Building the National EHR Strategy

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1 Building the National EHR Strategy SUS: Brazilian Unified Health System Prof. Ricardo Staciarini Puttini, PhD University of Brasilia/Ministry of Health BRAZIL Aug-2015, HIC 2015, Brisbane

2 Inspired after Helen Bevan presentation on HIC 2015

3 A dream dreamed alone is just a dream. A dream dreamed together is reality. Raul Seixas (Brazilian Song Writer and Poet)

4 Cartoon adapted from: About me...

5 As a researcher at University of Brasilia I ve been working with distributed information systems About me... As a scientist consultant to MoH I ve been searching for interoperability architectures for Healthcare Information Systems

6 The Dream Brazilian ehealth Vision ( ) 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

7 The Laboratory 5 th largest country (7,682,300 km 2 ) 5 th largest population (193 million)(2011) 6 th largest economy (GDP 2.5 trillion USD)(2011) Young democracy (Constitution from 1988) Political stability

8 The Laboratory National Federation 5 Geographical Regions 26 States + DF 5,565 Municipalities

9 The Laboratory Brazilian Unified Health System: Integral health care for all citizens Regionalized, Decentralized, and Federated Governance at 3 levels: National State Municipal

10 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). The Laboratory Brazilian Unified Health System 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) , , , , , , , , ,79 PIB per capita, PPC (1) , , , , , , , ,89 Despesas per capita de saúde (dólar corrente, US$) 5.629, , , , , ,65 891, ,56 278,02 Despesa per capita em saúde, PPC (const internacional $) (1) 4.519, , , , , , , ,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 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

11 The Laboratory Brazilian Unified Health System

12 National EHR Strategy As part of a (major) ehealth Strategy Directions: 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)

13 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.

14 esus Family Specialized Care esus Hospitalar Specialized Care esus Ambulatorial Prymary Care esus AB Urgency and Emergency esus SAMU e esus UPA Citizen s Portal & Mobile App Third Party Solutions Applications based on EHR API National EHR Strategy National Health Card and EHR Strategy E-Health Applications Governance Adoption and DIssemination Citizens Regulatory Framework Healthcare Professional Providers Vendors Innovation Foundation: Infostructure Service Bus (Interoperability) E-Health Vision Training & Education National Health Card System National EHR Clinical Knowledge and Terminology Services Security and Privacy Services Decision Support Systems (secondary use) Foudation: Infrastructure Resilient Computing (Central Systems) Conectivity Technical Enterprise Architecture Local Infrastructure Technical Architecture Governance Adapted from ISO TR 14639

15 Evolving EHR: Business Case (Information Model) Architecture and Governance (Maturity Model) Applications (esus-*, Citizen s Portal, third party) National EHR Project Business Case (Information Models) Each EHR Implementation Phase evolves all Dimensions Phase 1 Phase 2 Phase 3 Applications Architecture and Governance (EHR Functionality)

16 EHR Phase 1 (Rolling Out) National EHR Project 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)

17 Business Case Driven The Business Case Approach 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)

18 The Business Case Approach Clinical Information Modeling Source: Ocean Informatics

19 The Business Case Approach Clinical Information Modeling OpenEHR Clinical Ontology Knowledge Artifacts o o o Source: T. Beale & S. Heard (OpenEHR Foundation) Templates Archetypes Terminologies

20 The Business Case Approach Clinical Information Modeling Source: CENTERMS

21 EHR Technical Architecture Adopted Standards for Interoperability (Ministerial Act / 2011) Clinical Content: OpenEHR Document Registry & XDS.b Repository Patient Identifier: IHE PIXv3 PDQv3 Terminologies: Lab Coding: Clinical terms: SNOMED Image coding: DICOM Primary Care: ICPC-2 Brazilian standards for clinical procedures LOINC (Logical Obs. Identifiers, Names and Code)

22 EHR Technical Architecture Source: Oracle

23 Achievements ( ) 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) 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)

24 EHR Project ( ) 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 Basic EHR Semantic Framework Basic Decision Support Knowledge Governance Enhanced Decision Support Phase 1 Phase 2 Phase

25 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

26 Thank You! Prof. Ricardo Staciarini Puttini, PhD University of Brasilia/Ministry of Health BRAZIL Aug-2015, HIC 2015, Brisbane

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