Working towards a single electronic health record for every citizen
The engineer Mariano Soratti is the head of the Sistema Integrado de Información Sanitaria Argentino (Argentinian Integrated Healthcare Information System, SISA) being developed by the National Health Ministry, Argentina. We interviewed him to find out how such an ambitious project is put together, bearing in mind that Argentina is a federal country in which each province has an autonomous government and its own regulations regarding healthcare.
EHealth Reporter Latin America: What must a developer take into account when planning a new clinical system so that, once implemented, it can interact with SISA?
Mariano Soratti: To interact with the site? You’ve asked an interesting question. Firstly, if it is a new project, they need to assess whether it can be developed on web platforms, which would facilitate interoperability with SISA greatly as the system works on a web platform. The second point is related to the data: the potential extent of it and whether the system interacts with those of the authorities of the establishment and jurisdiction because SISA publishes data dictionaries for different records. So it’s useful to keep in mind different data dictionaries, the nominal SISA records, and adapt to them as far as possible, making an effort right from the start to record the same or more information as that being implemented in SISA. And another relevant piece of advice would be to ensure that the coding is compatible.
EHRLA: How does one ensure that the coding is compatible?
MS: The world of coding is pretty disorganized. In general everyone codes according to their own choices and capabilities. As SISA also makes its coding public, it is also a good idea for developers and projects under development to use either the same codes or ones that they have been using but that have a mapping mechanism for these codes. If the local system uses the codes of its own area, it needs a mechanism that allows its code to interact with the code of the local INDEC area, which is the one used by SISA. This is basic technical advice that will help to adapt systems to facilitate inter-system dialogue.
EHRLA: Do you think that this will one day lead to a healthcare system that connects the whole country?
MS: That’s the idea but we know that there’s a long way to go. The other piece of advice, I don’t know if it’s advice or just a thought, is to keep in mind that this process takes time, many months and years of work and a lot of records. Everything will come together in time to create the citizen’s record and ensure the regular functioning of all the nominal records. But the process needs to be shepherded. Not everything is written yet, it’s not as though you can just sit down and program for a couple of weeks and get everything done. It is a process that involves many aspects that we still can’t really envisage, you have to take notes with each development, progress, liaise with the authorities, and plan many different things here at the Ministry. It’s a progressive development process.
EHRLA: Is it accompanied by the necessary legislation?
MS: Yes, but it isn’t completely synchronized. In terms of operations and technology, SISA is ahead while the legislation and regulations lag behind a little. Generally, there are two ways in which state technical development progresses: The resolution, regulation, law or whatever appears and after that a project is created that tries to fulfill its parameters. An example of this is ANMAT (National Administration of Medications, Foods and Medical Technology): Firstly, the famous traceability resolution was issued and now every actor is adapting its systems or looking at ways in which they can follow and meet the resolution. Then there’s the other path, which was the one taken by SISA which consists of starting out with a technical proposal, the development of a technological project that includes certain aspects such as records, strategies and plans, which later leads to resolutions being issued. For example: the Blood Donor Registry (REDOS) is a project that was originally discussed with the person responsible, Mabel Maschio. We started out with her, discussed the registry and then I put my team to work on its technical development and we’re currently carrying out pilot test projects. It will start operations in the next few months and Mabel has only recently started on getting the resolution approved. But the reason she’s doing that is she knows that she now has SISA, which can house the registry.
EHRLA: What other examples are there of a development path in which the construction project was followed by regulations after the fact?
MS: The same thing happened with the Federal Code of Establishments. Today there is a resolution that approves its existence but that approval came a year and a half after the record was operational. The record started operations, started to interact with the different provinces and after the product and record were functional in technical terms, the resolution appeared.
EHRLA: In percentage terms, how far has SISA’s implementation progressed?
MS: It’s definitely at 50 per cent.
EHRLA: What needs to be done for it to become fully functional?
MS: Currently SISA has three functioning pillars that you’ll already be aware of: healthcare resources, which are interdisciplinary establishments and the citizen’s record, which is a concept that includes nominal records for the citizen and healthcare services. Both are 80 per cent complete, developed, functioning and being improved as new options are added. The quality of the information is also improving. The third key to SISA is made up by the nominal records, this aspect is a little behind due to its complexity and because we only started on it relatively recently.
EHRLA: What are nominal records?
MS: For example, a professional will log in to SISA and upload a vaccination they administered to a patient, but the complete vaccination record is not yet completely implemented. The implementation of a nominal record, which is what NOMIVAC (Nominal Federal Vaccination Record) will be, is a job beyond the remit of the most dedicated programmer; it requires strategic planning by the authorities. You have to reach 7000 areas, 1500 hospitalization facilities, and private healthcare providers, it requires interaction, determining who will use the web service and who will provide patch updates, all of which needs several months of implementation work. And we still need to develop several more records.
EHRLA: Do these records exist physically on paper?
MS: Yes, there are healthcare plans at the Health Ministry but the information is shared in precarious ways. The most famous of these are the Remediar (Reparation) or Nacer (Birth) plans but there are a lot of programs; more than twenty. Some never saw the light of day because they didn’t have the chance to be computerized, such as the Department of Mental Health. This department is obliged by law to implement a center every two years for patients housed in neuropsychiatric wards but it has never had the necessary technology or support to equip such a center. Now, however, it will start to work with SISA. There are several cases like this in which the computerization has been carried out precariously, which need to be improved, where major gaps still need to be filled such as: vectors, community medical programs, several different billing models, maternity, infants and oncology.
EHRLA: Where does one start with so much still to do?
MS: The most important aspect is to consolidate the citizen’s record. The citizen’s record is an instrument in which a significant number of nominal records will be concentrated. We need to consolidate and develop it, analyze the information and define how it will be shared. The twenty records that today are kept separately, with different levels of implementation, will function from the citizen’s record.
EHRLA: The issue of sharing this information is pretty sensitive, isn’t it?
MS: Of course. That’s why the national and provincial political authorities need to issue good regulations. All the records contain sensitive information about people. How can we share it? Not everyone can see everything but the method for sharing the information needs to be regulated. And that’s more political than technical.
EHRLA: How do you go about getting the necessary political direction?
MS: I interact with the national political authorities, but we need to have involvement from people who can take decisions in every sphere. Sometimes a difficulty arises in that authorities want to see more results than we have available to finish evaluating and consolidating the strategy politically. It might be necessary to make a little more progress with the individual results for each record and when we have a few, maybe four or five nominal records working well, then we’ll be able to sit down and discuss the right political approach to take. Our work with the implementation of nominal records isn’t quite mature enough.
EHRLA: How will establishments and professionals in the provinces be trained to use these records?
MS: We have created a training format that can be implemented in person or remotely. There are two basic instruments: an online training guide for SISA users focused on the practical ways in which one learns to use each of the modules. The other tool is the training environment, which is a fictional replica of SISA that can be used for practice. We make these two resources available and when we go to the establishments to give a course in person we also leave printed material – which can also be downloaded as a pdf – that all those attending can use to replicate the course in their provinces if they so choose.
EHRLA: To sum up, what needs is SISA designed to resolve?
MS: Basically, the fragmentation of healthcare information. It is very likely that a complementary effect will be to help to resolve other forms of fragmentation, such as organizational fragmentation. It also helps to optimize resources because when the information is integrated into a technological project, much less money is spent on systems development. We are making a major investment which will then be used in many different spheres. It also optimizes human and equipment resources. The work is streamlined because the final objective is to reduce the number of information systems that will in turn optimize working procedures at different levels. This will be a significant but gradual change. In the national, provincial and private spheres, SISA will help to facilitate work, so that one isn’t always filling in hundreds of forms, so that we’re always using the same language, codes and criteria to make everyone’s job easier.
This story originally appeared at E-Health Reporter Latin America.