kidseyes, Author at Pediatric Ophthalmology…

Improving the quality of healthcare using clinical decision support systems: is “CHITS” ready? #HI201 #MSMHI wk11 #clinicaldecisionsupport

November 1, 2014 by kidseyes Leave a Comment

Week 11’s driving question was how can a clinical decision support system (CDSS) improve the quality of healthcare? Specifically, the task was to think of a clinical scenario and suggest a CDSS that can be imbedded in Community Health Information Tracking System (CHITS), an electronic medical record system crafted by the University of the Philippines Manila National Telehealth Center (UPM-NTHC), now being used in some government regional health units.

and

www.americanehr.com

CDSS espouses evidence-based medicine, envisioned to reduce practice variation and improve quality of care. CDSS provides both the physician a (or health care professional) and the patient with computer-generated knowledge, at the point of care. It should be able to provide reminders and warnings, to both the one providing care, and the one seeking care; and pertinent to my hypothetical case, generate a list of patients eligible for a specific intervention (as for example, immunisation).

This hypothetical case is that of Jacob, a 10-year old boy who consults the regional health unit for fever and colds. When his chart was pulled up by the nurse, his immunisation record showed that while he received his BCG, DPT, OPV and Hepatitis B vaccination (required in the Philippines’ Expanded Program of Immunization), he never received his measles vaccination which should have be given at around 9 months of age.

A good CDSS for this case, should have “flagged” Jacob for having missed his measles vaccination. The system should allow the scheduling of the vaccination, which naturally has to take place after being treated for his colds. This alert should continue until such vaccination is received. The CDSS should allow scheduling of appointments for vaccination, and should also permit entry of the information when the vaccination is finally received.

Ideally, a CDSS that will address measles vaccination and compliance should be able to generate a list of patients in the system eligible for receiving our desired intervention, which is the measles vaccination in this case. When such a list is generated, health care providers, and perhaps in some cases the local government units or social workers, can help track such patients, and make them available for the intervention.

Additionally, CDSS alerts for rubella vaccination can also be used even before conception. Family planning seminars a requisite for getting a marriage license is perfect timing for would-be mothers to receive information and vaccination. The same is true for mothers who consult prenatally at the regional health units. There should be no second child with rubella. Nine months before a child is born, is plenty of opportunity to alert this mother of the need for a rubella vaccine when the situation is ripe for her to receive such a vaccine. In the same manner, mothers who give birth to patients with rubella, should be alerted that all other children not exposed as yet are good candidates for receiving the vaccine.

For rubella vaccination to achieve our desired outcome or reduced mortality and morbidity from congenital rubella syndrome, a 95% vaccination coverage is necessary. The Philippines used to reach 70%, and even then we lament. Latest figures put Metro Manila at 40%, we waited for an epidemic before a LIGTAS TIGDAS campaign was launched. While yet unable to achieve targets, a question of sustaining immunisation campaigns should also be addressed. Incorporating alerts, reminders, and trackers in CHITS is one such means to achieve this goal. Is CHITS ready?

#HI201 wk9 Task: Personal Health Records (Do we need it?)

October 25, 2014 by kidseyes Leave a Comment

Driving question?: What features are considered critical or most useful by users of personal health records (PHR)? This assignment was coupled with a requirement to sign up for a free trial on an online PHR service or a mobile PHR application, create a scoring system to evaluate usefulness of PHRs and publish on your blog.

To understand what a PHR is, how it works, and how I can evaluate one (for this assignment), I signed my mother up at WEBMD. Not that I didn’t want to expose myself to risks with my own health data, I felt with my mom’s long list of life-threatening and chronic illnesses, I may as well use to opportunity to create a health record for her. I had my ulterior motives. Perhaps now I need not write down all that I can remember that was important… her diabetes, ventricular arrhythmia, hypothyroidism, cirrhosis, bicytopenia, portal hypertension, splenomegaly, etc. and of course the history of a near fatal anaphylactic reaction to penicillin.

For a scoring system, I borrowed emoticons from clipartbest.com, to represent my 5-point grading scale. Tongue out for 1, a pout for 2, a sleepy smiley for 3, a thumbs up for 4, and a two thumbs up for 5.

ACCESS and SECURITY.

WebMD did not permit me to create a PHR for my mom through my account. I couldn’t make one for my entire family using my one and only account. I guess it’s one email = one account. Realizing this, I created an email in her behalf, with my email as her rescue email. After signing in for webMD, I proceeded to explore what I can do with the site. Security features were password protection, and the fact that the system logged you out after 20 min of inactivity. I hesitate only because I wasn’t sure how secure data handling was. But so far I liked what I saw.

PERSONAL INFORMATION.

This section was the best, and the most user friendly of all its features. A primary and secondary emergency contact persons were permitted allowing access inc axe of an emergency. Even insurance information and legal initiatives and lawyers had their own spaces. There was an unlimited number of physician contacts allowed, as it should be when there were more than one physician addressing my mom’s numerous medical problems.

USABILITY.

There was no room for story telling, a clinical history so to speak, as we would ordinarily in clinical practice. How long have you had symptoms? What were the triggers? Associated with trauma? Family History?. The system went straight to diagnosis. The PROCEDURES section however, provided good usable fields in required data input.

To DIAGNOSIS I go then. I quickly realised there were occasions when different terminologies were used from what I was accustomed to. I would have preferred the facility of an ICD-10 code to come with the diagnosis, and perhaps a free text for additional remarks. If one were to foresee that PHR will later be integrated into the health care provider’s electronic medical records, a common language should be utilised. It was good too, that I was able to enter both current and old diagnosis.

It was worse when I tried to input LABORATORY TESTS and PROCEDURES. I started with the routine complete blood count (CBC). For the life of me, it contained one box for one figure. Isn’t the CBC a test for haemoglobin, white blood cells and platelets? Did they mean blood to be haemoglobin only? The same happened for urinalysis. What saved WEBMD was the fact that one could still record entries as individual tests for CBC, as there were separate listings for red blood cell, white blood cell, platelets, among others. I wasn’t sure how to go about entries for urinalysis. For total cholesterol, low density lipoprotein and high density lipoproteins, all the entries were in one “test.” I couldn’t change the units of measure that was used in the laboratory that provided the result. The same was true for thyroid function tests that included thyroid stimulating hormone, free T3, and free T4, that had only one numerical blank to fill in, when there were three tests. The results tabulation was also cryptic, making it difficult to detect problems at first glance. What I liked about it is that the system allowed a tracker graph to represent data that was entered showing trends. In addition, useful health information was also readily accessible at this site.

MEDICATIONS and IMMUNIZATIONS

Listing of medications was impressive, as even the prescribing physician, prescription number, dispensing pharmacy, dates dispensed, quantity and number of days of supply were all tracked. WebMD also issued medical alerts and informs the user almost as soon as an entry is suspicious for drug interactions, wrong dosage, and side reactions. Alerts were classified as potentially inappropriate, potential drug-condition interaction, each classified further as mild, moderate, or severe. Guiding literature about drugs and their interaction were made available. Drug allergies were also clearly defined. The immunisation section, however, can still be improved as it caries no alerts for when the next booster dose is due.

Personal Health Records (PHR) can be very useful even just for the patient to have a clear picture of her past and current illness that affect his current sense of well-being. At the very least, WEBMD provided a more consistent, and more reliable clinical history that permitted health care providers to exchange clinical health data.

So, do we need a PHR? My answer is YES. Even in its present condition, i.e., with inability to connect with physician provider, or be integrated into a physician’s patient chart, WEBMD, provided a consistent PHR format that will gain more widespread clinical utility as the Health Information Exchange infrastructure improves.

OVERALL RATING.

Developing a National eHealth Strategy (It’s more fun in the Philippines)

September 29, 2014 by kidseyes Leave a Comment

Task 6 #MSMHI #HI201: Managing the Complexity of a National Health Information System PH

This week’s driving question: If a hospital information system in one facility is a complex process by itself, how much more complex will a national health information system be? How can government manage this complexity?

There is not doubt that the complexity of the national health information system, in this case, the Philippines is formidable. Data sources come from different sites, sources, platforms. The sources of information include the health centres, field reports, regional health units, the Field Health Services and Information System, Surveillance in Post Extreme Emergencies and Disasters (SPEED), Philippine Health Insurance Corporation databases (includes patient (client), provider, procedure, terminology and even payment registry), the National Institute of Health, the Philippine Health Information Network, Philippine Network for Injury Data Management System, the ICT4H networks among many others.

How does a country manage these data complexity? It starts with setting our goals, identifying our objectives, having the right mix of health sector champions and a driven technical group espousing “two concepts”: Information Technology (IT) Governance, and Enterprise Architecture. IT governance takes care of seven key components for successful national eHealth Strategy–(1) leadership and governance, (2) strategy and investment, (3) Services and applications, (4) Standards and interoperability, (5) Infrastructure, (6) Human resources, and (7) eHealth Solutions (information sources, delivery of services, information flows).

To date, the Philippines has already has two versions of a Philippine eHealth Strategic Framework and Plan, the latest of which is published in 2014, for 2014-2020, a manual that contains our dreams, our goals, our achievements, our assignments, as patient, citizen, health care provider, as a stakeholder in our own health system.

It should not stop with knowing IT governance and creating an enterprise architecture. The government should follow through, defining standards for interoperability, implement capacity-building programs, create services and applications based on these standards, and create a compliance and monitoring system for the whole enterprise to fly high. (3)

In the end, the challenge is not answering HOW to manage this complexity, but rather HOW to implement, sustain and improve on management of the challenges presented by the complex health system that is the Philippines.

References:

1. Philippines eHealth Strategic Framework and Plan 2014-2020.

2. WHO-ITU Toolkit. http://www.searo.who.int/entity/health_situation_trends/documents/full_version_national_ehealth_toolkit.pdf

3. Marcelo A. The Philippines eHealth Strategic Framework and Plan: The Story of its Evolution. Last modified Sep 24, 2014. http://ehealth.atlassian.net

Relying on free market forces for information infrastructure in health

September 18, 2014 by kidseyes Leave a Comment

BUILDING A NATIONAL INFORMATION INFRASTRUCTURE: Do we need the government?

Task 5 for #HI201 #MSMHI

This week’s driving question asks if free market forces alone are adequate for providing appropriate deployment of the national information infrastructure in support of health and health care in the Philippines?

In the Philippines, we need our PPPs–public-private partnerships to build a robust national information infrastructure (NII) supporting health and healthcare. Free market forces alone cannot be adequate if the NII is envisioned for the country’s greater good. There is a realisation, however, that we need both the private sector (driven by market forces) and our own government represented by the Department of Health (DOH) and the Department of Science and Technology (DOST) see this through. For the Philippines, key movers led to the creation of the technical working group, now under the leadership of the DOH-DOST Steering Committee. For several years, our national information infrastructure has been slowly taking shape.

“The DOH is mandated to be the overall technical authority on health that provides national policy direction and develop national plans, technical standards and guidelines on health.”(1). It is the regulator, provider, policy maker, health financier (together with the Philippine Health Insurance Corporation), developer of standards and softwares, ensurer of equitable healthcare delivery and access, protector of rights of privacy, intellectual property and security, and the entity tasked to overcome jurisdictional barriers to cooperation. (1, 2) The DOH recognised the need for internet technology (IT) governance including the health sector need for an enterprise architecture. Only government can convene stakeholders, discuss standards, publish them and implement the same. Only government can rein in the players in the wide open field of health informatics.

The Department of Science and Technology on the other hand, possess the technical knowhow. It is the “director, provider, leader, coordinator of the country’s scientific and technological efforts…It is mandated to provide central direction, leadership and coordination of scientific and technological efforts, and ensure that the results thereof are geared and used in areas of maximum economic and social benefits for the people.”

Thus, these two agencies are at the very core of the government’s efforts for a national health information infrastructure.

It is not unusual to expect free market forces to be driven by profit. It is naiveté to expect free market forces to influence players morally to think about health and healthcare much less provide a NII. Privacy, interoperability, and even setting of standards cannot be expected of private enterprise without government regulation. In the country known for monopolies and cartels, only the moral persuasion of the government can regulate this business milieu. In a free market system, that which is not profitable, is not sustainable, and is unavailable. Only government can change that.

The noble cause of providing for an NII for health and health care should be the responsibility of government. Only when government cannot do this alone is there a need to tap into the private sector. Allowing government to take the lead role in this undertaking should be built on trust, as only the government can lead such an enormous project. Only government can assure equitability of health care benefits across the country.

In the Philippines, we need both government and the free market economy to work together for a NII for health and health care.

References:

1. Harmonize and strengthen health information systems. Health Policy Nots of the Department of Health 2008; 2(3).

2. Shortliffee EH, Bleigh HL, Caine CG et al. The federal role in the health information infrastructure: a debate of the pros and cons of government intervention. J Am Med Informatics Assoc 1996; 3 (4), 249-257.

3. Republic of the Philippines, Executive Order 128.

4. Philippines eHealth Strategic Framework & Plan 2013-2017. http://uhmis1.doh.gov.ph/UnifiedHMIS/draft-issuances/229-philippines-ehealth-strategic-framework-and-plan-2013-2017-version-3-0.html

5. Why do we need COBIT5? http://www.csi-india.org/c/document_library/get_file?uuid=6d3e2cd0-8004-48b7-91ab-b2823215dbcd&groupId=10157

Bridging the Gap and Avoiding Collisions

September 8, 2014 by kidseyes Leave a Comment

#HI201 #MSMHI week 4 Task: Mindmap of Challenges of Sustainability of Health Information Systems in Developing Countries

Bridging the Gap and Avoiding Collisions

Heeks (1) design-reality gap model quite simplistically, summarised challenges of sustainability of health information systems along seven dimensions: (1) information, (2) technology, (3) processes, (4) objectives and values, (5) staffing and skills, (6) management systems and structures, and (7) other resources. To succeed, HIS design and concepts should be as close to how these factors are in the real world.

Information processed by HIS should be of sufficient quantity, of good quality, and flows well from data collection to processing and analysis. If the design does not meet the data requirements on the field, HIS is bound to fail. HIS should also take into consideration the wealth of informal communication that may influence any HIS.

Technology encompasses infrastructure, software development, hardware, and even telecommunications equipment. For the HIS design to work, all these should be considered before implementation on ground zero.

Processes that require automation cannot dissociate completely from those requiring human input. An old system that has worked and is efficient, cannot just be replaced by an unproven novel system, and worse, by one that cannot exceed the efficiency of the old system. If the comparison is status quo, it will tilt the balance towards retention of old ways. Novel procedures and processes will not be accepted.

Objectives and Values should be defined by different stakeholders–the healthcare professional, the health facility manager, the patient, researchers, non medical personnel, the government (department of health) may all have different objectives that may not always be in perfect unison and may clash despite a common goal. Different perceptions of reality, variations in objectives and values affect the clinical utility of an HIS. As such, the developer and designer should not just make assumptions, but rather consult all possible stakeholders and end-users before undertaking an HIS that will be attuned to the needs of all, if not that of the greater majority. A tough feat!

Staffing and Skills. Human resources remain wanting for HIS. The task is daunting, and the personnel too few. When available and trained well, they may get lured by brain drain, redeployment and find themselves “moving on” to another task. Not only should there be warm bodies, they have to be skilled in both healthcare and information technology, and involve themselves in training for the HIS to be accepted and for HIS to work efficiently. To bridge the gap, hybrids (e.g., health personnel trained in information technology) or “bridgers” who coordinate with different stakeholders should be around to modify, innovate and improvise.

Management System and Structures rarely have gaps but may still be susceptible to manipulation by human resources, opinion leaders, and decision makers.

Other resources especially in terms of time and funding also affect sustainibility. Implementation of an enormous task, such as the setting up of a health information system for a whole country requires the luxury of time. However, funding agencies, whether they are local or international would set finite time tables by which HIS are evaluated. In addition, after initial capital outlay or investment, there is continuing expenditure that should not deviate much from the initial budget proposed, and would requre that fund sources are available if not limitless. If this can be achieved, nirvana is within reach.

Other factors that this author would like to add are the country’s political landscape, our geography, and our culture. Politics affects bureaucratic red tape, the speed by which projects get approved, or receives a budget from government appropriation. Geography, as in the Philippines for example, the fact that we are an archipelago creates logistics and planning nightmare. The differences in culture, the fact that patients want to “see the physician eye to eye,” religious customs and rituals, all these affect implementation of an efficient information technology system attuned to health care delivery.

Communication systems also play a major role in starting, maintaining, as well as sustaining the success of any HIS. Internet speed is always an issue, as developing countries still grope for the optimal speed for the information superhighway. Tools for innovation, analysis and ability to compromise, modify, and improvise favour sustainability and success of an HIS. Communication lines between end-users, developers, and fund providers should be amicably intertwined and coexistent. Common goals and agenda can be set.

In summary, while the perfect fit is impossible, reducing the mismatch between actuality and design spells success and sustainability for any HIS anywhere.

References:

1. Heeks R. Health information systems: Failure, success and improvisation. Int J Med Informatics 2006; 75: 125-137.

2. Kimaro HC & Nhampossa JL. The challenge of sustainability of health information systems in developing countries: comparative case studies of Mozambique and Tanzania. J Health Informatics in Developing Countries 2007; 1 (1): 1-10.