Improving mission-critical healthcare processes by digitally transforming the sector requires developing, integrating, updating, maintaining, and deploying a range of information domains or software applications that are key to those processes’ functionality. A variety of IT components serve this purpose, such as EHR systems and applications for telemedicine, community health, epidemiological surveillance, self-diagnosis, or contact exposure notifications. However, it is important to understand that no one software system can meet all needs, so the system’s enterprise architecture is important. If we use the analogy of a house, applications and services would be the different rooms—with their own specific uses—, and the enterprise architecture would be the blueprints showing each room’s function and how it connects with the rest of the house

Paradoxically, the most important consideration with regards to these applications is not digital at all: no software solution will magically fix bad or nonexistent processes. Identifying and designing solutions to the pressing problems of a country’s health system is a job that first has to be done in the analog world before the digital one. This task is closely tied to the governance of the health system and of digital health. Similarly, digital advances need to align with the country’s overall health strategy at all times so technology does not become an end in itself.¹ This section will explore two of the main applications: EHR systems and telehealth applications.

For a digital healthcare system to work effectively, it needs other applications besides EHR systems and telehealth solutions. Also crucial are the human resource management system, the pharmaceutical and dispatch system and other similar systems, the information system for integrating medical imaging, the national disease registry, public health monitoring systems, patient portals, and numerous others. Additionally, many health sector applications, can utilize services from other sectors, like identity documents or digital signatures. All of these applications should work in a synchronized way via the organizational architecture.

The IDB Digital Health Solutions platform shares examples of initiatives and projects, many led by LAC governments, and also allows any person or entity to share solutions with the digital community.

EHR systems

There are currently different conceptions, terms, and definitions of what an EHR system is. This often creates confusion. It can be helpful to learn what this type of system can do in order to gain an understanding of what it is. The table below provides key examples of how it works.

FExample functions of an EHR system
Function	Example of how it works in a basic EHR system
Health information and data
Functions related to recording information about the patient. For example: demographic data, problems, medications, clinical notes, medical history, and followup.	The authorized provider at a public healthcare institution enters information in the EHR system. The provider can see information about the patient in real time from providers from different public or private institutions. The information that the provider updates is also available in real time to other providers with electronic access to the information.
Entering/managing orders
Functions related to entering and storing prescriptions, tests, and other services to enhance legibility, reduce duplicates, and handle orders faster.	The authorized provider at the public institution enters the information in the EHR system. The provider can see information about previous prescriptions from other providers at different institutions in real time. The provider puts in an order at the patient’s pharmacy, and, in real time, the pharmacy confirms whether the medication is available so the patient can come pick it up.
Managing results
The ability of providers to evaluate and use information on old and new patients from different sources to improve medical care processes and strategies, like imaging and laboratory diagnoses. Ability to use reminders, messages, alerts, and computerized decisionmaking support systems to improve compliance with clinical practices and ensure regular checks and other preventive practices. Some examples can be: warnings about drug interactions or contraindications, highlighting out-of-range levels in tests, and real-time reminders about interventions according to guidelines or explorations.	The authorized provider at the health center requests a lab test and an x-ray. In the patient’s EHR, the provider can see information about prior tests. They see that the patient recently had one of these tests done, so it does not need to be done again. The provider reviews it in the EHR system and refers the patient to a specialist at a different medical institution. The specialist can see all prior results. The supplier enters a prescription in the EHR system. The provider receives, in real time, an alert from the clinical decision-making support tool that a prescription written by a different provider from another institution is contraindicated for use with the one just prescribed. The patient is prescribed a different medication.
Source: United States Institute of Medicine (2003); table structure from DesRoches, Campbell, Rao et al. (2008) at https://socialdigital.iadb.org/en/sph/resources/research-publications/5006.

A key step in determining whether an application is right for the system being developed is comparing and reviewing evidence about its effectiveness. For EHR systems, it is important to bear in mind that the current literature often focuses on success factors linked to specific applications not necessarily found in all EHR systems: for example, computerized clinical decision support systems (CDSS) or computerized provider order entry (CPOE). For this reason, the IDB developed a tool for measuring and comparing the features of EHR systems based on international standards.

Another essential step in developing an EHR system is deciding whether the systems should be purchased, built from scratch, or adapted from an existing solution. The IDB Guide to Open Source Electronic Health Records provides detailed information about this software and the benefits of using it for healthcare, with special emphasis on EHR

Meanwhile, the report Electronic Health Record Systems: Definitions, Evidence, and Practical Recommendations for Latin America and the Caribbean covers the fundamentals and technical details of implementing EHR systems. Among the topics it covers, it gives the following recommendations to LAC countries as they consider investing in an EHR system:

• Understand your current state: what systems are implemented in the country, what standards are followed, and what functions do they serve, etc.
• Formally adopt a clear definition of an EHR system..
• Create the business case for EHR systems for your context.
• Study and share your results
• Do not digitalize bad processes.
• Design with the user.
• Build an inter-disciplinary team.
• Intentionally plan the transformation as part of the strategy.

Telehealth

Telehealth encompasses a wide range of technologies that healthcare service provider institutions use to serve populations that in most cases are geographically distant. Telemedicine, on the other hand, is the use of IT and telecommunications to hold synchronous or real-time medical appointments between health professionals and their patients. Telehealth services include: telemedicine (which could include telepathology, teledermatology, telecardiology, teleoncology, or other specialties), telecare, telementoring, mHealth (mobile health—healthcare assistance using mobile devices), remote patient monitoring, telesurveillance, telediagnosis, and many other services.

Telemedicine is not new. From 2005 to 2016, countries that invested in remote public care achieved surprising results, eliminating 70 to 80% of transfers of patients to specialized or higher-level healthcare centers, saving 10 to 15% of the municipal health budget, and receiving 10,000,000 second opinions on electrocardiograms and imaging tests. ²

The pandemic reaffirmed the relevance of this set of technologies, which allowed care services to continue, especially for non-communicable chronic diseases and mental health conditions.³ UA survey conducted in the United States in April 2020 by the American Telemedicine Association (ATA) found that 97% of primary care doctors used telemedicine to treat patients, and more than three quarters of them stated that telemedicine helped provide better care. Meanwhile, 83% of patients surveyed indicated that they will potentially continue using telemedicine after the pandemic.⁴

Furthermore, in LAC,⁵ telemedicine offers major potential to improve the efficiency of healthcare. For example, estimates indicate that it could eliminate 60% of emergency room visits, a very important achievement considering the fact that many hospitals in the region do not have enough staff or resources to meet the demand for care.⁶.

The webinar Telemedicine during the COVID-19 pandemic: Lessons learned one year later, organized by PAHO and IDB, shares the experiences of four countries in the region that were able to successfully expand telemedicine. It offers their challenges, successes, and opportunities for improvement as resources for other countries in the region.

However, using telehealth and telemedicine on a large scale requires overcoming technological, human and social, psychosocial and anthropological, governance, and economic barriers. For this reason, it is important to plan and implement these strategies in an organized way as part of a long-term national digital health strategy and with a comprehensive approach that includes each of these aspects.

To help countries and institutions assess their level of maturity before launching telemedicine services, the IDB partnered with the PAHO to develop a tool that scores institutions’ level of maturity for introducing remote medical care on a scale of 1 to 4.

Another important resource in this area is the WHO report eHealth in the Region of the Americas: Breaking down barriers to implementation, which shares key findings from the WHO’s Third Global Survey on eHealth and key recommendations in different areas

The array of applications and digital health practices is very broad, and achieving widespread use of a tool is a highly complex endeavor. However, there is consensus on some aspects that are essential to success. All applications must:

• Be aligned with the governance environment and digital health policy.
• Have sustainable public and/or private funding.
• Tangibly address an unmet and priority need.
• Ensure ease of use, interoperability, and adaptability.
• Include the end-user at each stage of the development process.
• Be implemented by all stakeholders and actors, after first training and motivating them to undergo the change the tool entails.

On a more general level, there are two preconditions for using any tool or practice, especially in LAC countries. First, it is crucial and urgent to address the digital divide that excludes a significant portion of the population. Second, an application will not solve structural problems in the medical care system, such as institutions that lack a strategic vision, clear clinical processes, or governance. These problems should be addressed prior to or in parallel with the implementation of a digital health application.

A major area of opportunity

One field in which the benefits of technological tools have gained wider recognition is mental health care via telemedicine. The COVID-19 health crisis demonstrated the exponential value of this modality . Movement restrictions forced providers and patients to look for ways to access and provide care in a safer way, with everything from therapy to meditation sessions done by video call. This comes as no surprise, given the rise in mental health problems during the crisis. In fact, in June 2021 in the United States, 60% of diagnoses treated using telemedicine were related to mental health. Of these, 28.3% were generalized anxiety disorder, 23.6% were major depressive disorder, and 18.3% were adjustment disorder.

In upcoming years, the region must explore new and substantial ways for its health sector, in particular, and public services, in general, to address its population’s mental health. During the pandemic, telemedicine was an essential bridge that allowed care to continue. There is now an opportunity to build on the progress made and the reinvent online and hybrid models that enhance access to assistance and care, as well as their outcomes and affordability.