Which patients are concerned by the referring doctor system?
To be able to choose a referring doctor, patients must fulfil these two conditions:
· they must have at least one long-term condition whose seriousness or chronic nature requires prolonged treatment and considerable coordination due to the intervention of several healthcare providers.
· they must have an activated electronic health record (DSP) held by the Agence eSanté.
Long-term conditions are defined in appendix 1 to the agreement between the CNS and the AMMD. The appendix lists 32 long-term conditions, including multiple sclerosis, Alzheimer's disease, Parkinson's disease, cystic fibrosis etc.
What is a referring doctor?
The referring doctor is the doctor who knows the patient best and is consulted first in the event of a health problem. He plays a central role in providing follow-up for the patients targeted by the referring doctor system (see question 1). His missions include:
- coordinating healthcare and ensuring the best possible follow-up;
- guiding patients to other healthcare professionals where necessary (specialists, physiotherapists etc.);
- managing the medical file, centralising all the information about his patients' care and state of health (examination results, diagnoses, treatments etc.);
- regularly monitoring the content of the electronic health record (DSP)
These missions are defined in article 19b of the Luxembourg Social Security Code.
What is the electronic health record (DSP)?
The electronic health record ("dossier de soins partagé" or DSP), managed and made available by Agence eSanté, is the patient's secure electronic medical record, used by the healthcare professionals involved with the patient. The patient can control his DSP directly, and it is available to him free of charge. Access to the DSP is reserved solely for the patient and for the approved health professionals in Luxembourg who treat the patient and are granted access by the patient.
The primary goal of the DSP is to promote exchange between healthcare professionals and enable more coordinated patient care by centralising all the essential information about the patient's state of health. The DSP brings together the relevant health information necessary for optimum patient care, including the results of X-rays and/or biological tests, consultation and hospitalisation reports, prescriptions etc.
The DSP is a collaborative tool for health professionals and is available to the patient.
Agence eSanté has put stringent technical measures in place to guarantee a high level of security and data protection.
By agreement with the CNPD, the DSP was piloted from June 2015 with patients who had declared a referring doctor. Starting at the end of September 2015, Agence eSanté also offers DSPs to people with no referring doctor based on a voluntary request to open a record. The DSP will be rolled out to all patients once the pilot has been approved and the Grand Ducal regulation in application of article 60c and 60d of the Luxembourg Social Security Code, scheduled for early 2017, has taken effect.
For more information, see the information and documents on the Agence eSanté website (www.esante.lu), including the leaflet "The electronic health record (DSP) – Discover the essentials of your personal, secure electronic health record".
Does the patient have to have a referring doctor?
No, there is no obligation. The patient can continue to see his general practitioner or specialist without having to sign the declaration.
What are the advantages of the referring doctor?
The referring doctor is a special advisor who provides follow-up for patients suffering from chronic long-term conditions. He carries out the examinations and/or provides the treatments that are best suited to the patient's state of health. This can:
- offer better follow-up for people suffering from chronic conditions, who require more in-depth care;
- avoid unnecessary consultations;
- limit the examinations and/or analyses to be carried out;
- avoid interactions and/or duplication of medication and thus optimise the patient's drug consumption.
Who can be a referring doctor?
The doctor contacted by the patient can only accept the role of referring doctor if:
- he offers primary care with a global approach outside the hospital setting, and
- he has studied the medical disciplines of general practice or paediatrics.
Does the patient have to see the referring doctor first in order to consult a different doctor or a specialist?
No. The patient can see a specialist or any other doctor of their choice without seeing the referring doctor.
How does the patient tell the Caisse nationale de santé who the referring doctor is?
To tell the Caisse nationale de santé who the referring doctor is, the patient and doctor together must complete a "referring doctor declaration" form.
If the patient is a minor or under legal guardianship, the legal representative or authorised person must sign the form.
The referring doctor must send the completed, dated and signed form to the "referring doctor department" of the Caisse nationale de santé.
For further details, see the "Referring Doctor Declaration" explanatory note.
How long does the referring doctor declaration remain valid?
The relationship with the referring doctor is of indefinite duration. The declaration remains valid as long as the patient and the doctor agree to continue the patient/referring doctor relationship.
In the following cases, the patient is no longer bound the by the referring doctor declaration and is free to choose a new referring doctor:
- if his referring doctor dies;
- if he revokes the referring doctor declaration.
In the first case, the CNS informs the patient by letter.
When does the relationship between the referring doctor and the patient take effect?t prend-elle effet ?
The relationship takes effect on the first day of the month following the Caisse nationale de santé's approval of the referring doctor declaration.
As soon as it receives the declaration, the CNS checks the information provided. Following its approval, the CNS generates a unique referring doctor declaration number and communicates it in writing to the referring doctor, the patient and, where relevant, the patient's legal representative or authorised person, together with the date when the referring doctor declaration takes effect. The existence of the referring doctor relationship is reported by the Caisse Nationale de Santé to Agence eSanté, automatically triggering the relationship between the patient and the referring doctor in the patient's electronic health record.
Example: a declaration approved on 10 November 2016 by the CNS will take effect on 1 December 2016.
Can the patient change the referring doctor?
Yes. Patients are free to change their referring doctor.
During the first twelve months, the relationship can only be revoked by agreement between the patient and the referring doctor, with a two-month notice period.
To terminate the relationship jointly, the patient and the referring doctor complete the "Revocation of a referring doctor declaration by joint agreement" form together and send it, dated and signed, to the referring doctor department of the Caisse Nationale de Santé.
A declaration received on 10 March 2016 by the CNS and approved during March 2016 by the CNS will take effect on 1 April 2016. If on 5 May 2016 the CNS receives a "Revocation of a referring doctor declaration by joint agreement" signed on 3 May 2016, the termination takes effect on 3 July 2016. A new referring doctor declaration can then be submitted to the CNS.
From the second year, the relationship can be revoked unilaterally at any time, by either the patient or the referring doctor, with a two-month notice period.
If the revocation is initiated by the patient, the patient sends the form "Revocation of a referring doctor declaration by the insured person" to the referring doctor, also sending a copy to the Caisse Nationale de Santé.
If the referring doctor decides to end the declaration, the doctor sends the form "Revocation of a referring doctor declaration by the referring doctor" to the patient, also sending a copy to the Caisse Nationale de Santé.
For further details, see the "Revoking a referring doctor declaration" explanatory note.
Once the previous referring doctor declaration has been revoked, the patient can choose a new referring doctor. To tell the Caisse Nationale de Santé who the new referring doctor is, the patient must complete a "referring doctor declaration" form with the new doctor he has chosen (see question 7).
Note: a new declaration can only be recorded once the previous declaration has been revoked. It can only take effect after the legal notice period has ended (two months).
Can the relationship be ended in any other way?
If the patient or the referring doctor dies, the CNS informs the other party as quickly as possible that the referring doctor relationship has automatically ended.
If the patient blocks the referring doctor's access to his electronic health record (DSP), or closes the DSP, his relationship with the referring doctor is terminated after one month following notice sent by Agence eSanté to the patient, the referring doctor and the CNS.
What is the summary of services?
Starting on the date when the referring doctor relationship takes effect, and by 01 July 2016 at the earliest the CNS updates the patient's DSP annually with a summary of the services paid for by the health, maternity, accident and dependency insurance funds over the last three years, , then every year at the anniversary date a summary over of one year.
What is the patient summary?
Within three months of the referring doctor relationship taking effect (first day of the month following the validation of the declaration by the CNS), the referring doctor updates the DSP with a patient summary. If the patient requests it, the referring doctor explains the content of the patient summary and provides a free copy.
The referring doctor must update the patient summary in the DSP following every contact with the patient, adding any new clinical or therapeutic information relevant to the patient's state of health that may be useful in coordinating the healthcare services provided by health professionals.
Where can the legislation and the different documents concerning the primary care doctor be consulted?
The links to the legislation and the different documents regarding the primary care doctor can be found here.