#MSMHI #HI201

Enterprise Architecture atbp., Q and A: Week 7 assignment under Dr. Marcelo in #HI201 #EA #MSMHI

November 1, 2014 by kidseyes Leave a Comment

We were tasked to post questions about enterprise architecture and others as it relates to health. Below are my questions, and answers from Dr. Alvin Marcelo, and a few others.

#1 Is interoperability addressed by using open EHR?

See Doctors Find Barriers to Sharing Digital Medical Records http://www.nytimes.com/2014/10/01/business/digital-medical-records-become-common-but

Marcelo: In the US, the EMRS got bigger before the Health Information Exchanges (the interoperability layer). In such a situation, it becomes harder for mature EMRS to connect “back” to an HIE. The lesson is to quickly define the HIE and ask the EMRs to comply with it.

Up to a certain point [interoperability can be addressed by open EHRs] but not beyond it. OpenEHR helps organize clinical knowledge and structure it consistently. That helps with managing the complexity of clinicians having varying ways of representing their knowledge … [In an openEHR workshop, group] members given the same clinical scenario …had varying mindmaps for that case. If they proceeded to create the EMRs from their mindmap, for sure, their EMRs will not be interoperable because they had already diverged at the clinical knowledge layer (in EA, the business architecture). OpenEHR is like a bucket of lego blocks from where you can get pre-built blocks (representing clinical knowledge) which you can then put together to create your EMR. Since all of you got your building blocks from the same bucket, the chances that your EMRs can connect to each other is higher.

#2 Will open EMR prevent this type of scenario?

See Billing Dispute Leads to Blocked Patient Data in Maine. http://www.bostonglobe.com/news/nation/2014/09/21/electronic-health-records-vendor-compugroup-blocks-maine-practice-from-accessing-patient-data/6ILpMv78NARDsrdU5O0T9N/story.html?event=event25

Marcelo: No it will not. There are at least three layers of interoperability that need to exist before data flows effectively — business, information, technical. Open electronic medical records can address information and technical interoperability but cannot assure that there will be business interoperability (that is, two entities agreeing to do business with each other). The article is interesting that it actually states that information and technical interoperability already existed but a disagreement in how to run the business prevented the exchange of information. Similar cases abound in healthcare.

ITITan: I saw one contract where it is explicitly stated that there is an extra charge for extracting records at end of contract.

PSantiago: Is this practice fusion?

ITITan: It was a local EMR product

AJReyes: Have installed openemr and giving it a good look. What do you think about it?

PSantiago: I am suspicious of a hidden agenda… Whats in it for them? I don’t know yet, still exploring…

AJReyes: FOSS is like that. They may make money from professional support, or from having it in their CV or they just enjoy doing it. Still the data model is open to you (mysql RDBMS) so in theory, you should not get stuck, the way Full Circle was. FOSS aside, Full Circle should know, doctor lang ang puwedeng pilitin mag T.Y.

MAAlcantara-Santiago If you are implementing the openEMR in your own institution or hospital by “yourself” (meaning there is no third party implementor), then no, it should not be a problem.

But, in cases where you have a third party implementor of openEHR, then the problem of this happening in your institution will depend on the contract. In this case, it doesn’t matter if its openEMR or not. What matters is what is stated in the contract. If the institution failed to correct an implementor’s stated penalty wheb the institution is not able to pay, then the legal department of that institution is incompetent. I would rather not do business with an implementor that holds access to information when problems with payment or financials are experienced.

Sorry have to correct myself on this. I meant openMRS and not openEHR. OpenEMR is the open source EMR. OpenHR is a standards tool and contains concepts or archetypes which can be used in any EMR.

But, the problem of information lockdown is still dependent on the contract between implementor and the institution.

AHSantiago This is not an issue of implementing another system or not just to solve the problem. This is just a simple question of is this stipulated in the contract between vendor and client. In the world of entrepreneurship, if a businessman owns a bank money that he used for his business and does not pay back the bank can take back what is rightfully theirs in any form in which will be stated in their contract. This is like what happened between stradcom and lto, where system access was used as a bargaining chip to complete the payment deal. I think LTO won legally

AJReyes If you choose to run the system on your own computers, as opposed to having someone else host them, you should always be able to use it, even as a second system (inconvenient). Given the quality of our broadband system, I doubt if any local would seriously consider outside hosting. As to importing the data to a new system so you can have seamless access, the base implementation of openemr has over 170 tables but only for form* tables, and a few others have the clinical data so it’s doable by an independent provider but only if your contract is big enough. Would it retain it’s legal validity? The advantage of FOSS is that you can fire your support staff and hire another group if need be.

PPlanas This is what the IT department is for you back-up your data, so that whatever the local EMR vendor wants between you and management, regardless of the legalities, continuity of care can still be done on another EHR. Just implement a business continuity plan for vendor related lock-ups.

#3 Should PGH adopt an IT governance and an enterprise architecture? Or are we in the middle of it? What are our barriers?PGH has a wealth of clinical data but is not a DOH hospital. How can we harvest this data or integrate with the DOH system?

THerbosa: Through an interoperability layer. Mela Lapitan onboard

TLeachon: Just met with Atty Deegee, Staff of Sen Pia, She asked how to support this.

#4 Can we make all departments’ EHR/EMR interoperate so we get a better picture of our patients in PGH? First things first, EHRs for different departments in PGH, make them interoperable and fully accessible by health care provider?

Marcelo: First definitions: an EMR is an electronic system for recording patient data in one facility. An EHR on the other hand is a person’s longitudinal record which may comprise of data coming from different EMRs. So in PGH, ISIS is the EMR of the Department of Surgery. In IM, they have their own EMR. But patient Juan dela Cruz should only have one EHR which is a collection of his data from Surgery and IM.

How is this possible? Through interoperability — a system that allows the collection of Juan’s data from the different EMRs where his data resides. Do we need to design this from scratch? No, the Integrating the Healthcare Enterprise (www.ihe.net) has already described how this could be done in a health system.

#5 Practice Fusion claims free electronic health records, “no hidden costs, no strings attached.” Really? Is there a hidden agenda? Practice fusion sells “anonymised data.” Are we as physicians willing to take that risk?

From Practice Fusion Privacy Policy: http://www.practicefusion.com/pages/privacy-policy.html

“We use non-personal information for the following purposes: Auditing, research, measurement and analysis in order to maintain, administer, enhance and protect our Services, including analyzing usage trends and patterns and measuring the effectiveness of content, advertising, features or services; Creating new features and services; Contextual and cookie-based automated content delivery, such as tailored ads or search results;Health and medical research; public health and service activities; healthcare- and medical-related services; and Other purposes described in this Policy or your User Agreement.

We may also use non-personal information to prepare aggregate reports for current or future advertisers, sponsors or other partners to show trends about the general use of our Services. Such reports may include age, gender, geographic, demographic or other general user information, but do not include personal information.”

Marcelo: Everyone has a hidden agenda, (deliberately or not). The key is agreeing on principles. Based on Data Privacy Act of 2012, personal information is not sharable….except when anonymized for research…     so technically, practice fusion is above the table…     (I have no stocks with PF).

http://www4.pcmag.com

#5a If data is anonymised for market research, and not health research, such as pharmaceuticals establishing trends and analysing physicians’ practice patterns, is this still acceptable?

Marcelo: Based on the Data Privacy Act of 2012 (Chapter 1, Section 4 (d)), processing personal information for “research purposes” is allowed by law. As the section states, “research purpose” is out of scope of the Act. But is it acceptable (who defines “acceptable)? (Make sure to consult a lawyer prior to implementing this for your protection).

“SEC. 4. Scope. – This Act applies to the processing of all types of personal information and to any natural and juridical person involved in personal information processing including those personal information controllers and processors who, although not found or established in the Philippines, use equipment that are located in the Philippines, or those who maintain an office, branch or agency in the Philippines subject to the immediately succeeding paragraph: Provided, That the requirements of Section 5 are complied with.

This Act does not apply to the following:
(a) Information about any individual who is or was an officer or employee of a government institution that relates to the position or functions of the individual, including:
(1) The fact that the individual is or was an officer or employee of the government institution;
(2) The title, business address and office telephone number of the individual;
(3) The classification, salary range and responsibilities of the position held by the individual; and
(4) The name of the individual on a document prepared by the individual in the course of employment with the government;
(b) Information about an individual who is or was performing service under contract for a government institution that relates to the services performed, including the terms of the contract, and the name of the individual given in the course of the performance of those services;
(c) Information relating to any discretionary benefit of a financial nature such as the granting of a license or permit given by the government to an individual, including the name of the individual and the exact nature of the benefit;
(d) Personal information processed for journalistic, artistic, literary or research purposes;
(e) Information necessary in order to carry out the functions of public authority which includes the processing of personal data for the performance by the independent, central monetary authority and law enforcement and regulatory agencies of their constitutionally and statutorily mandated functions. Nothing in this Act shall be construed as to have amended or repealed Republic Act No. 1405, otherwise known as the Secrecy of Bank Deposits Act; Republic Act No. 6426, otherwise known as the Foreign Currency Deposit Act; and Republic Act No. 9510, otherwise known as the Credit Information System Act (CISA);
(f) Information necessary for banks and other financial institutions under the jurisdiction of the independent, central monetary authority or Bangko Sentral ng Pilipinas to comply with Republic Act No. 9510, and Republic Act No. 9160, as amended, otherwise known as the Anti-Money Laundering Act and other applicable laws; and
(g) Personal information originally collected from residents of foreign jurisdictions in accordance with the laws of those foreign jurisdictions, including any applicable data privacy laws, which is being processed in the Philippines.”

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?

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

Health Informatics Philippines: What Makes You Fly? or Sink?

August 31, 2014 by kidseyes 2 Comments

Week 3 Task: What are the factors affecting advancement of the field of health informatics in the Philippines. This is the blog explaining the infographic for this task. #MSHI #HI201 #healthinformaticsphilippines

HEALTH INFORMATICS PHILIPPINES

What Makes You Fly?

2005: The University of the Philippines System Master of Science in Health Informatics (UP MSHI) program is at the forefront of inititiatives for Health Informatics to take off in the Philippines. Since its approval by the Board of Regents in 2004, the program started to train Masters of Science in Health Informatics since the school year 2005-2006. The graduates who stayed are now at the helm of Health Informatics in the country.

2013 & 2014. The Philippines eHealth Strategic Framework and Plan 2013-2017 and 2014-2020 Edition, contains the framework that the Department of Health leadership under Secretary Ona and other key decision makers have adopted, a favourable stance towards Internet Technology (IT) governance. We hope these initiatives will continue on through the next administration. The building of infrastructure, and supportive business and regulatory environments favour the rising of health informatics. The DOH understands that implementation of its project: Universal Health Care requires better health information systems.

The Philippine Health Insurance Corporation (PHILHEALTH) is also adopting internet technology to improve its services. I saw a glimpse of the a proposed health-sector wide enterprise architecture suggesting the future looks bright and sunny.

(from Dr. Alvin Marcelo’s+ “” page).

105% Huge cellphone subscriber base. Known as the texting capital of the world, Philippines now has been estimated to exceed 105 million cellphone users. These users now access Facebook, twitter and google among others. Certainly this resource can only pump hot air into an already flying balloon.

33.3M Internet-savvy population. In 2011, the number of internet users was estimated to reach 33.3M (or 33%), and expected to reach 59M (or 59%) by 2016. This tilts the balance in favour of health informatics and its applications.

What Makes You Sink?

Infrastructure and hardware
slow internet connection
lack of human resources
enormity of project
limited funding
lack of awareness
lack of trust
ningas kugon
political landscape

Infrastructure and hardware. Not only is our internet slow, our service providers contend that since heavy users comprise only %, we now also have to contend with data capping. According to rappler.com, data capping is Data caps, also called bandwidth or broadband capping, is a method by which Internet service providers (ISPs), network service providers, and telecommunications groups manage or control their data. This is done through a process known as throttling, where the amount of data sent and received on a given communications channel – or bandwidth – is lessened.

Slow Internet Connection. The average internet connection speed in the Philippines in only 3.9 Mbps, compared to Singapore’s 16.9 Mbps. (Brunei 7.9 Mbps, Thailand 4.32 Mbps) [Ookla data in abs-cbn.com news report]. Our broadband speed ranks 155th in the world. In addition, there are allegations, that Philippine Long Distance Telephone Company, deliberately keeps internet traffic slow by not providing a unified internet exchange (IX), instead, internet service providers are routed through a different backbone in Hongkong.

“In its latest State of the Internet Q2-2014, Akamai said the Philippines ranked 103rd on the list in terms of average connection speeds. The Philippines only had an average Internet speed of of 2.5 Megabits per second (Mbps) in the second quarter, although this was a 58 percent improvement from year-ago figures.”

Lack of Human Resources. Despite the steady increase in the number of health informatics professionals, there remains a palpable lack of personnel to undertake the daunting task of making health informatics in the Philippines soar to greater heights and implementation.

Enormity of Project. The Philippine eHealth Strategic Framework and Plan for 2013-2017 as crafted by the Department of Health and the Department of Science and Technology proposed a budget of close to PhP 297 million. Where the money will come from is another obstacle, as the government’s Disbursement Acceleration Plan is close to being shot down by the nation’s own Supreme Court for being unconstitutional. Necessarily too, because of the large scale, the project will outlive leadership terms. For the project to take off, it should be carried out on its own merits, regardless of personalities.

Lack of funding. Donor funds, international sources from entities like the World Health Organization need to augment local fund resources. Often, these funding have a finite timeframe for implementation and evaluation, and may be too short for the health informatics initiatives in the Philippines to fully take off.

Lack of awareness. Despite the huge cellphone users base, many have not optimized eHealth access by just typing the correct search terms. The populace should transcend the use of social media to benefit health care access and delivery.

Lack of trust. The wealth of data that can be exchanged over the “information superhighway” should have the patient’s privacy in mind. The lack of regulatory bodies and laws, and perhaps more the lack of police power make people distrust this initiative. Proof of its confidentiality and its utility need to be presented before full trust can even be achieved. Laggards will always also claim distrust of the system and will refuse to adopt something new until it is perhaps the bandwagon.

from Rxfire.net

Ningas kugon. Known as a Filipino “bad” habit, it compares the drive to finish a task to the burning of the cogon grass, that is, the propensity of the fire rage in the beginning only to stop before it is completed. We would like the hot air from this fire, from this desire to pump the hot air needed for health informatics to fly.

Political Landscape. It is said that unfinished projects will not be touched by the next leader voted to power. The current leadership is supposed to end terms in 2016. Many of these project will exceed implementation of the date they step down from office. The country is also peppered with allegations of red tape and corruption, so that even meaningful projects do not gain ground if one did not have the right person behind it to push it forward.

References:

Marcelo AB. Health informatics in the Philippines, APAMI 2006, in conjunction with MIST 2006, S25-S27.
De Dios A. Philippine Basic Education, May 26, 2013. http://philbasiceducation.blogspot.com/2013/05/digital-literacy-skills.html, accessed December 7, 2014
Philippines eHealth Strategic Framework and Plan 2013-2017, September 2013. Accessed December 7, 2014. http://www.doh.gov.ph/sites/default/files/Philippines_eHealthStrateg icFrameworkPlan_February02_2014_Release02.pdf
Philippines eHealth Strategic Framework and Plan 2014-2020. Accessed December 7, 2014. http://uhmis.doh.gov.ph/downloads/forms/229-philippines-ehealth-strategic-framework-and-plan-2013-2017.html
Marcelo A, google+ page, About
Philhealth improves business processes as it gears for 20^th century computing. http://www.philhealth.gov.ph/news/2012/ea_business_process.php
Marcelo AB. Health informatics in the Philippines, APAMI 2006, in conjunction with MIST 2006, S25-S27.
Barreiro Jr., V. Average Philippine Internet Speed 155^th in the world. May 2, 2014. http://www.rappler.com/technology/news/57037-average-philippine-internet-speed
NTC Summons Globe on Data Caps, Eyes Fair Use Rules, Feb 2, 2014. http://www.rappler.com/business/industries/215-tech-biz/49979-ntc-globe-internet-data-caps
How PLDT deliberately keeps local internet traffic slow and expensive in the Philippines. http://www.reddit.com/r/Philippines/comments/2aurzq/how_pldt_deliberately_keeps_local_internet
PH has 4th fastest internet speed in ASEAN study by abscbn news. http://www.abs-cbnnews.com/business/05/28/14/ph-has-4th-fastest-internet-speed-asean-study
Evans P. Philippines – Telecoms, Mobile, Broadband and Forecasts – See more at: http://www.budde.com.au/Research/Philippines-Telecoms-Mobile-Broadband-and-Forecasts.html
ABS-CBN news. Philippines still has one of slowest internet speeds in Asia. http://www.abs-cbnnews.com/business/10/02/14/philippines-still-has-one-slowest-internet-speeds-asia.