[Implementation of telemedicine in the Americas: Barriers and facilitatorsBarreiras e facilitadores para a implementação da telemedicina nas Américas]. / Barreras y facilitadores a la implementación de la telemedicina en las Américas.

With millions of people in the world in situations of physical distancing because of COVID-19, information and communication technology (ICT) has become as one of the principal means of interaction and collaboration. The following advantages of ICT have been cited since the start of the new millennium: increased access to information and service delivery, educational strengthening, quality control of screening programs, and reduction of health care costs. In the case of telemedicine, however, a number of barriers-especially technological, human and social, psychosocial, anthropological, economic, and governance-related-have stood in the way of its adoption. The past 20 years have seen an increase in the availability of resources and technical capacity, improvements in digital education, empowerment of patients regarding their treatment, and increased public interest in this area. Successes have included the use of interdisciplinary teams, academic and professional networking, and virtual medical consultations. After reviewing the state of telemedicine in the Region of the Americas, the authors recommend the urgent adoption of measures aimed at implementing national telemedicine policies and programs, including a regulatory framework and adequate funding. Implementation of the measures should be integrated and interoperable and include the support of academic networks and the collaboration of specialized institutions. The policies should generate an enabling context that ensures sustainability of the progress achieved, bearing in mind the possible barriers mentioned.

Com milhões de pessoas no mundo em situação de distanciamento físico devido à COVID-19, as tecnologias da informação e comunicação (TICs) se enquadraram como um dos meios principais de interação e colaboração. Já no início deste milênio, começaram a ser mencionadas as seguintes vantagens: maior acesso à informação e à prestação de serviços; fortalecimento da educação; controle de qualidade dos programas de detecção e redução dos custos na atenção à saúde. No entanto, entre as principais barreiras de adoção da telemedicina se encontram as de caráter: tecnológico; humano e social; psicossocial e antropológico; de governança e econômico. Nestes 20 anos, houve um aumento nos recursos e na capacidade técnica, uma melhora na educação digital, um empoderamento do paciente em seu tratamento e um maior interesse público nessa área. Em especial, são consideradas bem-sucedidas a constituição de equipes interdisciplinares e as redes acadêmicas e profissionais, e as consultas médicas virtuais. Após revisar o estado da telemedicina na Região das Américas, os autores recomendam a adoção de medidas urgentes para implementar políticas e programas nacionais de telemedicina, incluindo o marco normativo e o orçamento necessário. Essa implementação deve ser realizada de maneira integral e interoperável e sustentada por redes acadêmicas, de parceria e instituições especializadas. Tais políticas devem gerar um contexto favorável, dando sustentabilidade ao avanço obtido e considerando os aspectos mencionados nas possíveis barreiras.

Mild prolonged chronic hyponatremia and risk of hip fracture in the elderly.

BACKGROUND: Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic hyponatremia (>90 days duration) and risk of hip fracture in the elderly. METHODS: We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic hyponatremia, defined as plasma sodium values <135 mmol/L, lasting >90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic hyponatremia after adjustment for the propensity to have hyponatremia, fracture risk factors and relevant baseline characteristics. RESULTS: Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)]. CONCLUSION: Mild prolonged chronic hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting hyponatremia will result in a reduction of hip fractures is lacking.

Inhospital mortality among clinical and surgical inpatients recently diagnosed with venous thromboembolic disease.

Venous thromboembolism (VTE) is the most common cause of preventable mortality in hospitalized patients, and pulmonary embolism is responsible for 5-10 % of all hospital deaths. To estimate the hospital mortality in hospitalized patients who developed VTE during hospitalization. Prospective cohort of all adult inpatients >17 years admitted to the hospital between August 2006 and August 2013, and follow-up until discharge to measure death. VTE incident cases were captured prospectively from the Institutional Registry of Thromboembolic disease in a tertiary hospital care in Buenos Aires. In hospital global mortality and fatality rate of inpatients with VTE was calculated. The cumulative incidence of VTE was 1.8 % (95 % CI 1.77-1.93 %), representing 1.32 % (95 % CI 1.23-1.41 %) in the subgroup of surgical patients and 2.1 % (95 % CI 1.9-2.2 %) in clinical inpatients. The overall hospital mortality was 2.4 % (95 % CI 2.35-2.53); being 3.95 % (95 % CI 3.78-4.12) in clinical inpatients and 1.15 % (95 % CI 1.06-1.23) in surgical patients. The death in patients who had developed VTE, represented between 4 and 7 % of hospital deaths, and it increases with age in both clinical and surgical patients. In Argentina there are few data of hospital mortality in patients with VTE. This information is useful when assessing the need for resources for prevention, diagnosis and treatment in inpatients.

Prognosis of patients with suspected pulmonary embolism in Buenos Aires: a prospective cohort study.

BACKGROUND: The prognosis of patients with suspected pulmonary embolism (PE) in whom PE has been ruled out (RPE) is unclear. We aimed to evaluate survival and diagnosis of new cancer in suspected PE patients at follow up. METHODS: A prospective cohort study nested in a prospective Institutional Registry of Venous Thromboembolic Disease was performed between 2006 and 2011. This study was designed to evaluate all consecutive, incident cases of suspected PE in adults. The study was performed at the Hospital Italiano de Buenos Aires, a tertiary level hospital, in hospitalized patients and outpatients. Suspected PE cases were collected using a computerized system that alerts whenever a physician requests pulmonary angiography, angiotomography, or ventilation-perfusion scintigraphy. PE was defined by pre-specified criteria and RPE was defined when diagnostic tests were negative for PE. RESULTS: We included 1736 cases of suspected PE. The prevalence of PE was 29% (n = 504). There was no difference in the overall survival at 30 days and follow-up between PE and RPE patients. The presence of provoked or unprovoked venous thromboembolic disease in these patients did not affect survival. The main causes of death were PE in the confirmed PE group (60%), and neoplasm (42%) and sepsis (37%) in the RPE group. Survival at 90 days was 63% for PE (95% CI 58-67%) and 67% for RPE patients (95% CT 64-69%). At follow-up, there was no difference in diagnosis of new cancer between PE and RPE patients (2% vs 2%, p = 0.82), even when taking into account the unprovoked group. CONCLUSIONS: Even when the main cause of death in PE patients is PE itself, the overall mortality is similar between PE and RPE patients. The reason for this finding could be because of the more frequent and severe comorbidities in RPE than in PE patients. TRIAL REGISTRATION: HomeClinicalTrial.gov: NCT01372514.

Predictive score for estimating cancer after venous thromboembolism: a cohort study.

BACKGROUND: Venous thromboembolism (VTE) has been associated with a higher risk of developing malignancy and mortality, and patients with VTE may therefore benefit from increased surveillance. We aimed to construct a clinical predictive score that could classify patients with VTE according to their risk for developing these outcomes. METHODS: Observational cohort study using an existing clinical registry in a tertiary academic teaching hospital in Buenos Aires, Argentina. 1264 adult patients greater than 17 years of age presented new VTE between June 2006 and December 2011 and were included in the registry. We excluded patients with previous or incident cancer, those who died during the first month, and those with less than one year of follow up (< 5%). 540 patients were included. Primary outcome was new cancer diagnosis during one year of follow-up, secondary composite outcome was any new cancer diagnosis or death. The score was developed using a multivariable logistic regression model to predict cancer or death. RESULTS: During follow-up, one-quarter (26.4%) of patients developed cancer (9.2%) or died (23.7%). Patients with the primary outcome had more comorbidities, were more likely to have previous thromboembolism and less likely to have recent surgery. The final score developed for predicting cancer alone included previous episode of VTE, recent surgery and comorbidity (Charlson comorbidity score), [AUC of 0.75 (95% CI 0.66-0.84) and 0.79 (95% CI 0.63-0.95) in the derivation and validation cohorts, respectively]. The version of this score developed to predict cancer or death included age, albumin level, comorbidity, previous episode of VTE, and recent surgery [AUC = 0.72 (95% CI 0.66-0.78) and 0.71 (95% CI 0.63-0.79) in the derivation and validation cohorts, respectively]. CONCLUSIONS: A simple clinical predictive score accurately estimates patients' risk of developing cancer or death following newly diagnosed VTE. This tool could be used to help reassure low risk patients, or to identify high-risk patients that might benefit from closer surveillance and additional investigations. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01372514.

Immunogenicity induced by the use of alternative vaccine platforms to deal with vaccine shortages in a low- to middle-income country: Results of two randomized clinical trials.

BACKGROUND: Shortages of component two of Sputnik V vaccine (rAd5) are delaying the possibility of achieving full immunisation. The immunogenic response associated with the use of alternative schemes to complete the scheme was not explored. METHODS: We did two non-inferiority randomized clinical trials with outcomes measures blinded to investigators on adults aged 21-65 years, vaccinated with a single dose of rAd26 ≥ 30 days before screening and no history of SARS-CoV-2. Participants were assigned (1:1:1:1:1) to receive either rAd5; ChAdOx1; rAd26; mRNA-1273 or BBIBP-CorV. The primary endpoint was the geometric mean ratio (GMR) of SARS-CoV-2 anti-spike IgG concentration at 28 days after the second dose, when comparing rAd26/rAd5 with rAd26/ChAdOx1, rAd26/rAd26, rAd26/mRNAmRNA-1273 and rAd26/BBIBP-CorV. Serum neutralizing capacity was evaluated using wild type SARS-CoV-2 reference strain 2019 B.1. The safety outcome was 28-day rate of serious adverse. The primary analysis included all participants who received ≥ 1 dose. The studies were registered with NCT04962906 and NCT05027672. Both trials were conducted in Buenos Aires, Argentina. FINDINGS: Between July 6 and August 3, 2021, 540 individuals (age 56·7 [SD 7·3]; 243 (45%) women) were randomly assigned to received rAd5 (n=150); ChAdOx1 (n=150); rAd26 (N=87); mRNAmRNA-1273 (n=87) or BBIBP-CorV (n=65). 524 participants completed the study. As compared with rAd26/rAd5 (1·00), the GMR (95%CI) at day 28 was 0·65 (0·51-0·84) among those who received ChAdOx1; 0·47 (0·34-0·66) in rAd5; 3·53 (2·68-4·65) in mRNA-1273 and 0·23 (0·16-0·33) in BBIBP-CorV. The geometric mean (IU/ml) from baseline to day 28 within each group increased significantly with ChAdOx1 (4·08 (3·07-5·43)); rAd26 (2·69 (1·76-4·11)); mRNA-1273 (21·98 (15·45-31·08)) but not in BBIBP-CorV (1·22 (0·80-1·87)). INTERPRETATION: Except for mRNA-1273 which proved superior, in all other alternatives non-inferiority was rejected. Antibody concentration increased in all non-replicating viral vector and RNA platforms. FUNDING: The trials were supported (including funding, material support in the form of vaccines and testing supplies) by the Buenos Aires City Government.

Evaluation of a COVID-19 Vaccine Campaign and SARS-CoV-2 Infection and Mortality Among Adults Aged 60 Years And Older in a Middle-Income Country.

Importance: Although there are reports of COVID-19 vaccine implementation in real-world populations, these come from high-income countries or from experience with messenger RNA technology vaccines. Data on outcomes of vaccine deployment in low- or middle-income countries are lacking. Objective: To assess whether the pragmatic application of the 3 COVID-19 vaccines available in Argentina, 2 of which have no reports of evaluation in real-world settings to date, were associated with a reduction in morbidity, all-cause mortality, and mortality due to COVID-19. Design, Setting, and Participants: This cohort study used individual and ecological data to explore outcomes following vaccination with rAd26-rAd5, ChAdOx1, and BBIBP-CorV. To correct for differences in exposure times, results are shown using incidence density per 100 000 person-days from the start of the vaccination campaign (December 29, 2020) to the occurrence of an event or the end of follow-up (May 15, 2021). Participants included 663 602 people aged at least 60 years residing in the city of Buenos Aires, Argentina. Statistical analysis was performed from June 1 to June 15, 2021. Main Outcomes and Measures: Diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction, death from all causes, and death within 30 days of a diagnosis of COVID-19. Poisson regression models were fitted to estimate associations with all 3 outcomes. Results: Among 663 602 residents of the city of Buenos Aires included in the study, 540 792 (81.4%) were vaccinated with at least 1 dose, with 457 066 receiving 1 dose (mean [SD] age, 74.5 (8.9) years; 61.5% were female [n = 281 284]; 68.0% [n = 310 987] received the rAd26-rAd5 vaccine; 29.5% [n = 135 036] received ChAdOx1; 2.4% [n = 11 043] received BBIBP-CorV) and 83 726 receiving 2 doses (mean [SD] age, 73.4 [6.8] years; 63.5% were female [n = 53 204]). The incidence density of confirmed COVID-19 was 36.25 cases/100 000 person-days (95% CI, 35.80-36.70 cases/100 000 person-days) among those who did not receive a vaccine, 19.13 cases/100 000 person-days (95% CI, 18.63-19.62 cases/100 000 person-days) among those who received 1 dose, and 4.33 cases/100 000 person-days (95% CI, 3.85-4.81 cases/100 000 person-days) among those who received 2 doses. All-cause mortality was 11.74 cases/100 000 person-days (95% CI, 11.51-11.96 cases/100 000 person-days), 4.01 cases/100 000 person-days (95% CI, 3.78-4.24 cases/100 000 person-days) and 0.40 cases/100 000 person-days (95% CI, 0.26-0.55 cases/100 000 person-days). COVID-19-related-death rate was 2.31 cases/100 000 person-days (95% CI, 2.19-2.42 cases/100 000 person-days), 0.59 cases/100 000 person-days (95% CI, 0.50-0.67 cases/100 000 person-days), and 0.04 cases/100 000 person-days (95% CI, 0.0-0.09 cases/100 000 person-days) among the same groups. A 2-dose vaccination schedule was associated with an 88.1% (95% CI, 86.8%-89.2%) reduction in documented infection, 96.6% (95% CI, 95.3%-97.5%) reduction in all-cause death, and 98.3% (95% CI, 95.3%-99.4%) reduction in COVID-19-related death. A single dose was associated with a 47.2% (95% CI, 44.2%-50.1%) reduction in documented infection, 65.8% (95% CI, 61.7%-69.5%) reduction in all-cause death, and 74.5% (95% CI, 66%-80.8%) reduction in COVID-19-related death. Conclusions and Relevance: This study found that within the first 5 months after the start of the vaccination campaign, vaccination was associated with a significant reduction in COVID-19 infection as well as a reduction in mortality.

Usefulness of the functionalities of an electronic medical record on a Latin American medical web portal.

The medical record is a key component in the modern health systems, a fundamental basis of higher functionalities that guaranties quality care and the possibility of improved clinical management. The dissemination of information systems for the electronic medical record (EMR) has a growing acceptance and use in developed countries. This type of recognition however has not been widespread in Latin America. Realizing this we conducted a web survey to users of a Latin American medical portal to assess their perception of the EMRs usefulness. Among the results we found that over 90% of respondents were in favor of its use, with values that exceed 80% in the analysis of the utilities by categories. More in-depth studies are needed to determine the reasons for the lack of dissemination and implementation of EMR in our region.

Three-dimensional morphometric analysis of the distal femur: a validity method for allograft selection using a virtual bone bank.

Tumor excision is the primary treatment of aggressive or recurrent benign bone tumors and malignant bone sarcomas. This requires a surgical resection with the potential for large residual osseous defects that could be reconstructed using fresh frozen allografts. Virtual bone banks enable the creation of databases allowing a 3D pre-surgery evaluation of such allgorafts, based on segmentation of DICOM-CT images. This study demonstrates the usefulness of patient specific 3D models for an accurate host-donor allograft match. We describe one way to select the best match according to size and shape. The results suggest that a robust and reliable technique has been established. Since it is difficult to plan an allograft on a distal femur deformed by the tumor, we propose to plan the surgery on the contralateral side. Our results support this limb symmetry hypothesis. The use of this measurement protocol enables accurate selection of allografts from a contralateral healthy femur 3D CT model achieving the best match possible considering the geometry of available allograft candidate femur specimens.

Development and implementation of an integrated EHR for Homecare Service: a South American experience.

This paper describes the development and implementation of a web based electronic health record for the Homecare Service program in the Hospital Italiano de Buenos Aires. It reviews the process of the integration of the new electronic health record to the hospital information system, allowing physicians to access the clinical data repository from their Pc's at home and with the capability of consulting past and present history of the patient health care, order, tests, and referrals with others professionals trough the new Electronic Health Record. We also discuss how workflow processes were changed and improved for the physicians, nurses, and administrative personnel of the Homecare Services and the educational methods used to improve acceptance and adoption of these new technologies. We also briefly describe the validation of physicians and their field work with electronic signatures.

Integration of healthcare information: from enterprise PACS to patient centered multimedia health record.

Every single piece of healthcare information should be fully integrated and transparent within the electronic health record. The Italian Hospital of Buenos Aires initiated the project Multimedia Health Record with the goal to achieve this integration while maintaining a holistic view of current structure of the systems of the Hospital, where the axis remains are the patient and longitudinal history, commencing with section Computed Tomography. Was implemented DICOM standard for communication and image storage and bought a PACS. It was necessary adapt our generic reporting system for live up to the commercial RIS. The Computerized Tomography (CT) Scanners of our hospital were easily integrated into the DICOM network and all the CT Scans generated by our radiology service were stored in the PACS, reported using the Structured Reporting System (we installed diagnostic terminals equipped with 3 monitors) and displayed in the EHR at any point of HIBA's healthcare network.

External validation of the unified model of information systems continuance (UMISC): An international comparison.

CONTEXT: The Unified Model of Information Systems Continuance (UMISC) is a metamodel for the evaluation of clinical information systems (CISs) that integrates constructs from five models that have previously been published in the literature. UMISC was developed at the Georges Pompidou University Hospital (HEGP) in Paris and was partially validated at the Saint Joseph Hospital Group (HPSJ), another acute care institution using the same CIS as HEGP. OBJECTIVE: The aim of this replication study was twofold: (1) to perform an external validation of UMISC in two different hospitals and country contexts: the Italian Hospital of Buenos Aires (HIBA) in Argentina and the Hospital Sirio Libanes in Sao Paulo, Brazil (HSL); (2) to compare, using the same evaluation model, the determinants of satisfaction, use, and continuance intention observed at HIBA and HSL with those previously observed at HEGP and HPSJ. METHODS: The UMISC evaluation questionnaires were translated from their original languages (English and French) to Brazilian Portuguese and Spanish following the translation/back-translation method. These questionnaires were then applied at each target site. The 21 UMISC-associated hypotheses were tested using structural equation modeling (SEM). RESULTS: A total of 3020 users, 1079 at HIBA and 1941 at the HSL, were included in the analysis. The respondents included 1406 medical staff and 1001 nursing staff. The average profession-adjusted use, overall satisfaction and continuance intention were significantly higher at HIBA than at HSL in the medical and nursing groups. In SEM analysis, UMISC explained 23% and 11% of the CIS use dimension, 72% and 85% of health professionals' satisfaction, and 41% and 60% of continuance intention at HIBA and HSL, respectively. Twenty of the 21 UMISC-related hypotheses were validated in at least one of the four evaluation sites, and 16 were validated in two or more sites. CONCLUSION: The UMISC evaluation metamodel appears to be a robust comparison and explanatory model of satisfaction, use and continuance intention for CISs in late post adoption situations.

Workforce Development Strategy for Health Information System Implementation at the Public Health System of Buenos Aires.

One of the challenges of implementing health information and communication technology is the need for a skilled workforce that understands health care and ITC. There are also people and organizational challenges involved. This work describes the strategies to create such a workforce for the public network of healthcare facilities in the City of Buenos Aires, which include promoting the adoption of technologies and providing lines of contention for continuous training.

Face to Face Appointment vs. Telemedicine in First Time Appointment Orthopedic Oncology Patients: A Cost Analysis.

Medicine has evolved considerably in recent decades in part thanks to information and communication technologies in health (ICTs). However, face-to-face consultations continue to be the predominant model, since alternatives such as telemedicine are still the subject of debate. On the other hand, in some very specific specialties, centralization is relevant, mainly due to the low frequency and prevalence of diseases, as well as the need to have highly specialized professionals, causing problems in terms of accessibility and costs for the health system. In this study we have analyzed the first consultations to an orthopedics oncology service at a tertiary institution and performed an analysis of economic costs was carried out between 2 possible scenarios: face-to-face consultations versus telemedicine. Analyzing the 2 scenarios, there would be a cost-benefit in the use of telemedicine leading to a decrease in healthcare cost between 12.2% and 72%.

[Changes in physicians' attitudes to computerized ambulatory medical record systems: a longitudinal qualitative study]. / Modificaciones en las perspectivas de los médicos sobre el registro médico electrónico: investigación cualitativa longitudinal.

OBJECTIVES: To explore physicians' beliefs about a computerized ambulatory medical record system at different stages of its implementation. METHODS: We performed a longitudinal qualitative in-depth interview study (July 2001 to December 2003) in the Hospital Italiano, Buenos Aires, Argentina. Semi-structured interviews were conducted in 20 primary care cardiologists purposively selected before, during and after the system's implementation process (10 interviews per stage). The interviews were independently analyzed by 2 researchers, who jointly designed an agreed category list. RESULTS: Both before and during the first stage of the implementation process, the physicians expected that that the system would improve healthcare-related administration and increase accessibility to individual data. However, they did not foresee that the system's shared information could modify the clinical aspects of patient care. By the end of the implementation process, the physicians realized that the system provided them with a broader perspective on their patients, which in turn improved their own professional performance. Throughout the implementation, the physicians were against using the computer while the patient was present. This opposition prevented them from regarding the system as part of the medical consultation and from considering data from the system as direct patient-related signs. CONCLUSIONS: The system's implementation modified the physicians' views on computerized ambulatory medical records, as they eventually considered them as an ancillary tool to clinical activity. The value assigned to the system depends on its relevance within the institutional framework.

Effectiveness of a chronic disease surveillance systems for blood pressure monitoring.

Information Technology (IT) enables health care providers to manage patients with chronic conditions through identification, follow up and administration of specific interventions. In our setting, we developed a surveillance system for chronic diseases. The aim of this study was to show its efficacy on monitoring blood pressure throughout a cluster randomized controlled trial. Patients without blood pressure registries (condition 1) or with high blood pressure measurements (condition 2) were randomized to be detected by the surveillance system or to receive usual care. The proportion of patients with at least one blood pressure measurement within three months of follow up was 49.9% (207 patients) in the intervention group and 37% (195) in the control group (p<0.001) for condition 1. And 61% (224) vs. 50% (239) respectively (p=0.002) for condition 2. Patients under the surveillance system have higher proportion of blood pressure measurements, showing this study an improvement on the process of care with this IT tool.

Creation and evaluation of a terminology server for the interactive coding of discharge summaries.

Free text entry versus structured data has been proposed as models in data entry in health information systems. A new user interface was developed with the objective of improving data capture. It also implemented a modification of the discharge summary data entry user interface that allowed the selection of already coded terms from a local terminology in the context of an inpatient electronic medical record. This software interacts online with a terminology server to provide feedback on data entry to clinical users in order to automatically code data. To evaluate the impact of this new software, we measured user satisfaction and the impact on autocodification rate. The new system had good acceptance from the users who ranked it high using QUIS (Questionnaire for User Interaction Satisfaction) and the auto codification rate improved from 61.5% to 88.39%.

Creation of a local interface terminology to SNOMED CT.

This paper describes the steps followed in the creation of a local Interface Terminology to SNOMED CT (as reference terminology) with a strong focus on user acceptability. The resulting list of terms is used for clinical data input by physicians and nurses at the Hospital Italiano in Buenos Aires, Argentina. Description includes data model, mappings to SNOMED CT and classifications, subsets definitions and extensibility mechanisms. The Interface Terminology is currently used in the recording of diagnosis and procedures in inpatient discharge summaries and its coverage is improving from user feedback. Its current size is 24,800 concepts, 67% of them needed post-coordination for appropriate semantic representation, due to a very flexible policy that allows the use of any number of modifiers on concepts.

Analysis and redesign of a knowledge database for a drug-drug interactions alert system.

Physicians tend to ignore drug-drug interactions alerts, this is due to the large amount of irrelevant interactions displayed and the interface in which these alerts are shown. The high rate of clinically inadequate alerts produce "alerts fatigue". This high number of incorrect alerts predisposes physicians to underestimate the electronic prescription systems as useful tools in their practice. We decided to analyze and redesign our drug-drug interactions alerting system knowledge database. In order to do so, we cleaned our knowledge database according to the clinical significance of drug-drug interactions. New drug interactions taxonomy was created in four levels based on clinical significance and the recommendations given in each single monograph of interaction. We proceeded to recategorize the alerts as Active, which present themselves to the physician interrupting the prescribing process, or Passive, which allow physicians to accept the recommendations, and adopt some action in order of minimizing the interaction risks.

Representation of People's Decisions in Health Information Systems.* A Complementary Approach for Understanding Health Care Systems and Population Health.

OBJECTIVES: In this study, we aimed: 1) to conceptualize the theoretical challenges facing health information systems (HIS) to represent patients' decisions about health and medical treatments in everyday life; 2) to suggest approaches for modeling these processes. METHODS: The conceptualization of the theoretical and methodological challenges was discussed in 2015 during a series of interdisciplinary meetings attended by health informatics staff, epidemiologists and health professionals working in quality management and primary and secondary prevention of chronic diseases of the Hospital Italiano de Buenos Aires, together with sociologists, anthropologists and e-health stakeholders. RESULTS: HIS are facing the need and challenge to represent social human processes based on constructivist and complexity theories, which are the current frameworks of human sciences for understanding human learning and socio-cultural changes. Computer systems based on these theories can model processes of social construction of concrete and subjective entities and the interrelationships between them. These theories could be implemented, among other ways, through the mapping of health assets, analysis of social impact through community trials and modeling of complexity with system simulation tools. CONCLUSIONS: This analysis suggested the need to complement the traditional linear causal explanations of disease onset (and treatments) that are the bases for models of analysis of HIS with constructivist and complexity frameworks. Both may enlighten the complex interrelationships among patients, health services and the health system. The aim of this strategy is to clarify people's decision making processes to improve the efficiency, quality and equity of the health services and the health system.