Faculdade de Medicina da Universidade do Porto

Current state of informatic Current state of informatic infrastructures in infrastructures in Portuguese health centers Portuguese health centers and its evolution since and its evolution since 20022002

Faculdade de Medicina da Universidade do Porto

Introdução à Medicina

March 2006

João Alhais; João Gonçalves; João Neves; João Rodrigues; João Alhais; João Gonçalves; João Neves; João Rodrigues; Jorge Ferreira; Jorge Rodrigues; Vanessa RodriguesJorge Ferreira; Jorge Rodrigues; Vanessa Rodrigues

Class 12

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ContentsContents

IntroductionIntroduction

Material and MethodsMaterial and Methods

ResultsResults

DiscussionDiscussion

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Medical informaticsMedical informatics

The field of information science The field of information science concerned with the analysis and concerned with the analysis and dissemination of medical data dissemination of medical data through the application of through the application of computers to various aspects of computers to various aspects of health care and medicinehealth care and medicine

Coiera, E., (2003) Guide to health informatics. Arnold editions. Lisboa

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• It deals with the resources, devices and It deals with the resources, devices and methods required to optimize the acquisition, methods required to optimize the acquisition, storage, retrieval and use of information in storage, retrieval and use of information in health and biomedicine; (wikipedia)health and biomedicine; (wikipedia)

• Health informatics tools include not only Health informatics tools include not only computers but also clinical guidelines, formal computers but also clinical guidelines, formal medical terminologies, and information and medical terminologies, and information and communication systems. (wikipedia)communication systems. (wikipedia)

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Importance of medical informatics Importance of medical informatics in primary carein primary care

In primary health care, especially in In primary health care, especially in developed countries, the use of different developed countries, the use of different types of information technology (IT) has types of information technology (IT) has progressed considerably.progressed considerably.

Tomasi, Elaine et al; Health information technology in primary health care in developing countries: a literature review

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Such evolution can be attributed partly to the Such evolution can be attributed partly to the peculiarities of the primary health-care sector peculiarities of the primary health-care sector such as:such as:

- its scope, its status as a large market for - its scope, its status as a large market for computer businesses, and its need for computer businesses, and its need for facilities for information storage and facilities for information storage and management;management;

- improvements in quality of care, and - improvements in quality of care, and expenditure control, in both the public and expenditure control, in both the public and private sectors. (WHO)private sectors. (WHO)

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EHR - Electronic Health RecordEHR - Electronic Health Record

• A general term describing computer-A general term describing computer-based patient record systems;based patient record systems;11

• Is basically a facility that retrieves Is basically a facility that retrieves patient data from a number of patient data from a number of information systems and presents the information systems and presents the data in a coherent way to the data in a coherent way to the authorised user;authorised user;22

1 - Coiera, E., (2003) Guide to health informatics. Arnold editions. Lisboa 2 - David W. Bates, MD et al. (Jan / Feb 2003) A Proposal for Electronic Medical Records in U.S. Primary Care. JAMIA.

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Impact of EHR:Impact of EHR:

- Since the beginning of electronic patient - Since the beginning of electronic patient registration, It have been improvements in registration, It have been improvements in the interfacing and fusion capabilities of a the interfacing and fusion capabilities of a large variety of computer and large variety of computer and telecommunication technologies; ( world telecommunication technologies; ( world health)health)

- It will become a major support tool in - It will become a major support tool in health care delivery. (van bemel)health care delivery. (van bemel)

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When compared to manual registration, the main When compared to manual registration, the main advantages of EHR are:advantages of EHR are:

-greater accuracy (1) and a higher proportion of correct -greater accuracy (1) and a higher proportion of correct information (2, 3);information (2, 3);

-time saved in locating information (-time saved in locating information (88); );

-more economical use of financial resources (12); -more economical use of financial resources (12);

-greater ease and speed of recovery of patient data -greater ease and speed of recovery of patient data ((1212).).

1- Hassey A, Gerrett D, Wilson A. A survey of validity and utility of electronic patient records in a general practice. BMJ 2001;322:1401-5. 2- Flygt C, Homelius B, Jacobsson B, Foldevi M, Trell E. Essential data set for computer management of distributed primary care services. Medical Informatics 1995;20:331-41. 3- Gaudet LA. Electronic referrals and data sharing: can it work for health care and social service providers? Journal of Case Management 1996;5:72-7. 4-Borowitz SM. Impact of a computerized patient tracking system in a pediatric clinic. International Journal of Proceedings: a Conference of the American Medical Informatics Association. AMIA Annual Fall Symposium Medical Informatics 1996. p. 508-11.5-Wager KA, Lee FW, White AW, Ward DM, Ornstein SM. Impact of an electronic medical record system on community-based primary care practices. Journal of the American Board of Family Practice 2000;13:338-48.

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Denmark’s Health Denmark’s Health SystemSystem In Denmark the private health care represents only In Denmark the private health care represents only

3% of all;3% of all;11

there are 30 OOH which permit access to GP's 24h a there are 30 OOH which permit access to GP's 24h a day, every day:day, every day:22

– 91% of the patients are treated within 1 or 2 91% of the patients are treated within 1 or 2 months;months;33

– 90% of GP's use EPR;90% of GP's use EPR;33

1 - Brown, J., Day, M., Jones, T., Miller, M., Westcott, Dean., Bailey, D., (2000) Healthcare in Denmark direction for the NHS Published by The certified Acountants Educational Trust on behalf of the Assotiation of Chartered Certified Accountants2 - http://www.bcma.org/public/news_publications/publications/policy_papers/ITPaper/GettingITRight_AppendixA.htm#TopOfPage#TopOfPage 3 - Danish Ministry of Health, (2001) Health Care in Denmark, (Ash J. S. et al)

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UK Health SystemUK Health System

Currently, 96% of English GP’s are connected Currently, 96% of English GP’s are connected by NHSnet - a system which connects by NHSnet - a system which connects doctors, hospitals and other NHS doctors, hospitals and other NHS institutions;institutions;11

15% of GP's run completely paperless 15% of GP's run completely paperless consultations;consultations;11

Development of lab-links which permit data Development of lab-links which permit data exchange between doctors and laboratories;exchange between doctors and laboratories;2 2

1- http://www.bcma.org/public/news_publications/publications/policy_papers/ITPaper/GettingITRight_AppendixA.htm#TopOfPage#TopOfPage2 - Majeed, Azeem. "Ten ways to improve information technology in the NHS", BMJ volume 326, 25 January 2003.

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Denmark and UK Denmark and UK

In both countries exists a significant In both countries exists a significant percentage of private investment in health percentage of private investment in health care, although in Denmark this value is care, although in Denmark this value is higher (17,8% in 1999);higher (17,8% in 1999);

There is a greater expenditure There is a greater expenditure per capitaper capita in in Denmark (1,679 121 Euro) than in U.K (1,079 Denmark (1,679 121 Euro) than in U.K (1,079 780 Euro);780 Euro);

Both countries spent 6% to 7% of their GDP Both countries spent 6% to 7% of their GDP on healthcare;on healthcare;

Brown, J., Day, M., Jones, T., Miller, M., Westcott, Dean., Bailey, D., (2000) Healthcare in Denmark direction for the NHS Published by The certified Acountants Educational Trust on behalf of the Assotiation of Chartered Certified Accountants

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– In Portugal there are 347 Health In Portugal there are 347 Health centers;centers;11

– In 2000, The World Health In 2000, The World Health organization published a report organization published a report about health systems where about health systems where Portugal has achieved the 12th Portugal has achieved the 12th place on global ranking, better than place on global ranking, better than U.K., Germany, Canada and USA;U.K., Germany, Canada and USA;22

1 – Instituto Nacional de Estatística

Portuguese Health Portuguese Health SystemSystem

2 - World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000.2 - World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000.

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However, some problems in Portugal Health System still However, some problems in Portugal Health System still remain;remain;11

– Portugal spent in Health as much as 9% of its low Portugal spent in Health as much as 9% of its low

gross domestic product;gross domestic product;22


1 - Correia, R., Almeida. F., Freitas, A., Costa-Pereira, (2002 ), A. Current State of Electronic Health Records 1 - Correia, R., Almeida. F., Freitas, A., Costa-Pereira, (2002 ), A. Current State of Electronic Health Records in Portugal, Biostatistics and medical informatics, Faculty of Medicine, Oporto University.in Portugal, Biostatistics and medical informatics, Faculty of Medicine, Oporto University.2 - OCDE Health Data 2003.2 - OCDE Health Data 2003.

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– The organizational primary care The organizational primary care infrastructures are outdated and new infrastructures are outdated and new reforms have not yet been implemented;reforms have not yet been implemented;1 1

– Health Centers organization has a lot of Health Centers organization has a lot of fragilities as well as the centralization of fragilities as well as the centralization of these health institutions;these health institutions;11


1 - Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. Portugal. The European Observatory on Health 1 - Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. Portugal. The European Observatory on Health Care Systems; Copenhagen 2003.Care Systems; Copenhagen 2003.

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– Low development in the use of the Low development in the use of the informatic technologies in 2002;informatic technologies in 2002;11

– No relevant data is available No relevant data is available to the public to the public about the present state of the use oabout the present state of the use off informatic technologies in primary care;informatic technologies in primary care;11

1 - Relatório da OCDE; HIT do Observatório Europeu.


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Resources are clearly poorly invested (lack of Resources are clearly poorly invested (lack of efficiency in using them);efficiency in using them);11

The way of financing is a constant subject of The way of financing is a constant subject of debate;debate;11

1 - Costa-Pereira, A., Escoval, A., Nunes, A., Vaz, A., Costa, C., Pinto, C., Pereira, J., Bentes, M., Mateus, M., Amaral, M., Giraldes, M., Gonçalves, M., Gouveia, M., Barros, P., (1997) Financiamento da Saúde em Portugal documento de trabalho 4/97 Associação Portuguesa de Economia de Saúde

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– SNSSNS:: Sistema Nacional de Saúde (NHS - Sistema Nacional de Saúde (NHS - National Health System);National Health System);

– Primary Health CarePrimary Health Care:: medical care medical care access on health centers; access on health centers;

– IGIFIGIF:: Instituto de Gestão Informática e Instituto de Gestão Informática e Financeira da Saúde (Informatic and financial Financeira da Saúde (Informatic and financial management Institute);management Institute);


http://www.igif.min-saude.pt/upload/igif/img/Enq-SAM-SAPE.pdf

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SONHO -SONHO - Sistema de Gestão de Doentes Sistema de Gestão de Doentes Hospitalares (Management system of hospital Hospitalares (Management system of hospital patients);patients);

SINUS - SINUS - Sistema de Informação para as Sistema de Informação para as Unidades de Saúde (Informatic system for Unidades de Saúde (Informatic system for Health units);Health units);

SAM -SAM - Sistema de Apoio ao Médico (Medical Sistema de Apoio ao Médico (Medical Support system);Support system);


http://www.igif.min-saude.pt/upload/igif/img/Enq-SAM-SAPE.pdf

2020

ObjectivesObjectives

1.1.stst - To estimate the informatic resources in - To estimate the informatic resources in Portuguese health centers;Portuguese health centers;

2.2.ndnd - To compare the results we will obtain with - To compare the results we will obtain with those from a previous research (2002);those from a previous research (2002);

3.3.rdrd - To analyze the evolution within this 3 year - To analyze the evolution within this 3 year period; period;

4.4.thth - To study the utility of the informatic - To study the utility of the informatic resources specially the electronic health records resources specially the electronic health records (EHR) in the primary care; (EHR) in the primary care;

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ObjectivesObjectives

5.5.thth – Evaluate the main barriers to the – Evaluate the main barriers to the implementation of efficient informatic implementation of efficient informatic infrastructures and define ways and strategies infrastructures and define ways and strategies to overcome them. to overcome them.

6.th6.th – Compare the actual state of the – Compare the actual state of the Portuguese informatic infrastructures with Portuguese informatic infrastructures with prestigious foreign ones.prestigious foreign ones.

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25 health centres:25 health centres:

– 25 out of 50 aleatorily chosen in 25 out of 50 aleatorily chosen in 2002.2002.

The inquiries will be made in two The inquiries will be made in two stages:stages:

– 11stst stage: telephonic inquest to the stage: telephonic inquest to the 25 H.C. directors;25 H.C. directors;

– 22ndnd stage: stage: fax fax inquests; inquests;

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– Informatic system implementation Informatic system implementation planning strategies:planning strategies:

Difficulties;Difficulties;

Possible ways to overcome them;Possible ways to overcome them;


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LimitationsLimitations

Lack of previous studies;Lack of previous studies;

Inerent problems to an unpersonal Inerent problems to an unpersonal questioner;questioner;

Difficulty in comparing the data Difficulty in comparing the data obtained in Portugal and the foreign obtained in Portugal and the foreign one;one;

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ResultsResults

HEALTH CENTERS 2006 2002

Nº. Patients per doctor 1991 1823

% Internet-linked computers 73 16

% of computers with access to RIS 65 40

% which use SINUS 100 94

% of computers using SINUS 64 73

% health centres that make appointments in other health institutions 28 31

% health centres using SAM 40 2

% of computers for clinical use 22 13

% positive answers on 9 criteria used relatively to the use of SAM 38 67

% of health centres that use paper records 96 98

Table 1 – Telephonic inquests results from 2006 and 2002 comparison

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ResultsResults

HEALTH CENTERS (N=25)MEDIAN

2006 2002

Inscribed Patients 10000 13000

Doctors 7 8

Computers 15 8

Computers with Internet connection 5 1

Computers with RIS connection 5

Computers that use SINUS 10

Computers with computerized patient records 0 0

Table 2 – Median of the results obtained on telephonic inquests and their comparison between 2002 and 2006

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ResultsResults

Main benefits to EHR implementation in Primary care

7%

21%

21%

21%

21%

29%

29%

29%

36%

36%

50%

64%

0% 10% 20% 30% 40% 50% 60% 70%

To contain or to reduce costs

To f ill the legal requirements or the assumed norms

To improve the clinical processes or the eff iciency of "w orkflow "

To improve the capture of clinical data

To support the physician decision

To establish an infrastructure more eff icient as a competitive advantage

To reduce medical errors

Medical staff satisfaction

Remote access to clinical registers

To improve the clinical documentation

To improve health cares

To share patient data betw een medical staff

Graphic 1 – Main benefits to EHR implementation in Primary Care

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ResultsResults

Graphic 2 – EHR use

EHR use for

0%

0%

21%

36%

57%

57%

0% 10% 20% 30% 40% 50% 60%

Pre-visit cares evaluation

After-visit patient support

Email betw een patients and physicians

Remote access to the EHR by physicians

Information on health conditions, illnesses, w elfare or new developments inhealth

Booking

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ResultsResults

Graphic 3 – Main barriers to CPR/EPR implementation in Primary Care

Main Barriers to CPR/EPR implementation in Primary Care

0%

0%

14%

14%

14%

21%

21%

29%

64%

0% 10% 20% 30% 40% 50% 60% 70%

Lack of structured medical terminologies

Inability to f ind EHR at affordable cost

Diff iculty in f inding an EHR not fragmented

Inadequate information standards, data or code sets

Diff iculty in evaluating EHR solutions available

Lack of medical staff support

Incapacity to f ind a EHR solution that f ills our functional necessities or techniques

Diff iculty on electronic data introduction

Lack of adequate funding

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ResultsResults

Main strategies to overcome EHR implementation barriers

0%

7%

7%

14%

14%

29%

36%

0% 5% 10% 15% 20% 25% 30% 35% 40%

To built a consensus to support a especif ic technical solution

To demonstrate the EHR costs/benefits

To become familiar w ith professional associations to improve the norms orconditions

To built a consensus around a strategy for the information systems

To request additional funds or resources

To Educate and to demonstrate the EHR capacities in the improvement of thehealth cares and clinical processes

To w ait until better solutions are available

Graphic 4 – Main strategies to overcome EHR implementation barriers

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ResultsResults

Main privacy and security concerns on EHR information

7%

7%

7%

14%

21%

36%

71%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Limited security functionalities

Inadequated norms of data locking

Breaking on policies and pratices in data access

Inappropriate access to information by authorized users in the exterior

Inappropriate access to information by authorized users inside theorganization

Inadequate data protection on the Web

Access to information by not authorized users inside the organization

Graphic 5 – Main privacy and security concerns on EHR information

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Low evolution registered since 2002 as the Low evolution registered since 2002 as the exception of internet connected computers exception of internet connected computers and in the use of SAMand in the use of SAM;;

We can not help notice that, even that the We can not help notice that, even that the number of health centres using EHR is number of health centres using EHR is growing, the percentage of establishments growing, the percentage of establishments running paperless has not decrease that running paperless has not decrease that much (only 2%)much (only 2%);;

3333


From the results we conclude that the patient From the results we conclude that the patient data sharing is definitively the major benefit data sharing is definitively the major benefit of the EHR implementation (64%)of the EHR implementation (64%);;

As well as in 2002 the main barrier to this As well as in 2002 the main barrier to this implementation is the lack of adequate implementation is the lack of adequate funding (64%)funding (64%);;

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As it concerns to the main strategies of the As it concerns to the main strategies of the health centres to overcome the barriers, the health centres to overcome the barriers, the most common answer is “to wait until better most common answer is “to wait until better solutions are available” (36%)solutions are available” (36%)

Also in the study, we noticed that the main Also in the study, we noticed that the main concern of the health centres functionaries is concern of the health centres functionaries is the access to the information by non the access to the information by non authorized users (71%)authorized users (71%)

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We should strive to have a national system of EHRs that can We should strive to have a national system of EHRs that can share information on any patient in any health care setting.share information on any patient in any health care setting.

From the point of view of the patient, he or she should be From the point of view of the patient, he or she should be able to enter any health care setting and see a clinician who able to enter any health care setting and see a clinician who has comprehensive access to information about that patient. has comprehensive access to information about that patient.

From the health care provider's perspective, this access From the health care provider's perspective, this access should be fast, the information should be easy to find, and should be fast, the information should be easy to find, and the process should help rather than hinder the workflow. the process should help rather than hinder the workflow.

Health care will be safer for the patient and more satisfying Health care will be safer for the patient and more satisfying for the clinician, who would now be able to provide far better for the clinician, who would now be able to provide far better care and feel more secure in his or her decision making. care and feel more secure in his or her decision making. (factors JAMIA)(factors JAMIA)

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KeyKey wordswords

Electronic Health Records;Electronic Health Records; Medical Informatics;Medical Informatics; Health Centers;Health Centers; Primary Health Care;Primary Health Care;

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