Mayor uso de teleconsultas programadas y mensajería asincrónica del portal en atención primaria / Increased Use of Scheduled Teleconsultations and Asynchronous Portal Messaging in Primary Care

Introducción: durante la pandemia de COVID-19 hubo un auge sin precedentes de la telemedicina, probablemente por la forzada adopción de tecnología ante las medidas restrictivas. El presente estudio se propuso comparar la interacción y la comunicación entre médicos de cabecera (MC) y pacientes, antes y durante el período de pandemia, en términos de consultas ambulatorias programadas y mensajes del Portal de Salud. Materiales y métodos: corte transversal con muestreo consecutivo de turnos programados y mensajes, ocurridos entre las semanas epidemiológicas (SE) 10 y 23, de 2019 y 2020, respectivamente. Se incluyeron 147 médicos del Servicio de Medicina Familiar y Comunitaria, y una cápita de 73 427 pacientes afiliados al Plan de Salud del Hospital Italiano de Buenos Aires. Se realizó análisis cuantitativo y cualitativo. Resultados: hubo una reducción del 70% de las consultas presenciales (de 76 375 en 2019 a 23 200 en 2020) y un aumento concomitante de teleconsultas (de 255 en la SE13 a 1089 en la SE23). En simultáneo, los mensajes aumentaron sustancialmente (de 28 601 en 2019 a 84 916 en 2020), con un inicio abrupto al comienzo del confinamiento, y una tendencia decreciente a lo largo del tiempo. Antes de la pandemia, el contenido estuvo relacionado con órdenes electrónicas de estudios complementarios, control de resultados, recetas de medicación crónica y/o interconsultas a especialistas, mientras que los dominios más frecuentes durante la pandemia fueron necesidades informativas epidemiológicas, como medidas preventivas para COVID-19, vacuna antineumocócica, vacuna antigripal, casos o sospechas, resultados de hisopados, entre otras. Conclusión: el auge de las tecnologías de la comunicación e información durante la pandemia permitió dar continuidad a los procesos asistenciales en salud pese al distanciamiento físico. Hubo mayor utilización de mensajería por necesidades informativas de los pacientes, y la relación médico-paciente se ha modificado. (AU)

Introduction: during the COVID-19 pandemic, there was an unprecedented boom in telemedicine, probably due to the forced adoption of technology in the face of restrictive measures. This study aimed to compare the interaction and communication between general practitioners and patients before and during the pandemic based on scheduled outpatient consultations and Health Portal messages. Materials and methods: Cross-sectional study with a consecutive sampling of scheduled appointments and messages, occurring between epidemiological weeks (EW) 10 and 23 of 2019 and 2020, respectively. We included 147 physicians from the Family and Community Medicine Service and a capita of 73427 patients affiliated with the Hospital Italiano de Buenos Aires health plan. We conducted a quantitative and qualitative analysis. Results: there was a 70% reduction in face-to-face consultations (from 76375 in 2019 to 23200 in 2020) and a concomitant increase in teleconsultations (from 255 in EW13 to 1089 in EW23). Concurrently, messages increased substantially (from 28601 in 2019 to 84916 in 2020), with an abrupt onset at the beginning of confinement and a decreasing trend over time. Before the pandemic, the content involved electronic orders for complementary studies, outcome monitoring, chronic medication prescriptions, or expert consultations. The most frequent domains during the pandemic were epidemiological information needs, such as preventive measures for COVID-19, pneumococcal vaccine, influenza vaccine, cases or suspicions, and swab results, among others. Conclusion: the rise of communication and information technologies during the pandemic allowed the continuity of healthcare processes despite the physical distance. There was increased use of messaging for patients' information needs, and the doctor-patient relationship has changed. (AU)

Mobile Application for Home Healthcare: Physician's Expectations and Perceptions.

The aging of the population and the increase in chronic diseases generated the need for care at home for pluripathological patients, who can no longer access outpatient care due to functional and social problems. The use of Electronic Medical Records (EMR) improves continuity of care, simplifies data collection, decreases overhead costs, and reduces mortality in chronically ill patients. The use of an App to check and record data in the EMR during the home visit saves time for professionals and helps to avoid transcription errors. This article shares our experience with the design and implementation of a Mobile Application with EMR functionalities for the Homecare setting of the Hospital Italiano de Buenos Aires network.

An Improved Immunization Record to Support Vaccination During the COVID-19 Pandemic at a University Hospital in Argentina.

WHO and UNICEF highlight vaccination as the most cost-effective method of prevention of infectious diseases. An effective public health strategy requires efficient tracking of vaccination to assess coverage, safety, and efficacy of these vaccines. Paper-based immunization records are still being used in most low and middle-income countries. Adequate Electronic Logistic Management Information Systems, Immunization Registries and Records are crucial for proper data collection and analysis, and for making better decisions at an individual and at a population level. In this paper we share our experience in the redesign of an interoperable immunization record to track vaccination, including the recently developed vaccines for the novel coronavirus SARS-CoV-2 (COVID-19).

Tana, a Healthcare Chatbot to Help Patients During the COVID-19 Pandemic at a University Hospital in Argentina.

A Chatbot or Conversational Agent is a computer application that simulates the conversation with a human person (by text or voice), giving automated responses to people's needs. In the healthcare domain, chatbots can be beneficial to help patients, as a complement to care by health personnel, especially in times of high demand or constrained resources such as the COVID-19 Pandemic. In this paper we share the design and implementation of a healthcare chatbot called Tana at the Hospital Italiano de Buenos Aires. Considering best practices and being aware of possible unintended consequences, we must take advantage of information and communication technologies, such as chatbots, to analyze and promote useful conversations for the health of all people.

Recurrence of Hypoglycemia in Hospitalized Adult Patients in Non-Critical Areas: An Opportunity to Improve Patient Care Using Electronic Health Records.

Electronic Health Records offer an opportunity to improve patient care (in terms of quality and/or safety) by making available patient health information stored in a single Clinical Data Repository. We aimed to estimate the frequency of hypoglycemic recurrences in hospitalized adult patients in non-critical areas. We designed a cross sectional study with hospitalizations between 2017 and 2018, which included patients with at least one hypoglycemia health record (defined as a value <70 mg/dL, either by capillary glycemic monitoring or serum measurement). Recurrence was defined as those who presented a second event, with at least 2 hours of difference. We included 1884 patients, and 573 presented recurrences, yielding a global prevalence of 30.41% (95%CI 28.34-32.54). Due to the high frequency, it is important to identify vulnerable populations, to implement preventive measures to assist clinicians for decision-making tasks, as a clinical decision support system.

De la presencialidad a la virtualidad en tiempos de pandemia: la experiencia del Hospital Italiano de Buenos Aires / From face-to-face to virtuality in pandemic times: the experience of the Hospital Italiano de Buenos Aires

El 11 de marzo de 2020, la Organización Mundial de la Salud (OMS) declaró el COVID-19 como pandemia, afectando drásticamente la atención de la salud. A nivel global se adoptaron medidas como el distanciamiento social y la cuarentena. Ello representó un enorme desafío para los Sistemas de Información en Salud (SIS), que rápidamente debieron adaptarse, frente a una razón ineludible para abrazar por completo la transformación digital. Surge la necesidad de explorar las tecnologías digitales utilizadas durante la pandemia y considerarlas para su uso continuado en el tiempo o cíclicamente en caso de brotes recurrentes. Las herramientas informáticas se han utilizado para la prestación de servicios de telemedicina, monitorización remota de pacientes, comunicación digital entre líderes políticos y autoridades científicas, monitorización de datos para analizar la propagación y evolución del COVID-19, etc. Los países y organizaciones han impulsado el uso de soluciones tecnológicas con distintas limitaciones. El Hospital Italiano de Buenos Aires posee una trayectoria de más de 20 años en implementaciones e innovaciones tecnológicas; sin embargo, la pandemia impulsó una serie de adaptaciones en su SIS. El objetivo de este trabajo fue describir dicho proceso de adaptación digital desde marzo a diciembre de 2020, e identificar los principales resultados utilizando un modelo sociotécnico. Se empleó el modelo de Sittig que incluye 8 dimensiones: Infraestructura, Contenido clínico, Interfaz Humano-computadora, Personas, Comunicación y procesos, Regulaciones, Características organizacionales y Políticas internas y Medición y monitorización. (AU)

On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic, dramatically affecting health care. Measures such as social distancing and quarantine were adopted globally. This new context represented a huge challenge for Health Information Systems (HIS) that had to adapt quickly, facing an inescapable reason to fully embrace the digital transformation. There is a need to explore the digital technologies used during the pandemic and consider them for continued use over time or cyclically in the event of recurring outbreaks. Digital tools have been used for the provision of telemedicine services, remote patient monitoring, digital communication between political leaders and scientific authorities, data monitoring to analyze the spread and evolution of COVID-19, etc. Countries and organizations have promoted the use of technological solutions with different limitations. The Hospital Italiano de Buenos Aires has a history of more than 20 years in technological implementations and innovations, however, the pandemic prompted a series of adaptations in its SIS. The objective of this work was to describe said digital adaptation process from March to December 2020, and to identify the main results using a sociotechnical model. Sittig´model was used, which includes 8 dimensions: Infrastructure, Clinical Content, Human-Computer Interface, People, Communication and Processes, Regulations, Organizational Characteristics and Internal Policies, and Measurement and Monitoring. (AU)

Ferroelectret-based Hydrophone Employed in Oil Identification-A Machine Learning Approach.

This work focuses on acoustic analysis as a way of discriminating mineral oil, providing a robust technique, immune to electromagnetic noise, and in some cases, depending on the applied sensor, a low-cost technique. Thus, we propose a new method for the diagnosis of the quality of mineral oil used in electrical transformers, integrating a ferroelectric-based hydrophone and an acoustic transducer. Our classification solution is based on a supervised machine learning technique applied to the signals generated by an in-home built hydrophone. A total of three statistical datasets entries were collected during the acoustic experiments on four types of oils. The first, the second, and third datasets contain 180, 240, and 420 entries, respectively. Eighty-four features were considered from each dataset to apply to two classification approaches. The first classification approach is able to distinguish the oils from the four possible classes with a classification error less than 2%, while the second approach is able to successfully classify the oils without errors (e.g., with a score of 100%).

Implementation of a New Traceability Process for Breast Milk Feeding.

Many newborns at the neonatal intensive care unit are unable to feed themselves, and receive human milk through enteric nutrition devices such as orogastric or nasogastric probes. The mothers extract their milk, and the nursing staff is responsible for the fractionation, storage and administration when prescribed by physicians. It is very important to remind that it is a bodily fluid that carries the risk of disease transmission if misused. Health information technologies can enhance patient safety by avoiding preventable adverse events. Barcoding technology could track every step of the milk manipulation. Many processes must be addressed to implement it. Our goal is to explain our planning and implementation process in an academic tertiary hospital.

User-centered design improves the usability of drug-drug interaction alerts: Experimental comparison of interfaces.

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.

Lessons Learned After Redesigning a Personal Health Record.

On May 2016, our institution implemented a redesign of the personal health record (PHR) with the aim of enhancing its use. The objective of this research was to know and to understand end users' opinions as regards PH functionalities and the difficulties they have addressed while using the new PHR version. Research was based on a self administered survey, patient interviews and focus groups performed with out-patients. Topics examined: ways of access to the PHR log-in web page, frequency of use, type of device, most used functionalities, the different uses patients gave to PHR, perception as regards the redesign. This research allowed us to know the uses patients give to the PHR in this institution and to understand the difficulties they found in what refers to its re-design. This information constitutes the clue to motivate and accompany PHR users in the process of adoption of a patient portal.

Improving Patient Safety Through the Design and Development of a Computerized Provider Order Entry for Parenteral Nutrition Linked to a Barcode Medication Administration Record.

Among adverse events related to medication errors, the defects in parenteral nutrition administration pose a special threat to patient safety. Two high impact strategies to reduce these errors require implementing a Computerized Provider Order Entry and the use of bedside bar-code verification prior to medication administration. In this study, we share the deep field analysis of the current workflow performed to include inpatient bedside barcoding verification for parenteral nutrition administration in a large academic health center. Then, we propose a process optimization and a new parenteral nutrition ordering tool embedded in the prescription module. Structuring physicians' ordering and the bar-code verification of administration can increase patient safety. The next steps would involve the creation of a Clinical Decision Support System to improve patient nutrient goals.

User-Centered Design Improves the Usability of Drug-Drug Interaction Alerts: A Validation Study in the Real Scenario.

Decision support systems can alert physicians to the existence of drug interactions. The Hospital Italiano de Buenos Aires, Argentina, has an in-house electronic health record with computerized physician order entry and clinical decision support. It includes a drug-drug interaction alert system, initially developed under traditional engineering techniques. As we detected a high alert override rate, we rebuilt the knowledge database and redesigned the alert interface with User-Centered Design techniques. A laboratory crossover study using clinical vignettes showed that new alerts were more usable than traditional ones.This paper aimed to validate these results through a controlled and randomized experimental study with two branches (old vs. new design) in a real setting. We analyzed, quantitatively, every fired alert between April 2015 and September 2016. Finally, we performed user surveys and qualitative interviews to inquire about their satisfaction and perceptions.In real scenarios, user-centered design alerts were more usable, being more effective and satisfactory, but less efficient than traditional alerts. "Safe omission", as a new concept, emerged from our stratified analyses and interviews.

Bringing Knowledge to Users in One Click: Infobuttons in the Problem List of an EHR.

The infobuttons allows the solving of information needs. In our study, the use of Infobuttons is described, analyzing the number of queries to UpToDate® from the problem list of an Electronic Health Record. There were 26419 requests in 8 months. The highest average use occurred in June. The links to knowledge bases can help to solve information needs, even before they occur.

Computerization of a Nursing Chart According to the Nursing Process.

The benefits associated with the computerization of clinical records are known since a long time ago. Documentation evolution from paper to electronic format aims to always improve communication, reduce errors and facilitate continuity of care. Ideally when improvements to nursing records are contemplated, they should consider the nurses needs, new functionality workflow impacts and correspondence with representation models of standardized data that are specific to their domains practices. The aim of this study was to describe the development and implementation of computerized nursing record at Hospital Italiano de Buenos Aires.

Evaluating the Feasibility of Using Mobile Devices for Nurse Documentation.

The use of electronic health records (EHR) has changed the quality of clinical documentation and improved quality of patient assistance, allowing better communication between health professionals and increased data recording that helps the nursing assistance process. The use of mobile devices for compiling data at the assistance moment has increased, and more studies have demonstrated its usefulness. The aim of this study was to evaluate the use of mobile devices in the nursing staff of the Hospital Italiano de Buenos Aires, in a pilot test to measure their use and user satisfaction.

Patient Safety at Transitions of Care: Use of a Compulsory Electronic Reconciliation Tool in an Academic Hospital.

Medication errors are responsible for most inpatient adverse events. Medication reconciliation emerged as an effective strategy to decrease these problems, enhancing patient safety. Electronic health records with reconciliation tools could improve the process, but many aspects should be considered in order to reach expected outcomes. In this paper we analyzed how a compulsory, electronic reconciliation application was used at Hospital Italiano in Buenos Aires, through admission and discharge processes. We evaluated all medications that were reconciled during patient admission and discharge since its implementation, from February to November 2014. During that period, there were 78,714 reconciled medications regarding 37,741 admissions (2.08 reconciled medications per hospitalization), of 27,375 patients (2.88 medications per patient). At admission, 63% of medications were confirmed and the remaining were paused or deleted. At discharge, 41% of all medications were reconfirmed. In the creation of the best possible medication history, the use of an electronic reconciliation tool would clean overloaded lists, but at the same time medications could be erroneously deleted.

Pre-Implementation Study of a Nursing e-Chart: How Nurses Use Their Time.

In clinical practice, nurses perform different activities that exceed direct care of patients, and influence workload and time administration among different tasks. When implementing changes in an electronic nursing record, it is important to measure how it affects the time committed to documentation. The objective of this study was to determine the time dedicated to different activities, including those related to electronic documentation prior to implementing a redesigned nurse chart in an Electronic Health Record at the Hospital Italiano de Buenos Aires. An observational work sampling study was performed. Nursing activities observed were categorized as direct care, indirect care, support, non-patient related, and personal activities. During the study, 74 nurses were observed and 2,418 observations were made in the Intensive Care Unit (32.22%), the Intermediate Care Unit (29.57%), and the General Care Unit (38.21%). Nurses' activities included 37.40% of direct care, 41.18% of indirect care, 0.43% support tasks, 11.14% non-related to patient tasks, and 9.77% personal activities. The results allow for the estimation of the impact of a nursing e-chart on nurses' activities, workflow and patient care.

Electronic Health Record System Contingency Plan Coordination: A Strategy for Continuity of Care Considering Users' Needs.

Electronic Health Record system downtimes may have a great impact on patient care continuity. This paper describes the analysis and actions taken to redesign the Contingency Plan Procedure for the Electronic Health Record System of Hospital Italiano de Buenos Aires. After conducting a thorough analysis of the data gathered at post-contingency meetings, weaknesses were identified in the procedure; thus, strategic actions were recommended to redesign the Contingency Plan to secure an effective communications channel, as well as a formal structure for functions that may support the decision-making process. The main actions were: 1) to incorporate the IT Contingencies Committee (Plan management); 2) to incorporate the Coordinator (general supervision of the procedure); and 3) to redefine the role of the Clinical Informatics Resident, who will be responsible for managing communication between the technical team and Electronic Health Record users. As users need the information for continuity of care, key users evaluated the impact of the new strategy with an adapted survey.

Multimedia Health Records: user-centered design approach for a multimedia uploading service.

Multimedia elements add value to text documents by transmitting information difficult to express in words. In healthcare, many professional and services keep this elements in their own repositories. This brings the problem of information fragmentation in different silos which hinder its access to other healthcare professionals. On the other hand patients have clinical data of their own in different formats generated in different healthcare organizations which is not accessible to professionals within our healthcare network. This paper describes the design, development and implementation processes of a service which allows media elements to be loaded in a patient clinical data repository (CDR) either through an electronic health record by professionals (EHR) or through a personal health record (PHR) by patients, in order to avoid fragmentation of the information.