Healthcare Information Technology Infrastructures in Turkey ( Saglik & Medula )

1. Healthcare Information TechnologyInfrastructures in Turkey (Saglik.net & Medula) Prof.Dr.Halit Hami ÖZ Kafkas University, Kars, Turkey

2. IntroductionandObjectives • TheHealthTransformation Program [1] of theMinistry of Health, Turkey, was published in 2003. One of the main components of this program is achieving e-health, withthefollowingobjectives

13. Saglik.net • Ensuringstandardization of data used in healthcare, • Creatingthe Electronic HealthRecordforcitizens, • Data analysissupportformanagers (DecisionSupportSystem), • Speedinguptheflow of informationamongstakeholders, • Savingresourcesandincreasingefficiency in thehealthcaresystem.

14. Sağlik-Net • Theobjective of thispaper is todescribesome of themincludingSağlik-Net, togetherwithitstwomajorcomponents, • namely, theNationalHealth Information System (NHIS) • [2] andtheFamilyMedicine Information System (FMIS) [3]. • TheotherinfrastructuressurveyedincludetheCentralizedHospitalAppointmentSystem (CHAS) [4], • theBasic HealthStatisticsModule (BHSM), • theCoreResources Management System (CRMS) • andthe e-prescriptionsystem of theSocial Security Institution. 

15. Sağlık-Net • http://www.e-saglik.gov.tr/

20. Saglik.net

21. Saglik.net

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23. Saglik.net • Inadditiontothemajorcomponents, it alsocontains • theNationalHealth Data Dictionary (NHDD) [5], • theHealthCoding Reference Server (HCRS) [6] • andtheDecisionSupportSystems. • TheSağlık-Net is withthenationale-prescriptioninfraalsointegratedstructuremaintainedbytheSocial Security Institution. • TheTurkish e-identitypilot project has successfullybeenconcludedanddistribution of e-identitycardstoTurkishcitizenswas startedJanuary 2014.

24. TheHealthCoding Reference Server • TheHealthCoding Reference Server encapsulatesalltheinternationalandnationalcodingsystemsused in Turkeywithin a publiclyaccessible server. • Some of thecodingsystemsavailablefromHealthCoding Reference Server areinternationalsuch as ICD-10 [7] orAnatomicalTherapeuticChemicalClassificationSystem [8] andmostarelocallydefinedforcertainsets of informationsuch as Clinics, PatientDischargeType, PregnancyResult, orBabyMonitoringCalendar. • Currently, thereare 329 codingsystemsmaintained in the server.

25. TheNationalHealth Data Dictionary • TheNationalHealth Data Dictionary [5] containsthecommonlyusedhealthcare data elementssuch as “Address”, “Name”, “Main Diagnosis”, “Vaccination”, and “TreatmentMethod”. • Theformat of these data elements is definedaccordingtotherulesandguidelinesgiven in ISO/IEC 11179-4 Standard [9]. • Thefirstversion of thedictionarythat was activefrom 2008 tomid 2012 had 261 data elements, whilethecurrentversion, which is an update of thefirstversionbased on feedbackfromtheusersanddecisionmakers, has 464 data elements.

26. TheNationalHealth Data Dictionary • The “AggregateCore Components”, whicharecalledMinimum Health Data Sets(MHDSs), areformedusingthese data elements [2]. • TheMinimum Health Data Sets define the data thatemerge at the time of presenting a specifichealthcare service, e.g. infantmonitoringdata set orpregnantmonitoring data set. • Therewere 46 Minimum Health Data Sets in thefirstversion of theNationalHealth Data Dictionary, andnowthereare 65 of them. • The data elementswithinthe Minimum Health Data SetsaremostlycodedusingcodingsystemsthatareavailablefromtheHealthCoding Reference Server.

27. NationalHealth Information System (NHIS) • TheNationalHealth Information System of Turkey (NHIS) [2] is a nation-wideinfrastructureforcollectingandtosomeextentsharingpatients’ Electronic HealthRecords(EHRs). • Thecurrentimplementation of NHIS supportsthetransfer of episodicEHRsfromsecondaryandtertiaryhealthcareproviderinformationsystemsto NHIS servers at theMinistry of Health. • Yet, onlythegeneral practitioners(GPs) can accesstheEHRs of theirownpatients, throughtheirFamilyMedicine Information System(FMIS) clientapplications.

28. NationalHealth Information System (NHIS) • Inthefirstversion of the NHIS, whichbecameoperational in January 2009, NHIS and FMIS weretwoseparatesystemswiththeirowndatabasesand Web services on the server side, whichcreatedproblems in linkingthe EHR data betweenprimarycareandsecondary/tertiarycare. • This problem is solved in August 2012 withthe 2.0 release of the NHIS, which is an improved, standardscompliantandtechnicallymorecapableredevelopment of thefirstrelease, based on theexperiencesgainedfromitsfirstversion. • Inthenewrelease, the data collectedthroughtheprevious NHIS and FMIS systemsaremergedandpreserved. With NHIS 2.0, alltheclientsideapplications of primary, secondaryandtertiarycareprovidersinteractwiththeuniquenationalsystem.

29. NationalHealth Information System (NHIS) • TheepisodicEHRscollectedthroughthe NHIS, alsocalledtheTransmission Data Sets, areaggregatedfromthe Minimum Health Data Sets. • Inthepreviousversion of NHIS implementation, therewere 41 Transmission Data Sets; • eachdedicatedto a Minimum Health Data Set suchas • “15-49 Age FemaleObservation”, • “MouthandTeethExamination”, • “Vaccine Notification”, • “InfantNutrition” and • “Diabetes”. • Inthecurrentrelease of NHIS, thereareonlysevenbroaderTransmission Data Sets, namely • “CitizenRegistration”, • “Examination”, • “PatientDemographics”, • “Test Results”, • “Inpatient”, • “HIV” and • “Death Notification”, whicharecapable of collectingall65 Minimum Health Data Setsin variouscombinations.

30. NationalHealth Information System (NHIS) • TheTransmission Data SetsaremappedtoHL7 CDA Release 2 tocreatethe “TransmissionSchemas” as described in [2]. • Inbrief, the Minimum Health Data Setsaremappedto CDA sections, andthe data elements of theMHDSsaremappedto CDA entryclassesandtheirattributes. • A “TransmissionSchema” instanceconstitutesthepayload of an NHIS EHR exchangemessageand HL7 v3 Web Services Profile [10] is used at the transport layer.

31. NationalHealth Information System (NHIS) • Itshould be notedthatthedata requiredbythe NHIS is automaticallygeneratedbythehealthcareproviderinformationsystemsandare sent byinvoking NHIS Web Services; hencetheprocess is transparenttothehealthprofessionalswhocreatethecontent of the EHR documents. • Thehealthprofessionalscontinueusingthehealthcareproviderinformationsystems as before; thevendors of thesesystemshavedevelopedwrapperapplicationsthatpopulatethe NHIS conformantmessagesfromthe data collectedfromtheirownsystemsandsendthembyinvokingthe NHIS Web Services.

32. NationalHealth Information System (NHIS) • NHIS is opentoextensions: • Whena needfor a new EHR documentarises, theexisting Minimum Health Data Setsare re-usedifpossible; • ifnot, thenew Minimum Health Data Setsareconstructedbyusingtheexisting data elementsandtheNationalHealth Data Dictionary is expandedbydefiningnew Data Elementswhennecessary. • Theseupdatesarethenreflectedtotheoperationalelectronicservices. • Sofar, onemajorand a number of minorupdateshavetakenplace.

33. FamilyMedicine Information System (FMIS) • Incomparisontomanyothercountries, Turkey was late in migratingtothefamilymedicinepractice. • Previously, primaryhealthcare was deliveredeitherthroughhealthpostsdistributedalloverthecountryorbyhospitalswhichareconventionallyresponsibleforthesecondaryandtertiaryhealthcareservices. • However, withtheintroduction of HealthTransformation Program in 2003, there has beenconsiderableprogress in realizingfamilymedicine in Turkey.

34. 5.1 Implementation of FMIS • TheFamilyMedicine Information Systemis a nationalsystemforexchangingprimarycarerecordsamong general practitionersandtheMinistry of Health. • Thecontent of healthcare data undertheGPsresponsibility is alsodefinedthroughthe Minimum Health Data Sets, whichareavailable in theNationalHealth Data Dictionary.

35. 5.1 Implementation of FMIS • TheFMIS has a client-server basedarchitecture. • Thecentralizedpartis hostedbytheMinistry of Health in Ankara andthedesktopclientapplicationsareusedbytheGPs in theirownoffices. • Theclientapplications can bothstoreintoandretrieve data fromtheMinistryservers. • Communicationis based on Web Services exposed on theMinistryside. • PriortoAugust 2012, FMIS had itsdedicatedcentraldatabaseandproprietary Web Services forcommunicatingwiththe FMIS clientapplications. • WithNHIS 2.0, theseclientapplicationsusetheHL7compliant Web Services of theharmonized NHIS, whicharealsousedbysecondaryandtertiaryhealthcareproviders as explained in theprevioussection.

36. 5.1 Implementation of FMIS • Until a yearago, theMinistry of Healthusedtodistribute a simple FMIS clientapplicationtoGPsforfree. • Eventhen, manyGPsoptedforusingmorecapableanduserfriendly FMIS clientapplicationsby3rd partyvendors.

37. 5.1 Implementation of FMIS • TheclientapplicationsthatareusedbytheGPs can workboth in online and offline modes. • Theycan eitherrecordpatientobservationslocallyandsynchronizewiththeMoH Web Services immediately, orsynchronizethelocal data later. • Thesecondapproach is especiallyusefulwhenGPsvisittheirpatients in theruralareastogetherwiththeirlaptops. • As mentionedearlier, it is alsopossibletoretrieve data fromtheMoHcentralservers. • Forexample, whena citizenmovesto a newcityordistrict, thenew GP assignedtohim is abletoretrieveall his previousrecordsinto his FMIS clientapplicationthroughthe Web Services.

38. 5.1 Implementation of FMIS • TheMinimum Health Data Setsthataredefined in thefamilymedicine domain andexchangedvia Web Services are (someapplytosecondaryandtertiarycare domain as well): • InfantObservation • Child Observation • VaccineTracking • 15-49 Age WomanObservation • PregnancyObservation • PuerperalObservation • Death Notification • GenericPatientExamination • Consultation Notification

39. 5.2 Performance Evaluation of theGPsthroughFMIS • FMIS is alsousedtoevaluatetheperformance of theGPs, whichaffecttheirsalaries. • TheGPshave a baselinesalarywhich can increaseordecreasedepending on theirperformancescorescalculatedbythe FMIS. • Whentheycompletealltheexpectedpatientobservations, theirsalariesincrease. Intheoppositecase, theirsalariesmaydecreasebelowtheirbaselinesalaries

40. TheperformancecriteriaforGPsarecomposed of fivemeasuresthatarecalculatedeachmonth: • Vaccinesuccess rate: Division of thenumber of vaccinesappliedbythenumber of vaccinesthatshouldhavebeenapplied. • Thelatter is calculatedbased on thevaccinecalendarforbabieswhoareregisteredtothe GP. • Thecentralsystemkeeps an instance of thisvaccinecalendarforeachinfantper GP andthesuccess rate of a GP is calculatedautomaticallyaccordingtotheexpectednumberversustherealizednumber of vaccines.

41. TheperformancecriteriaforGPs • Infantobservationsuccess rate: Division of thenumber of infantobservationsmade, bythenumber of infantobservationsthatshouldhavebeenmade. • This is similartothevaccinesuccess rate; this time there is an infantobservationcalendarwhichnecessitates seven distinctobservationsuntilthebaby is ten monthsold.

42. TheperformancecriteriaforGPs • Pregnancyobservationsuccess rate: Division of thenumber of pregnancyobservationsrealizedbythenumber of pregnancyobservationsthatshouldhavebeenmade. • Thereis a pregnancyobservationcalendarwhichdividesthecompletepregnancyprocessintofourperiods, and in each of theseperiods at leastonepregnancyobservation has to be madebytheresponsible GP.

43. TheperformancecriteriaforGPs • Referral rate: This is calculatedbased on thenumber of referralsthatthe GP made, the total number of patientsregisteredtothe GP andtheaveragenumber of patientvisitsto a healthcareprovider in Turkey. • Withthiscalculation, theGPsareencouragedtorefertheirpatientstosecondaryhealthcareserviceswhen it is necessary.

44. TheperformancecriteriaforGPs • Thenumber of citizens in need of mobile service: TheGPshavetovisittheirpatientswhoarephysicallyimpairedorliving in hard toreachruralareas. • Thesevisitsarewithinthescope of mobile servicesandthisextraworkgeneratesextraincomefortheGPs.

45. TheperformancecriteriaforGPs • Each GP is responsiblefromabout3500 citizens. • Whena GP is officially on leave, all of his patientsareassignedto a proxy GP sothatneither his patientsnor he face a medicallyorfinanciallydisadvantagedsituation. • Apart fromthat, citizensarefreetochangetheirGPs at any time, as long as thegeographicconstraintsaresatisfied.

46. 5.3 DecisionSupportSystem of FMIS • TheDecisionSupportSystem(DSS) of FMIS provides an overallview of theprimarycarepatientrecords at variouslevels, e.g. in thecountry as a whole, orstatisticsperprovince/countyorper GP. • Furthermore, thepatientrecords can be groupedaccordingtothetopicswhiledisplayingstatisticaldata. • Forexample, with a singleclick, it is possibletolistallwomenwhoare in the final month of theirpregnancy, andthendigintotheirindividualrecords, findtheresponsible GP, etc.

47. 5.3 DecisionSupportSystem of FMIS • DSS is based on Oracle Business Intelligence(BI) solutions [11] andprovidescustomizedinterfacesforseveralrolesthatareaccessiblethrough Web: • Thepolicymakers(i.e. decisionmakers) includingtheMinister of Health: Theyareabletoseeallprimarycare data in Turkey. • Administrators: They can seeall data andhandleadministrativetasks of the Web portal. They can alsocreatenewinterfaces/queries. • Province/CountyHealthManagers: They can seeall data in theprovince/county in whichtheyareresponsible. • PublicHealth Center staff: There is a PublicHealth Center foreach 100,000 population. Thestaffs of thesecentershavethesamecapabilities as theProvince/CountyHealthManagers. • General Practitioners: TheGPsareabletoseeall data thatbelongtothepatientsregisteredtothem.

48. 6 CentralizedHospitalAppointmentSystem (CHAS) • CentralizedHospitalAppointmentSystem(CHAS) enablesthecitizenstomakeappointments in anypublicsecondaryandtertiaryhealthcareproviderbycallingthe CHAS Call Center phonenumber“182” oronlinethroughtheCHAS Web Portal [12] and mobile applications in allmajor mobile operatingsystems (i.e. Android, iOS, Windows Phone, Blackberry). • Thecitizensareassistedby online operatorsduringphonecalls. Allthehealthcareprofessionalsworking in publichealthcareproviderssharetheircalendars of at least 15 dayswiththeMinistrythrough CHAS Web Services toenablecitizenstomakeappointmentsaccordingtothesecalendars. • CHAS, which was introduced in 2009 in allprovinces, becameoperational in thewholecountryby 2011.

49. 7 Basic HealthStatisticsModule (BHSM) • Basic HealthStatisticsModule(BHSM) is usedtocollectinformationaboutthehealthstatus, healthrisksandindicatorsacrossthecountrytodirecttheresourcesandprograms of Central andProvincialDirectorates of theMinistry of Health. • Thereareabout70 Basic HealthStatistics Forms andsome of themarereportedtothe World HealthOrganization (WHO) as well. • However, most of theseformsarefilledoutmanually.

50. 7 Basic HealthStatisticsModule (BHSM) • An analysisbytheMinistry of Healthrevealedthefactthatsome of the data in theformsarealreadyavailablefromtheFamilyMedicine Information System, such as Infant/Child Follow-uporPregnancyFollow-up. • Therefore, currentlythework is in progresstoimprovethe FMIS DecisionSupportSystemtoobtainthesereportsautomaticallytoreplacethemanual BHSM reports. • Fortheautomation of theotherforms, thereareplansfortheautomaticgeneration of thesereportsfromtheNationalHealth Information Systemtotheextentpossible.