the context of the management and financing of health care institutions
(MKG, MPG)11. Through the coding of diagnosis and treatment in the medical
records (ICPC-coding, used in primary care and DHCP coding in hospitals
{see 2.2.3}), unambiguous exchange of medical information is made
possible. Coding systems enable the extraction of minimal datasets for
epidemiologic studies and for management purposes. The minimal datasets
in their own right fall outside the scope of our work, that is aiming at the
clinical aspects of patient data. Of course the clinical datasets form the
source from which minimal datasets are built.

2.2.3. Standards for classification and nomenclatures

10
Sumehr: Summarized electronic health record
(https://portal.health.fgov.be/pls/portal/docs/PAGE/INTERNET_PG/HOMEPAGE_MENU/GEZOND
HEIDZORG1_MENU/AUTOMATISERING1_MENU/HOPITAUX9_MENU/SUMEHRPHOTOSANTE1_ME
NU/SUMEHRPHOTOSANTE1_DOCS/2006-09-08-SUMEHR.PDF)
11
MKG: Minimale klinische gegevens (minimal clinical patient data), MPG: minimale
psychiatrische gegevens (minimal phychiatric patient data)
Standardization and coding of the data, forms a crucial aspect when one
wants to store information in a digital format. To retrieve data efficiently and
accurately, the health care provider needs to be able to rely not only on well
structured data but preferably on carefully coded data. Many different
standards and classification methods exist in health care. In this paragraph
we will discuss the main standards and classifications for electronic health
care data that are of interest for our research. We will only consider the
standards for classification of health care data on the level of the disease or
more in general the health care problem. In the paragraph on interoperability
(2.2.5), standards for exchanging health care data will be discussed. These
standards are interlinked, but have a different core concept. We briefly
discuss the definitions for ICD9/10 (a), ICPC2 (b) and ICF (c) according to the
WHO12 in this paragraph, but elaborate on their particularities when they are
used within chapters 3 and 4.

The standards for classification depend mainly on the specification of the

health care discipline. These differences were developed historically and
have now grown into classifications that are more appropriate for a typical
health care domain and are better suited to the needs of the health care
providers working in that domain. To illustrate this, without detailing what
the different classification codes are, the following example:

A GP will try to code / classify a health care problem with a patient at the level
of the disease. For instance a patient comes to the GP with an ankle sprain. This
is classified at the level of the disease. The primary goal of the doctor is to cure
this patient by eliminating the disease . The patient is usually considered as
cured when he/she does not return to the doctors’ office for this health care
problem. However for a physiotherapist, it is necessary that he is able to make
statements not only on the status of the disease but also on the amount of pain,
possibilities of daily life activities etc. This is needed for the therapy planning
and measuring the progress of the patient.

a. ICD 9/10 (International classification of diseases, v9 or v10)13

The ICD is the international standard diagnostic classification for all

general epidemiological, many health management purposes and
clinical use. The ICD codes include the analysis of the general health
situation of population groups and monitoring of the incidence and
prevalence of diseases and other health problems in relation to other
12
WHO: World Health Organisation: more info on: www.who.int
13
ICD9/10: more information on: http://www.who.int/classifications/icd/en/
 variables such as the characteristics and circumstances of the
individuals affected, reimbursement, resource allocation, quality and
guidelines.

It is used to classify diseases and other health problems recorded on

many types of health- and administrative records including death
certificates and health records. In addition to enabling the storage and
retrieval of diagnostic information for clinical, epidemiological and
quality purposes, these records also provide the basis for the
compilation of national mortality and morbidity statistics by WHO
Member States.

b. ICPC2 (International classification of primary care, second edition)14

ICPC-2 classifies patient data and clinical activities in the domains of

General/Family Practice and primary care, taking into account the
frequency distribution of problems seen in these domains. It allows
classification of the patient’s reason for encounter (RFE), the
problems/diagnosis managed, interventions, and the ordering of these
data in an episode of care structure. It has a biaxial structure and
consists of 17 chapters, each divided into 7 components dealing with
symptoms and complaints (comp. 1), diagnostic, screening and
preventive procedures (comp. 2), medication, treatment and
procedures (comp. 3), test results (comp. 4), administrative (comp. 5),
referrals and other reasons for encounter (comp. 6) and diseases
(comp. 7).

c. ICF (International classification of functioning, disability and health)15

The International Classification of Functioning, Disability and Health,

known more commonly as ICF, is a classification of health and health-
related domains. These domains are classified from body, individual
and societal perspectives by means of two lists: a list of body functions
and structure, and a list of domains of activity and participation. Since
an individual’s functioning and disability occurs in a context, the ICF
also includes a list of environmental as well as personalfactors [78, 79].

14
ICPC2: more information on:
http://www.who.int/classifications/icd/adaptations/icpc2/en/index.html
15
ICF: International Classification of Functioning, Disability and Health. More info on:
http://www.who.int/classifications/icf/en/
2.2.4. Data integrity and security

When dealing with clinical data, data integrity and security aspects are very
import . Examples are protecting the patients’ privacy [72-73], managing the
authorization rules for accessing the EHRs [85], especially in a shared
medical record situation. Other legal facets of the e-health systems need to
be controlled very carefully to form a solid basis for a good EHR structure.
For example, the patients’ rights to access his own EHR(s), and the list of
accesses by other parties to his medical data, as recommended by the IMIA
working group on security in health information of 2006 [87]

These aspects however fall outside the scope of this work, because they
need an in-depth understanding of the legal structures of the health care-
system.

Although it will not be discussed in detail here, there is one aspect of this
topic that was partially subject of this work: data encryption. It will be
discussed further in chapter 3.

2.2.5. Interoperability

Interoperability is currently a major issue when dealing with EHRs.

Interoperability is the ability of different information technology systems and
software applications to communicate, to exchange data accurately,
effectively, and consistently, and to use the information that has been
exchanged to good purpose. Making health care information systems
interoperable will reduce cost of health care and will contribute to more
effective and efficient patient care [80]. For many years EHRs have been
developed in many sectors of the health care domain, but only few of them
are ready to communicate with each other. Interoperability can be looked at
in many ways and depends also on the data structure (see 2.2.2) that is
used.

Interoperability can be investigated at different levels, such as the

interoperability of the messages exchanged between health care
applications and interoperability of complete EHRs. Another aspect of
interoperability is the mutual exchange of patient identifiers, coding terms,
clinical guidelines and health care business processes. Graphically the
interoperability between two EHRs or in general health care applications can
be represented as in figure 3.

Figure 3: Standardized message exchange between two health care applications, e.g. EHRs
(schematically from Dogac et al. 2007 [80]). Typically, a messaging interface gathers data from the
back-end application systems, encodes the data into a message, and transmits the data over a
network such as a Value Added Network (VAN) to another application. On the receiver side, the
received messages are decoded, processed and the data which have been received are fed into the
receiver’s back-end systems to be stored and processed

Furthermore, all these categories can be investigated in two major layers:

the syntactic interoperability layer and the semantic interoperability layer.

Syntactic interoperability (which we term as messaging layer), involves the

ability of two or more systems to exchange information. Syntactic
interoperability involves several layers: network and transport layer (for
example Internet), application protocol layer (such as HTTP(S)), messaging
protocol and message format layer, and the sequencing of the messages.
Syntactic interoperability guarantees the message to be delivered but does
not guarantee that the content of the message will be machine processable
at the receiving end.

To guarantee message content interoperability, either the message content

should conform to a single machine processable standard or semantic
interoperability must be provided, such as the ones we discussed in
paragraph 2.2.3. Semantic interoperability is the ability for information
shared by systems to be understood at the level of formally defined domain
concepts.

As with classification standards it is impossible to discuss all the available

interoperability standards in this work. Moreover that not only international
standards but also national or system specific standards exist. Therefore we
will restrict ourselves to some global definitions of the different standards
that are useful for our research, and we will provide an in depth discussion
related to our research in the next chapters.
To address the EHR interoperability problem, there are several standards
currently under development such as the Health Level 7 (HL7) Clinical
Document Architecture (CDA) (a), CEN EN 13606 (b) and openEHR (c). These
standards aim to structure and markup the clinical content for the purpose of
exchange. There is also an industry initiative called “Integrating the Health
care Enterprise (IHE)” (d) which specified the Cross-Enterprise Document
Sharing (XDS) integration profile for this purpose. As mentioned above also
national standards for exchanging messages exist, although only one third of
the EU countries mention interoperability in their action plan. For our
research we have primarily focused on the current standard that is used in
Belgium, Kmehr-bis (e).

a. Health Level 7, Clinical Document architecture (HL7-CDA) [80-83]

HL7-CDA is organized into three levels where each level iteratively

adds more markup to clinical documents, although the clinical content
remains constant at all levels. “Level One" focuses on the content of
narrative documents. It consists of two parts, the CDA Header and the
CDA Body, which are based on the HL7 data types. The document
header is derived from RIM and unambiguously defines each entry in
the document. The body contains the clinical document content, and
can be either an unstructured text, or can be comprised of nested
containers such as sections, paragraphs, lists, and tables through
structured markup. Hence there is no semantics in Level One body; it
offers interoperability only for human-readable content. In fact, CDA
Level One describes a kind of HTML document with a standardized
header that contains additional information on the document. Level
Two CDA models the fine-grained observations and instructions within
each heading through a set of RIM (Reference Information Model) Act
classes. With Level Two, it is possible to constrain both structure and
content of a document by means of a template and thereby increase
interoperability since the receiver “knows what to expect". However, a
completely structured document where the semantics of each
information entity is specified by a unique code will only be possible
with “Level Three" providing for machine processing.

b. CEN EN 13606 [80, 84, 86]

The CEN Pre-standard ENV 13606:2000 “Electronic Health care Record

Communication" is a message-based standard for the exchange of
electronic health care records. It also defines a list of machine-
 readable domain terms that can be used to structure EHR content, a
method of specifying “distribution rules", that is, rules under which
certain EHR content may be shared with other systems and, finally,
request and response messages that allow systems to exchange
subsets of an EHR. EN 13606, called EHRcom, will be a five-part
standard consisting of:

• The Reference Model,

• Archetype Interchange Specification,
• Reference Archetypes and Term Lists,
• Security Features, and
• Exchange Models (communication protocol).

c. OpenEHR [34, 35, 80, 84, 86]

The most noteworthy concept introduced by G(ood)EHR/openEHR is

the “archetype" concept. This approach uses a two-level methodology
to model the EHR structure. In the first level, a generic reference
model that is specific to the health care domain but still very general is
developed. This model typically contains only a few classes (e.g. role,
act, entity, participation) and must be stable over time. In the second
level, health care and application specific concepts such as blood
pressure, lab results etc. are modeled as archetypes, that is, constraint
rules that specialize the generic data structures that can be
implemented using the reference model. As an example, a constraint
may restrict a generic “Observation" class, for example, to “Blood
Pressure" archetype. An archetype definition basically consists of three
parts: descriptive data, constraint rules and ontological definitions.

d. IHE-XDS [80, 86]

The basic idea of IHE-XDS is to store health care documents in a(XML)

registry/repository to facilitate their sharing. IHE-XDS is not concerned
with document content; it only specifies metadata to facilitate the
discovery of documents. In the IHE-XDS integration profile, a group of
health care enterprises that agree to work together for clinical
document sharing is called the “Clinical Affinity Domain". Such
institutes agree on a common set of policies such as how the patients
are identified, the consent is obtained, the access is controlled, and the
common set of coding terms to represent the metadata of the
documents. As already mentioned, IHE-XDS handles health care
 documents in a content neutral way, that is, a document may include
any type of information in any standard format such as simple text,
formatted text (for example, HL7 CDA Release One), images (e.g.,
DICOM16) or structured and vocabulary coded clinical information (e.g.,
CDA Release Two, CEN ENV 13606 or DICOM SR). Given this, to ensure
the interoperability between the document sources and the document
consumers, the clinical affinity domains also agree on the document
format, the structure and the content.

e. Kind Messages for Electronic Health Records, Belgian Implementation

Standard (Kmehr-bis) [53]

Kmehr-bis a proposed Belgian medical data standard, in order to

enable the exchange of structured clinical information. It is funded by
the Belgian federal Ministry of public health and assessed in
collaboration with Belgian industry. The initiative lead to the
specification of about 20 specific XML messages. A Kmehr XML
message is composed of two components a header and at least one
folder. The header of the message describes the sender, the
recipient(s) and a few technical statuses. The folder itself gathers the
information about a patient, where each folder identifies the subject of
care (patient) and contains at least one medical transaction. The
medical transaction item gathers the information reported by one
health care professional at a given instance. Its attributes are type,
author, date and time.

16
DICOM: Digital Imaging and Communications in Medicine (DICOM) is a standard for
handling, storing, printing, and transmitting information in medical imaging. More info on:
http://medical.nema.org/
Refrences
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