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Health Information Systems in Brazil Beatriz de Faria Leão, MD, PhD Claudio Giulliano da Costa, MD, MSc Jussara Macedo Pinho Rötzsch, MD, MSc Lincoln de.

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Presentation on theme: "Health Information Systems in Brazil Beatriz de Faria Leão, MD, PhD Claudio Giulliano da Costa, MD, MSc Jussara Macedo Pinho Rötzsch, MD, MSc Lincoln de."— Presentation transcript:

1 Health Information Systems in Brazil Beatriz de Faria Leão, MD, PhD Claudio Giulliano da Costa, MD, MSc Jussara Macedo Pinho Rötzsch, MD, MSc Lincoln de Assis Moura Jr, MSc, DIC, PhD Marivan Santiago Abrahão, MD

2 2 Jan-07 The Brazilian Delegation Claudio Giulliano A. da Costa - CIO São Paulo City Health Authority, Treasurer Brazilian Health Informatics Association ( Jussara Macedo P. Rötzsch - General Manager of Standards - National Agency for Supplementary Health ( Marivan Santiago Abrahão - Brazilian HL7 Chair, Coordinator of the Health Users Group of São Paulo Society of Computers Users Beatriz de Faria Leão - Consultant Health Informatics, Coordinator Standards and Software Certification Brazilian Health Informatics Association

3 3 Jan-07 Agenda Brazil - the soft power Brazilian Telehealth Program Health Informatics and Standards in Brazil The Brazilian Standard to Exchange Information between Healthcare Providers and Payers São Paulo City Health Information System: SIGA Saúde The Role of HL7 in Brazil Next Steps

4 Brazil: Soft Power - Emerging Giant

5 5 Jan-07 Some Facts about Brazil 9 th Largest Economy in the World 190 million Inhabitants Larger than Continental USA It is a Country of Huge Contrasts: some top quality institutions and a very bad income distribution, though improving 22 million Internet users today, some 5M with broadband access e-business: 5th largest market in e-business U$15Bi in e-commerce in % of IRS Tax Return Forms on the Web Voting System is 100% Electronic More than 100 million voters Recent National Election Results in Less than 12 hours

6 6 Jan-07 Brazil – Geo-political Perspective The largest country in Latin America The only Portuguese- speaking country in LA (52% of South America speak Portuguese) The 5th most populated country in the World The 2nd country in number of Internet hosts in America

7 7 Jan-07 Brazil Strategic Data Mercosul Gateway: borders with 9 countries (Argentina, Bolivia, Colombia, French Guiana, Guyana, Peru, Surinam, Uruguay, and Venezuela); World's largest producer of regional jets, 3rd in shoes and soft drinks, 4th in commercial aircraft, 8th in steel, 10th in automobiles; Largest livestock in the world Latin America's largest forestry-based industry; 5th world rubber industry, and the 7th-largest paper and pulp industry; World's 6th-largest market for cosmetics, with annual sales of US$ 9 billion. A modern and competitive textile complex, with 30,000 companies and annual sales of US$ 21 billion. 22% of the world's arable land surface. The most advanced banking system and one of the most high-tech telecommunications systems in the world. In Brazil, 99% of tax returns are filed over the internet The world largest fresh water resource

8 8 Jan-07 Alcohol x Flex Fuel x Gasoline

9 9 Jan-07 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) Inefficiency Paper base uncoordinated system, multiple formularies Lack of adequate information to support decision making, quality of care evaluation and to monitor disease management programs; Lack of common health and healthcare information standards within the sector Failed attempts of bottom-up standardization

10 10 Jan-07 SUS – The Brazilian Health System Universal Access Health is a Right of All (~ 145M 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 ~ 2,000 HMOs (~ 45M individuals) ANS (Agência Nacional de Saúde Suplementar) Regulates the Sector

11 11 Jan-07 The Brazilian Healthcare Market Extremely Fragmented Market: ~ U$ 90B/year SUS is the major Payer: ~ 66% in volume and some 50% in $ 190M inhabitants, spread over cities Around 7,500 Hospitals and 2,000 Health Plan Operators (HMOs) 70% of Hospitals have less than 80 beds Estimate that only 10% of Hospitals have Information Systems 90% HMOs cover less than 50,000 lives each Only 3% of HMOs cover more than 200,000 each The largest HMO covers less that 4M lives There is no important network of Health Organizations Lack of notion of production chain, added value and best practices National Standards on their way Its a Market of Discontent Fragmented and Uncoordinated Market Small and Badly Connected Players! Little Investiment in Management and IT

12 12 Jan-07 SUS Organization & Financing State Dept of Health City Local Management National Health Council State Health Council Municipal Health Council Municipal Health Fund Tri-party & Bi-party Committees Tri-party & Bi-party Committees National Health Fund $$$$ Information State Dept of Health $$ Dept o Health (Federal Govrnt)

13 13 Jan-07 SUS – Negotiation City Big City State PPI: Agreed and Integrated Covenant Distribution of Health Resources based on Health Indicators and Benchmarking PPI: Agreed and Integrated Covenant Distribution of Health Resources based on Health Indicators and Benchmarking

14 14 Jan-07 Patient Flow Control (Regulation of Care) Polyclinics DiagnosticCenter Specialty Center Clinic Primary Care Unit Private Hospital University Hospital Charity Hospital Primary Care High Complexity - Hospitals counter-reference referência regionalization Medium Complexity Primary Care Unit referência Patient Flow Control Electronic Health Record Entry Level Entry Level axes

15 15 Jan-07 Health Informatics Trends in Brazil Electronic Health Record Unique Identifier for Patients and HC Workers Know the Patient – Follow Up Treatment Decision Support at Point of Care Patient Flow Control (Regulation) Operate the Reference – Counter-Reference Model Find Fast and Resolving Pathways Unique Identifiers Health Care Units Management HIS Conectivity Integrate Clients – In and Outside the Organization HMOs, HC Providers, Clients and Authorities Public x Private Integration Health System Management Surveillance and Control Strategic and Tactic Decision Support Operation of the Healthcare System

16 Ministry of Health Brazilian Telehealth Program Franciso Eduardo Campos Laboratory of Excellence and Innovation in e-Health Latin America and Europe - I Workshop Belo Horizonte – Minas Gerais November 2006

17 Ministry of Health Tele-health 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)

18 18 Jan-07 Telehealth points in Brazil for 2007 Participation of all Brazilian States Points of Telehealth Ministry of Health


20 20 Jan-07 Brazilian HC National Standards Unique HC Identifiers Individual HC providers and professionals 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

21 21 Jan-07 Brazilian HC National Standards TISS – Private Health Information Exchange Content, Vocabularies and Data Transmission XML based Enforces Data Confidentiality and Privacy Simplifies Data Exchange Between Providers and Payors Security National PKI infrastructure Software Certification Brazilian Health Informatics Society + Federal Medical Council

22 22 Jan-07 Brazilian HC National Standards: National Unique Identifiers: Individuals (116 million people uniquely identified) Healthcare providers ( 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

23 23 Jan-07 Brazilian National Health Providers and Professionals Registry -

24 Private Healthcare Insurance Market beneficiaries HPOS 1.891active Health Plan Organizations estimated Healthcare providers Sources; NShA 2005/08 CNES 2005/08 ANS State Regulation Self- regulation

25 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

26 26 Jan-07 TISS standards: Building the Consensus August 2004 ANS prepared the first version of TISS standards August 2004 – January 2005 Meetings with stakeholders (HPO, health providers and managers) February 2005 a two-month public comment Oct 26th 2005 Standard was published ANS Rule 114 TISS February 2006 Creation of the National Health Information Standards Advisory Committee 21 members representatives of all sides involved and five subcommittees: steering group, terminology, information structure, messaging, privacy any modification to the standard only after 12-month period beginning at the date the standard is initially adopted

27 27 Jan-07 TISS standards Information structure: billing formularies 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 and SBIS/CFM Software Certification Mandatory from May 2007 on

28 28 Jan-07 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 Resp. Claim Payment Accounts Payable

29 29 Jan-07 TISS schemas

30 30 Jan-07 TISS Implementation Policy In order to facilitate TISS compliance, ANS provides: Opensource software prototype to generate the electronic messages XML EDI Management software (TISS-NET) E- learning training Workshops to interested HPOs and Healthcare providers during the implementation

31 31 Jan-07 TISS Expected Results Efficiency and effectiveness Improvement of the health care sector in general Reduction of administrative costs Enhancement of healthcare quality Increase ability to develop quality measures and facilitate implementation of disease management programs

32 32 Jan-07 TISS: What have we learned so far? Stakeholders Involvement was a critical success factor ANS governance and support was a key factor TISSnet helps implement the standards COPISS, ANS´s Standards Committee, is now the Forum where the standard evolves The market is willing to move to the electronic transactions The project received a national award for fostering e-business Alignment with the national e-Health initiative

33 33 Jan-07 TISS Challenges Change management requirements Staff and resource demands both for data submissions and in using the data Completeness and quality of the database Provider limitations (e.g. lack of automation, high staff turnover) Sustainable financing and how to equitably share the burden of funding the project Implementation timeline Legislation issues – privacy protection legislation

34 Sao Paulo City Health Dept Information Technology Coordination

35 São Paulo is a very large City..

36 São Paulo is a Cosmopolitan City

37 São Paulo is a City full of Contrasts

38 East Region Tiradentes15 E. Matarazzo18 Guianases20 Itaim Paulista22 Itaquera31 São Mateus28 São Miguel24 Campo Limpo29 Cidade Ademar20 Boi Mirim34 Parelheiros9 Socorro24 Sto Amaro20 Aricanduva12 Ipiranga29 Jabaquara13 Mooca25 Penha29 V Mariana31 V Prudente36 Southern Region North Region Casa Verde16 Freg/Brasilandia26 Perus9 Pirituba25 Santana20 Tremembe/Jacana13 V Maria/V Guilherme18 South Region Medium-West Region Butantã27 Lapa29 Pinheiros14 Sé36 Population: Population: Population: Population: Population : inhabitants

39 39 Jan Primary Care Encounters Medical Emergencies Medical Procedures Specialized Encounters Hospital Admissions Health Public Sector Figures for São Paulo City / 2005 Fonte: SIA/SUS - SIH/SUS – CNES/MS 2005

40 40 Jan-07 SIGA Saúde – SP City Information System SIGA Saúde is São Paulo Citys Integrated and Distributed System for Managing the Public Healthcare System. It belongs to the Brazilian Dept of Health and SP City SIGA Saúde has been developed using open-source free-software concepts. São Paulo is the largest city in South America, with 12M inhabitants and some 22M in the Metropolitan Area. Basic Figures: 400 Primary Care Units 60 Policlinics 160 Hospitals 11M Users 8.5M Emergency T/year 550k Inpatients/year 11M Primary Care C/year

41 41 Jan-07 SIGA Saúde Essentials National HC User Identification (Cartão SUS) Identifies Patient Uniquely, according to the National Standard National Registry of Workers & Providers Unique ID Relationships Patient Flow Control Quote Distribution According to PPI and FPO Controls Flow Related to Specialties, Ancillary Exams and Procedures, and In-patient Admission and Emergency Ambulatory Electronic Health Record Integrates and Distributes the Essential Dataset Embodies Intelligence (such as mandatory notification of diseases) Role-based Integrated Access Control System Access Authorization based on User Profile Single Sign-On System is on-line, 100% open, based on Internet Architecture

42 42 Jan-07 SIGA Saúde Healthcare Conceptual Model Auditing Billing & Processing Assessment Health Surveillance HC Services Management Specialties Inpatients Exams Electronic Health Record Primary Care Emergency HC Workers Hospitals and Healthcare Units Domain Tables and Vocabularies Users (Patients) National Registry Role-basedAccess ControlRole-basedAccess Control Flow Control Consultations Beds Exams Emergency Authorization

43 43 Jan-07 SIGA Saúde – Schematics Ambulatory Electronic Health Record (Primary, Specialties, High Complexity) Patient Flow Control (Consultations, Procedures, Beds) Heath Care Management (Surveillance, Audit and Billing) Internet SMS-SP Dept of Health Secure Access Datacenter

44 44 Jan-07 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

45 45 Jan-07 SIGA Saúde now 372 using the system via Internet (85% of all Primary Care units) 11,878,294 individuals are registered (uniquely identified) 12,000+ medical appointments daily 20,000 on-line authorizations for high cost procedures per month Two Units Using the Electronic Health Record module (pilot project)

46 46 Jan-07 Manual vs Electronic High-Cost Procedure Orders Electronic Manual / Paper-based

47 47 Jan-07 Our current challenges Improve internet connectivity of health basic units More investment in development and infrastructure Integration with the National Health Information system Partnership with other cities and, perhaps, countries Wish List: Hospital Information System Orders/Observations Lab (using HL7!!!)

48 48 Jan-07 Integration Model of System Electronic Health Record (SIGA System) Hospital Information System WebservicesWebservices Lab Systems* PACS (Medical Images) National Information Systems HL7 * Only six months to implement What do we need ? Education in HL7 (orders/obs) Translation LOINC HL7

49 49 Jan-07 Java One 2005 Video

50 50 Jan-07 Conclusion SUS is Modeled and Based on a Recognised Model Deployment of SUS is not homogeneous throughout the Country Dire need for Information Systems Dept of Health Systems are very Fragmented Dissociation between Dept of Health Policies and Practices National Standards Fastly Improving National Health Card, Essential Dataset, CNES and TISS are very recent Internet-based Information Systems Gain Acceptance Safety, Privacy and Confidentiality are Deemed Essential Some Trend to Use Open and Free Software Trend to Create Comunities that Share SW Development Interoperability is Recognized as Essential Integration with Existing Systems (XML / HL7) Trend to Integrate SUS and the Private Health System Watch Out for TISS!!

51 HL7 Role in Brazil

52 Main Issues Foster international Collaboration Harmonize HL7 to Brazilian HC Standards Understand and Discuss Policy and Bylaw Organize Local Meetings Promote HL7 Training Establish liasons with: Brazilian Tele-health Committee ANS - National Agency for Supplementary Health SBIS - Brazilian Health Informatics Association

53 Priorities for HL7 in Brazil Lab integration Hospital Discharge Compliance with TISS Compliance with the national HC standards for the public sector Training and Education


55 55 Jan-07 Amazons pirarucu and the pink dolphin

56 Obrigada! Thank you! Hope to welcome you there! Danke schön, bis Köln!

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