EL BLOG DE LA FIIAPP. Cooperación Española

The main aim of this European Commission-funded project to strengthen the management of the Tunisian health system is to implement a medical-financial information system in Tunisian hospitals. The project is being managed by FIIAPP. In other words, to improve the organisation of files and medical records to help reduce costs in the sector.

Carlos Armendariz is Chief Medical Director of the Castilla – La Mancha Health Service (SESCAM) and he worked as head of this European Union twinning project alongside Tunisian experts.

What progress have you seen in the six years since the project’s beginnings?

When we first started the project, the objective was to implement a medical-financial information system in sixteen hospitals. To do this, the first thing that needed to be done was to take a step that was unheard of here: consolidate the medical histories. The histories were scattered in different locations; if you went to seven different services over the course of a year, you would have a medical history in each of them. This is a totally antiquated way of working.

How are things different, now that patients have a single medical history?

Streamlining medical histories brings nothing but advantages. Each of the specialists a patient sees makes their notes, their diagnoses, treatments, and the next professional to see the patient knows what has happened before. The contextual information any doctor who sees a patient gets from this history is always crucial.

What else has been put into practice?

It was also important to make the professionals aware of how important it is that they complete a discharge report, which was not done in any of the hospitals. These discharge reports are not only beneficial, they are a patient’s right. This has been hard work because there was no custom or habit of completing them.

What is the next step?

The Tunisians who are involved in the project, alongside the Spanish experts, defined a Minimum Data Set (MDS) for Tunisia. This is a collection of data for every hospital process that allows the subsequent analysis of the hospital’s activity.  This means that you can know how many patients with pneumonia have been seen during a year, or which types of pneumonia have been seen, or how many appendicitis operations have been performed, etc.

How is it analysed?

By coding it. The coding allows more refined information to be obtained: it allows us to know the types of diseases, the procedures or techniques that a hospital has used. Births, surgeries, cardiac catheterisations, infection by this or that bug… Everything always has a code.

Has everything that was planned been achieved?

The project entailed a change in the way the Tunisian health system works that I think has been achieved, but it has been slightly hobbled. In the sense that, in a project of this magnitude, the change needs to be accompanied by mandatory rules. In Spain, how a file works is highly regulated, as is the length of time medical records must be kept, which documents they must contain, etc. And this has been done, but there is no national legislation requiring that these things be done.

Otherwise, I think that a great deal has been achieved. We have won over many followers in the hospitals, people who were initially very reticent who, when they saw the benefits and advantages of working in this way, became firm supporters. And as they are best able to recognise and acknowledge the advantages and disadvantages, they are the new system’s best advocates. Without these people the project would not have taken off.

What did you think of Tunisia personally?

Tunis reminded me a lot of Madrid at the end of the 1960s, when I was small. Working-class neighbourhoods like those on the outskirts of Tunis: houses with two or three storeys in run down neighbourhoods with unpaved streets. Otherwise, it is a Mediterranean country with a similar sensibility as ours in some things.

And with respect to health?

Very similar. There are old hospitals with old structures where it is not the same for patients as it is in our country, with rooms for one or two people. But when I was a medical student, in the Madrid Clinic there were rooms with eight patients. I think health care is like any other service, it adapts to the resources that society makes available to it.

The doctors generally have good training. They have a lack of resources and technology, probably, but I do not think that health care here is bad. It seems to me that it could improve, but the staff are knowledgeable and they know what they are doing. The results can certainly be as good as anywhere else.

When Margarita went to her Social Security hospital in El Salvador for her regular type 2 diabetes check-up, her medical record had disappeared. After hours of fruitless searching, she went in to see her doctor with a temporary (empty) file so that he could prescribe the appropriate medicines. Due to the lack of medical information, the doctor told her that he could not prescribe her glimepiride, one of the key drugs for treating her diabetes, until he had some accurate analyses of her medical condition. Margarita had to wait almost a month to get the result of the new clinical analyses, without receiving proper medication in the meantime. After nearly three months, the file was finally found, surprisingly, among the records of those who had died.

Managing medical records properly is essential for improving the treatment of patients and the exercise of their rights, as well as the effective and efficient functioning of the healthcare system. However, this is a daunting task that requires confronting huge challenges, such as a lack of storage space or human and financial resources. At the same time, the patients’ personal details must be properly protected and the complex process of transferring the files from a paper format to an electronic one must be carried out in stages.

Well aware of the pressing need to tackle this issue in El Salvador, the Institute for Access to Public Information (IAIP), the Ministry of Health (MINSAL) and the Salvadoran Institute of Social Security (ISSS) have joined forces with the aim of building the foundations for a new era in the management of medical records in this Central American country’s public healthcare sector.

The EUROsociAL+ Programme, funded by the European Commission and managed by the FIIAPP, is helping El Salvador with this process. As a first step, between 25 and 28 September, representatives of the three Salvadoran institutions visited Madrid to find out about the progress made and the challenges faced by Spain in this area. For a week, they were able to exchange experiences and lessons learned with the Ministry of Health, Equality and Social Services, the Castilla-La Mancha Health Service (SESCAM), the Community of Madrid’s Hospital Clí­nico San Carlos, the Ministry of Education, Culture and Sports General Sub-Directorate of State Archives and the Spanish Data Protection Agency. The visit included a tour of the Hospital Clí­nico San Carlos archives and the Central Archives of the State Administration in Alcalá in addition to a presentation of the lessons learned from the Tunisian electronic file project headed by the FIIAPP and funded by the European Union.

This activity was the first step in promoting inter-institutional dialogue in El Salvador, advancing toward creating operating instructions and new regulations, and promoting cultural change, which is needed in order to improve the quality of healthcare in this Central American country.

Borja Díaz Rivillas, Senior Officer of Democratic Governance. EUROsociAL+

In El Salvador, few topics go as unnoticed in public and media agendas as the management of medical records. The irony is that these documents contain sensitive personal information on the health of thousands of people that should be protected with the highest quality standards. This issue is even more important in the public healthcare sector (Encuesta de Hogares de Propósitos Múltiples (Multi-Purpose Household Survey) 2014, DIGESTYC-MINEC).

Between January and March 2017, the Institute for Access to Public Information (IAIP) carried out a series of interviews with key staff in the Ministry of Health (MINSAL) and the Salvadoran Social Security Institute (ISSS) to gather preliminary information on some aspects of document management and personal data protection. The information will help the IAIP, as the governing body in this area, to issue guidelines regarding these matters. A complex reality was revealed by these first interviews.

In terms of standardisation, at least six documents were found that contain different criteria for handling medical records. However, there is no standard management process for the entire public sector. For example, filing documents has become a problem that is literally overwhelming the public health system. Although it is not the same at all care centres, there are warehouses in which these documents are stored with no other criterion than their weight in kilos.

Another finding was that there is little or no knowledge about ARCO rights (Access, Rectification, Cancellation and Opposition to information). On the one hand, there are healthcare operators that do not guarantee full exercise of these rights and, on the other, users who do not demand them. But how to demand a right that is not known by those who must guarantee it?

In the interviews, challenges in managing medical records appeared one after another. Almost all the interviewees agreed on the need to migrate to single electronic formats. Something that, among other benefits, would permit the interoperability of the information. In other words, having access to the medical history of a patient for an operation from wherever he or she might be. But although there are ample arguments in favour, the possibility of migrating collides with another reality: Implementing this would require a significant financial investment. Preliminary data, provided by both institutions, show that this would be an investment of approximately $40 million. But, even in a favourable scenario, standardising management does not end with migrating to an electronic format. In fact, whatever action is taken to implement it, at least two initial challenges must be faced.

Firstly, standardising the documentary management and personal data protection of records that are currently kept on paper. In other words, what to do with what there is. Secondly, a commitment by all those involved in managing these documents, apart from the MINSAL operators.

The IAIP, as the body governing document management and personal data protection, could simply issue guidelines and verify that they are complied with. But is this what interests us? Delimiting our involvement in these two actions would mean denying an extremely complex reality that finds expression in many dimensions. The management of medical records, in this case in the El Salvador public health sector, requires, first of all, an in-depth institutional dialogue that will permit the design of a path toward the necessary changes. To do this, it is also necessary to know how similar processes were developed in other countries in Latin America and the European Union. Otherwise, however well-designed the regulation is technically, it would not be sustainable over time.

Alicia Miranda Duke is the head of studies and research at the Institute for Access to Public Information (IAIP) in El Salvador