Healthcare IT in France is a mix of gems and some persistent dark spots. The former arises from its world-class ‘dirigiste’ policies for high-technology in general. The latter are mainly due to the complexities of its welfare system (in the shape of enduring healthcare budget deficits) and its generally slower adoption of the Internet – ironically, a legacy of that erstwhile Internet-like early bird, the Minitel. Nevertheless, recent years have witnessed a sharp escalation in awareness about the need to take up a leadership role and pioneer new directions in healthcare IT.
Doubling Healthcare IT Spending by 2012
France’s 2012 Hospital Plan seeks to double the share of spending on hospital information systems (HIS) from 1.7% - a level at the bottom rungs of the EU league table - to 3%, and their modernisation constitutes one of the Plan’s over-arching objectives.
The outlays are impressive. According to leading French financial daily Les Echos, the Hospital Investment Plan 2012 would entail 5-year investments of 10 billion Euros.
The roots of this resolve date back to 2000, when France established the Technical Agency for Information on Hospitalisation (known by its French acronym ATIH). ATIH is a public authority responsible for the technical coordination of the country's backbone hospital information system(s).
Its mission has been to replace slow, inefficient and expensive manual processes for data processing and exchange between hospitals and regional healthcare agencies, as well as meet the demand for increased frequency of administrative data filing on areas like pathology, patient treatment, and diagnosis.
Its own IT system, built on JEE architecture, automates the generation of healthcare activity metrics, manages data exchanges across secure connections and speeds up healthcare budget evaluation and allocation.
Smartcards and Biometrics
ATIH, on its part, coupled into another bellwether IT initiative in France focused on smart cards, a technology area where the country has long been considered a pioneer. The key goal of the so-called smart health card (first rolled out in 1998) has been to computerise and thus simplify and speed up medical treatment.
Currently, there are almost 600,000 users of the CPS smart card – targeted at giving healthcare professionals access to the e-Health infrastructure. In addition, there are almost 60 million recipients of the Carte Vitale – for patients. A new version of the Carte Vitale was introduced in 2006 (initially in Brittany and the Pays de la Loire), and in stages, is expected to cover the entire population by 2010.
The new smart card, Carte Vitale 2, includes a digital facial biometric photograph to cut down on fraud and includes a host of other patient data: personal contacts for an emergency, blood group, the name of the GP, details on membership of a sickness fund and position on organ donation.
Activity-Based Hospital Financing
In 2004, France added further momentum to its healthcare IT modernisation drive with the establishment of new activity- based funding systems at hospitals. This has compelled them to optimise IT systems to ensure they accurately record clinical activity in order to get paid. Alongside, wider awareness of factors such as RoI and quality of care metrics are also driving demand for healthcare IT.
The DMP: Anytime, Anywhere Patient Data
2004 also saw the legal foundations of the Dossier Médical Personnel (DMP) or ‘personal medical file’, which has sought to create Electronic Medical Record for all French residents covered by health insurance.
As with similar initiatives elsewhere in Europe, the DMP seeks to improve healthcare efficiency and quality by facilitating information exchange and coordination between health professionals as well as medical facilities, during consultations, diagnosis and treatment. Overall, the DMP seeks to improve the continuity and quality
of care by enabling access to patient data from anywhere at any time.
Building e-Health Bottom Up, Too
Meanwhile. a host of pilots and standalone regional efforts seek to draw mileage from the DMP and, in turn, add value in a bottom-up positive feedback loop which strengthens the wider e-Health infrastructure in France.
For example, Paris-based Institut Curie has developed Promethee, a meta-search engine which allows physicians and other healthcare professionals to access its own DMP (known as Elios) and the hospital’s
entire database, and find both patient data as well as compare/evaluate medical best practices and treatment pathways.
E-Health initiatives targeted at patients too are on the upswing. The Auvergne Mobil’Assistance project begun last year, for example, aims to establish a tele-warning service via the local mobile telephone network. This project falls under the broader e-Health rubric of ‘medical teleassistance’, which were investigated in depth by an official study on the possibilities in healthcare arising from the broadband revolution. Another instance is a joint initiative by Grenoble and Toulouse University Hospital Centres, to enable diabetic patients to send their glycaemia data via mobile phones to their patient records hosted on a dedicated web server. The updated records are consulted by doctors, who then advise patients by SMS or synthesised voice message.
One of the most advanced regions in France (and Europe) in terms of e-Health is Nord Pas de Calais, where a swathe of telemedicine efforts have been conceived and kicked off in the late 1990s. The region’s hospitals share networks, and videoconferencing for multi-centre consultations have long been commonplace. One direct result is a decline in the number and urgency of inter-hospital transfers. Follow-on efforts are embedded within a discussion group called the e- Health Circle (Le Cercle e-santé), which proposes pilot projects.
A Mood of Cautious Optimism
Nevertheless, French industry and hospital sources consulted by HITM remain cautiously optimistic about future directions in healthcare IT and e-Health. Some are outright sceptical about the e-Health hype.
They cite a 2006 White Paper from Lesiss (the French association of healthcare IT professionals and industry), which found only 10% of French healthcare facilities had shared patient dossiers at the hospital level – while 30% had partial sharing. Meanwhile, it is not uncommon to find some of the most advanced hospitals in the country having 50-60 different IT systems.
One of the first challenges is to ensure that local and regional initiatives do not duplicate one another, and instead plug seamlessly into a national healthcare IT/ e-Health infrastructure, and one which does not neglect the role of hospitals in smaller Tier II and III cities and towns.
Equally, it is important that such developments remain consonant with still-emerging EU and international standards and regulations. France has a strong tradition of technological elitism. There is thus a real risk of an undue focus on technology for its own sake, rather than the increasingly user-facing requirements of the present cost-sensitive healthcare mood and culture in Europe.
Alongside, some healthcare opinion leaders believe that politicians do not appreciate the real revolution that IT and e-Health can provide for the general public and that the legislative agenda is neither quick enough or in tune with the sheer scale and pace of technological change.
The other challenge is that of information to the general public. As elsewhere, many French citizens remain seriously concerned about the security of confidential data in the DMP, especially since its access from anywhere at any time is a critical component of its utility.
At the end of 2005, French Senator Jean- Jacques Jegou submitted a highly critical report on the DMP, calling it “unrealistic” and describing the scheme as an airplane without a flight plan and a cockpit without a pilot.” Some of the Senator’s 10 proposals have specific relevance for the healthcare IT community – in terms of making physicians more IT friendly (and doing so on a continuing education basis), as well as anchoring the DMP more strongly within the wider landscape of modernising hospital information systems.
The French mass media too have stoked up bouts of hysteria over the DMP, especially in terms of security issues. At the end of 2006, the daily Liberation carried an article on the DMP headlined: ‘De big docteur à Big Brother’ (From Big Doctor to Big Brother), and warning its readers of the potentially grave consequences of misuse of patient data.
At the end, enhanced acceptance in France will depend on encouraging public involvement and use of the e-Health system. Some experts believe the answer will lie in growing integration of popular, mobile technology and imaginative projects which deliver healthcare the home, and call on the healthcare IT industry to take a leadership role in such a process.
On its part, the French government has also sought to get its population e-Health ready. The official health portal www.sante.fr provides the general public with information and links to all government health agencies.
Such umbrella initiatives have been bolstered by ad-hoc efforts on high-concern areas such as bird flu, where a dedicated official site (set up in 2006) catalysed an enormous number of visitors – and also acquainted them with the reach and benefits of the Internet in terms of healthcare.