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Health Information Systems in Brazil

Health Information Systems in Brazil. Beatriz de Faria Le ão, MD, PhD Claudio Giulliano da Costa, MD, MSc Jussara Macedo Pinho Rötzsch, MD, MSc Lincoln de Assis Moura Jr, MSc, DIC, PhD Marivan Santiago Abrah ão, MD. The Brazilian Delegation.

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Health Information Systems in Brazil

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  1. Health Information Systems in Brazil Beatriz de Faria Leão, MD, PhD Claudio Giulliano da Costa, MD, MScJussara Macedo Pinho Rötzsch, MD, MScLincoln de Assis Moura Jr, MSc, DIC, PhDMarivan Santiago Abrahão, MD

  2. The Brazilian Delegation • Claudio Giulliano A. da Costa - CIO São Paulo City Health Authority, Treasurer Brazilian Health Informatics Association (www.sbis.org.br) • Jussara Macedo P. Rötzsch - General Manager of Standards - National Agency for Supplementary Health (www.ans.gov.br) • 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. 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. Some Facts about Brazil • 9th 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 2005 • 95% 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. 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 populatedcountry in the World • The 2nd country in number of Internet hosts in America

  7. 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. 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

  9. 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

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

  11. SUS Organization & Financing Dept o Health (Federal Govrnt) National Health Council National Health Fund State Dept of Health State Dept of Health State Dept of Health State Dept of Health Tri-party & Bi-party Committees $$$$ Information State Health Council $$ LocalManagement Information City City City City City City Municipal Health Council MunicipalHealth Fund

  12. SUS – Negotiation City City State City Big City City City City PPI: Agreed and Integrated Covenant Distribution of Health Resources based on Health Indicators and Benchmarking

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

  14. 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

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

  16. 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)

  17. Points of Telehealth Telehealth points in Brazil for 2007 Participation of all Brazilian States Ministry of Health

  18. “FOR DECADES IN A ROW BRAZILIAN’S POLITICAL DECISION HAS BEEN TO BUILD STEADLY A STRONG UNIVERSAL AND EQUITATIVE HEALTH SYSTEM. • TELE-HEALTH IS PART OF IT”

  19. 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

  20. 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

  21. Brazilian HC National Standards: National Unique Identifiers: • Individuals (116 million people uniquely identified) • Healthcare providers (153.903 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

  22. Brazilian National Health Providers and Professionals Registry - www.datasus.gov.br/cnes

  23. Private Healthcare Insurance Market 45.408.621beneficiaries 1.891active Health Plan Organizations 600.000 estimated Healthcare providers Self-regulation HPOS ANS State Regulation Sources; NShA 2005/08 CNES 2005/08

  24. 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

  25. 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

  26. 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 17799 and SBIS/CFM Software Certification • Mandatory from May 2007 on

  27. 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 Resp. Claim Payment

  28. TISS schemas

  29. 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

  30. 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

  31. 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

  32. 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

  33. Sao Paulo City Health Dept Information Technology Coordination

  34. .. São Paulo is a very large City

  35. São Paulo is a Cosmopolitan City

  36. São Paulo is a City full of Contrasts

  37. East Region North Region 10.679.760 inhabitants Population: 2.396.940 Population: 2.136.977 Southern Region Medium-West Region South Region Population: 2.499.294 Population: 1.244.456 Population: 2.402.093

  38. Health Public Sector Figures for São Paulo City / 2005 10.347.595 Specialized Encounters 9.640.906 Primary Care Encounters 592.992 Hospital Admissions 11.027.517 Medical Emergencies 164.704.060 Medical Procedures Fonte: SIA/SUS - SIH/SUS – CNES/MS 2005

  39. SIGA Saúde – SP City Information System • SIGA Saúde is São Paulo City’s 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

  40. 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, andIn-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 SIGA Saúde Essentials System is on-line, 100% open, based on Internet Architecture

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

  42. 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

  43. 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)

  44. Electronic Manual / Paper-based Manual vs Electronic High-Cost Procedure Orders

  45. 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!!!)

  46. Integration Model of System W e b s e r v i c e s Hospital Information System HL7 Electronic Health Record (SIGA System) Lab Systems* HL7 PACS (Medical Images) HL7 National Information Systems • * Only six months to implement • What do we need ? • Education in HL7 (orders/obs) • Translation LOINC

  47. Java One 2005 Video

  48. 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!!

  49. HL7 Role in Brazil

  50. 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

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