current state of informatic infrastructures in portuguese health centers and its evolution since...

Current state of informatic Current state of informatic infrastructures in Portuguese health infrastructures in Portuguese health centers and its evolution since 2002centers and its evolution since 2002

Faculdade de Medicina da Universidade do Porto

Introdução à Medicina

May 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

22

ContentsContents

IntroductionIntroduction

Material and MethodsMaterial and Methods

ResultsResults

DiscussionDiscussion

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Medical informatics Medical informatics [1][1]

The field of information science concerned withThe field of information science concerned with::

- the analysis and dissemination of medical data;- the analysis and dissemination of medical data;

- through the application of computers;- through the application of computers;

-application on various aspects of health care and -application on various aspects of health care and medicine.medicine.

1 Enrico Coiera. Recent Advances: Medical informatics. BMJ 1995;310:1381-1387

44


• It deals with the resources, devices and It deals with the resources, devices and methods required to optimaze: methods required to optimaze: [2-3][2-3]

- Acquisition;- Acquisition;

- Storage;- Storage;

- Retrieval;- Retrieval; - Use of information in health and biomedicine.- Use of information in health and biomedicine.

2 Coiera, E., Guide to health informatics. Arnold editions. 2003; chapter 3: 32-403 Degoulet P, Fieschi M. Introduction of clinical informatics. Springer. 1997; chapter 6: 81-90

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• Health informatics tools include: Health informatics tools include: [4-5][4-5] - computers; - computers; - clinical guidelines;- clinical guidelines; - formal medical terminologies;- formal medical terminologies;

- information and communication - information and communication systems;systems;

4 Dick R et all. The computer based patient record. Nat academy press 1997; chapter 2: 74-1005 Wyatt J. Clinical data systems, part 2: components and techniques. Lancet 1994; 344: 1609-12

66


Medical informatics aims to improve Medical informatics aims to improve care given to patients by improving care given to patients by improving (within others) the: (within others) the: [2][2]

- - Accuracy; Accuracy;

- Speed;- Speed;

- Reliability of clinical information flow.- Reliability of clinical information flow.

2 Coiera, E., Guide to health informatics. Arnold editions. 2003; chapter 3: 32-40

77


Importance of medical informatics in primary Importance of medical informatics in primary care care [6-8][6-8]

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

6 Tomasi E et al. Health information technology in primary health care in developing countries: a literature review. Bull World Health Organ. 2004; 82: 867-747 De Lusignan S, Lakhani M, Chan T. The role of informatics in continuing professional development and quality improvement in primary care. J Postgrad Med 2003;49:163-5 8 De Lusignan S. et al. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309

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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: [6-8][6-8]

- its status; - its status;

- its need for facilities for information storage and - its need for facilities for information storage and management;management;

- its need for improvements in quality of care, and - its need for improvements in quality of care, and expenditure controlexpenditure control

6 Tomasi E et al. Health information technology in primary health care in developing countries: a literature review. Bull World Health Organ. 2004; 82: 867-747 De Lusignan S, Lakhani M, Chan T. The role of informatics in continuing professional development and quality improvement in primary care. J Postgrad Med 2003;49:163-5 8 De Lusignan S. et al. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309

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EHR - Electronic Health Record EHR - Electronic Health Record

A general term describing computer-based patient A general term describing computer-based patient record systemsrecord systems[10][10];;

• Is basically a facility that:Is basically a facility that:

- retrieves patient data from a number of information - retrieves patient data from a number of information systems;systems;[11][11]

- presents the data in a coherent way to the - presents the data in a coherent way to the authorised userauthorised user[11-12][11-12];;

10 Coiera, E.. Guide to health informatics. Arnold editions. 2003; chapter 5: 58-7411 David W. et al. A Proposal for Electronic Medical Records in U.S. Primary Care. JAMIA 2003; 12 Tamblyn R et al. The development and evaluation of an integrated electronic prescribing and drug management system for primary care. JAMIA 2006; 13: 148-59

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IntroductionIntroduction When compared to manual registration, the main When compared to manual registration, the main

advantages of EHR for health centers (as for the other advantages of EHR for health centers (as for the other sectors of health care) are:sectors of health care) are:

-greater accuracy -greater accuracy [13][13] and a higher proportion of correct and a higher proportion of correct information information [14, 15][14, 15];;

-time saved in locating information -time saved in locating information [16][16]; ;

-more economical use of financial resources -more economical use of financial resources [17][17];;

-greater ease and speed of recovery of patient data -greater ease and speed of recovery of patient data [17][17]..

13 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. 14 Flygt C et al. Essential data set for computer management of distributed primary care services. Medical Informatics 1995;20:331-41. 15 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. 16 Borowitz SM. Impact of a computerized patient tracking system in a pediatric clinic. Intern J. of Proceedings: a Conference of the American Medical Informatics Association. AMIA Annual Fall Symposium Medical Informatics 1996. p. 508-11.17 Wager KA et al. Impact of an electronic medical record system on community-based primary care practices. Journal AmerBoard of Family Practice 2000;13:338-48.

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The factors shown to be important for success of EHR adoption are [18][18]

1. Environmental;

2. Organizational;

3. Personal;

4. Technical.

18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12

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EnvironmentalEnvironmental -Environmental factors concern mainly financial and -Environmental factors concern mainly financial and

safety issues:safety issues:

- On the financial side, both health centers and - On the financial side, both health centers and health care providers are struggling because the health care providers are struggling because the financial managent is not being made by their own.financial managent is not being made by their own.

- Information technology has been touted widely - Information technology has been touted widely

as a tool that can improve the quality and safety of as a tool that can improve the quality and safety of patient care. patient care.


1313


PersonalPersonal

clinicians of health centers may be reluctant to adopt clinicians of health centers may be reluctant to adopt new ways of manage health information that interfere new ways of manage health information that interfere with their workflow; with their workflow;

Overall, when clinicians have access to larger amounts Overall, when clinicians have access to larger amounts of information with which to make decisions, and when of information with which to make decisions, and when the system fits their workflow, they tend to use it. the system fits their workflow, they tend to use it.


1414


OrganizationalOrganizational

The organizational culture must be ready to support The organizational culture must be ready to support adoption by the individuals within it;adoption by the individuals within it;

clinicians have / have not experienced a sense of clinicians have / have not experienced a sense of collaboration and trust between them and hospital collaboration and trust between them and hospital administration;administration;

if clinicians believe the administration wants to force them if clinicians believe the administration wants to force them to use EHR, for example, they may dig in their heels;to use EHR, for example, they may dig in their heels;

They may be more resistant to arguments based on safety They may be more resistant to arguments based on safety and patient care benefit if the level of trust is not there.and patient care benefit if the level of trust is not there.


1515


On the other hand, if the impetus comes from the On the other hand, if the impetus comes from the clinical staff, other clinicians may be more apt to clinical staff, other clinicians may be more apt to adopt sooner, and readiness will be at a higher level.adopt sooner, and readiness will be at a higher level.

In particular, administrators at the highest level must In particular, administrators at the highest level must offer both moral and financial supportoffer both moral and financial support

In addition, there need to be sufficiently skilled In addition, there need to be sufficiently skilled implementation, training, and support coordinators; implementation, training, and support coordinators;

S. Ash, joan; Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion , JAMIA, 2005;12:8-12

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TechnicalTechnical

There are many definitions of the EHR at There are many definitions of the EHR at numerous levels of sophistication and numerous levels of sophistication and functionality. functionality.

When one contemplates the highest levels, however, When one contemplates the highest levels, however, the ability of this system to interoperate with another the ability of this system to interoperate with another is paramount. is paramount.

S. Ash, joan; Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion , JAMIA, 2005;12:8-12

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Denmark’s Health Denmark’s Health SystemSystem

In Denmark the private health care represents only 3%;In Denmark the private health care represents only 3%;[19][19]

There are 30 out of office hours (OOH) which permit access There are 30 out of office hours (OOH) which permit access to GP's 24h a day, every day:to GP's 24h a day, every day:[20][20]

– 91% of the patients are treated within 1 or 2 months;91% of the patients are treated within 1 or 2 months;– 90% of GP's use EPR;90% of GP's use EPR;[21][21]

19 Brown, J., Day, M., Jones, T., Miller, M., Westcott, Dean., Bailey, D. Healthcare in Denmark direction for the NHS .Published by The certified Acountants Educational Trust on behalf of the Association of Chartered Certified Accountants. 2002

20http://www.bcma.org/public/news_publications/publications/policy_papers/ITPaper/GettingITRight_AppendixA.htm#TopOfPage#TopOfPage

21 Ash J. S. et al. Health Care in Denmark. Danish Ministry of Health, 2001

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UK Health SystemUK Health System

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

15% of GP's run completely paperless consultations;15% of GP's run completely paperless consultations;[20][20]

Development of lab-links which permit data exchange Development of lab-links which permit data exchange between doctors and laboratories;between doctors and laboratories;[22][22]

19 http://www.bcma.org/public/news_publications/publications/22Majeed A. Ten ways to improve information technology in the NHS. BMJ 2003; 326: 25-31.

1919

Denmark and UK Denmark and UK

In both countries exists a significant percentage of private In both countries exists a significant percentage of private investment in health care, although in Denmark this value is investment in health 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 Denmark (1679 in Denmark (1679 Euro) than in U.K (1079 Euro, while Portugal spends Euro) than in U.K (1079 Euro, while Portugal spends 1273 Euro ; ;

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

19 Brown, J et al. Healthcare in Denmark direction for the NHS Published by The certified Acountants Educational Trust on behalf of the Assotiation of Chartered Certified Accountants. 2000

2020

– In Portugal there are 347 Health centers;In Portugal there are 347 Health centers;[23][23]

– In 2000, The World Health organization published a In 2000, The World Health organization published a report about health systems where Portugal has report about health systems where Portugal has achieved the 12th place on global ranking, better than achieved the 12th place on global ranking, better than U.K., Germany, Canada and USA;U.K., Germany, Canada and USA;[24][24]

– In 2005, Portugal still ranks in 12th place, in front of In 2005, Portugal still ranks in 12th place, in front of countries such as Germany.countries such as Germany.

23 Instituto Nacional de Estatística

Portuguese Health Portuguese Health SystemSystem

2424 World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000. World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000.

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Portugal spent in Health as much as 9% of its low gross Portugal spent in Health as much as 9% of its low gross domestic product;domestic product;[25][25]

Resources are clearly poorly invested (lack of efficiency in Resources are clearly poorly invested (lack of efficiency in using them);using them);[26][26]

The way of financing is a constant subject of debate;The way of financing is a constant subject of debate;[26][26]

2525 OCDE Health Data 2003. OCDE Health Data 2003.26 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. Financiamento da Saúde em Portugal documento de trabalho 4/97 Associação Portuguesa de Economia de Saúde 1997

2222

– The organizational primary care infrastructures are The organizational primary care infrastructures are outdated and new reforms have not yet been outdated and new reforms have not yet been implemented;implemented;[27] [27]

– Health Centers organization has a lot of fragilities as well Health Centers organization has a lot of fragilities as well as the centralization of these health institutions;as the centralization of these health institutions;[28][28]

– Spenditure/money available relation higher than in other Spenditure/money available relation higher than in other countries?countries?


2727 Correia, R., Almeida. F., Freitas, A., Costa-Pereira, A. Correia, R., Almeida. F., Freitas, A., Costa-Pereira, A. Current State of Electronic Health Records in PortugalCurrent State of Electronic Health Records in Portugal, , THERE 2002 THERE 2002 2828 Bentes M, Dias CM, Sakellarides C. Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. PortugalHealth Care Systems in Transition. Portugal. The European Observatory on . The European Observatory on Health Care Systems; Copenhagen 2003.Health Care Systems; Copenhagen 2003.

2323

By law, all Portuguese citizens may access the NHSBy law, all Portuguese citizens may access the NHS

NHS is composed by:NHS is composed by: 9696 hospitals hospitals 339090 health centres health centres 14261426 health centres extensions health centres extensions

Due to the relatively small role of the private sector in Due to the relatively small role of the private sector in both primary and hospital care, most medical data is both primary and hospital care, most medical data is held by the NHS-ISheld by the NHS-IS

The NHS-IS was created, developed and still The NHS-IS was created, developed and still maintained by governmental IGIF – Institute for maintained by governmental IGIF – Institute for Financial and Information ManagementFinancial and Information Management

HIS in PortugalHIS in Portugal

2424

HIS in PortugalHIS in Portugal - IGIF - IGIF

Administrative

DRG INTEGRADOR

Clinical SAM

2000SNIMAI SONHO

LDRG

1980 1985 1990 1995

NationalCentralized Approach

Hospital CentralizedApproach

Main Problems• Main IGIF concern is Financial Management• Lack of NHS Strategy for Clinical IS• Clinical application (SAM) is a medical view of a

administrative application (SONHO)• IGIF - Software creator instead of Software

regulator

2525

Medical Informatics Medical Informatics R&DR&D

0 5 10 15 20 25 30 35 40 45 50

Cardiology

Multi-disciplinary

Radiology

Neurology

Obstetrics

Gastro

Imunology

Management

Oftamology

Prescription

Psychiatry

Medical Education

Articles

Doctor Degrees

Funded Projects

Main Problems• Some specialities represent most of R&D

efforts

Population: Funded Projects, Doctor Degrees, ArticlesSource: Portuguese Science and Technology Observatory, MedlineDate: October 2003

2626

Technology use in Technology use in Primary CarePrimary CareGeneral Practitioners use of Informatics General Practitioners use of Informatics (Computer, PDA, Palmtop)(Computer, PDA, Palmtop) %%

PortugalPortugal 3737

EU 15EU 15 8080

General Practitioners with Internet ConnectionGeneral Practitioners with Internet Connection


EU 15EU 15 6161

Use of Electronic Health Care RecordsUse of Electronic Health Care Records


EU 15EU 15 4848

Main Problems• Poorly use of technology by medical

staff• Poorly use of EHCR

Population: General PractitionairesSource: Flash Eurobarometre 104Author: EOSGallup EuropeDate: July 2002

2727

– Low development in the use of the informatic Low development in the use of the informatic technologies in 2002;technologies in 2002;[29][29]

– No relevant data is available No relevant data is available to the public to the public about the about the present state of the use opresent state of the use off informatic technologies in informatic technologies in primary care;primary care;[29][29]

– Resources are clearly poorly invested (lack of efficiency Resources are clearly poorly invested (lack of efficiency in using them);in using them);[30][30]

– The way of financing is a constant subject of debate;The way of financing is a constant subject of debate;[30][30]

29 OCDE Health Data 2003.30 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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ObjectivesObjectives

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

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

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

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

2929

ObjectivesObjectives

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

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

3030

Material and MethodsMaterial and Methods

50 health centres:50 health centres:– aleatorily chosen in 2002.aleatorily chosen in 2002.

The data acquisition was made in two stages:The data acquisition was made in two stages:

– 11stst stage: telephonic questionnaire to the stage: telephonic questionnaire to the 50 H.C. directors50 H.C. directors

Concerning informatic resources in Portuguese health Concerning informatic resources in Portuguese health centerscenters

– 22ndnd stage: stage: fax fax questionnaire; questionnaire; Concerning informatic system implementation Concerning informatic system implementation

planning strategies:planning strategies:– Beneficts, use and barriers to the implementation;Beneficts, use and barriers to the implementation;

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

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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;

3232

ResultsResults

Table 1 – Telephonic inquests results from 2002 and 2006 comparison

2002 2006

2 40

1 10

50 25

8 15

5 3,4 4,3

95 24,4 57,9

16 73

0 1

15 60

5 10

5 1 2,3

95 21,6 35,5

13 22

0 0

22 20

40 65

0 0

37 60

%

n

Percentiles

n total

%

Minimum

Maximum

Median

Health centres using SAM

Computers for clinical use

Health centers

Computers with access to RIS

Computers per health center

Median

Percentiles

%

Minimum

Maximum

Internet-linked computers

%

Minimum

Maximum

Computers using SINUS

3333

ResultsResults

2002 2006

94 100

47 25

50 25

26 28

13 7

50 25

13000 10000

5 4450 4197,5

95 48850 70100

8 7

5 1,1 4

95 21 32,1

96 96

48 24

50 25

n

n total

Percentiles

Percentiles

n total

%

Health centers

%

n

%

n

n total

Inscribed Patients

Doctors per health center

Median

Median

Health centers that use SINUS

Health centres that use paper records

Health centres that make appointments in other health institutions

Table 2 - Telephonic inquests results from 2002 and 2006 comparison

Without computers for clinical use 1367

With computers for clinical use 1956

Number of patients per doctor

2006

3434

ResultsResults

Graphic 1 – Main benefits to EHR implementation in Primary Care, comparison of the results from 2002 and 2006

Main benefits to EHR implementation in Primary care

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

To contain or to reduce costs

To improve the clinical processes or the efficiency of "workflow"

To fill the legal requirements or the assumed norms

To improve the capture of clinical data

To support the physician decision

To establish an infrastructure more efficient 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 between medical staff

20062002

3535

ResultsResults

Graphic 2 – EHR use in clinical practice, comparison of the resultos from 2002 and 2006

EHR use for

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pre-visit cares evaluation

After-visit patient support

Email between patients and physicians

Remote access to the EHR by physicians

Information on health conditions,

Booking

20062002

3636

ResultsResults

Main Barriers to CPR/EPR implementation in Primary Care

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Lack of structured medical terminologies

Inability to find EHR at affordable cost

Inadequate information standards, data or code sets

Difficulty in finding an EHR not fragmented

Difficulty in evaluating EHR solutions available

Incapacity to find a EHR solution that fills our functional necessities or techniques

Lack of medical staff support

Difficulty on electronic data introduction

Lack of adequate funding

20062002

Graphic 3 – Main barriers to CPR/EPR implementation in Primary Care, comparison of the resultos from 2002 and 2006

3737

ResultsResults

Graphic 4 – Main strategies to overcome EHR implementation barriers, comparison of the resultos from 2002 and 2006

Main strategies to overcome EHR implementation barriers

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

To built a consensus to support a especif ic technical solution

To demonstrate the EHR costs/benefits

To become familiar with professional associations to improve the norms or conditions

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 the health cares

To wait until better solutions are available

20062002

3838

ResultsResults

Graphic 5 – Main privacy and security concerns on EHR information, comparison of the resultos from 2002 and 2006

Main privacy and security concerns on EHR information

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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 the organization

Inadequate data protection on the Web

Access to information by not authorized users inside the organization

20062002

3939


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

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

4040


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

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

4141


The forces of competition in health care may be The forces of competition in health care may be providing pressure as well, as more patients become providing pressure as well, as more patients become aware of the potential of health care information aware of the potential of health care information systems. systems.

The misalignment of incentives represents perhaps The misalignment of incentives represents perhaps the single most important barrier to moving ahead the single most important barrier to moving ahead and is especially problematic in the health centers and is especially problematic in the health centers progress.progress.

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LimitationsLimitations

Lack of previous studies;Lack of previous studies;

Inerent problems to an unpersonnal questionnaire;Inerent problems to an unpersonnal questionnaire;

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

current state of informatic infrastructures in portuguese health centers and its evolution since...

Documents

primary health care

primary care informatics

health information technology

various aspects of health

use of information

role of informatics

portuguese health centers

dissemination of medical