11th International HL7 Interoperability Conference - IHIC2010 May 14 - 15, 2010 – Windsor Barra Hotel Rio de Janeiro, RJ, Brasil

Electronic Health Record Initiatives in South America Beatriz de Faria Leão, MD, PhD Health Standards Architect HL7 Brazil - Co-Chair Advisory Council ABNT Health Informatics Committee WG8 Convener ISO TC 215 WG8 Vice-Convener

Agenda • Introduction • EHR experiences – Uruguay – Argentina – Brazil

• Final Remarks

Thanks to all that contributed for this presentation: • Alvaro Margolis – President of IMIA-LAC, Uruguay • Ana Estela Haddad – Ministry of Health, Brazil

• Claudio Giulliano A. da Costa – SBIS President, Brazil • Diego Kaminker – Chair, HL7 Argentina • Fernán G. B. de Quirós – Hospital Italiano, Argentina • Julio Carrau – Chair, HL7 Uruguay • Jussara Macedo – Ministry of Health, Brazil • Lincoln A. Moura Jr – IMIA Treasurer, Brazil • Marivan Santiago Abrahão – Chair, HL7 Brazil • Sergio A. König – Chair, HL7 Chile

Uruguay National eHealth Policy Basic Data (2009 Estimate) • GDP U$ 32 Billion • Per capita U$ 12,800 • 3.5 million people

Uruguay eHealth Policy • Sept 30th, 2003 – Federal Government issued the bill 396/003, on the EHR for all citizens, mandating the use of international standards, such as HL7 and DICOM; • March 2006 – the elected Government, presents to the parliament the project of the National Integrated Health System (Sistema Nacional Integrado de Salud) by which sharing of information among all HC providers is mandatory, from 2007 on.

Priorities for the Sistema Nacional Integrado de Salud • Health care delivery • Promotion and prevention • Management and administrative health information systems • EHR with emphasis on primary care data • Interoperability • Standards

SUEIIDISS Sociedad Uruguaya de Estandarización, Intercambio e Integración de Datos e Información de Servicios de Salud • Founded in November 2005 • HL7 affiliate (country 26) • 46 Members • Mission: to promote, develop, and provide training and capacity building on interoperability standards to share health information for patient care and health care management with all HC actors • Focus on HL7 v3, CDA and IHE

www.sueiidiss.org

Uruguay / SUEIIDIS Interoperability Standards in use • IHE profiles: – Security digital certificates based on national PKI infrastructure

• Consistent Time service provided by SUEIIDIS • CDA (HL7v3) for document sharing • Uruguay National Identification Standards – SUEIIDISS-UY-ESP-001:STID

• OIDs for object identification – Common WSDL defined and shared among all participants

Results • Vital Statistics Systems • Maternal and Child Health Program • Perinatal Information System • Aduana Program: child follow-up till 2 years old • Electronic Death Certificate (CD-e) • EHR

FEMI Salud Digital Líneas de acción Especificaciones: Funcional – Interoperabilidad Especificación Construcción

Implantación

Alineación – Estándares – HL7 Vocabularios de Referencia Coordinación con el resto de los actores del Sistema Uruguayo de Salud Cambio Cultural Formación: Médicos – Enfermería – Informáticos - Administradores Prototipos de funcionalidad federal Prototipos de Telemedicina Infraestructura Redes

Dimensionamiento Hoy

eHealth Standards in Argentina Basic Data (2009 Estimate) • GDP U$ 305 Billion • Per capita U$ 13,800 • 41 million people

HL7 Argentina • Founded on December 5th, 2001 • 28 members (9 of them individuals) • HL7 is not a national standard, but several developments involve the use of HL7 standards for eclaims and interdepartmental interoperability – mainly using HL7 V2.x and CDA R2

• Focus on training and dissemination of HL7 standards • Virtual learning platform: – 1,500 people trained since 2001, from different countries in LA for the Spanish version – 200 international students for the English version

http://campus.hl7.org.ar/

eHealth in Brazil Basic Data (2009 Estimate) • GDP U$ 1.5 Trillion • Per capita U$ 10,200 • 198 million people

Brazil – Geo-political Perspective • The largest country in Latin America • The only Portuguesespeaking country in LA • The 5th most populated country in the world • The 3rd country in number of Internet hosts in America

SUS – The Brazilian Health System • Universal Access – Health is a Right of All (~ 150M individuals)

• Full Coverage, Free of Charge – All Services and Procedures

• SUS principles: – Equity – Universality – Integrality

• Funding and Management are Shared – Federal, State and Municipal Levels

• Suplementary Health for Those Wiling to Pay – ~ 1,600 HMOs (~ 49 M individuals) – ANS (Agência Nacional de Saúde Suplementar) Regulates the Sector

The Brazilian Healthcare Market • Extremely Fragmented Market: ~ U$ 90 Bi/year – SUS is the major Payer: ~ 66% in volume and some 50% in $ – 198M inhabitants, spread over 5.500 cities – Around 7,000 Hospitals and 1,400 Health Plan Operators – 70% of Hospitals have less than 80 beds – Estimate that only 10% of Hospitals have Information Systems – 90% HPOs cover less than 50,000 lives each – Only 3% of HMOs cover more than 200,000 each – There is no important network of Health Organizations – It’s a “Market of the Discontent”

Healthcare Challenges in Brazil • Increasing demand for health care (aging, emerging of new diseases, re-emerging of considered overcome diseases); • Skyrocketing healthcare costs (Health Technology); • Inefficient, paper-base uncoordinated systems, multiple formularies, poor resource allocation; • Siloed systems - one for each health program; • Lack of adequate information to support decision making, quality of care evaluation and to monitor disease management programs; • Few common health and healthcare information standards within the sector.

Brazilian HC National Standards • Unique HC Identifiers – Individuals (170 Million) – HC providers (215 Thousand) – Health Workers (1.5 Million)

• Content and Vocabularies – – – – – – – – –

Essential Encounter Dataset Diagnostics (ICD-10), Procedures Immunization Charts Birth and Death National Registries (> 50 years) Notifiable Diseases ( Work related, external causes and communicable diseases) Hospital Discharge Summaries High Complexity Utilization Reports LOINC IHSTDO (under consideration)

Brazilian HC National Standards: National Unique Identifiers: • Individuals (170 million people uniquely identified) • Healthcare providers (181.903 uniquely identified) – Includes information on: – Medical specialties, number of beds, equipments, private and public distribution, complexity level, – Health professionals (physicians, nurses and administrative personnel) – 1.5 million healthcare professionals uniquely identified

Brazilian HC National Standards • Interoperability – TISS – Private Health Information Exchange – Lab Integration (LOINC + HL7 Brazil)

• Security – National PKI infrastructure

• Software Certification – Brazilian Health Informatics Society + Federal Medical Council (www.sbis.org.br/certificacao) • 4 products certified • 3 products under auditing • 120 people trained

TeleHealth National Project • 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

TeleHealth National Project

Coverage: Nine State Clusters implementing Telehealth in 900 health units supporting about 2,700 Health Family teams, covering 11,000,000 inhabitants.

Private Healthcare Insurance Market 1,400 active Health Plan Organizations

600,000 estimated Healthcare providers

49.3 million beneficiaries Selfregulation HPOS

ANS State Regulation

Sources; www.ans.gov.br Set 2008

TISS - the Brazilian standard for HPOs and HC providers communication NSHA DATABASE

(enroll/disenrollments , services utilization, health care indicators)

HMOS

NHS

TISS - XML

Demographics, Vital Statistics, Discharge Summary, Notifiable Diseases

Healthcare providers

Source: Jussara Macedo, ANS, 2007

TISS - Standards • Information structure: billing forms – – – –

Consultation Hospital Discharge Lab, Medical Images Authorization for High Cost and High Complexity Procedures

• Core Health Terminologies and Code Sets (e.g ICD10) • Messaging: XML schemas and Web services • Privacy: ISO/NBR 17799 and SBIS/CFM Software Certification • Mandatory from May 2007 on

Source: Jussara Macedo, ANS, 2007

TISS Transactions PROVIDERS

Eligibility and prior Authorization Claim Generation Service Billing

Claim Status Inquiries Accounts Receivable

HPOS Health care Services Delivery

Pre certification and Adjudication

Claims

Claims Acceptation

Patient Info Claim Status Inquiry Claim Status Response

Claim Payment

Adjudication

Accounts Payable

Source: Jussara Macedo, ANS, 2007

www.hl7brazil.org

HL7 Brazil Actions • Harmonize National Standards with HL7 • Training Programs • Working Groups – CDA, LOINC, Snomed, Support

• Membership – Individual - 10 – Corporate - 15 • Intersystems, Zilics, Microsoft, • Intel, ANS, Serasa

Hl7 Brazil Activities • Februarr/2007 – creation of Institute HL7 Brazil • Courses – October 2007 – I Basic Course of HL7 - with John Ritter - 70 persons - São Paulo – April 2008 – HL7 - VERSION 3.0 - with Mead Walker - 40 persons, São Paulo

• Meetings – October 2007 – Open Forum HL7 Intel – with Ed. Hammond São Paulo – October 2007 – 1er Congreso Iberoamericano de Informática Médica Normalizada, Montevideo, Uruguay – April 2008 – Open Forum HL7 – IT-Mídia - with Mead WalkerSão Paulo

SIGA Saúde

São Paulo City’s Health Information System Lab Integration

São Paulo City HIMS São Paulo is the largest city in South America, with 12M inhabitants and some 22M in the Metropolitan Area. Current Figures: 

400 Primary Care Units +  300 Health Units  15M Users  8.5M Emergency T/year  550k Inpatients/year  11M Primary Care C/year  70k Scheduling requests processed daily  40k authorization requests processed monthly

SIGA Saúde IT Model Management SMS-SP

(Surveillance, Auditing and Billing) Dept of Health

Internet

Patient Flow Organization & Mngmnt (Specialties, Beds, Exams)

Electronic Health Record SP City Datacenter

Access Control

SIGA Saúde Figures for May, 2008 • • • •

14,301,383 registered users 1,017,463 primary care scheduling / month 189,393 specialized care consultations / month 1,738,807 medical prescriptions attended over the counter / month • 35,000 authorizations of high cost & complexity procedures / month • 30% reduction in the waiting time for specialized consultations & procedures • Medication available at local pharmacies - supply chain control

SIGA Saúde Lab Integration • 32 millions exams in 2009 (2.6M / month) – About 300 different labs exams without previous authorization – Others need prior authorization

• Manual process: transcription errors, duplication of exams, bad resource allocation • Ordering HC providers – 403 Primary care Units – 100 Emergency and Specialized Units – 15 Hospitals

• Executing Labs – Private Labs (3) + Public Labs (6)

SIGA Saúde Lab Integration Lab Orders LAB 1

LAB 2

LAB N

LAB 3

XML SIGA Web Service: LAB

XML Sample Collection

Lab Order

Authorization

UBS

AE

AMAS

Hospital

Emergency

SIGA Saúde Lab Integration Lab Results LAB 1

LAB 2

LAB 3

LAB N XML

SIGA Web Service: SIGA

XML Lab Results (Common, Micro, Pathology) - CDA in Phase 1

UBS

AE

AMAS

Hospital

Emergency

Standards used for SIGA’s Lab Integration • Identification: – Patient’s – National Health Card Number – HC provider and HC worker - National Registry (CNES)

• Messages: – TISS: XML schemas (simpleTypes, complexTypes, Messages, WSDL) – HL7 v3 - Lab orders and results information content (translated tags) – HL7 v3 pan-Canadian Messaging Standards

• Vocabulary: – LOINC - Logical Observation Identifiers Names and Codes

References HL7 CDA R2 Normative Edition 2005 ISO-639-1 –Identificadores de Idiomas ISO 3166 – Identificadores de Países ANVISA – RDC 302 Pan Canadian Lab Messages IHE – Integrating the Healthcare Enterprise – Laboratory Technical Framework - Volume 3

OIDs defined OID

Descrição

2.16.840.1.113883.1.3

Identificador únivoco do CDA R2

1.3.6.1.4.1.19376.1.3.3

Identificador únivoco do template CDA para laboratórios clínicos

2.16.840.1.113883.13.36

CNES

2.16.840.1.113883.6.1

LOINC

2.16.840.1.113883.5.25

Confidentiality code - Vocabulário HL7

2.16.840.1.113883.13.37

CNS

2.16.840.1.113883.5.1

Administrative Gender – Vocabulário HL7

2.16.840.1.113883.2.21.20

Conselho Federal de Medicina

2.16.840.1.113883.2.21.21

Conselho Federal de Farmácia

2.16.840.1.113883.13.69

Conselho Federal de Biologia

2.16.840.1.113883.13.70

Conselho Federal de BioMedicina

1.3.6.1.4.1.19376.1.3.1.1"

Identificador únivoco do template IHE para laboratórios clínicos

Lab Report CDA Structure • Header

CDA entry Elemento entry para exames isolados …/section/entry/observation …/section/entry/observation/id …entry/observation/code/statusCode …entry/observation/code/effectiveTime …entry/observation/code/value …entry/observation/interpretationCode ...entry/observation/methodCode ...entry/observation/referenceRange/observationRange ...entry/observation/referenceRange/observationRange/value ...entry/observation/referenceRange/observationRange/low ...entry/observation/referenceRange/observationRange/high ....entry/observation//referenceRange/precondition ...entry/observation//referenceRange/precondition/criterion

Results • 250 lab exams were translated and mapped to the Brazilian Procedures • OIDs defined (Brazilian unique identifiers) • Implementation Guide for CDA R2 Lab Results for the integration with Lab systems to SIGA Saúde • Project deployed in one region of the city and under evaluation

Lessons learned • LOINC translation and mapping took longer than planned; • The Implementation Guide was a key success factor for CDA implementation; • Training developers.

Conclusions for Latin-America • Increase in use of EHR systems, concepts and legislation; • Increase in use of HL7 and standards in general; • Need to have more LA countries in ISO TC 215; • Increase in collaboration among LA countries; • Uruguay has a strong government policy foundation; • Argentina has a great experience in eHealth capacity builnding; • IMIA-LAC has played a major role in attracting countries to join the International Community and adopt best practices.