Medical record systems for primary care in Portugal

Portugal has one of the most centralised approaches to clinical information systems in Europe. Unlike many countries where hospitals and GP practices independently procure software from competing vendors, the Portuguese national health service, the Serviço Nacional de Saúde (SNS), has historically developed and deployed its own medical record system platforms through a dedicated government agency. For clinicians, administrators, and technology decision-makers working in or entering the Portuguese market, understanding which systems are in use, how they evolved, and where the gaps remain is essential context for any discussion of clinical workflows, digital health investment, or AI-assisted documentation.

How primary care is organised in Portugal

Portuguese primary care is delivered through a network of community-based units grouped under ACeS (Agrupamentos de Centros de Saúde), which are administrative clusters overseen by regional health administrations. Within each ACeS, care is provided through several types of units:

• USFs (Unidades de Saúde Familiar): The most common model, organised as small, semi-autonomous teams of GPs, nurses, and administrative staff, often operating under performance-linked contracts.

• UCSPs (Unidades de Cuidados de Saúde Personalizados): Traditional health centre units providing similar services but with a different organisational and contractual structure.

• UCCs, UCSs, and USPs: Specialist community units covering care coordination, public health, and community nursing.

This structure means that primary care in Portugal is delivered through a relatively standardised institutional framework, which has made it feasible, at least in principle, for the government to deploy a single national medical record system across all SNS primary care settings.

The dominant legacy systems: SAM and SAPE

For more than a decade, the two dominant clinical record systems in SNS primary care were SAM (Sistema de Apoio ao Médico) and SAPE (Sistema de Apoio à Prática de Enfermagem). SAM was designed for use by GPs and medical staff, supporting consultation documentation, electronic prescribing, and patient record management. SAPE served an equivalent function for nursing staff, covering nursing assessments, care plans, and clinical documentation specific to nursing practice.

Both systems were developed and maintained by SPMS (Serviços Partilhados do Ministério da Saúde), the shared services agency of the Portuguese Ministry of Health responsible for health IT infrastructure. While SAM and SAPE were functional and widely embedded across SNS units, they were built on older technical architectures that increasingly limited interoperability, usability, and integration with newer national health data platforms.

A pilot study among Portuguese GPs published in Informatics in Primary Care found that most clinicians, both experienced GPs and trainees, reported satisfaction with their medical record system use. Established GPs showed significantly more difficulty adapting to electronic systems than trainees, with greater challenges in maintaining updated records and heightened concern about prescribing errors. This generational dimension to adoption has been a consistent feature of digital health transitions in Portuguese primary care.

SClínico: the national standard replacing SAM and SAPE

SClínico CSP (Cuidados de Saúde Primários) is the Portuguese government's unified medical record system for primary care, developed by SPMS as a direct successor to SAM and SAPE. It consolidates the functionality of both predecessor systems into a single, modernised application covering medical, nursing, and administrative workflows within the same interface.

The rollout of SClínico CSP has been a multi-year national programme. As of August 2024, SPMS confirmed that SClínico CSP 4.x is operational in all SNS primary care units across Portugal. This milestone also marked the full discontinuation of four legacy systems, including SINUS and earlier versions of SClínico. The final migration completed at the Unidade Local de Saúde de Matosinhos at the end of July 2024.

Key facts about SClínico CSP:

• Adopted by more than 300 institutions and used by over 13,000 healthcare professionals across Portugal

• Developed entirely in-house by SPMS, making Portugal among a small number of European countries with government-designed medical record systems in both primary and hospital care

• Version 4.x introduces significant technological, graphical, and workflow improvements over its predecessors

• Covers medical consultations, nursing documentation, electronic prescribing, clinical coding, and administrative functions within a single platform

• Deployed as the standard system across USFs, UCSPs, and other SNS primary care units

The SClínico ecosystem also extends into hospital settings, where a parallel version, SClínico Hospitalar, supports inpatient and outpatient documentation. This creates a degree of continuity across care settings that is unusual by European standards.

MedicineOne: the leading system in private and some public settings

Outside the SNS, the most widely adopted clinical record system in Portugal is MedicineOne, a Portuguese-developed platform built specifically for clinical management in primary care, hospital care, long-term care, and occupational health settings. It is available both as an on-premise installation and via cloud computing.

MedicineOne is particularly prominent in private clinics, occupational health services, and some specialist outpatient settings. Its prescribing module, My MedicineOne, is reported to be the most widely used electronic prescribing tool among Portuguese doctors, supporting a significant user base across multiple specialties.

The system positions itself around what its developers describe as "clinical intelligence", covering structured data capture, decision support, and interoperability with national health platforms. For private care providers who need to connect to national prescribing and referral infrastructure, MedicineOne offers a compliant route without relying on SPMS-developed software.

Academic research from the pre-SClínico period identified three main medical record systems in use in Portugal: SAM, MedicineOne, and VitaCare. All three supported electronic prescribing by International Non-proprietary Name or brand name, a legal requirement under Portuguese prescribing regulations.

Other systems present in the Portuguese market

Beyond SClínico and MedicineOne, several other platforms have a presence in specific segments of the Portuguese healthcare market:

• Glintt (formerly Alert): Glintt is a Portuguese health IT company whose clinical and administrative systems are used primarily in hospital and specialist settings. Its products cover areas including emergency triage, pharmacy management, and outpatient workflows. While not a primary care medical record system in the traditional sense, Glintt systems appear in environments where primary and secondary care intersect.

• VitaCare: Historically identified as one of the three medical record systems used in Portuguese primary care, VitaCare has had a smaller footprint than SAM or MedicineOne and is less prominent in current market discussions.

• International vendors: As noted in industry reporting on Portugal's health IT market, international medical record system vendors including Cerner (now Oracle Health) have shown interest in the Portuguese market, primarily targeting private hospital groups and larger health networks. The dominance of SPMS-developed software within the SNS limits the addressable market for external vendors in public primary care.

Interoperability and the role of the RSE

One of the defining features of Portugal's health IT infrastructure is its national interoperability framework, centred on the RSE (Registo de Saúde Eletrónico) and the associated PDS (Plataforma de Dados de Saúde). These platforms aggregate and share clinical data across different medical record systems, allowing clinicians to access a unified patient record regardless of whether the patient was last seen in a USF using SClínico, a private clinic using MedicineOne, or a hospital using a different system.

The SNS 24 Portal provides a professional access layer through which SNS-registered clinicians can view data from multiple healthcare facilities, spanning primary, secondary, and tertiary care. This national data layer sits above individual medical record systems and is a key part of what makes Portugal's approach distinctive.

Academic research on interoperability in Portuguese family medicine has noted that SClínico and the PDS have enabled greater integration between primary and secondary care, including the national referral management module integrated with SClínico for Advice and Guidance and referral workflows. The same research highlighted that interoperability in practice remains incomplete, with clinicians frequently encountering gaps when attempting to access records from outside their immediate care setting.

Efforts to improve access to medical record data for research and surveillance have also identified structural barriers in how data flows between clinical systems and public health infrastructure. This challenge is not unique to Portugal but is particularly visible given the scale of the country's centralised data ambitions.

Key challenges facing medical record system adoption in Portuguese primary care

Despite Portugal's relatively advanced position on medical record system adoption, recognised by the OECD's 2025 PaRIS survey as a strength of the country's primary care system, several persistent challenges affect how clinical record systems function in day-to-day practice:

• Documentation burden: Portuguese GPs, like their counterparts across Europe, report significant time spent on administrative documentation within their medical record systems. Structured data entry requirements, mandatory clinical coding, and the volume of fields required for quality indicator reporting all contribute to a documentation load that competes with direct patient care time.

• Legacy system transitions: The migration to SClínico CSP 4.x, while now complete, involved years of parallel running and transition management across hundreds of institutions. Clinicians who had adapted their workflows to SAM or earlier SClínico versions faced relearning curves, and data migration from legacy systems introduced its own risks.

• Usability limitations: Research among Portuguese GPs has consistently found that, while satisfaction with medical record system use is broadly positive, older clinicians report greater difficulty with system usability and record maintenance. Government-developed systems have not always prioritised clinical workflow efficiency over data completeness.

• Integration gaps between care settings: Despite the RSE and PDS frameworks, real-world interoperability between primary and secondary care remains imperfect. Discharge summaries, specialist letters, and diagnostic results do not always flow automatically into the GP's SClínico record, requiring manual follow-up.

• Limited clinical decision support: Current deployments of SClínico CSP provide some structured decision support, but the depth of AI-assisted clinical guidance available within the platform is limited compared to what is emerging in more commercially competitive medical record system markets.

These challenges are not uniform across all settings. USFs operating under performance contracts tend to have more structured medical record system use and stronger data quality than UCSPs, in part because their funding models incentivise accurate documentation and coding.

The role of AI and clinical documentation tools in Portuguese primary care

AI-powered clinical documentation tools, including ambient voice technology and AI medical assistants, are beginning to complement existing medical record systems in Portugal, as they are across European primary care more broadly. These tools do not replace the medical record system. They integrate with it to reduce the manual effort of documentation during and after consultations.

Ambient voice technology works by listening to a clinical consultation and automatically generating structured clinical notes, including SOAP notes, clinical codes, and patient letters, which the clinician reviews and approves before they enter the medical record system. In systems like SClínico CSP, where structured data entry is mandatory and documentation fields are numerous, the potential time saving is significant.

The documentation burden associated with administrative and clinical record-keeping is a well-documented contributor to clinician burnout across primary care systems. Tools that reduce cognitive load during consultations, by handling real-time transcription and note structuring in the background, allow clinicians to focus more directly on the patient encounter itself.

For the Portuguese market specifically, any AI clinical documentation tool must meet several requirements to be viable: it must support Portuguese-language transcription accurately, comply with GDPR and EU data residency requirements, and output structured notes compatible with SClínico or MedicineOne data formats. The GDPR dimension is particularly important given that clinical data is among the most sensitive categories of personal data under EU law. Portuguese healthcare providers face oversight from both the CNPD (Comissão Nacional de Proteção de Dados) and the broader EU regulatory framework.

AI tools operating as medical devices, where their output could directly influence clinical decisions, are also subject to Medical Device Regulation compliance requirements. This adds a further layer of regulatory consideration for vendors and procurement teams.

What to consider when evaluating a clinical record system in Portugal

For clinic managers, healthcare administrators, or primary care networks evaluating medical record system options in the Portuguese market, the following criteria are the most relevant:

SNS compliance and SPMS integration

For any unit operating within the SNS, SClínico CSP is the mandated system and is not subject to competitive procurement at the unit level. The relevant question for SNS settings is not which medical record system to choose, but how to optimise workflows within SClínico and which complementary tools, including AI documentation assistants, can be layered on top of it.

GDPR and data residency

All clinical data processed in Portugal is subject to GDPR. For cloud-based tools and AI assistants, GDPR and EU data residency is a baseline requirement for most public sector procurement. Vendors should be able to demonstrate where data is stored and processed, and provide documentation of their security posture, including certifications such as ISO 27001.

Interoperability with the RSE and PDS

Any system used in a clinical setting that handles patient records should connect to Portugal's national interoperability infrastructure. For private providers, this includes the ability to submit electronic prescriptions through the national prescribing platform and to access shared patient data through the SNS 24 professional portal.

Support for structured notes and clinical coding

Portuguese primary care documentation requirements include ICPC-2 (International Classification of Primary Care) clinical codes, structured problem lists, and performance indicator data. Systems and complementary tools should support these structured data formats natively, rather than relying on free-text entry that cannot be aggregated or reported.

Language and localisation

Portugal is a linguistically specific market. Medical record systems and AI documentation tools must support European Portuguese, not Brazilian Portuguese, with sufficient accuracy for clinical use. This is a non-trivial requirement for international AI vendors whose models may have been trained predominantly on Brazilian Portuguese data or English-language clinical text.

Vendor stability and support

Given the critical nature of clinical record systems, the long-term viability of the vendor and the quality of local support are material considerations, particularly for private providers who do not have the SPMS support infrastructure available to SNS units.

The Portuguese primary care medical record system landscape is, in structural terms, more consolidated than most European comparators. The completion of the SClínico CSP 4.x rollout in 2024 marks the end of a long transition away from fragmented legacy systems toward a single national platform. The more active area of development now lies in what is built around and on top of that platform: interoperability layers, AI-assisted documentation, and clinical decision support tools that can reduce the burden on clinicians while improving the quality and completeness of the records they produce.

Frequently asked questions

▶ What medical record system do GPs use in Portugal's national health service?

GPs working within the Serviço Nacional de Saúde (SNS), Portugal's national health service, use SClínico CSP (Cuidados de Saúde Primários). Developed by SPMS (Serviços Partilhados do Ministério da Saúde), the shared services agency of the Portuguese Ministry of Health, SClínico CSP replaced the older SAM (Sistema de Apoio ao Médico) and SAPE (Sistema de Apoio à Prática de Enfermagem) systems. As of August 2024, it's operational in all SNS primary care units across Portugal.

▶ What replaced SAM and SAPE in Portuguese primary care?

SClínico CSP replaced both SAM and SAPE. SAM supported GP consultation documentation and electronic prescribing, while SAPE covered nursing assessments and care plans. SClínico CSP consolidates both functions into a single platform covering medical, nursing, and administrative workflows. Version 4.x, the current release, completed its national rollout in July 2024 with the final migration at the Unidade Local de Saúde de Matosinhos.

▶ Which medical record system is used in private clinics in Portugal?

MedicineOne is the most widely adopted medical record system in private clinics, occupational health services, and some specialist outpatient settings in Portugal. It's a Portuguese-developed platform available as an on-premise installation or via cloud computing. Its prescribing module, My MedicineOne, is reported to be the most widely used electronic prescribing tool among Portuguese doctors across multiple specialties.

▶ How does interoperability work between different medical record systems in Portugal?

Portugal's national interoperability framework centres on the RSE (Registo de Saúde Eletrónico) and the PDS (Plataforma de Dados de Saúde). These platforms aggregate and share clinical data across different medical record systems, so clinicians can access a unified patient record regardless of where the patient was last seen. The SNS 24 Portal provides a professional access layer spanning primary, secondary, and tertiary care. In practice, however, research has found that interoperability remains incomplete, with gaps when clinicians attempt to access records from outside their immediate care setting.

▶ What are the main challenges with medical record system use in Portuguese primary care?

Several challenges persist despite Portugal's relatively advanced position on medical record system adoption. Documentation burden is significant, with GPs spending considerable time on structured data entry, mandatory clinical coding, and quality indicator reporting. Usability research has found that older clinicians report greater difficulty with system use and record maintenance than trainees. Integration gaps between primary and secondary care mean that discharge summaries and specialist letters don't always flow automatically into the GP's SClínico record. Clinical decision support within SClínico CSP is also limited compared to more commercially competitive markets.

▶ What clinical coding standard does Portuguese primary care use?

Portuguese primary care documentation requires ICPC-2 (International Classification of Primary Care) clinical codes, structured problem lists, and performance indicator data. SClínico CSP supports these structured data formats. Any complementary tool, including AI documentation assistants, should support ICPC-2 coding natively rather than relying on free-text entry that can't be aggregated or reported.

▶ Can AI clinical documentation tools be used alongside SClínico in Portugal?

AI-powered clinical documentation tools, including ambient voice technology (which listens to a consultation and automatically generates structured clinical notes for clinician review), can complement SClínico CSP without replacing it. They integrate with the medical record system to reduce the manual effort of documentation. For the Portuguese market, any such tool must support European Portuguese transcription accurately, comply with GDPR and EU data residency requirements, and produce structured notes compatible with SClínico or MedicineOne data formats.

▶ What GDPR and regulatory requirements apply to clinical AI tools in Portugal?

All clinical data processed in Portugal is subject to GDPR (General Data Protection Regulation). Portuguese healthcare providers face oversight from the CNPD (Comissão Nacional de Proteção de Dados) and the broader EU regulatory framework. For cloud-based tools and AI assistants, EU data residency is a baseline requirement for most public sector procurement. Vendors should demonstrate where data is stored and processed, and provide documentation of their security posture, including certifications such as ISO 27001. AI tools whose output could directly influence clinical decisions are also subject to Medical Device Regulation (MDR) compliance requirements.

▶ Does SClínico cover hospital care as well as primary care in Portugal?

Yes. The SClínico ecosystem extends into hospital settings through a parallel version called SClínico Hospitalar, which supports inpatient and outpatient documentation. This creates a degree of continuity across care settings that is unusual by European standards, and it's one of the features that makes Portugal's approach to health IT distinctive. Portugal is among a small number of European countries with government-designed medical record systems in both primary and hospital care.

▶ What should private healthcare providers in Portugal consider when evaluating a medical record system?

Private providers should assess several criteria. GDPR compliance and EU data residency are baseline requirements. Any system handling patient records should connect to Portugal's national interoperability infrastructure, including the ability to submit electronic prescriptions through the national prescribing platform and access shared patient data through the SNS 24 professional portal. Support for ICPC-2 clinical coding and structured data formats is essential. Language localisation matters too: tools must support European Portuguese, not Brazilian Portuguese, with sufficient accuracy for clinical use. Vendor stability and the quality of local support are also material considerations, since private providers don't have the SPMS support infrastructure available to SNS units.