Diagnosis related groups (DRGs) were the first health management tool to group patients in clinical meaningful categories with homogeneous resources consumption. They belong to case mix measures that have been introduced in the USA in the seventies to identify clinical differences in groups of patients as well as to document variation in hospitals and physicians practices by comparing similar groups with each others. They are also used to adjust payment rates and to improve quality of care. This innovative concept migrated from the USA to several Western European countries and to Australia first, to Eastern Europe and Asia soon thereafter. The main objective in most countries concerns a hospital financing new methodology, based on similar groups of patients, by applying a global budget. The main result of this international overview of 25 countries is to show the difficulty to make international comparisons, mainly because of the absence of a universal classification system for procedures. Furthermore, diagnostic classification systems to group patients vary also by country. These obstacles to compare hospital and physician practices have profound roots in cultural differences and in political sensitivity for organising health care delivery between countries. The development of an appropriate Case Mix grouper tool including uniform diagnoses and procedures codes, leading to international use becomes a public health priority.

Ethical rules are similar for physicians in most countries that follow the Hippocratic oath. They have no formal legal force, but can be used as a reference to provide answers to solve individual cases. It appears erroneous to believe that privacy is about information. It is about relationship. In medicine, there is a contract between a patient and a physician, where health care personnel has to respect secrecy, while integrity and availability of information should be obtained for continuity of care. These somewhat contradictory objectives have to be applied very carefully to computerised biomedical information. Ethical principles have to be made clear to everyone, and society should take the necessary steps to organise their enforcement. Several examples are given in the delivery of health care, telediagnosis, patient follow-up. clinical research as well as possible breakthroughs that could jeopardise privacy, using biomedical information.

The electronic health record offers all advantages of computer based memories. It is accessible over networks, highly structured and allows exchange of information both within the institution and across its borders. However, it has potential disadvantages among which a great risk for confidentiality, integrity and availability of information about identifiable patients exists. The present paper discusses advantages and disadvantages of the electronic health record as well as methods in order to control and use appropriately identifiable patient data. Personal data protection requires a legislation, a code of conduct, information contracts, an organisation under the responsibility of a physician, technical tools for health security, risk analysis methods, standards for development and implementation of computer systems as well as training and teaching sessions.

Access rules to electronic patient records (EPR) have been issued by the Belgian Council of Physicians. Access to identifiable data of the EPR is restricted to anyone responsible for diagnosis, treatment and continuity of care of the patient. By delegation, associated personnel, like secretaries, can also be authorised to have access. A new perspective is given by the availability in 2003 of a national identification card allowing electronic signature of patients. It could not only authorise but also forbid some accesses. A law in 2002 gives right to patients to access to their own record. Health personnel can also be identified by cards but the system is not yet implemented. In the meantime, local measures have been made. We describe practical solutions that have been taken as priorities in a University Hospital. It was felt more important to allow access to lifesaving EPR data than to restrict its access by too strictly theoretical rules. A pilot study (S3 project) is also in progress for interinstitutional communication in Belgium, using the unique identification number of the patient and a "third server".