Sergio Miranda Freire

Modeling healthcare authorization and claim submissions using the openEHR dual-model approach

BackgroundThe TISS standard is a set of mandatory forms and electronic messages for healthcare authorization and claim submissions among healthcare plans and providers in Brazil. It is not based on formal models as the new generation of health informatics standards suggests. The objective of this paper is to model the TISS in terms of the openEHR archetype-based approach and integrate it into a patient-centered EHR architecture.MethodsThree approaches were adopted to model TISS. In the first approach, a set of archetypes was designed using ENTRY subclasses. In the second one, a set of archetypes was designed using exclusively ADMIN_ENTRY and CLUSTERs as their root classes. In the third approach, the openEHR ADMIN_ENTRY is extended with classes designed for authorization and claim submissions, and an ISM_TRANSITION attribute is added to the COMPOSITION class. Another set of archetypes was designed based on this model. For all three approaches, templates were designed to represent the TISS forms.ResultsThe archetypes based on the openEHR RM (Reference Model) can represent all TISS data structures. The extended model adds subclasses and an attribute to the COMPOSITION class to represent information on authorization and claim submissions. The archetypes based on all three approaches have similar structures, although rooted in different classes. The extended openEHR RM model is more semantically aligned with the concepts involved in a claim submission, but may disrupt interoperability with other systems and the current tools must be adapted to deal with it.ConclusionsModeling the TISS standard by means of the openEHR approach makes it aligned with ISO recommendations and provides a solid foundation on which the TISS can evolve. Although there are few administrative archetypes available, the openEHR RM is expressive enough to represent the TISS standard. This paper focuses on the TISS but its results may be extended to other billing processes. A complete communication architecture to simulate the exchange of TISS data between systems according to the openEHR approach still needs to be designed and implemented.

Survey of openEHR storage implementations

Efficiently storing and retrieving archetype-based patient information can be a challenging task. This paper surveys current archetype-based system implementations in the world and in particular the different approaches that have been used to create 13606- or openEHR-based storage repositories. Data is reported from systems with a few records to millions of records, including both deployed systems in production and experimental systems. Worldwide 21 projects were found, 4 did not reply and 1 did not provide data. Many systems (n=11) base their storage on RDBMS, then often (n=6) with some XML data fields. Dedicated XML (n=3) and object-oriented (n=2) databases were other examples of storage used. Query formalisms used include SQL, AQL, XQuery and XPath. Service interfaces via SOAP (n=12) or REST (n=6) are common. Most systems support dynamic configuration using new/changed archetypes and templates dynamically without system restart. Some (n=7) systems use demographic archetypes. In addition to the built in DBMS indexing mechanisms, one project reports use of an additional inverted index to achieve improved performance.

A record linkage process of a cervical cancer screening database

This paper aims at to present the integration of the files of the Brazilian Cervical Cancer Information System (SISCOLO) in order to identify all women in the system. SISCOLO has the exam as the unit of observation and the women are not uniquely identified. It has two main tables: histology and cytology, containing the histological and cytological examinations of women, respectively. In this study, data from June 2006 to December 2009 were used. Each table was linked with itself and with the other through record linkage methods. The integration identified 6236 women in the histology table and 1,678,993 in the cytology table. 5324 women from the histology table had records in the cytology table. The sensitivities were above 90% and the specificities and precisions near 100%. This study showed that it is possible to integrate SISCOLO to produce indicators for the evaluation of the cervical cancer screening programme taking the woman as the unit of observation.

Validation of Models for Predicting the Use of Health Technologies

Validation must be carried out before a model can be used confidently as a tool of managerial decision making in health care. The authors describe a bootstrap approach to validating models for predicting the utilization of four technologies used in neonatal care: measurement of blood gases (gasometry), the oxygen hood, continuous positive airway pressure (CPAP), and mechanical ventilation. These models were fitted by stepwise multiple linear regression from 20 prognostic covariates of 193 neonates. One hundred bootstrap samples were generated to validate the choices of covariates in the models based on their frequencies of selection. This approach validated the models for the oxygen hood and CPAP. The regression coefficients and standard deviations for the CPAP and oxygen hood models were estimated using 200 additional bootstrap samples. A close agreement between stepwise and bootstrap estimates was observed for both models. These results suggest that bootstrap can be useful for validating models for predicting the utilization of health technologies Key words: ne onatal intensive care, forecasting; health facility planning; health technology; bootstrap; model validation; regression analysis; linear models. (Med Decis Making 1998;18: 311-319)

Sistema de informação para integrar os dados da assistência oncológica ambulatorial do Sistema Único de Saúde

This study focuses on the development of a system to integrate monthly outpatient cancer care data in the Unified National Health System (SUS). The system was modeled to retrace the treatment evolution in each cancer case and services output, with the following advantage: the system focuses on the cancer case, does not require knowledge by the user in order to handle the database, and allows updating the base as new data emerge. The results of direct queries in the system were identical to those obtained from direct inspection of the original database and those from another integration approach. The use of a tool with these characteristics by public administrators can help improve the quality of outpatient cancer care provided by the National Health System.

The nursing process and its application in intensive care at Rio de Janeiro as a support to the development of an electronic patient record

This study aims at evaluating the utilization of the nursing process in intensive care units in the metropolitan area of Rio de Janeiro, in order to identify the potential conditions for the deployment of a computerized system in those units. Interviews with 27 nursing team leaders were performed in the period from January to July 2003. The interviews revealed that: the nursing process was not fully implemented and not systematically including the nursing diagnostic stage; 13 units had nursing prescription forms, but only 11 released them; and, 5 units used some type of computerized information system. From the forms so obtained, 128 different nursing actions were identified with high variability of use and no existence of standards for data recording. In this scenario, it can be concluded that the conditions for a computerized system for the nursing process are not adequate.

Relação entre índice de resistência obtido pela ultra-sonografia Doppler transfortanela e o neurodesenvolvimento até o primeiro ano de vida em recém-nascidos a termo com encefalopatia hipóxico-isquêmica leve e moderada

OBJECTIVE To evaluate the relation between the resistance index (RI) obtained by transfontanellar Doppler ultrasonography, and the neurodevelopment until one year of life, at term newborns with mild or moderate hypoxic-ischaemic encephalopathy due to intrapartum asphyxia. METHOD 20 term newborns, with mild or moderate hypoxic-ischemic encephalopathy, high values of resistance index in the first exam, and without cerebral morfologic abnormalities or other diseases. They were submitted to serial bimonthly transfontanellar Doppler ultrasonography, from the seventh day of life on, and monthly clinical neurodevelopment assessment until one year of life. RESULTS There was a progressive normalization of RI values until the last examination. In five cases there were clinical neurologic normalization in the neonatal period after the first Doppler exam. Fifteen infants presented neurologic abnormalities, with normalization after the second trimester of life. CONCLUSION There was a relation between the normal RI values with the normalization of the clinical assessment.

Integrating Brazilian health information systems in order to support the building of data warehouses

IntroductionThis papers aim is to develop a data warehouse from the integration of the files of three Brazilian health information systems concerned with the production of ambulatory and hospital procedures for cancer care, and cancer mortality. These systems do not have a unique patient identification, which makes their integration difficult even within a single system.MethodsData from the Brazilian Public Hospital Information System (SIH-SUS), the Oncology Module for the Outpatient Information System (APAC-ONCO) and the Mortality Information System (SIM) for the State of Rio de Janeiro, in the period from January 2000 to December 2004 were used. Each of the systems has the monthly data production compiled in dbase files (dbf). All the files pertaining to the same system were then read into a corresponding table in a MySQL Server 5.1. The SIH-SUS and APAC-ONCO tables were linked internally and with one another through record linkage methods. The APAC-ONCO table was linked to the SIM table. Afterwards a data warehouse was built using Pentaho and the MySQL database management system.ResultsThe sensitivities and specificities of the linkage processes were above 95% and close to 100% respectively. The data warehouse provided several analytical views that are accessed through the Pentaho Schema Workbench.ConclusionThis study presented a proposal for the integration of Brazilian Health Systems to support the building of data warehouses and provide information beyond those currently available with the individual systems.

Implementation of a fault-tolerant PACS over a grid architecture

The goal of this paper is to describe the experience of the Heart Institute (InCor) on the implementation of a fault-tolerant Picture Archiving and Communication System (PACS) over a data grid architecture. The system is centered on a DICOM image server with a distributed storage and failover capability. The proposed data grid architecture is deployed over a gigabit Ethernet network which integrates the two main public Hospitals in Sao Paulo and one University Hospital in Rio de Janeiro, both in Brazil. Distributed data storage in the three sites is managed by the Storage Resource Broker (SRB) developed at the University of California at San Diego. The architecture of the implemented PACS image server can be divided into two major functional modules: a) DICOM protocol handler; b) Distributed storage of image data. Fault-tolerance is achieved by injecting redundancy into the modules, which are provided with failover capability. The DICOM protocol handler comprises a series of server processes hosted by different machines and a load-balancer node which distributes the computational load among the servers. The load balancer is provided with a backup node which is triggered in case of failure, thus assuring the continuous operation of the system. Distributed storage of image data is implemented as a thin software layer over the SRB. Image data are replicated at the three sites, so the PACS server is able to retrieve image data even when only a single site is available. A prototype of the DICOM image server has been deployed in this environment and is currently under evaluation.

Avaliação da proteína amilóide A sérica na atividade clínica da artrite reumatóide

A artrite reumatoide (AR) e uma doenca auto-imune, cronica, caracterizada pelo comprometimento inflamatorio das articulacoes sinoviais perifericas. A proteina amiloide A serica (SAA) e uma das principais proteinas de fase aguda (PFA), porem seu uso na rotina do laboratorio clinico ainda e pouco difundido. OBJETIVO: O objetivo deste trabalho foi analisar a utilidade da SAA na avaliacao da atividade clinica da AR. METODOS: Foram estudados 113 pacientes com AR, diagnosticados segundo os criterios do Colegio Americano de Reumatologia. Para a caracterizacao da atividade de doenca, foi utilizado o Indice de Atividade de Doenca (IAD), proposto pela Liga Europeia Contra o Reumatismo. RESULTADOS: A SAA apresentou correlacao positiva, estatisticamente significativa, com a proteina C-Reativa (PCR), tanto como a α-1-glicoproteina acida (AGP), quanto com o IAD. Nossos resultados demonstraram que a SAA apresentou, particularmente, uma maior sensibilidade na determinacao da atividade inflamatoria da AR, em comparacao as outras PFA. Apresentou, tambem, uma boa capacidade de discriminar os grupos de atividade moderada e alta do IAD. Como o IAD nao mede unicamente o componente inflamatorio da AR, a dosagem de uma PFA e de grande utilidade para a caracterizacao da atividade dessa enfermidade. CONCLUSOES: Os resultados deste estudo sugerem que a SAA pode ser de grande valor na determinacao da atividade inflamatoria da AR.