Evaluation of the association between different patient indexing strategies and effective

indexing in health centers of the public system of the Autonomous City of Buenos Ai-
res. An exploratory study.

Santiago Esteban1, Cecilia Palermo1, Leandro Alassia1, M. Victoria Giussi1, Analía

Baum1, Fernán González Bernaldo de Quirós2.
1
Clinical informatics, Statistics and Epidemiology Office, Health Ministry, Ciudad Autónoma de Buenos Aires, Argentina
2
Government Health Advisor, Ciudad Autónoma de Buenos Aires, Argentina

Abstract implementation of a single, common strategy for all centers,

During the implementation of an electronic health records
(EHR) system in the public system of the city of Buenos Aires,
Argentina, different patient indexing strategies were devised
and implemented. We sought to assess the association between
these strategies and effective indexing (proportion of patiens
who are indexed and have a consultation registered in the
EHR.
Strategies were grouped in three modalities (high,
intermediate and low intensity). We estimated hazard ratios
for high and low intensity strategies vs intermediate.
The crude analyses showed a significant difference between
the curves (p < 0.0001). In the multivariate analysis, the
hazard ratios (HR) of high and low intensity interventions
showed on average values above 1 from 0 to 90 days
compared to the intermediate intensity strategy (High: 2.08
(1.65, 2.52); Low: 2.59 (2.29, 2.9)). From that point on, the
HRs of both strategies were not different from 1.
Keywords:
Electronic Health Records
Introduction
During the implementation of an electronic health records
system, the processes of identity accreditation and the creation
of a master patient index (MPI) are critical in order to avoid
duplication or misassignment of a person's clinical data to
another[1; 5; 12]. In turn, depending on the implementation
context, these two processes may present different levels of
complexity, which conditions the strategies used to promote
patint indexing[6; 10].
Beginning in June 2016, the Ministry of Health of the
Autonomous City of Buenos Aires, through the Office of
Clinical Informatics, Statistics and Epidemiology (OCISE),
started implementing the computerization of all health records
from the public health system[2]. This involves the
deveolpment and and implementation of an electronic health
record (EHR) covering initially outpatient clinics but also
projects to more complex levels of care, such as hospitals. In
this context, the patient indexing process presents particular
difficulties. Factors related to physical resources, human
resources and characteristics of the population of each center
condition the indexing methodology, making the
impossible.
The reason why different strategies coexist is because each
primary care heatlh center is virtualy autonomous. Our team
had to negotiate with the chairmen of each center on how to
implement the patient indexing process. Thus, a particular
indexing strategy was devised by the chair of each primary
care health center taking into account the characteristics of the
center and its population. With the aim of improving the
implementations in future centers, we decided to evaluate the
association between the different indexing implementation
strategies and effective patient indexing.
Methods
General design and data source
The design is a prospective cohort based on secondary data,
extracted from the electronic medical records system of the
city of Buenos Aires. We used the term ‘prospective’ because
the intervention was defined and recorded, prior to the
occurrence of the result.
Population
All persons enrolled in the computerized health system
(SIGEHOS) of the city of Buenos Aires, between 1/6/2016
and 11/24/2016, were included. Two health centers were
excluded: one was already implemented prior to the start of
the current process (prior to June 2016); the other, the
implementation process has just begun (November 2016).
Intervention
During the first weeks of implementation in each center,
sociologists made ethnographic observations[4] of the patient
indexing process dynamics and heald extensive and recurrent
interviews[9] with the administrative staff involved in the
process. From the information obtained, typologies[11] were
constructed with a qualitative approach[3] in order to classify,
structure, order and compare the different conceptualizations
of the indexing strategies[7; 8]. The differences in the
strategies and their intensities gave rise to 3 types:
 Low intensity: The registration is taken as an
alternative instance to the usual process of attention
since the use of the paper medical record
predominates. The indexing process depends on the
 time availability of the administrative staff. Paper and significant itneraction terms were dropped form the model. All
electronic medical records coexist. analyzes were performed using R (R Foundation for Statistical
Computing, Vienna, Austria URL:. Https://www.R-
 Intermediate intensity: Indexing is offered to those project.org ).
patients who request new appontments and to those
who visit the center requesting maternal formula or
need to fill in paperwork related to social security. Results
Paper and electronic medical records coexist.
 High intensity: registration is proposed as a condition Figure 2 shows the distribution of health centers implemented
in all instances of consultation at the center and the in the cit of Buenos Aires. The color indicates the indexing
EMR is the main registration system. strategy used.

Outcome
As the result, we used the time from registration to the first
visit recorded in the EMR or administrative censorship
(24/11/2016 or maximum of five months). This was done
since the raw indexing total (total number of indexed patients)
can reflect many patients who are indexed without actually
needing to see someone from the health staff (for example, in
several centers, the handout of maternal formula was used as
an instance to promote indexing). This situation is a problem
for patients who need medical attention, since they may decide
skip indexing because of the long waiting times and queues,
thus promoting paper the perpetuation of the paper
records. Given the short duration of the study and the type of
population (outpatient population), no competing risks such as
death were considered.
Covariates
Baseline variables were extracted from the EMR at the time of
each patient's indexing, such as sex, age, type of housing,
district of residence, programmatic area in which they were
registered, number of professionals of the main specialties at
the center of attention (Obstetrics, tocoginecology, pediatrics,
family medicine) and number administrative staff.
Model structure Figure 2. Map of the city of Buenos Aires with the
Figure 1 shows the directed acyclic graph (DAG) of the implemented primary care health centers by indexing strategy.
defined structure to try to resolve confounding between
exposure (A = indexing strategy) and the result (Y = first visit
recorded in the EMR) model. In these graphs, time runs from
left to right, lines denote association (bidirectional), arrows Table 1 shows the baseline characteristics of the patients. The
indicate causal direction and the boxes around the variables distribution of age categories represents a characteristic broad-
reflect controlling by that variable and therefore the rupture of based pyramid with a clear predominance of women. In turn,
the association flow thorugh that path . the vast majority of patients reported residing in Buenos Aires
(87%). 49% of the indexed patients come from four of the 18
centers analyzed (Hosp. Grierson, 5, 7 and 35). This is due to
a combination of implementation time, size of the center in
terms of population served and indexing strategy. On the other
hand, since the process began in the south-west area of the
city, two programmatic areas of the six, account for 72% of
the registered patients.

Table 1. Patients’ baseline characteristics.

Figure 1. DAG for the fully adjusted model.
High Intermedia Low p
intensity te intensity intensity
Statistical analysis
No. of 14547 22974 8581
The crude proportions of effective indexing were estimated patients
using the Kaplan-Meier method and compared by means of 9590 (65.9) 14740 (64.2) 5651 (65.9) <0.001
Sex: Female
the log rank test. The level of significance for all tests was set
at 0.05. The Cox proportional hazards model was used for Age 16.76 [5.33, 15.40 [5.08, 14.32 [4.72, <0.001
(median 34.15] 32.49] 31.41]
multivariate adjustment. The proportionality of risk was
analyzed by analyzing the Schoenfeld residuals (graphic and [IQR])
test analysis) and also by means of the log-log grpahs for each Age <0.001
variable. The variables for which the assumption did not hold categories in
were incorporated into the model thorugh an interaction with a years (%)
flexible function of time (natural cubic spline). Non-
 0 - 10 5633 (38.7) 9110 (39.7) 3612 (42.1) Proportional hazards assessment
11 - 20 2252 (15.5) 4051 (17.6) 1316 (15.3) All variables were analyzed using the systematic described in
the methods section. The scaled Schoenfeld residuals test was
21 - 30 2241 (15.4) 3332 (14.5) 1323 (15.4)
highly significant for many of the variables included in the
31 - 40 1705 (11.7) 2631 (11.5) 1028 (12.0) model; however, graphical analysis in many cases did not
show significant deviations from proportionality. This was
41 - 50 1129 ( 7.8) 1707 ( 7.4) 600 ( 7.0)
probably due to the large sample size for which minimal
51 - 60 745 ( 5.1) 1102 ( 4.8) 356 ( 4.1) differences were detected. The intervention varaible also
478 ( 3.3) 667 ( 2.9) 224 ( 2.6)
showed no proportionality of hazards (figure 4).
61 - 70
71 - 80 267 ( 1.8) 280 ( 1.2) 84 ( 1.0)

81 - 90 92 ( 0.6) 88 ( 0.4) 37 ( 0.4)

>90 5 ( 0.0) 6 ( 0.0) 1 ( 0.0)

Residence: 11873 (82.3) 21254 (94.4) 6958 (81.5) <0.001

City of
Buenos
Aires (%)
Informal 2763 (19.0) 12026 (52.3) 1419 (16.5) <0.001
housing (%)
Administrat <0.001
ive regions
(%)
Argerich 384 ( 2.6) 0 ( 0.0) 2315 (27.0) Figure 4. Assessment of the proportional hazards
assumption. Log-log and scaled Schoenfeld residuals graphs.
Durand 0 ( 0.0) 647 ( 2.8) 0 ( 0.0)

Grierson 0 ( 0.0) 7202 (31.3) 0 ( 0.0)

To resolve this situation, the follow-up time was divided into
Penna 2484 (17.1) 9446 (41.1) 972 (11.3) seven-day intervals and the risk of each intervention (High
and Low) vs the reference (Intermediate) was
Ramos 2151 (14.8) 0 ( 0.0) 0 ( 0.0)
calculated. Within each interval the risks proved to be
Santojanni 9528 (65.5) 5679 (24.7) 5294 (61.7) proportional. Figure 5A shows the progression of the hazard
ratios of the high and low intensity strategies vs intermediate
Effective 8401 (57.8) 11796 (51.3) 4432 (51.6) <0.001
intensity, for the crude model. An initial benefit is observed
indexing
(%)
approximately during the first 30 days if favour of the high
and low intensity strategies. The adjusted model included sex,
district of residence, type of housing, no. of administrative
staff at the indexing health center, no. of professionals at the
Survival curves
indexing health cente (medical clinic, pediatrics, obstetrics,
The cumulative probability curves for the three strategies are tocoginecología, familiar medicine) and programmatic area of
plotted in Figure 3. The three initially show a rapid ascent, due the indexing health center. It is observed that the hazard ratios
to those who register and have a consultation on the same day of the low and high intensity strategies lose significance after
or the following day. From that moment on, the curves approximately 90 days from the starting point, comparing
diverge; the high intensity is associated with a shorter time against the intermediate intensity strategy (Figure 5B, Table
until the first visit registered in the EHR. Intermediate and low 2).
intensity strategies initially differ, but each similar levels after
60 days . The log rank test showed statistically significant
differences between the curves (p <0.0001).

Figure 3. Curve of cumulative probability.

 those patients who seek to effectively attend the health center
for medical reasons. The analysis of the results of our model
shows evidence in favor of the high and low intensity
interventions, at least during the first 90 days. During this
period, high and low intensity interventions were more
frequently associated with effective indexing. It is possible to
think that the intermediate-intensity intervention, which made
focus on indexing people who attended the health center
mostly for non-medical reasons, does not lead to an effective
indexing, since these patients do not concur with the objective
of receiving care. After 90 days, all three strategies resulted
equally effective. These results are possible explained in
different ways. On the one hand, it would be expected that
over time all registered patients, sooner or later, will be visit
the clinic, independently from which indexing strategy they
were exposed to. On the other hand, it could respond to
intrinsic and subjective factors of the patients that we are not
capturing in our model, so there would be residual confusion
that would not allow to see differences between strategies.
Finally, the typology constructed does not represent a static
model associated with each health center, but is subject to
modifications over time. The centers can modify their strategy
Figure 5 A&B. Hazard ratios of high and low intensity to political, managerial and technical factors.
strategies compared to intermediate intensity.
It was striking to observe the relative greater effectiveness of
the low intensity strategy compared to the intermediate
intensity strategy. The centers that adopted low intensity
Table 2. Hazard ratios for each time interval per intervention
strategies mainly focused on registering patients during certain
strategy.
hours. This, in many cases, was due to a policy of the center’s
Time intervals High intensity Low intensity management to accompany the overall EHR implementation
(days) HR (95% CI) HR (95% CI) process, but without complete commitment. This highlights
[0,7] 2.77 (2.56 ,3) 3.13 (2.76 ,3.55) one of the biggests if not the biggest problem we experienced
during the whole process which is the lack of gobernance.
(7,14] 3.46 (3.02 ,3.96) 2.68 (2.21 ,3.24) Eventhough all centers are part of the same public health
(14,21] 3.51 (3.01 ,4.08) 3.21 (2.62 ,3.93) system, they act independently. Even withing each center,
gobernance is a problem, since in many of them the medical
(21,28] 2.72 (2.31 ,3.19) 3.3 (2.67 ,4.07)
management does not have gobernance over the
(28,35] 1.99 (1.67 ,2.38) 2.98 (2.36 ,3.76) administration staff or even the medical staff.
(35,42] 1.57 (1.26 ,1.95) 3.22 (2.45 ,4.22) In contrast, many of the intermediate indexing intensity
centers chose to promote indexing in instances not related to
(42,49] 1.41 (1.11 ,1.78) 2.07 (1.49 ,2.87)
healthcare. Therefore, the majority of the registered people did
(49,56] 1.45 (1.13 ,1.87) 1.73 (1.19 ,2.51) not correspond to people in need of being seen by somebody
1.64 (1.23 ,2.18) 2.51 (1.68 ,3.75)
from the healthcare staff in the short term. This, coupled with
(56,63]
a partial adherence to the use of the EHR by professionals, can
(63,70] 1.81 (1.3 ,2.51) 2.27 (1.43 ,3.59) explain the difference between both strategies.
(70,77] 1.64 (1.12 ,2.41) 2.22 (1.35 ,3.66) Regarding the high intensity strategy, it basically consists of
(77,84] 1.78 (1.15 ,2.77) 2.45 (1.44 ,4.17) promoting indexing in all the instances (appointments +
maternal formula handout or social security realted
(84,91] 1.36 (0.81 ,2.3) 1.94 (1.06 ,3.54) consultations) coupled with a strong motivation for the use of
(91,98] 0.69 (0.37 ,1.3) 1.65 (0.86 ,3.14) the EHR, which in many cases, started at the beginning of
implementation process. However, even without a formal test,
(98,105] 0.91 (0.46 ,1.79) 2.13 (1.04 ,4.35) there does not seem to be significant differences between the
(105,112] 1.09 (0.58 ,2.06) 1.78 (0.84 ,3.78) high and low intensity strategies. One possible explanation for
this may be that the high-intensity strategy represents a
(112,119] 0.69 (0.34 ,1.38) 1.05 (0.45 ,2.44)
combination of the low intensity (focused on some patients
(119,126] 1.12 (0.47 ,2.66) 2.29 (0.86 ,6.11) seeking attention in certain time slots) and the intermediate
intensity (focused on people who attend the center mostly
(126,133] 0.79 (0.33 ,1.9) 1.77 (0.65 ,4.79)
without needing to be seen by the healthcare staff in the short
(133,140] 0.71 (0.24 ,2.1) 1.29 (0.39 ,4.34) term).
(140,147] 2.63 (0.62 ,11.08) 2.01 (0.38 ,10.69) Like any observational study, our study presents limitations
mainly related to potential residual confounding and
misclassification, both at baseline and time dependent. We
Discussion were not able to collect information regarding characteristics
of the center’s management, the atitude of the professionals
Our study sought to explore the association between different towards the EHR implementation process and the availability
strategies for the implementation of patent indexing and what of appointments at the center. On the population side, we
we defined as effective indexing, that is, the registration of could not record data related to the level of disease burden per
patient. Also, since we are in the first stage of the Health Information Exchange Using Exact Matching, Appl
implementation of an EHR system we could not assess the Clin Inform 7 (2016), 330-340.
impact of indexing on any healthcare outcomes. As mentioned
above, classification error is also a potential source of bias in Address for correspondence
our estimates. We have confidence in the basic Dr. Santiago Esteban.
characterization of the centers, however, we believe that there Email : santiagoesteban@gmail.com
are errors in the classification of centers over time because
many, due to internal or external motivations (implementation
in other centers, direct intervention of the ministry of health),
changed the intensity of the strategy initially chosen.

Conclusion

As part of the project to implement an EMR system in the city

of Buenos Aires, there are still more than 25 centers to be
implemented in the next year. The results of our study provide
us with more information to be able to discuss and negotiate
with the management of each center, the possible benefits of
each strategy and thus select the one that best suits the needs
of the center and the overall implementation process of the
EMR.

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