By Daniela Chueke
In an exclusive interview with Ehealth Reporter Latin America, Doctor Sergio Montenegro tells us about the IT department’s successful implementation of the system at the Dr. Ramón Madariaga Intensive Care Hospital in Posadas, the capital of the Province of Misiones, Argentina.
This famiy doctor was one of the first graduates from the Hospital Italiano de Buenos Aires’ Medical Information Technology Program. He is currently the Head of Medical Information Technology at the Institution in Posadas.
The Hospital’s Information Technology Department was founded in November 2009, six months before the hospital opened its doors to the public.
The Department is run by Pablo Guccione, who took charge of putting together its initial team to carry out the planning for the implementation of technologically advanced equipment at the Hospital. Currently its biggest challenge is the Provincial Computerization Project. The Department is in charge of all areas of information technology, including both clinical and administrative processes, management, research and education. It also takes care of maintenance of hardware, telephones and security.
We asked Doctor Montenegro about theepartment’s future plans and challenges:
EHealth Reporter Latin America: How important is the implementation of the rapid patient identification system to the clinical administration of the hospital?
Dr. Sergio Montenegro: The rapid identification system for oncology patients is one of the most important functions of a module in our system called the “Patient Enroller.” This tool allows us to identify patients with certain characteristics (oncology patients, diabetics, people with hypertension, people who are HIV positive) and to group them in a determined pattern so that they can be treated in an organized and appropriate manner. This system has great potential for application in the institutional clinical administration project, because it can be used for different health problems (oncological, infectious, cardiovascular, chronic, non-transmissible, and other diseases). In the case of oncology patients, it is being used to address a very common problem for our population with clinical but also social consequences.
EHRLA: How does it help to improve the model for care and the efficiency of administration?
SM: There are currently 130,190 patients identified on the SIS, the Institution’s Healthcare Information Technology System, making up 11.8% of the total population of Misiones (1,101,593 according to INDEC’s 2010 census). Before the implementation of the patient enroller, it was very difficult to tell which patients were oncology patients, which had preneoplastic, or cardiovascular disorders, etc. We also didn’t know how many there were, their demographic characteristics, how often they visited the Institution, which specialties they made use of, or how much their treatment cost. After the implementation of the enroller, most of these questions are being answered.
Furthermore, the implementation of this system made it possible to speed up care and diagnostic, therapeutic and monitoring procedures resulting in benefits for patients and family members, with shorter waiting times for treatment, bearing in mind that a large and growing part of the population using our Institution is from the interior and have very few resources available to them.
EHRLA: What changes have you seen since the system was put in use?
SM: Since we started to use the tool, we have managed to create a pattern of oncology patients which currently includes 682 patients with preneoplastic disorders, with 546 ongoing cases. Furthermore, different functions are available within these patterns: 1) Visual Alerts: A System for doctors and administrators which can be used in any part of the hospital to rapidly identify the patient and their condition for more efficient care; 2) Changes in the Care Processes: The Hospital Management has implemented guidelines for doctors and administrators, which set priorities for the care of oncology patients and those with preneoplastic disorders. This system prevents patients from spending long amounts of time in waiting rooms with patients who perhaps have less serious conditions, so that sufferers’ quality life is improved. Furthermore, it became possible to organize diagnostic appointments far more quickly. Before the implementation of the patterns, a patient with a preneoplastic disorder might have had to wait 6 months to do the full diagnostic circuit. Today, this time has been cut down to less than a month. The most important point is that these improvements in care have helped us to cut mortality rates for cancer with early diagnoses. Also, when doctors can see the list of appointments for themselves, they can prioritize oncology patients and those with preneoplastic injuries and attend them first; 3) Statistical Reports: The groundwork has been laid for the generation of local statistical reports on these patients, making it possible to obtain rapid information for decision making and facilitate the generation of statistical evidence. Using these reports, it is possible to get online, up to the minute (at a click) information on the number of people in the pattern, the personal contact details of each member, the demographic characteristics of each pattern, the medical services they have consulted, and the health problems for which these consults were made.
EHRLA: Do you expect to see more changes which have not yet become apparent?
SM: So far, the impact of the process on patient care has not yet been quantified because the process indicators haven’t been defined. We are planning to work on this aspect this year in order to monitor the care process for these patients and then use this information to monitor them and establish continuous improvement programs.
Another goal for the future is to be able to calculate the cost of treatment of these patients to our health system. This not only applies to oncology patients but also patients with chronic diseases such as Diabetes, Arterial Hypertension, COPD – Chronic Obstructive Pulmonary Disease, Chronic Renal Insufficiency, etc. in which prevention and control of said pathologies is extremely important for the control of costs.
Although this institution works with seriously ill patients, we believe that better management of resources requires better control over chronic patients.
EHRLA: Did you meet with any obstacles when you implemented the system?
SM: One of the biggest obstacles we’ve come across up to now is “organizational change,” which is a common problem in computerization processes. Changing the institutional culture is always the hardest task. To achieve it we worked hard on training and awareness programs for the entire healthcare team, as well as developing auditing systems which would allow us to monitor users and thus not be so dependent on health records.
Also, the lack of quality of the records was and continues to be an obstacle. When we began to analyze the information recorded, we found incomplete and in many cases poor quality records. For this reason, the conclusions that can be reached using the information extracted from the system were deficient and incomplete. In this case, the auditing tools also helped us to improve this situation as it allowed us to monitor the quality of the record and the users themselves and thus to create guidelines for use which were shown to users, in the form of traffic lights so that they would be more aware of their own mistakes. This traffic light system had set colors depending on the quantity of errors committed within a determined period of time, which was established as a month.
EHRLA: What are the system’s limits and potential for working change in the hospital and the efficiency of patient care?
The limitations to the system which we have encountered so far are, on the one hand, organizational, due to the continued lack of awareness on the part of some users and, on the other, there are limits to resources which prevent us from being able to expand the tool more generally to other public institutions so that they can experience the same benefits. At the moment, at least. Although we do plan to do this in the future, we encounter many similar obstacles of this kind.
With regard to the potential of the system to produce changes in the hospital and improve the efficiency of care, I think it is infinite. Everything depends on how far one is willing or able to go and, among other factors, the resources available.
EHRLA: Who was responsible for developing the solution?
SM: The Hospital has its own multidisciplinary team made up of 22 people. This team is coordinated by the department head and made up of technical, administrative and training staff, developers, network and database administrators and a doctor specializing in Medical Information Technology.
Currently, we are using Electronic Clinical Record software from the company “Sistemas Clínicos Web”, which is based on concepts developed by the Information Technology Department at the Hospital Italiano de Buenos Aires; currently the most advanced Institution in terms of Medical Information Technology in Argentina. This software was taken by the hospital’s development team and adapted to the institution’s parameters. It will gradually be replaced by a more advanced system we have developed ourselves which will be implemented in the other locations in the province of Misiones.
EHRLA: Could you describe the system’s development process?
SM: The development process was fairly quick, because it started with a ready-made solution provided by the company “Sistemas Clínicos Web”. The modules were developed and adapted in 6 months after which the “New Dr. Ramón Madariaga Intensive Care Teaching Hospital” opened its doors and was thus able to enter its patients in Electronic Health Records from that moment on. That was in March 2010.
The system is developed with OpenSource tools, using a MySQL system as a database driver and PHP, ajax and javascript as the programming languages. The system is very flexible, scalable and easily adaptable.
EHRLA: How was it financed?
SM: The main financing for this project came from Misiones Province via the Ministry of Public Health and the Hospital itself who made a major initial investment in the technology infrastructure and in Human Resources to administer and maintain the System.
The success of the system’s implementation is due in part to the commitment and technical skills of the people leading the project and the significant training and monitoring work carried out every day.
Furthermore, the unconditional academic support provided by the Healthcare Information Technology Department at the Hospital Italiano indirectly helped the growth of the project.
EHRLA: How did you work with the medical staff of the hospital to implement the new system at the hospital?
SM: We had the advantage that the system was already running when the Hospital opened its doors, which was a prerequisite, so that doctors could begin to work and use the system and thus ensure it was accepted by the professional staff.
Furthermore we also received committed support from the Ministry of Health and the Medical Management in order to advance with the implementation so we didn’t meet with much political resistance from the Services.
Apart from that, we have a training department which took charge of standardizing the process in the Hospital. This measure ensured that all of the system’s users had to take and pass the appropriate training courses in order to get an access code for the system. Delivery of the access code also required the user to sign a confidentiality agreement which emphasized the importance of confidentiality and privacy of the information accessed via the code.
Finally, we used some indicators during the implementation which allowed us to quantify and classify the use of the record in order to identify users who don’t make use of the system, and those who use it in error, in order to retrain them or identify strategies to encourage them to use the record.
EHRLA: What other projects does the Hospital’s Information Technology Department have planned?
SM: One of the largest projects now being carried out by the Department of Information Technology is the computerization of the other Public Hospitals in the Province to create a province-wide Electronic Clinical Record.
