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Accenture

Confronted with a heterogeneous political and technological landscape, Spain is now taking steps toestablish the parameters for EHR implementation.

The Spanish healthcare system is based on the principles of “universalidad”: global coverage, equality and a decentralized structure. The Spanish healthcare scenario is highly fragmented, organized by each of the 17 “autonomous communities” (roughly equivalent to states in the United States, with wide legislative and executive autonomy and their own parliaments and regional governments) across Spain, each with full healthcare services management and decision-making capabilities. The central government’s Ministry of Health and Consumption plays a leading role in coordination and inter-territorial compensation, defining the healthcare policies applicable to the 17 autonomous communities.

Similar to the National Health Service (NHS) in the United Kingdom, the Spanish system is based on a national health service model, mostly financed with public funds (accounting for nearly 90 percent of national spending in health-related services), and complemented by working agreements with private healthcare services.

There is also a growing private healthcare market, accounting for the remaining 20 percent of national spending. Three private health insurance companies, sharing nearly 80 percent of the private market, dominate the private healthcare area. These “big three” maintain their own small- and medium-sized healthcare center networks and medical benefit companies that reimburse medical expenses. They support the emerging hospitals networks — private healthcare organizations (such as hospitals and clinics) that contract surplus capacity to the public healthcare sector.

As with the healthcare industry, the IT systems in the healthcare organizations are characterized by heterogeneous, immature technological environments with investment rates of less than 1 percent. This situation has strong growth potential, with several upgrade initiatives focused on information consolidation/centralization, increased access for the patient, expanding computerization to clinical practices and implementing an EHR standard.

With respect to health information systems and EHR on a national level, the Ministry of Health and Consumption maintains a centralized database of citizens’ information, including a national repository of basic data on hospital admissions and discharges (CMBD). The CMBD is fed with information from all 17 autonomous communities, as well as from the private healthcare sector. Based on the number of patient names and contacts with healthcare providers (not yet, however, on the type and quality of the contact), the CMBD determines the amount of the subsidy paid out to each autonomous community by the Ministry.

EHR Approach and Objectives

The basic concept behind the coming EHR implementation in Spain is a template that contains a patient’s complete health history, with all information generated by healthcare professionals providing any level of healthcare.

The increasing mobility of people and the “local” generation of records throughout an individual’s life affect not just the health centers, but also national and European policies. This is why the Spanish healthcare system considers EHR as a group of reports scattered in different locations, virtually associated by sequence links coordinated through a single patient identification code. The database systems storing this information should be “open” and interconnected through large capacity communication networks to enable EHR access both by patients and physicians over the Internet (and incorporating security and privacy functionalities).

Given the fragmented healthcare structure and the need to link clinical information from all autonomous communities, the Spanish Healthcare Information Society (Sociedad Española de Informática Sanitaria, or SEIS) has set three EHR functions:

• Help promote and maintain patient health and safety;
• Function as a legal document; and
• Provide a source of knowledge for research and education.

Current Situation for EHR

Bearing in mind the healthcare industry’s technical heterogeneity, the baseline situation for EHR implementation in most of the 17 autonomous communities can be generally characterized by:

1. The consolidation of a healthcare card system (mostly based on a magnetic band without clinical data) and a patient ID card. These systems are complex and complete (covering 98 percent of the population) and include a patient’s administration information as a prerequisite to EHR implementation.
2. Hospital environments with ERP systems (human resources, financial, logistics and maintenance) and patient management (HIS-ADT, mostly standard packaged solutions provided by vendors such as HP, Siemens, Novasoft or SAP), consolidated with approximately 100 percent coverage. Specialized outpatient care relies on the hospitals and shares the same information systems. Computerization in departmental areas is achieved with HIS-integrated systems at the local level (RIS, PACS, laboratories, pathological anatomy, etc.). The technological environment is decentralized and client-server based, making information sharing and remote access difficult. Autonomous communities generally maintain showcase “excellence hospitals” where new management models are developed and latest-generation technology EHR systems (intra-hospital) have already been implemented.
3. The Centros de Salud (primary healthcare centers) are nearly 100 percent computerized, with patient information, clinical management and EHR (standard packaged solutions, developed at the national level by vendors such as Stacks and Novasoft) capabilities. The IT architecture is characterized by distributed client server environments that hamper the transfer of patient clinical information to other primary healthcare centers or hospitals.
4. Initiatives to integrate primary and specialized healthcare systems, primarily for patient appointments and the request and receipt of diagnostic tests. In certain autonomous communities, patients are given access to appointment systems to make it easier for them to manage their queries. These initiatives represent the first step in the consolidation of relevant clinical information and EHR implementation. Given the heterogeneous nature of the IT environments, enterprise application integration-based solutions were selected (such as Biztalk, Tipco or Rhapsody).
5. To enable EHR implementation, large functional and technological transformation projects are under way. These involve system centralization/consolidation, with Internet technology at the primary and specialized healthcare levels, the definition and convergence of HL7 and IHE-based integration standards, XML messaging and Web services.
6. Similarly fragmented development and progress in the private healthcare sector, although EHR implementation initiatives focused on providing citizens with access to their clinical data (appointments, discharge reports and test results) exist.

Funding of both public and private projects is generally undertaken by the corresponding organizations launching these projects.

Remaining Challenges

The technology for EHR implementation has been available in the autonomous communities for some time. Nevertheless, it is necessary to define and reach a consensus on the necessary standards that make a modern EHR system possible, and make it accessible from any location — fulfilling the needs both of patients and physicians.

In Spain, EHR implementation is a government mandate and is regulated by the Health Care Law and Law on Protection of Personal Data (LOPD). But in contrast to conventional paper medical records, an EHR is more demanding and requires greater legal and technical guarantees with respect to physical and logical security.

Factors for Success

The creation of a patient master file should be considered first. This file should be unique and common for the entire organization, containing basic patient data and ensuring secure patient identification throughout the entire healthcare network. Automated update and replication mechanisms are needed to maintain current records on all relevant systems.

It is also advisable to consider global standard clinical encoding solutions that cover the patient’s entire clinical history and enable system interoperability — to eliminate the existing barriers for information transfer between heterogeneous systems.

Finally, by guaranteeing information security from the solution design origin, ensuring data integrity, confidentiality and availability from the patient and physician perspectives:

• The healthcare professional has the right to access the patient EHR by creating the corresponding access profiles;
• The patient’s express consent is needed to share information with healthcare professionals; and
• The patient has access to check his/her clinical records.

Moving Forward

Achieving EHR implementation in each of the autonomous communities can be enhanced by significant corporate projects, where change management is a key element and more relevant than technology. Change management will establish mechanisms to guarantee the quality of deliverables, ensuring that these meet requirements and are aligned with the overall corporate strategy.

EHR implementation is directly related to the level of technological development. This means all involved agents should meet and exceed a “technology threshold” to ensure success, and avoid a situation where one agent is technologically advanced (such as primary healthcare) and another does not meet the minimum requirements (such as specialized healthcare). Therefore, EHR implementation must be approached globally, and not begun through a single agent.

Summary

Heterogeneity and the standardization difficulties are key characteristics of the Spanish healthcare environment. Generally functionality and service suffer when systems are standardized at any price. Consequently, these heterogeneous systems should be integrated through service-focused architectures, integration platforms and integration standards. Using standard solutions with open systems will make it possible to benefit from the knowledge and experience of others.

EHR implementation in Spain will require a high level of technology and human commitment. This implies managing the resources needed to achieve a functional and reliable EHR system. The autonomous communities will take the initial steps toward this ultimate goal during the next two to three years.