FACULTY OF MEDICINE – UNIVERSITY OF PORTO
Department of Biostatistics and Medical Informatics
Introdução à Medicina 2005/2006
Current state of informatics infrastructures in Portuguese
health centers and its evolution since 2002
João Alhais,
João Gonçalves,
med05108@med.up.pt
med0500@med.up.pt
Jorge Ferreira,
Jorge Rodrigues,
João Neves,
João Rodrigues,
med05002@med.up.pt med05001@med.up.pt
Vanessa Rodrigues,
med05006@med.up.pt med05007@med.up.pt med05243@med.up.pt
Adviser: Filipa Almeida, filipa.almeida@med.up.pt, Class: 12
Abstract
Introduction
The informatic infrastructures play a central role in medical performance, mainly where primary
care is given (Health Centers).
Objectives
The main goal of this work is to estimate the state of informatic resources in the Portuguese health
centers and compare it not only with 2002 situation but also with others European contries state. We pretend
to determine the main barriers to informatic infrastrucures implementation as well as to define possible ways
to overcome them.
Methods
Through a transversal study we applied fax and telephonic inquiries to 50 Health Centers alleatorily
chosen in a work performed in 2002, to which it is being given continuation.
Results
Among other results, are worth of notice: the raise on the number of computers connected to the
internet (16% in 2002 to 76% in 2006) and also the number of health centers using SAM (2% in 2002 to 40%
in 2006) the rest of the results are at the same level with those from 2002. It is curious to notice that, despite a
greater use of the EHR, the percentage of using the paper clinical records has not decreased that much. This
owes probably to the slowliness on the introduction of data by the Health Centers workers, as a consequence
of the lack of formation.
The majority of the health centers considers the patient data sharing between medical personal the
main benefit of the EHR (67%) being the main barrier to their implementation the lack of adequate funding
(64%). The best strategy the health centers have to overcome these barriers is really to wait until new
solutions are available (36%).
( retirar alguma coisa daki de cima se possível)
It seems that within four years the health centers became disappointed with EHR. Perhaps the
meeting with the practice changes their opinion.
Portugal did not accomplish the informatic revolution so the gap between its health center resources
and other europenean contries situation is huge.
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Key-words
Primary care, health centers, informatic infrastructures, EHR.
Introduction
Problem definition
During the late years has a consequence of a strong technologic development, it
surged an implementation of those technologies in the health area. The primary care was
not an exception to this fact, observing an adaptation of the electronic resources to their
structure of functioning looking forward to improve their service quality.
The use of computers has become a key piece in primary care which importance has
being continuously growing in the late years. It is an unskirtable act that the use of new
technologies brings advantages and disadvantages which reflect in the performance of the
health professionals.
It is known the fact that this implementation in first-line health development countries
resulted in a raise of the quality of the service as well as the satisfaction of the patients
[1]
.
From this fact emerges the necessity of evaluating the actual state of the Electronic Health
Records in Portugal; the know how of the implementation of the electronic resources, and if
that fact is bringing better conditions to our health centers
Currently, in Portugal there is a complete unknowledge about the informatic
infrastructures available in each health center. Continuing the work “Current State of
Electronic Health Records in Portugal”[2] from 2002, it was newly evaluated the state
(existence and accessibility) of the informatic infrastructures in Portuguese health centres.
Theoretical basis
Medical informatics comprises the theoretical and practical aspects of information
processing and communication, based on knowledge and experience derived from
processes in medicine and health care [3].
Information systems are usually introduced in health care with the expectation that
effectiveness and efficiency of care will improve and increase, or even that the efficiencies
of the whole process will increase. These aspects are, indeed, potential benefits of an
information system. Unfortunately, history teaches us that it is not easy to make benefits in
health care visible. In general, three types of benefits may be distinguished such as: non
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quantifiable benefits (for example: more complete, precise and uniform records; and the
improvement of the accessibility to the patient data), quantifiable benefits that can be
express quantitatively, although not in monetary terms (for example the reduction of
waiting time) and quantifiable benefits that can be expressed in monetary terms (for
example reduction of wasted materials) [3].
The application of medical informatics to the practical life is made in Portugal, in
the majority of the cases, through SONHO, SINUS and SAM:
SONHO was created in order to satisfy the organization needs, in the end of the
80’s and beginnings of 90’s, in the NHS. It is an integrated system of hospital information,
which has as data management base, the Oracle version 7.3. Since its implantation it has
assumed a fundamental role in administrative information on the patient management
registration [4].
SINUS is the software privileged by most of the Portuguese health units and is
functionally similar to SONHO (IGIF). The main difference between them lies in the fact
that the exploration/registration of information in SINUS is done based on the doctor’s
perspective and in a web environment. The quantity of clinical/administrative information
treated on SINUS is fewer than in SONHO.
SAM is system guide to the doctor’s activity, based on the clinical-administrative
information processed on SINUS. However, the functionalities of SAM for primary care
are much less than in SINUS. SAM was developed from web technology (graphic
interface), and the only health professionals that have access to this system, as well as its
manipulation, are doctors [4].
The Health Informatic Web (RIS) emerged with the crescent necessity of
information exchange between the diverse Health Institutions and has as objective to ensure
the inter-connection with quality, fiability, efficiency and safety of the Health Institutions
which need it [4].
Primary care is the provision of integrated, accessible health care services by
clinicians who are countable for addressing a large majority of personal health care needs,
developing a sustained partnership with patients and practicing in the context of family and
community. In some countries, therefore, primary care is also called first-line health care,
whereas primary care physicians are generally called general practitioners (GPs) [3].
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The formal aspects of clinical information are largely contained within the patient
record, which serves as the single point of deposition and access for nearly all archival
clinical data [5].
An electronical medical record is much more than an electronic replacement of
existing paper systems. The EHR can start to actively support clinical care by providing a
wide variety of information services. However, it is hard to understand what information is
really important to clinical care and what is simply occasionally desirable
[6]
. The EHR
bring uncountable advantages in primary health care detaching such as the faster access to
information, the updated information, it allows having a clinical process with all the patient
clinical information and an easier access to information (ex: allows the simultaneous access
from different locations). Although all these advantages, the EHR still have some failures
as: the security break problems (leading to the invasion of people privacy), the need of
specific formation from the health professionals and dispends on initial resources in
training and education [7].
In one form or another, the method of recording patient data on paper has served
clinical practice successfully for centuries. The way paper lends itself to being handled,
marked upon and stored is often taken for granted, but has some remarkably implications.
Disadvantages of the paper-based record include its fragility, its limitation to a single user
at any one time, the ease with which records can be misplaced or lost and the effort
required researching for information, either in large single records, or from collections of
records.
Background
In 2000, The World Health organization published a report where, for the first time,
the health systems of the 191 membership countries were compared about their
performance. Portugal has achieved the 12th place on global ranking, better than U.K.,
Germany, Canada and USA [8].
However, some problems in Portugal Health System still remain.
Firstly, dislike other Organization for Economic Cooperation and Development
(OECD) countries, Portugal (a small country with 10,3 million of habitants)
Health as much as 9%
[9]
spent in
of its low gross domestic product. On the other hand, the
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organizational primary care infrastructures were outdated and new reforms have not yet
been implemented.
Nowadays, these applications are still totally outdated from functionally and
technological view even so having an important “pedagogical” role in Health care [10].
Health Centres organization has a lot of fragilities, mainly due to lack of
information available for management, low participation of citizens, and absence of
adjusted information systems as well as the centralization of these health institutions. But
the main point that differences us from United Kingdom and Denmark is that theirs health
centers directors have full gestive powers controlling and modelling their budget to their
own needs, in opposition, in Portugal is needed a previous requirement of funds [11].
Either Denmark and U.K. present developed health systems, specially Denmark,
which health system is pointed out as being one of the best examples in the world. This is
clearly demonstrated by the smashing percentage of population satisfied with their NHS
(90%, 56% of which very much satisfied, and only 7,6% in U.K.), among many other
statistic data. In the other hand, 6% of the Danes are unsatisfied, opposite to 41% in U.K..
In both countries exists a significant percentage of private investment in health care,
although in Denmark this value is higher (from 12,2% in 1980 to 17,8% in 1999
[12]
.
However, this can also be seen as a negative fact. These countries rely very much on the
new technologies (information technology with computer decision support systems have
already been proved that can help reduce medication errors [13].
These countries rely very much on the new technologies, existing already a huge
adherence from doctors: already in 1996, 96% of the English GP’s used data bases, and
15% already run paperless consultations [14]. In Denmark, 90% also use EPR, 90% of which
use it also to data exchange. Currently, 97% of English GP’s are connected by NHSnet - a
system which connects doctors, hospitals and other NHS institutions
[15]
. It is now in a
terminal status the Lab-link developing project, making possible the data transference
between doctors and laboratories. In order to this, there was, in 1998-99, an investment of ₤
1 billion in I.T. (information technologies). In 2000 it was created a plan with the purpose
of reforming and reinvest, in order to 75% of the hospitals and 50% of the primary care
electronically prescript and appoint consultations, goal which is expected to be reached in
2008 [16].
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We verified that there is a greater expenditure per capita in Denmark than in U.K
(1,679 euro per head on Denmark compared with 1,079 euros per head spent by the UK)
[17]
. Another great difference is that in Denmark the private health care represents only 3%
of all. Moreover, the passage from public sector to private one is not seen as an acceptable
situation by the Danes. This fact leads to an extreme social equality, as the wealthier and
the poorer have access to the exact same health cares. In U.K. the private sector is far more
developed. Besides this, the average of population per GP, as well as hospital, is quite
lower in Denmark [18].
Generally, Denmark has a great decentralization when it comes to public
administration. The highest level of responsibility falls down on the lowest level of
management, having the health minister a mere legislative and supervisor role. This system
already proved out to be efficient, because it has not suffered major changes since 1970.
Any changes that may occur is, despite being anxiously, is also strongly supported either by
the general public and media, according to several surveys [18].
In Danish hospitals, the budget is tightly controlled, and doctors have fixed salaries,
non depending on other factors, as the hours they work or the operations they do. This
induces a greater professionalism, pride and better treatment of the patient. Moreover,
everyone can have access to the best doctors, seen that, by law, they have to practice in the
public sector, being only allowed to work on the private one on their free time. This way,
the GP's are the link between hospitals and specialists. It is also evident a strong power of
making decisions, fearless of assuming unpopular measures. This system is nowadays
under a great risk due to the recent centralization tendencies.
It is consensual that Portugal spents enough in health. However, this resources are
clearly poorly invested. There is obviously a lack of efficience in using them. Even the way
of financing is a constant subject of debate. Some argue that public and private funding
may lead to an overspending. Others claim that there are countries, like Denmark, in which
this modality has been successfully implemented. Also the role of the GP as an
intermediate between hospitals and specialists and public with private sector is not yet
clearly definite. Co-payment is also expected to be a disciplinarian measure when it comes
to controlling the excessive search of the services. However, it can only be seen with a
regulating purpose, and not as a way of an extra funding source. This can also generate
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some discordance, as some find the amount families pay already heavy enough. The
function of the primary care as "gatekeepings" to the hospital system should be more
efficient, in screening the patients, promoting this way a more specialized treatment [19].
Aims
The realization of this work is based in a series of objectives being the most
important estimate, in a coherent and credible way, the state of informatic infrastructures
available in the Portuguese Health Centers. We intend to compare the results we obtained
with the ones from a study performed in 2002 [2] in order to estimate the evolution occurred
since then.
In manner to complete the study we will inquire which are the main obstacles /
barriers which oppose to the correct implementation of the informatic infrastructures and
the possible ways to overcome them.
We will proceed to a comparison about the level of implementation and importance
of medical informatics between Portugal and the first line European countries whose
Primary care success is internationally recognized.
Methods and participants
The informatics infrastructures play a central role in medical performance, mainly
where primary care is given (Health Centers).
With the objective of studying the current state (existence, accessibility and utility)
and evolution of the informatics infrastructures in Portuguese Primary Care we have
realised a transversal study as a continuation of other transversal study realised in 2002. In
this study were analysed 50 health centers aleatorily chosen in a previous study made in
2002 [2].
Thus, on a first stage we have made a telephone inquest to the 50 health centers
directors trying to describe what informatics means they had and used.
On a second stage we sent fax inquests about informatics system implementation,
planning strategies, main difficulties and possible ways overcome them, to the Health
centers which answered the first questionnaire.
It must be highlighted that these inquiries are much alike those from 2002, in which
these ones are based on. (See annexes I and II)
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Limitations
During the realization of this work we faced a series of obstacles, difficulties which
delayed this study.
Due to the absence of similar studies to the one realized, there is a serious lack of
bibliographical references in what concerns to the methodological and structural character.
During the research about the previous publications on the informatic resources in
Portuguese Health Centers, it was verified a preoccupying lack of information about the
existence of these resources their quality and quantity.
In the realization of the telephonic inquiries it was hard to find qualified people to
answer correctly about the subject in question due to their internal lack of organization. In
the other hand, in certain cases health centers functionaries revealed unavailable to answer
the telephonic inquest.
In the comparison with 2002 there were several parameters analysed solely in one of
the studies. The fax questioner from 2002 had one extra question relatively to 2006 and the
2006 questioner had 2 new ones also. Besides that, some questions from 2006 have new
answer options available.
There is also the additional difficulty in comparing the results obtained from the
study with the data obtained of the foreign countries, which give relevance to relatively
different parameters.
On the fax ones, the answer was sent, in the majority of the cases, lately, resulting
from this situation that, despite the insistence, many have not been sent yet.
Another difficulty faced, perhaps the greatest, was the fact that the results from the
work realized in 2002 were delivered very lately, which conditioned seriously some
objectives of our work, like the comparison between the recent data and the one from 2002.
Only after receiving it, it was possible to proceed to an evaluation of the evolution verified
throughout this years.
The fact that the Health centers were distributed all over Portugal, made impossible
a personal inquire, which lead to a telephonic/fax inquire with the implications brought by
them, among others the impossibility of ensuring that the person who was answering the
inquest, was indeed the most qualified to the situation or that it was answering the
questionnaire with seriety.
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Most of the telephonic numbers disponibilized to the work group were incorrect.
Much time was lost trying to find the actual numbers.
Results
After inquires realisation, either by fax and telephone, we have made data statistic
analyses. Moreover, we also introduced the results previously obtained in 2002, allowing us
to compare both results.
Table 1 – Telephonic inquest data
Health centers
Health centres using SAM
2002
2006
%
2
40
n
1
10
n total
50
25
Median
Computers per health center
Internet-linked computers
Computers using SINUS
Computers for clinical use
Computers with access to RIS
Health centers that use SINUS
Health centres that make appointments in other health
institutions
Inscribed Patients
Percentiles
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
Percentiles
21,6
35,5
%
13
22
Minimum
0
0
Maximum
22
20
%
40
65
Minimum
0
0
Maximum
37
60
%
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
Health centres that use paper records
Percentiles
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Table 2 - Number of patients per doctor
Number of patients per doctor
Without computers for clinical use
1367
With computers for clinical use
1956
2006
Discussion
The median of doctors per health center has diminished since 2002, this has
reflected in the raise of the number o patients per doctor (from 1823 in 2002 to 1991 in
2006)
The median of computers per health center registered a very accentuated raise (from
8 in 2002 to 15 in 2006), detaching even more the percentage of computers web-linked
(from 16% to 73%), this is owed overall to the large divulgation of this resources for all the
country in the late years resulted from their cost diminish (per example the appearance of
adsl).. The large expansion of the internet in the health informatic circuit took to a raise,
although less accentuated of computers with access to RIS (from 40% to 65%)
The SINUS nowadays presents a complete divulgation through the Portuguese
health centers, following what was registered in 2002 when it was already registered a very
elevated value (94%). This is also reflected in the median of computers that use SINUS
where it was verified a raise from 5 to 10.
There were not registered statistically significative in the percentage of health
centers which make appointments in other health services, maintaining approximated
values (from 26% in 2002 to 28% in 2006).
As foreseen the percentage of health centers that use paper health records has
diminished, due to their gradual substitution for the electronic health records (from 83% to
70%).
The health centers which do not resource to computers for clinical ends have a
much smaller number of patients per doctor, concluding from that, that computers raise the
doctors efficiency, contributing to a better service to the patients. (1367 patients per doctor
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in health centers without computers for clinical use, and 1956 patients per doctor in health
centers with computers for clinical use).
According to the analyses of graf.1 (annex III), we can verify a crescent disbelief on
he electronic health records. From the enumerated positive effects, in all of them occurred a
decrease on the favourable opinions about this subject. This reflects an overconfidence
caused by the newness of the electronic health records, believing that they would solve all
their problems. So that, after experimenting, it was evidenced that there was a clarification
on the EHR limitations/advantages relation, which traduced on a diminution of the trust in
such resources, accenting this disbelief in the containment and cost reduction (from 68% in
2002 to 13% in 2006). Besides this, the sharing of medical information (69%) and
improvement of health services (56%) as the main advantage of the EHR still domain.
By the analyses of graf.2 (annex III), is of easy conclusion that, by the almost total
discrepancy between the 2002 and 2006 opinions, during the introduction of the EHR there
was not a clear idea on their truly potentialities, idea only clarified by their usage.
Therefore, in 2002, it was thought that the EHR main utility would be the agendings (the
only which still maintains), and the remote access the EHR by the doctors. Although, it was
not then considered the utility for doctors about the patients health condition information.
In 2006, besides maintaining the agending as their main function (56%), the
information about the patients health conditions appears also as the most voted (56%).
According to the opinion reflected on the results, the pre-evaluation of patient’s condition
and as a pos-visit support has still no practical use (both 0%).
By the analysis of the health centres directors opinions(graph 3, annex III), it was
made clear that the main barriers to the implementation of EHR are similar to those from
2002, evidencing among them the lack of funding (69%). Knowing that Portugal is one of
the countries that most invest relatively to the PIB, it can be said that there is a
misapplication of resources. On the other side, the less appointed reasons were the lack of
structured medical terminologies and the inexistence of informatical resources at accessible
prices.
Analysing graf.4 (annex III), the main strategies to overcome the barriers in 2002
would be mostly the education and demonstration of the EHR capacity (28%), and the
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necessity of extra funding (24%), in order to become familiar with professional associations
to improve the norms or conditions (24%) and to demonstrate the EHR costs/benefits
(24%).
Besides all this, these barriers seem to have been overcome; having mainly the
experience and recurrent usage of the new technologies solved the majority of these
problems. Therefore, in the opinion of the health centres directors, the best way of
overcoming the barriers would be to wait until better solutions are available (40%), that is,
confirming the deep disappointment and disbelief installed about EHR, hoping for a new
solution to their problems.
Finally, analysing graf.5 (annex III), the main privacy and security concerns on
EHR problems in 2002, would be the access of non-authorized people inside the
organization to information (60%), an inadequate protection in the Internet (56%) and
breaking on policies and practices in data access (56%). In 2006, is by far the access of
non-authorized people that still concerns the most (73%), which may lead to the conclusion
that the other problems have already been partially or totally solved out, being relegated to
second plan.
References
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way. Medinfo 2004; 11; 1110-1114
[2] Correia, R., Almeida. F., Freitas, A., Costa-Pereira, A. Current State of Electronic
Health Records in Portugal, THERE 2002
[3] Van Bemmel, JH. Mark, AM.. Handbook of medical informatics. Springer editons.
1997; chapter 13: 95-121
[4] Instituto de Gestão Informática e Financeira da Saúde (IGIF) - www.igif.min-saude.pt
[5] De Lusignan S. What Is Primary Care Informatics? JAMIA 2003; 10: 304–309
[6] Coiera, E.. Guide to health informatics. Arnold editions. 2003; chapter 5: 58-74
[7] Soto CM, Kleinman KP, Simon SR. Quality and correlates of medical record
documentation in the ambulatory care setting. BMJ 2002; 341: 31-52
[8] World Health Report 2000. Health Systems: improving performance, OMS, Genebra,
2000
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[9] Instituto Nacional de Estatística (INE) - www.ine.pt
[10] Bentes M, Dias CM, Sakellarides C. Health Care Systems in Transition. Portugal. The
European Observatory on Health Care Systems; Copenhagen 2003.
[11] Ministério da Saúde de Portugal (www.min-saude.pt)
[12] Danish Ministry of Health (DMH) - www.im.dk/
[13] UK Ministry of Health (www.medical-devices.gov.uk/)
[14] Gulliford MC, Jack RH, Adams G, Ukoumunne OC. Availability and structure of
primary medical care services and population health and health care indicators in England.
BMJ 2005; 354: 213-245
[15] Majeed A. Ten ways to improve information technology in the NHS. BMJ 2003; 326:
202-206
[16] Thomas P, Griffiths F, Kai J, O`Dwyer A. Networks for research in primary health
care. BMJ 2001; 322: 588-590
[17] 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 Assotiation of Chartered Certified Accountants. 2000
[18] Ash J. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI
Discussion. JAMIA 2005; 12: 8-12
[19] 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.
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de Economia de Saúde 1997
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Annex I
FACULDADE DE MEDICINA DA UNIVERSIDADE DO PORTO
Serviço de Bioestatística e Informática Médica
Factores que Influenciam EHR
Registos electrónicos de Saúde
1º Quais são os principais factores de gestão/administração que influenciam a necessidade
de Sistemas de Registos de Saúde Electrónicas nos Centros de Saúde?
□ A necessidade de partilhar dados de pacientes comparáveis entre diferentes locais num
sistema de saúde composto por vários parceiros;
□A
necessidade de melhorar a documentação clínica com suporte aos serviços de
facturação;
□ A obrigação de conter ou reduzir custos na prestação de cuidados de saúde;
□ A necessidade de estabelecer uma infra-estrutura mais eficiente como uma vantagem
competitiva;
□ A necessidade de preencher os requisitos legais ou de normas assumidas;
□ Outros ..........................................................................................................
2º Quais são os principais factores clínicos que influenciam a necessidade de Sistemas de
Registos de Saúde Electrónicos nos Centros de Saúde?
□ Melhorar
a capacidade de partilhar a informação dos registos dos pacientes entre
prestadores de cuidados de saúde;
□ Melhorar os cuidados de saúde;
□ Melhorar os processos clínicos ou na eficiência do “wokflow”;
□ Melhorar a captura de dados clínicos;
□ Reduzir erros médicos (aumentar a segurança dos pacientes);
□ Permitir o acesso remoto a registos clínicos;
□ Facilitar o suporte à decisão do clínico;
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□ Melhorar a satisfação dos prestadores de cuidados de saúde;
□ Outros.............................................................................................................
3º Que aplicações relacionadas com o EHRs, baseadas na web ou em serviços de e-mail,
têm em uso actualmente ou tem planeado para implementação futura?
□ Acesso remoto ao EHR por clínicos;
□ Marcação de consultas e/ou admissões,
□ Informação sobre condições de saúde, doenças, bem estar, ou novos desenvolvimentos
na saúde,
□ E-mail entre pacientes e clínicos;
□ Educação de pacientes pós-visita;
□ Avaliação de casos pré-visita;
□ Outros..............................................................................................................
4º Quais são as maiores barreiras para implementar os EHR?
□ Falta de fundos ou recursos adequados;
□ Falta de suporto pelos profissionais de saúde;
□ Incapacidade de encontrar uma solução de registos clínicos ou componentes a um preço
acessível;
□ Dificuldade
em encontrar um plano de migração dos registos em papel para os
electrónicos;
□ Dificuldade de encontrar uma solução de EHR que não seja fragmentada por vários
vendedores ou diferentes plataformas tecnológicas;
□ Inadequação dos “standards” de informação, conectividade ou codificação;
□ Dificuldade em avaliar, comparar ou validar as capacidades de soluções de EHR ou
componentes que estão disponíveis no mercado;
□ Incapacidade de encontrar uma solução de EHR que preencha as nossas necessidades
funcionais ou técnicas;
□ Falta de terminologias médicas estruturadas;
□ Outros .............................................................................................................
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5º Quais são as principais estratégias ou aproximações que planeia tomar para ultrapassar
as barreiras?
□ Planeamos
construir um consenso em torno de uma estratégia, migração, ou
implementação para os sistemas de informação:
□
□
Vamos utilizar recursos internos ao Centro de Saúde;
Vamos utilizar consultores externos ao Centro de Saúde;
□ Planeamos educar e demonstrar as capacidades de um EHR no melhoramento dos
cuidados de saúde e processos clínicos;
□ Pretendemos demonstrar os custos/benefícios dos EHR:
□
□
Já existem “benchmarks” de comparações de custos;
Ainda não existem “benchmarks” de comparações de custos;
□ Planeamos construir um consenso para suportar uma solução especifica técnica ou de
um vendedor;
□ Planeamos solicitar fundos ou recursos adicionais;
□ Pretendemo-nos tornar familiares com as organizações
de normas ou associações
profissionais para melhorar as normas ou condições;
□ Pretendemos esperar até que melhores soluções estejam disponíveis;
□ Outras estratégias ou soluções........................................................
6º Quais são as principais preocupações no que concerne à privacidade e segurança da
informação do EHR?
□ Acesso
inapropriado a informação de pacientes por utilizadores autorizados no
interior da sua organização;
□ Acesso a informação de pacientes por utilizadores não autorizados no interior da sua
organização;
□ Violação de politicas e praticas de acesso a dados;
□ Acesso inapropriado de pacientes por utilizadores
autorizados no exterior da sua
organização;
□ Protecção inadequada de dados na Internet;
□ Funcionalidades limitadas de segurança nos sistemas vendidos;
□ Normas de segurança de dados inadequados;
□ Outros.............................................................................................................
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Annex II
QUESTIONÁRIO AOS CENTROS DE SAÚDE
Com este trabalho pretende-se estudar a utilização de aplicações informáticas nos
Centros de Saúde de Portugal.
Numa 1.ª fase foram escolhidos de forma aleatória 50 centros de saúde, nos quais
serão efectuados inquéritos telefónicos aos respectivos directores.
Numa 2.ª fase pretendemos estudar a opinião de cada um dos contactados
relativamente à estratégia de implementação de sistemas de informação bem como das
principais dificuldades existentes. Assim, serão enviados questionários anónimos em papel
que pedimos para preencher e devolver, utilizando para tal um envelope enviado.
Descrição do centro de saúde
1) Nome do centro de saúde: .................................................................................................
2) Director do centro de saúde: .............................................................................................
Número aproximado de:
3) Médicos (do quadro e de apoio) que trabalham na sede do centro de saúde (excluindo as
extensões): .........................................................................................................................
4) Utentes que o centro de saúde serve: .................................................................................
5) Quantas extensões tem o centro de saúde: .........................................................................
Descrição da utilização informática
Quantos computadores:
6)
7)
8)
9)
possui o centro de saúde: ...................................................................................................
possuem acesso à Internet: ................................................................................................
possuem acesso à RIS: ......................................................................................................
Que aplicação é utilizada para a gestão de consultas: SINUS 
9.1) Outra: ...................................................................................................................
9.1.1) Se outra, qual o nome da empresa que a comercializa:.............................
9.2) Quantos computadores a utilizam: ......................................................................
9.3) Pode fazer marcação de consultas noutras unidades de saúde (hospitais)?.......
10) Quantos computadores existem para uso clínico (nos gabinetes para inserir e/ou
visualizar o processo clínico do utente): ............................................................................
10.1) Nome da aplicação: SAM 
Outra: ...............................................................
10.1.1) Se outra, qual o nome da empresa que comercializa a aplicação .................
10.2) Introduzem a história clínica..................................................................................
10.3) Introduzem prescrição............................................................................................
10.4) Introduzem os resultados de exames complementares...........................................
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10.5) Introduzem diagnósticos.........................................................................................
10.5.1) Existe lista pré-definida de diagnósticos.......................................................
10.6) Introduzem procedimentos.....................................................................................
10.6.1) Existe lista pré-definida de procedimentos...................................................
10.7) Imprimem receitas médicas....................................................................................
10.8) Imprimem relatórios médicos (resumos clínicos, atestados)..................................
10.9) Existe processo clínico em papel............................................................................
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Annex III
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 "
To contain or to reduce costs
2006
2002
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Graphic 1 – Main benefits to EHR implementation in Primary Care
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%
80%
90%
100%
Graphic 2 – EHR use for
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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
0%
2006
2002
10%
20% 30%
40% 50% 60%
70% 80%
90% 100%
Graphic 3 – Main barriers to CPR/EPR implementation in Primary Care
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
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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
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