Parallel Session 1.5 Choosing and using standards for. Beatriz de Faria Leao, MD, PhD

Transcription

1 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 Brazil Introduction Current HIS challenges SDOs in Brazil Using the standards Summary 2

2 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 % 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 3 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 4

3 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 from 2009 on individualized records High Cost / High Complexity procedures MRIs, CT scans, dialyses, hemotherapy, Cardiac catheterization, stents, pacemakers 5 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 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 6

4 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) 7 HC Standards in use Content Patient ID and Profile ISO/TS 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 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 ti t dataset t Inpatient dataset High Cost / High Complexity procedures Archetypes 8

5 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 EHR for Minas Gerais State under a bidding process 9 HC Standards in use Security National PKI Infrastructure compatible with ISO Public Key Infrastructure-1 Framework and Overview ISO Public Key Infrastructure-2 Certificate Profile ISO Public Key Infrastructure-3 Policy Management of Certification Authority Information Security Management in Health using ISO/IEC ABNT NBR ISO/IEC 27002:

6 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 self declared process, free of charge on Internet From 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 11 HC Standards used in the software certification process HL7 EHR Functional Model ISO/BR TS Requirements for an electronic health record architecture ISO/BR TR Electronic health record Definition, scope and context ISO Health Care data types - (being translated to Portuguese) 12

7 Software Certification Quality Stamp 13 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 iti HL7 Brazil Founded 2007 Focus on Training ISO TC 215 Mirror Committee Founded Dec 2006 Brazilian TeleHealth Association 14

8 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 15 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 16

9 ABNT Health Informatics TC - Results Standards published ISO/ABNT TS Requirements for an electronic health record architecture ISO/ABNT TR Electronic health record - Definition, scope and context ISO/ABNT TR Health informatics - Health informatics profiling framework Standards being translated ISO/TS Identification of Subjects of Health Care extended ISO/TS Provider Identification ISO/TS Health Indicators ISO/TR Good principles p and practices for a clinical data warehouse (CDW) ISO/TS Deployment of a Clinical Data Warehouse ISO/ABNT Information Security Mgmt in Health using ISO/IEC 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 18

10 ISO TR ehealth Enterprise Architecture for 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. 19 Where the national standards are being used? Brazilian TeleHealth Strategy SIGA Saúde - São Paulo Health Information System Using Health Information 20

11 Brazilian TeleHealth Strategy Brazil Telehealth Program - remote assistance and permanent education Pilot Project: 9 states and 900 points Open University of the Brazilian Unified Health System - provides in-service training for thousands of health care providers Source:M PMAC, Macedo, Bangkok, Jan Telemedicine University Network - RUTE, initially connecting 57 University Hospitals in collaborative research and education across all federal states 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: PMAC, Ana Bangkok, Estela Haddad, Jan 2010Bellagio, August,

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13 SIGA Saúde São Paulo City Health Information System SIGA Saúde is São Paulo City Integrated 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 using free-software & open-code concepts. 25 Examples of Primary Care Units in São Paulo 26

14 SIGA Saúde - Dec ,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, authorizations ti of high h cost & complexity procedures / month 30% reduction in waiting time for specialized consultations & procedures Medication available at local pharmacies - supply chain control 15,000 people p trained on the system 27 SIGA s evaluation 28

15 SIGA evaluation 29 SIGA evaluation 30

16 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 31 Health Information Use, Dashboards & Indicators 32

17 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) 34

18 Final Remarks It is not enough to have an ehealth Policy document It is necessary to implement the policy Proper organizational i arrangements are critical i Continuity across governments Financing Training ABNT TC is pushing the use of IS in the country 35 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) 36

19 Come visit us in May!! Come visit us! ISO TC 215 Health Informatics Plenary M ti Meeting, M May HL7 Plenary Meeting, M May Windsor Barra Hotel, Rio de Janeiro Brazil Janeiro, Thank you! bfleao@gmail.com 37