The infrastructure for central exchange

In the Netherlands, there is currently an exchange of patient data through a central organization, the “Landelijk Schakelpunt” (LSP). It is a system that elaborates on the National Electronic Health Record (EPD) that was introduced in 2008. The EPD was initiated by the Ministry of Health, Welfare and Sport (VWS) with the aim of retaining digital patient data and making it available.

In 2011, it was decided not to proceed with the EPD because the system would not be safe. Since then, a similar system has been developed, the LSP. This system is managed by VZVZ, a communication specialized organization consisting of twenty parties from the care sector. The main differences between the current LSP and the original EPD are:

  1. Every patient must explicitly give permission for participation in the national EPD
  2. No automatic and mandatory EPD participation by health care providers
  3. No national system but a regional set-up

National exchange from care providers: the Landelijk Schakelpunt (LSP)

The LSP is a care infrastructure where the majority of public and outpatient pharmacies, General Practitioner, GP practices, and hospitals in the Netherlands are connected. Through this network it is possible to consult medical data of patients in each other’s systems. The LSP has been specially developed and secured for this purpose.

It is important to state that the LSP is not a database, since no medical data is stored. It is a highly secure infrastructure where data is transported. The data is only available if patients have given permission. In addition, there are only two health care providers who can make the medical data available to a patient for insight by other health care providers through the LSP: the general practitioner and the pharmacist. They may only do so with the patient’s express consent: the opt-in.

Permission from the patient

When requesting permission, the general practitioner and the pharmacist must first inform the patient properly. The patient needs to know exactly what he/she gives permission for. This is described in the leaflet “Your medical data available through the LSP. Only if you agree ” The folder contains a permission form. The patient can fill in the form, sign it and return it in to his or her doctor or pharmacist.

Besides giving written permission, the patient is also able to give permission online. Many GP practices and pharmacies participate in the website “www.volgjezorg.nl.” On this website, the patient can look up his or her care provider and then, using their DigiD (Dutch authorization system), give online permission. The permission form can be found on the link below:
https://www.volgjezorg.nl/toestemming

The third possibility, besides written permission and permission online, is the patient giving verbal permission in the general practice or the pharmacy. This possibility is randomly checked by VZVZ throughout the Netherlands because of the susceptibility. When it concerns a verbal consent, it must be clearly stated that it is a matter of sharing patient data through the LSP.

When a patient has given his or her consent, a notification goes to the referral index within LSP. This registration is coded with to the unique identification code for citizens in the Netherlands: the BSN. The registration is recorded centrally. Permission does not includes the sharing of all information in once, the permission is divided per category (hospital, pharmacy, general practitioner). If a patient wants to share all information, permission must be given for all components. Since recently it is also possible for pharmacies to make applications, this is not yet possible for hospital pharmacies.

Available patient data in the LSP

When the patient gives permission, the patient data will become available for the LSP. This information can be requested using the BSN number. Once the request is received, the concerning general practitioner discloses a part of the patient’s file: the professional summary or General Practitioner data. These include:

  • The episode list (all open episodes);
  • The journal list (consultations of the last four months or the last five consultations);
  • prescribed medication for the last four months;
  • Measurements and results within the period of the delivered journal;
  • Contraindications;
  • Current transfer data.

The pharmacist provides an overview of the medication provided to the patient: the medication overview. This includes:

  • The medication provided to the patient in the last six months;
  • The data on intolerances, contraindications and allergies.

 Terms and conditions for joinging the LSP

To be able to join the LSP, a healthcare institution must first have a secure network. Connecting to the LSP includes an audit of care systems and an audit on care networks. Only by means of a GBZ (well-managed care system) and a GBN (well managed network), one can connect to the LSP. Healthcare professionals must have a UZI card. This is a card with which identification, authentication and authorization of a healthcare professional takes place. A healthcare institution must have a UZI server certificate. The UZI server certificate confirms the electronic identity of the system if the healthcare provider logs in to the LSP.

A GBZ (well-managed care system) means that the healthcare information system must comply with a program of technical and organizational requirements for the proper and safe exchange of medical data. VZVZ has provided a list of accepted XISs that provide a GBZ.

A GZN (well managed network) is a network that ensures good and safe communication between the GBZ and the LSP. VZVZ has also provided a list for this subject with accepted GZNs.

When all conditions are met, institutions can request medication or information in the LSP using a ‘viewer’.

Terms and conditions for requesting data LSP

Besides the fact that patient data are only available to the LSP after explicit consent from the patient, there are also strict conditions for retrieving this data. A healthcare provider may only request data when he or she has a treatment relationship with the patient and this is necessary for the treatment of the patient. In addition to a UZI card, a healthcare provider must also have a BIG registration. The BIG register includes doctors, pharmacists, physiotherapists, health care psychologists, psychotherapists, dentists, obstetricians and nurses.

Regional exchange from care providers: Regionalization of the LSP

For the exchange of patient data within the LSP, the network is subdivided into 44 regions.

A region within the LSP consists of at least one HDS (general practitioner service structure) with collaborating general practitioners and a service pharmacy with collaborating pharmacies.

Every care provider is divided into one region based on his work area. A healthcare provider can also join multiple regions. This can be the case when:

  • A healthcare provider is established in the working area of ​​the HDS and / or service pharmacy of another region;
  • The patient population of a healthcare provider partially lives in another region;
  • A healthcare provider request data types that are shared via the LSP within a different region.

Data exchange within the Regional Cooperation Organization (RSO)

A RSO is an organization that promotes data exchange within the region. A RSO is initiated by the healthcare providers themselves who are working in that specific region, therefore a RSO has a broad mandate and trust. This means that an RSO has the opportunity to implement communication solutions in the region and increase the use of them. RSOs are not bound to a specific solution or specific supplier; they make use of the facilities that provide the needed exchange of information. An example of this is the exchange of visual material through the XDS network.

Within the RSOs, another kind of patient data is exchanged compared to the LSP, such as: general practitioner data, medication data, data from the youth health care and data from the mental health care. RSOs are independent and manage the infrastructure for data exchange themselves, using their own regional manager. The Healthcare providers can only exchange medical data within their region. Hospitals are the exception, they have the possibility to request data throughout the whole country.

“RSO Nederland” is the umbrella association of all regional cooperation organizations in the Netherlands. They guarantee the quality and interests of the RSOs and promote standardization in healthcare communication for all RSOs in the Netherlands. To prevent all RSOs from exchanging information with each other and creating their own exchange paths, a project is started to centralize communication via the LSP. This project is currently in the start-up phase.

There are currently nine RSOs in the Netherlands: GERRIT, IZIT, Sleutelnet, RZCC, RSOHaaglanden, REN, EZDA, TRIJN en RijnmondNet.

The figure above shows that not all regions have a RSO yet. For the regions where no RSO has yet been developed, the exchange takes place through bilateral links or doesn’t happen at all. In the future, all regions will conduct their own management by means of an RSO.