Building the National EHR Strategy - HISA · Building the National EHR ... ò no B r as i l o si...
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Prof. Ricardo Staciarini Puttini, PhD University of Brasilia/Ministry of Health BRAZIL Aug-2015, HIC 2015, Brisbane SUS: Brazilian Unified Health System Building the National EHR Strategy
Transcript of Building the National EHR Strategy - HISA · Building the National EHR ... ò no B r as i l o si...
Prof. Ricardo Staciarini Puttini, PhDUniversity of Brasilia/Ministry of Health
BRAZIL
Aug-2015, HIC 2015, Brisbane
SUS: Brazilian Unified Health System
Building the National EHR Strategy
Inspired after Helen Bevan presentation on HIC 2015
“A dream dreamed alone is just a dream. A dream dreamed together is reality.”
Raul Seixas (Brazilian Song Writer and Poet)
Cartoon adapted from: http://www.nma.gov.au/exhibitions/behind_the_lines_2006_the_years_best_cartoons/news_of_the_day
About me...
About me...
As a researcher at University of Brasilia… I’ve been
working with distributed information systems…
As a scientist consultant to MoH… I’ve been
searching for interoperability architectures for
Healthcare Information Systems
The Dream
Brazilian eHealth Vision (2014-2020)
What is?
Provide opportunistic Information,
seamlessly, for the health care process
as a mean of transforming and
improving the process (Vision)
National EHR in Brazil
The Laboratory
• 5th largest country (7,682,300 km2)
• 5th largest population (193 million)(2011)
•6th largest economy (GDP 2.5 trillion USD)(2011)
• “Young” democracy (Constitution from 1988)
• Political stability
The Laboratory
• National Federation
• 5 Geographical Regions
• 26 States + DF
•5,565 Municipalities
The Laboratory
•Brazilian Unified Health System: Integral health care
for all citizens
• Regionalized, Decentralized, and Federated
• Governance at 3 levels:
• National
• State
• Municipal
The Laboratory
Brazilian Unified Health System
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CÂMARA DOS DEPUTADOS CONSULTORIA DE ORÇAMENTO E FISCALIZAÇÃO FINANCEIRA NÚCLEO DA SAÚDE
participação do setor público ganha maior importância no financiamento da saúde em países que adotam sistemas de cobertura universal.
Como se verifica na Tabela I, a participação de fontes públicas no financiamento da despesa total dos sistemas varia de 68,5%, na Austrália, a 82,7%, na Inglaterra, com uma média de 70% (cf. Indicadores de Desenvolvimento Mundial do Banco Mundial de 2013).
Tabela I Indicadores Econômicos e de Despesas em Saúde Mundiais
Países/
Descritor Canadá França Austrália
Reino
Unido
União
Europeia Espanha Argentina Brasil China
PIB per capita (dólar corrente) 50.343,69 42.379,26 61.789,48 38.974,32 34.923,04 31.984,73 10.941,96 12.593,89 5.444,79
PIB per capita, PPC (1) 35.714,79 29.820,09 34.852,66 32.808,79 28.048,60 26.952,35 ------ 10.278,63 7.417,89
Despesas per capita de saúde
(dólar corrente, US$) 5.629,73 4.952,00 5.938,65 3.608,65 3.550,68 3.026,65 891,80 1.120,56 278,02
Despesa per capita em saúde, PPC
(const. 2005 internacional $) (1) 4.519,96 4.085,48 3.691,55 3.321,67 3.259,80 3.040,78 1.433,70 1.042,73 432,28
Despesas privadas de saúde, (% do
PIB) 3,31 2,70 2,84 1,61 2,33 2,49 3,19 4,83 2,28
Despesas públicas de saúde, (% do
PIB) 7,87 8,92 6,19 7,71 7,82 6,95 4,92 4,07 2,89
Despesas públicas de saúde (% do
total de despesas em saúde) 70,41 76,74 68,51 82,70 77,04 73,59 60,64 45,74 55,89
Despesas totais de saúde (% do PIB) 11,18 11,63 9,03 9,32 10,15 9,44 8,11 8,90 5,16
Fonte: Indicadores de Desenvolvimento Mundial do Banco Mundial, in http://data.worldbank.org/data-catalog/world-development-indicators, consultado em
maio/2013. Elaboração: Consultoria de Orçamento e Fiscalização da Câmara dos Deputados. OBS: (1) per capita com base na paridade de poder de compra –
PPC (tradução do inglês purchasing power parity -PPP).
IV.1 Parâmetros de Gasto no Brasil
Em 2011, o gasto total com saúde no Brasil (público e privado) atingiu o equivalente a 8,9% do PIB, percentual pouco abaixo daqueles observados nos países com cobertura universal, conforme anteriormente mencionado. Entretanto, nesses países o setor público apresenta participação significativa no financiamento total da saúde – acima de 60% – situação essa que não se reflete no Brasil, cuja participação do setor público nos gastos totais foi de 45,7%, o que significa dizer que 54,3% dos gastos foi financiado pela instância privada.
Tal concentração dos gastos privados na área da saúde no país é apontada pela FIOCRUZ, na publicação “A Saúde no Brasil em 2030”, capítulo Estruturas do Financiamento e do Gasto Setorial, quando esclarece que na prática o sistema de saúde no Brasil é pluralista. Segundo o documento, “no Brasil o sistema de saúde é pluralista tanto em
termos institucionais12
quanto no que diz respeito a fontes de financiamento e a modalidades de
atenção à saúde. Essa pluralidade se expressa em quatro vias básicas de acesso da população aos
serviços de saúde: (i) o Sistema Único de Saúde (SUS), de acesso universal, gratuito e financiado
exclusivamente com recursos públicos (impostos e contribuições sociais); (ii) o segmento de planos
e seguros privados de saúde, de vinculação eletiva, financiado com recursos das famílias e/ou dos
empregadores, composto em junho de 2009 por 1.116 operadoras de planos de assistência médico-
hospitalar e 406 de planos exclusivamente odontológicos;13
(iii) o segmento de atenção aos
servidores públicos, civis e militares e seus dependentes, de acesso restrito a essa clientela,
financiado com recursos públicos e dos próprios beneficiários, em geral atendidos na rede
geral ou seguro de saúde compulsório) tendem a ser mais equitativos que sistema de pré-pagamento voluntário. Os pagamentos diretos do bolso
seriam a forma mais regressiva de financiamento (WAGSTAFF et. al., 1999; KUTZIN, 2010). 12 Sua estrutura é composta por entes públicos (federais, estaduais e municipais) e privados (com e sem fins lucrativos). 13 ANS, Caderno de Informações set. 2009.
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Brazilian Unified Health System
As part of a (major) eHealth StrategyDirections:• Business Value: Business Case driven• Evolutionary: Architecture Maturity Model• Consistency: Governance Model• Digital Engagement: Participation/Collaboration -
People, Organizations and Vendors• Innovation: Opportunity driven (at the Market)
National EHR Strategy
Develop infostructure and infrastructure for National EHR. Deliver e-Health applications (e.g. medical systems, citizen’s health portals, management systems).Establish adoption and dissemination of solutions and promote innovation. Establish the governance framework.
National EHR Strategy
National EHR Strategy
E-Health Applications
Prym
ary
Car
ee
SUS
AB
Urg
ency
and
Em
erge
ncy
eSU
S SA
MU
e e
SU
S U
PA
Spec
ializ
ed C
are
eSU
S H
osp
ital
ar
Governance
Service Bus (Interoperability)
Foundation: Infostructure
National Health Card System
National EHR
Cit
izen
s P
ort
al &
M
obile
App
Security and Privacy Services
Decision Support Systems(secondary use)
Foudation: Infrastructure
Resilient Computing
(Central Systems)Conectivity
Local Infrastructure
Technical Enterprise Architecture
Regulatory Framework
E-Health Vision
Technical Architecture Governance
National Health Card and EHR Strategy
Adoption and DIssemination
Vendors
Training & Education
Citizens
Healthcare Professional
Clinical Knowledge and
Terminology Services
Innovation
ProvidersSp
ecia
lized
Car
e eS
US
Am
bula
tori
al
Thir
d P
arty
Sol
utio
ns
Ap
plic
atio
ns
base
d o
n
EHR
AP
I
eSU
S Fa
mily
Adapted from ISO TR 14639
Evolving EHR:
• Business Case (Information Model)
• Architecture and Governance (Maturity Model)
• Applications (eSUS-*, Citizen’s Portal, third party)
National EHR Project
Each EHR Implementation Phase evolves all Dimensions
Business Case (Information Models)
Architecture and Governance
(EHR Functionality)
Applications
Phase 1
Phase 2
Phase 3
EHR Phase 1 (Rolling Out)• Business Case: Primary Care
• Information Model: Encounter Summary
• Architecture and Supported Features
• Demographics (PIX/PDQ)
• Basic Document sharing (XDS) (both pdf and OpenEHR)
• EMR Applications
• eSUS-AB and SIGA (São Paulo)
• Regulatory Framework
• Term for Patient Consent
• Term of Usage (Providers)
• Basic Security & Privacy Policy (opt out)
National EHR Project
• Business Case Driven
• Use cases relates to specific context and information use, delivering specific value
Benefits Realization
Clinical Information Modeling
Target EMR Application
• Quick to realize (6-12 months from start to initial roll out)
• Typical Business Cases
• Summaries (Primary Care, Discharge, Health Summary)
• Chronic Diseases (Care Program Oriented)
• Medication (Prescription, Dispensation)
• Per Specialties (Ambulatory Care)
The Business Case Approach
Clinical Information Modeling
The Business Case Approach
Source:Ocean Informatics
Clinical Information Modeling
The Business Case Approach
• OpenEHR
• Clinical Ontology
• Knowledge Artifacts
o Templates
o Archetypes
o TerminologiesSource:T. Beale & S. Heard(OpenEHR Foundation)
Clinical Information Modeling
The Business Case Approach
Source:CENTERMS
Adopted Standards for Interoperability (Ministerial Act 2.073 / 2011)
Clinical Content: OpenEHRDocument Registry & XDS.bRepositoryPatient Identifier: IHE – PIXv3 PDQv3Terminologies:
Lab Coding: LOINC (Logical Obs. Identifiers, Names and Code)
Clinical terms: SNOMEDImage coding: DICOMPrimary Care: ICPC-2Brazilian standards for clinical procedures
EHR Technical Architecture
EHR Technical Architecture
Source: Oracle
• Regulatory framework (initial definition 2011, evolving)
• Demographics: National Health Card (deployed 2012, scaling)
• PIXv3/PDQv3
• Interoperability Infrastructure: Service Bus (deployed 2012, scaling)
• National e-Health Vision 2014-2020 (2014)
• National EHR “system of systems” (conception)
• Technical Interoperability Architecture (defined 2014)
• EHR v1.0: Primary Care Summary (rolling out 2015)
• Target Applications: eSUS-AB and SIGA (São Paulo)
• Patient Consensus Term (defined 2015)
• Knowledge Artifacts and Terminology
• Governance Model (2014)
• CKM adoption (2014)
• IHTSDO/SNOMED-CT affiliation (on-going 2015)
Achievements (2012-2015)
Core technical architecture defined
Evolutionary approach (maturity model)
Main Milestones:
Phase 1: Basic EHR functionality + Pilot project with São Paulo city (12M lives)
Phase 2: Semantic framework – Clinical Knowledge and Terminology services + Basic Decision Support system
Phase 3: Knowledge Governance + Enhanced Decision Support
EHR Project (2015-2016)
Phase 1 Phase 2 Phase 330.09.2015 31.05.2016
Basic EHRKnowledge GovernanceEnhanced Decision Support
Semantic FrameworkBasic Decision Support
31.12.2016
Lessons Learned• Business Case Approach:
• Project based
• Allows for specifics to be discussed in details
• Alignment with on-going care strategy (public and private sectors)
• Well defined deliverables
• Business value delivered and monitored
• Technical Architecture
• Long time to define architecture roadmap (done)
• Focus on semantic interoperability (clinical information models)
• Legacy software are not interoperating: green field
• Interoperability models: using OpenEHR documents directly
• EHR APIs will allow innovative applications (patient and clinical professionals)
• Incremental governance
• EMR Applications
• Focus on eSUS Family (Primary Care, Hospitals and Specialties)
• Working with vendors for Third-Party applications support
Thank You!
Prof. Ricardo Staciarini Puttini, PhDUniversity of Brasilia/Ministry of Health
BRAZIL
Aug-2015, HIC 2015, Brisbane
