I carnegie ago 2010v2


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Presentation Brazilian Telehealth Program made for ICarnegie at the MOH
August 2010

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I carnegie ago 2010v2

  1. 1. Brazil Telehealth
  2. 3. Brazil Population: 190,000,000 States: 26 + 1 Federal District Municipalities: 5,563 40% in metropolitan areas 220 native ethnicities (0,2% of the population) 185 languages
  3. 4. Brazilian Health System - SUS (Sistema Unico de Sa úde) <ul><li>National Constitution of 1988 dictates that health is a right, and it is the government’s duty to ensure it. </li></ul><ul><li>The Unified Health System has the following principles: </li></ul><ul><ul><li>Universal Care </li></ul></ul><ul><ul><li>Equitable Care </li></ul></ul><ul><ul><li>Comprehensive Care </li></ul></ul><ul><ul><li>Unified Care </li></ul></ul><ul><ul><li>Regionalized Services Network </li></ul></ul><ul><ul><li>Social Participation </li></ul></ul>
  4. 5. Primary Health Care <ul><li>Brazilian Family Health Strategy </li></ul><ul><ul><li>started in 1994 </li></ul></ul><ul><ul><li>Family health team (FHT): 1 Medical Doctor (MD), 1 Registered Nurse (RN), 1 Dentist </li></ul></ul><ul><ul><li>2 technical-degree nurses and 4 to 6 Community Health Workers </li></ul></ul><ul><ul><li>30.000 FHT covering 90 million people in 60% of the Brazilian municipalities </li></ul></ul><ul><ul><li>major impact in the reduction of children mortality in the last decade ( temos os dados? ) </li></ul></ul>
  5. 6. Family Health Strategy 1998 5% coverage FHT/Community Workers/Oral Health FHT/Community Workers Community Workers Without any kind
  6. 7. Family Health Strategy 2009 90% coverage FHT/Community Workers/Oral Health FHT/Community Workers Community Workers Without any kind
  7. 8. Brazilian Telehealth Strategy Brazil Telehealth Program - remote assistance and permanent education Pilot Project: 9 states and 900 points www.telessaudebrasil.org.br Open University of Unified Health System - provides in-service training for thousands of health care providers www.universidadeabertadosus.org.br Telemedicine University Network - RUTE, initially about 80 University Hospitals in collaborative research and education across all federal states – http://rute.rnp.br
  8. 9. Brazilian Telehealth Program <ul><li>Pilot project to support primaru care activities </li></ul><ul><li>Objectives: </li></ul><ul><li>Improve Primary Care quality </li></ul><ul><li>Prepare FHT workers </li></ul><ul><li>Integrate academic institutions and Primary Care Providers </li></ul><ul><li>Promote distance education (e-education) </li></ul><ul><li>Structure an e-consultation and a Second Opinion </li></ul><ul><li>Create a Virtual Library for Primary Care (BVS-APS) </li></ul>
  9. 10. Brazil Telehealth Program Coverage: 9 states centers implementing telehealth in 900 e-health points supporting about 2,700 FHT, covering 11 M inhabitants
  10. 11. Brazil Telehealth Program 9 states centers implementing telehealth in 900 e-health points supporting about 2,700 FHT, covering 11 M inhabitants Expansion states (3 + Federal District) Priority: Northeast region and Brazilian Amazon Coverage:
  11. 12. Brazil Telehealth Program <ul><li>Inclusion Criteria: </li></ul><ul><li>Municipalities with geographic access barriers; </li></ul><ul><li>Municipalities with population less or equal to 100,000 inhabitants; </li></ul><ul><li>Municipalities with FHS coverage equal or bigger than 50%; </li></ul><ul><li>Municipalities with Human Development Index less than 0,500 (low human development) </li></ul><ul><li>Distribution: 80% of the points in rural areas </li></ul>
  12. 13. Brazil Telehealth Program <ul><li>Participant Institutions: </li></ul><ul><li>Ministry of Health </li></ul><ul><li>Ministry of Education (MEC) </li></ul><ul><li>Ministry of Science and Technology </li></ul><ul><li>Ministry of Defense </li></ul><ul><li>Ministry of Communications </li></ul><ul><li>Department of State - Federal Government </li></ul><ul><li>Bireme/PAHO/WHO </li></ul><ul><li>Brazilian Community and Family Health Society </li></ul>
  13. 14. Brazil Telehealth Program <ul><li>Participant Institutions: </li></ul><ul><li>USP - University of São Paulo </li></ul><ul><li>UFMG - University of Minas Gerais </li></ul><ul><li>UERJ - University of Rio de Janeiro </li></ul><ul><li>UFCE - Federal University of Ceará </li></ul><ul><li>UFAM/UEA - Federal and State Universities of Amazonas </li></ul><ul><li>UFRGS - Federal University of Rio Grande do Sul </li></ul><ul><li>UFPE - Federal University of Pernambuco </li></ul><ul><li>UFG - Federal University of Goiás </li></ul><ul><li>UFSC - Federal University of Santa Catarina </li></ul>
  14. 15. Number of State Centers Total: 1209 points (Primary Health Care Units) AM 42 CE 102 GO 151 MG 132 PE 99 RJ 105 RS 199 SC 160 SP 219
  15. 16. Brazilian Telehealth Figures
  16. 17. www.telessaudebrasil.org.br <ul><li>Health Virtual Library in Primary Health Care: </li></ul><ul><li>supports teleassistance and continuous education; </li></ul><ul><li>  access to best evidences in Primary Health Care and Telehealth; </li></ul><ul><li>decision support through the Formative Second Opinion </li></ul>2008-2009 13,000 accesses/month
  17. 18. Portaria GM/MS # 402 February 2010 <ul><ul><li>National Comittee: DEGES/SGTES/MS </li></ul></ul><ul><ul><li>State Comitee – ( SES, CIES, COSEMS, Center Coordinator and ETSUS Director) </li></ul></ul><ul><ul><li>University Center </li></ul></ul><ul><ul><li>Point of Telehealth </li></ul></ul><ul><ul><li>Advanced Point of Telehealth (ETSUS, RNP, PET Salud) </li></ul></ul>
  18. 19. Professional Councils <ul><ul><li>Federal Medical Council </li></ul></ul><ul><ul><li>Federal Nursing Council </li></ul></ul><ul><ul><li>Federal Dentistry Council </li></ul></ul>
  19. 20. Health Ministry investments in Telehealth 1º Phase 2007 – 2008 2º Phase 2009 – 2010 R$ 14.831.778,35 US$ 7 M R$ 21.830.720,00 US$ 11 M Total: R$ 36.662.498,35 (±US$ 18,400,000)
  20. 21. Implementation A Telehealth Center R$ 200.000,00 ( (± US$100,000) A Telehealth point of care R$ 2.800,00 (± US$1,400)
  21. 22. <ul><li>Important factors : </li></ul><ul><ul><ul><li>Center infrastructure </li></ul></ul></ul><ul><ul><ul><li>Human Resources – Coordination Team </li></ul></ul></ul><ul><ul><ul><li>Formative Second Opinion costs </li></ul></ul></ul>Implementation
  22. 23. Maintenance costs Maintenance of teleconsultants of a center/month for 100 points of Telehealth R$ 31.560,00 ( ± US$15,500) Maintenance costs of Human Resources by center/month for 100 points of Telehelth R$ 29.560,00 ( ± US$15,000)
  23. 24. Costs reduction <ul><li>Evaluation of 33 pilot municipalities at North and Northeast of Minas Gerais : </li></ul><ul><ul><li>Referral costs in Primary Health Care were 8x more expensive when compared to the Second Opinion offered by TeleHealth . </li></ul></ul><ul><ul><li>The economy was about 5 referrals/municipalities/month or 1,5% of referrals were avoided: it’s enough to cover telehealth activities </li></ul></ul>
  24. 25. Professional Fixation Minas Gerais – Clinical Hospital: survey with 105 professionals of PHT from 32 municipalities: 67% of the respondents felt that access to training at the workplace was a major factor in to stay in their hometowns Important 67% Medium 27% Low importance 2% No important 4%
  25. 26. Rio Grande do Sul Patient Referral (December 2007 – September 2009) Avoided 70% It was not avoided for other reasons 2% didn’t know 1% Referral required 3% Referral decided after teleconsultation 14%
  26. 27. Standards National Policy of Standards for Informatics in Health and Telehealth <ul><li>PNIIS – National Policy of Health Information and Informatics – 2004 National Council of Health </li></ul><ul><li>Portaria GM/MS # 402 February 2010 </li></ul>
  27. 28. HI Standards in Brazil <ul><li>Unique identifiers: </li></ul><ul><ul><li>for persons (190 M in the national database) </li></ul></ul><ul><ul><li>HC providers </li></ul></ul><ul><ul><li>HC professionals </li></ul></ul><ul><ul><li>ICD 10 since 1988 </li></ul></ul><ul><ul><li>Electronic exchange of billing between HC providers and payers for the private system (mandatory since 2207) </li></ul></ul><ul><ul><li>Software certification process Brazilian Health Informatics Association + Federal Medical Council for EHR systems ( 9 systems certified) </li></ul></ul>
  28. 29. Healthcare Challenges in Brazil <ul><li>Increasing demand for health care (aging, emerging of new diseases, re-emerging of considered overcome diseases)‏ </li></ul><ul><li>Skyrocketing healthcare costs (Health Technology)‏ </li></ul><ul><li>Inefficiency, paper base uncoordinated system, multiple formularies, poor resource allocation </li></ul><ul><li>Siloed systems - one for each health program </li></ul><ul><li>Lack of adequate information to support decision making, quality of care evaluation and to monitor disease management programs; </li></ul><ul><li>Few common health and healthcare information standards within the sector </li></ul>
  29. 30. PC Health Informatics, Mirror Committee of TC 215 – Health Informatics, Brazil
  30. 31. Brazilian ISO TC 25 Mirror Committee ABNT - PC Health Informatics <ul><li>ABNT </li></ul><ul><ul><li>Created in September 1940 </li></ul></ul><ul><ul><li>Represents Brazil in International SDOs </li></ul></ul><ul><ul><li>Some 120 Technical Committees and growing </li></ul></ul><ul><li>PC-Health Informatics </li></ul><ul><ul><li>Created in November 2006 </li></ul></ul><ul><ul><li>An initiative of Ministry of Health and Santa Catarina Federal University </li></ul></ul><ul><ul><li>Initial Focus on TeleHealth </li></ul></ul><ul><ul><li>Attracted people from the 20-year-old Brazilian Health Informatics Society </li></ul></ul><ul><ul><li>Became formally a Mirror Committee in March 2007 </li></ul></ul><ul><ul><li>Some 100 people working at varied levels of effort and commitment </li></ul></ul><ul><ul><li>Relies 100% on Volunteers </li></ul></ul>
  31. 32. ISO TC 215 Organization
  32. 33. How PC-Health Informatics Works <ul><li>Adoption of ISO TC 215 Standards </li></ul><ul><ul><li>ISO 18308 - Requirements for an Electronic Health Record Reference Architecture </li></ul></ul><ul><ul><li>ISO 20514 - Electronic Health Record Definition, Scope and Context </li></ul></ul><ul><li>Adaptation of ISO TC 215 Standards </li></ul><ul><ul><li>ISO TS 22220 Identification of Subject of Care </li></ul></ul><ul><li>Creation of new Standards based on ISO TC 215 </li></ul><ul><ul><li>NBR.. Hospital Discharge Summary Data ( under development) </li></ul></ul><ul><li>NWIP (New Work Item Proposals) </li></ul><ul><ul><li>ISO TS 14639 eHealth Architecture for Emerging and Developing Countries </li></ul></ul><ul><ul><li>ISO TS 14441 Security and privacy requirements for compliance testing of EHR systems </li></ul></ul><ul><ul><li>Telehealth Standards on quality of service </li></ul></ul>
  33. 34. How PC-Health Informatics Works <ul><li>Resources </li></ul><ul><ul><li>Collaboration Tool: Livelink (ABNT/ISO) </li></ul></ul><ul><ul><ul><li>Livelink has been chosen as the formal and official communication tool </li></ul></ul></ul><ul><ul><ul><li>Our use of Livelink set up a new paradigm for ABNT </li></ul></ul></ul><ul><ul><li>Web-conferencing, for daily work* </li></ul></ul><ul><ul><ul><li>Proven to be very effective </li></ul></ul></ul><ul><ul><li>Video-conferencing joining 5 cities, for monthly Plenary Sessions** </li></ul></ul><ul><ul><ul><li>Video-Conferencing was a major innovation at ABNT </li></ul></ul></ul><ul><ul><ul><li>* , ** Unifesp – São Paulo Federal University </li></ul></ul></ul><ul><ul><ul><li>** RNP – National Research Network </li></ul></ul></ul><ul><ul><ul><li>** Datasus – National Department of Health IT Division </li></ul></ul></ul>
  34. 35. Results for 2007 – 2008 <ul><li>Standards Adoption (ISO Standards Translation) </li></ul><ul><ul><li>Around 30 Standars under Study </li></ul></ul><ul><ul><li>12 being translated </li></ul></ul><ul><ul><li>02 Standards in Public Consultation </li></ul></ul><ul><ul><ul><li>ISO 13606.1 EHR Communication - Part 1: Reference Model </li></ul></ul></ul><ul><ul><ul><li>ISO 18104 Terminologia de Referência para Enfermagem </li></ul></ul></ul><ul><ul><li>05 Standards Published as NBR </li></ul></ul><ul><ul><ul><li>ISO TR 20514 Registro Eletrônico de Saúde ─ Definição, Escopo e Contexto </li></ul></ul></ul><ul><ul><ul><li>ISO TS 18308 Requisitos para uma Arquitetura do Registro Eletrônico em Saúde </li></ul></ul></ul><ul><ul><ul><li>ISO TR 17119 Framework para o Estabelecimento de Perfis em Informática em Saúde </li></ul></ul></ul><ul><ul><ul><li>ISO TS 21667 Quadro Conceitual de Indicadores de Saúde </li></ul></ul></ul><ul><ul><ul><li>ISO TS 17117 Terminologia Controlada Relacionada à Saúde – Critérios para Categorização e Avaliação de Terminologias em Saúde </li></ul></ul></ul>
  35. 36. Standards Government <ul><li>Active participation on ABNT (Brazilian Association of Technical Standards) - GT2 </li></ul><ul><li>Health Education Management Department and Executive Secretary: sponsored the activities of ABNT </li></ul><ul><li>ABNT strictly follows the ISO standards </li></ul>
  36. 37. National Program