Directorate-General of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Prior to the implementation of the Death Certificate’s Information System, the doctor had to fill the death certificates on paper and it was then hand delivered to the Civil Registration Office by the relatives of de deceased. The certificates were later scanned and sent to the Directorate-General of Health (DGS) for central processing. During central processing, the information was manually entered in the databases for statistical purposes. The forms sent by the doctors were filled by hand, which often led to difficulties in interpretation and required that further information had to be asked for. To have access to more detailed information, for example related to violent deaths, the DGS had to request information through mail to the District Attorney office or to the Police. This was a slow procedure that generally took six months to a year. This meant that any change in the population death patterns or the detection of a problem related to any specific group was delayed at least a year and made immediate response and timely intervention of public health authorities very difficult (or impossible, for example response to acute public health threats).

B. Strategic Approach

 2. What was the solution?
The Directorate-General of Health (DGS) addressed the problem by creating the Death Certificate Information System (SICO). This information system’s main goal is to allow a better articulation between the different parties involved in the process of death certification, providing a faster and more accurate service, that is accessible in real-time to all the intervening parties. SICO’s main objectives are: 1. The dematerialization of the death certificates; 2. The statistical treatment of data related to the causes of deaths; 3. The National Health Service users’ database update and the users’ number of identification update; 4. Electronic issuing and transmission of the death certificates. SICO registers and certificates the all the deaths occurred in Portugal’s national territory of the following individuals: 1. Person deceased with 28 or more days of age; 2. Live born children that deceased before completing 28 days of age; 3. Stillborn fetus of 22 week gestational age or more; 4. Stillborn fetus with a gestational age of less than 22 weeks, when required by the proper authorities. The Directorate-General of Health will then use SICO’s data for matters of registration, analysis and cause of death coding, in accordance to the International Classification of Disease’s. This encoded information is then periodically sent to the National Statistics Institute (INE). SICO allows for electronic connection between all entities involved in the death certification process: 1. Shared Services, Ministry of Health (SPMS) 2. DirectorateGeneralof Health (DGS) 3. NationalInstitute of Medical Emergency (INEM, I.P.) 4. National Instituteof Legal Medicine (INML, I.P.) 5. Prosecutor 6. Police authorities Reducing the burden of administrative procedures for families and ensuring confidentiality of health and personal data. With SICO, the Director-General of Health is aware of deaths and causes of death in real time, as the death certificates are filled in directly in a computer and into the SICO’s online platform. In addition to health professionals, the National Institute of Legal Medicine’s workers, Prosecutors and Police Officers have access to SICO and may join on time relevant information to processes such as autopsies results and forensic reports.The electronic certificate is sent by DGS an hour after registrationfor protective reasons. The DGS waits after the death registration takes place in the civil registry office, which takes one or two days. When it receives the information, sends it to the national register of users (RNU), accelerating the update of the lists. The SICO allows an articulation of entities involved in the process of certification of deaths, with a view to: a) Fostering a proper use of resources; b) Improve the quality and accuracy of information; c) Speed up the access to data in safe conditions and respect for the privacy of the citizens. The information obtained through the SICO will allow short-term real-time surveillance of mortality, enabling the provision of information to all levels of decision-making in health.

 3. How did the initiative solve the problem and improve people’s lives?
The death certificates information system (SICO), established by the Portuguese Law No. 15/2012 of April 3rd, allows the articulation between all entities involved in the process of death certification, ensuring: a) Electronic Communication of the death certificate to the Civil Registry Office; b) Improvement of the causes of death’s coding quality, statistical processing of the information and epidemiological surveillance of mortality; c) National Health Service user’s database update (NHS) and the corresponding identification number assigned under the national register of users (RNU); d) Efficient communication between health services, Prosecutor's Office services, the National Institute of Legal Medicine and forensic sciences, IP and Police Authorities. To our knowledge, SICO is currently the only death registration system that is completely electronic and Portugal is the first country that has implemented this solution in 100% of the territory.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The information system of death certificates (SICO) was instituted by law No. 15/2012 to April 3. The start of the trial period/transition took place in November 15, 2012 CHUC and was completed December 31, 2013. During this period a core central team and seven regional teams (regional coordinators) were appointed to implement training in SICO's usage, for doctors in healthcare centers (public and private). At the same time training was also given to all public prosecution services and police authorities of the same geographic area. SICO coordinators have thus been appointed in regional health administrations (5 ARS in Mainland Portugal), autonomous regions of Madeira and the Azores and local Coordinators for the Directorate-General of Health. Various formations were performed and were attended by all stakeholders: Courts, police and Ministry of Health.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
According to law No. 15/2012 of April 3rd establishing the death certificate’s information system (SICO), the Director-General of Health is the entity responsible for the development and implementation of SICO. The following entities interact with SICO in accordance with their respective profiles: civil registration (IRN, I.P); Ministry of Health; National Institute of Medical Emergency (INEM, I.P.); National Institute of Legal Medicine (INML, I.P.); Public Prosecutor; Policeauthorities, The terms and conditions under which each entity operates were converted into protocols between the various entities involved. Their final approval was dependent on a favorable opinion by the National Commission for data protection.
 6. How was the strategy implemented and what resources were mobilized?
The program SICO was entirely financed by the Portuguese Ministry of Health and the development of the software had the total cost of 100 000 Euros. Besides the initial investment in software development, expenditure in the program includes: 1. 5 fulltime employees; 2. The occasional temporary hiring of personnel when some specific job requires it; 3. Initial training of the Ministry of Health's users all across Portugal; 4. Server rental fees and technical support. The training costs of the remaining entities were the responsibility of the Ministry of Health, Ministry of Justice and the Ministry of Internal Affairs.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The current level of use of SICO (100% of death certicates) makes Portugal the only country in the world with a dematerialized system for certification of deaths (e-death certification) implemented, only on pair by the USA where about 50% of the death certificates are electronic. This advancement allows a quality response to the World Health Organization guidelines in terms of public health surveillance-chronic diseaseand acute/emerging disease’s with an impact on the population’s health, as well as the improvement of the planning and administration of health by providing a real-time update to the national register of users. SICO enables efficient articulation of the entities involved in the process of death certification, as it undertook a transversal approach to the various ministries in the development of the system. This facilitates the communication of information to the citizens and simultaneously guarantees its reliability. To date the usage of the system took place in a sustained manner and its integration into the daily practice of: doctors; hospitals; civil registry office and Prosecutor's Office have been made to ensure the improvement of practices and procedures that support the improvement of system reliability and validity of mortality statistics. The work on the analysis pertaining to daily mortalityhas already started, allowing, for the first time, the understanding of the evolution of health problems. In October 2014, the SICOfeatured another fundamental and innovative functionality, the electronic-mortality surveillance (eVM). This tool is accessible to the entire population by accessing the DGS website ( and on the homepage of SICO ( Through the eVM users can obtain real time information on the number of deaths that occurred by day and by cause of death. Users can also choose the month, week, and day, for a better analysis regarding daily mortality. The presentation of data on eVM, is available in table and chart form, for a better reading of the data. This information is available to those responsible for health planning and administration, to support surveillance needs of specific health programs (ex: extreme weather emergency plans, cold and heat waves, influenza….).

 8. What were the most successful outputs and why was the initiative effective?
SICO enables efficient articulation of entities involved in the process of certification of deaths, once assumed a transversal approach to the various ministries in the development of the system. This aspect facilitates communication of information to the citizens and simultaneously guarantees its reliability. SICO's performance is constantly being monitored: 1. Quantitatively by, through regular checks to the percentage of electronic certification and data quality (validation of all registries). With 100% of death certificates being registered through this system, the level of usage of SICO currently makes Portugal the only country in the world with a fully dematerialized system for certification of deaths implemented. 2. Qualitatively by: a. Regular checks to the data quality (validation of all registries); b. User's surveys, through the filling of mandatory fields and drop boxes, in which user's satisfaction is accessed and suggestions are taken into account for future improvement of the system. c. Are carried out periodic evaluation meetings with the ARS ´ s and autonomous regions of Madeira and the Azores.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles detected were the following: 1. End-user's resistance in accepting the protocol change for the death certification, mainly by the doctors certificating the death and by public prosecutors; 2. Hardware-software compatibility issues; 3. Lack of logistic support for the training sessions. This obstacles were overcame by the involvement of all agencies in the field and by central strategic approach to training in all ministries and strong inter-agency commitment to implementation of the system.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
From this initiative we've obtained the following two key benefits: 1. Better articulation between the stakeholders from the different Ministries that ensured a better electronic communication and better confidentiality of the data. This allowed for the requirements of the Personal Data Protection Law to be fulfilled. 2. Improvement on the quality of the information on the causes of death in Portugal. This information is the main indicator used to assess the population health's status and the one that better reflects the incidence of the diseases that have the most impact on what the National Health System primarily seeks to delay, death. In this way, this program is a valuable tool to all the policy and decision makers in Portugal, providing them with valuable and reliable information, in a faster way than the previous system.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The maintenance costs of the system are sustained by the Portuguese Government that has the responsibility of ensuring that this service is provided. The system, in its current state, can easily be replicated by other countries and Portugal has been showcasing this tool in several WHO meetings and among experts in this area. The feedback given by other European countries (Hungary, Finland - scheduled) has been positive and they've shown great interest in this system, sending representatives to Portugal to get a better understanding of the system to make their own developments.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
With this experience we've learned that it is possible to ensure the cooperation of stakeholders from different areas and to create a platform of communication and understanding. We've also learned how to assure the participation from all the different levels of the governmental machine (national, regional and local). We've learned that a well structured regulation with legislative support and guidelines is required to implement this sort of nationwide system. Finally we've learned that by associating this tool to the current health vigilance systems we can provide better healthcare services.

Contact Information

Institution Name:   Directorate-General of Health
Institution Type:   Government Agency  
Contact Person:   Catia Sousa Pinto
Title:   Dr  
Telephone/ Fax:   351218430625
Institution's / Project's Website:  
Address:   Alameda D. Afonso, 45
Postal Code:   1049-005
City:   Lisbon

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