Henrique Manuel Gil Martins, chairman of SPMS (Shared services of the Ministry of Health) provides an insight into the uptake of technology in Portugal’s Ministry of Health and National Health Service (NHS). Furthermore, he describes the importance of becoming more technologically aware as it reduces costs and makes health activities much easier.
Can you provide a brief overview of SPMS and its role in Portugal’s healthcare system?
“Portugal is unique in Europe as it has electronic health records designed by the government in primary care and hospitals”
SPMS is a young agency that was created eight years ago as the first shared the government agency with the intention of building solutions that are used for different facilities and entities of the ministry.
SPMS started to have a significant role in healthcare in 2012, when the previous government made the decision to move the IT department to the agency. The reason behind this change was simple; they wanted to join procurement (centralized procurement, framework agreements, and all legal instruments) with IT—to make expenses clear.
The agency addresses several kinds of procurement, not framework agreements but buying on behalf of companies. SPMS began with vaccines, then therapeutic components, and over the years with the change of government it increased its offering. Today, the SPMS buys more than one billion Euros of drugs. The SMPS also acts as the central procurement agency for the Ministry of Health, which involves purchasing various product categories that hospitals, need from helicopters to paper, computers, paracetamols, HIV drugs, electricity, etc.
The primary activity representing 60 to 70 percent of the revenue derives from IT projects. Portugal is unique in Europe as it has electronic health records designed by the government in primary care and hospitals. The software hospitals use for most functions (admitting a patient, documentation, discharge) are produced by SPMS’s team.
Furthermore, we manage many national projects, such as the Portuguese electronic vaccination card, the electronic death certificate, and the tuberculosis electronic notification system. The SPMS has been working on more than a dozen projects nationwide in the last few years.
How has the company developed in recent years?
Recently, the company has evolved to incorporate an academic function and now provides support to agencies in the Ministry to teach. Using processes and trainers certified by the Ministry of Education, e-learning and real learning the SPMS offers teaching assistance.
Since 2018, the SPMS has taken on the communication and marketing unit for the Minister of Health and runs the Facebook page of the NHS. We run promotional videos for vaccines, healthy eating and the importance of exercising across social media. All the communication for the ministry is carried out by the SPMS communication team.
Finally, a minor function of SPMS is logistics, as we operate in warehouses and distribution.
Switching operations of procurements and digitalization from multiple actors to one agency, the SPMS, must have been challenging. How did pharmaceutical companies and hospitals welcome the introduction to the SPMS as the center to all healthcare activities linked with the government?
Initally, relationships with pharma companies were tense they were afraid when they heard SPMS would take over centralized procurement. However, now they understand the model and the fact that SPMS collects information from hospitals. Indeed, the SPMS has made the market become more stable and created value for many of these companies as they were able to better predict outcomes with the agency’s help.
Around the months of March and April, hospitals are already being asked how many pills they want for all sort of diseases. Pills are not a big issue as they are easy to produce if they need more. However, for biological agents, vaccines, monoclonal antibodies, and plasma derivatives, it becomes more complicated. These drugs are costly and take a long time to produce. The fact that pharma companies started to have stable numbers around seven to eight months before made it much simpler to decide the number of pills they need for the country. We, therefore, improve uncertainty and in economics reducing uncertainty means getting more money.
Hospitals were also reluctant at the start as they usually like to buy by themselves. Nonetheless, they understood it was complicated, , and they faced legal problems. The SPMS has a robust legal department that is prepared for this kind of issue, enabling a healthy and trusting environment.
How important is health management training in Portugal?
In Portugal, compared to many other countries, healthcare professionals (doctors, pharmacists, nurses) are intensely trained in management, meaning that a large number of hospitals’ CEOs are doctors. This does not happen because of the law—as is the case in Japan—where hospitals’ CEOs have to be doctors, but simply because in Portugal, doctors were able to acquire management and leadership skills during their doctoring years. Finding a doctor that also has management and leadership capacities is a strength and is ensures the doctor is better equipped for the job because they will be able to control and understand the clinical part of the organization as well as IT, finances and planning.
What has been the impact of transferring to paperless subscriptions?
Firstly, the SPMS has been successful overall and for the last five years has overseen a financial surplus. Of course, paperless prescription is a project that the entire country is aware of, and Portugal was the first in Europe to implement the system, generating the first prescription in September 2015. From recent numbers, 11 percent of Portuguese citizens exit clinical offices without any paper in their hands (even though the paper prescription is still available if needed), and receive their orders by SMS or email, which they can then use in any pharmacy nationwide. For a country where 30 percent of people don’t use the internet, it is a high number. Today, 11 percent of people trust the system to the point that they don’t ask anymore for the paper; although our target is to get to at least 25 percent.
This project helped substantially in bill saving. Before, all paper prescriptions (seven billion per month) were left in pharmacies, and the pharmacist was obliged to send it back to a conference center to be reimbursed. Portuguese patients pay one third, and the government spends the remainder to the pharmacist. The government needs to know exactly what the prescription was, and what they must pay to pharmacists, which is why they need to send every month a tremendous amount of paper prescriptions. This cost more than 100 million Euros per month. About five million per year was spent on labor to scan and look at prescriptions to say how much should each of the 3,000 pharmacists be paid. With paperless prescription and electronic dispensation this 100 million now goes digital, and the cost has been reduced to 1.5 million.
What other projects have been successful for SPMS?
The central vaccination project has also been a roaring success. Despite starting recently, in May 2017, today everyone can see their vaccination record online, can carry it on their mobile phones with an app developed by SPMS. It means that when getting a vaccine in a pharmacy, in a hospital, or in the private sector, all of them will be immediately registered in the central database. The team knows exactly how many people did not get the vaccine and can create a letter, email or call to warn them. This vaccine and immunization record seems to interest other countries, as SPMS has been contacted by the European Center of Disease Control located in Sweden.
What are your expectations for SPMS for the year 2018?
One of our priorities is to work on consolidation and increase the number of users. Today 1.8 million people are using the platform, but it could quickly go to 7 million as this is the number of Portuguese using the internet. At this day, many Portuguese are still not aware that they can do all these things online, and it will take time to convince people and communicate them the benefits.
Another expectation for the year 2018 is the mobile prescription project, allowing doctors to be able to prescribe with their phones. The plan should be implemented by the summer. The patient will receive an SMS with his prescription, which will reduce barriers to homecare and telemedicine.
SPMS was able over the years to get well established and recognized in Portugal. What are the agencies plans for international expansion?
SPMS is now developing its international initiatives, and we currently have eight EU funded projects (electronic identification, sharing of data, procurement, etc. with multiple partners.
Given that Portugal is the leading country for launching paperless prescriptions, SPMS is leading initiatives to communicate and promote the project abroad to enable a prescription dispensed in Portugal to be available in Finland, for instance.
Public health invests less than 0.3 percent of its budget in digital technology. You commented in a previous interview that this should be at least five to ten times more. What more can the government do to embrace the digital elements of the healthcare sector?
The government is trying to lead by example; from 2107 to 2018, they increased their spend in the SPMS by 40 percent because having an excellent and intuitive portal and the best application possible is expensive.
What helped SPMS to grow was the impulse from the government. In some cases, projects last so long that money won’t be recovered, and implementation is extended, stakeholders prefer to stop investing money in it. This was the case in several countries in Europe, where many projects failed. Eventually, the government will make paperless prescriptions compulsory, and everyone will be forced to adapt. The sooner you adapt; the sooner you receive benefits. Being the first to invest provides a competitive advantage.
SPMS benefited from two ministers that were very strong on E-health, and even though the government changed, they maintained this strategy of using IT to leverage change in healthcare. Stability & determination from the government created an environment where companies were willing to invest in something that won’t give them value in the first two years.
You will soon be celebrating SPMS’s 10th birthday in 2020. What are your expectations and goals that SPMS will achieve in the next years to come?
Overall it can have a role in not only digital transformation but innovation and processes. The fact that the SPMS is undertaking experiments with robots in care is proof that the agency is going more in-depth in its methods. The same is happening in telemedicine: we host a national center for telehealth, where we produce software and seek to innovate processes.
In two years, the SPMS will be able to leverage new reforms which are not only centered on digital reforms and transformation, and we can also be the introducers of innovation, integration of care, therefore changing the way we provide healthcare in Portugal.