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doi:10.3233/978-1-61499-830-3-709

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 Aires: An Exploratory Study

Santiago Estebana, Cecilia Palermoa, Leandro Alassiaa, M. Victoria Giussia,

Analía Bauma, Fernán González Bernaldo de Quirósb
a
Clinical informatics, Statistics and Epidemiology Office, Health Ministry, Ciudad Autónoma de Buenos Aires, Argentina
b
Government Health Advisor, Ciudad Autónoma de Buenos Aires, Argentina

Abstract had to negotiate with the chairmen of each center on how to

During the implementation of an electronic health record
(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 patients
who are indexed and have a consultation registered in the
EHR). Strategies were grouped into three modalities (High,
Intermediate, and Low intensity). We estimated hazard ratios
(HR) comparing the High and Low intensity to the
Intermediate strategies. The crude analyses showed a
significant difference between the curves (p < 0.0001). In the
multivariate analysis, the HRs 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
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
future implementations, we decided to evaluate the association
between the different indexing implementation strategies and
effective patient indexing.
Methods
General Design and Data Source
This study utilized a prospective cohort design based on
secondary data extracted from the EHR 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

Introduction All persons enrolled in the computerized health system

During the implementation of an electronic health record
(EHR) system, the processes of identity accreditation and the
creation of a master patient index are critical in order to avoid
duplication or misassignment of a person's clinical data [1-
3]. 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 [4; 5].
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 [6]. This involves the
deveolpment and and implementation of an EHR, initially
covering outpatient clinics but also more complex levels of
care, such as hospitals. In this context, the patient indexing
process is particularly difficult. Factors related to physical
resources, human resources, and characteristics of the
population of each center condition the indexing methodology,
making the implementation of a single, common strategy for
all centers, impossible.
The reason why different strategies coexist is because each
primary care health center is virtualy autonomous. Our team
(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 [7] of the patient
indexing process dynamics and held extensive and recurrent
interviews [8] with the administrative staff involved in the
process. From the information obtained, typologies [9] were
constructed with a qualitative approach [10] in order to
classify, structure, order, and compare the different
conceptualizations of the indexing strategies [11; 12]. The
differences in the strategies and their intensities gave rise to 3
types:
x 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
EHRs coexist.
710 S. Esteban et al. / Evaluation of the Association Between Different Patient Indexing Strategies and Effective Indexing

x Intermediate Intensity: Indexing is offered to patients significant itneraction terms were dropped form the model. All
who request new appontments and to those who visit analyzes were performed using R (R Foundation for Statistical
the center requesting maternal formula or need to fill Computing, Vienna, Austria URL:. Https://www.R-
in paperwork related to social security. Paper and project.org ).
EHRs coexist.
x High Intensity: Registration is proposed as a condition Results
in all instances of consultation at the center and the
EHR is the main registration system. Figure 2 shows the distribution of health centers implemented
in the city of Buenos Aires. The color indicates the indexing
Outcome strategy used.
We used the time from registration to the first visit recorded in
the EHR or administrative censorship (24/11/2016 or
maximum of five months). This was done to account for the
fact that 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 (e.g.,, 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
to 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 EHR 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 1 shows the directed acyclic graph (DAG) of the
defined structure to try to resolve confounding between
exposure (A = indexing strategy) and the result (Y = first visit
recorded in the EHR) model. In these graphs, time runs from
left to right, lines denote association (bidirectional), arrows
indicate causal direction and the boxes around the variables
reflect controlling by that variable and therefore the rupture of
the association flow thorugh that path .
Figure 2- Map of the city of Buenos Aires with the
implemented primary care health centers by indexing strategy
Table 1 shows the baseline characteristics of the patients. The
distribution of age categories represents a characteristic broad-
based pyramid with a clear predominance of women. In turn,
the vast majority of patients reported residing in Buenos Aires
(87%). 49% of the indexed patients came 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 southwest area of
the city, two programmatic areas of the six, account for 72%
of the registered patients.

Survival Curves

Figure 1 - DAG for the fully adjusted model
Statistical Analysis
The crude proportions of effective indexing were estimated
using the Kaplan-Meier method and compared by means of
the log-rank test. The level of significance for all tests was set
at 0.05. A Cox proportional hazards model was used for
multivariate adjustment. The proportionality of risk was
assessed by analyzing the Schoenfeld residuals (graphic and
test analysis) and also by means of the log-log graphs for each
variable. The variables for which the assumptions did not hold
were incorporated into the model through an interaction with a
flexible function of time (natural cubic spline). Non-
The cumulative probability curves for the three strategies are
plotted in Figure 3. The three strategies initially show a rapid
ascent, due to those who register and have a consultation on
the same day or the following day. From that moment on, the
curves diverge; the High intensity is associated with a shorter
time until the first visit registered in the EHR. Intermediate
and Low intensity strategies initially differ, but each reaches
similar levels after 60 days. The log-rank test showed
statistically significant differences between the curves (p
<0.0001).
 S. Esteban et al. / Evaluation of the Association Between Different Patient Indexing Strategies and Effective Indexing 711

Table 1- Patients’ baseline characteristics probably due to the large sample size for which minimal
differences were detected. The intervention varaible also
High Intermediate Low p showed no proportionality of hazards (figure 4).
intensity intensity intensity
No. of patients 14547 22974 8581
Sex: Female 9590 (65.9) 14740 (64.2) 5651 (65.9) <0.001
Age (median 16.76 [5.33, 15.40 [5.08, 14.32 [4.72, <0.001
[IQR]) 34.15] 32.49] 31.41]
Age categories in <0.001
years (%)
0 - 10 5633 (38.7) 9110 (39.7) 3612 (42.1)
11 - 20 2252 (15.5) 4051 (17.6) 1316 (15.3)
21 - 30 2241 (15.4) 3332 (14.5) 1323 (15.4)
31 - 40 1705 (11.7) 2631 (11.5) 1028 (12.0)
41 - 50 1129 ( 7.8) 1707 ( 7.4) 600 ( 7.0)
51 - 60 745 ( 5.1) 1102 ( 4.8) 356 ( 4.1)
61 - 70 478 ( 3.3) 667 ( 2.9) 224 ( 2.6) Figure 4 - Assessment of the proportional hazards
71 - 80 267 ( 1.8) 280 ( 1.2) 84 ( 1.0) assumption. Log-log and scaled Schoenfeld residuals graphs
81 - 90 92 ( 0.6) 88 ( 0.4) 37 ( 0.4)
>90 5 ( 0.0) 6 ( 0.0) 1 ( 0.0) To resolve this situation, the follow-up time was divided into
seven-day intervals and the risk of each intervention (High
Residence: City 11873 (82.3) 21254 (94.4) 6958 (81.5) <0.001
of Buenos Aires
and Low) vs the reference (Intermediate) were
(%) calculated. Within each interval the risks proved to be
Informal housing 2763 (19.0) 12026 (52.3) 1419 (16.5) <0.001
proportional. Figure 5A shows the progression of the hazard
(%) ratios of the high and Low intensity strategies vs Intermediate
<0.001
intensity, for the crude model. An initial benefit is observed
Administrative
regions (%) approximately during the first 30 days in favour of the High
and Low intensity strategies. The adjusted model included sex,
Argerich 384 ( 2.6) 0 ( 0.0) 2315 (27.0)
district of residence, type of housing, number of
Durand 0 ( 0.0) 647 ( 2.8) 0 ( 0.0) administrative staff at the indexing health center, number of
Grierson 0 ( 0.0) 7202 (31.3) 0 ( 0.0) professionals at the indexing health center (medical clinic,
Penna 2484 (17.1) 9446 (41.1) 972 (11.3) pediatrics, obstetrics, tocoginecología, familiar medicine), and
programmatic area of the indexing health center. It was
Ramos 2151 (14.8) 0 ( 0.0) 0 ( 0.0)
observed that the hazard ratios of the Low and High intensity
Santojanni 9528 (65.5) 5679 (24.7) 5294 (61.7) strategies lose significance after approximately 90 days from
Effective 8401 (57.8) 11796 (51.3) 4432 (51.6) <0.001 the starting point when compared against the Intermediate
indexing (%) intensity strategy (Figure 5B, Table 2).

Figure 3 - Curve of cumulative probability

Proportional Hazards Assessment

All variables were analyzed using the procedures described in Figure 5 A&B - Hazard ratios of High and Low intensity
the methods section. The scaled Schoenfeld residuals test was strategies compared to Intermediate intensity
highly significant for many of the variables included in the
model; however, graphical analysis in many cases did not
show significant deviations from proportionality. This was
712 S. Esteban et al. / Evaluation of the Association Between Different Patient Indexing Strategies and Effective Indexing

Table 2 - Hazard ratios for each time interval per intervention process, but without complete commitment. This highlights
strategy one of the biggest, if not the biggest, problems we experienced
during the whole process which was the lack of governance.
Time intervals (days) High intensity Low intensity Even though all centers are part of the same public health
HR (95% CI) HR (95% CI)
system, they act independently. Even within each center,
[0,7] 2.77 (2.56 ,3) 3.13 (2.76 ,3.55)
governance is a problem, since in many of them the medical
(7,14] 3.46 (3.02 ,3.96) 2.68 (2.21 ,3.24) management does not have governance over the
(14,21] 3.51 (3.01 ,4.08) 3.21 (2.62 ,3.93) administration staff or even the medical staff.
(21,28] 2.72 (2.31 ,3.19) 3.3 (2.67 ,4.07) In contrast, many of the Intermediate indexing intensity
(28,35] 1.99 (1.67 ,2.38) 2.98 (2.36 ,3.76) centers chose to promote indexing in instances not related to
health care. Therefore, the majority of the registered people
(35,42] 1.57 (1.26 ,1.95) 3.22 (2.45 ,4.22)
did not correspond to people in need of being seen by
(42,49] 1.41 (1.11 ,1.78) 2.07 (1.49 ,2.87) somebody from the health care staff in the short term. This,
(49,56] 1.45 (1.13 ,1.87) 1.73 (1.19 ,2.51) coupled with a partial adherence to the use of the EHR by
(56,63] 1.64 (1.23 ,2.18) 2.51 (1.68 ,3.75) professionals, can explain the difference between both
strategies.
(63,70] 1.81 (1.3 ,2.51) 2.27 (1.43 ,3.59)
(70,77] 1.64 (1.12 ,2.41) 2.22 (1.35 ,3.66) Regarding the High intensity strategy, it basically consists of
promoting indexing in all the instances (appointments and
(77,84] 1.78 (1.15 ,2.77) 2.45 (1.44 ,4.17)
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
(98,105] 0.91 (0.46 ,1.79) 2.13 (1.04 ,4.35)
implementation process. However, even without a formal test,
there did 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
(112,119] 0.69 (0.34 ,1.38) 1.05 (0.45 ,2.44) for this may be that the High intensity strategy represents a
(119,126] 1.12 (0.47 ,2.66) 2.29 (0.86 ,6.11) combination of the Low intensity (i.e., focused on some
(126,133] 0.79 (0.33 ,1.9) 1.77 (0.65 ,4.79)
patients seeking attention in certain time slots) and the
Intermediate intensity (i.e., focused on people who attended
(133,140] 0.71 (0.24 ,2.1) 1.29 (0.39 ,4.34) the center mostly without needing to be seen by the health
(140,147] 2.63 (0.62 ,11.08) 2.01 (0.38 ,10.69) care staff in the short term).
Like any observational study, our study has limitations,
mainly related to potential residual confounding and
Discussion misclassification, both at baseline and over time. We were not
able to collect information regarding characteristics of the
Our study sought to explore the association between different center’s management, the attitude of the professionals towards
strategies for the implementation of patient indexing. We the EHR implementation process, and the availability of
defined as effective indexing, the registration of patients who appointments at the center. On the population side, we could
seek to effectively attend the health center for medical not record data related to the level of disease burden per
reasons. The analysis of the results of our model shows patient. Also, since we are in the first stage of the
evidence in favor of the High and Low intensity interventions, implementation of an EHR system we could not assess the
at least during the first 90 days. During this period, High and impact of indexing on any health care outcomes. As
Low intensity interventions were more frequently associated mentioned above, classification error is also a potential source
with effective indexing. It is possible to think that the of bias in our estimates. We have confidence in the basic
Intermediate intensity intervention, which focused on indexing characterization of the centers, however, we believe that there
people who attended the health center mostly for non-medical are errors in the classification of centers that occur over time
reasons, does not lead to an effective indexing, since these because many, due to internal or external motivations (i.e.,
patients do not concur with the objective of receiving care. implementation in other centers, direct intervention of the
After 90 days, all three strategies were equally effective. ministry of health), changed the intensity of the strategy
These results can be explained in different ways. On the one initially chosen.
hand, it would be expected that over time all registered
patients, sooner or later, will visit the clinic, independently
from which indexing strategy they were exposed to. On the
Conclusion
other hand, it could respond to intrinsic and subjective factors
of the patients that we are not capturing in our model, so there As part of the project to implement an EHR system in the city
would be residual confusion that would not allow us to see of Buenos Aires, there are still more than 25 centers to be
differences between strategies. Finally, the typology implemented in the next year. The results of our study provide
constructed does not represent a static model associated with us with better information that can be used when discussing
each health center, but is subject to modifications over time. and negotiating with the management of each center. This
The centers can modify their strategy to political, managerial includes the possible benefits of each strategy when selecting
and technical factors. the one that best suits the needs of the center and the overall
implementation process of the EHR.
It was striking to observe the relatively greater effectiveness
of the Low intensity strategy compared to the Intermediate
intensity strategy. The centers that adopted Low intensity References
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Address for correspondence

Dr. Santiago Esteban.
Email : santiagoesteban@gmail.com