In 2019, 97% of the prescriptions in the public health sector of Portugal were electronic. At the seventh stop of our AlgoRail through Europe, Paula Simoes reports that whilst the digitization of the system has led to an optimization of resources and reduced costs, a major benefit was a crackdown on medical prescription fraud – a reduction by 80% during the first year. 

In 2016, the “paperless prescriptions” program and the electronic medical prescriptions system were implemented and were made mandatory for the public sector, although exceptions were allowed in some cases. Data from several databases are used by the Control and Monitoring Center from the Portuguese Public National Health Service in order to detect and fight prescription fraud. 

Doctors fill in the prescription in a software certified by the Shared Services of the Ministry of Health, sign it digitally, either with their citizen card or with their Order of Doctors’ card, and send it to the patient’s mobile phone by text message or email, or print it out. Doctors can also use a mobile app to issue prescriptions, even remotely, by signing them with their Digital Mobile Key, a means of authentication created by the Portuguese government that allows for linking a mobile phone number with a national citizen identification number. Citizens can also use their citizen card to buy the prescribed medicines in a pharmacy. 

When the system was announced, back in 2015, the national newspaper  Público reported that about 15% of the seven million prescriptions written each month were not bought, either because patients could not afford them or because they decided to forego treatment. The new system lets doctors know if the prescriptions were bought or not. Another novelty is that patients can buy the prescribed medicines from different pharmacies, in case a pharmacy does not have all of them. 

Controlling fraud

Besides these motives, as well as an optimization of resources and reduced costs, one of the major motivations for the use of the electronic prescription was to control usage and detect fraud. 

Fraud was reduced by 80% during the first year of the new system, according to the National Health Service (SNS). In 2019, 97.28% of the prescriptions in the public health sector were electronic (the share of electronic prescriptions is much lower in the private sector, where the practice is not mandatory.). The system allows the control center of the SNS to quickly monitor and detect irregularities by automatically analyzing patterns in the prescription and dispensation of medicines. 

The Control and Monitoring Center uses data from invoices issued by pharmacies and other providers of services, such as medical exams. This data set is complemented by information from electronic or paper prescriptions. The control is made at the prescription phase, where the system verifies that the doctor is registered and can make the prescription, and that the patient exists and can benefit from it. 

Phony prescriptions

In 2011, RTP, the public sector broadcaster, reported that the police was investigating a case of fraud that happened in 2009 and 2010, before the new system was in place. Prescriptions had been written in the name of deceased doctors, using falsified signatures, or to deceased patients. Several doctors were using the same professional license number and one doctor made 32,000 prescriptions in only one year – one every 3 minutes. The targets were expensive medicines with a high percentage of reimbursement by the SNS. That news report mentioned that medicines represented 40% of all fraud on public expenditure. 

The fraud control system also uses the Ministry of Health’s National Registry of Health Users, which contains information about the benefits patients are entitled to. This allows for the immediate verification of each transaction to the different health providers. The National Commission for Data Protection authorized the practice. 

Back in public hands

The computerization of the system of fraud detection for complementary means of diagnosis and therapy dates back to the 1980s. The system was extended to medicine prescriptions in 2003, under the aegis of the Central Administration of the SNS, with data coming from the regional health administrations. 

In 2007, the Council of Ministers earmarked over 30 million euros for four years to create and implement the Invoice Control Center, now called Control and Monitoring Center. The project was carried out by a private company, PT Comunicações, from the design to the implementation and operation phase. 

At the same time, the Ministry of Health tried to increase the use of electronic prescriptions – from an estimated at 40% at the time. The promise of timely and easy fraud detection was a big motivation for the push towards digitization. However, it could only be done if the entire technological ecosystem was updated to deal with it. 

The Invoice Control Center started operations in 2010. Two years later, the Information Exploration Unit was created to analyze data gathered by the Center and to detect anomalous and potentially fraudulent situations, to develop a fraud risk analysis model and to forward suspicious cases to the police. 

During the first seven years, the central unit detected irregularities amounting to hundreds of millions of euros, and was instrumental in starting many prosecution for fraud in the health system. According to the Ministry of Health, in the first semester of 2017, the Invoice Control Center processed 356.2 million euros’ worth of prescriptions and flagged 21.1 millions euros to the State prosecutor. 

Although the Invoice Control Center was always under the Central Administration of the SNS, the management, maintenance, and operation of the center was provided by a private operator until June 2018. At that time, the Council of Ministers transferred responsibilities for this unit to the Shared Services of the Ministry of Health, putting it entirely under the control of the public sector. 

The government justified the transition by considering the activity of the Center as strategic to the efficiency of the SNS and to the management of the public expenditure. Data protection considerations also played a role. 

In December 2019, the adjunct Secretary of State for Health, Jamila Madeira, made an official visit on the premises of the Invoice Control Center. She said the center was a priority for the government because “rigor, transparency and permanent monitoring are essential instruments in the fight against fraud and corruption”. Each month, the center checks 8 millions documents, 70% of them digital. 

That’s it for this seventh stop of our AlgoRail through Europe, on which we want to learn more about how algorithmic systems are used in our European neighborhood. Now we are setting off all the way in the east and will report from Greece next week.  

This story was shortened by  Julia Gundlach. The unabridged story was  published  on the AlgorithmWatch website. 

The blog series AlgoRail is part of the Automating Society Report 2020 by Bertelsmann Stiftung and AlgorithmWatch, which will be published this fall and is coordinated by  Dr. Sarah Fischer. In addition to journalistic stories like this one, the report gives an overview of various examples of algorithmic systems as well as current debates, policy responses and key players in 15 countries.  A first issue of the report  was published in January 2019. 

This text is licensed under a Creative Commons Attribution 4.0 International License