Daniel R. Luna

Health Informatics in Developing Countries: Going beyond Pilot Practices to Sustainable Implementations: A Review of the Current Challenges

Objectives Information technology is an essential tool to improve patient safety and the quality of care, and to reduce healthcare costs. There is a scarcity of large sustainable implementations in developing countries. The objective of this paper is to review the challenges faced by developing countries to achieve sustainable implementations in health informatics and possible ways to address them. Methods In this non-systematic review of the literature, articles were searched using the keywords medical informatics, developing countries, implementation, and challenges in PubMed, LILACS, CINAHL, Scopus, and EMBASE. The authors, after reading the literature, reached a consensus to classify the challenges into six broad categories. Results The authors describe the problems faced by developing countries arising from the lack of adequate infrastructure and the ways these can be bypassed; the fundamental need to develop nationwide e-Health agendas to achieve sustainable implementations; ways to overcome public uncertainty with respect to privacy and security; the difficulties shared with developed countries in achieving interoperability; the need for a trained workforce in health informatics and existing initiatives for its development; and strategies to achieve regional integration. Conclusions Central to the success of any implementation in health informatics is knowledge of the challenges to be faced. This is even more important in developing countries, where uncertainty and instability are common. The authors hope this article will assist policy makers, healthcare managers, and project leaders to successfully plan their implementations and make them sustainable, avoiding unexpected barriers and making better use of their resources.

Factors associated with nonattendance at clinical medicine scheduled outpatient appointments in a university general hospital

Introduction Nonattendance at scheduled outpatient appointments for primary care is a major health care problem worldwide. Our aim was to estimate the prevalence of nonattendance at scheduled appointments for outpatients seeking primary care, to identify associated factors and build a model that predicts nonattendance at scheduled appointments. Methods A cohort study of adult patients, who had a scheduled outpatient appointment for primary care, was conducted between January 2010 and July 2011, at the Italian Hospital of Buenos Aires. We evaluated the history and characteristics of these patients, and their scheduling and attendance at appointments. Patients were divided into two groups: those who attended their scheduled appointments, and those who did not. We estimated the odds ratios (OR) and corresponding 95% confidence intervals (95% CI), and generated a predictive model for nonattendance, with logistic regression, using factors associated with lack of attendance, and those considered clinically relevant. Alternative models were compared using Akaike’s Information Criterion. A generation cohort and a validation cohort were assigned randomly. Results Of 113,716 appointments included in the study, 25,687 were missed (22.7%; 95% CI: 22.34%–22.83%). We found a statistically significant association between nonattendance and age (OR: 0.99; 95% CI: 0.99–0.99), number of issues in the personal health record (OR: 0.98; 95% CI: 0.98–0.99), time between the request for and date of appointment (OR: 1; 95% CI: 1–1), history of nonattendance (OR: 1.07; 95% CI: 1.07–1.07), appointment scheduled later than 4 pm (OR: 1.30; 95% CI: 1.24–1.35), and specific days of the week (OR: 1.00; 95% CI: 1.06–1.1). The predictive model for nonattendance included characteristics of the patient requesting the appointment, the appointment request, and the actual appointment date. The area under the receiver operating characteristic curve of the predictive model in the generation cohort was 0.892 (95% CI: 0.890–0.894). Conclusion Evidence related to patient characteristics, and the identification of appointments with a higher likelihood of nonattendance, should promote guided strategies to reduce the rate of nonattendance, as well as to future research on this topic. The use of predictive models could further guide management strategies to reduce the rate of nonattendance.

A medical informatics distance-learning course for Latin America. Translation, implementation and evaluation.

BACKGROUND There is a growing need and interest worldwide for healthcare and information technology professionals trained in medical informatics. Distance learning technologies are increasingly used to deliver such education, but have mainly been limited to the English language. OBJECTIVE Describe the implementation and student satisfaction of a medical informatics course delivered in Spanish for a Latin American audience. METHODS The course was based on the 10 x 10 program of the American Medical Informatics Association and Oregon Health & Science University that was translated and adapted to the Latin American setting. The initial course consisted of ten one-week units, currently the course has 15 modules that are delivered in 16 weeks with topics that address the needs of medical informatics in the region. We also administered an anonymous questionnaire of student satisfaction. RESULTS A total of 499 individuals have enrolled in the course, and 70% have completed it. Most of the students have been healthcare professionals (86%), with the largest proportion from Argentina. Student satisfaction with all aspects of the course was high. After the initial experience and feedback from the students, the course has been adapted to better meet regional needs. CONCLUSION The initial experience obtained in training healthcare professionals in medical informatics in Latin America in their own language demonstrated that it could be used across the region, and this could represent a model for disseminating knowledge of medical informatics across other languages and cultures.

Why Patient Centered Care Coordination Is Important in Developing Countries? Contribution of the IMIA Health Informatics for Development Working Group.

UNLABELLED Patient Centered Care Coordination (PCCC) focuses on the patient health care needs. PCCC involves the organization, the patients and their families, that must coordinate resources in order to accomplish the goals of PCCC. In developing countries, where disparities are frequent, PCCC could improve clinical outcomes, costs and patients satisfaction. OBJECTIVE the IMIA working group Health Informatics for Development analyzes the benefits, identifies the barriers and proposes strategies to reach PCCC. METHODS Discussions about PCCC emerged from a brief guide that posed questions about what is PCCC, why consider PCCC important, barriers to grow in this direction and ask about resources considered relevant in the topic. RESULTS PCCC encompasses a broad definition, includes physical, mental, socio-environmental and self care. Even benefits are proved, in developing countries the lack of a comprehensive and integrated healthcare network is one of the main barriers to reach this objective. Working hard to reach strong health policies, focus on patients, and optimizing the use of resources could improve the performance in the devolvement of PCCC programs. International collaboration could bring benefits. We believe information IT, and education in this field will play an important role in PCCC. CONCLUSION PCCC in developing countries has the potential to improve quality of care. Education, IT, policies and cultural issues must be addressed in an international collaborative context in order to reach this goal.

Implementation of a clinical decision support system using a service model: results of a feasibility study.

Numerous studies have shown that the quality of health care is inadequate, and healthcare organizations are increasingly turning to clinical decision support systems (CDSS) to address this problem. In implementing CDSS, a highly promising architectural approach is the use of decision support services. However, there are few reported examples of successful implementations of operational CDSS using this approach. Here, we describe how Hospital Italiano de Buenos Aires evaluated the feasibility of using the SEBASTIAN clinical decision support Web service to implement a CDSS integrated with its electronic medical record system. The feasibility study consisted of three stages: first, end-user acceptability testing of the proposed CDSS through focus groups; second, the design and implementation of the system through integration of SEBASTIAN and the authoring of new rules; and finally, validation of system performance and accuracy. Through this study, we found that it is feasible to implement CDSS using a service-based approach. The CDSS is now under evaluation in a randomized controlled trial. The processes and lessons learned from this initiative are discussed.

User-centered design improves the usability of drug-drug interaction alerts

Clinical Decision Support Systems can alert health professionals about drug interactions when they prescribe medications. The Hospital Italiano de Buenos Aires in Argentina developed an electronic health record with drug-drug interaction alerts, using traditional software engineering techniques and requirements. Despite enhancing the drug-drug interaction knowledge database, the alert override rate of this system was very high. We redesigned the alert system using user-centered design (UCD) and participatory design techniques to enhance the drug-drug interaction alert interface. This paper describes the methodology of our UCD. We used crossover method with realistic, clinical vignettes to compare usability of the standard and new software versions in terms of efficiency, effectiveness, and user satisfaction. Our study showed that, compared to the traditional alert system, the UCD alert system was more efficient (alerts faster resolution), more effective (tasks completed with fewer errors), and more satisfying. These results indicate that UCD techniques that follow ISO 9241-210 can generate more usable alerts than traditional design.

A Machine Learning Approach to Clinical Terms Normalization.

We propose a machine learning approach for semantic recognition and normalization of clinical term descriptions. Clinical terms considered here are noisy descriptions in Spanish language written by health care professionals in our electronic health record system. These description terms contain clinical findings, family history, suspected disease, among other categories of concepts. Descriptions are usually very short texts presenting high lexical variability containing synonymy, acronyms, abbreviations and typographical errors. Mapping description terms to normalized descriptions requires medical expertise which makes it difficult to develop a rule-based knowledge engineering approach. In order to build a training dataset we use those descriptions that have been previously matched by terminologists to the hospital thesaurus database. We generate a set of feature vectors based on pairs of descriptions involving their individual and joint characteristics. We propose an unsupervised learning approach to discover term equivalence classes including synonyms, abbreviations, acronyms and frequent typographical errors. We evaluate different combinations of features to train MaxEnt and XGBoost models. Our system achieves an F1 score of 89% on the Hospital Italiano de Buenos Aires (HIBA) problem list.

Physicians Perceptions of an Educational Support System Integrated into an Electronic Health Record

The purpose of this study is to determine the perceptions by physicians of an educational system integrated into an electronic health record (EHR). Traditional approaches to continuous medical education (CME) have not shown improvement in patient health care outcomes. Hospital Italiano de Buenos Aires (HIBA) has implemented a system that embeds information pearls into the EHR, providing learning opportunities that are integrated into the patient care process. This study explores the acceptability and general perceptions of the system by physicians when they are in the consulting room. We interviewed 12 physicians after one or two weeks of using this CME system and we performed a thematic analysis of these interviews. The themes that emerged were use and ease of use of the system; value physicians gave to the system; educational impact on physicians; respect for the individual learning styles; content available in the system; and barriers that were present or absent for using the CME system. We found that the integrated CME system developed at HIBA was well accepted and perceived as useful and easy to use. Future work will involve modifications to the system interface, expansion of the content offered and further evaluation.

Modificaciones en las perspectivas de los médicos sobre el registro médico electrónico: investigación cualitativa longitudinal

Objetivos: Conocer las creencias de los medicos sobre un registro medico electronico para la atencion ambulatoria en diferentes etapas del proceso de implementacion del sistema. Metodos: Investigacion cualitativa longitudinal basada en entrevistas en profundidad (desde julio de 2001 hasta diciembre de 2003), desarrolladas en el Hospital Italiano de Buenos Aires (Argentina). Se entrevisto a 20 cardiologos de atencion ambulatoria con perfiles profesionales diversos (muestreo intencional) antes, durante y al finalizar la implementacion del sistema (10 entrevistas por etapa). El analisis fue realizado por 2 investigadores independientes y las categorias refinadas conjuntamente. Resultados: Antes y durante la primera etapa de la implementacion los medicos esperaban que el sistema mejorara los procesos administrativos de la atencion y la disponibilidad de los datos individuales que cada uno habia registrado en consultas anteriores, pero no imaginaban que la informacion colectiva pudiera modificar los aspectos medicos de la atencion. Al finalizar la implementacion, en cambio, percibieron que el sistema les permitia acceder a una vision integral del paciente que modificaba el desempeno profesional. Durante la implementacion, los medicos opusieron el contacto con el paciente a la interaccion con el ordenador, oposicion que les impide categorizar su uso como parte del acto medico y considerar los datos del sistema como signos directos del paciente. Conclusiones: Con la implementacion, los medicos modificaron su perspectiva sobre el registro medico electronico, llegando a percibirlo como un auxiliar para la practica medica. El valor que se asigna al sistema depende de su relevancia dentro del marco institucional.

Clinical Information Systems

Clinical information systems (CISs) are examined from a hospital point of view and considering two use cases, the HIBA (Hospital Italiano de Buenos Aires) and the HEGP (Hopital Europeen Georges Pompidou) in Paris. Strategic planning and functions of CISs, their subsystems, organizational aspects, and evaluation methodologies are compared in both institutions that share the same EMRAM 6 EHR maturity level but differ by their internal organization, their relationships to the broader health information systems, and the underlying national healthcare system.