Joining efforts to reach optimal quality and equity. Bernat Soria. eHealth Conference 2009. (Praga, 2009).

1. The Spanish National Health System
Ministry of Health and Consumer Affairs
JOINING EFFORTS TO REACH OPTIMAL
QUALITY AND EQUITY
Bernat Soria, MD, PhD
Minister of Health and Consumer Affairs

2. SPANISH NATIONAL HEALTH SYSTEM
UNIVERSAL COVERAGE
NATIONAL HEALTH SYSTEM
SOCIAL SECURITY Coverage (SINCE 1986)
SYSTEM (UNTIL 1986)
Insured population All citizens covered
Includes
Restricted to active immigrants
employees and their
families
1986 2006
Primary
First Primary 13.000 Primary
Healthcare
Healthcare Healthcare
Centres built Centres

3. SPANISH NATIONAL HEALTH SYSTEM
I. Among the best in the world
- Ranked 4th among the 19 most developed countries
Health Affairs ( Health Affairs 27: 58-71 (2008);)
- Ranked 6th among 191 countries
British Medical Journal (2001)
- Ranked 7th among 191 countries
WHO (World Health Report 2000. Health Systems. Improving performance )
II. Number one in the world in organ transplantation
FIRST IN THE WORLD IN CADAVERIC ORGAN DONATION. SPAIN, EU-27 AND USA
COUNTRIES SPAIN EU-27 USA
Population
(million inhabitants) 45.2 492.3 303.9
Cadaveric Organ Donor 1,550 8,293 8,089
(Rate –pmp-) (34.4) (16.9) (26.6)

5. BACK TO THE FUTURE:
QUALITY AND INNNOVATION STRATEGIES
5 GOALS.12 STRATEGIES
189 PROJECTS
HEALTH STRATEGIES
CLINICAL EXCELLENCE
e-HEALTH
KNOWLEDGE MANAGEMENT

6. ICT: Information and communication technologies
Consultations in Health Centres
Hospital activity in laboratory tests
National Health System 2007 8
National Health System 2007 9
with ICT with ICT
97% 99.8%
no ICT
3%
no ICT
with ICT no ICT 0.2%
with ICT no ICT
8 Information from Region of Valencia and Andalusia has not been 9 Information from Andalusia, Region of Valencia, Galicia and
included in the figure Cantabria (TI) has not been included in the figure
Source: red.es from data supplied by the regional Departments of Health Source: red.es from data supplied by the regional Departments of Health
Patient management system: External hospital consultations Patient management system: Hospital emergencies
National Health System 2007 National Health System 2007
10 11
with ICT with ICT
99% 98%
no ICT
no ICT 2%
1%
with ICT no ICT
with ICT no ICT
10 Information from Andalusia and Region of Valencia has not been 11 Information from Andalusia and Region of Valencia has not
included in the figure been included in the figure

7. e-HEALTH: ELECTRONIC HEALTH
RECORD IN SPAIN
JOINING EFFORTS TO REACH THE FUTURE
- Digital health records
- Personal health card
- Electronic prescription

8. EHR IMPROVEMEMENTS
1998-2008
• All the regions have developed EHR:
- 90% primary health care doctors have access to EHR
- 14 regions have developed advanced
processes of implementation in specialist health care
- 95% of electronic prescription in primary health care
• The national government has supported this effort with 141 additional millions
(2006-2008)
• The Ministry of health has developed a central point of exchange and a central
database of Personal Health Card with an unique number of identification for
each citizen
• Electronic prescription: where implemented, 22% unnecessary visits to General
Practitioners

9. CITIZENS AND HEALTHCARE SERVICES. II.
HEALTHCARE
Digital medical record in health centres and population covered
National Health System 2007
100.00%
90.00%
80.00%
Population with Health Card
70.00%
60.00%
50.00% 100% 98.8%
40.00%
30.00%
20.00%
10.00%
0.00%
Population with Primary care EHR
health card software
registered at health
centres

10. Implementation of the main information systems linked to the electronic health record7
National Health System 2007
Health Centres Hospitals
National Health Service healthcare centres
4%
100% *
3% 8%
12% 15% 16%
90%
38%
80%
70%
60%
50% 97%
96% 92%
88% 85% 84%
40%
62%
30%
20%
10%
0%
Picture
Hospital Radiology Pathology
Primary Single- LAB
Archiving
Information dose
care EHR cal
Information
Management Pharmacy Anatomy and
Systems Systems
software
Communication systems
with ICT no ICT

11. JOINING EFFORTS WITH THE
REGIONS AND THE HEALTH
PROFFESSIONALS
In developing EHR in each region
In Creating an unified database of personal health cards for all the
countries
In agreeing common clinical guidelines
In agreeing common technological standards

12. EHR: THE CHALLENGE
• 4.5 million people receive every year clinical assistance in a
different region than the one they come from
• We have to develop a project for the whole country to
guarantee the access to the clinical information at any place
and any time regardless where it has been generated

13. INFORMATION CIRCULATES

14. COLLABORATION IN BUILDING
AN UNIFIED PERSONAL HEALTH
CARD DATABASE
803410
ANDALUCIA
ARAGÓN REGION DE MURCIA
CONSEJERIA DE SANIDAD Y CONSUMO
S.N.S. SERVICIO MURCIANO DE SALUD
01
803408 FRVR5608149009015
300078991111
743295999X CADUCA 12/ 99
F JAVIER XXXXXXXXX XXXXXXXXXXX
.
803411
• With an unique identifier for each person
• Developed in collaboration with the 17 regions
• Integrated with all the EHR of the Country
• Universal coverage (45 million users)

15. AGREED SCOPE AND CONTENT
Scope: To provide professionals and citizens with access to any clinical datasets that are
relevant for healthcare (including diagnostic imaging)
Patient Summary
Electronic documents: Primary healthcare reports
Emergencyde Urgencias
Informes Room Reports
Discharge & Sp. y Consulta
Informes Alta Surgery rep.
Nursing Care reports
Lab tests
Imaging
Imagen
Other tests
Otras pruebas

16. HOW?
Professional Consensus (37 Professional Citizens and
Technical Associations)
Agreement on the contents of the e-documents
Work Groups: Group 1 C. Discharge Report
Consultation Report
Group 2 Emergency Room Report
Group 3 Summarised Medical Record
Primary Health Care Report
Group 4 ARS
Group 5 Lab Tests Report
Group 6 Imaging Tests Report
Imaging Attributes
Group 7 Nursing Care Report

17. No Central Data Base but Exchange Data System
Healthcare
Intranet
SNS
Central
node
Regional Healthcar
e
Intranet
Regional
Node
Healthcar
e
Healthcar
e
Healthcar
e
Healthcar
e
Healthca
re
Healthc
are
Healthcare

18. Online patient referrals to specialized care: implementation and use
National Health System 2007
Healthcare centres with Annual patient referrals
online patient referral arranged online*
systems
36%
67%
Health centres 33%
9,283,836
without online
patient referral 64%
systems
2,256 health
centres with
online patient
referral systems
Online referrals
Healthcare centres with online referral
systems
Traditional referrals
Healthcare centres without online referral
systems
Source: red.es from data supplied by the regional Departments of Health

19. 60 Million Centralized Appointments in 2007
(data from one region of 8 million inhabitants)
Web
Centralized BDU
appointment
Back Office
Telephone
CEIS
Users
eMail
Presential
Data Warehouse
Others channels

20. OUTCOME: Improve effectiveness in primary care
Provides users with access to pharmaceutical facilities thus
making it unnecessary for patients in poor health to go in person
Simplifies and speeds up authorization of prescriptions
Increases time devoted to patients. 22% LESS OF UNNECESARY
VISITS….22% MORE OF AVAILABLE TIME OF GPs
Entire treatment prescribed by specialists
Possibility of better support for correct prescription
Significant promotion of Pharmaceutical Assistance
Reduction of management expenses and billing of prescriptions.
Improved follow-up and control of rational use of drugs (RUD)
Correct assignment of responsibility in RUD among levels
Greater control in alerts and pharmacovigilance programs

21. Breast Cancer ( results of the comprehensive approach) Health area
of 1.2 million people
2003 2005
1st visit after GP referral, average time
• 8.2 days 3.4 days
• Mammogram delay after request, average time 37 days 8 days
• Pathology diagnostic report after biopsy 5 days Same day
• Surgical average time after diagnosis 37 days 16 days
1st visit in less than 1 week after GP referral
• 60,6% 92,8%
• Surgery in less than 1 month after pathology 63,44% 96,29%
• Conservative surgery 30% 62%
• Request for mammograms, percentage from 2003 --- -24%
• Global Patient Satisfaction 85.01% 93.3%

22. 2008 marks a new era in legal and policy
framework for EU Cooperation on eHealth
• Proposal for a European Directive on patients’ rights in cross-border
healthcare
• Commission Recommendation on cross-border interoperability of
electronic health record systems
• Commission Communication on telemedicine for advanced home
care and chronic diseases
• eHealth Standardisation Mandate 403

23. epSOS – a highly political project
• Member State obligation to deliver the best possible medical
treatment – at home or when travelling
• Introducing a new dimension in national healthcare systems
• Main political objectives:
– support patient mobility nationally and in the EU
– ensure that patient safety is guaranteed
– increase efficiency and cost-effectiveness
in cross-border care

24. CONCLUSSIONS
The EHR is being implemented in each of the 17 regions
(90% Primary Care)
It has been created a national database with more than 40 million
users
We are implementing through a collaborative effort EHR for
the whole country (starting on March 2009 with 10 regions
representing more than 60% of the Spanish population)

25. The epSOS Project Team
• The Project Team consists of 27 beneficiaries from 12
member states:
– 9 National Ministries of Health
– 16 National/regional Competence Centers Including
100+ Contributors
– IHE-Europe representing ICT industry team
– Empirica responsible for administrative management

26. Reminder - From Strategies to Services
• Provide concrete cross border services that ensure safe, secure
and efficient medical treatment for citizens when travelling across
Europe
• Focus on services close to the patient:
– European Patient Summary
– ePrescribing across the EU
• Build on existing National eHealth Projects and use experiences
and knowledge from all Member States

27. TO MOVE THE AGENDA
FORWARD
THE NATIONAL AGREEMENT FOR
HEALTHCARE (TO BE SIGNED IN
JUNE 2009)
• Involving the 17 Regions
• Involving all the Political Parties
TOPICS OF THE AGREEMENT
• Human Resources Policy
• Common Services
• Sustainability of the Health Budget
• Health Policies
• Quality and Innovation
• Prevention of Addictive Drugs
Consumption

28. NHS SPAIN
Barcelona
2010, 15-18
march