Portugal

Owned by Federica Andreoni
Last updated: Nov 22, 2024
7 min read

Portugal was the first country in Europe to decriminalize the possession and use of all drugs in 2001. Since then drug-related deaths have remained below the European Union average; the proportion of prisoners sentenced for drug offenses has decreased from 40% to 15%; and rates of drug use have consistently been below the EU average (Transform Drug Policy Foundation 2021).

Country’s healthcare system in a nutshell

Portugal has universal health coverage through its public healthcare system, known as the Serviço Nacional de Saúde or SNS. The government fulfils both roles of payer and provider. As a provider, the SNS operates and manages healthcare facilities, including hospitals, health centres, and clinics, and employs a substantial portion of the healthcare workforce. Simultaneously, as a payer, the government finances the SNS through public funds, covering healthcare costs and managing subsidies and co-payments to ensure access to care for all citizens and legal residents of Portugal. National health coverage includes all medical care, with the exception of dental care costs (Global Citizen Solutions, 2024).

Under Law Decree No. 37/2022, co-payments are only required for emergency services if the patient is not referred by the National Health Service (NHS) or if hospitalisation does not occur. Where co-payments are applicable, exemptions exist for those experiencing financial hardship and certain specific categories. These exempt groups include pregnant women, women in labour, children up to and including 12 years old, individuals with a disability of 60% or more, blood donors, living donors of cells, tissues, and organs, firefighters, transplant patients, and military or former military personnel who are permanently disabled due to service (SNS24, 2022).

According to the most recent data from 2010, health insurance covers the entire population of Portugal. This coverage encompasses both those who are members of health insurance schemes and those who have free access to state-provided healthcare services (Our World in Data, n.p.).

Public vs private

 

Screenshot 2024-11-22 at 16.55.40.png
Source: The World Bank.
The pink column refers to the public expenditure as a % of the country’s total healthcare expenditure. The blue dot is the country’s expenditure on health per capita, expressed in international dollars at purchasing power parity.

The national PHR

History

Over the years, Portugal has developed various digital healthcare platforms for different purposes. The first patient-facing system, created in 2008/9, was an e-booking platform that allowed individuals to schedule appointments with their GPs. The second portal, launched in 2011, enabled patients to check their waiting times for surgery (PKB interviews, 2023).

It was not until 2011, during the country’s financial crisis, when Portugal required a bailout, that the first steps towards a more comprehensive patient portal were taken. As part of the EU Commission’s conditions for granting a €75 billion loan, Portugal was given 11 months to create a platform for data sharing, called the Personal Computer Record (PKB interviews, 2023).

Henrique Martins, at the time president of SPMS - Portugal's Digital Health Agency- proposed the creation of three portals: a professional, a patient, and an institutional one.

The patient portal was the first to be launched in April 2012, followed by the professional portal in July 2012, which connected 365 health centres. An accompanying app was introduced in 2017.

The development and implementation of the platform faced several challenges. Most notably, the project initially had a very low budget of €60,000, as it was difficult to gain political recognition of the economic value of patient empowerment. However, the situation improved the following year, and by 2023, total investment in the portal had reached €5–6 million. Another significant challenge was the shortage of programming skills among the population (PKB interviews, 2023).

Public portal (SNS 24)

SNS 24, operated by the Portuguese National Health Service, functions through four channels: the SNS 24 Portal, Telephone Line, SNS 24 App, and SNS 24 Counter. Each channel is dedicated to delivering information and services to citizens, enhancing the accessibility of the National Health Service (SNS) to the public (SNS24 website, 2024).

Within the platform, the electronic health record (EHR) portal, SNS 24 Portal, consists of two areas: the citizen area and the professional area. The professional area supports clinical procedures, allowing healthcare professionals working within the SNS to access EHR data from different healthcare facilities, including primary care units and tertiary care units (SNS24 website, 2024).

Citizens can log in to their ‘personal area’ on the SNS 24 Portal, where they can access the following health information collected at SNS institutions:

  • Their identification and contact details.

  • The health centre where they are registered.

  • Benefits granted such as exemptions and contributions.

  • Allergies.

  • Current medications.

  • Diagnoses and conditions.

  • Their position on the surgery waiting list, if applicable.

  • Vaccination record.

  • Habits, such as alcohol consumption.

  • Test results/measurements: BMI, Glycaemia, Blood pressure, Triglycerides, O2 saturation, INR, Heart rate, Total cholesterol, LDL cholesterol, HDL cholesterol, HbA1c.

  • Organ donor status.

Through this service, users can select who can have access to their information, such as GPs or hospital doctors.

Patients can also add their own data to most of the fields listed above, but they must choose from predefined options. For instance, they cannot manually enter a condition but must select from a drop-down menu of conditions.

When the platform was first launched, it only collected data from public providers and GPs. Over time, some private healthcare providers joined SNS 24, while others continued to use different platforms.

Certain types of patient data, such as prescriptions, sick leave, and certificates (e.g., doctor’s certificates for driving licences), are present in the SNS 24 portal regardless of the provider.

There are two different rules for data access:

  • If data are entered by a healthcare professional, whether from a private or public provider, all other professionals can access it.

  • If data are entered by the patient, they can choose whether or not professionals can view it.

Public app SNS24

Through the SNS24 App, patients can access the following services:

  • Vaccination Bulletin.

  • Declaration of contact with the SNS 24 Line.

  • Sick leave.

  • Treatment Guides and dispensed medication leaflets.

  • Health Agenda.

  • Self-Declaration of Illness.

  • ADSE Card.

  • Blood donor card.

  • Living will.

  • Multipurpose Disability Medical Certificate.

  • QR Code – Electronic Kiosk.

  • Pathologies (allergies and rare diseases).

  • Exams (Performance and Results Guide).

  • Clinical referrals.

  • Consultation of usual medication.

  • Application for renewal of usual medication.

  • Contacts of health facilities.

  • Contact with SNS 24 – via 808242424 and using the accessible contact – Portuguese Sign Language.

  • Teleconsultation (via CSR Live).

  • Availability for teleconsultation: the user registers his/her availability to make teleconsultation.

  • EU Digital COVID Certificate.

  • Possibility to add multiple users.

  • Access to the SNS 24 portal.

  • Access to the App MySNS.

  • Access to the App MySNS Times.

  • Access to the App Telemonit SNS 24.

  • Record 3 types of measurements: Glycaemia, Blood pressure, Body Mass Index.

Comparison Between SNS24 Portal and App

Key differences between the SNS24 portal and app include:

  • Portal: No appointment management, teleconsultation, or clinical referrals. It features the surgical waiting list, organ donor status, habits tracking, and control over provider access to health data.

  • App: Includes appointment management, teleconsultation, and clinical referrals but lacks the surgical waiting list, organ donor status, habits tracking, and control over provider access to health data.

Challenges and areas for improvement

Several challenges were encountered during the development and implementation of the system:

  • A formal agreement or strategy with the private healthcare sector was never developed. As a result, the platform's data is limited to contributions from public healthcare providers, apart from some exceptions. This may be a key reason why patient usage has been steady but never exponential in growth.

  • Low digital literacy among patients. 20% of the Portuguese population has never used the internet. To overcome this challenge, since 2015, administrative staff have been assisting patients in navigating the portal.

The platform’s primary weaknesses are the lack of data from most private healthcare providers and its inability to integrate with medical devices. Moreover, although patients can add personal data to their records, they are limited to selecting from pre-defined options, such as choosing from a drop-down menu of diseases. Additionally, patients are unable to share their records with trustees.

(PKB interviews, 2023)

Screenshots

The home page features links to four main areas. In the top left corner, patients will find the 'My Area,' which contains essential personal information, including their identification details, emergency contacts, advance directives, authorisations, and a log of who has accessed their information. On the top right, the 'I Need To...' section allows patients to navigate various options: they can select to book a consultation for themselves or others, request a referral, check their test results and medical leave, view details about upcoming surgeries, access home respiratory care, obtain proof of attendance, retrieve their COVID digital certificate, and consult attestations or self-declarations of illness. Moving to the bottom left, patients can access the 'My Records' area. This section provides a comprehensive overview of their health summary, medical reports, diabetes risk calculator, and measurements. Patients can also review health data they have personally entered, individual care plans, their rare diseases card, and their non-donor status. Finally, in the bottom right corner, patients can click on 'Know More,' which provides information on co-payments, treatments abroad, a list of healthcare providers, and a library of informative resources.
In the ‘measurements’ area, patients can self-enter their measurements.
Patients can add various health measurements to their records, but only those provided in the platform's predefined list. The available measurements include: Body Mass Index (BMI), glycemia, blood pressure, triglycerides, oxygen saturation (O₂ saturation), International Normalised Ratio (INR), heart rate, total cholesterol, LDL cholesterol, HDL cholesterol, and HbA1c.
In the 'My Habits' section, patients have the opportunity to log and monitor their lifestyle choices. This includes recording their eating habits, indicating whether they smoke, detailing their alcohol consumption and noting any sports or physical activities they engage in.
Patients have the ability to self-enter the medications they are currently taking. This feature allows them to select their medicines from a dropdown list, specify the start date and duration of the treatment, and provide an explanation of the reason for each medication.
Patients have the capability to document any allergies in their health records. This includes specifying the date of the allergy, identifying the allergen, detailing the reaction experienced, assessing the severity of the reaction, and providing any additional descriptions or observations.
Patients can include any medical conditions or diagnoses in their health records. This feature allows them to specify the date the condition began, the date it ended (if applicable), and any additional comments or observations.
In their health records, patients can view their rare disease card if they have been diagnosed with a rare disease. This feature is particularly valuable for emergency care, as it provides critical information about the patient's condition, ensuring that healthcare providers can respond appropriately in urgent situations.
The non-donor individual card is designed for those who choose not to be organ donors, as Portuguese law automatically designates individuals as donors at birth.

Bibliography

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