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Health Information Systems in Brazil Beatriz de Faria Leão, MD, Ph. D Claudio Giulliano Health Information Systems in Brazil Beatriz de Faria Leão, MD, Ph. D Claudio Giulliano da Costa, MD, MSc Jussara Macedo Pinho Rötzsch, MD, MSc Lincoln de Assis Moura Jr, MSc, DIC, Ph. D Marivan Santiago Abrahão, MD

The Brazilian Delegation Claudio Giulliano A. da Costa - CIO São Paulo City Health 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 HL 7 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 Jan-07 2

Agenda ¾ Brazil - the “soft power” ¾ Brazilian Telehealth Program ¾ Health Informatics Agenda ¾ Brazil - the “soft power” ¾ Brazilian Telehealth Program ¾ Health Informatics and Standards in Brazil ¾ The Brazilian Standard to Exchange Information between Healthcare Providers and Payers ¾ São Paulo City Health Information System: SIGA Saúde ¾ The Role of HL 7 in Brazil ¾ Next Steps Jan-07 3

Brazil: “Soft Power”- Emerging Giant Brazil: “Soft Power”- Emerging Giant

Some Facts about Brazil ¾ ¾ ¾ ¾ Jan-07 9 th Largest Economy in Some Facts about Brazil ¾ ¾ ¾ ¾ Jan-07 9 th 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 5 M with broadband access e-business: • 5 th largest market in e-business • U$15 Bi 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 5

Brazil – Geo-political Perspective The largest country in Latin America The only Portuguesespeaking country Brazil – Geo-political Perspective The largest country in Latin America The only Portuguesespeaking country in LA (52% of South America speak Portuguese) The 5 th most populated country in the World The 2 nd country in number of Internet hosts in America Jan-07 6

Brazil Strategic Data v Mercosul Gateway: borders with 9 countries (Argentina, Bolivia, Colombia, French Brazil Strategic Data v Mercosul Gateway: borders with 9 countries (Argentina, Bolivia, Colombia, French Guiana, Guyana, Peru, Surinam, Uruguay, and Venezuela); v World's largest producer of regional jets, 3 rd in shoes and soft drinks, 4 th in commercial aircraft, 8 th in steel, 10 th in automobiles; v Largest livestock in the world v Latin America's largest forestry-based industry; v 5 th world rubber industry, and the 7 th-largest paper and pulp industry; v World's 6 th-largest market for cosmetics, with annual sales of US$ 9 billion. v A modern and competitive textile complex, with 30, 000 companies and annual sales of US$ 21 billion. v 22% of the world's arable land surface. v 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 v The world largest fresh water resource Jan-07 7

Healthcare Challenges in Brazil ¾ Increasing demand for health care (aging, emerging of new Healthcare Challenges in Brazil ¾ Increasing demand for health care (aging, emerging of new diseases, re-emerging of considered overcome diseases) ¾ Skyrocketing healthcare costs (Health Technology) ¾ Inefficiency ¾ Paper base uncoordinated system, multiple formularies ¾ Lack of adequate information to support decision making, quality of care evaluation and to monitor disease management programs; ¾ Lack of common health and healthcare information standards within the sector ¾ Failed attempts of bottom-up standardization Jan-07 9

SUS – The Brazilian Health System Universal Access ¾ Health is a Right of SUS – The Brazilian Health System Universal Access ¾ Health is a Right of All (~ 145 M individuals) Full Coverage, Free of Charge ¾ All Services and Procedures SUS principles: ¾ ¾ ¾ Equity Universality Integrality Funding and Management are Shared ¾ Federal, State and Municipal Levels Suplementary Health for Those Wiling to Pay ¾ ¾ Jan-07 ~ 2, 000 HMOs (~ 45 M individuals) ANS (Agência Nacional de Saúde Suplementar) Regulates the Sector 10

The Brazilian Healthcare Market et ark Extremely Fragmented Market: ~ U$ 90 B/year d The Brazilian Healthcare Market et ark Extremely Fragmented Market: ~ U$ 90 B/year d M ! te SUS is the major Payer: ~ 66% in volume anda some 50% in $ers din Play 190 M inhabitants, spread over 5. 500 cities or co. Health Planed (HMOs) Around 7, 500 Hospitals andn U 2, 000 nect Operators nd 70% of Hospitals have less than 80 n a o beds d C Estimatete only 10% of y that Hospitals have Information Systems n e. HMOs cover. Badl 50, 000 lives each 90% less than gm a Only 3%and cover more than 200, 000 each t in Fr en of HMOs ll alargest HMO covers less that eslives tim d IT The Sm v 4 M Organizations In Health nt an There is no important network of ttle chain, added value and best practices me Lack of notion of Li production ge National Standards on their way na Ma ¾ ¾ ¾ Jan-07 It’s a “Market of Discontent” 11

SUS Organization & Financing Dept o Health (Federal Govrnt) or m at $ $$ SUS Organization & Financing Dept o Health (Federal Govrnt) or m at $ $$ $ Tri-party & Bi-party Committees State Dept of State Dept of Health State Health io n National Health Fund City I City Municipal Health Fund Jan-07 $$ In f Local Management National Health Council City i at State Health Council on rm o nf City Municipal Health Council 12

SUS – Negotiation City Big City State City PPI: Agreed and Integrated Covenant Distribution SUS – Negotiation City Big City State City PPI: Agreed and Integrated Covenant Distribution of Health Resources based on Health Indicators and Benchmarking Jan-07 13

Patient Flow Control (“Regulation of Care”) axes Patient Flow Control University Hospital Charity Hospital Patient Flow Control (“Regulation of Care”) axes Patient Flow Control University Hospital Charity Hospital Specialty Center Clinic ia nc erê ref counter-reference Diagnostic. Center n alizatio Primary Care Unit Entry Level Jan-07 cia rên e ref Polyclinics Primary Care Unit Medium Complexity Private Hospital region Electronic Health Record High Complexity - Hospitals Primary Care Unit Primary Care 14

Health Informatics Trends in Brazil Electronic Health Record ¾ ¾ ¾ Unique Identifier for Health Informatics Trends in Brazil Electronic Health Record ¾ ¾ ¾ Unique Identifier for Patients and HC Workers Know the Patient – Follow Up Treatment Decision Support at Point of Care Patient Flow Control (Regulation) ¾ ¾ ¾ Operate the Reference – Counter-Reference Model Find Fast and Resolving Pathways Unique Identifiers Health Care Units Management HIS Conectivity ¾ ¾ ¾ Integrate Clients – In and Outside the Organization HMOs, HC Providers, Clients and Authorities Public x Private Integration Health System Management ¾ ¾ ¾ Jan-07 Surveillance and Control Strategic and Tactic Decision Support Operation of the Healthcare System 15

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

Tele-health National Project ü Promote the use of technology by the ü ü ü Tele-health National Project ü Promote the use of technology by the ü ü ü 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) Ministry of Health

Points of Telehealth points in Brazil for 2007 Participation of all Brazilian States Jan-07 Points of Telehealth points in Brazil for 2007 Participation of all Brazilian States Jan-07 Ministry of Health 18

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

Brazilian HC National Standards Unique HC Identifiers ¾ ¾ Individual HC providers and professionals Brazilian HC National Standards Unique HC Identifiers ¾ ¾ Individual HC providers and professionals Content and Vocabularies ¾ ¾ ¾ ¾ Jan-07 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 ¾ ¾ ¾ Content, Brazilian HC National Standards TISS – Private Health Information Exchange ¾ ¾ ¾ Content, Vocabularies and Data Transmission XML based Enforces Data Confidentiality and Privacy Simplifies Data Exchange Between Providers and Payors Security ¾ National PKI infrastructure Software Certification ¾ Jan-07 Brazilian Health Informatics Society + Federal Medical Council 21

Brazilian HC National Standards: National Unique Identifiers: Individuals (116 million people uniquely identified) Healthcare Brazilian HC National Standards: National Unique Identifiers: Individuals (116 million people uniquely identified) Healthcare providers (153. 903 uniquely identified) ¾ 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 Jan-07 22

Brazilian National Health Providers and Professionals Registry www. datasus. gov. br/cnes Jan-07 - 23 Brazilian National Health Providers and Professionals Registry www. datasus. gov. br/cnes Jan-07 - 23

Private Healthcare Insurance Market 1. 891 active Health Plan Organizations 600. 000 estimated Healthcare Private Healthcare Insurance Market 1. 891 active Health Plan Organizations 600. 000 estimated Healthcare providers 45. 408. 621 beneficiaries Selfregulation HPOS ANS State Regulation Sources; NSh. A 2005/08 CNES 2005/08

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

TISS standards: Building the Consensus August 2004 ¾ ANS prepared the first version of TISS standards: Building the Consensus August 2004 ¾ ANS prepared the first version of TISS standards August 2004 – January 2005 ¾ Meetings with stakeholders (HPO, health providers and managers) February 2005 ¾ a two-month public comment Oct 26 th 2005 ¾ Standard was published ANS Rule 114 TISS February 2006 ¾ ¾ ¾ Jan-07 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 ¾ ¾ Consultation Hospital Discharge Lab, Medical Images TISS standards Information structure: billing formularies ¾ ¾ 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 Jan-07 27

TISS Transactions PROVIDERS Eligibility and prior Authorization Claim Generation Service Billing Claim Status Inquiries TISS Transactions PROVIDERS Eligibility and prior Authorization Claim Generation Service Billing Claim Status Inquiries Accounts Receivable Jan-07 HPOS Health care Services Delivery Pre certification and Adjudication Claims Patient Info Claims Acceptation Claim Status Inquiry Claim Status Resp. Claim Payment Adjudication Accounts Payable 28

TISS schemas Jan-07 29 TISS schemas Jan-07 29

TISS Implementation Policy In order to facilitate TISS compliance, ANS provides: ¾ Opensource software TISS Implementation Policy In order to facilitate TISS compliance, ANS provides: ¾ Opensource software prototype to generate the electronic messages ¾ XML EDI Management software (TISS-NET) ¾ E- learning training ¾ Workshops to interested HPOs and Healthcare providers during the implementation Jan-07 30

TISS Expected Results ¾ Efficiency and effectiveness Improvement of the health care sector in TISS Expected Results ¾ Efficiency and effectiveness Improvement of the health care sector in general ¾ Reduction of administrative costs ¾ Enhancement of healthcare quality ¾ Increase ability to develop quality measures and facilitate implementation of disease management programs Jan-07 31

TISS: What have we learned so far? ¾ Stakeholders Involvement was a critical success TISS: What have we learned so far? ¾ Stakeholders Involvement was a critical success factor ¾ ANS governance and support was a key factor ¾ TISSnet helps implement the standards ¾ COPISS, ANS´s Standards Committee, is now the Forum where the standard evolves ¾ The market is willing to move to the electronic transactions ¾ The project received a national award for fostering e-business ¾ Alignment with the national e-Health initiative Jan-07 32

TISS Challenges ¾ ¾ ¾ ¾ Jan-07 Change management requirements Staff and resource demands TISS Challenges ¾ ¾ ¾ ¾ Jan-07 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 Sao Paulo City Health Dept Information Technology Coordination

. . São Paulo is a very large City . . São Paulo is a very large City

São Paulo is a Cosmopolitan City São Paulo is a Cosmopolitan City

São Paulo is a City full of Contrasts São Paulo is a City full of Contrasts

East Region North Region Tiradentes E. Matarazzo Casa Verde Guianases 20 Itaim Paulista 22 East Region North Region Tiradentes E. Matarazzo Casa Verde Guianases 20 Itaim Paulista 22 Itaquera 31 São Mateus 28 São Miguel 26 18 24 16 Freg/Brasilandia 15 Perus 9 Pirituba 25 Santana 20 Tremembe/Jacana 13 V Maria/V Guilherme 18 Population: 2. 136. 977 Population: 2. 396. 940 10. 679. 760 inhabitants Southern Region Aricanduva Ipiranga Butantã 27 Lapa 29 13 Mooca South Region 29 Jabaquara Medium-West Region 12 25 14 Sé 36 Population: 1. 244. 456 29 Penha 29 Cidade Ademar Pinheiros Campo Limpo 20 V Mariana 31 Boi Mirim 34 V Prudente 36 Parelheiros 9 Socorro 24 Sto Amaro 20 Population: 2. 402. 093 Population: 2. 499. 294

Health Public Sector Figures for São Paulo City / 2005 9. 640. 906 Primary Health Public Sector Figures for São Paulo City / 2005 9. 640. 906 Primary Care Encounters 11. 027. 517 Medical Emergencies Jan-07 592. 992 Hospital Admissions 10. 347. 595 Specialized Encounters 164. 704. 060 Medical Procedures 39 Fonte: SIA/SUS - SIH/SUS – CNES/MS 2005

SIGA Saúde – SP City Information System São Paulo is the largest city in SIGA Saúde – SP City Information System São Paulo is the largest city in South America, with 12 M inhabitants and some 22 M in the Metropolitan Area. Basic Figures: 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. Jan-07 Ø 400 Primary Care Units Ø 60 Policlinics Ø 160 Hospitals Ø 11 M Users Ø 8. 5 M Emergency T/year Ø 550 k Inpatients/year Ø 11 M Primary Care C/year 40

SIGA Saúde Essentials National HC User Identification (Cartão SUS) ¾ Identifies Patient Uniquely, according SIGA Saúde Essentials National HC User Identification (Cartão SUS) ¾ Identifies Patient Uniquely, according to the National Standard National Registry of Workers & Providers ¾ ¾ Unique ID Relationships Patient Flow Control ¾ ¾ 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 ¾ ¾ Integrates and Distributes the Essential Dataset Embodies Intelligence (such as mandatory notification of diseases) Role-based Integrated Access Control System ¾ ¾ Access Authorization based on User Profile Single Sign-On System is on-line, 100% open, based on Internet Architecture Jan-07 41

SIGA Saúde – Schematics Heath Care Management SMS-SP (Surveillance, Audit and Billing) Dept of SIGA Saúde – Schematics Heath Care Management SMS-SP (Surveillance, Audit and Billing) Dept of Health Internet Patient Flow Control (Consultations, Procedures, Beds) Ambulatory Electronic Health Record (Primary, Specialties, High Complexity) Datacenter Jan-07 Secure Access 43

Advantages of the Architecture ¾ Several Cities can share servers and services; ¾ Simple Advantages of the Architecture ¾ Several Cities can share servers and services; ¾ Simple machines at the point of care; ¾ No need for computer personnel at healthcare units; ¾ Complexity stays away from the user, under central control; ¾ Model can be rolled out to other places; ¾ New functionalities can be added easily; ¾ SIGA Saúde: Periodic Updates Jan-07 44

SIGA Saúde now ¾ ¾ ¾ Jan-07 372 using the system via Internet (85% SIGA Saúde now ¾ ¾ ¾ Jan-07 372 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) 45

Manual vs Electronic High-Cost Procedure Orders Electronic Jan-07 Manual / Paper-based 46 Manual vs Electronic High-Cost Procedure Orders Electronic Jan-07 Manual / Paper-based 46

Our current challenges Improve internet connectivity of health basic units More investment in development 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: ¾ Hospital Information System ¾ Orders/Observations Lab (using HL 7!!!) Jan-07 47

Integration Model of System Electronic Health Record (SIGA System) National Information Systems Jan-07 W Integration Model of System Electronic Health Record (SIGA System) National Information Systems Jan-07 W e b s e r v i c e s HL 7 Hospital Information System HL 7 Lab Systems* HL 7 PACS (Medical Images) * Only six months to implement What do we need ? • Education in HL 7 (orders/obs) • Translation LOINC 48

Java One 2005 Video Jan-07 49 Java One 2005 Video Jan-07 49

Conclusion SUS is Modeled and Based on a Recognised Model ¾ ¾ Deployment of Conclusion SUS is Modeled and Based on a Recognised Model ¾ ¾ 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 ¾ National Health Card, Essential Dataset, CNES and TISS are very recent Internet-based Information Systems Gain Acceptance ¾ ¾ ¾ 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 ¾ Integration with Existing Systems (XML / HL 7) Trend to Integrate SUS and the Private Health System ¾ Jan-07 Watch Out for TISS!! 50

HL 7 Role in Brazil HL 7 Role in Brazil

Main Issues v. Foster international Collaboration v. Harmonize HL 7 to Brazilian HC Standards Main Issues v. Foster international Collaboration v. Harmonize HL 7 to Brazilian HC Standards v. Understand Discuss Policy and Bylaw v. Organize Local Meetings v. Promote HL 7 Training v. Establish liasons with: ¾ Brazilian Tele-health Committee ¾ ANS - National Agency for Supplementary Health

Priorities for HL 7 in Brazil l Lab integration l Hospital Discharge l Compliance Priorities for HL 7 in Brazil l Lab integration l Hospital Discharge l Compliance with TISS l Compliance with the national HC standards for the public sector l Training and Education

www. hl 7 brazil. org www. hl 7 brazil. org

Amazon’s pirarucu and the pink dolphin Jan-07 55 Amazon’s pirarucu and the pink dolphin Jan-07 55

Obrigada! Thank you! Hope to welcome you there! Danke schön, bis Köln! Obrigada! Thank you! Hope to welcome you there! Danke schön, bis Köln!