Electronic information exchange in the Belgian healthcare system

Electronic information management and electronic information exchange offer enormous potential for increasing healthcare quality and patient safety, supporting health research and policy, avoiding unnecessary costs, empowering all stakeholders, especially the patient, and reducing the administrative burden on patients and healthcare providers. But of course it must be used in a secure way and with the necessary safeguards to protect the privacy of the patient and the professional secrecy of the healthcare provider.

Practically all people, throughout their lives, are simultaneously or sequentially in contact with a variety of healthcare providers (general practitioners, specialists, nurses, pharmacists, physiotherapists, psychotherapists, dieticians, etc.) and healthcare institutions (hospitals, rehabilitation centres, rest and care homes, etc.). This is especially the case for the ever-growing group of chronically ill patients. Patients are also increasingly mobile, both within their own country and abroad, and care is increasingly provided remotely (e.g. telemonitoring). It is very important that information about the patient’s state of health, about the care treatments received and about the results achieved is carefully kept in a well-structured way by each of the healthcare providers and institutions involved, at all levels of care and across disciplines. And it is even more important that this information is made available electronically in an efficient but secure way to other healthcare providers or institutions that are caring for the patient at the same time or later on. And this in a way that allows decision support systems to be applied to them automatically, while of course respecting the therapeutic freedom of the healthcare provider.

The patient himself must also be able to consult, store or make available certain data electronically. He must be able to participate as a full, empowered partner in the care process, and in the supporting electronic data and knowledge sharing. After all, his health is at stake.

Efficient and effective care is therefore multidisciplinary and transmural care, in which the healthcare providers are well attuned to each other. Where they can have a good knowledge of the patient’s information and the state of the art and use it when they need it. And where they actively involve the patient in the care of his health.

The rapid, secure, electronic exchange of data also avoids unnecessary multiple examinations, which place an unnecessary burden on the patient and generate unnecessary costs.

It can also relieve patients and healthcare providers of the time-consuming task of filling in numerous paper forms, which wastes valuable time that could be better spent on care. Well-thought-out and secure electronic processes at each actor and especially across actors can greatly reduce this burden and significantly cut waiting times for obtaining care.

Finally, electronic data exchange can support health policy and research by bringing together accurate and longitudinal electronic information on many patients, treatments and outcomes in an anonymised or pseudonymised manner, without inappropriately compromising the privacy of each individual patient.

In order to promote and coordinate proper electronic information management and especially information exchange in the Belgian healthcare sector, the eHealth platform was created in 2008. This public institution is building on the results of the Crossroads Bank for Social Security, which has succeeded in bringing the effectiveness and efficiency of the use of information and communication technology (ICT) in Belgian social security up to a level that was declared global best practice by the United Nations in 2006. The Belgian eHealth approach was awarded a Sharing & Reuse Award by the European Commission in 2019.

To ensure that all healthcare actors can trust and cooperate in the informatization, the eHealth platform is managed by representatives of these actors: healthcare providers, healthcare institutions, health insurance funds, patients, federal public institutions competent for aspects of healthcare and, since the cooperation protocol, also representatives of Communities and Regions competent for aspects of health policy.

In order to ensure proper privacy protection and information security in the process of informatization, an independent Information Security Committee, appointed by Parliament, has been created. All electronic exchanges of personal data in the health sector must be authorised in advance either by the patient concerned or by law or by prior authorisation of that Information Security Committee. Very great attention is paid to the safety of the managed and exchanged data.

In accordance with our social standards, the system does not include a central storage of all personal health data of the patients. These data remain stored and managed under the responsibility of the various healthcare providers and healthcare institutions or the patient himself. However, nothing prevents certain healthcare providers, healthcare institutions and/or patients from agreeing to the physical storage of data with the necessary high-level encryption and access rights on common hosting platforms, managed under their joint responsibility, or even to be gradually placed in the cloud.

The eHealth platform does not manage health data as such, but instead it manages a reference directory in which the patient can have references registered to the healthcare providers or institutions that possess health data on him or her. In this way, even a healthcare provider or institution that has a sporadic therapeutic relationship with a patient can easily find all relevant data.

In order to enable the electronic exchange of the decentralised personal data, standards and specifications have been defined according to which the data are stored and communicated. In addition, standards have been established with which software packages  for healthcare providers and institutions must comply. These norms, standards and specifications relate, for instance, to quality, security and semantic and content interoperability, and are based as much as possible on international norms, standards and specifications. Only if the software packages comply with the norms, standards and specifications, will the healthcare providers and institutions using them be reimbursed by the government for their purchase and use. This will encourage everyone to use software packages that allow to adequately store and share information in the interests of the patient.

The use of relevant international norms, standards and specifications avoids an unnecessary huge amount of time spent on the development of specifically Belgian norms, standards and specifications, allows users of software packages to choose products on the international market, and makes it easier for Belgian companies to offer their products on the international market. This reduces the cost of software and promotes open international competition.

The eHealth platform has also developed a number of basic services that are available free of charge to healthcare providers and institutions and their ICT service providers to support efficient and secure electronic data exchange.  Examples include a uniform system for healthcare providers to prove their identity, their status as a healthcare provider and their therapeutic relationship with a patient to all kinds of applications, a system for healthcare providers to encrypt electronic information so that no one other than the recipient can intercept and read it, or a system for coding or anonymising personal data so that they can be used in de-identified form for research purposes or to support policy.  The eHealth platform supports providers of software for healthcare providers, healthcare institutions and patients to access these services from their packages and provides connectors for this purpose free of charge.

By making these basic services and connectors available free of charge throughout the country, avoids having to develop them several times and, above all, avoids burdening healthcare providers with multiple systems that are not compatible with each other and therefore with unnecessary burdens and costs.

The eHealth platform is used for many applications.  For example, the secure eHealthBox is used extensively for the exchange of health data between healthcare providers and institutions.  Prescriptions for medicines, both in hospitals and in the outpatient care, are created and exchanged electronically, so that it is no longer necessary to copy information and there is a basis for the shared electronic pharmaceutical record.  Building on existing local and regional initiatives, general practitioners, specialists, hospitals and other care providers, who are able to prove a therapeutic relationship with the patient, can access the data that are useful for quality treatment and that are available at all hospitals, clinical laboratories and medical imaging centres in Belgium. The same target group can also access information from extra-mural care providers (medication scheme, vaccinations, allergies, recent diagnoses, care plans, …) available in the patient’s extra-mural health vault.  Access to data can be organised very granularly, depending on the type of healthcare provider, for example, using highly sophisticated access control and encryption techniques. The cancer register and the prosthesis and implant registers (all of which support multidisciplinary and transmural care) are fed and consulted electronically, while medical assessments of disabled people are exchanged electronically and birth registrations can also be made electronically.  The rights of patients in health insurance can be consulted electronically directly at the health insurance funds by the healthcare providers and healthcare institutions authorised to consult them.  Invoicing of costs by healthcare providers and healthcare institutions may, insofar as the law permits, be carried out directly to the health insurance funds by electronic means, thus enabling faster payment of invoices.  Requests for reimbursement of medicines, prostheses and implants, for which the health insurance fund must give its approval, can be submitted electronically using simplified processes, and the right to reimbursement can be consulted online by healthcare providers regarding their own patients. For general practitioners, there are decision support systems that can be applied directly to properly structured electronic patient records, which can advise them on quality care and draw their attention to possible errors. Patients can consult relevant data about their health and examinations, as well as evidence-based health advice, via the portal MyHealth.

Other projects are being considered. Documents with relevant data for the reimbursement of healthcare costs by supplementary hospitalisation insurers could be created almost automatically by the software packages of the healthcare providers and institutions involved and transferred electronically to the insurer in a standardised manner. With the consent of the patient (or his/her parents), healthcare providers could electronically drop sickness reports in the mailbox of his/her employer or school. Also, all kinds of useful databases, such as a database of medicines (with usage guidelines, contraindications, incompatibilities and reimbursement conditions) would be accessible to everyone via the eHealth platform and could be called up directly from the healthcare provider’s or institution’s own software.

Gradually, some of these services are made available for mobile devices. This requires software-as-a-service platforms, customised communication tariffs and reliable, high-performance internet coverage throughout the country.

The described evolution of the use of ICT in healthcare is absolutely necessary for the above-mentioned purposes of optimising the quality of care and patient safety, policy and research support, cost efficiency, empowerment and administrative simplification. But it must be done well, with trust and a willingness to change on the part of all actors, and with out-of-the-box thinking where necessary. Healthcare providers must dare to change their working methods in the interest of the patient, and the government must adjust its legislation where necessary. Telecom operators should offer low-cost broadband to actors in the healthcare sector. All processes that are sub-optimal in the light of the aforementioned objectives should be rethought, in dialogue between all actors involved. To this end, a multi-annual action plan is agreed upon annually between all actors. Financing mechanisms are adapted so that they contribute to ICT being used to achieve these goals, i.e. output financing (financing for achieving the goal) rather than input financing (financing of the ICT resources deployed).

The eHealth platform is counting on everyone’s contribution to this enormous evolution, which, if it succeeds, could place Belgium among the world leaders in effective and efficient ICT support in healthcare, as it is for social security.

More than 10.4 million Belgians (89.8 %) have already recognised the benefit of electronic sharing of health data and have given their informed consent to this. In 2021, the basic services of the eHealth platform were used more than 19.6 billion times for the electronic and secure exchange of data.

For more information on eHealth, in a dynamic perspective, please visit www.ehealth.fgov.be.