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1 2017 ACTIVITY REPORT

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3 2017 activity REPORT Technical Agency for Information on Hospital Care

4 EDITORIAL For the first year of our new Objectives and Performance Contract (contrat d objectifs et de performance - COP), the Technical Agency for Information on Hospital Care (ATIH) made efforts to broaden, facilitate and secure access to health data. The data collected by the Agency are accessible in the National Health Data System (système national des données de santé - SNDS), with access simplified through the implementation of this system.

5 2017 marks the start of the post-acute care and rehabilitation (soins de suite et de réadaptation - SSR) funding reform. The Agency has undertaken major work to adapt the technical funding tools to this transitional period of scaling up the new model. As part of the optimisation of the health system, work was carried out focusing on patient-adapted care (partial hospitalisation, day hospitalisation, ambulatory care, etc.), which would be supported by financial incentives to promote such care. In the medico-social sector, ATIH contributes to ongoing projects on funding reform, in particular by performing cost studies on organisations and services within the scope of the reform to adapt funding to the pathways of people with disabilities (Services et Etablissements: Réforme pour une Adéquation des financements aux parcours des Personnes Handicapées - Serafin PH), residential care institutions for dependent adults (etablissements d hébergement pour personnes âgées dépendantes - EHPAD) and home nursing care services (service de soins infirmiers à domicile - SSIAD) and multidisciplinary home aid and care services (service polyvalent d aide et de soins à domicile - SPASAD). To stimulate stakeholders thoughts on improving the funding of healthcare and medico-social organisations, the ATIH proposes a platform of access to both raw data and synthetic data in the form of indicators. This year, teams from the Agency went into the field to meet with physicians from Medical Information Departments (départements d information médicale - DIM) at the organisations, to gather information on their needs and to see how to meet their expectations for ATIH services and products. Experts in the field, including clinicians, were also asked to join working groups and provide their operational experience. ATIH is part of the work undertaken by public authorities, both on innovative funding to improve patient care and, more generally, on thoughts about transformation of the French healthcare system and in particular hospital funding. To enhance its collaboration with its various partners, ATIH adapts its organisation and the way it works, to further increase efficiency and to be open to all of its users. Housseyni Holla Managing Director of ATIH 2017 ACTIVITY REPORT

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7 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES Facilitate use of ScanSanté Promote knowledge of ScanSanté data Create new indicators ATIH A CENTRE OF EXPERTISE... SUMMARY OF WORK IN PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA Collect more data Secure and facilitate access to data Enrich the data available on the secure access server Ensure the quality of data A WORD FROM THE TEAMS Secure access to data POSITION THE AGENCY OPTIMALLY IN ITS ENVIRONMENT... Build lasting connections with partners in the field: institutions and ARS... Improve the internal performance of the Agency... Evaluate the Agency s audience satisfaction Publications Glossary IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES Adapt classifications to refine institutional funding Optimise and apply funding mechanisms Collect information about costs in healthcare and medico-social sectors A WORD FROM THE TEAMS Cost studies in the medico-social sector ACTIVITY REPORT

8 6 L'ATIH A CENTRE OF EXPERTISE

9 ATIH A CENTRE OF MULTIPLE EXPERTISE Founded in 2000, the Technical Agency for Information on Hospital Care (ATIH) is a public administrative institution overseen by the Ministers for Health and Social Security. The headquarters of the Agency are located in Lyon with a branch based in Paris. The Agency s strategic guidelines are dictated by a Board of Directors, a steering committee and a scientific council. The head of the Board of Directors is appointed by the Ministers for Health, Social Affairs and Social Security. ATIH is in charge of: - collection, hosting and analysis of the medico-economic activity of healthcare organisations - technical management of institutional funding mechanisms - conducting cost studies for healthcare and medico-social institutions - development and maintenance of health classifications (nomenclatures) ACTIVITY REPORT 7

10 AUDIENCE General Secretariat of the Ministries for Social Affairs General Directorate of Health Services (DGOS), General Directorate of Social Cohesion (DGCS), General Directorate of Public Finance (DGFIP), Directorate of Social Security (DSS), General Directorate of Research, Studies, Evaluation and Statistics (DREES), General Inspectorate of Social Affairs (IGAS), Study and consulting firms, the media, etc. Companies State services Court of Audit (Cour des comptes) Teachers, researchers National Health Insurance Healthcare and medico-social institutions Regional Health Agencies (ARS) National organisations Hospital, medico-social federations Biomedicine Agency (ABM), National Support Agency for the Performance of Healthcare Organisations (ANAP), National Management Centre (CNG), National Solidarity Fund for Autonomy (CNSA), French National Authority for Health (HAS), National Cancer Institute (INCA), etc. 8 L'ATIH A CENTRE OF EXPERTISE

11 INTERNAL ORGANISATION OF THE AGENCY Management - External communication - Regional Health Agencies (Agences régionales de santé - ARS) mission - Data restitution mission (ScanSanté) Secretariat general - Quality - Legal affairs and deals - Budget, accounting, management - Human resources and internal communication management - Secretariat Responses to outside requests Architecture and IT production Classifications, medical information and funding models - Medicine, surgery, obstetrics and dentistry (Médecine, chirurgie, obstétrique et odontologie - MCO)/hospitalisation at home (hospitalisation à domicile - HAD) - SSR/Psychiatry - Health classifications (nomenclatures) - Medical statistics National cost studies Funding and economic analysis - Allocation of resources to healthcare organisations - Monitoring the National Objective for Health Care Spending (Objectifs nationaux de dépenses d assurance maladie - ONDAM) - Analysis of data and performance indicators - Web information system - Medical information collection systems - Software for healthcare organisations - System and network 2017 ACTIVITY REPORT 9

12 Staff As of 31 December 2017, the Agency employed 118 employees on a contractual basis and civil servants on secondment or provision. 5% Other 8% Comptroller 10% Physician 35% Statistician 16% Administrative 26% IT specialist 10 L'ATIH A CENTRE OF EXPERTISE

13 2017 AGENCY BUDGET ATIH s expenses amounted to 28,945,000 and its revenue was 29,443,000. Breakdown of expenses 3% Investment 39% Support grants for healthcare institutions 31% Personnel Breakdown of revenue 27% Operating 1% Other extraordinary income 8% National Solidarity Fund for Autonomy (CNSA) 32% Health insurance 52% Funds for modernisation of public and private healthcare organisations (Fonds pour la modernisation des établissements de santé publics et privés - FMESPP) 7% Private resources 2017 ACTIVITY REPORT 11

14 12 SUMMARY OF WORK

15 SUMMARY OF WORK IN M PATIENTS HOSPITALISED IN FRANCE 3,331 HEALTHCARE ORGANISATIONS 7.2 M patients hospitalised in public institutions 5.3 M patients hospitalised in private commercial institutions 1.5 M patients hospitalised in private institutions of public interest 753,000 deliveries 352,000 in-hospital deaths Data from the Program for Medicalisation of Information Systems (programme de médicalisation des systèmes d information - PMSI), rounded to the nearest thousand 2017 ACTIVITY REPORT 13

16 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA Collect more data In 2017, ATIH began to prepare for new collections scheduled to start in 2018, including the tool to manage calls for projects on health research and innovation (Innovarc) and applications such as: the System for Identification, Management and Analysis of Scientific Publications (système d'interrogation, de gestion et d'analyse des publications scientifiques - SIGAPS) and the Information and Management System for Research and Clinical Trials (système d'information et de gestion de la recherche et des essais cliniques - SIGREC). Secure and facilitate access to data Enrich data available on the secure access server and make it easier to use In 2017, financial data of public and private non-profit institutions was added for the ARS, such as the statement of revenue and expenditure estimates (état des prévisions de recettes et de dépenses - EPRD), the subannual statement, the accounting adjustment (retraitement comptable - RTC), as well as data from A&E care summaries. Hospital data user monitoring groups were also established, to discuss their practices, collect information about their needs and identify improvements expected. ATIH participates in the organisation of access to health data as part of the new data access authorisation system by the National Health Data Institute (Institut national des données de santé - INDS) and the Expert Committee for Health Research, Studies and Evaluations (comité d'expertise pour les recherches, études et évaluations en santé - CEREES). Following the publication of the security framework in spring 2017, ATIH audited its secure data access server to meet the requirements of this framework. 14 SUMMARY OF WORK

17 12.2 M PATIENTS IN MEDICINE, SURGERY, OBSTETRICS AND DENTISTRY (MCO) MCO 7.4 M PATIENTS TREATED IN FULL HOSPITALISATION 6 M MILLION PATIENTS HOSPITALISED AS OUTPATIENTS 1.6 M patients hospitalised for endoscopy 1.3 M patients hospitalised for cardiovascular disease 1.2 M cancer patients hospitalised 569,000 patients having undergone cataract surgery 169,000 elective abortions performed at institutions 150,000 patients for palliative care 138,000 patients having undergone a total hip replacement 120,000 patients treated for a stroke 1 M 91,000 patients hospitalised after having had a prosthesis fitted (arthritis of the hip or knee) PATIENTS IN POST-ACUTE CARE AND REHABILITATION 52,000 (SSR) patients in post-stroke rehabilitation 34, ,000 patients for palliative care PATIENTS UNDER FULL-TIME TREATMENT 2017 ACTIVITY REPORT 15

18 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES Adapt classifications to refine institutional funding Optimise and apply funding mechanisms In matters of medical information (collection, classification), ATIH adapted its work method, calling on experts at the institutions. Clinicians were also asked to participate, to build, update or validate changes of classification. As part of the reform of the activity s funding model, the descriptive tool for SSR activity is undergoing revision. Thus, in 2017, ATIH finalised a new version of the medico-economic groups (groupes médicoéconomiques - GME) classification in SSR. With a view to redesigning the funding model for HAD activity in 2020, ATIH continues work on building a new classification in 2018, in connection with professionals in the field. Classification works in MCO on outpatient surgery will lead to a revision of the classification for some major diagnostic categories. The Agency worked on the concrete implementation of the 2017 rate and budget campaign and began preparatory work on the 2018 budget and rate campaign. Collect information about costs in healthcare and medico-social sectors In the healthcare sector, the decree adopted in 2016 to regulate the procedures for designating establishments to participate in national cost studies (études nationales de coûts - ENC), when volunteer participation is not enough to obtain a representative sample, was applied for the first time in 2017 on the ENC covering data for the year 2018 in the 3 healthcare fields: MCO, SSR and HAD. In the medico-social sector, ATIH worked on completing a national cost study for medicosocial structures and organisations treating people with disabilities as part of the Serafin PH project. The Agency also performed a study on home nursing care services (SSIAD) and multidisciplinary home aid and care services (SPASAD). 16 SUMMARY OF WORK

19 417,000 PSY 342,000 80,000 PATIENTS IN PSYCHIATRY PATIENTS UNDER FULL-TIME TREATMENT PATIENTS HOSPITALISED 134,000 patients with mood disorder 96,000 patients with schizophrenia and delusional disorders 21,000 patients with pervasive developmental disorders (autistic) 32, ,000 patients for palliative care 23,000 PATIENTS IN HOSPITALISATION patients with complex dressings AT HOME (HAD) and specific care 6,400 patients with intensive nursing care 4.9 M DAYS 2017 ACTIVITY REPORT 17

20 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES To facilitate the use of ScanSanté, access to data was simplified and new restitutions were proposed: all-fields institution form, flow between institutions representation tool (outil de représentation des flux entre établissements - ORFEE), chronic addictions, long-term hospitalisations and involuntary commitment, use of medicinal products from the additional list, work units cost framework, etc. To promote awareness of ScanSanté data, information sessions were organised and an ARS user group was created. New indicators were developed on analysis of activity, readmissions and potentially avoidable hospitalisations, and on purchase and consumption of medicinal products at the hospital. POSITION THE AGENCY OPTIMALLY IN ITS ENVIRONMENT Build lasting connections with partners in the field Improve the internal performance of the Agency To better identify the needs and the information and response circuits to offer the DIMs, in 2017 ATIH organised a comprehensive meeting at the facilities of certain stakeholders in the field, identified based on their good knowledge of the issues. ATIH developed internal and budget control, simplified management of software contracts and defined a framework for the use of outside services. To evaluate the Agency s audience satisfaction, the Agency regularly asks its users to find out their overall satisfaction level with all of its missions: data collection campaigns, database distribution, on-demand data processing and its website. 18 SUMMARY OF WORK

21 THE AGENCY S 2017 IT DATA STORAGE, FLOW AND PROCESSING +50 PHYSICAL SERVERS +380 VIRTUAL SERVERS +400 INTERNET/ INTRANET PLATFORMS including 31 INTRANET PLATFORMS TOTAL VOLUME 75 Tb used 83,000 USER ACCOUNTS 45,000 IN THE HEALTHCARE SECTOR 38,000 IN THE MEDICO-SOCIAL SECTOR 151,875 DATA TRANSMISSIONS for all MCO, HAD, SSR and psychiatry fields, including 4,801 for cost studies 10,000 PAYMENT ORDERS occurred in MCO, via the e-pmsi platform, allowing payment of activity of institutions for an amount exceeding 40 billion euros ACTIVITY REPORT 19

22 20 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA

23 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA 2017 ACTIVITY REPORT 21

24 Collect more data New data collections were announced in the ATIH COP. ATIH has begun preparing the framework for these collections planned to start in Regarding innovation, ATIH was asked by the General Directorate of Health Services (Direction générale de l offre de soins - DGOS) to manage calls for projects on health research and innovation (Innovarc). These national or regional research projects may focus on clinical or nursing topics or on evaluation of care practices. Regarding innovation, ATIH was asked by the General Directorate of Health Services (Direction générale de l offre de soins - DGOS) to manage calls for projects on health research and innovation (Innovarc). Regarding management of research publications and clinical research activity, ATIH will take over development of the SIGAPS and SIGREC applications, initially managed by CHU de Lille [Lille University Hospital Centre]. - The System for Identification, Management and Analysis of Scientific Publications (SIGAPS) lists publications made by hospital doctors within their institution. - The Information and Management System for Research and Clinical Trials (SIGREC) measures the number of patients from an institution involved in multi-centre research protocols. These applications are used to create a funding distribution indicator for teaching, research, reference and innovation missions (missions d enseignement, de recherche, de référence et d innovation - MERRI). Secure and facilitate access to data Organisation of access to health data In April 2017, the National Health Data System (SNDS), the new data access authorisation system by the National Health Data Institute (INDS) and the Expert Committee for Health Research, Studies and Evaluations (CEREES). As part of the SNDS, ATIH participates in the working and steering groups. For example, the low-risk group, started in 2016, submitted its conclusions in late 2017, and will probably lead ATIH to establish rules in the display of data on ScanSanté by defining a minimum number to avoid any risk of reidentification of patients. Security framework The Ministry published a security framework in spring In this context, ATIH audited its secure data access server to meet the requirements of this framework and then proposed an action plan to achieve compliance. 22 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA

25 Control of data outputs ATIH records all processing carried out on its secure server, to ensure that users do not export raw or re-identifying data in accordance with the law. In 2017, first inspections were conducted and generated alerts. A systematic control project will be developed in Creation of a standard file for the French Data Protection Authority (Commission nationale de l informatique et des libertés - CNIL) ATIH, in connection with the DGOS, worked on the creation of a standard CNIL file for healthcare organisations, to facilitate the CNIL authorisation process and to obtain multi-year access, as well as extend their access to data. Once in place, the organisations should save time when writing their CNIL requests. The objective is for this standard file to be ready in early It was submitted to the National Health Data Institute (INDS) and is undergoing analysis by the Expert Committee for Health Research, Studies and Evaluations (CEREES). Enrich the data available on the secure access server 550 users at the end of 2017 counted on the secure server More than 550 users at the end of 2017 counted on the secure server. According to an ATIH satisfaction survey conducted among users last December, this figure is continuously growing. 95% of respondents said they were satisfied or very satisfied with the PMSI databases and their access system. 95% of respondents said they were satisfied or very satisfied with the PMSI databases 2017 ACTIVITY REPORT 23

26 In 2017, financial data of public and private non-profit institutions was added for the ARS, such as the statement of revenue and expenditure estimates (EPRD), the sub-annual statement, the accounting adjustment (RTC), etc. Availability of programs On the secure server, specific programs are available to users, to meet their demands on ATIH productions and adapt them to their needs. For example: a program for working on 7-day readmissions, a program that provides indicators for elderly persons at risk of loss of autonomy (PAERPA), etc. Configurable data analysis tool A query tool, implemented on the updated databases, is being designed. The query tool will be carried out on activity indicators at a regional level, from work carried out by the Grand Est region. The objective is to offer users queries to facilitate the use of raw data and to develop others on different subjects according to user demand. Make accessible data from A&E care summaries With the implementation of the reporting of A&E care summaries (résumés de passages aux urgences - RPU), through the decree of July 2013, healthcare organisations are required to send RPU to the ARS. ATIH worked on the quality of RPU data and their comprehensiveness. Programming tables with the data were created and made accessible on the secure data server to the ARS, institutions, organisations, etc. Ensure data access for all users Secure server user monitoring groups were initiated to discuss their practices, collect information about their needs and identify improvements expected. 4 groups were created: General Directorate of Research, Studies, Evaluation and Statistics (Direction de la recherche, des études, de l évaluation et des statistiques - DREES), ARS, federations and territorial hospital groups (groupements hospitaliers de territoire - GHT) support organisations. For access to data from private providers, a new deal was concluded for 2017 with the Secure Data Access Centre (centre d accès sécurisé aux données - CASD) to continue offering this service. 24 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA

27 Ensure the quality of data Develop control tools A major change was made to the tables of the data validation tool (Ovalide) by institutions and the ARS to develop supplemental tables incorporating the new SSR activity funding mode. Coordinate collection systems ATIH continued automatic supply of activity information from the annual statistics of institutions (statistique annuelle des établissements - SAE), managed by DREES, with data from the PMSI and added the field of SSR activity in When institutions complete the SAE survey, they see their prefilled PMSI data, which eases their collection burden and improves consistency between the two tools ACTIVITY REPORT 25

28 A WORD FROM THE TEAMS SECURE ACCESS TO HOSPITAL DATA Sandra Steunou, statistics engineer Brice Sauvageon, IT engineer For users, these common databases facilitate the exchange of programs or projects. 26 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA

29 What is the assessment of the new PMSI data access device via the Agency s server one year later? 550 users registered, 150 structures including about a hundred institutions. Today, users benefit from access to a multitude of structured information, on a common server, which has standardised data processing practices. Secure data access is a key point of the project. It goes through the strong authentication of users via both a password and a token in the form of an electronic box that generates a different encrypted code every minute. In addition to PMSI data, different resources are available on the server, such as PMSIspecific classifications Joint Classification of Medical Procedures (Classification Commune des Actes Medicaux - CCAM), ICD-10, Specific Catalogue of Rehabilitation Procedures (Catalogue Spécifique des Actes de Rééducation et Réadaptation - CSARR) as well as more general information, such as FINESS (National Directory of Health and Social Service Establishments) history (institution numbers), connections of geographical levels, etc. The descriptive and administrative databases of the annual statistics of institutions (SAE), managed by DREES, are accessible on this server. For users, these common databases facilitate the exchange of programs or projects. For some types of profiles, regular meetings are organised to integrate their needs and expectations and to share field experiences. 4 types of user groups have been started: - ARS: quarterly monitoring committee - Hospital federations: bimonthly phone meetings - Institutional: bimonthly phone meetings - CHU and GHT support organisations: regular phone meetings How did the implementation of this new secure data access method take place? Initially, the project targeted only the ARS, i.e. 80 users, and was expanded to all institutional and healthcare facilities to centralise access to data collected by the Agency. The expansion of the audience involved has required major reorganisation of the platform, to support the additional increase in load. ATIH has accompanied users during this change through training and information sessions. What were the main actions? This project mobilised IT and data management teams. IT had to design and supervise the setting up of the infrastructure in connection with outside service providers to simultaneously manage authentication, hosting, storage and processing of data. Data managers prepared the PMSI national databases (annual and sub-annual), i.e. more than 1100 databases, to be made available to users and identified their needs in terms of general and medical classifications. A weekly update is carried out from the latest ARS-validated data. Data managers are attentive to the needs of users, to provide them with work tools and facilitate use of the data. Major work was carried out on the management of the different user profiles. Based on the profiles, information is adapted according to users rights and CNIL authorisations. This additional security feature protects against the possibility of data modification. Procedures have been established to manage user accounts, their structures and their access. Major financial investments were necessary to acquire new servers, licences for various software programs, and support and maintenance service ACTIVITY REPORT 27

30 What are the procedures related to establishing an account? Forms were created to initialise requests for creation, modification, deletion and renewal of user accounts. Each form triggers a process, and the ATIH is committed to the processing times of the request. Monitoring is managed through a tickets system that tracks the progress of various stages of the request. To absorb the workload, part of the processing has been outsourced to our support provider. What have you taken from this experience about secure data access? Brice - It is very motivating to work on a brand new project from scratch. It lets you design a solution and implement new tools without having to consider the past. Besides the technical aspect, I was able to set up process and monitoring concepts with strong service level constraints, which were not present in our workflow until now. Working with the statistical survey teams helped me better understand all of the data collected at the Agency and how it is used. In addition, discussions with other teams from the Agency were very enriching, both technically and in terms of work methods. The success of this project required a major human investment. Sandra - It has taught me a lot in terms of developing new technical and organisational skills. In addition, I had to work closely with the IT team, which was very rewarding. The changes implemented with the different user groups are very constructive and stimulating. Their satisfaction is extremely motivating! On the other hand, the investment in terms of time is very significant to best respond to our commitment of service towards the users. 28 PROVIDE ACCESSIBILITY TO HOSPITAL AND MEDICO-SOCIAL DATA

31 2017 ACTIVITY REPORT 29

32 30 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

33 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES 2017 ACTIVITY REPORT 31

34 Adapt classifications to refine institutional funding In 2017, ATIH developed is work method on matters of medical information (collection, classification) by asking medical information experts at institutions in order to obtain a clearer vision of issues in the field and practices of teams. This field vision particularly helped us ensure the feasibility of the changes proposed. Clinicians were also asked to help build, update or validate changes of classification, in all fields of activity. New version of the post-acute care and rehabilitation (SSR) classification With an aim to reviewing the activity s funding model, the descriptive tool for SSR activity is undergoing revision. In 2017, ATIH finalised redesign works for GME classification in SSR. This new version of the classification offers new concepts, such as: - nosological sub-groups to describe certain types of populations, such as paediatrics - a summary index of medico-economic burden (indice synthétique de lourdeur médico économique - ISLE) to describe the severity of pathologies and integrate patient characteristics (dependency level, age, etc.). It combines complications and associated morbidities (complications et morbidités associées - CMA) and patient-related variables. - better identification of the level of rehabilitation proposed for the patient. This new version of the classification was finalised in summer 2017 and was used as the basis for impact tests on institution activity valuation. Simulations were evaluated with these impacts, considering what could be attributed to the new tools: new classification and, at the same time, new cost scales. Following this work, the federations requested a postponement of the implementation of this classification scheduled for March 2018, asking in particular that ATIH propose improvements to the classification (for example, relating to cardiology and pulmonology). 32 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

35 GME classification: methodological evolution Major category Nosological group (groupe nosologique - GN) Subdivision of GN aiming to explicitly identify certain populations and/or certain care (example: marker procedures) Sub-GN Medically readable description of stays Index in 3 levels reflecting the increase in economic burden, with fixed main disease, due to different patient characteristics. Levels of burden Macro-economic description of stays Groups reflecting the different levels of equivalent patient rehabilitation Rehabilitation groups 2017 ACTIVITY REPORT 33

36 New classification project in hospitalisation at home (HAD) Like for SSR, work is under way to review the funding model in connection with the DGOS, for a reform scheduled for The HAD classification is to be built in its entirety. In 2017, ATIH brought together professionals from the field of HAD, including specialists in certain types of care: perinatal care, paediatrics, chemotherapy, etc. Based on their feedback, ATIH moved forward with building components of the classification that will be used as a basis for the creation of the V0 expected in Work in classification in medicine, surgery and obstetrics (MCO) on outpatient surgery The work will lead to a revision of the classification, concerning the Major Diagnostic Category (MDC) 09, diseases and disorders of the skin, subcutaneous tissue and breast. The choice to review this MDC is based on feedback from federations, in particular Unicancer, and the diagnosis of the Agency on the opportunity for this review. The idea is to refine the classification to better consider the procedures performed in an outpatient setting and better identify the burden of outpatient care. Work in 2017 will lead to an implementation of the new version of the classification in Work related to breast diseases was finalised in the autumn, and could have led to an implementation for However, in agreement with the federations, it was decided to continue this work to include changes relating to the skin conditions (including skin grafts), and to supplement this update with the revision of another MDC (to be defined). One-off work was carried out at the request of the federations, concerning the inclusion or the reorientation of procedures from MDC 03 (Diseases and Disorders of the Ear, Nose, Mouth and Throat) and MDC 05 (Diseases and Disorders of the Circulatory System). From a point of view of work to better describe outpatient medical activity (beyond surgical activity), and with a view to encouraging development of this practice, reflection on the variables to be collected will be conducted in 2018, in connection with clinicians. 34 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

37 Optimise and apply funding mechanisms Concrete implementation of the 2017 rate and budget campaign As at the beginning of the year, teams mobilise to produce the technical elements necessary for institutional funding according to the guidance issued by the Ministry. These elements will lead to the creation of several deliverables. Rate campaign deliverables Description PMSI notice in different fields Rates from costs Rate orders Annual flat rates Funding notice Activity valuation Simulation files Details all the news about PMSI collection from year N by field of activity Created by ATIH, on line at our website Cost scale adjusted on the annual amount funding the activity. This scale respects the hierarchy of costs between the different services Made by the Ministry to establish new rates, published in the Official Gazette Used by ARS to delegate credits to institutions Lists all funding news: about hospital services, technical methods for construction of rates and supplements on the rules of collection and coding Establishes value of activity from year N-1 according to funding modalities of year N, to see the impact of the new rates on the valuation of the activity Sent to institutions as part of the evaluation of their annual revenue For each institution, identifies the impact of the campaign on its rates Distributed to ARS 2017 ACTIVITY REPORT 35

38 Preparatory work on the 2018 budget and rate campaign Preparation work for the N+1 campaign begins at the end of year N. ATIH is responsible for performing the technical work that will concretely translate the measures taken in the social security financing draft bill (projet de loi de financement de la Sécurité sociale - PLFSS). Medicine, surgery and obstetrics Three focus areas on funding modalities are under way, involving conceptual and simulation work. 1. Issue of patient transport The question focuses on the reintegration of the cost of transportation related to the patient transfer into the hospital budget; it is currently included in community care. This will require finding the best funding vector and possibly evaluating the effects, in particular financial, of this transfer of jurisdiction. Previously, the institution was simply the prescriber; in the future, it will become both prescriber and transport manager. 2. Dynamic of ambulatory care The rate changes implemented as part of the campaign reflect the Ministry s willingness to support the transformation of care toward the outpatient setting. For 2018, the Ministry proposes a global support plan for the development of outpatient medicine. 3. Creation of a safety coefficient This new coefficient will apply to rates and rate scales, according to the status of institutions: public, private or private nonprofit. Today, differential charges exist, in particular through the competitiveness and tax credit (crédit d impôt compétitivité emploi - CICE), which benefits private institutions. To date, the rate scales have taken into account the existence of these mechanisms. Starting in 2018, a reduction coefficient will modulate the rates of the establishments. The value of this coefficient will depend on the status of the institution (public, private non-profit, private commercial). 36 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

39 Post-acute care and rehabilitation The PLFSS extended the temporary mechanism established in This mechanism is built around a combination of old and new funding modalities. Following simulation work, the DGOS decided not to implement the new classification in However, conceptual work about the 2017 funding and adjustment of the 2017 rates will be carried out, especially in relation to issues such as persistent vegetative states (PVS) or minimally conscious states (MCS), palliative care and unclosed stays. Hospitalisation at home For the second year, ATIH used the collection information about expensive medicinal products, excluding those from the additional list, funded by missions of general interest (MIG). The objective is to find out how to divide the amount of the MIG budget among HAD institutions that dispense expensive medicinal products. In 2016, the 2015 data were collected via a Fichsup file, an overall file provided per institution, but its data quality was insufficient. In 2017, the 2016 data were collected via a Fichcomp file, a file linked to the patient stay. This information is more reliable and more discriminating, and thus allows a more relevant distribution of funding ACTIVITY REPORT 37

40 Collect information about costs in healthcare and medico-social sectors 2 ways to ways to be included in the ENC Healthcare sector A decree adopted in 2016 regulates the procedures for designating establishments to participate in ENC, when volunteer participation is not enough to obtain a representative sample. Volunteering Institutions targeted under the decree This decree was applied for the first time in 2017 on the ENC based on data for the year Based on this decree, the 2018 sample was comprised of three healthcare fields: MCO, SSR and HAD. Thanks to this decree, the Agency was able to call upon target institutions and enter into a dialogue with them to include them in the ENC in the coming years. To date, the Agency has reached out to a target sample of establishments, but not all have responded. From now on, the decree requires them to respond and to justify a possible refusal to participate in the ENC or be subject to financial penalties applicable by the ARS. At the same time, numerous institutions have volunteered to be part of the 2018 ENC. 95 institutions total 135 institutions total 10 new volunteer institutions SSR 18 new institutions in the sample including 2 from the decree procedure 13 volunteers 3 changes in legal scope MCO 38 institutions total 5 new volunteer institutions HAD 38 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

41 Medico-social sector As part of the annual convention with the National Solidarity Fund for Autonomy (Caisse nationale de solidarité pour l autonomie - CNSA), ATIH ensures technical supervision of new funding models in the medico-social field, with a contribution to the project on the pathways of people with disabilities and a study on home nursing care services (SSIAD) and multidisciplinary home aid and care services (SPASAD). ATIH prepares the methodology of cost studies within the framework of various technical committees with representatives from federations and associations in each sector. Services and Institutions: Reform to Adapt Funding to the Pathways of People with Disabilities (Serafin PH) An ENC is being prepared following two annual cost surveys. It is planned for 2018 data. The objective is to stimulate reflection on the reform of funding for the sector of people with disabilities. The survey was based on the services classification (nomenclature) and institutions collected the costs of each service provided at their establishment. To that, the ENC added descriptive elements of the people who received care, based on the classification of needs and on the cost markers defined by a working group led by Serafin PH. Home nursing care services (SSIAD) and multidisciplinary home aid and care services (SPASAD) A study is under way to update the rate equation for services in the SSIAD and SPASAD sectors. Today, the activities used to calculate this equation are insufficiently precise and have become obsolete as a result of changes in practice, evolution of care, etc. Since April 2017, representatives from the sector have been working in a technical committee to develop the methodology of this study. The framework and modalities of the study are validated by a steering committee, comprised of federations from the sector and chaired by the General Directorate of Social Cohesion (Direction générale de la cohésion sociale - DGCS). So that this cost measurement is as representative as possible, in 2018 a sample of 200 departments, evidencing the diversity of SSIAD, will collect information about care dispensed and about the characteristics of each patient present during two or three one-week periods. To alleviate the administrative burden on departments participating in the study, their accounting data, sent in 2018 on the CNSA s ImportCA platform, will be used. Compensation will be allocated to the structures that transmit the study data on the ATIH platform, in due form within the time limit. To form this sample, a call for applications was launched in late 2017 on the ATIH website ACTIVITY REPORT 39

42 A WORD FROM THE TEAMS COST STUDIES IN THE MEDICO-SOCIAL SECTOR Nelly Boulet, statistics engineer Frédéric Quichon, research manager Aurélie Garnier, IT specialist Concerning the sample size for the survey on people with disabilities, it was necessary to adapt to the sector, which includes a wide variety of structures. 40 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

43 How are the ATIH teams organised to work on this new sector? We have had to adapt our operations to this sector, which is less prepared to respond to our requests than the healthcare sector, where everything has been structured for several years with dedicated representatives at healthcare institutions. The work at ATIH is organised in a global project mode where most of the Agency s professions are represented, in order to have high reactivity. Everyone receives the information at the same time and moves forward with their part. There are tight deadlines for completing the work. The schedule is controlled by the CNSA and the DGCS. All of our work procedures have been multiplied. Concerning the sample size for the survey on people with disabilities, it was necessary to adapt to the sector, which includes a wide variety of structures. For example, the 2016 survey focused on a sample of 250 structures, while in the healthcare sector, the sample size is smaller. The same is true for the SSIAD cost survey, which is based on a sample of more than 200 structures. It is not the diversity of structures that motivated the sample size, but the objective of updating the rate equation, which requires a large and representative sample of the sector. In concrete terms, how did this happen internally? The Agency had to simultaneously broaden its skills in data collection, software creation and quality processes. For data collection, we have proposed custom support materials to help field teams know what and how to collect, since most of them do not have an information system integrated with their tools like in the healthcare sector. The teams are small and mobilised on many topics. The IT team made use of a service provider to help in the design and development of this software and asked an ergonomist to design an easy-to-use tool, integrating the import of data, offering standard forms for manual collection and wording adapted to the vocabulary of the sector. This is a new organisation with different work methods. It had to be put in place quickly between the different parties involved in the project inhouse at ATIH and with the provider. Tests have been carried out with users, in particular at SSIAD, to validate proper function of the software. In the national cost studies department, one person was recruited especially for their skills in creating software quality processes. The objective was to improve our specifications, our documentation, and to provide paper forms for collection of information in the field that would be easy to re-transcribe into the data collection software. The ENC team also carried out a lot of work supporting people in the field in management control and data collection. For example, in the SSIAD sector, more than 600 people were trained in 50-person groups to promote discussions and be more in touch with the field. Is the role of ATIH different compared to the role in the healthcare sector? In the medico-social sector, ATIH does not have national databases available like it does for the healthcare sector with the PMSI. In that sector, we recover data from the CNSA. Not owning the national databases leads to additional work in understanding the databases, verification and correction. As a result, very regular points are planned for collection from our institutional partners of information about the data, which are not hosted at the Agency. Since this project involves different parties, inter-agency working groups (IWG) have been created at the moment for work on EHPAD costs, bringing together teams from ATIH, the CNSA, the DGCS and the National Health Insurance Fund for Salaried Workers (Caisse nationale d assurance maladie des travailleurs 2017 ACTIVITY REPORT 41

44 salariés - CNAMTS). This new operating method was then extended to other projects managed by the Agency. The more we work on the medico-social sector, the more we adapt to the sector, especially in the analysis performed on the data collected. While healthcare ENC lead to calculation of national average cost-of-care frameworks, in the persons with disabilities sector, which includes 12,500 very different structures, the notion of average cost is difficult for the sector to accept. It prefers to focus on dispersion of costs. What are the relationships with the representatives of the sector? In this project, the institutions in charge are the CNSA and the DGCS, who have the business knowledge to shed light on the results. The Agency, as the implementer had to familiarise itself with this complex sector and learn its codes to be able to present arguments to the parties involved. The medico-social sector includes many federations. For example, there are up to 15 different federations among people with disabilities, with divergent interests on specific topics As a result, ATIH has to be very precise and comprehensive to best respond to the different issues. During our work in the medical-social sector, we found our representatives during the first dossier on EHPAD, then Serafin PH and then SSIAD. Thus, we have established lasting relationships with industry experts who have different hats, which has helped to legitimise us in the new fields in the eyes of the various parties involved: the CNSA, federations, etc. How does the Agency fit into a comprehensive reform of the funding modalities of the sector? ATIH must manage the restitution of results by becoming part of a more comprehensive context. The parties in the sector had fears about the funding reform project, in particular with the intervention of ATIH and its experience in the healthcare sector. At a technical expert, the Agency had to respond by integrating the constraints and demands of the parties. What have you taken from this experience in the medico-social sector? Nelly - It is interesting to discover a new and very different sector. It is less routine than the healthcare sector, where ENC have been performed for several years. That is the whole appeal of innovation. Frédéric - I am sometimes afraid of not getting enough information for our surveys or studies to be successful. It took a lot of appealing to each other. The partnership must be strong for it to work. In the end, it is an enriching experience, full of surprises Aurélie - For IT, the innovation was establishing different work methods and organisation by using a service provider. This experience was rich in methodology and project management. 42 IMPROVE FUNDING MODELS FOR HOSPITAL AND MEDICO-SOCIAL ACTIVITIES

45 2017 ACTIVITY REPORT 43

46 44 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES

47 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES 2017 ACTIVITY REPORT 45

48 Facilitate use of ScanSanté Simplified access to data New restitutions Redesign of the homepage The homepage of the ScanSanté platform has been improved to facilitate use of hospital data. - Restitutions have been grouped by major data topic: activity, costs-funding, etc. - A search engine was integrated to facilitate targeting of information. - A specific input was created for territorial hospital groups (GHT). - The platform help now offers detailed information, improved with examples of analysis, video tutorials, topic sheets, etc. - A rich site summary (RSS) is offered to stay informed of the latest updates. All-fields institution form The new all-fields institution form offers a cross-functional view of the activity of an institution: - on all of its healthcare activity (MCO, HAD, SSR, psychiatry), - from different types of information: activity, positioning in its environment (market share), patient population, financial situation, etc. For most of the indicators, a benchmark is proposed between the institution selected and its category, its region or even all institutions in France. Addition of a basket of institutions GHT filter In some restitutions, ScanSanté allows calculation of indicators on a free grouping of institutions called basket of institutions. To easily select the institutions that make up a GHT, a new filter identifying the institutions of a GHT was added to the basket of institutions for restitutions: flow between institutions representation tool, activity analysis indicators and MCO case-mix. This functionality will be deployed on other restitutions in Flow between institutions Developed in partnership with the National Support Agency for the Performance of Healthcare Organisations (Agence nationale d appui à la performance des établissements de santé - ANAP), the flow between institutions representation tool (ORFEE) allows measurement and comparison of institutions in their territories by describing: - the activity of an institution or a group of institutions and the flow of MCO/MCO, MCO/SSR and MCO/HAD exchanges - the concentration of activity and valuation associated with each case-mix homogeneous patient group (groupe homogène des malades - GHM) - the evolution of activity and market shares - the flow of exchanges in the territory between MCO, SSR or HAD institutions. 46 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES

49 Chronic addictions The new multi-field Chronic Addictions restitution (psychiatry, MCO, SSR) characterises healthcare services and management of chronic addictions in a selected geographical area. It returns epidemiological indicators, on reception facilities and about consumption of care (in medico-social or health structure) of residents of the area suffering from one or more chronic addictions. Psychiatry Long-term hospitalisations In addition to the three existing Medicoeconomic restitutions in psychiatry applications, the new Long-term hospitalisations in psychiatry restitution characterises long-term full-time psychiatric hospitalisations by documenting, for each institution, the socio-demographic and medical characteristics of patients with at least one long-term hospitalisation during the year and their consumption of care. Involuntary commitment Focuses were added to the Data by institution and Aggregated data restitutions to document involuntary treatment provided at psychiatry institutions. They detail the number of days and patients according to the legal mode of care for each type of treatment. Use of medicinal products from the additional list In keeping with the needs of the observatories for medicines, medical devices and therapeutic innovation (observatoires du médicament, des dispositifs médicaux et de l'innovation thérapeutique - OMEDIT), a redesign of the existing sub-annual statistics in ScanSanté on the consumption of medicinal products and implantable medical devices from the additional list by healthcare institution was carried out. New data formats were added and data are also available on the SSR field in addition to the MCO and HAD fields. Work units cost framework The work units cost framework, calculated from national data of public and private nonprofit institutions on accounting adjustments, has evolved considerably in both form and content. The objective is to facilitate access and provide users with detailed work unit costs for care activities and for support functions. With this restitution, it is possible for an institution to position, for an activity (such as medicotechnical), its work unit cost compared to a custom-developed reference (choice of institutions comprising the reference) ACTIVITY REPORT 47

50 Promote knowledge of ScanSanté data Information sessions National stakeholders were training on the use of ScanSanté during two one-day information sessions. ATIH also finished its ARS tour of France started in 2016 with three additional trips to the regions to ensure an information day for ARS agents. In partnership with the School of Public Health (école des hautes études en santé publique - EHESP), ScanSanté user training sessions were offered at healthcare institutions. These twoday sessions, included in the Processing and combined use of various healthcare databases (ScanSanté, SNDS, etc.) module, are based on practical cases and allow trainees to the change to use the tool. An initial session took place in November 2017 with 10 participants. In 2018, an informational half-day on the use of ScanSanté will also be included in the Geographic and strategic analysis module of the EHESP. Other informational activities were also conducted with users at institutions at the Adelf Emois days, at Paris Healthcare Week and at the Occitanie health data days in Montpellier. ARS user group In addition to the various groups run by ATIH, a user group was started to identify the expectations of ARS in terms of content and functionalities and to adapt the restitutions according to users needs. Two meetings were held in 2017 and discussions will continue in According to the same principle, an institution user group will be started in Coordination of tools by the ARS ATIH contributed to the coordinated implementation of tools available to the ARS in partnership with the Secretariat General of the Ministries for Social Affairs and the DREES. Its active participation in work to harmonise indicators between ScanSanté and the Diamant tool of the Ile de France ARS, led by the General Secretariat, laid the foundation for an alignment of indicators in the field of psychiatry. Discussions initiated in the MCO field in 2017 will continue in Moreover, an inventory of indicators available in ScanSanté was conducted with the DREES as part of the health indicator governing project. 48 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES

51 Create new indicators Analysis of activity The problem is two-fold, involving both the question of organisation of the care of a territory and the result of the care. Regarding these issues, ATIH has been asked by the Ministry for several years to produce indicators on readmissions and potentially preventable hospitalisations. In 2017, the work resulted in the development of indicators and a distribution according to two focuses. Analysis of activity of an institution s production, using the 7-day readmissions indicator This is not a quality of care indicator. It is offered to uses as an indicator of analysis of the activity produced by an institution at the most restricted level (for example, GHM in MCO). The institution can learn its readmission rate and position itself compared to a national average readmission rate. Therefore, in the analysis, it may be interesting to identify activities for which there is a deviation, to take an in-depth look at the reasons for this deviation and possibly to identify inappropriate practices. This indicator must be refined. For example, the method does not specifically handle scheduled hospitalisations. Moreover, it is also not checked whether the readmission is medically related to the first stay. All of these reasons led to its positioning as an indicator of analysis or alert. This indicator was presented to users during a meeting of the steering committee on care quality and safety indicators (indicateurs de qualité et de sécurité des soins - IQSS). It is distributed via ScanSanté so that institutions may take ownership of it. Analysis of healthcare services in a health territory, using indicators about potentially avoidable hospitalisations and 30-day readmission These indicators can alert to problems of coordination between all of the parties that contribute to the care, in the city, in the hospital and in the medico-social sector. The idea is to typify territories with specific potentially avoidable hospitalisation rates or 30-day readmission rates. For these territories, a territorial diagnostic approach to coordination of care could be carried out. It is an approach towards ARS, so they can consider new organisations to resolve these issues. These two indicators respond to two different logics. All of these elements are distributed on the ScanSanté platform to the parties in question. Purchasing and consumption of medicinal products at the hospital The objective is to learn about consumptions of medicinal products used by the institutions, medicinal products on the MCO and HAD additional list and medications included in the GHM and for which information is not collected separately to date. ATIH has performed this collection since 2015 and offers adapted tools to facilitate the collection and restitution of data. ENQUÊTE Achat et consommation de médicaments à l hôpital 2017 ACTIVITY REPORT 49

52 2016 medicinal products survey, top 20 ranking ATC2* 2016 total quantity dispensed ATC2 ATC2 Description Total amount dispensed ATC total amount delivered ATC2 ATC2 Description Amount dispensed N02 Analgesics 182,428,133 L01 Antineoplastic agents B05 Blood substitutes and perfusion solutions 141,662,695 L04 Immunosuppressants N05 Psycholeptics 101,538,042 J05 Antivirals for systemic use 292,116,611 B01 Antithrombotic agents 56,930,261 J06 Immune sera and immunoglobulins 228,857,728 J01 Antibacterials for systemic use 52,606,319 B02 Antihæmorrhagics A02 Drugs for acid related disorders 42,539,625 B05 Blood substitutes and perfusion solutions A03 Drugs for functional gastrointestinal disorders 34,102,406 A16 Other alimentary tract and metabolism products 156,830,000 A06 Drugs for constipation 33,770,935 J02 Antimycotics for systemic use 105,736,789 N03 Antiepileptics 32,990,022 B01 Antithrombotic agents 93,882,589 A12 Mineral supplements 30,032,960 J01 Antibacterials for systemic use 80,354,639 N01 Anaesthetics 27,487,774 N01 Anaesthetics 66,236,349 N06 Psychoanaleptics 26,110,325 B03 Antianaemic preparations 55,765,711 C03 Diuretics 25,263,086 M03 Muscle relaxants 35,017,532 D08 Antiseptics and disinfectants 25,125,471 V03 All other therapeutic products 30,316,911 R03 Drugs for obstructive airway diseases 23,473,573 N02 Analgesics 30,084,787 C07 Beta blocking agents 20,269,183 N05 Psycholeptics 29,747,364 H02 Corticosteroids for systemic use 19,924,260 V08 Contrast media 27,741,807 C01 Cardiac therapy 18,640,275 C09 Agents acting on the renin angiotensin system S01 Ophthalmologicals 18,178,432 R07 Other respiratory system products 22,168,913 C02 Antihypertensives 20,255,427 L03 Immunostimulants 19,578,064 * Anatomical Therapeutic and Chemical Classification System 50 PRODUCE INDICATORS TO BETTER UNDERSTAND HEALTHCARE SERVICES

53 For institutions in the 2017 survey, supplemental regional data and ranking by field of activity were offered. The data collection campaign started in March. The collection software is available on the ATIH website. The e-med platform allows data to be deposited, and in 2018 will offer restitution of data from previous years in the form of rankings. For the 2017 survey : 876 institutions participated on 2015 data, representing 51% of activity in days of hospitalisation 915 institutions participated on 2016 data, representing 55% of activity in days of hospitalisation In 2017, a service provider reached out to institutions to encourage them to join the survey. This collection included all medicinal products, regardless of conditions of prescription and dispensing. It involved collecting the unit prices and quantities of medicinal products consumed at each institution, for example to learn the prescription practices and use of generics and biosimilars ACTIVITY REPORT 51

54 52 POSITION THE AGENCY OPTIMALLY IN ITS ENVIRONMENT

55 POSITION THE AGENCY OPTIMALLY IN ITS ENVIRONMENT 2017 ACTIVITY REPORT 53

56 Build lasting connections with partners in the field Improvement of the ATIH s responses to the needs of healthcare institutions is a strategic objective of the Agency. Two main target functions have been identified: financial affairs departments (directions des affaires financières - DAF) and medical information departments (DIMs). In 2016, after the reform establishing territorial hospital groups (GHT), ATIH initiated a working group with representatives of DIM physicians (French-speaking Society of Medical Information [Société Francophone de l'information Médicale - SoFIMe], National Association of Medical Information [Collège National de l'information Médicale - Cnim]) from the public sector, who were the only ones to be affected by the reform. This group initially aimed to support the implementation of groups to facilitate discussions with professionals to adapt the tools prepared by ATIH. The experience from the first meetings on GHT revealed problems related to an insufficient circulation of information between ATIH and DIMs, between participants and all DIM physicians, as well as the ATIH s sometimesimperfect knowledge of the very concrete difficulties that can be faced by stakeholders in the field. To better identify the needs and the information and response circuits to offer the DIMs, ATIH organised an informal but comprehensive meeting at the facilities of certain stakeholders in the field, identified based on their good knowledge of the issues. The selections made cover the three types of status and different sizes of institutions. These visits, held from July to October, were held with various representatives (physicians, statisticians, IT specialists, medical information technicians, executives) in interviews lasting 2 to 4 hours, prepared by sending a meeting outline to structure the discussions. These interviews resulted in a summary identifying the needs, the possible shortcomings, as well as measures for improvement. This summary also contains general elements about preferred methods of communication, documentation, etc., as well as detailed proposals for improvement on points that are sometimes very specific but that can significantly improve the daily lives of the professionals in question. In addition, a partnership with SoFIMe was created, focused mainly on the problems of diagnostics coding or even description of activities. Moreover, new groups of experts, in each of the fields, were formed to establish close ties to secure work on both medical information and classification. 54 POSITION THE AGENCY OPTIMALLY IN ITS ENVIRONMENT

57 Improve the internal performance of the Agency Internal control mechanisms These mechanisms are part of the overall control of the Agency s activities The main aspects involved in the risk management process are : - satisfaction of ATIH contacts (satisfaction survey and review of project with relevant authorities) - security of information systems (state information systems security policy [programme de sécurité des systèmes d information de l Etat - PSSIE] and SNDS security framework) - internal accounting and budget control (CICB). Concerning the CICB, ATIH continues to improve its budget management and public accounting (Gestion budgétaire et comptable publique - GBCP) reform through its dialogue with operational departments. The Agency has initiated the internal budget control process, in addition to the internal accounting control implemented several years ago. Examples of actions implemented as part of the CICB: - monthly meetings with the two main purchasing centres for contract monitoring. - quarterly budget meetings with all centres. - integration of systematic thinking during the creation of contracts through a breakdown in commitment authorisation and payment appropriation throughout the entirety of the contract. - implementation of quarterly monitoring of commitment authorisations and payment appropriations, as part of discussions with the accounting agent. Simplify management of software contracts In 2017, ATIH dematerialised the management of software license agreements and launched a new Déclic platform. This project allows paper contracts for paid software license agreements (grouping functions, group programs, Dalia) to be eliminated for all fields (MCO, SSR, HAD, psychiatry). The Déclic platform lets the client monitor the status of their order (pending processing, validated, billed, etc.) at any time. This platform for dematerialisation of the sale of ATIH products also meets the demand of users following an annual satisfaction survey conducted with healthcare institutions and IT companies. It is part of a more global process of dematerialisation of invoicing and the accounting chain initiated in 2017 (electronic invoicing on the Chorus Pro platform, dematerialisation of the financial account, dematerialisation of supporting documentation for payment and recovery orders) ACTIVITY REPORT 55

58 Define a framework for the use of outside services The expansion of ATIH s missions in recent years has led the Agency to increasingly turn to outside services. During a seminar, the Board of Directors carried out an assessment and feedback of various departments, with a view to defining a framework for the use of outside services for the coming years. The main areas for use of outside services were confirmed and the type of missions to be entrusted to service providers was clarified, to guarantee a good quality of service rendered. In addition, the decision was made to gradually use third-party maintenance for a number of applications. In order to support managers and agents in these developments, since 2017 the training plan has included training on management of projects with outside services. Evaluate the Agency s audience satisfaction To measure and improve its performance, ATIH relies in particular on a satisfaction barometer. The Agency regularly questions its audience to learn about their overall and detailed level of satisfaction according to some key criteria. The questionnaires, usually short and online, let respondents participate in improving a service/product in a quick and easy way through a few questions. People can also leave their contact details for additional contribution if the Agency wishes to conduct further study. The Agency uses this barometer to: - obtain relevant and regular feedback about its activities - adapt by undertaking actions targeted at the priority expectations of the audience - evaluate its efforts by observing the effects on the satisfaction of its audiences. In particular, this barometer covers each data collection campaign (such as PMSI, ENC, financial account, etc.), each database distributed (such as PMSI, RTC, etc.), the website and on-demand data processing. In 2018, it will expand to ScanSanté restitutions and to publications, to cover the main restitutions produced by the Agency. 56 POSITION THE AGENCY OPTIMALLY IN ITS ENVIRONMENT

59 2017 ACTIVITY REPORT 57

60 PUBLICATIONS