The Role of Interoperability Standards for Emerging Countries

Beatriz de Faria Leão, MD, PhDHealth Standards Architect

Zilics Health Information Systems, São Paulo, BrazilHL7 Brazil - Co-Chair Advisory Council

Agenda

• Overview and Health Challenges• Standards and National eHealth Policies in

– Uruguay– Argentina– Chile– Brazil

• The role of HL7 in South America

Thanks to all that contributed for this presentation:

• Alvaro Margolis - President IMIA - LAC• Ana Estela Haddad - Director of Management of Education in

Health - Ministry of Health Brazil• Claudio Giulliano da Costa - CIO São Paulo Dept of Health, Brazil• Diego Kaminker - Chair HL7 Argentina• Fernán González B. de Quirós - Hospital Italiano, Buenos Aires,

Argentina• Julio Carrau - Chair HL7 Uruguay• Jussara Macedo - Brazilian Supplementary Health Agency• Lincoln A. Moura Jr – IMIA Board - Treasurer • Marivan Santiago Abrahão - Chair HL7 Brazil• Sergio A. König - Director IT&GS Consultores Ltda.

• 4th continent in size• Area 17,840,000 km²• Population 371 millions• Countries 12• Languages: Spanish,

Portuguese, French, Dutch, English ….

• GDP $3.33 Trillion

SOUTH AMERICA

http://www.globalhealthfacts.org/topic.jsp?i=46

Facts: In spite of the huge difference in the health expenditure between South American countries and US …

Health Expenditure Per Capita (US$ - 2003)

0

1000

2000

3000

4000

5000

6000

Argentina Brazil Chile United States ofAmerica

Uruguay

Health indicators are not that different…Some health figures in Brazil

• Prenatal coverage increased from 23% to 70% (including 6 doctor visits) over the last 15 years.

• 90% vaccine coverage• Free access to antiretroviral treatment and to high

complexity care. AIDS quick tests are available for 1/3 of deliveries and free ARV is guaranteed

• Second country in the world in organ transplantations, first in publicly-funded transplants.

Uruguay National ehealth Policy

• 3.46 million people• 1.7 million live in the

capital Montevideo and its metropolitan area

Uruguay eHealth Policy

• Sept 30th, 2003 - Federal Government issued the bill nº 396/003, on the EHR for all citizens, suggesting 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) where sharing of information among all HC providers is mandatory, from 2007 on.

SUEIIDISSSociedad Uruguaya de Estandarización,

Intercambio e Integración de Datos e Información de Servicios de Salud

• Founded in Nov 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 y CDA and IHE

www.sueiidiss.org

Uruguay / SUEIIDISInteroperability Standards in use

• IHE profiles:– Security digital certificates based on national PKI

infrastructure

• Consistent Time service provided by SUEIIDIS• CDA (HL7v3) for documents sharing• Uruguay National Identification standards• OIDs for objects identifications• Common WSDL defined and shared among all

participants

eHealth Standards in Argentina

• 40 million people (estimate 2008)

• GDP (nominal) 2007 estimate– Total $260.7 billion – Per capita $6,548

HL7 Argentinawww.hl7argentina.org

• Founded on December 5th, 2001 • 28 members (9 of them individuals) • HL7 is not a national Standard for Argentina, but there

are several developments involving the use of HL7 standards for e-claims and interdepartmental interoperability (mainly using HL7 V2.x and CDA R2)

• Focus on training and dissemination of the HL7 standards - > virtual learning platform – 600 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 Chile

• Population 16,598,074 (June 2007 estimate)

• GDP (nominal) 2007 estimate– Total $163.792 billion– Per capita $9,879

http://www.hl7chile.cl/

Brazil: “Soft Power”- Emerging Giant

Brazil – Geo-political Perspective

• The largest country in Latin America

• The only Portuguese-speaking country in LA (52% of South America speak Portuguese)

• The 5th most populated country in the World

• The 3rd country in number of Internet hosts in America

• GDP (nominal) 2008 estimate– Total US$ 673 billion

– Per capita US$ 3,640.88

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

• Supplementary 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$ 90B/year

– SUS is the major Payer: ~ 66% in volume and some 50% in $– 190M inhabitants, spread over 5.500 cities– Around 6,000 Hospitals and 1,600 Health Plan Operators

(HMOs)– 70% of Hospitals have less than 80 beds– Estimate that only 10% of Hospitals have Information Systems– 90% HMOs cover less than 50,000 lives each– Only 3% of HMOs cover more than 200,000 each– The largest HMO covers less that 4M lives– There is no important network of Health Organizations– Lack of notion of production chain, added value and best

practices– National Standards on their way– It’s a “Market of Discontent”

Fragmented and Uncoordinated Market

Small and Badly Connected Players!

Little Investiment in

Management and IT

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)• Inefficiency, paper base uncoordinated system,

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– Individual (160 Million)– HC providers (180 Thousand)– Health Workers (1.4 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

Brazilian HC National Standards: National Unique Identifiers:

• Individuals (160 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)

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

Coverage:

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

TeleHealth National Project

Private Healthcare Insurance Market

49.3 millionbeneficiaries

HPOS

1.600 active Health Plan

Organizations

600.000 estimated Healthcare providers

Sources; www.ans.gov.br Set 2008

ANSState Regulation

Self-regulation

NHS Healthcare providers

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

Demographics, Vital Statistics, Discharge Summary, Notifiable

Diseases

HMOS TISS - XMLTISS - XML

TISS - the Brazilian standard for HPOs and HC providers communication

Source: Jussara Macedo, ANS, 2007

Source: Jussara Macedo, ANS, 2007Source: 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 ICD-10)

• Messaging: XML schemas and Web services• Privacy: ISO/NBR 17799 and SBIS/CFM Software

Certification• Mandatory from May 2007 on

TISS Transactions

PROVIDERS HPOS

Eligibility and prior Authorization

Claim Generation Service Billing

Claim Status Inquiries

Pre certification and Adjudication

Claims Acceptation

Adjudication

Accounts Receivable

Health care Services Delivery

Claims

Claim Status Inquiry

Patient Info

Claim Status Response

Claim PaymentAccounts 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

• Affiliationship– Individual - 10– Corporate - 15

• INTERSYSYEM, ZILICS, MICROSOFT, INTEL, ANS, SERASA

HL7 BRAZIL ACTIVITIES

• FEB/2007 - creation of Institute HL7 Brazil • COURSES

– Oct/ 2007 - I BASIC COURSE OF HL7 - with John Ritter - 70 persons - São Paulo

– Abr /2008 - HL7 - VERSION 3.0 - with Mead Walker - 40 persons, São Paulo

• MEETINGS– Oct/2007 - OPEN FORUM HL7 INTEL - with William Edward

Hammond - São Paulo– 1er Congreso Iberoamericano de Informática Médica

Normalizada, Montevideo, Uruguay– April /2008 - OPEN FORUM HL7 - IT-MÍDIA - with Mead

Walker- São Paulo

Case Studies

• InCor – São Paulo Heart Institute– Continuous Glucose Monitoring System on a

Intensive Care Unit HL7 V2.X

• Fleury Laboratory– Microbiological Exams Management System

• São Paulo City Health Department – SIGA Saúde LAB Integration

SIGA Saúde

São Paulo City’s Health Information System

Lab Integration Claudio Giulliano da Costa, MD

CIO São Paulo Health Department

São Paulo is the largest city in South America, with 12M inhabitants and some 22M in the Metropolitan Area.

Initial Figures: 400 Primary Care Units 60 Polyclinics 160 Hospitals 11M Users 8.5M Emergency T/year 550k Inpatients/year 11M Primary Care C/year

São Paulo

• SIGA Saúde is São Paulo City’s Integrated and Distributed System for Managing the Public Healthcare System

• The system belongs to São Paulo City, which is willing to share it with other cities, states and countries

• SIGA Saúde has been developed using free-software open-code concepts.

SIGA Saúde is present in 100% of

São Paulo City public health care providers

SIGA SAÚDE

SIGA Saúde IT Model

Electronic Health Record

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

Management(Surveillance, Auditing

and Billing)

Internet

SP CityDatacenter

SMS-SP

Dept of Health

Access Control 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

• 2.7 millions exams / month– About 300 different labs exams without previous authorization– Others need prior authorization

• Manual process: transcribe 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 IntegrationLab Orders

LAB 1 LAB 2 LAB 3 LAB N

UBS

SIGA Web Service: LAB

AE AMAS Hospital Emergency

Lab Order Sample Collection

Authorization

XML

XML

SIGA Saúde Lab IntegrationLab Results

LAB 1 LAB 2 LAB 3 LAB N

UBS

SIGA Web Service: SIGA

AE AMAS Hospital Emergency

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

XML

XML

Standards used for SIGA’s Lab Integration

• Identification:– Patient’s - National Health Card Number– HC provider and HC provider - National Registry CNES

• Messages:– TISS: XML schemas (simpleTypes, complexTypes, Messages,

WSDL)– HL7 v3 - Lab orders and results information content (tags

translated)– HL7 v3 pan-Canadian Messaging Standards

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

HL7 v3 for LAB

• Why V3?– Information content of lab orders and result is VERY GOOD,

much better than V2

• V3 Messages are too big, why?– Events that belong to applications are part of the message

• Our approach– Use the core information content from V3– Change the “envelope” and “roles” to a simpler schema– Leave the information about the events on the application

(Web Service or not)– Make a clean message - take advantage of the unique

identifiers

TISS envelope

SIGA Saude Lab Integration: Current Status

• Order messages in test• Results messages:

– Common Lab Results - structured + Observations in free text– Microbiology - structured + text – Pathology - mostly text based

• Web service is under testing• Results:

– Phase 1: with a CDA approach (PDF attachment)– Phase 2: results structured using LOINC (October 15th on)

SIGA SADT Lab IntegrationChallenges

• LOINC was almost unknown in the beginning of the project (jan 2007)

• Language Barriers / HR• Labs: had to redefine all internal codes and pre-

formatted sentences to LOINC codes• HL7 was not used, some have heard of v2, v3

was too “scary” and tools were too complicated• Solution - > T R A I N I N G HL7 and LOINC

SIGA Saude Lab IntegrationLOINC Translation and Mapping

• LOINC mapping to the SUS Procedure Table• For each SUS code:

– There could be one or more LOINC codes for orders– Example:

SIGA SADT Lab IntegrationWhat have we achieved so far?

• First LOINC translation to PT is ready, thanks to one of the private Lab

• Today LOINC is being considered as the national vocabulary for exams both for the private and public systems

• Shift of mind: from payment to patient care• Team work: mapping of the 300 exams is ready• Advantages of having a standard are now

clearly understood

HL7 Role for developing countries

• HL7 is “THE” organization able to foster standards development in emerging and developing countries

• It’s a place where PEOPLE come together to:– Learn about standards– Develop standards– To adapt what is already there– To propose new standards– To create, to innovate and above all,– To foster the development of interoperable health

information systems

HL7 role for developing countries

• Suggestions:– Promote South to South collaboration– Re-thinking of v3 (v4?)– Learn from international examples– Promote full interoperability with ISO 13606 - data

types alignment– Better tools on open source environments– Free Distribution of HL7 standards according to

country HDI

Above all, let’s keep HL7 friendly, open environment, where people leave their

“egos” outside the room and feel comfortable to think outside the box in

order to improve health care everywhere

A living example of that is:

Bellagio, July 2008, Interoperability WeekBellagio, July 2008, Interoperability Week

Thank you very much for your attention!Thank you very much for your attention!