Health Informatics – Page 3 of 4

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.

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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?

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.

Concept Map: Relevance of Health Informatics to Global Health and eHealth

September 1, 2014 by kidseyes Leave a Comment

Health Informatics: Relevance to Global Health and eHealth

Task 2: HI201 Concept Map

By Alvina Pauline D. Santiago, MD

I thought I got away with the first week’s blog assignment. I didn’t think the next blog would come any time soon. I was mistaken, it turns out we needed to blog about every week’s driving question! And tweet #MSMHI, or was it #HI201, and post on #PMIS page.

There was only one thing I was sure of when tasked to make a mind map… the central topic HEALTH INFORMATICS, and that it needed to be connected to Global Health, as well as eHealth. There goes my mind map!

It sounded simple enough… like a mother (Health Informatics) holding 2 kids (global health) and (eHealth)! But I was so sure I couldn’t end there. This picture, didn’t answer relevance. I wasn’t sure what to do! I went back to the definitions found in the articles we were assigned (and a little bit more). Trying to look for clues. Here is what I think I found.

Health informatics encompasses all that eHealth wants to achieve. Sometimes you would think they were synonyms, aren’t they? “The World Health Organisation defines eHealth as the use of information and communication technologies for health.” Whatever it is…database, health education, patient appointments, billing, pharmacy prescription, monitoring drug interaction,…. it is not difficult to imagine how Health Informatics plays a significant role in integrating, processing, and evaluating all these tasks.

Health services delivery should be efficient and effective, providing quality universal healthcare, equality of access between the remote communities and urbanised cities. This in turn provides good health outcomes. Health Services Management provides avenues for surveillance of diseases, injuries, disasters, and extreme emergencies. Necessarily there is a registry for all of these. It also covers analysis of these data; recommendations for disease (injury, disaster, or emergency) containment, eradication and prevention; as well as policies that emerge on the basis of data thus collected.

Health Data & Information. Through secure electronic health or medical records (eHR or eMR), health informatics can provide avenues for research, thereby improving education. Knowledge is improved from data culled from these sources; clinical practice guidelines can be crafted. To ensure that all data is interpreted together, eMRs should have interoperability, read by different health care systems. Access of both the patient and the health care professional ensures a more thorough clinical data. Privacy of information should however be protected. Health Education can come in the form of patient or physician blogs, which may or may not allow for interaction (ask your MD or leave a reply). The potential for sharing information thus obtained via social media is limitless. Reports of adverse drug reactions and drug interactions can be better collated (thus influencing drug dispensing policy and monitoring). Medical training is also improved by webinars, virtual environments, and open learning via the internet. Patients can make informed decisions earlier, and usually at the point of care. Health education can also provide innovations and solutions both for clinical and research applications that have wider implications for overall health care delivery. As for the Health Care Provider, with a wealth of information just at his fingertips, he can provide better for patients at his point of care. He will have a better total picture of what happened to the patient. Co-morbidities are not neglected. More rational requests for diagnostics, with less repetitions can be followed. Drug prescriptions are better monitored avoiding drug interactions and adverse drug reactions. Referral systems for institutions, other health care providers, local health centre units, and specialists can also be integrated by Health Informatics. Reporting and monitoring of outcomes for patients and diseases become readily accessible and doable. Finally, licensing and accreditation of the health care provider is also facilitated by informatics.

Telemedicine allows for remote data collection and workup where images or results can be transmitted to a remote site. Access to specialists who are otherwise unable to go to patient or data location is made possible by telemedicine. Remote diagnosis and analysis is made and subsequent recommendations are given. This shortens the lost hours due to traveling and queueing, and identifies the patients that need to make the trip, directed towards a specific facility providing care. Of course, health informatics provides for infrastructure for software development, data warehousing, mobile applications and information systems. The problem of connectivity still plagues the system. eCommerce such as claims processing and analysis by insurance companies and even our own Philippine Health Insurance Corporation use health informatics. Credit card payments, direct deposits to account, online payment transactions are some of the examples by which payments are processed through informatics. eHealth Solutions such as access to support groups, health care services and even electronic consultations for non-emergencies are all part of the bigger picture.

Global health was a little bit more difficult for me. International health? Third world diseases? Infectious diseases? Neoplasms? What is it that made the world unhealthy? To be relevant, what is it the Health Informatics can do to reverse the trend? To improve a population’s health (thereby improving individual patient care)? The realm of global health include infectious diseases, tropical diseases, non-communicable diseases, maternal and child health, vaccinations, tobacco and smoking, and even global burden of disease in terms of lost hours and disabilities. (There are articles that even talked about water and sanitation, which I could not get myself involved in despite the realisation that it does indeed affect global health, water-borne diseases notwithstanding). Epidemiology and statistics are made easier with automation provided by health informatics.

In any global health, ehealth, or health informatics undertaking, processes involved include interdisciplinary cooperation, information exchange, disease surveillance, disease monitoring that will dictate population strategy and policy. The World Health Organization had provided a standardised matrix to analyse data, specifically for computing life expectancy, disability adjusted life years and burden of disease.

Whew! I am not sure the reader is still with me. I may have gotten lost somewhere myself. One thing is sure, global health, eHealth, and health informatics are interrelated, perhaps even co-relevant in their own right.

References:

1. Philippine eHealth Strategic Framework and Plan 2013-2017. Department of Health, Department of Science and Technology, Philippines, September 11, 2013.

2. Murray CJ, Lopez AD. Measuring the Global Burden of Disease. New England J of Medicine 369:5:448-457.

3. Koplan J, Bond TC, Merson MH, et al. Towards a common definition of global health. LANCET 2009; 373: 1993-1995.

4. Oh H, Rizo C, Enkin M, et al. What is eHealth (3): A systematic review of published definitions. J Med Internet Res 2005; 7 (1): e1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1550636/