Parallel Session1 5 Brazil Experience V3

Parallel Session 1.5 Choosing and using standards for interoperable information systems

Beatriz de Faria Leao, MD, PhD

Zilics eHealth

Convener WG8 Brazilian ISO TC 215 Mirror Committee (ABNT- CEE-IS)

Vice-Convener WG8 - ISO TC 215 Health Informatics

2PMAC, Bangkok, Jan 2010

Brazil

Introduction

Current HIS challenges

SDOs in Brazil

Using the standards

Summary


Some Facts about Brazil

6th Largest Economy in the World (2007) 190 million Inhabitants 5th Largest Country in the World, Larger than Continental

USA It is a Country of Huge Contrasts:

• some top quality institutions and • a very bad income distribution, though improving

67 M Internet users today, some 12 M with broadband access

18% of houses have Internet access e-Business:

• 5th largest market in e-business• U$15Bi in e-commerce in 2009

95% of IRS Tax Return Forms on the Web National Voting System is 100% Electronic

• More than 100 million voters• Recent national election results in less than 12 hours


SUS – The Brazilian National Health System

Universal Access Health is a Right of All (~ 150M individuals rely on SUS)

Full Coverage, Free of Charge All Services and Procedures

SUS principles: Equity Universality Integrality

Funding and Management are Shared Across Levels Federal, State and Municipal Levels

Private Health Plans for Those Willing to Pay ~ 1,400 HMOs (cover ~ 50M individuals) ANS (Agência Nacional de Saúde Suplementar) regulates

the sector


HIS in Brazil

Vertical systems (more than 30 years) Immunization Primary Care (Child and maternity care, family health

program, housing and socio-economical data) Chronic diseases Special Programs (TB, AIDS) Diseases of Mandatory Notification Inpatient national database Outpatient database

• aggregate data 1986 - 2008 • from 2009 on individualized records

High Cost / High Complexity procedures• MRIs, CT scans, dialyses, hemotherapy, Cardiac

catheterization, stents, pacemakers…


Health Information Systems in Brazil

Health Information Systems have been used in the Public Sector since the 1970s

A huge collection of Public Health data is available from the Department of Health, on www.datasus.gov.br

As in many other places, vertical applications were the focus, leading to literally more than 250 siloed systems, such as HIV, Prenatal and Child Care, TB, Diabetes and others

Lack of national standards started to be reverted by two major projects at the end of the XX Century:

• The National Health Card Project defined unique identifiers for individuals (including HC workers), and

• The National Registry of HC Organizations and HC workers registry defined unique identifiers and the relationships among workers, equipment and organizations

http://www.datasus.gov.br/


HC Standards in Use

Currently in use Diagnosis: ICD-10 Procedures: Brazilian CPT Codes private X public Medication: several different vocabularies with billing

purposes

Recent developments ATC-Based Medication Codes Brazilian FDA agency (ANVISA) GMDN (being translated now) LOINC (translation and mapping Brazilian public CPT codes) TUSS - Unified Terminology for HC (Brazilian Supplementary

Health Agency) - mapping private and public procedures codes

Under consideration:• IHTSDO • dm+d (NHS Dictionary of Medicines and Devices)


HC Standards in use

Content Patient ID and Profile

• ISO/TS 22220 - Identification of Subjects of Health Care extended (ABNT standard- public consultation from Feb 2010)

HC Professional ID and Profile and HC Providers Registry• Extends ISO/TS 27527 - Provider Identification (ABNT)

Surveillance, Notification and Investigation Forms• 42 diagnoses

Primary Care and Family Health Program• Household conditions• Child and Maternity Health• Immunization• Specific diseases follow-up (diabetes, hypertension,

hypertension) Outpatient dataset Inpatient dataset High Cost / High Complexity procedures Archetypes


HC Standards in use

Interoperability XML for Messaging with External Systems

HL7 v3.0 (CDA R2) + LOINC for Clinical Lab Integration in Sao Paulo City

TISS - supplementary health billing, authorization and eligibility (XML and webservices between HC providers and payers)

• CDA R 2 now being considered for adding clinical content in supplementary health

13606 - EHR for Minas Gerais State – under a bidding process


HC Standards in use

Security National PKI Infrastructure compatible with

• ISO 17090-1 - Public Key Infrastructure-1 Framework and Overview

• ISO 17090-2 - Public Key Infrastructure-2 Certificate Profile

• ISO 17090-3 - Public Key Infrastructure-3 Policy Management of Certification Authority

Information Security Management in Health using ISO/IEC 27002 - ABNT NBR ISO/IEC 27002:2005


HC Standards in use

Software Certification for EHR systems

• A joint initiative of the Brazilian Federal Medical Council and SBIS - the Brazilian Health Informatics Association

• From 2004 - 2008 - self declared process, free of charge on Internet

• From 2009 - systems are audited and receive a Quality Stamp, according to profiles

Current profiles being assessed for certification:

• Outpatient, TISS Two software products received the Quality Stamp, so far Six products are currently being audited


HC Standards used in the software certification process

HL7 EHR Functional Model ISO/BR TS 18308 - Requirements for an electronic health

record architecture ISO/BR TR 20514 - Electronic health record Definition,

scope and context ISO 21090 Health Care data types - (being translated to

Portuguese)


Software Certification Quality Stamp


Health Informatics and SDOs in Brazil

SBIS - Brazilian Health Informatics Association Founded in 1986 National Conferences every two years Standards and Certification WG About 900 members Focus on academic and professional activities

HL7 Brazil Founded 2007 Focus on Training

ISO TC 215 Mirror Committee Founded Dec 2006

Brazilian TeleHealth Association


Brazil ISO TC 215 Health Informatics Mirror Committee

ABNT Created in September 1940 Represents Brazil in International SDOs Some 120 Technical Committees and growing

TC-Health Informatics Created in November 2006 An initiative of Ministry of Health and Santa Catarina

Federal University Initial Focus on TeleHealth Attracted people from the 20-year-old Brazilian Health

Informatics Society Became formally a Mirror Committee in March 2007 Some 100 people working at varied levels of effort and

commitment Relies 100% on Volunteers


How ABNT - Health Informatics TC Works

Resources Collaboration Tool: Livelink (ABNT/ISO)

• Livelink has been chosen as the formal and official communication tool

• Our use of Livelink set up a new paradigm for ABNT Web-conferencing, for daily work*

• Proven to be very effective Video-conferencing joining 8 cities, for monthly Plenary

Sessions**• Video-Conferencing was a major innovation at ABNT

– * Unifesp – São Paulo Federal University– ** RNP – National Research Network– ** Datasus – National Department of Health IT Division– ** RUTE - Brazilian TeleHealth University Network


ABNT Health Informatics TC - Results

Standards published ISO/ABNT TS 18308 - Requirements for an electronic

health record architecture ISO/ABNT TR 20514 - Electronic health record - Definition,

scope and context ISO/ABNT TR 17119 - Health informatics - Health

informatics profiling framework

Standards being translated ISO/TS 22220 - Identification of Subjects of Health Care

extended ISO/TS 27527 - Provider Identification ISO/TS 21667 - Health Indicators ISO/TR 22221 - Good principles and practices for a clinical

data warehouse (CDW) ISO/TS 29585 - Deployment of a Clinical Data Warehouse ISO/ABNT 27799 - Information Security Mgmt in Health

using ISO/IEC 27002


ABNT Health Informatics TC Results (cont)

1st Brazilian Symposium on Health Informatics Standards (July, 2008)

• Some 200 participants, 3 international speakers• Very successful in raising issues and increasing awareness

of the process• Help raised funds for taking more delegates to Istanbul

NWIP co-led by Brazil• WG4 – EHR Systems Certification Process (France + Brazil

leadership)• WG8 – Business Requirements for an integrated eHealth

enterprise architecture for emerging and developing countries (WHO and Brazil leadership)

Next ISO TC 215 Plenary meeting is in Rio May 9 - 13

Importance to Brazil Contribute to creating standards that will be useful to us Learning-teaching experience Contribute to harmonizing standards


ISO TR 14639 - eHealth Enterprise Architecturefor Emerging and Developing Countries: TR Structure

Part 1: Environmental Scan

Current international initiatives in the area of eHealth systems.

Part 2: Business Requirements

Framework for identifying business requirements that define an eHealth enterprise architecture in economically-constrained countries.


Where the national standards are being used?

Brazilian TeleHealth Strategy

SIGA Saúde - São Paulo Health Information System

Using Health Information


Brazilian TeleHealth Strategy

Brazil Telehealth Program - remote assistance and permanent educationPilot Project: 9 states and 900 pointswww.telessaudebrasil.org.br

Open University of the Brazilian Unified Health System - provides in-service training for thousands of health care providerswww.universidadeabertadosus.org.br

Telemedicine University Network - RUTE, initially connecting 57 University Hospitals in collaborative research and education across all federal states - www.rute.rnp.br

Source:M Macedo, Jan2010

http://www.telessaudebrasil.org.br/

http://www.universidadeabertadosus.org.br/

http://www.rute.rnp.br/


TeleHealth National Project

Supports about 3000 Health Family Teams, covering 11M people

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)

Source: Ana Estela Haddad, Bellagio, August, 2008


SIGA Saúde – São Paulo City Health Information System

SIGA Saúde is São Paulo CityIntegrated and Distributed System for Managing the Public Healthcare System.

Its history began in 2003/2004 when it was conceived and development started.

The system belongs to São Paulo City and given to other cities in Brazil

SIGA Saúde has been developed usingfree-software & open-code concepts.


Examples of Primary Care Units in São Paulo


SIGA Saúde - Dec 2010

14,500,000 registered users

1,200,000 primary care appointments scheduled / month

200,000 specialized care consultations scheduled / month

2,200,000 medical prescriptions attended over the counter

/ month

40,000 authorizations of high cost & complexity

procedures / month

30% reduction in waiting time for specialized consultations

& procedures

Medication available at local pharmacies - supply chain

control

15,000 people trained on the system


SIGA’s evaluation

http://vitalwaveresearch.com/healthit/





SIGA evaluation






Health Information for better health

Brazilian Health Indicators Set of demographic, socio-economic, morbidity and risks

factors, mortality, HC resources, HC coverage

Primary Care Pact Indicators Child Care Maternity and Woman Health Hypertension, Diabetes, TB, Hansen’s disease Oral Health Family Health Program coverage

All data is available on Internet Queries online back to the seventies


Health Information Use, Dashboards & Indicators

www.datasus.gov.br








Brazil HIS Challenges

Interoperability with local (state/municipal level) systems needs improvement

Locally defined interfaces - txt based for the national unique identifiers for persons

Web services for the national HC providers /professionals • Locally defined WSDL • Under tests with SIGA Saúde - São Paulo City health

System

Terminologies Lack of proper clinical vocabularies -> payment approach Translation and maintenance of clinical vocabularies

• LOINC (two years and is not ready)


Final Remarks

It is not enough to have an eHealth Policy document

It is necessary to implement the policy Proper organizational arrangements are critical Continuity across governments Financing Training

ABNT TC is pushing the use of IS in the country


Summary

An existing and active Brazilian Health Informatics Society has been crucial to ABNT-PC-HI success;

All work has been 100% voluntary, resources are required for hiring technical and administrative staff;

Developing and emerging countries should be part of the ISO TC 215 SDO

Standards themselves should be made freely available under some circumstances to promote their use;

SDO harmonization is vital to reduce redundancy; South to South collaboration! Organizations such as WHO (in our field) can play a role in adhering

themselves to standards and inducing governments to do so by:

• Providing training on HI standards

• Promoting free access to key standards

• Comissioning roadmaps and tools that implement standards (software components -> strengthening of the local expertise)


Come visit us !ISO TC 215 Health Informatics Plenary Meeting, May 9 -13

HL7 Plenary Meeting, May 14 - 22

Windsor Barra Hotel, Rio de Janeiro, Brazil

Thank you! [email protected]

Come visit us in May!!

Parallel Session1 5 Brazil Experience V3

Health & Medicine

Transcript of Parallel Session1 5 Brazil Experience V3