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The Role of Interoperability Standards for Emerging Countries Beatriz de Faria Leão, MD, PhD Health Standards Architect Zilics Health Information Systems,

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Presentation on theme: "The Role of Interoperability Standards for Emerging Countries Beatriz de Faria Leão, MD, PhD Health Standards Architect Zilics Health Information Systems,"— Presentation transcript:

1 The Role of Interoperability Standards for Emerging Countries Beatriz de Faria Leão, MD, PhD Health Standards Architect Zilics Health Information Systems, São Paulo, Brazil HL7 Brazil - Co-Chair Advisory Council

2 Agenda Overview and Health Challenges Standards and National eHealth Policies in –Uruguay –Argentina –Chile –Brazil The role of HL7 in South America

3 Thanks to all that contributed for this presentation: Alvaro Margolis - President IMIA - LAC Ana Estela Haddad - Director of Management of Education in Health - Ministry of Health Brazil Claudio Giulliano da Costa - CIO São Paulo Dept of Health, Brazil Diego Kaminker - Chair HL7 Argentina Fernán González B. de Quirós - Hospital Italiano, Buenos Aires, Argentina Julio Carrau - Chair HL7 Uruguay Jussara Macedo - Brazilian Supplementary Health Agency Lincoln A. Moura Jr – IMIA Board - Treasurer Marivan Santiago Abrahão - Chair HL7 Brazil Sergio A. König - Director IT&GS Consultores Ltda.

4 4th continent in size Area 17,840,000 km² Population 371 millions Countries 12 Languages: Spanish, Portuguese, French, Dutch, English …. GDP $3.33 Trillion SOUTH AMERICA


6 Facts: In spite of the huge difference in the health expenditure between South American countries and US …

7 Health indicators are not that different… Some health figures in Brazil Prenatal coverage increased from 23% to 70% (including 6 doctor visits) over the last 15 years. 90% vaccine coverage Free access to antiretroviral treatment and to high complexity care. AIDS quick tests are available for 1/3 of deliveries and free ARV is guaranteed Second country in the world in organ transplantations, first in publicly-funded transplants.

8 Uruguay National ehealth Policy 3.46 million people 1.7 million live in the capital Montevideo and its metropolitan area

9 Uruguay eHealth Policy Sept 30th, 2003 - Federal Government issued the bill nº 396/003, on the EHR for all citizens, suggesting 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) where sharing of information among all HC providers is mandatory, from 2007 on.

10 SUEIIDISS Sociedad Uruguaya de Estandarización, Intercambio e Integración de Datos e Información de Servicios de Salud Founded in Nov 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 y CDA and IHE


12 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 documents sharing Uruguay National Identification standards OIDs for objects identifications Common WSDL defined and shared among all participants

13 eHealth Standards in Argentina 40 million people (estimate 2008) GDP (nominal) 2007 estimate –Total $260.7 billion –Per capita $6,548

14 HL7 Argentina Founded on December 5th, 2001 28 members (9 of them individuals) HL7 is not a national Standard for Argentina, but there are several developments involving 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 the HL7 standards - > virtual learning platform –600 people trained since 2001, from different countries in LA for the Spanish version –200 international students for the English version


16 eHealth in Chile Population 16,598,074 (June 2007 estimate) GDP (nominal) 2007 estimate –Total $163.792 billion –Per capita $9,879


18 Brazil: Soft Power - Emerging Giant

19 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 3rd country in number of Internet hosts in America GDP (nominal) 2008 estimate –Total US$ 673 billion –Per capita US$ 3,640.88

20 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 Supplementary Health for Those Wiling to Pay –~ 1,600 HMOs (~ 49 M individuals) –ANS (Agência Nacional de Saúde Suplementar) Regulates the Sector

21 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 5.500 cities –Around 6,000 Hospitals and 1,600 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

22 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, 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

23 Brazilian HC National Standards Unique HC Identifiers –Individual (160 Million) –HC providers (180 Thousand) –Health Workers (1.4 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

24 Brazilian HC National Standards: National Unique Identifiers: Individuals (160 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

25 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 (

26 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

27 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



30 Private Healthcare Insurance Market 49.3 million beneficiaries HPOS 1.600 active Health Plan Organizations 600.000 estimated Healthcare providers Sources; Set ANS State Regulation Self- regulation

31 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

32 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

33 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 Payment Accounts Payable Source: Jussara Macedo, ANS, 2007


35 HL7 Brazil Actions Harmonize National Standards with HL7 Training Programs Working Groups –CDA, LOINC, Snomed, Support Affiliationship –Individual - 10 –Corporate - 15 INTERSYSYEM, ZILICS, MICROSOFT, INTEL, ANS, SERASA

36 HL7 BRAZIL ACTIVITIES FEB/2007 - creation of Institute HL7 Brazil COURSES –Oct/ 2007 - I BASIC COURSE OF HL7 - with John Ritter - 70 persons - São Paulo –Abr /2008 - HL7 - VERSION 3.0 - with Mead Walker - 40 persons, São Paulo MEETINGS –Oct/2007 - OPEN FORUM HL7 INTEL - with William Edward Hammond - São Paulo –1er Congreso Iberoamericano de Informática Médica Normalizada, Montevideo, Uruguay –April /2008 - OPEN FORUM HL7 - IT-MÍDIA - with Mead Walker- São Paulo

37 Case Studies InCor – São Paulo Heart Institute –Continuous Glucose Monitoring System on a Intensive Care Unit HL7 V2.X Fleury Laboratory –Microbiological Exams Management System São Paulo City Health Department –SIGA Saúde LAB Integration

38 SIGA Saúde São Paulo Citys Health Information System Lab Integration Claudio Giulliano da Costa, MD CIO São Paulo Health Department

39 São Paulo is the largest city in South America, with 12M inhabitants and some 22M in the Metropolitan Area. Initial Figures: 400 Primary Care Units 60 Polyclinics 160 Hospitals 11M Users 8.5M Emergency T/year 550k Inpatients/year 11M Primary Care C/year São Paulo

40 SIGA Saúde is São Paulo Citys 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 been developed using free- software open-code concepts. SIGA Saúde is present in 100% of São Paulo City public health care providers SIGA SAÚDE

41 SIGA Saúde IT Model Electronic Health Record Patient Flow Organization & Mngmnt (Specialties, Beds, Exams) Management (Surveillance, Auditing and Billing) Internet SP City Datacenter SMS-SP Dept of Health Access Control

42 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

43 SIGA Saúde Lab Integration 2.7 millions exams / month –About 300 different labs exams without previous authorization –Others need prior authorization Manual process: transcribe 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)

44 SIGA Saúde Lab Integration Lab Orders LAB 1 LAB 2LAB 3 LAB N UBS SIGA Web Service: LAB AEAMAS Hospital Emergency Lab Order Sample Collection Authorization XML

45 SIGA Saúde Lab Integration Lab Results LAB 1 LAB 2LAB 3LAB N UBS SIGA Web Service: SIGA AEAMAS Hospital Emergency Lab Results (Common, Micro, Pathology) - CDA in Phase 1 XML

46 Standards used for SIGAs Lab Integration Identification: –Patients - National Health Card Number –HC provider and HC provider - National Registry CNES Messages: –TISS: XML schemas (simpleTypes, complexTypes, Messages, WSDL) –HL7 v3 - Lab orders and results information content (tags translated) –HL7 v3 pan-Canadian Messaging Standards Vocabulary: –LOINC - Logical Observation Identifiers Names and Codes

47 HL7 v3 for LAB Why V3? –Information content of lab orders and result is VERY GOOD, much better than V2 V3 Messages are too big, why? –Events that belong to applications are part of the message Our approach –Use the core information content from V3 –Change the envelope and roles to a simpler schema –Leave the information about the events on the application (Web Service or not) –Make a clean message - take advantage of the unique identifiers

48 TISS envelope


50 SIGA Saude Lab Integration: Current Status Order messages in test Results messages: –Common Lab Results - structured + Observations in free text –Microbiology - structured + text –Pathology - mostly text based Web service is under testing Results: –Phase 1: with a CDA approach (PDF attachment) –Phase 2: results structured using LOINC (October 15th on)

51 SIGA SADT Lab Integration Challenges LOINC was almost unknown in the beginning of the project (jan 2007) Language Barriers / HR Labs: had to redefine all internal codes and pre- formatted sentences to LOINC codes HL7 was not used, some have heard of v2, v3 was too scary and tools were too complicated Solution - > T R A I N I N G HL7 and LOINC

52 SIGA Saude Lab Integration LOINC Translation and Mapping LOINC mapping to the SUS Procedure Table For each SUS code: –There could be one or more LOINC codes for orders –Example:

53 SIGA SADT Lab Integration What have we achieved so far? First LOINC translation to PT is ready, thanks to one of the private Lab Today LOINC is being considered as the national vocabulary for exams both for the private and public systems Shift of mind: from payment to patient care Team work: mapping of the 300 exams is ready Advantages of having a standard are now clearly understood

54 HL7 Role for developing countries HL7 is THE organization able to foster standards development in emerging and developing countries Its a place where PEOPLE come together to: –Learn about standards –Develop standards –To adapt what is already there –To propose new standards –To create, to innovate and above all, –To foster the development of interoperable health information systems

55 HL7 role for developing countries Suggestions: –Promote South to South collaboration –Re-thinking of v3 (v4?) –Learn from international examples –Promote full interoperability with ISO 13606 - data types alignment –Better tools on open source environments –Free Distribution of HL7 standards according to country HDI

56 Above all, lets keep HL7 friendly, open environment, where people leave their egos outside the room and feel comfortable to think outside the box in order to improve health care everywhere A living example of that is:

57 Bellagio, July 2008, Interoperability Week Thank you very much for your attention!

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