The French Perspective
Healthcare in France Today
The French government provides diverse and comprehensive healthcare coverage for all citizens. For more than 96 percent of the population, medical care is either entirely free or is reimbursed 100 percent. French people can also choose among healthcare providers, regardless of income level.
French health insurance is a branch of the social security system and is funded by workers salaries, indirect taxes on alcohol and tobacco, and by direct contributions proportional to income. Currently 85 percent of health expenditures are paid by the national social security program. The rest is paid by private health insurers.
More than 80 percent of French people have supplemental insurance, often provided by employers. Additionally, treatment costs for those who suffer from long-term illnesses are completely reimbursed.
Organization of the Healthcare System
The state exercises control over the healthcare system through central, regional and departmental services. Two large organizations work under the Ministry of Health: General Health Management, and Hospital and Healthcare Management. Numerous healthcare facilities function under the direction of these two large organizations.
The healthcare establishment is composed of three types of institutions: public hospitals, private clinics and not-for-profit healthcare.
In all hospitals, doctors, biologists and dentists are paid as hospital practitioners. Public hospitals are financed primarily by endowment funding that is paid for by health insurance funds.
Private clinics were originated by surgeons and obstetricians and eventually evolved into private hospitals. A 1991 law requires all doctors in private clinics to share medical files with colleagues and to create a medical care commission to formulate evaluation procedures.
Another sector of the French healthcare system, nonprofit private hospitals, was originally denominational and currently makes up 14 percent of inpatient services among French medical care institutions. Like public hospitals, they are financed through endowments but have the right to privacy like private clinics.
The cooperation between the public and private sector is a positive feature that allows citizens to avoid the waiting lists for surgeries often associated with socialized medicine. The unique combination of government-financed medical care and private medical services produces a healthcare system that is open to all and provides the latest in medical technology and treatment.
Setting the Stage for E-Health in France
Since 1990, France has been working on several e-health initiatives to improve the quality of care and increase efficiency. In March 2002, a law was enacted which granted French citizens access to their medical files. The problem, however, is that coordination along the continuum of the French healthcare system lacks structure. Any one patient can have medical records residing in different hospitals, with different physicians, creating a fragmented health record separated by geography. In this way, collaborative care cannot occur in a uniform or efficient way.
The DMP Frances Answer to the EHR
France took a step toward implementing e-health when a law was passed in August 2004 stating that every French citizen should have a personal electronic medical record dossier médical personnel or DMP by July 2007, and that care reimbursement could be reduced if a citizen fails to present a DMP to a physician.
The national DMP initiative is pushing healthcare providers to invest in new technologies or upgrade internal clinical information systems to:
- Deliver faster, safer diagnoses, based on a better understanding of patient history and current health status;
- Reduce redundant clinical testing and imaging;
- Avoid patient complications due to drug interactions;
- Create medical statistics for epidemiology and to serve as a basis for health investments; and
- Introduce transparency to make it easier to set protocols, create policy and structure how care is delivered.
The DMP is expected to improve health value for money by reducing the costs of poor quality, which the Health Quality Agency estimates to run at least 15 to 20 percent of Frances total health budget.
A combination of Frances social security system and private insurers will underwrite the cost of the DMP initiative. These funds will be managed by a public interest group.
How the DMP Will Work
DMP systems will collect and centralize information from automated sources such as imaging facilities and laboratories, as well as data keyed in by office-based and hospital physicians.
The DMP system, with a Web interface, will be accessible via the Internet to the patient and to providers with a health professional card (an electronic card supplied to healthcare professionals). Only practitioners to whom the patient will have granted access will be able to view the file.
The new version of Frances health card, when introduced in 2006-2007, will serve as a patient identification tool and fit into the DMP system. The new card will include several features it doesnt include now, including a photo, PIN number and a patient ID to verify identity.
The national DMP system will rely on hosters, meaning private companies who will be paid to host the national electronic health record on behalf of payers, providers and patients. The hosters will be validated by the state according to quality and commitment, and will be employed by service contracts. Services will be sold on a transactional basis and paid by social security funds through a public interest group.
Hosters will also be responsible for managing the physician-topatient relationship, while ensuring continual availability of service 24/7 in a redundant and safe technical environment. Hosters will need to submit a robust disaster recovery plan and will need to meet the native scalability challenge their applications will face in terms of storage. Hosters must also ensure data integrity, confidentiality and access traceability.
A dialogue body will be established to communicate between DMP hosters and public powers on topics such as service levels, norms and interoperability, pricing and deployment.
DMP hosters will also have to translate proprietary formats (such as imaging or biology) into easily readable formats, such as a PDF file that can be read by any Internet browser. These translations will have to occur as software versions evolve to ensure information remains readable for the lifetime of the medical records.
All access to the DMP will be highly authenticated through appropriate encryption and electronic signature processes. Hosters will also employ time-stamping for each and every document to certify who posted what and at what time.
The DMP Initiative Current State
The DMP is the largest national e-health initiative today in France and follows the launch of electronic reimbursement several years ago. Another precursor to the DMP was the introduction of Frances health cards four years ago. These steps have paved the way to adding clinical content, which is the main focus of the DMP initiative.
Accenture has been supporting Frances evolving health network since the end of the 1990s, gathering firsthand knowledge of the issues around medical information sharing and collaboration. In 2003 Accenture helped create a dedicated subsidiary to work on the DMP project, called inVita. inVita, a leading group of services and technology firms, works together to address the necessary dimensions of the DMP. It includes representatives from La Poste, 9 Telecom, IntraCallCenter, Sun, EMC-Documentum, SeeBeyond, BEA and Accenture.Working with several, nonprofit health insurers, inVita developed a prototype of the DMP.
French payers and providers show different levels of readiness to connect to the DMP. The DMP project is already triggering clinical IS (information systems) projects in hospitals and hospital groups, but these are occurring locally
Hospitals are probably further along in connecting to the DMP than other groups. For example, current law already dictates that all patients leaving a hospital receive a copy of their hospital documents showing any care received. These records will be routed to the DMP, where they will be stored and tagged, ready to be linked to patient records as the DMP is built. inVitas target hospital networks.
Physicians surveyed by Accenture are largely in favor of the national DMP; however, over 50 percent have PCs and laptops that are older than five years and will not handle the high-speed Internet connections needed to log on and access patient records on the initial DMP platform.
In terms of patient records, inVitas goal is to add 500,000 patient records by the end of 2005, 4 million records by 2006 and 40 million records by July 2007.
Several live pilots have been established in Lels, Rouen and Paris prior to national deployment this year. All testing and results from these projects have been favorable.
Privacy Concerns
Data confidentiality within the DMP framework is a complex issue. Although it seems appealing to encourage patients to share as much information as possible, patients who are eager to maintain their privacy might not want all caregivers to see their full records. A compromise must be achieved that does not sacrifice quality of care in the name of patient rights.
DMP project coordinators have suggested that patients should be able to hide a medical event from certain caregivers. This means, of course, that a huge responsibility is placed on physicians to educate patients about the risks involved in withholding information.
It is important to note that some emergency data (such as allergies) will be placed in an easily accessible part of the DMP, perhaps with an automated voice synthesizer to deliver information to a physician calling in an emergency. For these data, patients must accept less confidentiality (meaning lighter protection of data) because the information may be needed to save a life.
Lessons Learned
Bringing players up to speed and hearing all concerns about the DMP project has been a tremendous job for inVita. Reaching out to patient advocacy groups, physician unions, hospitals and original health organizations has already required a great deal of time, and all players need to be kept in the loop as the DMP system is launched. This step is especially important in a decentralized environment like the French healthcare system, as it is easy for physicians and hospitals to act independently and develop solutions that are incompatible with the evolving DMP.
The main lesson of the DMP initiative is that e-health pioneers must take a pragmatic approach toward implementation and must find the right compromise between theory and action. Tying together countless IS systems is a daunting task; the best way to test the system is to learn by doing. Getting started helps to actively solicit buy-in from providers by showcasing early project wins and by encouraging reluctant players to get in the game.
Next Steps
Deployment of the DMP is imminent. Unfortunately significant infrastructure items will not be in place before September 2005, including high-speed connections, physician authentication cards in hospitals, modems and full support for legacy systems.
The risk is greater, however, in waiting for these steps to be taken rather than proceeding. If project participants wait for the ideal moment when all people, processes and technology are in place, the initiative will stall and fail. Its best to build patient records from bits and pieces of information, with the understanding that some information is better than none.
The solution is to engage a durable approach that will adapt over time during what promises to be a multiyear venture. Participants know they will soon prove some initial assumptions wrong, requiring redesign and reconfiguration; however, the DMP will be stronger as a result and lessons learned can be applied to the next phase. The best tactic is to start with physicians and hospitals that are already wired, then gradually add providers as technology permits.
Summary
In 2000, the World Health Organization stated that France provides the best overall healthcare in the world. Recent initiatives to introduce e-health mechanisms are bound to help France maintain this ranking by improving diagnoses, reducing redundancies and providing more information to providers for better-quality care. Frances primary ehealth initiative, the DMP, will go live in September 2005. It promises to improve coordination among caregivers by outsourcing the management of the system to third-party DMP hosters. The challenge will be keeping a project of this magnitude moving forward. The project faces significant challenges including complex privacy issues and players at different stages of technology readiness. The biggest risk, however, is allowing the project to get sidetracked by technical issues. The strategy being employed by inVita and all project participants is to get started now to gain momentum while resolving technical and process issues as they appear. By staying focused and systematically adding providers to the system, the DMP will gain critical mass and deliver its promise of improved healthcare for all.
