Key Benefits:
The Minister of Health, Family and Disability,
In view of the Public Health Code, and in particular Articles L. 1421-3, L. 6113-7, L. 6113-8, L. 6114-2, L. 6114-3, R. 710-5-1 to R. 710-5-11, R. 710-5-23, R. 710-5-24, R. 714-3-43;
In view of the Code of Social Security, and in particular Articles L. 162-22-1, L. 162-30-1 and R. 166-1;
In view of the Penal Code, in particular Articles 226-13 and 226-14;
Law No. 78-17 of 6 January 1978, as amended Computers, files and freedoms;
In the light of Decree No. 78-774 of 17 July 1978 amended for the application of Chapters I to IV and VII of Act No. 78-17 of 6 January 1978 relating to computers, files and Freedoms;
Having regard to Decree No. 99-919 of 27 October 1999 taken for the application of Chapter V ter of the law n ° 78-17 of 6 January 1978 relating to computers, files and freedoms and the processing of personal data Health for evaluation or analysis of care and prevention practices and activities;
Due to the letter from the National Commission on Informatics and Freedoms dated June 24, 2003, number 03007340,
Stop:
I. -In order to carry out the medical-economic analysis of the health care activity carried out within them, the health facilities referred to in Articles L. 6114-2 and L. 6114-3 of the Public Health Code shall implement automated processing of the Following personal medical data: Standardized weekly summaries (HHR), with components identifying patients and their movements, for all patients who are cared for in medical units of follow-up care or rehabilitation (CRDD), in full hospitalization, Week, day and night, as well as in ambulatory treatments and cures. The definition of medical units belongs to each health care facility.
II. -The implementation of these automated treatments must be preceded, by the institutions concerned, by a request for an opinion or an ordinary declaration to the Commission Nationale de l' informatique et des libertés (CNIL). Health institutions shall fulfil their legal obligations by filling in the model set out in the Annex to this Order. Institutions that have, on the date of publication of this Order, made an application or a similar declaration pursuant to the Order of July 29, 1998, are not required to have a new formality.
III. -The health care facilities referred to in the I of this Article shall take all appropriate steps to enable patients to practice with the medical information doctor, through the practitioner who has established the File, their rights of access and rectification as provided for in Articles 34 and 40 of the aforementioned Law of 6 January
. -After being made anonymous, some of the information in the standardised weekly summaries shall be communicated, in the manner described in Article 6 below, to the regional hospital agencies. The communication of this data is in the form of anonymous weekly summaries (RHA) and chained, and in the form of semi-annual summaries of anonymous weekly summaries (SSRHA), as described in Article 5 below.
I. -Within each medical unit of follow-up or rehabilitation care, the categories of information recorded on the HHR are:
1 ° Patient identification information:
-patient administrative number;
- SSR residence number: Identifier corresponding to the total stay in the medical units of the health care facility;
-date of birth of the patient;
-sex of the patient;
-postal code of the place of residence of the patient Patient or country of residence code of patient.
2 ° Other mandatory information:
-health facility number in the national health and social facilities file (FINESS);
-medical device number;
-type of activity describing the type of patient care;
-week number ;
-patient days;
-and, only for patients in full or weekly hospitalization:
-dates and modes of entry and exit of the patient into the medical unit for follow-up or rehabilitation care;
-where appropriate, type of transfer or transfer (source, destination of patient);
-primary purpose of taking Load;
-main morbid event;
-etiological condition (if different from the main morbid event);
-date of last surgical procedure (if necessary);
-associated diagnosis (s) Significant (s) (if applicable);
-medical procedures;
-rating the dependency of the Patient according to a PMSI specific grid;
-use of a wheelchair during the stay;
-weekly time/workers for rehabilitation or rehabilitation activities.
This information must be consistent with the Contents of the medical folder.
II. -With the exception of 1 above, if the person was treated on condition of anonymity, the identity information is limited to the year of birth, sex, administrative number and the patient's SSR residence number.
I. -Several weekly summaries (RHS) can be produced consecutively during a stay. Each of these HHR is classified in a major clinical category (CMC) and in a homogeneous group of days (GHJ), as listed and described by the classification in the Official Bulletin of the Department responsible for the Health. A methodological guide, published in the Official Bulletin of the same Ministry, sets out the modalities for the production and coding of HHR. These publications in the Official Bulletin are supplemented, as necessary, by means of circulars, to incorporate the intermediate changes in the classification or the terms of the compendium.
II. -Morbidity variables (primary purpose of care, major disease manifestation, etiologic disease, and significant associated diagnoses) are coded according to the International Classification of Diseases (ICD) of the Organization World Health Organization (WHO), supplemented, where applicable, by extensions published by the Hospital Information Technical Agency (ATIH). Rehabilitation and rehabilitation activities are collected according to the catalogue of reeducation-rehabilitation activities published in the Official Bulletin of the Ministry of Health, in its latest version. The dependency variables are quoted according to a grid of dependence developed specifically for the HHR collection, presented in a methodological guide to the production of HHR published in the Official Bulletin of the Ministry of Health. Medical procedures are collected and coded according to the current classification, in its most recent publication.
I. -Within the framework of the provisions laid down in Articles R. 710-5-1 to R. 710-5-11 of the Public Health Code, the physician in charge of medical information for the health care institution shall be responsible for the constitution, from the data available to it File, from a HHR file. The retention period for a year's RHS files is five years.
II. -The physician in charge of medical information implements the group in GHJ of the weekly summaries and performs the processing of the nominal medical data necessary for the analysis of the activity. According to modalities adopted after the opinion of the Medical Commission or the medical conference of the establishment, it shall ensure the dissemination of the information resulting from these treatments to the management of the health care facility and the President of the The medical commission or medical conference of the institution, as well as the practitioners who provided care, under conditions that guarantee confidentiality of data and the anonymity of patients. It is informed of the purpose of the processing of the information requested and is involved in the interpretation of their results.
It ensures the quality of the data transmitted to it and advises the medical facilities and Medico-techniques for their production.
Under the conditions laid down by law, public health inspectors and practitioners of health insurance organisations have access, through the information doctor Medical, to HHR files. As part of the monitoring and data validation procedures, the practitioners responsible for the relevant structures are informed in advance of any HHR confrontation with a medical file.
It consists, under the responsibility of the physician referred to in section 4, of HHR and HSSHSS files. The HSSHSS provides additional information from those provided by the RHA and provides a synthetic picture of the conduct of hospitalization during the semester. Products by a computer program owned by the state, the RHA has a key to chaining patient stays, built by the irreversible anonymization of the social security number, sex and date of birth, as well as the whole HHR information with the exception:
-the administrative number of the patient;
-the SSR residence number, replaced by a sequential number of stay;
-the medical device number (only figure, in HSSHSS, the number of medical units attended during the stay);
-from the date of birth, replaced by the age expressed in years and calculated on the Monday of the observed week;
-the postal code, replaced by a geographical code assigned according to a list agreed at national level, in agreement with the CNIL;
-en Full or weekly hospitalization, dates of entry and exit, replaced In the RHA by the specification of a SSRs start week (yes/no), one week end of stay SSR (yes/no), the prior art of the SSR during the week under consideration, and an indicator based on the dates of entry or exit To order stays of the same patient in an institution;
-the number of the week, replaced, in the RHA, by month and year.
I. -For each half-year period, the health care facility shall transmit to the regional hospital agency the data files referred to in Article 1.IV and the content of which is specified in Article 5. These files are from the latest version of the RHA generator. Transmission shall be carried out on magnetic media or by a method of teletransmission approved by the services of the State responsible for the processing of the files, not later than three months after the end of the relevant semester
-After processing the data files mentioned in the previous article, the ARH will return to each institution statistical tables of
. -Each regional hospital agency shall transmit all or part of this data to those of the health insurance bodies or the services of the State of the region who contribute to its activity, in accordance with the specified terms and conditions In the application for authorisation granted by the CNIL in the abovementioned decision. The regional agency transmits to the Technical Agency for Information on Hospitalization (ATIH) the files consisting of all the information transmitted to it by the health institutions of the region in respect of the two semesters of the year Within six months of the end of the year in question.
The regional hospital agencies or the technical agency for hospitalization information communicate these files to any other insurance body Illness provided that it has been authorized to deal with it by National Commission on Informatics and Freedoms in the framework of the provisions of Chapter V ter of the aforementioned law of 6 January
. -For each health care facility, the physician responsible for medical information is responsible for the backup of the bundled RHS file, which is the source of the HHR files, HSSHA, and the preservation of the copy produced.
The director and chairman of the medical commission or medical conference of the institution are the recipients of statistics, aggregated by unit For the whole of the structure or, on their request and under the conditions laid down in Chapter V ter of the Law n ° 78-17 of 6 January 1978 relating to computers and freedoms, files of RHS, RHA, SSRHA or extracts of data From these files.
The order of 29 July 1998 on the collection, processing of medical activity data referred to in Article L. 710-6 of the Code of Public Health, by public health institutions and Article L. 710-16-1 of the same code, and the transmission, referred to in Article L. 710-7 of the Public Health Code, to the regional agencies of hospitalization, of information resulting from this treatment is Repealed.
The director of hospitalization and care organization at the Ministry of Health, Family and Disabled Persons is responsible for The execution of this Order, which will be published in the Official Journal of the French Republic.
Done at Paris, June 25, 2003.
For the Minister and by delegation:
The Director of hospitalization
and the care organization,
E. Couty
Note. -The order accompanied by its annex will be published in the Official Bulletin of the Ministry of Social Affairs, Social Work and Solidarity No. 2003/30 (Ministry of Health, Family and Disabled Persons) at a price of EUR 10.82, Available at the Official Journals Directorate, 26 Desaix Street, 75727 Paris Cedex 15
