Informatics for Peru in the new millennium

Abstract

As efforts continue to narrow the digital divide between the North and South, a new biomedical and health informatics training effort has been launched in Peru. This report describes the first year of work on this collaborative effort between the University of Washington (Seattle) Universidad Peruana Cayetano Heredia and Universidad Nacional de San Marcos (Peru)
To describe activities in the first year of a new International Research and Training Program in Biomedical and Health Informatics.
Descriptive analysis of key activities including an assessment of electronic environment through observation and survey, an in country short course with quantitative evaluation, and first round of recruitment of Peruvian scholars for long-term training in Seattle.
A two-week short course on informatics was held in the country. Participants' success in learning was demonstrated through pretest/posttest. A systematic assessment of electronic environment in Peru was carried out and two scholars for long-term training were enrolled at the University of Washington, Seattle.
Initial activity in the collaborative training effort has been high. Of particular importance in this environment is orchestration of efforts among interested parties with similar goals in Peru, and integration of informatics skills into ongoing large-scale research projects in country.

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MEDINFO 2001
V. Patel et al. (Eds)
Amsterdam: IOS Press
© 2001 IMIA. All rights reserved
1033
Informatics for Peru in the New Millennium
Bryant Thomas Karras
a
, Ann Marie Kimball
a
, Virginia Gonzales
a
, Nedra A. Pautler
a
, Jorge
Alarcón
b
, Patricia J. Garcia
c
, Sherrilynne Fuller
a
a
University of Washington, Seattle, Washington USA,
b
Universidad Nacional Mayor de San Marcos, Lima, Peru,
c
Universidad Peruana Cayetano Heredia, Lima, Peru
Abstract
Introduction: As efforts continue to narrow the digital
divide between the North and South, a new biomedical and
health informatics training effort has been launched in
Peru. This report describes the first year of work on this
collaborative effort between the University of Washington
(Seattle) Universidad Peruana Cayetano Heredia and
Universidad Nacional de San Marcos (Peru)
Objectives: To describe activities in the first year of a new
International Research and Training Program in
Biomedical and Health Informatics.
Methods: Descriptive analysis of key activities including an
assessment of electronic environment through observation
and survey, an in country short course with quantitative
evaluation, and first round of recruitment of Peruvian
scholars for long-term training in Seattle.
Results: A two-week short course on informatics was held
in the country. Participants’ success in learning was
demonstrated through pretest/posttest. A systematic
assessment of electronic environment in Peru was carried
out and two scholars for long-term training were enrolled
at the University of Washington, Seattle.
Discussion: Initial activity in the collaborative training
effort has been high. Of particular importance in this
environment is orchestration of efforts among interested
parties with similar goals in Peru, and integration of
informatics skills into ongoing large-scale research
projects in country.
Keywords:
Public Health; Medical Informatics; Education;
Information Science; Peru; International Cooperation
Introduction
Peru is a country of 22,453,000 with 48% of its population
under the age of 20. In the early 1990’s political and
economic difficulties created high unemployment, lowered
standards of living and put pressure on the sanitary and
public health infrastructure of the country [Veeken, 1993
#182]. The consistent lack of investment in public health
over these years contributed to the risk of communicable
diseases through low access to safe water and sanitation.
The resultant risk was realized in the cholera epidemic of
1991-1992.[1] This situation is only now being resolved.
The fragility of the Public Health infrastructure and
uncertain economy conspire to create a high-risk
environment for infectious diseases in this Andean country.
In Peru, as in much of Latin America, public health is a
younger discipline than medicine. Universidad Peruana
Cayetano Heredia (UPCH) and Universidad Nacional
Mayor de San Marcos are leading institutions in Lima and
typify the institutions offering public health training in
Peru. UPCH is the only school in Peru. Teaching at these
institutions is characterized by a reliance on print media.
The area of resource access is a target area of the
collaborative research and training program in informatics
described herein.
In 1999, the University of Washington (U.W.) received
support from the International Training In Medical
Informatics program of the Fogarty International Center
(http://www.nih.gov/fic
) to initiate training activities with
its collaborating institutions in Peru. This training program
evolved from a decade long collaborative research effort
among the three institutions.[2,3] The program consists of
both an in country short course in Lima and a two year
Scholars Masters Degree in the Bio-medical and Heath
Informatics Program in Seattle,
(http://depts.washington.edu/infomatx
)
(http://depts.washington.edu/uwmeded/dbhi
)
The specific objectives of the international research and
training program in biomedical and health informatics are:
1) to train key researchers and their support staff to use
modern information and technologies in the health sciences,
specifically in applied health research and health
surveillance activities in infectious diseases; 2) to work
towards the eventual creation of an integrated and self-
sustaining informatics and health program in each
institution participating; 3) to expand and improve the
ongoing collaborative research with researchers in these
groups in the prevention, control and treatment of diseases
of public health relevance in Peru; and, 4) to disseminate
technical information more broadly in the Andean sub-
region of the Americas in collaboration with the ongoing

Chapter 12: Education & Training
1034
program of the Pan American Health Organization (PAHO)
(www.paho.org
) [4]. Specific aims are to create a core
group of informatics competent researchers, to exchange
faculty and course materials and carry out training in order
to reinforce curriculum at the participating universities in
the area of informatics, to share genetic and drug-resistance
information on microbial infections, to strengthen
bibliographic resource access at participating universities,
and finally, to work with the Peruvian Ministry of Health to
extend surveillance capacity in public health through the
use of electronic networks and shared reference access
standards.
The training includes a combination of short term training
for resource personnel, and bringing many of the
information integration and organizational tools from
ongoing information technology projects at the U.W. A
recently published review described the evolution of
Peruvian publications. [5] Highlighted is the irregularity
with which national scientific publications occur, and the
small percent of Peruvian authors who have published in
foreign medical journals. The review ascribes to this the
emergence of the capacity to organize and systematize
investigational work. The information organization and
integration tools in informatics promise to hasten this
process in Peru.
Materials and Methods
Peru-based Short Course
In keeping with the objectives of the collaborative research
and training program, an interdisciplinary short course on
informatics was orchestrated by the University of
Washington at the Universidad Nacional Mayor de San
Marcos with the collaboration of the Universidad Peruana
Cayetano Heredia. This short course will be further
described under Results. Evaluation of the short course
took the form of a pre-test administered to all participants to
allow the profiling, through survey, of those participants’
interests as well as their level of knowledge and
information. This was complemented by a post-test
immediately following the course to assess the gain in
knowledge.
Electronic Working Environment
A survey to describe the electronic working environment of
the course participants was undertaken. This survey
activity within the course was complemented by on-sight
inspection with the collaboration of the two universities of
their electronic facilities.
Recruitment of Master Program Scholars
Information including the characteristics of the applicant
pool recruitment procedures and profile of the accepted
candidates were obtained and will be reported herein.
Results
Electronic Working Environment
Assessment of the electronic environment in Peru found
that substantial progress had been made in recent years.
The idea of organizing an informatics system to access the
information in Health Sciences in South America originated
in 1988 with the sponsorship of the Pan American Health
Organization with the goal of creating a network in Health
Sciences. This network started to operate in 1991. A
coordinating center for the informatics network was created
in each country and then a series of in country institutions
were selected to provide information to the network.
There are 55 institutions registered in the Peruvian network
that theoretically provide newly generated information.
The Universidad Peruana Cayetano Heredia has served as
the coordinating center and is part of the Regional Network
in Health Sciences (BIREME) based in Brazil. This
Coordinating Center has a technical and an executive
committee with representative persons of the Ministry of
Health, Social Security Institute, PAHO and two
universities (San Marcos and Cayetano Heredia).
The Universidad Nacional Mayor de San Marcos, the oldest
University in the Americas (founded in 1551), had an “old
fashion” library without informatics resources until 1995.
In 1996, the national library system in Peru was
incorporated as part of the governmental system.
Telemática Net, San Marcos Universities’ intranet, allows
access to databases across the university, and also provides
e-mail service to academics, non-academic staff, and
students (there are currently 35,000 e-mail accounts).
The Universidad Nacional Mayor de San Marcos does not
charge outside users for accessing the Internet and library
systems from computers located in the libraries of the
different campuses. However, the access time to the users
is limited to an hour per user.
The Centro de Informatica (Informatics Center) of the
Universidad Nacional Mayor de San Marcos was created as
a training center to increase the access and use of resource
information. Studies showed that in 1998 only 1% of users
of libraries were faculty, instructors or lecturers, due to the
dated nature of the materials kept in printed media. The
Telemática Net Service Unit has implemented a state-of-
the-art network at the Informatics Center, located two
blocks away from the University Central Library, with
Pentium II computers, all with access to the Internet.
Table 1 - Results of E-survey Analysis (Peru) current skills
Technology n
International Phone Calls
Monthly, Quarterly, Other, or Not used 13
Daily or Weekly 2
Faxes
Monthly, Quarterly, Other, or Not used 10
Daily or Weekly 3
Email lists (listproc, listserv)
Monthly, Quarterly, Other, or Not used 8
Daily or Weekly 8
World Wide Web
Monthly, Quarterly, Other, or Not used 2
Daily or Weekly 15

Chapter 12: Education & Training
1035
A survey tool was administered to the class participants and
outlined their computing capability (table 1 and 2) and
desired training (table 3).
Table 2 - Results of E-survey Analysis (Peru)
current skills (n=24)
Activities n
Transfer Large Datasets via Web
No, Other 11
Yes 10
Connectivity to Internet
No, Other 1
Modem 7
Directly 10
Reliability of Computer & Internet
No, Other 3
very, Mostly 19
Table 3 - Results of E-survey Analysis (Peru)
Need for Training in Various Areas (n=17)
Need Training in: % Need Training in: %
Computer Security Spreadsheets
Modest or Most 100 Modest or Most 69
Web Publishing None or Little 31
Modest or Most 94 Word Processing
None or Little 6 Modest or Most 59
Operating Systems None or Little 41
Modest or Most 81 Web Searching
None or Little 19 Modest or Most 71
Networking None or Little 29
Modest or Most 76 Email
None or Little 24 Modest or Most 41
Database Software None or Little 59
Modest or Most 72
None or Little 28
Peru-based Short Course
The Short Course on Informatics took place in the
Informatics Center of the Universidad Nacional Mayor de
San Marcos in Lima from June 19–24, 2000. Each
classroom was especially designed for Informatics courses
and was equipped with 26 Pentium II computers, all with
Internet connections, and one with LCD multimedia
projectors.
There were twenty-five participants in the two-week short
course offered in Peru. The short course provided an
overview of medical and health informatics. The
participants were largely physicians, fifteen out of twenty-
five, the remainder came from a diverse interdisciplinary
back ground including a Nurse, a Biologist, an
Anthropologist, a Statistical Engineer, a Psychologist, two
Librarians a Dentist and two students There was a fairly
even distribution of men (14) and women (11). There was
an overwhelming interest in the short-course (over 40
applicants) Seats were limited by institution 40% for each
university (San Marcos and Cayetano Heredia) and 20% for
employees of governmental institutions. The environment
for instruction was ensured, in part, by the provision of
SAS and Maptitude software by the University of
Washington to allow the teaching of the modules on
databases and geographic information systems.
Course Objectives
• Train key researchers and their support staff to use
modern information technologies in the health
sciences with emphasis in infectious diseases.
• Create an integrated and self-sustaining
informatics and health program at each of these
institutions.
• Expand and improve ongoing collaborative
research with these institutions.
• Disseminate technical information more broadly in
the Andean sub-region of the Americas in
collaboration with the ongoing program in health
information systems of the Pan American Health
Organization.
Table 4 - Health Informatics Course:
Pre-and Post test Evaluation Results Average Score
Pre-test 53%
Post-test 71%
Table 5- Health Informatics Course: Pre and Post test
Evaluation results by Topic, (Average Scores in %)
Topic
# Questions
Pre test %
Post Test %
Statistical Analysis (SAS) 4 62 74
Geographical Information Systems (GIS) 5 55 63
Web Page Design/HTML 9 43 59
Navigating the Web: Using Search Tools 5 67 80
Health Informatics: Elements of Clinical
Informatics & Telemedicine
3 55 73
Evidence Based Medicine 3 61 79
Role of Informatics in Technology 2 40 40
The evaluation of the course included a pre-test and post-
test on technical knowledge in the area of informatics.
General areas covered (Statistical Analysis (SAS),
Geographical Information Systems (GIS), Web Page
Design/HTML, Navigating the Web: Using Search Tools,
Health Informatics: Elements of Clinical Informatics &

Chapter 12: Education & Training
1036
Telemedicine, Evidence Based Medicine, Role of
Informatics in Technology). As shown in Table 4,
knowledge in all areas increased for the twenty-six
participants after the completion of the two-week course.
Analysis of individual pre and posttest questions revealed
improvement in 78% of the posttest questions, 67% of these
scores being above 50. Posttest scores remained the same
in 2 (6%) of the questions. In addition, post-test scores
declined in 16% of the questions. Average scores improved
on all general informatics topics. (Table 5)
Satisfaction Survey Data
An additional course evaluation included consumer
satisfaction. All students were questioned about their level
of satisfaction with the courses offered and individual
speakers were rated on their effectiveness in
communication. All sessions were simultaneously
translated and, in general, translation was not found to be a
difficult area.
A post-course survey was conducted among the participants
to determine different aspects of the course such as overall
rating, usefulness, amount of information and others.
Tables 6 - 8 summarize the results of the survey. Overall
the acceptance of the course was very good to excellent
with a rating of 4.2 (scale 1-5), and the usefulness of the
course was rated as very good. The audience also thinks
that they would recommend this informatics course to their
peers (rating of 4.8 in a scale of 1-5).
Table 6. Evaluation of the course
Overall rating of the course
1=Poor; 2=Fair; 3=Good; 4=Very Good; 5=Excellent
4.2
Usefulness of the course
1=Poor; 2=Fair; 3=Good; 4=Very Good; 5=Excellent
4.0
Amount of Information
1=Too little; 2=About right; 3=A little too much; 4= Way too much
2.7
Would you recommend this course to your peers?
1=Definitely not; 2=Unlikely; 3=Likely; 4=Definitely
3.8
Table 7. Evaluation of the course (Strengths)
Strengths of the course (Topics) % of
participants
SAS & GIS 34.62
Web Page Design 15.38
Navigating the Web 3.85
Clinical Informatics 3.85
Telemedicine 7.70
Evidence Based Medicine 46.15
All of them 11.54
There were some topics of curriculum that were of great
interest to the course participants. A significant percentage
of the students thought that Evidence Based medicine,
SAS&GIS, and Web Page design were among the most
important ones (see table 7). On the other side, some
weaknesses of the course were also noted. A large group of
participants (38.46%) mentioned that their background was
not adequate for some of the topics and a pre-course
training could have been very helpful for them.
Additionally, the participants felt that the time was too
short, and that they did not get enough practice time after
each lecture (Table 8).
Table 8. Evaluation of the course (Weaknesses)
Weaknesses of the course % of
participants
Time to short 30.77
Practice was not enough 15.38
Methodology not appropriate 7.69
Audience not homogeneous 7.70
Pre-course sessions for students who
lack of appropriate background
38.46
Overall, the course was very well received, the audience
was highly motivated and some helpful suggestions were
made, among them, the allocation of more time to SAS,
GIS and Web page design and the inclusion of new topics
in future courses. Requested topics to be added/changed in
future courses included the acquisition of databases for the
use of GIS, new technologies in communications, economic
analysis of health and clinical information systems
(CPR/EMR).
Recruitment of Master Program Scholars
Significant effort was put in the recruitment process of
qualified applicants in Peru for potential long-term training
at the University of Washington. A member of the U.W.
Fogarty program traveled to Peru in December 1999 to
work very closely with the representatives from San Marcos
and Cayetano Heredia in order to attract qualified
applicants. The recruitment took place by contacting
directly with potential candidates, by distributing the
pamphlet of our program in Peru, and with notices on web
site and through related networks. Most of our candidates
were nominated by their collaborating institutions.
We attracted five highly qualified applicants in a short time,
which included professionals with medical and library
sciences background from San Marcos and Cayetano
Heredia, and from two public health hospitals in Lima. Of
this pool of candidates, four were physicians and one was a
librarian. The five application packages were reviewed first
by an admissions committee composed of six faculty
members from the U.W. coming from different fields of
expertise such as informatics, public health, library sciences
and basic research. Different aspects were considered
during re-evaluation of the applications; professional
background, academic credentials, GPA score, TOEFL
scores, background in Informatics, academic potential,
current positions they were holding in their home countries,
interest in the program, proposed plans to develop in their
home institutions after their return to Peru, and
recommendation letters. The admission’s committee
unanimously selected three applicants.
Two candidates were able to enter the program. Both were
physicians. One candidate elected to focus in the area of
distance learning implementation. A second candidate from

Chapter 12: Education & Training
1037
the Ministry of Health has elected to focus on the area of
infectious disease surveillance, including the surveillance of
sexually transmitted diseases within Peru. Both of these
candidates are in training at the U.W.
Discussion
The Picture of the Electronic environment in Peru appears
very positive. However one must consider that there could
be a selection bias in the E survey since class had
prerequisite of at least basic computer usage and was
conducted at the two premier institutions in the country.
The decline in score (in 16% of post test questions) may be
due to difficult content or confusion in the wording of the
question. Some additional factors that could have
confounded or caused the un-expected errors on these
questions include the translation of the written questions
and errors in the simultaneous translation of the lecture(s)
themselves. Another factor that should be considered is
whether the students regularly attended all lectures. If
students missed some of the sessions, they would be in
disadvantage at the posttest because of the amount of
information that was quickly presented at each lecture. In
order to improve course evaluations and assess student
learning for further courses, these anomalies will be
examined further.
Conclusion
An international collaboration in research and training has
been successfully initiated through the collaboration of
three institutions, the University of Washington, the
Universidad Peruana Cayetano Heredia and the Universidad
Nacional Mayor de San Marcos. Peru is an active
environment in the area of informatics development with a
large coincidental investment by United States Agency for
International Development (USAID) in the Project Vigia
(Surveillance Project), which is now being realized with the
Ministry of Health. In addition, there is an emerging
workshop on infections, centered in the Amazon, which is
also externally funded. Thus, our effort is but one among
many in Peru to help bridge the technological gap between
North and South in the area of informatics.
The short course realization was successful and likely owes
its success to three elements. First, the objectives of the
course were tailored through discussion with our
collaborators in Peru to assure that the overall objectives of
the course suited the needs of the participating institutions
in that country. Second, a level of computer proficiency
was required of participants to enter the course and, thus,
basic computer literacy was not an issue. Finally, there was
active collaboration in realization of the course and
involvement of Peruvian as well as American faculty.
The electronics environment in Peru is rapidly changing. In
view of external and national investment in this area, it is
likely that rapid strides will be made. Nonetheless, our
survey suggests that the implementation of systems in Peru
that are inexpensive and sustainable will ensure the lasting
progress in informatics. The ultimate success of efforts
such as this international research and training program will
be in the long lasting collaborations, which are formed
through the training of individuals in North America and
faculty exchanges between Peru and the United States.
There was a pre-existing research agenda between
collaborative institutions and against this background the
eventual integration of new skills in informatics is ensured.
An email listserv among the participants and collaborating
universities has been set up and coordinated by UW to
encouraged ongoing dialog and discussions regarding
topics in Medical Informatics. The listserv is actively being
used.
The short course will be returning to Peru (May 24th
through June 6, 2001) and we hope to see further
improvement in the environment and in student’s
capabilities. With continued collaboration and perhaps
support from other efforts in the region we plan on
expanding to involve other Andean Countries.
Acknowledgments
We would like to acknowledge those who have made this
project a success. Alicia Silva–Santisteban, Arturo
Centurion-Lara, Tara Ann Sannicandro, Alejandro Llanos
M.D. This work was supported by a grant from the Forgarty
International Center’s International Health & Biomedical
Informatics Research and Training Grant: TW01286-02 and
the National Library of Medicine
References
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[2] Gotuzzo E, Sanchez J, Escamilla J, Carrillo C, Phillips
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[3] A World Health Organization Collaborating Center for
AIDS and STDs: http://depts.washington.edu/cfar/
[4] P.A.H.O. “Information Systems and Information
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75 12246 6. Pgs 62,63,65.
[5] Alarcon, J “Evolucion y Caracteristicas de las
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For additional references please email author
Address for correspondence
Bryant Thomas Karras MD, University of Washington, Box
357230
Seattle WA. 98195-7230 USA
bkarras@u.washington.edu