SIGA Saúde São Paulo City Health Information System

July 30, 2010

Beatriz de Faria Leao, MD, PhDHealth Informatics Consultant

FUNDAP, São PauloMOH Brazil - TeleHealth Program, Brasilia

JEMBI, South Africa

Panel: Renewal of Primary Health Care and the use of information technology

Some Facts about Brazil• 5th Largest Economy in the World (2010 )• 190 million Inhabitants• 5th Largest Country in the World, Larger than Continental USA• It is a Country of Huge Contrasts:

– some top quality institutions and – a very bad income distribution, though improving

• 74 M Internet users today, some 48 M with broadband access• 27% of houses have Internet access in 2010 (http://www.cetic.br/)• e-Business:

– 5th largest market in e-business– U$15Bi in e-commerce in 2009

• 95% of IRS Tax Return Forms on the Web• National Voting System is 100% Electronic

– More than 100 million voters– Recent national election results in less than 12 hours

SUS – The Brazilian National Health System

• Universal Access– Health is a Right of All (~ 150M individuals rely on SUS)

• Full Coverage, Free of Charge– All Services and Procedures

• SUS principles:– Equity, Universality and Integrality

• Funding and Management are Shared Across Levels– Federal, State and Municipal Levels

• Private Health Plans for Those Willing to Pay– ~ 1,200 HMOs (cover ~ 50M individuals)– ANS (Agência Nacional de Saúde Suplementar) regulates the

sector

Health Information Systems in Brazil

• Health Information Systems have been used in the Public Sector since the 1970s

• A huge collection of Public Health data is available from the Department of Health, on www.datasus.gov.br

• As in many other places, vertical applications were the focus, leading to literally more than 250 siloed systems, such as HIV, Prenatal and Child Care, TB, Diabetes and others

• Lack of national standards started to be reverted by two major projects at the end of the XX Century:

– The National Health Card Project defined unique identifiers for individuals (including HC workers), and

– The National Registry of HC Organizations and HC workers registry defined unique identifiers and the relationships among workers, equipment and organizations

SIGA Saúde

São Paulo City’s Health

Information System

Special thanks to

Heloisa Helena Andreetta CorralInformatics Advisor SMS-SP

And

Maria Aparecida Orsini, MDDirector Paulistana Mother Program

SIGA Saúde

SIGA Saúde is São Paulo City’s Integrated and Distributed System for

Managing the Public Healthcare System.

The system belongs to São Paulo City, which is willing to share it with other cities, states and countries.

SIGA Saúde has beendeveloped using

free-software open-code concepts.

São Paulo is the largest city in South America, with 12M inhabitants and some 22M in the Metropolitan Area.

SIGA Saúde is present in 100% (704) of

São Paulo City public health care providers

Before SIGA Saúde

• Access to health services was difficult: long waiting lines for specialized procedures and consultations

• No integration among health care providers

• No control of medication distribution

• Very little information for health care management

Tiradentes 15

E. Matarazzo 18

Guianases 20

Itaim Paulista 22

Itaquera 31

São Mateus 28

São Miguel 24

Aricanduva 12

Ipiranga 29

Jabaquara 13

Mooca 25

Penha 29

V Mariana 31

V Prudente 36

Southeast Region

North Region

Casa Verde 16

Freg/Brasilandia 26

Perus 9

Pirituba 25

Santana 20

Tremembe/Jacana 13

V Maria/V Guilherme 18

South Region

CenterEast Region

Butantã 27

Lapa 29

Pinheiros 14

Sé 36

Population:2,136,977

Population: 2,396,940

Population:2,499,294

Population:2,402,093Population:

1,244,456

Campo Limpo 29

Cidade Ademar 20

Boi Mirim 34

Parelheiros 9

Socorro 24

Sto Amaro 20

East Region

Volumes per HC Region in the City

15 million patients in the database

Examples of Primary Care Units in São Paulo

SIGA Saúde Building Blocks• Identifying Patients

• Based on Unique Nation-Wide Patient Identifier• Captures Encounter Data Set• On-line Access to Patient Information

• National Registry of HC Units and Workers– Unique Nation-wide Identifiers:

• Healthcare Workers, Units & Medical Equipment• Relationships Among Them

SIGA Functionalities

• Registries: Persons, HC professionals, HC facilities, Families, CHW• Scheduling: local and reffered• Primary Care: Child and Maternal Health, FHP, Immunizations,

Chronic Diseases, Oral Health• Specialized Care: Authorization Higgh Cost Complex Procedures• Real Time Surveillance• Patient flow – referral / counter referral• Encounter Information -> mandatory notifications• Medication• Lab Orders and Results• Reports on the BI tool

Auditing

Billing

Assessment

HealthSurveillance

HC ServicesManagement

Specialties Inpatients

Exams

Electronic HealthRecord

Primary Care

Emergency

HC Workers

Hospitals and Healthcare Units

Domain Tablesand Vocabularies

Users (Patients)

NacionalRegistry R

ole-based

Access Control

Flow Control

Consultations

Beds

Exams

Emergency

Authorization

SIGA Saúde Conceptual Model

SpecializedConsultations

Scheduling

SchedulingMedication

Medication at Home

CapturingEncounter

Information

Lab Integrationpilot project in 3 units 2010

AuditingMedical Images HIS

Adm / Manag. DSS

Health Information

SIGA Saúde Deployment Strategy

EHR Surveillance

Authorization processing of

high-cost, high-complexity

procedures

2004 -

2007

2007 -

2011

National HealthPatient Registry

National Health CareProviders RegistryInfra-structure

HR capacity2004

15.669.823

112 thousand prescriptions 2009

2 Millionmed/month

745 HC Units

12 M 2009

2.2 M (2009) 5 M in 408 HC units(2009)

369 thousand (2009)

Ensuring Equity and Integrality of Care

PolyclinicDiagnostic

Center Specialties DiagnosticCenter

PhysicianOffice

PrimaryCare Unit

PhysicianOffice

PrimaryCare Unit

PrimaryCare Unit

PrivateHospital

UniversityHospital

PublicHospital

Primary Care

High Complexity - Hospitals

Cou

nter

-ref

ere

nce

Referencereg

ion

alization

Med

ium

Com

plex

ity

PhysicianOffice

Reference

Patient Flow Organization & Control

Ele

ctro

nic

Hea

lth

Re

cord

Entry Level

axes

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: Project Timeline

• January 2004 - contract was signed• September 2004 - First deployment • 2004 - 2007:

• 700 health care providers connected

• Medication control and patient scheduling 100% of HC providers

• Authorizations of high cost / complexity procedures: 100% electronically

• Special programs data capture such as Paulista Mother

• Lab results integration under pilot deployment

• Investment• US$ 10M Software

• US$ 50M Hardware, Connectivity

• Training• 15,000 health professionals trained

Opening Screen in 2005

Opening Screen in June, 2008

– Type of Attendance

– Special Programs

– Anamnesis, Physical Exam, History

– Diagnosis

– Disabilities

– Procedures carried-out

– Requested procedures

– Medications

– Course of Action

Encounter Data Set

Work-Related Diseases

Communication Form

Notifiable Diseases

High-ComplexityProcedure Order Form

Notifiable Diseases Report

National Health Card RegistrySão Paulo city - SIGA Saúde

Usuários

Cadastrados

Cadastros de Usuários

AtualizadosDIGITADO SIGA 2004 18.074 1.923

Carga Inicial Set-04 2.535.175TOTAL 2004 c/ Carga 2.553.249DIGITADO SIGA 2005 2.130.158 235.717

Cargas 2005 5.227.269TOTAL 2005 c/ Cargas 7.357.427

TOTAL GERAL c/ Cargas 9.910.676 237.640DIGITADO SIGA 2006 2.370.437 753.810

TOTAL GERAL c/ Cargas 12.281.113 991.450DIGITADO SIGA 2007 1.868.745 1.370.810

TOTAL GERAL c/ Cargas 14.149.857 2.362.260TOTAL SIGA 2008 2.765.978 7.387.378

TOTAL GERAL c/ Cargas 16.915.835 9.749.638DIGITADO SIGA 2009 1.685.532 10.532.224

TOTAL c/ Cargas 18.601.368 20.281.862

Cadastro Cartão Nacional de Saúde - CNS - SUS - SIGA

Fonte: Prodam (SIGA) / Junho 2010

High Cost/Complex Procedure (APAC) 2005 -2009Paper X Electronic

Source: SMS-SP, Assessoria de Informática, July 2010

How IT can support MDG4 and 5 goals and really make a difference???

MDG 5: improve maternal health

•Target 5.A. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

•Target 5.B. Achieve, by 2015, universal access to reproductive health

Source:http://archive.student.bmj.com/issues/03/04/news/93b.php

Paulistana Mother

• A program created by São Paulo city Health authority in 2006, that extended the SUS maternal Health Program.

• The Paulistana Mother is an integrated program to assist and monitor ALL pregnant woman of São Paulo city.

If your name is not in our list, we’re goingkeep calling you….

Source: Diario de São Paulo, July 25th Pg. 53

Using SIGA Saúde and a BI tool the program:• Monitors all pregnancies within the public system,• Establishes the referrals to hospitals and emergencies,

– Hihg risk prenancies ate treated separately by special alerts in the system

• Guarantees the bed allocation for deliveries• Follows-up mother and child till the baby is one year old• Recharge of the transport card at each prenatal visit• Provides counseling on breast feeding and baby care, and • A full layette for the baby at delivery

Paulistana Mother

Paulistana Mother Results

• Free access to all pregnant women• Registration done in any of the 409 primary care

units• 36 hospitals • 25 specialized outpatients clinics• 80 thousand pts in the program• 10 thousand deliveries / month• 74% of pts with 7 or more prenatal

consultations

ANO 1980 1990 2000 2002 2004 2006 2007 2008COEFICIENTES

MORT. INFANTIL GERAL 50,62 30,90 15,80 15,10 13,96 12,86 12,54 11,99

MORT. INF. POS-NEONATAL 25,31 11,87 5,49 4,97 4,73 4,59 4,36 4,00

MORT. NEONATAL TOTAL 25,31 19,03 10,30 10,13 9,23 8,27 8,18 7,98

MORT. NEONATAL PRECOCE 18,29 15,36 7,70 7,27 6,31 5,74 5,46 5,60

MORT. NEONATAL TARDIA 7,03 3,67 2,60 2,86 2,91 2,53 2,72 2,38

MORT. PERINATAL 30,46 23,80 17,41 16,51 14,00 12,60 11,67 12,72

NATIMORTALIDADE 12,40 8,57 9,78 9,31 7,73 6,90 6,24 7,16

TAXA DE NATALIDADE** 28,23 20,71 19,90 17,56 17,19 16,07 15,77 15,89

NASCIDOS VIVOS 239.262 196.985 207.462 185.417 183.883 173.901 171.602 173.799FONTE: Fundação Sistema Estadual de Análise de Dados (SEADE).

* Coeficiente por 1.000 nascidos vivos (NV).

**Por mil habitantes

EVOLUÇÃO DOS COEFICIENTES* DE MORTALIDADE INFANTIL NO MUNICÍPIO DE SÃO PAULO, 1980 A 2008.

SIGA Saúde: Who else has it? (June, 2010)

• São Paulo City– 7800 health care providers– Focus on Patient Flow, Medication, Paulistana Mother

• São Paulo State– 28 Cities share the system for Hemodialysis and Hemophilia

• Camaçari, BA– Small City near Salvador (Bahia State)– 250,000 inhabitants, 32 Primary Care Units– Focus on EHR, Medication Dispensing, and Billing

• Campinas,SP – City 100km from São Paulo– 1.5 million inhabitants, 50 Primary Care Units– Focus on EHR and patient flow

• 19 municipalities around Campinas -> project planing phase

SIGA Saúde: Advantages of the Architecture

– Several cities can share servers and services;

– Simple machines at the point of care;

– No need for computer personnel at healthcare units;

– Complexity stays away from the user, under central control;

– Model can be rolled out to other places;

– New functionalities can be added easily;

– SIGA Saúde: Periodic Updates

Next Steps for SIGA Saúde

• Full EHRS• On-line lab reports:

– 8 labs using LOINC + CDA R2 (HL7 v3) for interoperability

• Municipal Hospitals IT Project • Health Information for the Citizen

– Empowering the patient

• Distance Learning• TeleHealth

SIGA’s evaluation http://vitalwaveresearch.com/healthit/

SIGA evaluation

http://vitalwaveresearch.com/healthit/

SIGA evaluation

Lessons learned

• DO not underestimate the TRAINNING • 30 % is software the rest is PEOPLEWARE.• Keep the systems as simple as possible at the point of

care • Be prepared for the political changes• Understand that health information systems are strategic

and therefore a state matter• Empower users and citizens • Use information provided by the systems asap -> BI

http://www.sdmx-hd.org/wiki/expert

Final Remarks

• IT can be the tool to promote the quantic jump to offer better health for all

• Today the recommendation from all big donors and HMN/WHO is to strengthen countries health systems by providing local ownership of an integrated eHealth Architecture, moving away from vertical applications

• SIGA Saúde is a proof of concept of this recommendation and can be used in other countries, specially for MDG4 and 5 goals

• SOUTH TO SOUTH COLLABORATION…

Thanks!! Questions?

Heloisa Helena Andreetta Corral hcorral@PREFEITURA.SP.GOV.BR

Maria Aparecida Orsini Maria.aparecida@uol.com.br

Beatriz de Faria Leão bfleao@gmail.com