How Portugal is advancing the use of eHealth in Europe

An interview with Diogo Martins, international projects coordinator at the Portuguese health ministry's central purchasing and IT authority, SPMS.
By Leontina Postelnicu
10:47 AM

Update: HIMSS20 has been cancelled due to the coronavirus. Read more here.

In the past year alone, a number of developments point to signs of Europe strengthening its foothold in the global digital health space. Innovators are excited about Germany's new Digital Care Act and consumers about the sharing of ePrescriptions between EU countries.

But these are only two initiatives of the kind. Ahead of HIMSS20, Healthcare IT News caught up with Diogo Martins, international projects coordinator at the Portuguese health ministry's central purchasing and IT authority, to find out more. 

This interview has been edited for length and clarity.

Healthcare IT News: Could you give our readers an overview of the SPMS’ (Shared Services of the Ministry of Health or Serviços Partilhados do Ministério de Saúde) role in Portugal, where it fits into the healthcare system, and your work there?

Martins: The Shared Services of the Ministry of Health (SPMS) was co-created in 2010, as a state-owned enterprise (SOE), by the Ministry of Health and the Ministry of Finance to better position Portugal for future health care challenges within the global economy. As such, our core mission is to both develop and provide shared services to all entities that constitute the Portuguese NHS, from local health providers to national authorities.

In order to support the operationalisation of our mission, SPMS was endowed with three major competences: SPMS is the central purchasing authority of the Portuguese Ministry of Health, it is the National ICT Authority for public health matters, and it is the National Authority for eHealth cross-border affairs.

Focusing on the Portuguese health reality, our NHS encompasses 54 hospitals and 359 primary care units to assist over 10 million citizens. We can affirm that our NHS is well integrated on a national scale since approximately 90% of our health providers entities use ICT solutions developed by us, both for health care and administrative processes. This undoubtedly facilitates the interoperability of information on a national scale.

I have been working at SPMS for three years. I started as a project manager in the field of telemedicine and the sharing of health information across hospitals. Though, as transnational challenges became more complex, the need to have a public authority for cooperation in digital health has become evident at European level. Thus, following the initiative of the SPMS' board of directors to create a Project and International Relations Unit, I was proposed to coordinate it.

Since then, I am coordinating a team that is developing new calls for joint projects in Europe in the areas of eHealth cooperation, ICT development and public procurement. Currently, I coordinate a nine-person team which manages eight international projects, two of which as a coordinator.

Our projects match our vision for a future European eHealth ecosystem. To this end, the areas of focus are interoperability, semantics, sustainability, innovative use of health data and, of course, the different challenges that can be overcome in terms of data exchange across borders.

HITN: Given your role, what would you say is the current state of digital health in Portugal at the moment? What are some of the most significant initiatives at a national level that you believe are driving forward the digital agenda for the benefit of citizens and staff alike?

Martins: I would like to start with a shift in momentum. In 2017, there was this resolution issued by the Council of Ministries supporting digital health. Of course, this was already in the agenda as a strategic priority for our Ministry of Health, but this was an important momentum, where the Council of Ministries was really pointing out the importance to achieve and put the citizens at the centre of the system in terms of digital health and access to health data.

This shift in momentum was emphasised by the creation of our first national strategy towards a health information ecosystem, bringing in different aspects such as access to health data portability, open data interoperability, and cross-border aspects. I believe this was a major step forward to foster digital health in Portugal in a more efficient way.

At the national level, I would like to highlight flagship international projects such as the paperless prescription. At this stage, approximately 98% of the Portuguese hospital sector, including both private and public entities, operate paperless prescription services in the primary care. For doctors, SPMS has deployed the possibility to prescribe through their own mobile phone by a safe process. From a societal perspective, citizens may now have their own medicines dispensed at any pharmacy without fearing the typical concern of losing or forgetting their prescription paper.

One important backbone of information that I would like to bring to your attention is our electronic health record (EHR) portals, made up of two areas: the citizen area and the professional area. Starting with the citizen area, it is possible to do such things as online screening for diabetes and obtain referrals to primary care units automatically. It is possible for you to add emergency contacts, health habits and so on. The immunisation records are also in place in this module, it is possible for me as a citizen to check what is my immunisation record and if there is a need to download it through a PDF. This information is available for the primary health care sector, private sector, hospitals, pharmacies, and, of course, in the end, it can be used by international vaccine centres. This is the area where the citizen engages with the system.

In terms of the professional area, this is the system that supports the clinical procedures. All healthcare professionals that work in the NHS can access the EHR data between the different healthcare facilities in terms of primary care units and tertiary care units. Basically, a hospital in the north can check, for example, the electronic health record provided by hospitals in the south. They can even do some teleconsultations between hospitals and units. Our main scope will be to enlarge this service by the end of 2020, in order to make grant citizens the opportunity to do teleconsultations with physicians or with the nurses.

HITN: The initiatives that you have launched are very interesting and it is clear that many in Europe would benefit from learning about your experience. When we look at digital health over here, however, many talk about the Nordics or the Netherlands first. Why is that the work being done in Portugal is not known more widely?

Martins: Acknowledging SPMS as a public enterprise, one of our main ambitions is to effectively deploy concrete services to the citizen. That is to say, our vision is to interoperate all kind of health services and provisions. Even though we are pretty state-driven in terms of access and (re) use of data, I think it is kind of a strategy. From 2010 unto now, these features were achieved to try to make the shift on the use of interoperability, the use of the new methodology, and to develop software that can devise this type of infrastructures. 

Concerning the visibility of SPMS' work abroad, I believe it is due to our country's size, with only 10 million citizens. We are not a huge country, like, for example, like France and Germany. Still, if you look at EU level cooperation and deployed information, you would assess, in particular in OECD documents, that Portugal action in the areas of telehealth, information systems stand at the forefront of the sector.

HITN: Later this month, you will be speaking at the HIMSS20 conference about the International Patient Summary. What can you tell about it and how it is supporting patient mobility abroad?

Martins: It is important to remember the path taken to achieve the operationalisation of Patient Summary and ePrescription services. It may look that we have created these services from one year to another. Yet, in order to deploy them, these cross-border services datasets needed to be underpinned by legal and organisational framework therewith semantic and technical specifications. This was a long cooperation process.

The patient summary contains the fundamental information of each patient so that health professionals can have at their disposal the necessary information for urgent and/or unscheduled care at a national or foreign health entity.

The current Patient Summary service holds six main attributes. These are the patient's: identification, allergies, chronic medication, immunisation information, medical and nursing diagnosis and medication procedures and services.

There was a kind of a momentum where we had to make some technological adjustment to update the service in accordance with the commonly agreed standards for cross-border interoperability. In particular, with HL7 FHIR.

HITN: Could you give us a few examples?

Martins: Of course. One good example is the immunisation record scenario. In the near future, every single Portuguese citizen, having access to the citizen portal, mHealth app, can indeed benefit from the digital card for immunisation systems, when travelling abroad, [showing it to] a healthcare provider.

For example, Diogo wants to travel to Bali, in Indonesia, and there is a need for a specific vaccination in the country of travel in which local authorities are going to check the immunisation records. There are two scenarios.

The first one it is that Diogo was assessed previously by digital means, that his tetanus vaccination is outdated and it is possible for him to go to an appointment and have this information updated in the system and later on to have the immunisation records updated with information that he can provide abroad or to the healthcare provider. One of the use cases is, how can we support the travellers in terms of the immunisation records at the national and of course at the cross-border level.

The second scenario is the possibility to check immunisation and allergies in an emergency event after an accident. For example, I am travelling to the US and am going to rent the car. Let’s say, I have an accident and I will have in my pocket the information already in a structured and coded way. Due to the fact that this is coded information, this information can be assessed by healthcare providers, or it can be checked in different types of languages due to the SNOMED translation.

Presently, our main ambition is, when travelling abroad, the patient holding the means to automatically translate its allergies, and of course, vaccination records to that specific country's mother tongue. In the end, we want to provide later this for all of the data. Still, there are some challenges to overcome.

HITN: Right. When you say that there are some challenges, what specifically are you referring to?

Martins: By some challenges, I am specifically referring to the work that needs to be done in terms of empowering people through e-skills, raising awareness on the availability of these services for citizens and the level of the assurance that they have. This is related to consent, authorisation and awareness of the existing services. Moreover, it is about the interoperability of health data and, of course, the type of investment that needs to be put into semantics and interoperability at the local, regional and national level. 

HITN: And I think these are challenges that everyone is facing, looking more widely. In Europe, however, how are you supporting others to deploy key use cases and help citizens from other countries across the EU get access to this kind of services?

Martins: One of the good features that I believe can be learned in Europe is that we are investing in these international affairs as an early implementer of patient summary and ePrescription activities in the scope of eHealth digital services. I stress the importance of understanding the effort carried out by pioneer countries such as Estonia, Finland, Malta, Luxembourg, Czech Republic and Croatia in these cross-border activities.

And I think this is due to the fact that, early in 2012, we understood and seized the opportunity to share best practice aimed at defining some common datasets to start sharing health information, because, in the end, all of these countries are facing concrete challenges in terms of, how can the health systems in the future be sustained, and how can digital help support these specific activities.

I think one of the things that need to be understood is that we started on the basis of using open-source resources that are developed by technicians from the different member states that, in the end, can be reworked and applied for their national health care services.

HITN: Lastly, at the moment, there is a lot of buzz around the ambition to create a European Health Data Space, and I wanted to get your thoughts on it. Do you think this is a realistic goal, given that we know that several countries in the EU are still behind or are running on paper based-processes?

Martins: Innovation is always a good thing, so I think these moonshot initiatives are of remarkable importance to be debated and discussed. We need to keep in mind that this is the first time that we moving the discussion from primary care to secondary care. That is to say, to start discussion use and reuse of health data for other purposes, such as research, innovation and wellbeing.

Right now, one thing I can say. I believe is the opinion of the vast majority of players in the sector, the potential of an EHDS is huge. While recognising that the different interests to develop the EHDS, I believe that it is possible to achieve with the current mindset and with the support of the European Commission and the different member states.

Diogo Martins will be speaking at HIMSS20 in the 'International Patient Summary: Cross-Border Interoperability on a Global Scale’ session on Wednesday 11 March in Hall E - Booth 8300 - Education Theater. You can also find SPMS at Booth 8300-22 where they will be running an Interoperability Showcase.​ HIMSS20 will be taking place from 9-13 March at the Orange County Convention Center in Orlando, Florida. 

Healthcare IT News is a HIMSS Media publication.

More regional news

(Top row: left to right) Dr Charles Alessi, HIMSS, Dr Peter Gocke, Charité in Berlin (Germany)

(Bottom row: left-right) Dr Afzal Chaudhry, Cambridge University Hospitals (UK), Dr Jan Kimpen, Philips (Netherlands)

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