Thesis Development:


A Major Automated System for

the Health Care Segment”

(trabalho final do Curso de Administração Hospitalar da Unaerp)

A b s t r a c t


Automated systems available in the market to be used by hospitals are useful tools for the control of patients, their admittance (either through the emergency rooms or the front desk), check-out and other daily routines (handling at floors, surgery rooms, intensive care units etc).


Nevertheless, hospitals are only the final part of a very complex chain which includes the healthcare companies as well as the materials and medicines industry. The principal aim of this paper is to suggest a design of a system which may offer a link between all different hospitals systems now in use to the industry and health assistance companies, proving a better control of costs in this important segment of the economy.



I n t r o d u c t i o n


The high costs involved in the recovery of patients make necessary the adoption of protocols of clinical, surgical and diagnosis procedures, determining standards for the use of materials, medicines and exams, in terms of quantity and quality.


Such protocols of “Critical Pathways” (“protocolos de caminhos críticos”) will, thus, stand the daily routines for a quicker, complete recovery in a minimum and previously established number of days, allowing a better control of the “bed turnover” (“giro de leitos”) and, consequently, maximizing profits while decreasing costs.


Many hospitals have already started with a managed-care operational procedure based on protocols but to convert such procedures into an effective way to reduce costs, some extra adjustments are necessary such as dividing all hospital areas in specific “cost centers” (“centros de custos”).


In this way, the process of the final invoicing to the Health Care Companies will be easier and, consequently, the risks of the so-called “glosas” (refusal of payments from healthcare companies) will be reduced as there will be no possibility of discussing procedures already made (or their costs) through medical auditing meetings because:


§      All clinical/surgical standard procedures (protocols) will be formally agreed in advance;


§      There will be a previously contracted “Daily Rates & Taxes Tables” (“Tabelas de Diárias e Taxas”) for “Open Accounts” (“Contas Abertas”); and


§      The Medical Honorary Tables (AMB, Ciefas etc) in use will be added to the contract in vigor, whenever a specific package is not in effect.


This previous arrangement is a sine qua non condition if we wish to implement a major system which will offer a link between hospitals (the final part of the chain) and healthcare companies (where all the process is started) or even the government, in the cases in which an assistance provided by third-parties (private clinics or hospitals) through the S.U.S.



The main purpose of this work is to suggest a design for such inter-connective system, which would comprehend the entire process involved in the health assistance segment, always considering higher benefits at lower costs and with a minimum length of stay.



Health: An Important Segment of the Economy


The Brazilian Private Health Care Assistance is now estimated in 42 million users (2002) while the approximated total of the country’s population (potential users of the public services) is estimated in 180 million inhabitants. These figures outline the importance of this segment in the domestic economy.


So, it is extremely relevant to have a very well-administrated private system not only to reach the perfect financial balance of these institutions but, also, as a manner of not increasing the costs of the country’s official assistance (SUS), since any adjustment in the final prices to users of the private network would certainly provoke a migration to SUS of part of this assisted population. Also, the necessity of better controlling global costs in this segment becomes mandatory if we consider the fact that the Brazilian population is aging fast.


It is also relevant to outline that after the implementation of the new Brazilian Consumer Code (“Código de Defesa do Consumidor”), costs originated by clinics and hospitals can no longer be used as an excuse to simply pass eventual costs to the final users of private plans, being now necessary a previous approval from the ANS (Agência Nacional de Saúde Complementar), the regulatory agency in charge of supervising the country’s private health services.


Closing the Cycle of Costs in the Hospital Field


As already said, the first step to have a better control of costs at hospitals is to divide such institutions in different cost centers (e.g.: emergency rooms, intensive care units etc) and, thus, to adopt PCPs routines.


If the assistance offered to patients does not follow standard protocols, it means that different physicians could systematically follow different procedures at different costs. A classical example of this lack of control (or standards) in terms of costs is the prescription of Diagnosis Procedures (or SADT’s – Serviços Auxiliares Diagnósticos e Terapias). So, if there is an suspicion of pneumonia and the internal protocol stands that the most appropriated SADT for this case is a simple X-Ray, there will be no need of a computerized tomography!


Another example of this lack of standards is about the use of antibiotics, a very common medicine administrated to inpatients for the control of hospital’s infection levels, among other clinical uses. Antibiotics have different types and the newest generations are much more expensive. To illustrate, we will consider two hypothetical types of antibiotics: the drug “A” at a cost of R$ 5.00 each pill and “B”, at R$ 15.00 (there are many other examples of commonly used drugs which have a higher cost per pill).


Taking into consideration that an inpatient consumes an average number of 6 pills a day, the daily cost per bed for “A” would be R$ 30.00 while “B” would cost R$ 90.00 (i.e.: a difference of R$ 60.00). If we multiply this difference by the total of beds (one hundred, for example) during the 365 days of the year, the difference would be of R$ 2,190,000.00!


Please note that 100 is a number of beds for a small hospital and institutions like Beneficência Portuguesa in São Paulo has more than 1.000 beds. So, in this specific case, the difference over one sole item would reach the incredible amount of R$ 21,900,000 per year, only because of the lack of standards in the administration of a drug largely used and which could not be the most adequate prescription in terms of cost versus benefits.


Another remarkable example is the use of needles and syringes, very common items highly consumed and with an apparently low cost (an average of R$ 0,50 for a set of one disposable syringe and one needle). However, if we analyze the total of injections administrated with no criteria to patients at hospitals, we will certainly reach a very high amount at the end of one year.


One last example involving the nursery is the use of gases, such as O2. If a previous protocol stands for a specific disease 30’ a day of oxygen at a certain flood as the ideal for the patient’s recovery – and the nursery forgets to control time (or to adjust the correct flood) using it for 60’ (or 30’ in excess) –, at the end of the year this lack of control will represent a higher, inefficient consume in cubic meters. It is important to emphasize that there are other gases much more expensive and commonly used as the azote protoxyde (N2O).


In all cases, the extra cost resulted by the deviation of a previously approved PCP may be reverted to the unit that has generated it, for a further written justification to the Case Manager, as the entire institution will be divided in different cost centers.



 Medical Ethics and Protocols


In the U.S.A, the Case Management of PCP’s is made by a professional graduated in Nursery (not necessarily a physician), provided this professional reports to a Clinical Director.


It is important to remember protocols are not a rule to be followed in 100% of cases as a physician may have a new different procedure for a specific disease. Also, the Ethics Code involved allows a professional to diverge from others in terms of procedures and prescriptions.


In this way, every new procedure (or deviations to an internal PCP) must be tolerated and, thus, evaluated by an internal medical group after the patient’s total recovery. If it is proved the efficiency of such new procedure as a better way to reduce the patient’s length of stay, the protocol in vigor may me partially or totally changed by the Clinical Director.


There are also cases of patients admitted under a protocol but with inter-occurrences during his/her stay. As protocols are routines to be daily followed, a PCP may be changed to another PCP at anytime, provided the new protocol is also prescribed by a physician and it was previously approved by the institution.


Anyway, discussions about protocols or evidences-based therapies are not the main purpose of this paper. But as the adoption of protocols is a basic condition to start a more efficient control of costs, this is an important topic to be emphasized.


Basic Masks and Screens


Very specific designs for all possible types of mask or screen will not be considered in this work. But, instead, four basic criteria are described below, which will enable a better control and interconnectivity between hospital’s operational systems and health care control systems:


1)   A “screen” to be filled out at the time of the admittance, classifying the type of patient (i.e.: “inpatient” or “outpatient”) as well as the protocol to be followed, prescribed by a physician and after a proper evaluation;


2)   Two “tables” or “directories” providing interconnectivity between the protocols available and patient’s records, as follows:



a)   A ‘table’ of “Packages with Closed Prices”, entered and maintained by the hospital’s commercial area, based on the use of services by healthcare companies; and



b)   A ‘table’ of “Open Accounts”, entered and maintained by the financial area of the hospital, based on the contracts signed to the healthcare companies.


3)   A “table” or “directory” comprising all PCPs previously approved by the Clinical Directory, to be maintained by the Case Manager;


4)   An “invoicing table” containing the data of all closing dates, as agreed in each legal contract signed by healthcare companies. A comprehensive list of all daily, weekly or monthly billings would be available by matching the information of this table with the current patient’s records. In order to exhibit the invoicing data available for a specific deadline, an input entry should consider:


a)   All protocols involved (if any);


b)   If not, a field to be filled out informing if the current request refers to an “Open Table” or a “Package”;


c)    A possibility of accessing an extra mask to manually enter some invoicing data, for the cases in which it is not possible to automatically generate bills or invoices


C o n c l u s i o n:


          An interconnection between the different links of the chain involved in the healthcare segment would provide a more rational use of services at a lower cost – as already described in details – with great benefits to the patient’s recovery.


This general interconnectivity was inspired in the systems used by airline companies throughout the world as from the late 70’s (Sita’s Gabriel, Varig Iris, British Airways BABS etc), which allowed them to automate complex reservations, sales & traffic routines as well as to have an on-line communication between their remote stations in different countries and the head-office, being also possible an easy connection between interline companies and the official regulatory authorities such as IATA or ICAO.


To conclude, kindly find below a list of other practical and remarkable advantages the use of this suggested interconnectivity facility would provide:


ü    All bills would be sent directly to the health care companies with no delays or risks of loosing deadlines as an automated time-generated list of valid invoices could be provided, with no need to use moto-boys or other similar services to deliver printed closings;


ü    Possibility of adopting an automatic threshold limit of amounts to be invoiced, covered by an “Adendo Contratual”. So, values trespassing a specific previously agreed amount would be automatically allocated to a next closing, avoiding:


§      Financial risks to the hospitals as all “glosas” cases would become “outstanding amounts” to the very next closing date – or to be renegotiated in advance;


§      Adoption of “fee-for-patient” procedures, as it occurs in the U.S.A., causing very high financial risks to the hospitals.


ü    Health care companies would be able to have an accurate control of the use of its medical services network by users, according to the type of contract held (i.e.: “individual”, “family” or “company”), through an analysis of the data migrated from hospitals and clinics, whenever an automated invoicing is received;


ü    Possibility of selling this global, major interconnection system in modules, as follows:


§       Module A: for the Medical Administration: PCP´s  and other related medical support systems such as the Automated Prescription, among others;


§       Module B: for the Hospital Operations: including both financial (tables) & commercial (packages) data, for a final automated invoicing;


§       Module C: for the Health Care Companies: with financial demonstrations of global and individual use per contract, allowing a better control of losses (“sinistralidade contratual”).


§       N o t e: as the focus is to provide a global communication involving the different links in the chain, an inter-connective system to be designed must consider the possibility of also being compatible to the already existing systems in use at hospitals and healthcare companies, until a possible purchase of any of the above mentioned modules happens.


ü    Health Care companies (the “paying parties”) would be able to easily analyze the most efficient hospitals (or “services suppliers”) and to direct new cases to the most efficient institutions (it is important to remember that in the U.S.A., some of the most recognized institutions like Johns Hopkins and Mayo Clinic are no longer simply general hospitals but specialized institutions with academic purposes. In Brazil, Incor and Hospital do Rim also have this profile);


ü    Benefits to the final users in terms of efficiency and costs, especially in the case of “co-pay” contracts, which determines that part of the treatment must be covered by the patient directly;


ü    As already mentioned, an open interface to different support systems such as: Electronic Prescription, Clinical Management, Pharmacy & Stock Control, Accounting, Invoicing, among others;


ü    Government Health Authorities would be able to better control:



§       The quality of services offered by private hospitals;


§       Prices practiced by healthcare companies, with no need to proceed a previous analysis of the “planilha de custos” (costs spreadsheets), which may not reflect the real financial situation to justify an increase in the final prices;


ü    Better control of ABC1 & XYZ2 Curves of both “Pharmacy” & “General Stock”, with a positive impact on the industry in terms of planning its sales efforts or the production;


ü  Possibility of implementing a joint on-line Pricing & Purchasing System, involving the industry (MAT/MED), the “paying parties” (healthcare companies) and the “services suppliers” (clinics and hospitals) avoiding the necessity of stocking high-cost materials such as: prosthesis, orthosis etc, as well as expensive drugs like Eli Lilly’s ReoPro;


ü     Possibility to better program all short/mid-term investments by allocating future receivables;


ü     A systematic overview of the entire healthcare segment, for studies and evaluations;


ü     Accurate control of Government Costs since S.U.S.(official public health assistance) could participate as one of the paying parties (“partes pagantes”), just like any private health care company, avoiding fraudulent Licitation and eventual deviation of public funds.





N O T E S:


  • ABC1 Curve: Refers to the MAT/MED of frequent use.


  • XYZ2 Curve: Refer to the items that must always be in stock due to the risk of death of patients in case of not being available for immediate administration.