Knowledge Brief Health, Nutrition and Population Global Practice Expansion of the Coverage of the Single Digital Health Record (EDUS) in the PHC system in Costa Rica Ana Lucia Rosado Valenzuela, Ashley Sheffel, Ana Maria Lara Salinas, Micaela Mussini, Laura Di Giorgio August 2023 KEY MESSAGES: • Costa Rica has one of the most comprehensive electronic health records in Latin America, becoming a cornerstone and innovator in guaranteeing the right to universal health coverage and improving the quality, effectiveness and efficiency of health services. • Only three years after the start of the Program for Results, the Single Digital Health Record has been installed at all levels of care, covering even remote areas of the country without electricity or Internet connectivity. • Strong political and institutional commitment, the proper execution of a solid strategic plan focused on the user and local needs, were some of the facilitators of the project's success. • Challenges faced included resistance to change, implementation lag, and some connectivity and information systems failures. • Digital innovation will define future plans by integrating predictive medicine and assisted intelligence with the use of data from the record for the improvement of services and people's health. In just 15 years, the Costa Rican Social Security Fund Introduction (CCSS, for its name in Spanish, Caja Costarricense de Seguro Social) has managed to implement one of the Electronic health records are user-centered records of most widely distributed and comprehensive electronic health services that provide immediate and secure health records in Latin America. (3) Its distribution covers information in digital format on each user's own health the entire CCSS system, from community care to the third data.(1) It is an essential tool of health information and level of care. It includes, of course, the medical and communication technologies (ICT), with the greatest clinical history of users, but it also contains vital potential to guarantee and catalyze the right and information for improving people's health, such as social universal health coverage, by improving the quality and determinants. efficiency of health services. In Costa Rica, the Single Digital Health Record (EDUS) was promoted with the The expansion of EDUS, specifically at the first level of objectives of strengthening the guarantee of the right to care, was driven through the Program for Results (PforR), life and health, advancing towards universality in access a World Bank financial instrument that incentivizes the to quality medical services, the opportunity to have a achievement of strategic program objectives and goals, in digital health record, reducing equity gaps, and which governments seek to improve the use of general promoting the interoperability of information within the public expenditures or improve their performance using system.(2) their own processes and institutions. In Costa Rica, this Page 1 HNPGP Knowledge Brief program ran from 2016-2023 for the Strengthening of an institutional priority and created an Executive Unit for Universal Health Insurance. Its initial objectives included the implementation, direction and administration of the modernizing and strengthening the primary health care project.(8) This allowed for the continuity of EDUS network, improving the quality of services, increasing implementation at the first level of care and that in 2015 population coverage, and making the network more implementation began at the second and third levels of capable of prevention, early diagnosis, and control of care. diseases relevant to the local, national, and regional epidemiological profile. In addition, the objective was also to improve the institutional and financial efficiency The EDUS system of the CCSS.(4) EDUS was conceived as more than an electronic record, it The EDUS has become a vital tool for the provision of is a "repository of patient data in digital format, which is health services and the clinical and administrative securely stored and exchanged and can be accessed by management of the CCSS.(5) Its reach has been so multiple authorized users."(2) This comprehensive extensive that the digital medical record incorporates system integrates clinical (e.g., information derived from 99% of total health services care and its mobile consultations and hospitalizations), social (e.g., application version, available to patients, has more than demographic and economic data of families) and 5.6 million downloads, being the most downloaded administrative (e.g., containing appointments for medical application in the "Health and Wellness" category in the consultations) information and supports the delivery of country. (6) In 2019, EDUS was awarded by the United health services with the inclusion of care support services Nations (UN) with the United Nations Public Service such as radiology, pathology, laboratory and pharmacy. It Award, recognizing the CCSS for its ability to digitally also has a component with information on community transform itself and better manage health.(7) care and the social determinants of each Costa Rican family (e.g., characteristics, location and basic services of The success of this project was possible thanks to the housing). This social information collected by the EDUS is adequate use of several facilitators that allowed its transferred to the National Information System and proper development, but at the same time, of a great Single Registry of Beneficiaries of the State, giving them effort to overcome the barriers and challenges about 80% of the total information they store.(10) Also, encountered along the way in a project that achieved a it not only stores, but also allows the management of total paradigm shift in its execution. This knowledge medical agendas and appointments for consultations or report, part of a broader series of knowledge reports support services. In addition, it brings patients closer by developed by the World Bank, seeks to describe the main offering them web and telephone appointment requests reasons for success, the challenges and the main lessons at "905-MiSalud", and electronic access to their personal learned during the EDUS implementation initiative, with records through the cell phone application, which the objective of providing a roadmap for other countries provides the essentials for the individual to become interested in implementing similar programs. empowered and take an active role in their health status.(8) Background EDUS planning and expansion Costa Rica has a long history of early adoption of ICT solutions to improve health services. (8, 9) But it was not Strategic planning until 2008 that, based on these previous experiences, the The implementation strategy was defined in stages, first isolated developments of EDUS began.(8) taking into account the complexity of the structure of the Subsequently, in 2013, the implementation of a digital levels of care, the willingness of local users, and the health record became a matter of national interest when infrastructure and resources available in the health "Law 9162" was published, establishing the bases and areas.(8) Likewise, we started with the centers and areas financial and strategic guidelines to develop and where there was greater interest, resources and implement the EDUS nationwide and at all levels of care infrastructure for implementation. By showing how some in a maximum time frame of five years. To comply with areas already had this technology, the demand for this, the Board of Directors established this mandate as implementation in the less interested centers and areas Page 2 HNPGP Knowledge Brief • was encouraged. It began with the first level of care with their data to be more secure in digital format than in the Basic Health Teams (EBAIS) and continued with the physical format.(13) second and third level hospitals, completing the implementation of the three levels only three years after FACILITATORS the beginning of the PforR. Many elements coexisted that were catalysts for the Being an ICT required technological equipment such as successful implementation of the EDUS. computers and tablets, as well as the necessary Political and institutional will with a legal framework: infrastructure to provide electricity and internet. These This project was declared of national interest and an inputs were negotiated with the local directors and were institutional priority for the CCSS. Therefore, it received provided with the budget designated to the EDUS the full support and accompaniment of the Board of implementation initiative. As for software, the CCSS Directors of the CCSS and the executive presidency of the made the decision to develop its own computer system institution. At the same time, there was a solid legal so that the EDUS would be aligned with local needs.(10) framework that included Law 9162, Regulation 8954 on Implementation EDUS, Law 8968 on personal data protection, and the Implementation at the institutional level was carried out publication of decrees by the CCSS Board of Directors. All once the clinical component had been approved. this worked as an important catalyst to achieve Regional directors were in charge of implementation, and implementation before the compliance deadline written those responsible for implementation in the Executing in the law. Unit made periodic visits to the centers where the EDUS User-centered design: From the beginning of the was being implemented. These visits allowed for on-site conceptualization of the EDUS, it was clear that value had monitoring to learn about the needs and problems on the to be offered to the end user, patients and providers front line, as well as for adaptation to the local context of interacting with the platform, which is why the EDUS each center.(11) For example, in indigenous software was designed from scratch. (10) The added communities, training was provided by local personnel value for patients was generated by facilitating their who were familiar with the needs of their population. interaction with the health system through telephone and web appointments, and the mobile application with EVIDENCE OF INTERVENTION SUCCESS access to their clinical and pharmacotherapeutic At the beginning of the Program by Results, in 2016, EDUS information. For health service providers, the added coverage at the first level of care was at 50%, and with value was through access to updated information for the momentum of the program it was possible to install decision making. a functional EDUS in 90.1% of health areas, including the most remote areas or vulnerable populations such as Strategy and implementation adapted to local needs: indigenous communities or low socioeconomic level.(11) The Executing Unit and senior executives of the CCSS In addition, following this support from the World Bank, monitored and accompanied the process, but functional coverage was achieved in the 29 hospitals of implementation was decentralized to the health areas the CCSS, complying with the timeframe stipulated by through the regional directors and with the support and Law 9162.(12) formation of Change Management Networks. This decentralization allowed for adequate communication in EDUS is a recognized brand in the country, generating an the field to adapt actions to local needs. increasing satisfaction among its users. Health care providers recognize the digital health record as an Change Management Component: The system's officers indispensable tool in their activities, adding value to their and users recognize the change management component patient care and as a method to generate more as fundamental in overcoming implementation homogenized, simple and agile processes that improve challenges. The change management methodology the management and quality of health care services.(10, included components of leadership, training, 13) Thanks to EDUS, more than 90% of patients reported communication and sustainability of the project over that their care was better or the same when using the time. These elements are not only transcendental for its computer, and the majority said that they considered implementation, but also for the evolution of the EDUS Page 3 HNPGP Knowledge Brief project with the integration of new adaptations and established were effective in achieving the projected additions that are generated to the system. Its operation goals. was established through the detection of leaders in the local communities where the EDUS would be CHALLENGES ENCOUNTERED AND SOLUTIONS implemented. These leaders served as change managers, APPLIED who, in turn, formed Change Management Networks in The transformation generated barriers and challenges each of the regional divisions until they covered the during implementation. In most cases there was entire national territory.(10, 14) adequate execution of strategies to mitigate these development challenges. Infrastructure: Infrastructure was one of the biggest challenges for the expansion of the EDUS in the primary health care areas. The two major challenges were the lack of access to internet and electricity. In 2012, only 28% of EBAISs had internet. (8) The solution to this was to visit each center to identify needs and design specific plans for each case. This was done with the support of a multidisciplinary team of CCSS engineers, health Figure 1. CCSS personnel in training. Credits: CCSS, 2022. personnel, and ICE staff. Once these designs were (6) approved, ICE was in charge of implementation. These actions even allowed the reduction of the digital divide in Training: Training was provided to change managers and the country. CCSS staff. A very successful component was peer-to- peer training, whereby users in the same role or Resistance to change: The transformation process profession trained their counterparts in other health generated resistance among health service providers and areas. This made communication and learning easier and health guilds due to fear of change in the way of working, less resistant, as there was an equal balance of power ignorance of the use of technological equipment, or among the professionals themselves. negative attitudes to the transformation process.(16) To deal with this, the team of change managers worked with Intersectoral collaborations beyond the CCSS: An these resistant users to show them the benefits of EDUS important part in the development of the EDUS was the and introduced them to training programs.(14) At the collaboration with other agents and institutions outside same time, to mitigate resistance from the unions, the CCSS, for a proper diversification of activities. Among strategic alliances were made with the unions (nurses, them were the College of Physicians, which implemented physicians, microbiologists, etc.), which generated ethics courses on EDUS implementation, the Costa Rican optimal communication between both parties to Electricity Institute (ICE) to provide electrical and fiber represent all interests. Another strategy that helped to optic infrastructure in places without access, as well as reduce resistance was to generate changes in the the Ministry of Science and Technology (MICIT) through provision of health services (for example, by temporarily the provision of 4,000 tablets and other academic reducing the number of consultations regularly offered institutions, trade groups, and private and governmental during the working day) to promote and facilitate institutions.(10, 15) familiarization with the EDUS. Financing: The EDUS project had solid financial backing Standardization of clinical information: When choosing designated exclusively for its development and to create its own software system, one of the biggest implementation. From 2013 to 2017 the total investment challenges was to standardize the clinical information to made for the EDUS exceeded 11.4 billion colones be included in the system, especially at the third level of (approximately 19.7 million USD).(8) care where complexity is greater. For example, one Being a PforR objective: The expansion of EDUS at the challenge was deciding which clinical recommendation first level of care was one of the indicators promoted guideline to use for the classification of medical through the PforR, by common agreement between the emergencies, as hospitals were using different CCSS and the World Bank. This ensured that the actions guidelines. This challenge of standardization of clinical Page 4 HNPGP Knowledge Brief • information still prevails, but the progress that has been unstable internet connections and almost 70% made has been achieved through communication and mentioned having a system failure in the last 6 work with the technical and clinical teams at the central months.(8) Likewise, other evaluations reported that the level to include evidence from internationally recognized system sustained connection problems and slow clinical guidelines. operation.(11) The main solution to this was to monitor and control the service managed by the Directorate of Information Technology and Communications. At the same time, an "EDUS disconnected" program was also implemented, which allowed computers that interrupted their Internet connection to temporarily save their information, so that when they were reconnected they could update their information in the system.(8) Equity and access: Previously, there were rural and Figure 2. EDUS coverage list by health areas. Credits: remote regions without access to internet or electricity. CCSS, 2022. (6) The EDUS implementation team worked closely with the change management networks in these disadvantaged Implementation lag: Not all facilities progressed at the health areas and generated collaborations with ICE to same pace of expansion. There were some health areas make the necessary infrastructure adaptations for the that lagged behind in implementation for various EDUS. These included the installation of satellite reasons. To accelerate this process, the Executing Unit antennas, electrical cabling, and even solar panels. On identified and accompanied these lagging areas. In the other hand, through the networks of change addition, healthy competition was promoted through the managers in the EBAIS, it was possible to provide training publication of a list of EDUS coverage in the different adapted to the language of the indigenous communities, health areas. The directors of each area could compare for access and proper use of the EDUS.(10) themselves with other areas and know where they stood against their peers.(10, 14) Although the COVID-19 THE ROAD AHEAD AND THE GAPS TO BE CLOSED pandemic, because it occurred after EDUS implementation, did not have a major impact on EDUS, it The EDUS is in the process of being certified by the did promote the implementation of the electronic Electronic Medical Record Adoption Model (EMRAM) of passbook, with COVID-19 vaccination, through the EDUS the Healthcare Information and Management Systems mobile app. Society (HIMSS), which facilitates the adoption of the digital environment in hospitals until they achieve the Information security aspects: Despite internal security complete elimination of paper.(10, 14) barriers, EDUS suffered a cyber-attack in May 2022, leaving the system dysfunctional for more than two months. This generated a paralysis in the activities of the CCSS, leading them to return to paper files for a few months. Fortunately, the disconnection protected the EDUS data and information. In response, the Security Department, within the Directorate of Information Technology and Communications, implemented the protocols established for these events, such as the application of antivirus and server cleaning. Subsequently, the medical management required a security certification of the equipment in each health facility. System failures and slowness: In an interim check Figure 3. Diagram of the future evolution of the EDUS. conducted in 2018, about 30% of EBAIS officials reported Credits: CCSS, 2022. (6) Page 5 HNPGP Knowledge Brief On the other hand, the objective of implementing and the first projects to be implemented is data science and making the EDUS functional at the three levels of care has data mining for Diabetes Mellitus type 2. (18) The goal of been achieved, but there is still a need to develop these projects is to provide predictive models based on activities that allow it to be "intelligent" in addition to the data contained in the EDUS. With these models, being digital. In the 2018 mid-term evaluations, it was health professionals could know the risk of their patients noted that there was still no consensus on the impact of developing diabetes mellitus, and thus, propose EDUS on improving the quality of health services. To this proactive actions to prevent the disease.(19) end, the Institution's strategic portfolio includes the The EDUS system was successfully implemented in each Strategic Program for Digital and Intelligent Health of the CCSS health centers, from the EBAIS to the most Facilities (PESDI, for its name in Spanish), a series of specialized hospitals. The lessons learned from this projects to generate innovation in healthcare facilities, successful program can be found in Box 1. The great improving the quality and efficiency of services, using the ability of the CCSS to adapt to a major change in service data produced by EDUS.(17) Also, the Directorate of delivery through the implementation of EDUS can serve Innovation and Digital Health is being integrated, which as a reference for other countries that would like to will be in charge of the development of digital innovation implement, or are in the process of implementing, a to advance analytical and predictive medicine, the use of similar project. the genome, telemedicine, and machine learning. One of Box 1. Lessons learned • Generate interest in decision-makers, preferably with a solid legal framework to back it up. • Develop a strategic plan at the national or institutional level and gradually implement it based on the local perspective to adapt it to the diversity of all regions of the country. • Include programs and training focused on change management to reduce resistance. • Promoting healthy competition catalyzes implementation to cover the last mile. • The integration of key stakeholders in the process and the generation of alliances with other sectors is fundamental for success. • The process and expected results should be evaluated with a view to further improvement. The World Bank's Health, Nutrition and Population Knowledge Briefs are a quick reference on key aspects of specific HNP-related topics that summarize new findings and information. They can highlight a problem and key interventions that have proven effective in improving health, or disseminate new knowledge and lessons learned from the regions. For more information on the topic, visit: www.worldbank.org/health. Generous funding support for this series of Knowledge Briefs was made possible by The Access Accelerated Trust Fund. Page 6 Generous funding support for this series of Knowledge Briefs was made possible by The Access Accelerated Trust Fund. HNPGP Knowledge Brief • References 1. (WHO) WHO. Third Global Survey on e-health. Indicator Metadata Registry List - Country has national Electronic Health Record (EHR) 2015 [Available from: https://www.who.int/data/gho/indicator-metadata- registry/imr-details/4791. 2. Single Digital Health Record Act 9162, 9162 (2018). 3. Robles Cordero É. Challenges and proposals for the National Health System. Academia de Centroamérica; 2022. p. 88. 4. The World Bank. 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Costa Rican Social Security Fund (CCSS). Memoria Institucional 2018. 2019. 16. Arias Duran L. CHANGE MANAGEMENT AND COMMUNICATION IN E-HEALTH PROJECTS: PEOPLE FIRST2019. Available from: https://recainsa.org/gestion-del-cambio-y-comunicacion-en-proyectos-de-e- health-primero-las-personas/. 17. Rodríguez Arce M. THE DIGITAL HOSPITAL: THE LEADING POINT FOR THE TRANSFORMATION OF HEALTH SERVICES2022. Available from: https://recainsa.org/el-hospital-digital-la-punta-de-lanza-para-la- transformacion-de-los-servicios-de-salud/. 18. Costa Rican Social Security Fund. Memoria Institucional 2021. 2022. 19. Zamora Moreira JM. Exploitation of Health Data with Data Mining2020. Available from: https://recainsa.org/explotacion-de-datos-en-salud-con-mineria-de-datos/. Page 7 HNPGP Knowledge Brief • Page 8