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The Role of Interoperability Standards for Emerging Countries

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

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The Role of Interoperability Standards for Emerging Countries

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  1. Beatriz de Faria Leão, MD, PhD The Role of Interoperability Standards for Emerging Countries 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. SOUTH AMERICA • 4th continent in size • Area 17,840,000 km² • Population 371 millions • Countries 12 • Languages: Spanish, Portuguese, French, Dutch, English …. • GDP $3.33 Trillion

  5. http://www.globalhealthfacts.org/topic.jsp?i=46

  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. SUEIIDISSSociedad 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

  11. www.sueiidiss.org

  12. Uruguay / SUEIIDISInteroperability 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 Argentinawww.hl7argentina.org • 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

  15. http://campus.hl7.org.ar/

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

  17. http://www.hl7chile.cl/

  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 Fragmented and Uncoordinated MarketSmall and Badly Connected Players! Little Investiment in Management and IT • 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 • It’s a “Market of Discontent”

  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 (www.sbis.org.br/certificacao)‏

  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. TeleHealth National Project Coverage: Nine State Clusters implementing Telehealth in 900 health units supporting about 2,700 Health Family teams, covering 11,000,000 inhabitants.

  28. System operation should be as simple as the local users

  29. Private Healthcare Insurance Market 49.3 millionbeneficiaries 1.600 active Health Plan Organizations 600.000 estimated Healthcare providers Self-regulation HPOS ANS State Regulation Sources; www.ans.gov.br Set 2008

  30. HMOS NHS TISS - the Brazilian standard for HPOs and HC providers communication NSHA DATABASE (enroll/disenrollments , services utilization, health care indicators)‏ TISS - XML Demographics, Vital Statistics, Discharge Summary, Notifiable Diseases Healthcare providers Source: Jussara Macedo, ANS, 2007

  31. 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 Source: Jussara Macedo, ANS, 2007 Source: Jussara Macedo, ANS, 2007

  32. PROVIDERS HPOS Eligibility and prior Authorization Pre certification and Adjudication Claim Generation Service Billing Claims Acceptation Adjudication Claim Status Inquiries Accounts Receivable Accounts Payable TISS Transactions Health care Services Delivery Claims Patient Info Claim Status Inquiry Claim Status Response Claim Payment Source: Jussara Macedo, ANS, 2007

  33. www.hl7brazil.org

  34. 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

  35. 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

  36. 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

  37. SIGA SaúdeSão Paulo City’s Health Information System Lab Integration Claudio Giulliano da Costa, MDCIO São Paulo Health Department

  38. São Paulo • 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

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

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

  41. 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

  42. 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)‏

  43. SIGA Saúde Lab IntegrationLab Orders LAB N LAB 1 LAB 2 LAB 3 XML SIGA Web Service: LAB XML Sample Collection Lab Order Authorization Hospital Emergency UBS AE AMAS

  44. SIGA Saúde Lab IntegrationLab Results LAB 1 LAB 2 LAB 3 LAB N XML SIGA Web Service: SIGA XML Lab Results (Common, Micro, Pathology) - CDA in Phase 1 UBS Hospital Emergency AE AMAS

  45. Standards used for SIGA’s Lab Integration • Identification: • Patient’s - 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

  46. 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

  47. TISS envelope

  48. 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)

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