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 March 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 The field of information science concerned with the analysis and dissemination of medical data through the application of computers to various aspects of health care and medicine The field of information science concerned with the analysis and dissemination of medical data through the application of computers to various aspects of health care and medicine Coiera, E., (2003) Guide to health informatics. Arnold editions. Lisboa

4. 4 Introduction It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine; (wikipedia)It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine; (wikipedia) Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. (wikipedia)Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. (wikipedia)

5. 5 Introduction Importance of medical informatics in primary care Importance of medical informatics in primary care 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. Tomasi, Elaine et al; Health information technology in primary health care in developing countries: a literature review

6. 6 Introduction Such evolution can be attributed partly to the peculiarities of the primary health-care sector such as: Such evolution can be attributed partly to the peculiarities of the primary health-care sector such as: - its scope, its status as a large market for computer businesses, and its need for facilities for information storage and management; - its scope, its status as a large market for computer businesses, and its need for facilities for information storage and management; - improvements in quality of care, and expenditure control, in both the public and private sectors. (WHO) - improvements in quality of care, and expenditure control, in both the public and private sectors. (WHO)

7. 7 Introduction EHR - Electronic Health Record EHR - Electronic Health Record A general term describing computer-based patient record systems; 1 A general term describing computer-based patient record systems; 1 Is basically a facility that retrieves patient data from a number of information systems and presents the data in a coherent way to the authorised user; 2 Is basically a facility that retrieves patient data from a number of information systems and presents the data in a coherent way to the authorised user; 2 1 - Coiera, E., (2003) Guide to health informatics. Arnold editions. Lisboa 2 - David W. Bates, MD et al. (Jan / Feb 2003) A Proposal for Electronic Medical Records in U.S. Primary Care. JAMIA.

8. 8 Introduction Impact of EHR: Impact of EHR: - Since the beginning of electronic patient registration, It have been improvements in the interfacing and fusion capabilities of a large variety of computer and telecommunication technologies; ( world health) - Since the beginning of electronic patient registration, It have been improvements in the interfacing and fusion capabilities of a large variety of computer and telecommunication technologies; ( world health) - It will become a major support tool in health care delivery. (van bemel) - It will become a major support tool in health care delivery. (van bemel)

9. 9 Introduction When compared to manual registration, the main advantages of EHR are: When compared to manual registration, the main advantages of EHR are: -greater accuracy (1) and a higher proportion of correct information (2, 3); -greater accuracy (1) and a higher proportion of correct information (2, 3); -time saved in locating information (8); -time saved in locating information (8); -more economical use of financial resources (12); -more economical use of financial resources (12); -greater ease and speed of recovery of patient data (12). -greater ease and speed of recovery of patient data (12). 1- 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. 2- Flygt C, Homelius B, Jacobsson B, Foldevi M, Trell E. Essential data set for computer management of distributed primary care services. Medical Informatics 1995;20:331-41. 3- 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. 4-Borowitz SM. Impact of a computerized patient tracking system in a pediatric clinic. International Journal of Proceedings: a Conference of the American Medical Informatics Association. AMIA Annual Fall Symposium Medical Informatics 1996. p. 508-11. 5-Wager KA, Lee FW, White AW, Ward DM, Ornstein SM. Impact of an electronic medical record system on community-based primary care practices. Journal of the American Board of Family Practice 2000;13:338-48.

10. 10 Denmark’s Health System In Denmark the private health care represents only 3% of all; 1 In Denmark the private health care represents only 3% of all; 1 there are 30 OOH which permit access to GP's 24h a day, every day: 2 there are 30 OOH which permit access to GP's 24h a day, every day: 2 –91% of the patients are treated within 1 or 2 months; 3 –90% of GP's use EPR; 3 1 - Brown, J., Day, M., Jones, T., Miller, M., Westcott, Dean., Bailey, D., (2000) Healthcare in Denmark direction for the NHS Published by The certified Acountants Educational Trust on behalf of the Assotiation of Chartered Certified Accountants 2 - http://www.bcma.org/public/news_publications/publications/policy_papers/ITPaper/GettingITRight_AppendixA.htm#TopOfPage#TopOfPage 3 - Danish Ministry of Health, (2001) Health Care in Denmark, (Ash J. S. et al)

11. 11 UK Health System Currently, 96% of English GP’s are connected by NHSnet - a system which connects doctors, hospitals and other NHS institutions; 1 Currently, 96% of English GP’s are connected by NHSnet - a system which connects doctors, hospitals and other NHS institutions; 1 15% of GP's run completely paperless consultations; 1 15% of GP's run completely paperless consultations; 1 Development of lab-links which permit data exchange between doctors and laboratories; 2 Development of lab-links which permit data exchange between doctors and laboratories; 2 1- http://www.bcma.org/public/news_publications/publications/policy_papers/ITPaper/GettingITRight_AppendixA.htm#TopOfPage#TopOfPage 2 - Majeed, Azeem. "Ten ways to improve information technology in the NHS", BMJ volume 326, 25 January 2003.

12. 12 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 (1,679 121 Euro) than in U.K (1,079 780 Euro); There is a greater expenditure per capita in Denmark (1,679 121 Euro) than in U.K (1,079 780 Euro); Both countries spent 6% to 7% of their GDP on healthcare; Both countries spent 6% to 7% of their GDP on healthcare; Brown, J., Day, M., Jones, T., Miller, M., Westcott, Dean., Bailey, D., (2000) Healthcare in Denmark direction for the NHS Published by The certified Acountants Educational Trust on behalf of the Assotiation of Chartered Certified Accountants

13. 13 –In Portugal there are 347 Health centers; 1 –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; 2 1 – Instituto Nacional de Estatística Portuguese Health System 2 - World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000.

14. 14 However, some problems in Portugal Health System still remain; 1 However, some problems in Portugal Health System still remain; 1 –Portugal spent in Health as much as 9% of its low gross domestic product; 2 Portuguese Health System 1 - Correia, R., Almeida. F., Freitas, A., Costa-Pereira, (2002­), A. Current State of Electronic Health Records in Portugal, Biostatistics and medical informatics, Faculty of Medicine, Oporto University. 2 - OCDE Health Data 2003.

15. 15 –The organizational primary care infrastructures are outdated and new reforms have not yet been implemented; 1 –Health Centers organization has a lot of fragilities as well as the centralization of these health institutions; 1 Portuguese Health System 1 - Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. Portugal. The European Observatory on Health Care Systems; Copenhagen 2003.

16. 16 –Low development in the use of the informatic technologies in 2002; 1 –No relevant data is available to the public about the present state of the use of informatic technologies in primary care; 1 1 - Relatório da OCDE; HIT do Observatório Europeu. Portuguese Health System

17. 17 Portuguese Health System Resources are clearly poorly invested (lack of efficiency in using them); 1 Resources are clearly poorly invested (lack of efficiency in using them); 1 The way of financing is a constant subject of debate; 1 The way of financing is a constant subject of debate; 1 1 - 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

18. 18 –SNS: Sistema Nacional de Saúde (NHS - National Health System); –Primary Health Care: medical care access on health centers; –IGIF: Instituto de Gestão Informática e Financeira da Saúde (Informatic and financial management Institute); Portuguese Health System http://www.igif.min-saude.pt/upload/igif/img/Enq-SAM-SAPE.pdf

19. 19 SONHO - Sistema de Gestão de Doentes Hospitalares (Management system of hospital patients); SONHO - Sistema de Gestão de Doentes Hospitalares (Management system of hospital patients); SINUS - Sistema de Informação para as Unidades de Saúde (Informatic system for Health units); SINUS - Sistema de Informação para as Unidades de Saúde (Informatic system for Health units); SAM - Sistema de Apoio ao Médico (Medical Support system); SAM - Sistema de Apoio ao Médico (Medical Support system); Portuguese Health System http://www.igif.min-saude.pt/upload/igif/img/Enq-SAM-SAPE.pdf

20. 20 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;

21. 21 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.

22. 22 Material and Methods 25 health centres: 25 health centres: –25 out of 50 aleatorily chosen in 2002. The inquiries will be made in two stages: The inquiries will be made in two stages: –1 st stage: telephonic inquest to the 25 H.C. directors; –2 nd stage: fax inquests;

23. 23 –Informatic system implementation planning strategies: Difficulties; Difficulties; Possible ways to overcome them; Possible ways to overcome them; Material and Methods

24. 24 Limitations Lack of previous studies; Lack of previous studies; Inerent problems to an unpersonal questioner; Inerent problems to an unpersonal questioner; Difficulty in comparing the data obtained in Portugal and the foreign one; Difficulty in comparing the data obtained in Portugal and the foreign one;

25. 25 Results HEALTH CENTERS20062002 Nº. Patients per doctor19911823 % Internet-linked computers7316 % of computers with access to RIS6540 % which use SINUS10094 % of computers using SINUS6473 % health centres that make appointments in other health institutions2831 % health centres using SAM402 % of computers for clinical use2213 % positive answers on 9 criteria used relatively to the use of SAM3867 % of health centres that use paper records9698 Table 1 – Telephonic inquests results from 2006 and 2002 comparison

26. 26 Results HEALTH CENTERS (N=25) MEDIAN 20062002 Inscribed Patients1000013000 Doctors78 Computers158 Computers with Internet connection51 Computers with RIS connection5 Computers that use SINUS10 Computers with computerized patient records00 Table 2 – Median of the results obtained on telephonic inquests and their comparison between 2002 and 2006

27. 27 Results Graphic 1 – Main benefits to EHR implementation in Primary Care

28. 28 Results Graphic 2 – EHR use

29. 29 Results Graphic 3 – Main barriers to CPR/EPR implementation in Primary Care

30. 30 Results Graphic 4 – Main strategies to overcome EHR implementation barriers

31. 31 Results Graphic 5 – Main privacy and security concerns on EHR information

32. 32 Discussion Low evolution registered since 2002 as the exception of internet connected computers and in the use of SAM; Low evolution registered since 2002 as the exception of internet connected computers and in the use of SAM; We can not help notice that, even that the number of health centres using EHR is growing, the percentage of establishments running paperless has not decrease that much (only 2%); We can not help notice that, even that the number of health centres using EHR is growing, the percentage of establishments running paperless has not decrease that much (only 2%);

33. 33 Discussion From the results we conclude that the patient data sharing is definitively the major benefit of the EHR implementation (64%); From the results we conclude that the patient data sharing is definitively the major benefit of the EHR implementation (64%); As well as in 2002 the main barrier to this implementation is the lack of adequate funding (64%); As well as in 2002 the main barrier to this implementation is the lack of adequate funding (64%);

34. 34 Discussion As it concerns to the main strategies of the health centres to overcome the barriers, the most common answer is “to wait until better solutions are available” (36%) As it concerns to the main strategies of the health centres to overcome the barriers, the most common answer is “to wait until better solutions are available” (36%) Also in the study, we noticed that the main concern of the health centres functionaries is the access to the information by non authorized users (71%) Also in the study, we noticed that the main concern of the health centres functionaries is the access to the information by non authorized users (71%)

35. 35 Discussion We should strive to have a national system of EHRs that can share information on any patient in any health care setting. We should strive 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. 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. (factors JAMIA) 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. (factors JAMIA)

36. 36 Key words Electronic Health Records; Electronic Health Records; Medical Informatics; Medical Informatics; Health Centers; Health Centers; Primary Health Care; Primary Health Care;