Health Identifiers Bill 2013: Second Stage

Question proposed: "That the Bill be now read a Second Time."

I welcome the opportunity to bring the Health Identifiers Bill 2013 before the House. It represents another step in the Government's reform programme which will provide a modern integrated health service that places patient care and safety at its centre. The Bill will allow us to introduce a system of unique identifiers for both individuals and providers of health services right across the health system, including both public and private providers. The Bill sets out what these identifiers are and who will use them, as well as governance arrangements, including the registers that will be put in place to hold the identifiers.

In developing a system of health identifiers, my Department has been keen to ensure the governance arrangements fully address any privacy concerns that individuals or health care providers may have. To that end, the Bill has been discussed with the Office of the Data Protection Commissioner during its development and I thank the office for its input which I believe has strengthened the governance arrangements set out in the Bill. I am sure Senators will agree that a strong governance framework is important to ensuring there is public confidence in the identifier system and right across the health system.

The case for health identifiers as key enablers of better patient safety and care is well established internationally. Individual health identifiers are fundamentally about patient safety and ensuring the right information is associated with the right individual at the right time - at the point of care.

The 2008 report of the commission on patient safety and quality assurance entitled, Building a Culture of Patient Safety, recommended the development and implementation of a unique identifier system for the health service. The national health information strategy also recommended the introduction of health identifiers and HIQA has advocated that identifiers should be provided for health care providers as well as individuals accessing health services. Health identifiers are not only an important tool in delivering safe and quality care; they will also play a critical role in managing the health service more efficiently and effectively. They are centrally important to the delivery of many reform initiatives - for example, the money follows the patient model - and the Government's ultimate goal for the health service, the introduction of universal health insurance to provide a single tier health service in which everyone can receive safe high quality treatment based on need rather than ability to pay.

Health identifiers also form an integral part of the e-health agenda. As Senators will remember, e-health strategy for Ireland was published on the same day as the Bill. The strategy sets out a strategic roadmap for improving health and well-being - for example, through the introduction of e-prescribing. The introduction of health identifiers will allow the health system to work much more efficiently. It will mean that the same information does not need to be collected on numerous occasions, something that can be a frustrating experience for both patients and health care providers. Unique health identifiers will also reduce the need for repeated diagnostic tests, because previous test results - even where they have been carried out by a different health provider - can be reliably associated with a patient's records.

Members will be aware that it had originally been intended to legislate for health identifiers in the Health Information Bill, on which the consultation process showed widespread support for the introduction of unique health identifiers. However, given their critically important role in supporting the effective delivery of the wider health reform agenda, a decision was made to develop a separate and focused Health Identifiers Bill, which takes account of the view of HIQA and other relevant stakeholders. In meeting publication timeframes, it was not possible to bring the Bill for pre-legislative hearing. Work is continuing on the other elements of the Health Information Bill.

The purpose of the Bill is to provide the legal framework for a system of unique health care identifiers for both individuals and health care providers. It is principally about patient safety, ensuring people are properly matched with their records, treatments and results.

The Bill sets out what health identifiers are, who can use them and the governance arrangements, including the establishment of registers to house the health identifiers. As I have mentioned, my Department has worked with the Office of the Data Protection Commissioner to ensure privacy considerations are fully addressed. In addition, the Bill provides for certain governance-related offences, which should also help to strengthen public confidence in the health identifier system. In relation to vaccination programmes and screening programmes, it is very difficult to have a true assessment of their effectiveness if doctors do not know what populations they are responsible for and if we cannot accurately determine who has been vaccinated and who has been screened. A unique health identifier will help in a major way.

I would now like to take members through the main provisions of the Bill. The first part of the Bill sets out a number of standard provisions, including commencement, interpretation, regulatory powers and provision for expenses incurred by the Minister for Health or any other government Minister.

Section 2 sets out a number of key definitions. "Specified persons" are defined as those who can use individual health identifiers and access the individual health identifier register. These health service providers and persons are listed in Schedule 2. "Authorised disclosee" is a person to whom an individual health identifier may be disclosed for a particular secondary purpose. Authorised disclosees are listed in Schedule 1. The Minister for Health can add to the list of specified persons and authorised disclosees by regulation, where doing so is in the public interest and following consultation with the Data Protection Commissioner. A "relevant purpose" defines the basis on which individual health identifiers can be collected, used and disclosed; this is divided into primary and secondary purposes. The "primary purpose" means the present, past or future provision of health services to an individual. A "secondary purpose" is defined as including the promotion of patient safety, including clinical audit and investigation and reporting of patient safety incidents; management of the health services, including planning, monitoring, delivering, improving, auditing and evaluating health services, investigating and resolving complaints about health services, and managing national health systems; certain health research; the provision of health or health-related insurance schemes; or the processing of personal data in accordance with the Data Protection Acts 1988 and 2003.

The second part of the Bill provides for individual health identifiers and the accompanying national register of individual health identifiers - the IHI Register. An individual health identifier will contain no personal data: it is simply a number.

Section 5 provides for the assignment of individual health identifiers. The Minister for Health can assign an individual health identifier to a living individual who is, has been, or may be provided with a health service, whether or not that individual is ordinarily resident in the State. An individual health identifier may also be assigned to a deceased individual where that person has died on or after the coming into operation of this section without having been assigned an individual health identifier when alive.

The section also makes clear that assigning an IHI does not indicate, in and of itself, entitlement to or eligibility for a particular health service. The intention is that members of the public will be advised of their IHI in making contact with the health service, allowing staff to confirm a person's identity in an efficient and cost-effective manner. The section also provides that the Minister for Health can put in place measures to help an individual to have his or her IHI made known to him or her or another person acting on his or her behalf, because of age, capacity or death, for example.

Section 6 provides for establishing and maintaining a national register of IHIs by the Minister for Health. The register will contain the IHI and any other known identifying information for each person who has been assigned an IHI. This identifying information, the basic details that allow a person to be uniquely identified, is defined in section 2. It includes, for example, a person's name, address, date of birth and PPSN. It also provides for a signature and photograph as further identifying information. The Minister for Health can make additions to this list but only following consultation with the Data Protection Commissioner. It must be stressed that the list of identifying information cannot include an individual's clinical information. The only items of information that can be contained in the IHI register are the IHI and the defined list of identifying particulars.

Sections 7 to 9, inclusive, enable the initial seeding of the national IHI register and provide for maintaining the accuracy of the information, which is vital if it is to operate efficiently and effectively. Section 7 allows the Minister for Health to make use of the identifying information with which he or the HSE must seed and populate the register in order to avoid having to ask people again for information they have already provided. It also allows a provider of health services to ask an individual who is, has been or will be provided with a health service for his or her identifying information. Health care providers must provide this information and relevant updates for the Minister for Health, as appropriate. Most of this exchange of information will be catered for by ICT systems that will be developed to underpin the register. It occurs to me that much of the confusion in the past over people's applications for medical cards where some information held locally was not transmitted centrally will be completely overcome by this provision. They will be able to obtain the information very quickly in an efficient fashion. Without getting into specifics, let me outline a recent case in which an individual's information was not known when a decision was made. This was understandable from the point of view of the GMS or PCRS section because there were approximately 133 people with the same name. What is proposed will overcome these difficulties.

Section 8 allows another Minister to provide the Minister for Health with a person’s identifying information but only where it is solely for the purpose of establishing and maintaining an accurate IHI register. Section 9 enables an ard-chláraitheoir to provide information for the Minister for Health relevant to the Minister's functions under the Bill.

Section 10 provides for access to the IHI register. The only persons allowed to gain access are the Minister for Health, a specified person as defined in section 2 and an equivalent person covered by an agreement under section 12. These persons can access the register only for relevant purposes. The Minister for Health may also access the register to perform a function conferred on him or her by the Bill or any other Act. The section requires the Minister for Health to put measures in place to allow the register to be accessed subject to these conditions and otherwise make it inaccessible in order to ensure the registry is secure and privacy is protected.

Section 11 sets out how the IHI and information on the register can be used. In providing a health service a health care provider must ask the individual for his or her IHI and the health care provider must associate the IHI with the patient's medical records and use it in relevant communications, with the provider's own identifier details, as per section 20 - for example, when a general practitioner writes a patient referral to a hospital consultant. Importantly, no one will be denied a health service solely because he or she either does not have an IHI or refuses to provide it. Obviously, however, by not providing one he or she would be making life very difficult for himself or herself and all those trying to help him or her. Given that the main reason for introducing IHIs is to enhance patient safety, it is reasonable to expect that very few people will refuse to co-operate positively with the new identifier system. However, it is important to recognise that certain occasions may arise, mainly in the area of very sensitive medical conditions, where someone may be reluctant to identify himself or herself fully. None of this changes the existing set of circumstances where a health care provider is entitled to satisfy himself or herself that it is right and safe to treat someone. The section also provides for disclosing an IHI and identifying particulars to an authorised disclosee for a particular secondary purpose.

Section 12 provides for the use of the IHI and access to the register in another member state in certain cases where an individual has travelled to that member state for a health service. This is subject to an agreement on which the Data Protection Commissioner has been consulted being in place between the Minister and the health service provider in that member state. The section is intended to provide for situations where, for example, the HSE has entered into an arrangement with a service provider outside the jurisdiction to provide services for a significant volume of patients. It is not intended for use in the case of individuals electing to seek services outside the jurisdiction or for small volumes of patient referrals.

Part 3 of the Bill provides for health service provider identifiers and the related national register of health service providers. The intention is that provider identifiers will be gradually rolled out to health service providers over time.

Section 13 sets out that health service provider identifiers can be assigned to a health practitioner such as a general practitioner or dentist; a relevant body such as a hospital; and a relevant employee or agent of a health practitioner or relevant body.

Section 14 provides for establishing and maintaining a national register of health service provider identifiers, the provider identifier register. Sections 15 to 18, inclusive, are designed to ensure the provider identifier register is seeded and accuracy is maintained on an ongoing basis. Sections 15 to 17, inclusive, make it clear that there is a proactive requirement on professional regulatory bodies, relevant bodies or health practitioners, as appropriate, to provide the specified information. The Minister for Health is not required to seek this information, either initially or for updating purposes. We intend to use existing professional registration numbers, in so far as it is possible to do so, in the new register - for example, by using Medical Council registration numbers for doctors. Section 18 allows the Minister to use relevant information he or she or the HSE already has to assign a health service provider identifier and establish and maintain the register.

Section 19 provides for access to the provider register, while section 20 provides for the use of the provider identifier and register. Senators should note that access to the provider register, under section 19, is different for the IHI register. Given its nature, the provider register will be publicly accessible and hold different information. As a register of health service providers, the only information that will be held on the provider register identifying individuals will relate solely to their role as health service providers. Consistent with section 10 and the use of the IHI, section 20 requires health service providers to associate their provider identifiers with patient records and relevant correspondence. However, this requirement does not apply where the provider is required by another Act to use the registration number given by his or her professional regulatory body when providing a health service.

Part 4 of the Bill provides for offences. Section 21 provides for offences relating to the assignment of IHIs, while sections 22 and 23 provide for offences relating to accessing the national register of IHIs and an offence relating to processing an IHI.

Section 24 provides for offences relating to the assignment of health service provider identifiers, while section 25 provides for offences by corporate bodies. These provisions are intended to secure the privacy and correct use of identifiers and registers.

Part 5 of the Bill provides for the delegation of certain functions of the Minister for Health. Section 26 provides that the Government may, by order, delegate to the HSE any or all of the Minister's functions under the Bill, except excluded functions. These excluded functions are the Minister's power to make regulations and enter into section 12 agreements. Any function delegated to the HSE continues to be vested concurrently in the Minister. The delegation does not remove or derogate from the responsibility of the Minister for Health to Dáil Éireann, or as a member of the Government, for the performance of any function that is delegated. When I mention the HSE, I mean it or any of its successor organisations. The section sets out that the Minister for Health is always responsible and, ultimately, accountable for the identifier system, which is as it should be. However, the section also recognises that responsibility for the actual day-to-day operation of the system may be delegated to the HSE as an organisation with the operational capacity to manage this national system.

Part 6 of the Bill addresses the application of the Data Protection Acts 1988 and 2003. The Data Protection Acts are concerned with the protection of the personal data of living identifiable persons. Section 27 deals with the relationship between the Bill and those Acts. Subsections (1) and (2) deal with the individual health identifier of a living individual. Under subsection (1), a living individual's IHI will be considered personal data under the Data Protection Acts when held by the Minister, a specified person or the HSE when acting in a section 26 capacity under the Bill. However, this should not be construed as preventing a living individual's IHI held by any other person from being treated as personal data in accordance with the Data Protection Acts.

Subsection (3) is concerned with the information on the register on a deceased individual. As an additional protection, it provides that sections 2(1)(d) and section 2C of the Data Protection Acts which deal with security arrangements for personal data will apply to the information in the IHI register in relation to a deceased individual in the same way as those sections apply to a living individual.

Part 7 of the Bill, sections 28 to 39, inclusive, provides for a range of matters. Under section 28, the Minister for Health can arrange for investigations to be carried out on the operation of any provisions of the Bill, as he or she considers reasonable and necessary for the proper monitoring of the assignment and use of identifiers. Section 29 provides that the Minister for Health can enter into an agreement with another person to carry out certain activities, for example, specialist IT support services. Section 30 allows the Minister for Health to carry out measures to verify any information provided to him or her under the Bill, or to establish the efficient and effective operation of the registers.

Section 31 provides for data exchange agreements between the Minister for Health and other relevant persons. These will specify the procedures to be followed by each party when exchanging personal data between them. The Minister for Health must consult the Data Protection Commissioner in relation to data exchange agreements. As a further privacy protection safeguard, under section 32, any processing of personal data by the Minister for Health or the HSE will go no further than is reasonably necessary for the performance of these functions.

Section 33 provides for the Minister for Health's power to specify the form of documents required for the purposes of the Bill. To provide the flexibility that is needed, section 34 sets out that the Minister for Health can extend the time period for providing the information required under the Bill.

Sections 35 to 39, inclusive, allow for the legislation in relation to health professional regulatory bodies to be amended to enable the Minister for Health or, if delegated, the HSE to make complaints to regulatory bodies where a professional has not complied with a provision of the Bill, for example, where a health care provider has failed to associate an IHI and its own provider identifier to a patient record. While there is no reason to expect that to happen, the legislation must provide for a means of dealing with such exceptional circumstances.

Schedule 1 covers authorised disclosees and Schedule 2 lists specified persons. As the Child and Family Agency Act 2013 is now in force, I propose to bring a Committee Stage amendment to include the new Child and Family Agency as a specified person in Schedule 2.

The provision of health identifiers will require investment in ICT to develop and maintain the registers' infrastructure to hold the required information. There will also be costs associated with rolling out the new system of identifiers, including the change management processes. However, using the HSE to operate the identifier system will ensure the technical and other expertise, as well as the operational infrastructure, of the Primary Care Reimbursement Service, PCRS, is maximised in implementing and operating the identifier systems on an ongoing basis. Likewise, appropriate leveraging of the public service card technology provides further possibilities for a cost-effective solution. The overall approach of building on the identity management infrastructure being developed by the Department of Social Protection will help to keep costs to a minimum. I acknowledge the considerable assistance and co-operation of the staff in that Department in preparing this legislation.

The HSE is engaged in ongoing work on costs, and the publication of the Bill provides an opportunity to engage with the market to get accurate cost estimates to develop the most appropriate and cost effective model. Senators should note that individual project components will be subject to peer review, including costs review, prior to project approval being sought, in line with Government policy, from the Minster for Public Expenditure and Reform. All of this is designed to ensure that we have accurate and reliable costs at the time decisions need to be made, and approval sought, on particular elements of the implementation model.

We all are concerned with our own patient care and safety and that of family, friends and anyone who uses our health system. Individual health identifiers are principally about patient safety, ensuring the right information is associated with the right individual at the right time - properly matching people with their records, treatments and results. The programme of health reform that I am implementing is designed to ensure that patient safety and quality care are the paramount concern of the broad health system, and the introduction of health identifiers is critically important in that regard, reducing the chance of duplication, confusion and unnecessarily repeating tests on patients who do not need to suffer twice for the same result.

We all want to build on health reform initiatives and the further development of a modern health system. Health identifiers will also support more efficient management and delivery of health services. They are, for example, an important component of fully implementing the concept of money follows the patient, in advancing the e-health agenda and, ultimately, delivering universal health insurance where everybody will be treated on the basis of medical rather than on what they can afford. Accordingly, I commend the Bill to the House. I look forward to Senators' contributions. I am always open to suggestions that will help improve the Bill and its operation.

I thank the Minister for yet again making himself available to the House. My party will be supporting this legislation and I have only a few brief points to make.

When it comes to data protection, sometimes I believe the practical application of the aspirations of the Acts are at times counterproductive to the needs of the individual in terms of the information that is available. So many aspects of Irish life require the same information that is sought in different ways and lodged and stored in different places, and then we must have this seemingly endless duplication and potential for human error, for instance, where one set of information cannot be got or gets lost because the wrong person had it, etc. My party would fully support the idea of health identifiers and health practitioner identifiers as something that can help bridge the gap in information breakdown, enhance safety in terms of health results but also have all the key information in the right place.

The big question is why we cannot have all of this information accessible to the key arms or Departments of State if and when that is required rather than going off and collecting it again, not only in the health area. In the area of social welfare, I, for one, would be an advocate of a national identification card, including a chip that stores all of this information and incorporating codes so that the appropriate professionals are the only ones with access such as the Department of Social Protection in the case of social welfare and the Department of Health in the case of health of the patient, etc., so as not to encroach too much into the area of data protection. It is a no-brainer and it can help.

The Minister has given a detailed overview of what the legislation proposes, which I appreciate. Clearly, we will have a look again prior to Committee Stage to see whether there are ways of improving it. The critical question I have is whether the resources will be available to make it work correctly. In terms of IT, the EU average spend on investment in IT in the health sector is 2.5%. In Ireland, it is 0.85%. It is not the percentage in itself; it is how it is applied. There was the disaster some years back with the centralised paying system. We all are concerned about this.

In December the Minister launched the e-health strategy. eHealth Ireland has its aspirations of what it will do and in early 2014 eHealth Ireland will publish a new IT strategy for the health system.

I presume this will be part of it. What will be contained in this strategy? When will it be published? In what way does this legislation fit into that? What kind of numbers are needed to adequately roll out this measure to ensure we have the successful practical application all of us yearn for and that the Minister envisaged in bringing forward the legislation? The Minister mentioned that the fact that the primary care reimbursement service, PCRS, has already been used is of great benefit in the context of how this measure will be rolled out. Is the PCRS system adequate? Is it capable of doing this particular job? The explanatory memorandum states the publication of the Bill provided the right opportunity to engage with the market to get accurate cost estimates for developing the most appropriate, cost-effective system. That sounds like a big Bill. Where are we on this? The Minister might expand on that aspect in his closing remarks, because it is a concern.

I am aware that this was a commitment given to the troika; its origins go back to 2009. The troika - as did the Health Information Quality Authority, HIQA - raised it as an issue in its April review of the programme and included a specific section to do with this area, but another report in 2012 showed that of those dealing with financial management within the health service, less than 10% have adequate qualifications to do that particular job. Are the IT specialists that are required to adequately bring this process forward in place? How much will they cost? What will be the recruitment process and will it be affected by the embargo? There are many questions to be asked, but I do not want to go on unnecessarily. The Minister has given a detailed output. All of us welcome the potential of the Bill, in terms of the introduction of health identifiers, for achieving cost-effective health services and, ultimately, for achieving savings, but it is clear that quite an amount of investment - the Minister said this also - is required. Will it be available? How much will it be? Presumably, we are learning from the Irish Water debacle in that regard.

I will conclude shortly to give other Members an opportunity to speak. I know it is not related to the Bill but, as we say in Ireland, while we have the Minister in the House we would be interested to know his view on the exclusion of a health professional or expert from the expert group, given his concerns expressed in writing to his ministerial colleague about the pylons. While we all welcome the review group-----

What has that got to do with this issue? The Acting Chairman is giving great latitude in this regard.

When you are as experienced as me in this House, if I want to talk about the health of a ping pong ball on Second Stage, I am entitled to speak about it. Is that okay?

We will go a long way before we-----

Senator Marc MacSharry to continue, without interruption.

We are talking about the Bill before the House.

Please, Senator. The Senator will have his opportunity to speak. Senator Marc MacSharry should speak through the Chair.

Given the Minister's concerns as expressed in writing to the Minister about the health implications of pylons and so on-----

I never wrote to him about pylons. Sorry, old boy.

-----I am interested to hear his specific view on the exclusion of a health professional or expert from the so-called expert group to consider the implications of this measure. I am sorry for going off the point, but none of the Minister's colleagues in Meath, Louth, Monaghan, Laois, Offaly, Mayo or Cork would disagree with me taking the opportunity to mention it. I would appreciate it if the Minister replied to that at the end of the debate. He could reply in a sentence or two.

I welcome the Minister and the Bill. It is an issue about which I have spoken a good deal in the past five years, particularly because I have examined the Danish, Finnish and Swedish systems, which are way ahead of ours, and other systems internationally, including the United States, on the issue of e-health. The Danes started developing their system as far back as 1994; therefore, we have a good deal of catching up to do.

The Bill clearly outlines the setting up of a structure in regard to individual health identifiers for patients and service users, and also the setting up of registered health service provider identifiers for health professionals and organisations. The idea behind the measure is to improve quality and safety of care, streamline record management, reduce repetitive and unnecessary care, as the Minister mentioned, reduce administrative costs, and facilitate e-health projects. It is interesting to read the report from HIQA which estimates that up to 30% of the health budget may be spent on handling, collecting, searching for and storing information. That is a huge part of the budget. Therefore, this legislation and this development is welcome.

To refer again to the Danish system, Denmark has a similar population to Ireland's and it is interesting that their system has saved over €1.8 billion over quite a short period in the provision of health care. Their system is interesting. Each person has a patient medication card. When a person goes to a general practitioner, the GP uses the person's card to access his or her file. Instead of handing him or her a prescription, the GP puts the prescription on the card and gives the card back to the person, who then goes to the pharmacist. The pharmacist can access the prescription on the card and give the person the prescribed drugs. Research has shown that approximately 27% of the handwriting on prescriptions from hospitals cannot be understood by pharmacists. Computerisation would make a major contribution in terms of ensuring the right information is given to the professionals dealing with the patient.

It is also about accessing records quickly and efficiently. Under the Danish system, a person admitted to hospital who has his or her patient medication card does not have to wait for three or four hours for the file to be found. Once the card is produced, access to the records can be gained immediately and there is no delay. We have a good deal of catching up to do in that area. When they introduced the system in Denmark in 1994, there were approximately 4,000 exchanges of messages. Last year, there were 60 million exchanges of messages within the health service because of the system they are using.

Regarding the sharing of information, I had a meeting recently with the Irish Pharmaceutical Society, the pharmacists of which believe they can make a far bigger contribution in terms of savings and also in developing the area of e-health. They are very much in favour of this development.

The Department of Health spoke about this issue as far back as 2001. Thirteen years on we are only now putting on the pressure to develop and implement it. It is long overdue. I welcome the work by the Minister and the Department on progressing this matter and ensuring it will be operational and effective in a short period. There will be savings and this is about getting better value for the taxpayer in the provision of health care.

The individual health identifier is a unique, non-transferable lifetime number assigned to all individuals accessing health and social care. Its purpose is to accurately identify the individual and enable health and social care to be delivered to the right patient at the right place and at the right time. That is the importance of this legislation.

On the benefits of an individual health identifier, it improves patient safety and quality of care, streamlines record management, reduces repetitive and unnecessary care, and reduces administrative costs. In terms of the benefits to the health service provider, it enhances the quality and safety of patient care, reduces the possibility of administrative and clinical error and reduces duplication. It also accelerates access to information, which is extremely important.

The Bill is comprehensively drafted. I will read it in more detail in the coming days, but it is a measure we should have introduced ten years ago because we are now far behind many other European countries in this area. It is interesting to see the developments in the Nordic countries such as Finland, Sweden and Denmark and how much they have achieved in a short period. There is no reason we could not do the same.

We have the expertise in this country. We have health care professionals who provide very good health care but we also need to make sure they can provide that level of health care in a far more effective and efficient way and within a shorter period of time. It is extremely important we ensure that is done.

The Minister has given an explanation of the medical card procedure. More than 1,983,000 people now have either a medical card or a GP only card. We have a great deal of information already computerised. The Minister was correct in highlighting the issue where decisions were taken, where the people taking them did not have access to the information they required. The introduction of this legislation and the setting up of the systems can eliminate many of the problems that have arisen in the medical card area and they can also ensure GPs, nurses and community nurses, in particular, can get the necessary information to look after patients in their own homes. Because we have such a high turnover of medical staff, especially among junior doctors, it is important they get all the correct information and that such information is available to them in the event of a person suddenly being admitted to hospital as they are on the front line.

This legislation will set up the structure that is needed within the health care sector. I welcome the Bill. I also welcome the work that the Minister, the Department of Health and the HSE are doing in this area.

Cuirim fáilte roimh an Aire. I am broadly in support of the idea of enhanced patient identification as a means of improving safety. There is no doubt that when one has as internally discordant set of health services as we have in this country that it is essential that we think of better ways of managing medical records and facilitating appropriate transferral of sensitive information. However, it is important to put the matter in context. There is a colossal problem with medical records in general in Irish hospitals. About 95% of the total dysfunction that occurs in Irish hospitals as a result of poor record systems will not be fixed by this initiative. The problem is internal in the hospitals. We have systems that cannot talk to each other, so to speak, within the same hospital. We have a reliance on paper charts. We have charts that disappear going from one clinic to another. These are issues which on a daily basis cause potential risks to the care of patients. This is the key priority in patient informatics which needs to be addressed. It needs to be addressed at a systems level, by mandate, with what, I believe, would be a relatively modest degree of infrastructure, and with what would be a colossal cultural change in the work practices of health professionals.

From a very simple point of view, in some rudimentary situations there are occasions where some aspects of medical information are displayed primarily electronically rather than on paper. Are there enough terminals? If one has three or four doctors and nurses working in one ward trying to deal with the problems of 15 or 20 patients, there is only one terminal and an orderly queue is forming, that is not a recipe for efficiency or safety. It is an incentive to cut corners and say "maybe that piece of information is not so important after all". I would not want to disrespect the notion of having the unique patient identifier and the provider identifier but nor would I want to overstate the impact it will have. By and large, the great majority of patient interactions occur along relatively well established referral pathways with relatively decent lines of communication. They will get better with this initiative but the fundamental problems will not be fixed.

I am addressing my remarks to the Minister today which, coincidentally, is the day that we found out that Her Majesty's House of Lords will debate an amendment to the Child Protection Act which will in one swoop make it illegal to smoke a cigarette in a car where a child is present and this is happening nearly two years after we introduced our legislation in this area.

I speak as somebody who is a little concerned about the prioritisation of reform within the health service. For the benefit of folks who perhaps have been lucky enough not to hear me say this before, all of us and pretty much everybody in this country agrees with the principle of socialised health care, of cross-community solidarity, of the rich subsidising the poor and of care determined by need, not by ability to pay. We all believe that, but there are different models of delivering it. One model which is used in a small number of developed countries is the general taxation or NHS model, where the government takes money at the beginning of the year and centrally runs, controls, co-ordinates, mandates and budgets the entire system on an annual basis prospectively. Budgets are predetermined. This is a system which is incredibly good for containing costs and that is the reason the NHS has one of the lowest cost outputs of any of the health systems in the developed world. It is also a system which incentivises waiting lists, inactivity and also an extreme degree of inefficiency. It is for that reason that many of us over the years who have studied health policy have examined other models such as the German model in particular. At the time of the last election, I believe the Minister, his Cabinet colleagues and two parties in government were given a thumping mandate from the electorate to introduce this kind of reformed health system. It is one which is based on universal insurance, competition, a level playing field for all patients, and all patients having a freely transferable insurance instrument, which they could take to a hospital of their choice, one which might be public, one which might be private, one which - my own preferred model - might be run by not-for-profit companies, by universities, by academic organisations or perhaps by charities. Most of all the truly great leading, international medical centres in the world would follow that model. They are led by people who have a board of governance who act with the mission of the institution in mind.

Let me parenthetically state at this stage that I was troubled for several weeks to hear the board of a large institution, which gets €206 million in direct Exchequer funding annually, say they now would concede the point that it was necessary to set up a public interest committee. If the board is not acting in the public interest, in whose interest is it acting? This is a question that needs to asked by the Minister of the governing boards of several of our largest hospitals.

On the tempo of the reforms we are seeing, I am prepared to concede the point the Minister has always stated that the goal of universal insurance-based reform is the ultimate goal and that it is not a short-term goal. I believe it could be a shorter-term goal than is being currently suggested. It is essential we do it now because until we do it we are copperfastening the inefficiencies, the waste and the poor quality throughout the system. Looking at this from the outside, I see a huge amount of effort being put into reforming the current system in the direction of - I ask the Minister not to not take this as too harsh a criticism - making it look like the NHS. In terms of elements such as having national contracts for doctors, in the kind of model we are talking about, doctors who are employed in different circumstances would have widely different kinds of contracts, depending on their working conditions, their employment and even their specialty. We talk of a model of money following the patient as if this is somehow the implementation of an insurance-based model. It must be remembered that in the Thatcher era with the reforms of the internal market in the National Health Service there was also an attempt at money following the patient and what we are doing in the short term, something which parenthetically will be facilitated by this unique identifier, appears to be introducing that type of health care instead. There is an increasing tendency for the HSE to refer to itself as "the health service". In the reforms we are talking about and the kinds of models we will have there will be many people who will have nothing to do with the HSE. They may well have occupationally, socially or privately-based insurance and may well deal, I hope, with the University College Dublin medical centre or the Eccles Street medical centre or some other hospital not owned by the HSE. They may have nothing to do with the HSE which should become a management organisation for a smaller number of State services. The introduction of the groups, while rational in some ways, will also have the effect of decreasing competition and bringing in more of a directed referral model, which has been something long espoused by the HSE.

I look forward to having more opportunities to look into some of the more complicated details of the Bill. I ask the Minister to clarify one issue for me which perhaps reflects on my lack of comprehension.

How much of the medical record of a patient will be available to anybody who has legitimate access to the unique identifier number? Will someone have complete access to records nationally? If not, what is the point of the system?

I am anxious to speak on the legislation before us. Listening to the Opposition, I fear it is taking advantage of the good and generous nature of the Acting Chairman by introducing extraneous material instead of discussing the Health Identifiers Bill 2013. We are talking about unique health identifiers. I welcome the Minister to the Chamber and say I am amazed these unique health identifiers are not already in place. They were first mooted in 2001 and again by an expert group in 2008. Some 13 years later, we are getting around to doing it. It is an indication of the continuous reform the Minister and the Government are achieving in the health services and in the provision of health service delivery.

Sharing information across the health service is what this is about. I was a psychiatric nurse for 28 years of my career and the real difficulty we had in the mental health service and in all branches of the health service was the sharing of information. Different hospitals, different units and different people in the same hospitals used different methods to keep track of records by allocating different numbers. Looking for a particular file on a patient involved searching under three or four filing records and one could still be unsuccessful. This was particularly the case in respect of out-of-hours admissions, such as in the middle of the night, when the medical records staff were not at the office. For ward staff, finding the relevant records was nigh-on impossible. This is a welcome initiative. Patient safety and efficient management of the system is what is intended in the introduction of these models.

I have several questions about the operation of the system and Senator John Crown referred to some of them by asking how much of the patient information will be available on the system administered through unique identifiers. The protection of patient privacy is of primary importance. I see this is ensured in the Schedule to the Bill. For instance, there does not seem to be difficulty if GPs in small practices access information on file. What about busy accident and emergency units or acute admission wards in the mental health services? In such cases, access would be required by all staff involved at some level. Does access to the system leave a unique identifier trace by the person accessing the records? There were media reports of unauthorised access to social welfare files some years ago and staff seemed to have easy access to information that was not relevant. It seemed to be the result of curiosity rather than delivery of a service. It is impossible to achieve the reform we are trying to achieve, the model of money following the patient, without these unique identifiers. It could not possibly work unless we can trace the patient with the money through the system.

Hearing ICT and the HSE in the same sentence is enough to spark terror in anyone's heart. We remember the PPARS system, which was proposed to be introduced at a cost of €6 million and ended up costing €250 million. It did not achieve the objective it set out to do. At the time, the PPARS system was there to collect only one type of information, payroll, and we could not deliver it. Do we have confidence that the system in place now has the ability to achieve results that PPARS could not? Is there a requirement for standardisation of templates of information gathering across all GPs? In complex medical situations, there is a tendency to generate huge volumes of information about patients. I see this in the mental health services where some nursing care plan models generate two or three pages of information a day about a patient. Does the system have the capacity, or is there a necessity, to record this information? Is there remote access to it? Is there a requirement that there will be a particular server or will it be stored in a cloud? These are questions that need to be asked. The idea that it will not cost a great deal of money is a statement from the Minister that I view with a sceptical eye. In Ireland, our ability to roll out ICT systems is such that they tend to cost a lot of money. I refer to the Garda PULSE system; we will not mention electronic voting, as it descended into farce. I have every confidence the Minister has considered these questions and has reached conclusions.

I welcome the Minister and will be supporting the Bill. Senator John Gilroy pointed out that it should have been in place a long time ago. It should not have taken so long for the previous Government to put this in place and it took the current Minister to introduce the Bill, which is a necessary development in the delivery of health services in the State.

Almost all Members have the experience of difficulties caused by the obvious disconnection in the different elements of the health services and the fact we do not have a joined-up approach which we hope the Bill will implement. There is little co-ordination between the records of patients kept by GPs and other providers of primary care, including the HSE. This also applies to the primary care providers and acute hospitals and providers at secondary and tertiary levels. Within hospitals, we have difficulties because of the absence of a single patient number for each patient and many people have experienced the repeated filling out of patient information forms during the course of one hospital visit, even when the hospital already has the patient information on record.

The purpose of the Bill is one we support, namely, to assign a unique health identifier to each individual to whom health service has been or may be provided. The focus must be kept on that simple and straightforward aim to ensure we get maximum benefit from this change. That is what the Minister is seeking to do ino rder that we can improve and enhance health care delivery as a consequence of the policy being implemented. Concerns have been raised about people's information being given to Departments and that information is used in the best possible way and that people's personal data is protected ino rder that we put prevent potential abuse of what is a very important, but also a very valuable, database of the population of the State. I am sure the Minister has been made aware of concerns, which have been expressed to him. In recent times, we saw US agencies misusing their position in respect of people's information. People have genuine concerns about this. We must also strike a balance and ensure we can provide the best health services. People will not object to being part of this and providing information. They will see the clear logic of having a personal identification number.

This issue was raised with me when I held a conference on health services in Waterford.

I invited experts such as GPs, consultants in hospitals and people who work in different forms of primary health care delivery. Part of the discussion was around the need to improve and join up services at primary level, as well as acute services. Even at that time, in 2002, we had experts calling for a single patient registration and identification numbering system. It has taken us a long time to get here, which is unfortunate, but the Bill is now before us. The aim of the legislation is very straightforward, but it could be very significant in its achievements and the potential improvements for the health care system. That cannot be understated, so I will certainly support the Bill and the Minister in this regard. I hope the Bill will be implemented as quickly as possible, although that may be down to the hospitals and people who work in the health service.

I welcome the Minister and thank him for bringing the legislation before us. The Bill seeks to establish a profile system of unique identifiers for individuals within the health system, as other Senators and the Minister have pointed out. It makes perfect sense, as we will be able to track an individual going through the system and his or her interaction with doctors, dentists, nurses and all medical personnel. We will know if a person is undergoing treatment and if he or she has reacted badly to a particular medicine or has an allergy. Patients are continually questioned about such issues.

Implementation of a unique identifier system is recognised as being an essential infrastructural initiative which will facilitate many significant improvements to the health system in areas such as patient safety and improved data access and quality, leading to improved overall systems efficiency. It is also a fundamental requirement for deploying electronic solutions and an essential building block for "money follows the patient" and universal health insurance, both of which are cornerstones of the Government's reform agenda in the health area.

There was a story from last April in the Irish Examiner which made it clear that this system is required. The journalist, Niamh Drohan, posing as a student, visited seven GPs displaying symptoms of depression which she had read about on the Internet. She subsequently received prescriptions from all seven GPs, with few advising about maximum dosage, and none advising about potential side-effects. The article posed a number of interesting issues but more than anything else, it exposed how people, if they so wish, could effectively "game" the system and receive multiple prescriptions. She wrote at the time that of the seven phone calls she made seeking an appointment, just two inquired if medical records needed to be transferred. Three prescriptions were issued for one month, one prescription was issued for two months, another was for three months and yet another was for six months. The total was approximately 20 months of antidepressant medication without the need to revisit any GP, which is incredible. In one case a three-month prescription was given out in fewer than ten minutes. This Bill should effectively clamp down on the issue in a very simple way and ultimately stop anybody from abusing the system in this way.

Senator Colm Burke has conducted some research on Scandinavian countries, where systems have been implemented that are ahead again of what we propose to implement. I visited Estonia recently on committee business. As that country is not coming from the same base as us, it was less complicated for them to implement a system, but it has a sophisticated system whereby a person's records are available to any medical practitioner. The people involved are very much aware of the data protection element. I was fascinated by their work and I am sure the departmental officials may have already considered the Estonian case. The information is available on a website and I can provide the information I was given if it could be a useful comparison.

I agree with Senator Marc MacSharry's comments on a national identity card. In Estonia, they do not stop at medical records and in a way it could be seen as bordering on "Big Brother", if one was somewhat paranoid. The country can track everything to do with a person's motor car and health, as well as systems like social welfare requirements. In certain circumstances, sensitive information can be held back and released with the consent of the person to whom the information applies.

It is clear the legislation is a building block and first step towards deploying e-health solutions that could provide us with better data access, better health care analytics and, overall, a better and more efficient health care system. Moreover, it is also a platform for the universal health care insurance. Health care reform has faced many obstacles, but we have been successful in reducing waiting times across the country. In a few months we will introduce free GP care for those who are six years and under and the Bill will also play a useful part in holistic health care strategy, as it will allow us to follow the patient, ensure the system is working efficiently and potentially highlight anomalies within the system in a very efficient way by giving us very straightforward data which can be analysed and potentially debated. There is no doubt that this will help us improve the national health care system.

Privacy concerns are important, which is why consultations have been held with the relevant data protection authorities. We must ensure to adhere to the best international data protection governance and I am confident we will do so. I congratulate the Minister and his officials for their work and commend the Bill to the House.

I thank the Senators for their contributions. The issue of resources was raised, with the ongoing exercise to estimate costs. My Department has asked the HSE to establish a project team to continue the work of developing high level estimates. Engagement with the market will be needed to determine the final cost, but there is no question of another personnel, payroll and related system, PPARS, fiasco. I can guarantee that. The ICT strategy being prepared by the HSE is nearly complete and it will complement the e-health strategy I published last month. Senator Gilroy is quite right in that now there is almost an allergic response to information technology in health services because of the PPARS debacle. We must grasp the nettle and are doing so. We must act in a way that will minimise the number of systems we must use, as there are approximately 1,700 different IT systems in the health services. They are not necessarily related to finances, but they must all be able to interact.

There were some comments about the myriad of people dealing with finance in the HSE who do not have financial experience. That has been corrected through the new chief financial officer and his financial reform board. We have a much greater grip on finances than we ever had before and it is clear to people that, having taken almost €4 billion out of a €16 billion budget in the past few years, there is no financial black hole in the health sector any more.

Senator Colm Burke raised the issue of the Swedish health system. The e-health strategy has had regard to the best practices in both Sweden, Denmark and other countries.

Senator John Crown spoke about cultural change, which is necessary, and the Bill and the e-health strategy are a step in the direction we want to go in order to kick-start that change.

Senator John Gilroy also raised the matter of security and access to the individual health identifier, IHI, register. It will be an offence to inappropriately access the IHI register, and it is intended that the implementation process will record who has accessed the system. We will be able to track those who access the system in that way.

Senator John Crown asked what would be available in the IHI. The identifier is used to identify a person and access to medical records, etc., is another matter entirely, which would be based on clinical need and the level of clinician involved. The identifier will help significantly in that process.

I thank Senators for their input.

We all share the view that the introduction of a unique system of identification for patients and providers would be a very positive and welcome development. It has taken an inordinate length of time. While its principle purpose relates to patient care and safety - that must be our absolute priority - an identifier system could bring a range of benefits across the health system in areas such as better and more reliable data quality, system efficiency in information collection and management, supporting desirable initiatives such as the money follows the patient model and facilitating the whole e-health agenda. In short, a unique health identifier is regarded internationally as essential to underpin a modern, integrated health system, and in framing the Bill we have had regard to international experience and best practice, as well as input from HIQA and others who have contributed much to the Bill.

It is critically important that as we reform, we learn. Underpinning our approach to the health service has been the aim of making it patient-centred and improving outcomes for patients while learning from the reforms we have introduced - reform, learn and reform again. In planning the health service, in observing how reform is operating and evaluating what we are doing, we need a unique health care identifier for patients to have much more accurate information. In a broader sense, we also need much better IT systems. We are looking at that issue also.

The Bill provides the appropriate enabling framework to implement a unique identifier system in a structured and planned way that will best suit the needs of the health system as we meet challenges in the future. I look forward to debating the issue further with Senators on Committee Stage. I am open to suggestions they might have to improve the Bill. I again thank them for their contributions.

Question put and agreed to.

When is it proposed to take Committee Stage?

Committee Stage ordered for Tuesday, 4 February 2014.
Sitting suspended at 1.15 p.m. and resumed at 1.35 p.m.