Health Information Systems in Brazil

Beatriz de Faria Leão, MD, PhD

Claudio Giulliano da Costa, MD, MSc

Jussara Macedo Pinho Rötzsch, MD, MSc

Lincoln de Assis Moura Jr, MSc, DIC, PhD

Marivan Santiago Abrahão, MD

2Jan-07

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

3Jan-07

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

Brazil: “Soft Power”- Emerging Giant

5Jan-07

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

6Jan-07

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 2nd country in number of Internet hosts in America

7Jan-07

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

9Jan-07

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

10Jan-07

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

11Jan-07

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 Market

Small and Badly Connected Players!

Little Investiment in

Management and IT

12Jan-07

SUS Organization & Financing

State Dept of Health

City City City City City City

LocalManagement

NationalHealth Council

State Health Council

Municipal Health Council

MunicipalHealth Fund

Tri-party &Bi-party

Committees

Tri-party &Bi-party

Committees

National Health Fund

$$$$

Info

rmat

ion

Informatio

n

State Dept of HealthState Dept of HealthState Dept of Health

$$

Dept o Health (Federal Govrnt)

13Jan-07

SUS – Negotiation

City

BigCity

CityCity

City

City

City

State

PPI: Agreed and Integrated Covenant Distribution of Health Resources based on Health Indicators and Benchmarking

PPI: Agreed and Integrated Covenant Distribution of Health Resources based on Health Indicators and Benchmarking

14Jan-07

Patient Flow Control (“Regulation of Care”)

Polyclinics DiagnosticCenter Specialty Center Clinic

PrimaryCare Unit

PrimaryCare Unit

PrimaryCare Unit

PrimaryCare Unit

PrimaryCare Unit

PrivateHospital

UniversityHospital

CharityHospital

Primary Care Primary Care

High Complexity - HospitalsHigh Complexity - Hospitals

coun

ter-

refe

renc

e

referênciaregio

nalizatio

n

Med

ium

Com

plex

ityM

ediu

m C

ompl

exity

PrimaryCare Unit

referência

Patient Flow Control

Ele

ctr

on

ic H

ea

lth

Re

co

rd

Entry Level

Entry Level

axes

15Jan-07

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

Ministry of Health

Brazilian Telehealth Program

Franciso Eduardo Campos Laboratory of Excellence and Innovation

in e-Health Latin America and Europe

- I Workshop

Belo Horizonte – Minas GeraisNovember 2006

Ministry of Health

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)

18Jan-07

Telehealth points in Brazil for 2007

Participation of all Brazilian States

Points of Telehealth

Ministry of Health

Ministry of Health

“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”

20Jan-07

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

21Jan-07

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

22Jan-07

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

23Jan-07

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

Private Healthcare Insurance Market

45.408.621beneficiaries

HPOS

1.891active Health Plan

Organizations

600.000 estimated Healthcare providers

Sources; NShA 2005/08 CNES 2005/08

ANSState Regulation

Self-regulation

NHS Healthcare providers

NSHA DATABASE (enroll/disenrollments , services utilization, health care indicators)

Demographics, Vital Statistics, Discharge Summary, Notifiable

Diseases

HMOS TISS - XMLTISS - XML

TISS - the Brazilian standard for HPOs and HC providers communication

26Jan-07

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

27Jan-07

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

28Jan-07

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 Resp.

Claim PaymentAccounts Payable

29Jan-07

TISS schemas

30Jan-07

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

31Jan-07

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

32Jan-07

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

33Jan-07

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

Sao Paulo City Health Dept

Information Technology Coordination

São Paulo is a very large City..

São Paulo is a Cosmopolitan City

São Paulo is a City full of Contrasts

East Region

Tiradentes 15

E. Matarazzo 18

Guianases 20

Itaim Paulista 22

Itaquera 31

São Mateus 28

São Miguel 24

Campo Limpo 29

Cidade Ademar 20

Boi Mirim 34

Parelheiros 9

Socorro 24

Sto Amaro 20

Aricanduva 12

Ipiranga 29

Jabaquara 13

Mooca 25

Penha 29

V Mariana 31

V Prudente 36

Southern Region

North Region

Casa Verde 16

Freg/Brasilandia 26

Perus 9

Pirituba 25

Santana 20

Tremembe/Jacana 13

V Maria/V Guilherme 18

South Region

Medium-West Region

Butantã 27

Lapa 29

Pinheiros 14

Sé 36

Population: 2.136.977

Population: 2.396.940

Population: 2.499.294

Population: 2.402.093

Population: 1.244.456

10.679.760inhabitants

39Jan-07

9.640.906Primary CareEncounters

11.027.517Medical

Emergencies164.704.060

Medical Procedures

10.347.595SpecializedEncounters

592.992Hospital

Admissions

Health Public Sector Figures for São Paulo City / 2005

Fonte: SIA/SUS - SIH/SUS – CNES/MS 2005

40Jan-07

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

41Jan-07

SIGA Saúde Essentials

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, and

In-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

System is on-line, 100% open, based on Internet ArchitectureSystem is on-line, 100% open, based on Internet Architecture

43Jan-07

SIGA Saúde – Schematics

Ambulatory Electronic Health Record

(Primary, Specialties, High Complexity)

Patient FlowControl

(Consultations, Procedures, Beds)

Heath Care

Management(Surveillance, Audit and Billing)

Internet

SMS-SP

Dept of Health

Secure AccessSecure AccessDatacenter

44Jan-07

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

45Jan-07

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)

46Jan-07

Manual vs Electronic High-Cost Procedure Orders

Electronic Manual / Paper-based

47Jan-07

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!!!)

48Jan-07

Integration Model of System

ElectronicHealthRecord

(SIGA System)

HospitalInformation SystemW

ebservices

LabSystems*

PACS(Medical Images)

NationalInformation

Systems

HL7

* Only six months to implementWhat do we need ?• Education in HL7 (orders/obs)• Translation LOINC

HL7

HL7

49Jan-07

Java One 2005 Video

50Jan-07

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!!

HL7 Role in Brazil

Main IssuesFoster 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

Priorities for HL7 in Brazil

Lab integration

Hospital Discharge

Compliance with TISS

Compliance with the national HC standards for the public

sector

Training and Education

www.hl7brazil.org

55Jan-07

Amazon’s pirarucu and the pink dolphin

Obrigada!

Thank you!

Hope to welcome you there!

Danke schön, bis Köln!