Transcript Current State of Electronic Health Records in Portugal

Faculdade de Medicina da Universidade do Porto
Introdução à Medicina
Current state of informatic infrastructures in
Portuguese health centers and its evolution
since 2002
João Alhais; João Gonçalves; João Neves; João Rodrigues;
Jorge Ferreira; Jorge Rodrigues; Vanessa Rodrigues
Class 12
May 2006
Contents

Introduction

Material and Methods

Results

Discussion
2
Introduction
Medical informatics
[1]
The field of information science concerned with:
- the analysis and dissemination of medical data;
- through the application of computers;
-application on various aspects of health care and medicine.
1 Enrico Coiera. Recent Advances: Medical informatics. BMJ 1995;310:1381-1387
3
Introduction
• It deals with the resources, devices and methods
required to optimaze: [2-3]
- Acquisition;
- Storage;
- Retrieval;
- Use of information in health and biomedicine.
2 Coiera, E., Guide to health informatics. Arnold editions. 2003; chapter 3: 32-40
3 Degoulet P, Fieschi M. Introduction of clinical informatics. Springer. 1997; chapter 6: 81-90
4
Introduction
• Health informatics tools include:
[4-5]
- computers;
- clinical guidelines;
- formal medical terminologies;
- information and communication systems;
4 Dick R et all. The computer based patient record. Nat academy press 1997; chapter 2: 74-100
5 Wyatt J. Clinical data systems, part 2: components and techniques. Lancet 1994; 344: 1609-12
5
Introduction

Medical informatics aims to improve care
given to patients by improving (within
others) the: [2]
- Accuracy;
- Speed;
- Reliability of clinical information flow.
2 Coiera, E., Guide to health informatics. Arnold editions. 2003; chapter 3: 32-40
6
Introduction

Importance of medical informatics in primary care
[6-8]
In primary health care, especially in developed
countries, the use of different types of information
technology (IT) has progressed considerably.
Tomasi E et al. Health information technology in primary health care in developing countries: a literature
review. Bull World Health Organ. 2004; 82: 867-74
7 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
7
8 De Lusignan S. et al. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309
6
Introduction

Such evolution can be attributed partly to the
peculiarities of the primary health-care sector such
as: [6-8]
- its status;
- its need for facilities for information storage and management;
- its need for improvements in quality of care, and expenditure
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: 867-74
7 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
8 De Lusignan S. et al. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309
Introduction

EHR - Electronic Health Record
A general term describing computer-based patient record
systems[10];
•
Is basically a facility that:
- retrieves patient data from a number of information
systems;[11]
- presents the data in a coherent way to the authorised
user[11-12];
10 Coiera, E.. Guide to health informatics. Arnold editions. 2003; chapter 5: 58-74
11 David W. et al. A Proposal for Electronic Medical Records in U.S. Primary Care. JAMIA 2003;
9
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
Introduction

When compared to manual registration, the main advantages
of EHR for health centers (as for the other sectors of health
care) are:
-greater accuracy
[14, 15];
[13]
and a higher proportion of correct information
-time saved in locating information
[16];
-more economical use of financial resources
[17];
-greater ease and speed of recovery of patient data
[17].
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.
10
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.
13
Introduction
The factors shown to be important for
success of EHR adoption are [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:
11 8-12
Introduction
Environmental
-Environmental factors concern mainly financial and safety
issues:
- On the financial side, both health centers and health
care providers are struggling because the financial
managent is not being made by their own.
- Information technology has been touted widely as a
tool that can improve the quality and safety of patient care.
18
Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12:
12 8-12
Introduction
Personal


18
clinicians of health centers may be reluctant to adopt new
ways of manage health information that interfere with their
workflow;
Overall, when clinicians have access to larger amounts of
information with which to make decisions, and when the
system fits their workflow, they tend to use it.
Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12
13
Introduction
Organizational

The organizational culture must be ready to support adoption
by the individuals within it;

clinicians have / have not experienced a sense of collaboration
and trust between them and hospital administration;

if clinicians believe the administration wants to force them to
use EHR, for example, they may dig in their heels;

They may be more resistant to arguments based on safety
and patient care benefit if the level of trust is not there.
18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12:
14 8-12
Introduction



On the other hand, if the impetus comes from the clinical
staff, other clinicians may be more apt to adopt sooner, and
readiness will be at a higher level.
In particular, administrators at the highest level must offer
both moral and financial support
In addition, there need to be sufficiently skilled
implementation, training, and support coordinators;
18 Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion , JAMIA, 2005;12:8-12
15
Introduction
Technical


18
There are many definitions of the EHR at numerous
levels of sophistication and functionality.
When one contemplates the highest levels, however, the
ability of this system to interoperate with another is
paramount.
Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. JAMIA 2005; 12: 8-12
16
Denmark’s Health System


In Denmark the private health care represents only 3%;[19]
There are 30 out of office hours (OOH) which permit access to GP's
24h a day, every day:[20]
– 91% of the patients are treated within 1 or 2 months;
– 90% of GP's use EPR;[21]
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
17
21 Ash J. S. et al. Health Care in Denmark. Danish Ministry of Health, 2001
19
UK Health System



19
Currently, 96% of English GP’s are connected by NHSnet - a
system which connects doctors, hospitals and other NHS
institutions;
15% of GP's run completely paperless consultations;[20]
Development of lab-links which permit data exchange
between doctors and laboratories;[22]
http://www.bcma.org/public/news_publications/publications/
A. Ten ways to improve information technology in the NHS. BMJ 2003; 326: 25-31.
22Majeed
18
Denmark and UK



In both countries exists a significant percentage of private
investment in health care, although in Denmark this value is higher
(17,8% in 1999);
There is a greater expenditure per capita in Denmark (1679 Euro)
than in U.K (1079 Euro), while Portugal spends 1273 Euro ;
Both countries spent 6% to 7% of their GDP on healthcare;
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
19
19
Portuguese Health System
– In Portugal there are 347 Health centers;[23]
– In 2000, The World Health organization published a report
about health systems where Portugal has achieved the
12th place on global ranking, better than U.K., Germany,
Canada and USA;[24]
– In 2005, Portugal still ranks in 12th place, in front of
countries such as Germany.
Instituto Nacional de Estatística
24 World Health Report 2000. Health Systems: improving performance, OMS, Genebra, 2000.
23
20
Portuguese Health System



Portugal spent in Health as much as 9% of its low gross domestic
product;[25]
Resources are clearly poorly invested (lack of efficiency in using
them);[26]
The way of financing is a constant subject of debate;[26]
OCDE Health Data 2003.
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
25
26
21
Portuguese Health System
– The organizational primary care infrastructures are outdated and
new reforms have not yet been implemented;[27]
– Health Centers organization has a lot of fragilities as well as the
centralization of these health institutions;[28]
– Spenditure/money available relation higher than in other
countries?
Correia, R., Almeida. F., Freitas, A., Costa-Pereira, A. Current State of Electronic Health Records in
Portugal, THERE 2002
28 Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. Portugal. The European
Observatory on Health Care Systems; Copenhagen 2003.
27
22
HIS in Portugal

By law, all Portuguese citizens may access the NHS

NHS is composed by:
 96 hospitals
 346 health centres
 1426 health centres extensions


Due to the relatively small role of the private sector in both
primary and hospital care, most medical data is held by the
NHS-IS
The NHS-IS was created, developed and still maintained by
governmental IGIF – Institute for Financial and Information
Management
23
HIS in Portugal - IGIF
National
Centralized Approach
1980
Administrative SNIMAI
1985
DRG
Hospital Centralized
Approach
1990
SONHO
LDRG
Clinical
1995
2000
INTEGRADOR
SAM
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)
24
• IGIF - Software creator instead of Software regulator
Medical Informatics R&D
0
5
10
15
20
25
30
35
40
45
50
Cardiology
Multi-disciplinary
Radiology
Neurology
Obstetrics
Gastro
Imunology
Management
Articles
Doctor Degrees
Funded Projects
Of tamology
Prescription
Psychiatry
Medical Education
Population: Funded Projects, Doctor Degrees, Articles
Source: Portuguese Science and Technology
Observatory, Medline
Date: October 2003
Main Problems
25
• Some specialities represent most of R&D efforts
Technology use in Primary
Care
General Practitioners use of Informatics
(Computer, PDA, Palmtop)
%
Portugal
37
EU 15
80
General Practitioners with Internet Connection
Portugal
20
EU 15
61
Use of Electronic Health Care Records
Portugal
28
EU 15
48
Main Problems
Population: General Practitionaires
Source: Flash Eurobarometre 104
Author: EOSGallup Europe
Date: July 2002
• Poorly use of technology by medical staff
26
• Poorly use of EHCR
Portuguese Health System
– Low development in the use of the informatic technologies in
2002;[29]
– No relevant data is available to the public about the present state
of the use of informatic technologies in primary care;[29]
– Resources are clearly poorly invested (lack of efficiency in using
them);[30]
– The way of financing is a constant subject of debate;[30]
OCDE Health Data 2003.
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
29
30
27
Objectives




1.st - To estimate the informatic resources in Portuguese health centers;
2.nd - To compare the results we will obtain with those from a previous
research (2002);
3.rd - To analyze the evolution within this 3 year period;
4.th - To study the utility of the informatic resources specially the electronic
health records (EHR) in the primary care;
28
Objectives


5.th – Evaluate the main barriers to the implementation of efficient
informatic infrastructures and define ways and strategies to overcome
them.
6.th – Compare the actual state of the Portuguese informatic
infrastructures with prestigious foreign ones.
29
Material and Methods

50 health centres:
– aleatorily chosen in 2002.

The data acquisition was made in two stages:
– 1st stage: telephonic questionnaire to the 50 H.C.
directors

Concerning informatic resources in Portuguese health centers
– 2nd stage: fax questionnaire;

Concerning
strategies:
informatic
system
implementation
planning
– Beneficts, use and barriers to the implementation;
– Possible ways to overcome them;
30
Key words




Electronic Health Records;
Medical Informatics;
Health Centers;
Primary Health Care;
31
Results
Health centers
Health centres using SAM
Computers per health center
Internet-linked computers
Computers using SINUS
Computers for clinical use
Computers with access to RIS
2002
2006
%
2
40
n
1
10
n total
50
25
Median
8
15
5
3,4
4,3
95
24,4
57,9
%
16
73
Minimum
0
1
Maximum
15
60
Median
5
10
5
1
2,3
95
21,6
35,5
%
13
22
Minimum
0
0
Maximum
22
20
%
40
65
Minimum
0
0
Maximum
37
60
Percentiles
Percentiles
Table 1 – Telephonic inquests results from 2002 and 2006 comparison
32
Results
Health centers
Health centers that use SINUS
Health centres that make appointments in other health
institutions
Inscribed Patients
2002
2006
%
94
100
n
47
25
n total
50
25
%
26
28
n
13
7
n total
50
25
Median
13000
10000
5
4450
4197,5
95
48850
70100
8
7
5
1,1
4
95
21
32,1
%
96
96
n
48
24
n total
50
25
Percentiles
Median
Doctors per health center
Percentiles
Health centres that use paper records
Number of patients per doctor
2006
Without computers for clinical use
1367
With computers for clinical use
1956
Table 2 - Telephonic inquests results from 2002 and 2006 comparison
33
Results
Main benefits to EHR implementation in Primary care
To share patient data betw een medical staff
To improve health cares
To improve the clinical documentation
Remote access to clinical registers
Medical staff satisfaction
To reduce medical errors
To establish an infrastructure more efficient as a competitive advantage
To support the physician decision
To improve the capture of clinical data
To fill the legal requirements or the assumed norms
To improve the clinical processes or the efficiency of "w orkflow "
2006
2002
To contain or to reduce costs
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
34
Graphic 1 – Main benefits to EHR implementation in Primary Care, comparison of the results from 2002 and 2006
Results
EHR use for
Booking
Information on health conditions,
Remote access to the EHR by physicians
Email between patients and physicians
After-visit patient support
Pre-visit cares evaluation
2006
2002
0%
10%
20%
30%
40%
50%
60%
70%
Graphic 2 – EHR use in clinical practice, comparison of the results from 2002 and 2006
80%
90%
100%
35
Results
Main Barriers to CPR/EPR implementation in Primary Care
Lack of adequate funding
Difficulty on electronic data introduction
Lack of medical staff support
Incapacity to find a EHR solution that fills our functional necessities or techniques
Difficulty in evaluating EHR solutions available
Difficulty in finding an EHR not fragmented
Inadequate information standards, data or code sets
Inability to find EHR at affordable cost
Lack of structured medical terminologies
2006
2002
0%
10%
20% 30%
40% 50% 60%
70% 80%
Graphic 3 – Main barriers to CPR/EPR implementation in Primary Care, comparison of the results from
2002 and 2006
90% 100%
36
Results
Main strategies to overcome EHR implementation barriers
To wait until better solutions are av ailable
To Educate and to demonstrate the EHR capacities in the improv ement of the health cares
To request additional f unds or resources
To built a consensus around a strategy f or the inf ormation sy stems
To become f amiliar with prof essional associations to improv e the norms or conditions
To demonstrate the EHR costs/benef its
2006
2002
To built a consensus to support a especif ic technical solution
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Graphic 4 – Main strategies to overcome EHR implementation barriers, comparison of the resultos from
2002 and 2006
37
Results
Main privacy and security concerns on EHR information
Access to information by not authorized users inside the organization
Inadequate data protection on the Web
Inappropriate access to information by authorized users inside the organization
Inappropriate access to information by authorized users in the exterior
Breaking on policies and pratices in data access
Inadequated norms of data locking
2006
2002
Limited security functionalities
0%
10% 20%
30%
40%
50% 60%
70%
80% 90% 100%
Graphic 5 – Main privacy and security concerns on EHR information, comparison of the results from
2002 and 2006
38
Discussion



General increase of the electronic resources;
Reduction of the number of General practicers
per health center;
Still remains the necessity of paper records;
39
Discussion



Disbelif and desilusion from general practioners in
the EHR benefits;
General practionners did not have a correct ideia of
the EHR use;
General practioners used to believe in their use to
after visit-patient support and pre-visit cares
evaluation;
40
Discussion



Although, it was not then considered the utility for
doctors about the patients health condition
information;
In a general way the main barriers to the
implementation of the EHR have maintained;
4 years ago the lack of funding was primary reason
followed by the lack of an adequate EHR system;
41
Discussion


Now it is followed by the difficulty on the data
introduction;
After experimenting the EHR most of the
general practioners agree to wait until better
solutions are available and to instruct personal
to their easily use;
42
Discussion


The acces to information by non authorized
users inside the organization keeps being the
main concern on EHR information security;
General practioners lost their afraid of out-side
breakings into the system;
43
Discussion


It should be strived to have a national system of EHRs
that can share information on any patient in any health
care setting;
From the point of view of the patient, he or she should
be able to enter any health care setting and see a
clinician who has comprehensive access to information
about that patient;
44
Discussion


From the health care provider's perspective, this access
should be fast, the information should be easy to find,
and the process should help rather than hinder the
workflow;
Health care will be safer for the patient and more
satisfying for the clinician, who would now be able to
provide far better care and feel more secure in his or her
decision making;
45
Discussion


The forces of competition in health care may be
providing pressure as well, as more patients become
aware of the potential of health care information
systems;
The misalignment of incentives represents perhaps the
single most important barrier to moving ahead and is
especially problematic in the health centers progress;
46
Discussion
Limitations

The sample used in this researche project may be a source of
bias as well as the method used in 2002 to adquire the data
(methods of colletion and questionnaire);

Inerent problems to an unpersonnal questionnaire;

Difficulty in comparing the data obtained in Portugal and the
foreign one;
47