1. Current state of informatic infrastructures in Portuguese health centers and its evolution since 2002 Faculdade de Medicina da Universidade do Porto Introdução à Medicina May 2006 João Alhais; João Gonçalves; João Neves; João Rodrigues; Jorge Ferreira; Jorge Rodrigues; Vanessa Rodrigues Class 12

2. 2 Contents Introduction Introduction Material and Methods Material and Methods Results Results Discussion Discussion

3. 3 Introduction Medical informatics [1] The field of information science concerned with: - the analysis and dissemination of medical data; - the analysis and dissemination of medical data; - through the application of computers; - through the application of computers; -application on various aspects of health care and medicine. -application on various aspects of health care and medicine. 1 Enrico Coiera. Recent Advances: Medical informatics. BMJ 1995;310:1381-1387

4. 4 Introduction It deals with the resources, devices and methods required to optimaze: [2-3]It deals with the resources, devices and methods required to optimaze: [2-3] - Acquisition; - Acquisition; - Storage; - Storage; - Retrieval; - Retrieval; - Use of information in health and biomedicine. - Use of information in health and biomedicine. 2 Coiera, E., Guide to health informatics. Arnold editions. 2003; chapter 3: 32-40 3 Degoulet P, Fieschi M. Introduction of clinical informatics. Springer. 1997; chapter 6: 81-90

5. 5 Introduction Health informatics tools include: [4-5]Health informatics tools include: [4-5] - computers; - computers; - clinical guidelines; - clinical guidelines; - formal medical terminologies; - formal medical terminologies; - information and communication systems; - information and communication systems; 4 Dick R et all. The computer based patient record. Nat academy press 1997; chapter 2: 74-100 5 Wyatt J. Clinical data systems, part 2: components and techniques. Lancet 1994; 344: 1609-12

6. 6 Introduction Medical informatics aims to improve care given to patients by improving (within others) the: [2] Medical informatics aims to improve care given to patients by improving (within others) the: [2] - Accuracy; - Accuracy; - Speed; - Speed; - Reliability of clinical information flow. - Reliability of clinical information flow. 2 Coiera, E., Guide to health informatics. Arnold editions. 2003; chapter 3: 32-40

7. 7 Introduction Importance of medical informatics in primary care [6-8] Importance of medical informatics in primary care [6-8] In primary health care, especially in developed countries, the use of different types of information technology (IT) has progressed considerably. In primary health care, especially in developed countries, the use of different types of information technology (IT) has progressed considerably. 6 Tomasi E et al. Health information technology in primary health care in developing countries: a literature review. Bull World Health Organ. 2004; 82: 867-74 7 De Lusignan S, Lakhani M, Chan T. The role of informatics in continuing professional development and quality improvement in primary care. J Postgrad Med 2003;49:163-5 8 De Lusignan S. et al. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309

8. 8 Introduction Such evolution can be attributed partly to the peculiarities of the primary health-care sector such as: [6-8] Such evolution can be attributed partly to the peculiarities of the primary health-care sector such as: [6-8] - its status; - its status; - its need for facilities for information storage and management; - its need for facilities for information storage and management; - its need for improvements in quality of care, and expenditure control - its need for improvements in quality of care, and expenditure control 6 Tomasi E et al. Health information technology in primary health care in developing countries: a literature review. Bull World Health Organ. 2004; 82: 867-74 7 De Lusignan S, Lakhani M, Chan T. The role of informatics in continuing professional development and quality improvement in primary care. J Postgrad Med 2003;49:163-5 8 De Lusignan S. et al. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309

9. 9 Introduction EHR - Electronic Health Record EHR - Electronic Health Record A general term describing computer-based patient record systems [10] ; Is basically a facility that: Is basically a facility that: - retrieves patient data from a number of information systems; [11] - retrieves patient data from a number of information systems; [11] - presents the data in a coherent way to the authorised user [11-12] ; - presents the data in a coherent way to the authorised user [11-12] ; 10 Coiera, E.. Guide to health informatics. Arnold editions. 2003; chapter 5: 58-74 11 David W. et al. A Proposal for Electronic Medical Records in U.S. Primary Care. JAMIA 2003; 12 Tamblyn R et al. The development and evaluation of an integrated electronic prescribing and drug management system for primary care. JAMIA 2006; 13: 148-59

10. 10 Introduction When compared to manual registration, the main advantages of EHR for health centers (as for the other sectors of health care) are: When compared to manual registration, the main advantages of EHR for health centers (as for the other sectors of health care) are: -greater accuracy [13] and a higher proportion of correct information [14, 15] ; -greater accuracy [13] and a higher proportion of correct information [14, 15] ; -time saved in locating information [16] ; -time saved in locating information [16] ; -more economical use of financial resources [17] ; -more economical use of financial resources [17] ; -greater ease and speed of recovery of patient data [17]. -greater ease and speed of recovery of patient data [17]. 13 Hassey A, Gerrett D, Wilson A. A survey of validity and utility of electronic patient records in a general practice. BMJ 2001;322:1401-5. 14 Flygt C et al. Essential data set for computer management of distributed primary care services. Medical Informatics 1995;20:331-41. 15 Gaudet LA. Electronic referrals and data sharing: can it work for health care and social service providers? Journal of Case Management 1996;5:72-7. 16 Borowitz SM. Impact of a computerized patient tracking system in a pediatric clinic. Intern J. of Proceedings: a Conference of the American Medical Informatics Association. AMIA Annual Fall Symposium Medical Informatics 1996. p. 508-11. 17 Wager KA et al. Impact of an electronic medical record system on community-based primary care practices. Journal AmerBoard of Family Practice 2000;13:338-48.

11. 11 Introduction [18] The factors shown to be important for success of EHR adoption are [18] 1. 1.Environmental; 2. 2.Organizational; 3. 3.Personal; 4. 4.Technical. 18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12

12. 12 Introduction Environmental -Environmental factors concern mainly financial and safety issues: - On the financial side, both health centers and health care providers are struggling because the financial managent is not being made by their own. - On the financial side, both health centers and health care providers are struggling because the financial managent is not being made by their own. - Information technology has been touted widely as a tool that can improve the quality and safety of patient care. - Information technology has been touted widely as a tool that can improve the quality and safety of patient care. 18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12

13. 13 Introduction Personal clinicians of health centers may be reluctant to adopt new ways of manage health information that interfere with their workflow; clinicians of health centers may be reluctant to adopt new ways of manage health information that interfere with their workflow; Overall, when clinicians have access to larger amounts of information with which to make decisions, and when the system fits their workflow, they tend to use it. Overall, when clinicians have access to larger amounts of information with which to make decisions, and when the system fits their workflow, they tend to use it. 18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12

14. 14 Introduction Organizational The organizational culture must be ready to support adoption by the individuals within it; The organizational culture must be ready to support adoption by the individuals within it; clinicians have / have not experienced a sense of collaboration and trust between them and hospital administration; clinicians have / have not experienced a sense of collaboration and trust between them and hospital administration; if clinicians believe the administration wants to force them to use EHR, for example, they may dig in their heels; if clinicians believe the administration wants to force them to use EHR, for example, they may dig in their heels; They may be more resistant to arguments based on safety and patient care benefit if the level of trust is not there. They may be more resistant to arguments based on safety and patient care benefit if the level of trust is not there. 18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12

15. 15 Introduction On the other hand, if the impetus comes from the clinical staff, other clinicians may be more apt to adopt sooner, and readiness will be at a higher level. On the other hand, if the impetus comes from the clinical staff, other clinicians may be more apt to adopt sooner, and readiness will be at a higher level. In particular, administrators at the highest level must offer both moral and financial support In particular, administrators at the highest level must offer both moral and financial support In addition, there need to be sufficiently skilled implementation, training, and support coordinators; In addition, there need to be sufficiently skilled implementation, training, and support coordinators; 18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion, JAMIA, 2005;12:8-12

16. 16 Introduction Technical There are many definitions of the EHR at numerous levels of sophistication and functionality. There are many definitions of the EHR at numerous levels of sophistication and functionality. When one contemplates the highest levels, however, the ability of this system to interoperate with another is paramount. When one contemplates the highest levels, however, the ability of this system to interoperate with another is paramount. 18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12

17. 17 Denmark’s Health System In Denmark the private health care represents only 3%; [19] In Denmark the private health care represents only 3%; [19] There are 30 out of office hours (OOH) which permit access to GP's 24h a day, every day: [20] There are 30 out of office hours (OOH) which permit access to GP's 24h a day, every day: [20] –91% of the patients are treated within 1 or 2 months; –90% of GP's use EPR; [21] 19 Brown, J., Day, M., Jones, T., Miller, M., Westcott, Dean., Bailey, D. Healthcare in Denmark direction for the NHS.Published by The certified Acountants Educational Trust on behalf of the Association of Chartered Certified Accountants. 2002 20 http://www.bcma.org/public/news_publications/publications/policy_papers/ITPaper/GettingITRight_AppendixA.htm# TopOfPage#TopOfPage 21 Ash J. S. et al. Health Care in Denmark. Danish Ministry of Health, 2001

18. 18 UK Health System Currently, 96% of English GP’s are connected by NHSnet - a system which connects doctors, hospitals and other NHS institutions; Currently, 96% of English GP’s are connected by NHSnet - a system which connects doctors, hospitals and other NHS institutions; 15% of GP's run completely paperless consultations; [20] 15% of GP's run completely paperless consultations; [20] Development of lab-links which permit data exchange between doctors and laboratories; [22] Development of lab-links which permit data exchange between doctors and laboratories; [22] 19 http://www.bcma.org/public/news_publications/publications/ 22 Majeed A. Ten ways to improve information technology in the NHS. BMJ 2003; 326: 25-31.

19. 19 Denmark and UK In both countries exists a significant percentage of private investment in health care, although in Denmark this value is higher (17,8% in 1999); In both countries exists a significant percentage of private investment in health care, although in Denmark this value is higher (17,8% in 1999); There is a greater expenditure per capita in Denmark (1679 Euro) than in U.K (1079 Euro), while Portugal spends ; There is a greater expenditure per capita in Denmark (1679 Euro) than in U.K (1079 Euro), while Portugal spends 1273 Euro ; Both countries spent 6% to 7% of their GDP on healthcare; Both countries spent 6% to 7% of their GDP on healthcare; 19 Brown, J et al. Healthcare in Denmark direction for the NHS Published by The certified Acountants Educational Trust on behalf of the Assotiation of Chartered Certified Accountants. 2000

20. 20 –In Portugal there are 347 Health centers; [23] –In 2000, The World Health organization published a report about health systems where Portugal has achieved the 12th place on global ranking, better than U.K., Germany, Canada and USA; [24] –In 2005, Portugal still ranks in 12th place, in front of countries such as Germany. 23 Instituto Nacional de Estatística Portuguese Health System 24 World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000.

21. 21 Portuguese Health System Portugal spent in Health as much as 9% of its low gross domestic product; [25] Portugal spent in Health as much as 9% of its low gross domestic product; [25] Resources are clearly poorly invested (lack of efficiency in using them); [26] Resources are clearly poorly invested (lack of efficiency in using them); [26] The way of financing is a constant subject of debate; [26] The way of financing is a constant subject of debate; [26] 25 OCDE Health Data 2003. 26 Costa-Pereira, A., Escoval, A., Nunes, A., Vaz, A., Costa, C., Pinto, C., Pereira, J., Bentes, M., Mateus, M., Amaral, M., Giraldes, M., Gonçalves, M., Gouveia, M., Barros, P. Financiamento da Saúde em Portugal documento de trabalho 4/97 Associação Portuguesa de Economia de Saúde 1997

22. 22 –The organizational primary care infrastructures are outdated and new reforms have not yet been implemented; [27] –Health Centers organization has a lot of fragilities as well as the centralization of these health institutions; [28] –Spenditure/money available relation higher than in other countries? Portuguese Health System 27 Correia, R., Almeida. F., Freitas, A., Costa-Pereira, A. Current State of Electronic Health Records in Portugal, THERE 2002 28 Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. Portugal. The European Observatory on Health Care Systems; Copenhagen 2003.

23. 23  By law, all Portuguese citizens may access the NHS  NHS is composed by:  96 hospitals  346 health centres  1426 health centres extensions  Due to the relatively small role of the private sector in both primary and hospital care, most medical data is held by the NHS-IS  The NHS-IS was created, developed and still maintained by governmental IGIF – Institute for Financial and Information Management HIS in Portugal

24. 24 HIS in Portugal - IGIF National Centralized Approach Hospital Centralized Approach Main Problems Main IGIF concern is Financial Management Lack of NHS Strategy for Clinical IS Clinical application (SAM) is a medical view of a administrative application (SONHO) IGIF - Software creator instead of Software regulator

25. 25 Medical Informatics R&D Main Problems Some specialities represent most of R&D efforts Population: Funded Projects, Doctor Degrees, Articles Source: Portuguese Science and Technology Observatory, Medline Date: October 2003

26. 26 Technology use in Primary Care General Practitioners use of Informatics (Computer, PDA, Palmtop) % Portugal37 EU 15 80 General Practitioners with Internet Connection Portugal20 EU 15 61 Use of Electronic Health Care Records Portugal28 EU 15 48 Main Problems Poorly use of technology by medical staff Poorly use of EHCR Population: General Practitionaires Source: Flash Eurobarometre 104 Author: EOSGallup Europe Date: July 2002

27. 27 –Low development in the use of the informatic technologies in 2002; [29] –No relevant data is available to the public about the present state of the use of informatic technologies in primary care; [29] –Resources are clearly poorly invested (lack of efficiency in using them); [30] –The way of financing is a constant subject of debate; [30] 29 OCDE Health Data 2003. 30 Costa-Pereira, A., Escoval, A., Nunes, A., Vaz, A., Costa, C., Pinto, C., Pereira, J., Bentes, M., Mateus, M., Amaral, M., Giraldes, M., Gonçalves, M., Gouveia, M., Barros, P., (1997) Financiamento da Saúde em Portugal documento de trabalho 4/97 Associação Portuguesa de Economia de Saúde Portuguese Health System

28. 28 Objectives 1. st - To estimate the informatic resources in Portuguese health centers; 1. st - To estimate the informatic resources in Portuguese health centers; 2. nd - To compare the results we will obtain with those from a previous research (2002); 2. nd - To compare the results we will obtain with those from a previous research (2002); 3. rd - To analyze the evolution within this 3 year period; 3. rd - To analyze the evolution within this 3 year period; 4. th - To study the utility of the informatic resources specially the electronic health records (EHR) in the primary care; 4. th - To study the utility of the informatic resources specially the electronic health records (EHR) in the primary care;

29. 29 Objectives 5. th – Evaluate the main barriers to the implementation of efficient informatic infrastructures and define ways and strategies to overcome them. 5. th – Evaluate the main barriers to the implementation of efficient informatic infrastructures and define ways and strategies to overcome them. 6.th – Compare the actual state of the Portuguese informatic infrastructures with prestigious foreign ones. 6.th – Compare the actual state of the Portuguese informatic infrastructures with prestigious foreign ones.

30. 30 Material and Methods 50 health centres: 50 health centres: –aleatorily chosen in 2002. The data acquisition was made in two stages: The data acquisition was made in two stages: –1 st stage: telephonic questionnaire to the 50 H.C. directors Concerning informatic resources in Portuguese health centers Concerning informatic resources in Portuguese health centers –2 nd stage: fax questionnaire; Concerning informatic system implementation planning strategies: Concerning informatic system implementation planning strategies: –Beneficts, use and barriers to the implementation; –Possible ways to overcome them;

31. 31 Key words Electronic Health Records; Electronic Health Records; Medical Informatics; Medical Informatics; Health Centers; Health Centers; Primary Health Care; Primary Health Care;

32. 32 Results Table 1 – Telephonic inquests results from 2002 and 2006 comparison

33. 33 Results Table 2 - Telephonic inquests results from 2002 and 2006 comparison

34. 34 Results Graphic 1 – Main benefits to EHR implementation in Primary Care, comparison of the results from 2002 and 2006

35. 35 Results Graphic 2 – EHR use in clinical practice, comparison of the results from 2002 and 2006

36. 36 Results Graphic 3 – Main barriers to CPR/EPR implementation in Primary Care, comparison of the results from 2002 and 2006

37. 37 Results Graphic 4 – Main strategies to overcome EHR implementation barriers, comparison of the resultos from 2002 and 2006

38. 38 Results Graphic 5 – Main privacy and security concerns on EHR information, comparison of the results from 2002 and 2006

39. 39 General increase of the electronic resources; General increase of the electronic resources; Reduction of the number of General practicers per health center; Reduction of the number of General practicers per health center; Still remains the necessity of paper records; Still remains the necessity of paper records; Discussion

40. 40 Disbelif and desilusion from general practioners in the EHR benefits; Disbelif and desilusion from general practioners in the EHR benefits; General practionners did not have a correct ideia of the EHR use; General practionners did not have a correct ideia of the EHR use; General practioners used to believe in their use to after visit-patient support and pre-visit cares evaluation; General practioners used to believe in their use to after visit-patient support and pre-visit cares evaluation; Discussion

41. 41 Although, it was not then considered the utility for doctors about the patients health condition information; Although, it was not then considered the utility for doctors about the patients health condition information; In a general way the main barriers to the implementation of the EHR have maintained; In a general way the main barriers to the implementation of the EHR have maintained; 4 years ago the lack of funding was primary reason followed by the lack of an adequate EHR system; 4 years ago the lack of funding was primary reason followed by the lack of an adequate EHR system; Discussion

42. 42 Now it is followed by the difficulty on the data introduction; Now it is followed by the difficulty on the data introduction; After experimenting the EHR most of the general practioners agree to wait until better solutions are available and to instruct personal to their easily use; After experimenting the EHR most of the general practioners agree to wait until better solutions are available and to instruct personal to their easily use; Discussion

43. 43 The acces to information by non authorized users inside the organization keeps being the main concern on EHR information security; The acces to information by non authorized users inside the organization keeps being the main concern on EHR information security; General practioners lost their afraid of out-side breakings into the system; General practioners lost their afraid of out-side breakings into the system; Discussion

44. 44 Discussion It should be strived to have a national system of EHRs that can share information on any patient in any health care setting; It should be strived to have a national system of EHRs that can share information on any patient in any health care setting; From the point of view of the patient, he or she should be able to enter any health care setting and see a clinician who has comprehensive access to information about that patient; From the point of view of the patient, he or she should be able to enter any health care setting and see a clinician who has comprehensive access to information about that patient;

45. 45 Discussion From the health care provider's perspective, this access should be fast, the information should be easy to find, and the process should help rather than hinder the workflow; From the health care provider's perspective, this access should be fast, the information should be easy to find, and the process should help rather than hinder the workflow; Health care will be safer for the patient and more satisfying for the clinician, who would now be able to provide far better care and feel more secure in his or her decision making; Health care will be safer for the patient and more satisfying for the clinician, who would now be able to provide far better care and feel more secure in his or her decision making;

46. 46 Discussion The forces of competition in health care may be providing pressure as well, as more patients become aware of the potential of health care information systems; The forces of competition in health care may be providing pressure as well, as more patients become aware of the potential of health care information systems; The misalignment of incentives represents perhaps the single most important barrier to moving ahead and is especially problematic in the health centers progress; The misalignment of incentives represents perhaps the single most important barrier to moving ahead and is especially problematic in the health centers progress;

47. 47 Discussion Limitations The sample used in this researche project may be a source of bias as well as the method used in 2002 to adquire the data (methods of colletion and questionnaire); The sample used in this researche project may be a source of bias as well as the method used in 2002 to adquire the data (methods of colletion and questionnaire); Inerent problems to an unpersonnal questionnaire; Inerent problems to an unpersonnal questionnaire; Difficulty in comparing the data obtained in Portugal and the foreign one; Difficulty in comparing the data obtained in Portugal and the foreign one;