Questions/Answers

The COVID-19 pandemic has profoundly impacted all areas of our society; and the public health sector was clearly one of the most affected. To address the toll on the healthcare system, EDUS (Unified Digital Health Records System) Costa Rica´s nationwide electronic health record (eHR) system, led the development of different strategies of reinvention and innovation through care modalities of patients with COVID-19. CCSS digital strategy Health systems that have best managed to minimize the impacts of the pandemic are those that have based their work on teleconsultation, remote patient monitoring, and home monitoring of patients with COVID-19. Costa Rica has been able to implement these strategies thanks to the availability of a clinical information system: EDUS. Among some of the modules that make up EDUS, there is the Integrated Health Record System (SIES), where health care actions of each user is recorded; the Identification System of Schedules and Appointments (SIAC), where it is made the scheduling and control of appointments of the users; the Integrated Family File System (SIFF) where care actions at community level and homes are recorded by primary care technical assistants; the Integrated Pharmacy System (SIFA) for the registration and dispatch of medicines through digital prescriptions; the Integrated Epidemiological Surveillance System (SIVE) for the epidemiological follow-up of public health events; and the Integrated Vaccination System (SIVA) for large-scale immunization registration. In this context, EDUS has provided the route for the national response to the COVID-19 pandemic. This has been based on eight fundamental pillars, namely: 1. Building up technical infrastructure 2. Nationwide electronic health registry 3. Home follow-up of patients 4. Home delivery of medicines 5. Teleconsultation 6. Virtual hospital visits 7. EDUS App (iOS, Android and Huawei) for patient monitoring and risk assessment 8. Dashboards (provide real-time nationwide information for knowledge-based-decisions for hospital bed management)

Special Category: Institutional Resilience and Innovative Response to Covid-19 Pandemic The COVID-19 pandemic primarily affected the public health sector which took the brunt of the worldwide epidemic. To survive the onslaught of patients the Caja Costarricense de Seguro Social (Costa Rica’s National Social Insurance Fund) – a public institution that provides universal health services for the population – pushed forward EDUS’ eight-tiered strategy to the forefront. Aligned with this strategy, the CCSS has prioritized the growth and diversification of information systems and digital health. Many lessons have been learned from this transformation process, allowing the institution to be strengthened.

The selected category chosen was: Institutional Resilience and Innovative Response to Covid-19 Pandemic. It is not related to directly to the SDGs and targets the United Nations promote. The initiative developed by CCSS contributes indirectly to the sustainable development goals, specifically with Good Health and Industry, innovation, and infrastructure. The first because all the initiatives developed by the institution aim to improve the health conditions of the population. The initiative deployed the delivery of innovative services for patients, as well as an implementation of new optimal infrastructure in record time. The use of a single digital record nationwide was fundamental.

The initiative is socio-economically sustainable thanks to the fact that the institution has a budget allocated for the attention of issues associated with national health. In addition to being the country's social security institution, this budget contemplates the evolutions that the initiative entails. The implementation of all the aspects related to the initiative have contributed to the elimination of paper in the provision of health services by digitizing care through the EDUS. The infrastructure of the facilities has been updated with state-of-the-art technology, which directly contributes to better performance and less environmental impact.

At the beginning of the Covid-19 Pandemic, different government agencies, like the CCSS and the Costa Rican Ministry of Health, had long drawn-out meetings trying to predict what COVID-19 would do to the Country. Although speculative, these meetings concluded that technology was the country’s best ally to not only attend to patients but also to thrive in the face of adversity. The innovative response was led by EDUS under the mantra that healthcare systems that most probably be spared from succumbing to the onslaught of the pandemic will be those that based their care on teleconsultation, remote patient monitoring and home follow-up of COVID-19 patients. Costa Rica has been able to implement these strategies thanks to the availability of a clinical information system: EDUS (nationwide electronic health record). Although not a shortfall of government, EDUS rose to the challenge of leading the country and assured the institutional resiliency ahead of pandemic times.

The implementation of digital health records as a resilience mechanism during COVID-19 pandemic through an eight-tiered strategy improved the lives of women throughout Costa Rica, assuring the best medical care possible. Bearing in mind that the consequences of the pandemic must be considered not only for today, the aftermath of future post-pandemic waves must also be considered. Factors such as increasing the number of patients with decompensated chronic non-communicable diseases (CNCD), psychological problems due to post-traumatic stress in patients, and Burnout Syndrome in clinical staff, must be taken into consideration.

The target group of the initiative is entirely related to providing social protection, more focused on health and encompasses all sectors of the Costa Rican population, with the vulnerable population benefiting perhaps most directly in the short term. This population benefits from the initiative in that they are able to obtain health services remotely in a timely manner, which has a beneficial impact on their health condition, without being affected by the pandemic and the risk of presenting themselves at health facilities, as well as having mechanisms to monitor their health condition in the course of their daily lives through remote recording of signs. In addition, decision making through the dashboard allows to emphasize the goals of first of all attending the vulnerable people and that everyone has the social protection in a timely manner.

EDUS was essential in the success of the transformation of one of the CCSS existing hospitals into the Specialized Centre for the Care of Patients with COVID-19 (CEACO), as well as making adjustments in the other 28 hospitals and 105 local health centres that had to be reorganized to provide differentiated care. Thanks to the extended use of EDUS throughout the CCSS health services network, this digital system was used as the care coordination mechanism: follow-up strategies were established for positive patients and their contacts. This monitoring is carried out both by medical professionals, nurses, and personnel from other disciplines. A specific tool was enabled on EDUS’s module for Integrated Health Record System (SIES), this tool called “Health Orientation” allows registering interventions and follow-up of patients on home care, following up the clinical guidelines. The CCSS established strategic alliances with public and private companies for the delivery of medicines at home. By means of these alliances, it is believed that a greater number of infections was avoided by preventing people from having to leave their homes to pick up their medicines at health facilities. One of the most important achievements of the use of technology was the strengthening of hospitalized patients’ communication with their relatives. Recognizing the social, affective, and emotional needs of patients and their families has been fundamental for the benefit of health service users. COVID-19 pandemic has served as a catalyst for massive use of data for more efficient management. The information management carried out by the Health Statistics Area, in conjunction with EDUS has facilitated useful information in real time for decision-making with a population scope and a high level of specificity. One of the best examples has been the integrated management of hospital beds across the national network of hospitals.

The main obstacle that could be mentioned was that of managing innovation in such convulsive times as those of the pandemic in such a large institution with such a national impact, where in a very short time it was necessary to adjust contracts with companies, involve various stakeholders and sponsors in order to provide the infrastructure, services and associated functionalities that would meet the needs of the country at such a critical time.

One of the best examples has been the integrated management of hospital beds across the national network of hospitals. Through EDUS, it was possible to adequately managing beds in each hospital using business intelligence tools, such as COVID- 19 Dashboard. The use of information systems and data quality management related to patients hospitalized for COVID-19 were the fundamental bases of the CCSS guidelines to avoid the collapse of the health system. The information system is used to maintain an inventory of hospital beds, as well as a strict census of inpatient occupancy.

The implementation of digital health records as a resilience mechanism during COVID-19 pandemic through an eight-tiered strategy is unique and stands out as a bright spot in the region. It drew inspiration from countries who were technologically more advanced (HIMSS 7) but that still didnt have the whole country integrated into an electronic healtcare system (100% of the country).

The COVID-19 pandemic has served as a catalyst for massive use of data for more efficient managerial management. The information management carried out by EDUS through the use of dashboards facilitated useful information in real time for decision-making with a population scope and a high level of specificity. One of the best examples has been the integrated management of hospital beds across the national network of hospitals. Through EDUS, it was possible to adequately managing beds in each hospital using business intelligence tools, such as COVID- 19 Dashboard. The use of information systems and data quality management related to patients hospitalized for COVID-19 were the fundamental bases of the CCSS guidelines to avoid the collapse of the health system.

Our initiative has not been transferred or adapted to any other countries. It is fully implemented in 100% of Costa Rica and provides real-time information for decision makers.

The only prerequisite to be able to transfer our initiative fully is that the country would have to have 100% of the country implemented with a single electronic health record. In order to fully take advantage of the all the possibilities (dashboards, for example). Even so, many countries could adopt many of the solutions in our initiative and could have a very positive impact.

In order to implement the initiative, various resources had to be used, in the first instance the financial resources were obtained from the institution's budget, the human resources were also composed in the great majority by personnel of the institution plus the participation of others involved in various institutions that have a direct relationship with the pandemic, such as the Ministry of Health, National Emergency Commission. In addition, donations were received from private companies that will help in achieving the objectives set out in the initiative.

The initiative is sustainable over time due to the commitment of the institutional sponsors, where what has been done is already part of the institutional operations in the way services are provided on a daily basis. The services that were deployed already have the necessary infrastructure to continue providing them, as well as the human resources that support them, and the associated regulations.

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The initiative was evaluated by the Copsta Rican Health Ministry.

Evaluation Goals 1. Gather evidence of the contribution that the EDUS system has made to increase the resilience of the CCSS in the face of the shock caused by the COVID-19 pandemic. 2. Generate a case study on the use of EDUS as a strategy to improve the integrated management of the CCSS service network. Conduct of the Evaluation The type of study conducted during the evaluation was descriptive-retrospective and the research design was cross-sectional-descriptive. Data collection took place through interviews with those in charge of the administration of the EDUS system at the central level of the CCSS.

The COVID-19 pandemic is a global health crisis that has caused unprecedented human life and economic costs. It has highlighted the continuing vulnerability of all our health systems. Keeping in mind that not only must the consequences of the pandemic be considered today; but the aftermath of future post-pandemic waves must also be considered. By increasing the number of patients with decompensated chronic non-communicable diseases (NCDs) and psychological problems due to post-traumatic stress in patients, and Burnout Syndrome in clinical staff. In this scenario, information management and the potential of digital health constitute critical success factors in containing and addressing this type of events; allowing for more timely, safe and reliable care as data is available for evidence-based decision making. For this reason, it is considered that the EDUS system has been a fundamental asset to increase the resilience of the institution to the exacerbated demand for services that the pandemic has implied, it is therefore recommended that further work should be done to present as a good management practice the experience of using an integrated digital information system throughout a health system such as EDUS.

In May 2012, the Board of Directors of the CCSS created an Executing Unit whose main function was the implementation, direction, and administration of the Unified Digital Health Records System. That year, the institution declared that EDUS will be institutional priority. In addition, in July 2013, the Congress of the Nation approved a bill to strengthen EDUS. Law No. 9162 established the scope and the necessary mechanisms of action to develop to implement EDUS, which include planning, financing, inputs, and resources. That law set that 2018 was the year when full compliance and implementation EDUS at all levels of health care should have been achieved. Having the entire country under a unique electronic healthcare system is one of the main pillars that sustain the success of our initiative. The COVID-19 pandemic is a global health crisis that has caused unprecedented impact on human lives and economic costs. In this scenario, information management and digital health’s potential are critical factors for success in containing and addressing this type of events, allowing more timely, safe, and reliable care if data is available for evidence-based decision making.

The pillar for the success of the initiative with all its component aspects was the collaboration, not only between the different institutional departments, but also with the participation of the national health governing body, the Ministry of Health, and the Department of Emergency Management, as well as private companies that collaborated and worked as a team to take on the challenge. The Costa Rican Electricity Institute was the entity contracted to deploy the necessary infrastructure for the betterment of technological infrastructure. Companies such as Telefonica, NGO's, social organizations participated by donating equipment and connectivity to allow patients to communicate with their families through video calls., All had active participation modelling the solution for the Pandemic crisis. In the evaluation process the Ministry of Health was called upon to evaluate the outcome of the proposals and rendered a formal evaluation as feedback to improve our initiative.

The COVID-19 pandemic is a global health crisis that has caused unprecedented human life and economic costs. It has highlighted the continuing vulnerability of all our health systems. In this scenario, information management and the potential of digital health constitute critical success factors in containing and addressing this type of events; allowing for more timely, safe and reliable care as data is available for evidence-based decision making. For this reason, it is considered that the EDUS system has been a fundamental asset to increase the resilience of the institution to the exacerbated demand for services that the pandemic has implied, it is therefore recommended that further work should be done to present as a good management practice the experience of using an integrated digital information system throughout a health system such as EDUS.