health information policies in south america · hl7 brazil - co-chair advisory council ... são...
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Electronic Health Record
Initiatives in South America
Beatriz de Faria Leão, MD, PhD
Health Standards Architect
HL7 Brazil - Co-Chair Advisory Council
ABNT Health Informatics Committee WG8 Convener
ISO TC 215 WG8 Vice-Convener
11th International HL7 Interoperability Conference - IHIC2010
May 14 - 15, 2010 – Windsor Barra Hotel
Rio de Janeiro, RJ, Brasil
Agenda
• Introduction
• EHR experiences
– Uruguay
– Argentina
– Brazil
• Final Remarks
Thanks to all that contributed for this presentation:
• Alvaro Margolis – President of IMIA-LAC, Uruguay
• Ana Estela Haddad – Ministry of Health, Brazil
• Claudio Giulliano A. da Costa – SBIS President, Brazil
• Diego Kaminker – Chair, HL7 Argentina
• Fernán G. B. de Quirós – Hospital Italiano, Argentina
• Julio Carrau – Chair, HL7 Uruguay
• Jussara Macedo – Ministry of Health, Brazil
• Lincoln A. Moura Jr – IMIA Treasurer, Brazil
• Marivan Santiago Abrahão – Chair, HL7 Brazil
• Sergio A. König – Chair, HL7 Chile
Uruguay National eHealth Policy
Basic Data (2009 Estimate)
• GDP U$ 32 Billion
• Per capita U$ 12,800
• 3.5 million people
Uruguay eHealth Policy
• Sept 30th, 2003 – Federal Government issued the bill 396/003, on the EHR for all citizens, mandating the use of international standards, such as HL7 and DICOM;
• March 2006 – the elected Government, presents to the parliament the project of the National Integrated Health System (Sistema Nacional Integrado de Salud) by which sharing of information among all HC providers is mandatory, from 2007 on.
Priorities for the Sistema
Nacional Integrado de Salud
• Health care delivery
• Promotion and prevention
• Management and administrative health information
systems
• EHR with emphasis on primary care data
• Interoperability
• Standards
SUEIIDISSSociedad Uruguaya de Estandarización,
Intercambio e Integración de Datos e Información
de Servicios de Salud
• Founded in November 2005
• HL7 affiliate (country 26)
• 46 Members
• Mission: to promote, develop, and provide training and
capacity building on interoperability standards to share
health information for patient care and health care
management with all HC actors
• Focus on HL7 v3, CDA and IHE
Uruguay / SUEIIDIS
Interoperability Standards in use
• IHE profiles:
– Security digital certificates based on national PKI infrastructure
• Consistent Time service provided by SUEIIDIS
• CDA (HL7v3) for document sharing
• Uruguay National Identification Standards
– SUEIIDISS-UY-ESP-001:STID
• OIDs for object identification
– Common WSDL defined and shared among all participants
Results
• Vital Statistics Systems
• Maternal and Child Health Program
• Perinatal Information System
• Aduana Program: child follow-up till 2 years old
• Electronic Death Certificate (CD-e)
• EHR
FEMI FEMI SaludSalud Digital Digital
LLííneasneas de de acciaccióónn
Especificaciones: Funcional – Interoperabilidad Construcción
Implantación
Alineación – Estándares – HL7 Vocabularios de Referencia
Cambio Cultural
Formación: Médicos – Enfermería – Informáticos - Administradores
Coordinación con el resto de los actores del Sistema Uruguayo de Salud
Infraestructura
Redes Dimensionamiento
Prototipos de funcionalidad federal
Prototipos de Telemedicina
Hoy
Especificación
eHealth Standards in Argentina
Basic Data (2009 Estimate)
• GDP U$ 305 Billion
• Per capita U$ 13,800
• 41 million people
HL7 Argentina
• Founded on December 5th, 2001
• 28 members (9 of them individuals)
• HL7 is not a national standard, but several
developments involve the use of HL7 standards for e-
claims and interdepartmental interoperability
– mainly using HL7 V2.x and CDA R2
• Focus on training and dissemination of HL7 standards
• Virtual learning platform:
– 1,500 people trained since 2001, from different countries in LA
for the Spanish version
– 200 international students for the English version
eHealth in Brazil
Basic Data (2009 Estimate)
• GDP U$ 1.5 Trillion
• Per capita U$ 10,200
• 198 million people
Brazil – Geo-political Perspective
• The largest country
in Latin America
• The only Portuguese-
speaking country in LA
• The 5th most populated
country in the world
• The 3rd country in
number of Internet
hosts in America
SUS – The Brazilian Health System
• Universal Access– Health is a Right of All (~ 150M individuals)
• Full Coverage, Free of Charge– All Services and Procedures
• SUS principles:– Equity
– Universality
– Integrality
• Funding and Management are Shared– Federal, State and Municipal Levels
• Suplementary Health for Those Wiling to Pay– ~ 1,600 HMOs (~ 49 M individuals)
– ANS (Agência Nacional de Saúde Suplementar) Regulates the Sector
The Brazilian Healthcare Market
• Extremely Fragmented Market: ~ U$ 90 Bi/year
– SUS is the major Payer: ~ 66% in volume and some 50% in $
– 198M inhabitants, spread over 5.500 cities
– Around 7,000 Hospitals and 1,400 Health Plan Operators
– 70% of Hospitals have less than 80 beds
– Estimate that only 10% of Hospitals have Information Systems
– 90% HPOs cover less than 50,000 lives each
– Only 3% of HMOs cover more than 200,000 each
– There is no important network of Health Organizations
– It’s a “Market of the Discontent”
Healthcare Challenges in Brazil
• Increasing demand for health care (aging, emerging of new diseases, re-emerging of considered overcome diseases);
• Skyrocketing healthcare costs (Health Technology);
• Inefficient, paper-base uncoordinated systems, multiple formularies, poor resource allocation;
• Siloed systems - one for each health program;
• Lack of adequate information to support decision making, quality of care evaluation and to monitor disease management programs;
• Few common health and healthcare information standards within the sector.
Brazilian HC National Standards
• Unique HC Identifiers– Individuals (170 Million)
– HC providers (215 Thousand)
– Health Workers (1.5 Million)
• Content and Vocabularies– Essential Encounter Dataset
– Diagnostics (ICD-10), Procedures
– Immunization Charts
– Birth and Death National Registries (> 50 years)
– Notifiable Diseases ( Work related, external causes and communicable diseases)
– Hospital Discharge Summaries
– High Complexity Utilization Reports
– LOINC
– IHSTDO (under consideration)
Brazilian HC National Standards:
National Unique Identifiers:
• Individuals (170 million people uniquely
identified)
• Healthcare providers (181.903 uniquely
identified)
– Includes information on:– Medical specialties, number of beds, equipments, private and
public distribution, complexity level,
– Health professionals (physicians, nurses and administrative
personnel)
– 1.5 million healthcare professionals uniquely identified
Brazilian HC National Standards
• Interoperability– TISS – Private Health Information Exchange
– Lab Integration (LOINC + HL7 Brazil)
• Security– National PKI infrastructure
• Software Certification– Brazilian Health Informatics Society +
Federal Medical Council (www.sbis.org.br/certificacao)
• 4 products certified
• 3 products under auditing
• 120 people trained
TeleHealth National Project
• Promote the use of technology by the
Family Health teams
• Decrease the number of patients sent to
secondary level
• Evaluate different technologies,
methodologies and costs
• Improve quality of primary care
• Leads to money-saving (preliminary
figures are 100:1)
Source: Ana Estela Haddad, Bellagio, August, 2008
Coverage:
Nine State Clusters
implementing Telehealth
in 900 health units
supporting about 2,700
Health Family teams,
covering 11,000,000
inhabitants.
TeleHealth National Project
Private Healthcare Insurance Market
49.3 million
beneficiaries
HPOS
1,400 active Health Plan
Organizations
600,000 estimated Healthcare providers
Sources; www.ans.gov.br Set 2008
ANSState Regulation
Self-regulation
NHS Healthcare providers
NSHA DATABASE
(enroll/disenrollments , services utilization, health care indicators)
Demographics, Vital Statistics, Discharge Summary, Notifiable
Diseases
HMOS TISS - XML
TISS - the Brazilian standard for HPOs and HC
providers communication
Source: Jussara Macedo, ANS, 2007
Source: Jussara Macedo, ANS, 2007Source: Jussara Macedo, ANS, 2007
TISS - Standards
• Information structure: billing forms
– Consultation
– Hospital Discharge
– Lab, Medical Images
– Authorization for High Cost and High Complexity Procedures
• Core Health Terminologies and Code Sets (e.g ICD-
10)
• Messaging: XML schemas and Web services
• Privacy: ISO/NBR 17799 and SBIS/CFM Software
Certification
• Mandatory from May 2007 on
TISS Transactions
PROVIDERS HPOS
Eligibility and prior Authorization
Claim Generation
Service Billing
Claim Status
Inquiries
Pre certification and Adjudication
Claims Acceptation
Adjudication
Accounts
Receivable
Health care Services Delivery
Claims
Claim Status Inquiry
Patient Info
Claim Status Response
Claim PaymentAccounts Payable
Source: Jussara Macedo, ANS, 2007
www.hl7brazil.org
HL7 Brazil Actions
• Harmonize National Standards with HL7
• Training Programs
• Working Groups
– CDA, LOINC, Snomed, Support
• Membership
– Individual - 10
– Corporate - 15
• Intersystems, Zilics, Microsoft,
• Intel, ANS, Serasa
Hl7 Brazil Activities
• Februarr/2007 – creation of Institute HL7 Brazil
• Courses– October 2007 – I Basic Course of HL7 - with John Ritter - 70
persons - São Paulo
– April 2008 – HL7 - VERSION 3.0 - with Mead Walker - 40 persons, São Paulo
• Meetings– October 2007 – Open Forum HL7 Intel – with Ed. Hammond -
São Paulo
– October 2007 – 1er Congreso Iberoamericano de Informática Médica Normalizada, Montevideo, Uruguay
– April 2008 – Open Forum HL7 – IT-Mídia - with Mead Walker-São Paulo
SIGA Saúde
São Paulo City’s Health Information System
Lab Integration
São Paulo is the largest city in South America, with 12M inhabitants and some 22M in the Metropolitan Area.
Current Figures:
400 Primary Care Units +
300 Health Units
15M Users
8.5M Emergency T/year
550k Inpatients/year
11M Primary Care C/year
70k Scheduling requests processed daily
40k authorization requests processed monthly
São Paulo City HIMS
SIGA Saúde IT Model
Electronic Health Record
Patient Flow
Organization & Mngmnt(Specialties, Beds, Exams)
Management(Surveillance, Auditing
and Billing)
Internet
SP CityDatacenter
SMS-SP
Dept of
Health
Access Control
SIGA Saúde Figures for May, 2008
• 14,301,383 registered users
• 1,017,463 primary care scheduling / month
• 189,393 specialized care consultations / month
• 1,738,807 medical prescriptions attended over the
counter / month
• 35,000 authorizations of high cost & complexity
procedures / month
• 30% reduction in the waiting time for specialized
consultations & procedures
• Medication available at local pharmacies - supply chain
control
SIGA Saúde Lab Integration
• 32 millions exams in 2009 (2.6M / month)
– About 300 different labs exams without previous authorization
– Others need prior authorization
• Manual process: transcription errors, duplication of
exams, bad resource allocation
• Ordering HC providers
– 403 Primary care Units
– 100 Emergency and Specialized Units
– 15 Hospitals
• Executing Labs
– Private Labs (3) + Public Labs (6)
SIGA Saúde Lab Integration
Lab Orders
LAB 1 LAB 2 LAB 3 LAB N
UBS
SIGA Web Service: LAB
AE AMAS Hospital Emergency
Lab Order Sample Collection
Authorization
XML
XML
SIGA Saúde Lab Integration
Lab Results
LAB 1 LAB 2 LAB 3 LAB N
UBS
SIGA Web Service: SIGA
AE AMAS Hospital Emergency
Lab Results (Common, Micro, Pathology) - CDA in Phase 1
XML
XML
Standards used for SIGA’s Lab Integration
• Identification:
– Patient’s – National Health Card Number
– HC provider and HC worker - National Registry (CNES)
• Messages:
– TISS: XML schemas (simpleTypes, complexTypes, Messages,
WSDL)
– HL7 v3 - Lab orders and results information content (translated
tags)
– HL7 v3 pan-Canadian Messaging Standards
• Vocabulary:
– LOINC - Logical Observation Identifiers Names and Codes
References
HL7 CDA R2 Normative Edition 2005
ISO-639-1 –Identificadores de Idiomas
ISO 3166 – Identificadores de Países
ANVISA – RDC 302
Pan Canadian Lab Messages
IHE – Integrating the Healthcare Enterprise – Laboratory Technical Framework - Volume 3
OIDs defined
OID Descrição
2.16.840.1.113883.1.3 Identificador únivoco do CDA R2
1.3.6.1.4.1.19376.1.3.3 Identificador únivoco do template CDA para laboratórios clínicos
2.16.840.1.113883.13.36 CNES
2.16.840.1.113883.6.1 LOINC
2.16.840.1.113883.5.25 Confidentiality code - Vocabulário HL7
2.16.840.1.113883.13.37 CNS
2.16.840.1.113883.5.1 Administrative Gender – Vocabulário HL7
2.16.840.1.113883.2.21.20 Conselho Federal de Medicina
2.16.840.1.113883.2.21.21 Conselho Federal de Farmácia
2.16.840.1.113883.13.69 Conselho Federal de Biologia
2.16.840.1.113883.13.70 Conselho Federal de BioMedicina
1.3.6.1.4.1.19376.1.3.1.1" Identificador únivoco do template IHE para laboratórios clínicos
Lab Report CDA Structure
• Header
CDA entry
Elemento entry para exames isolados
…/section/entry/observation
…/section/entry/observation/id
…entry/observation/code/statusCode
…entry/observation/code/effectiveTime
…entry/observation/code/value
…entry/observation/interpretationCode
...entry/observation/methodCode
...entry/observation/referenceRange/observationRange
...entry/observation/referenceRange/observationRange/value
...entry/observation/referenceRange/observationRange/low
...entry/observation/referenceRange/observationRange/high
....entry/observation//referenceRange/precondition
...entry/observation//referenceRange/precondition/criterion
Results
• 250 lab exams were translated and mapped to the
Brazilian Procedures
• OIDs defined (Brazilian unique identifiers)
• Implementation Guide for CDA R2 Lab Results for the
integration with Lab systems to SIGA Saúde
• Project deployed in one region of the city and under
evaluation
Lessons learned
• LOINC translation and mapping took longer than
planned;
• The Implementation Guide was a key success factor
for CDA implementation;
• Training developers.
Conclusions for Latin-America
• Increase in use of EHR systems, concepts and
legislation;
• Increase in use of HL7 and standards in general;
• Need to have more LA countries in ISO TC 215;
• Increase in collaboration among LA countries;
• Uruguay has a strong government policy foundation;
• Argentina has a great experience in eHealth capacity
builnding;
• IMIA-LAC has played a major role in attracting
countries to join the International Community and
adopt best practices.