“Mens sana in corpore sano”

A healthy mind in a healthy body is the ideal which we must all strive for. Hippocrates, the father of medicine said, “A wise man ought to realize that health is the most valuable possession.”

These days, we have more empowered patients taking more responsibility for their medical care than in the past. Many patients have come to realize that they can take a more active role in their own disease management. One way is by learning all that they can about their disease and treatment options, another is by maintaining their own personal health records.

My affirmation call when I face the mirror every morning is to commit to a firm set of health related goals and get myself in the best physical shape starting this moment. This assignment was timely, a doctor is never the best patient and I have resolved to monitor my blood pressure closely and eat healthy.

th-1

 

Driving question – “What features are considered critical or most useful by users of Personal Health Records?”

I chose to evaluate the mobile app, Capzule, one of the first to introduce a personal health record app. I also wanted to try onPatient but was unable to do so because of iOS incompatibility.

screen1136x1136screen1024x1024

 

According to its website, Capzule has the following functionalities:

  • Drive and Dropbox Interfaced
  • Keep Family Health Data Organized
  • Create Summary in PDF, Email, Export & Print
  • Import CSV from Mail Attachments/Other Apps
  • Scan Documents Using Camera into PDF
  • Create Custom Health Monitoring Templates to Track Any Chronic Condition
  • Set Unlimited Medication Reminders
  • Use iCloud For Data Backup/Restore
  • Set Doctor Appointment Reminders
  • Visualize Health Data in Graphical Timeline
  • Upload Files Directly From Computers
  • Edit Directly From A Computer Browser
  • Add Files From Other Apps
  • Transfer Data Between iOS Devices
  • Password Protected
  • Create QR Code Summary for Emergency Personnel
  • Data Backup/Restore Using Email or Computer
  • iOS Universal
  • Today View extension to show My Profile, Reminders and Appointments (iOS8)
  • Touch ID as alternative authentication (iOS8)
  • iPhone 6 & iPhone 6 Plus Supported

The website Appshopper rated the app as 4 averaged from 350 user ratings. I was unimpressed and would only give this app an overall rating of 3. My rating and the criteria which  I used were:

  • The Basics – the ability to add/delete/share/correct current and past medical records – Rating: 3
  • Tool Design and Ease of Use – Rating: 3
  • Proactive health monitoring and alert mechanism – Rating: 3
  • Security and control – Rating: 4
  • Cost and reliability of the software – Rating: 3

These are the most basic functionalities and ones which most users would expect  from a mobile personal health record app, nothing extraordinary. Other features that would definitely be plus factors and that others may look for, but may not be applicable to the Philippine setting  would be:

  • Ability to pull medical records automatically from healthcare providers
  • Compatibility with other health recording tools and the ability to share information with healthcare providers.

I took note that Apple was pushing its “Health” app and look forward to trying this out. Most health apps have only been data monitoring platforms. Now, if only Apple could transform Siri to act as my personal health assistant, that would truly be extraordinary as well as revolutionary!

References:

1. “How to choose a PHR.”  PHR Reviews website. Accessed thru: http://www.phrreviews.com/how-to-choose-a-phr

2. Kim MI and Johnson KB. Personal health records: evaluation of functionality and utility. J Am Med Inform Assoc 2002;9:171-180 http://jamia.bmj.com/content/9/2/171.full.pdf+html

 

Q&A for #EA

“Organizations were spending more and more money building IT systems and finding it more and more difficult to keep those increasingly expensive IT systems aligned with business need. The bottom line: more cost, less value.” – Roger Sessions

Q&A for #EA, Enterprise Architecture (EA) with Dr. Alvin Marcelo thru tweetchat:

Question 1:
How do we deal with current existing vertical information systems under the EA plan?

Answer: Vertical systems are results of poor (or lack of) architectural design. Often we blame information systems for these vertical programs but if you look closely, these information systems were simply artifacts that reflect the realities of the business processes. If you dissect the business architecture layer, you will see that the health programs are in fact operating in silos themselves.

These silos/vertical programs are detrimental to health service delivery and must be fixed — but how? This is one of the biggest challenges in eHealth right now — When you have mature information systems for vertical programs such as the TB and malaria, how do we re-integrate them?

Interestingly enough the answer seems obvious — re-orient information systems around the point-of-care (at the patient level) since all services converged with the patient and not with the programs. Thus while programs may be vertical, the patient remains the locus of interest or the hub where these vertical programs intersect. Therefore, a patient-oriented electronic health record design could be an effective way of dealing with vertical programs — a system where the patient’s longitudinal records are accessible from his/her perspective.

Question 2:
Is UMID part of the EA plan for data collection? Is a unique ID an integral part of HIS?

Answer: Not yet. The reason is that the UMID still does not assign a common reference number (CRN) for every citizen in the Philippines. Only formal employees have SSS. Only government officials have GSIS. Pag-ibig is optional. Only PhilHealth assigns a unique number for every person (including those below 18 years of age) thus the PhilHealth number is the national health identifier for use in the national eHealth plan.

Having said that, there is a Citizen Registry project in the works. This could be the client registry component of the Philippine Health Information Exchange.

Question 3:
Whats the bigger problem for capacity building  – tech infrastructure or human capital?

Answer: Human capital because all tech are operated by humans in the end. But there should be parallel build-up of tech infrastructure with human capacity so they are in sync.

The driving question for this session was: “Pretend you are the Chief Information Officer of the Department of Health. Which of the four major enterprise architecture frameworks will you choose to manage the information coming in from regional health units and DOH hospitals?”

This is EA:

Enterprise_Architecture_Domain_Reference_Architecture

 

 

Hospital information systems present a problem because of its complexity and poor business alignment when inappropriately designed. Enterprise architecture provides a means to build an IT structure which enables business processes and develops the path to take for the technology so that it can support the enterprise’s growth.

I posed the above questions to Dr. Marcelo to further consolidate my thoughts on issues tackled in earlier discussions. In my previous blogs, I talked of people, processes, technology and financial resources. Seen from another perspective, these same factors are those seen in the Fishbone or Ishikawa diagram for root cause analysis.

If I were to personify EA, he would be a problem solver wearing several thinking caps. Should EA be a director who sets the stage and gives actors their parts to play? The manager who oversees the schedule and flow of things? The engineer who sees the system as a whole flaws and all and corrects them? The finance officer who takes note of scarce resources and decides how best to use them? These are just some of the perspectives that should be looked into. Which particular architectural framework can help me?

Ninety percent in the industry use one of these four methodologies: the Zachman framework, the Open Group Architectural Framework (TOGAF), the Federal Enterprise Architecture and the Gartner Methodology.

If I would be permitted to do so, I’d like to transfer the scenario closer to home. If I were to choose any architectural framework for my hospital,  it would be TOGAF. It is popular, widely used with lots of information freely available and capable of aligning my IT processes with our business needs. One of the strengths of TOGAF is the provision of processes which ensures that IT is aligned with the various components of the enterprise. The table below (Table 1) assisted me in choosing this particular framework for our use.

I’ve listed my top 5 factors which I find most meaningful for my situation – a small, private hospital building up its IT infrastructure taking into account the cost of the system and the benefits I could derive from such a system:

  1. Process completeness  – refers to how fully the methodology guides you through a step by step process for creating an enterprise architecture
  2. Reference-model guidelines – refers to how useful the methodology is in helping you build a relevant set of reference models
  3. Practice guidance – refers to how much the methodology helps to assimilate the mindset of enterprise architecture into your organization and develop a culture in which it is valued and used
  4. Business focus – refers to whether the methodology will focus on using technology to drive business value in which business value is specifically defined as either reduced expenses and or increased income
  5. Information availability – refers to the amount and quality of free or inexpensive information about this methodology

EA table

That said, I would like to quantify that the better way would be to use a blended technology. Find the best fit for our hospital by choosing portions of frameworks, modify and merge them to fit our needs – particularly ones which excel in practice guidelines and business focus. During the tweet chat, Dr. Marcelo said mixing of  frameworks does happen.

Reference:

1. Sessions R. “A Comparison of the Top Four Enterprise-Architecture Methodologies” Accessed thru: http://msdn.microsoft.com/en-us/library/bb466232.aspx

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Fitting the pieces, finding solutions, making it work

Lego Blocks. It was just like fitting lego blocks or jigsaw puzzle pieces but this time with archetypes and templates. I was able to attend the openEHR workshop of Dr. Marcelo and found the concept interesting. It’s certainly worth looking more into and getting adept at. But I do know there’s a lot more into it. I’ve posted some slides on Slideshare – on the issues of EHR implementation in a private hospital as well as a journal review of its use and benefits.

Links:

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Dr. Mike Muin gave the driving question –

“Aside from cost, what are the issues and challenges in implementing an electronic health record in (setting of your choice) and how would I approach/resolve them?”

I hope this is an easy read – it gets confusing when I switch from the person asking the question, the one answering the question and likewise the presenter of the slideshow!

My presentation transcript:

Slide 1 –
These issues are presented in the context of my position as hospital administrator of a small private hospital. There are lots more, but these are the more pressing issues in my situation. Other issues not presented here may have more straightforward answers. I pose questions and solutions to the challenge of EHR implementation.

Slide 2
What makes EHR implementation difficult?
“Change is not the problem – but resistance to change can be a huge problem.” – Torben Rick

Slide 3
Who wants to make the change? Does it matter?
Is it management? Is it the medical staff? Is it the nursing staff? Is it the other departments in the hospital?

Any top down decision, an imposed change, is more difficult to implement.
People below feel excluded, yet are most directly affected.

Innovation is best done as a participative process. But it is slow one since it utilizes collective decisions. But this way, we can use action teams who are familiar with their areas to fine tune the process flow.

Make sure it is not your idea. If the demand is not indigenous, the system will not be sustained.

Two concepts must be understood and used if I were to propose EHR for our hospital – the concept of “Buy In” for top-level management and “Co-Ownership” of the idea for the other members of the hospital. Everyone must agree that EHR is the direction we want to go.

Slide 4
What do I do to make it work?
For IT projects, one size does not fit all. If a commercial off the shelf product is to be used, customization is needed.

Understand the current process – the clinical and workflow process. Support existing ones with the new.  We are trying to come up with solutions to problems, not everything has to be changed.

Do we go with big bang or the slow roll?
Make small progressive changes, instead of one big sweep. One area first, see what the change requires, modify as needed. Then repeat!

Slide 5
Understand what the change is for.
–  Is it to improve process flow?
–  Is it for data mining and research?
–  Is it for patient record keeping?
– Is it for improvement of patient services?
– Is it for better clinical outcomes of patients?
– Is it for optimization of business functions?

Define what we need from the system so we know what results to expect.
Develop with end use and end user in mind.

Slide 6
What do I do when doctors and nurses are dissatisfied with the system?

To prevent this, we have to address design- reality gaps at time of conception.
Make sure it works for clinicians. If it does not meet the needs of clinicians, it will fail.

From the very start as mentioned in the previous slide, we will have to be clear what the system is for. This way we can manage user expectation.

Slide 7
“Expectations management is the key to successful projects. The difference is the focus on managing the customer, rather than the product or development team.” – Gainer

Slide 8
Communicate! Explain the benefits to the different stakeholders as seen from their perspectives – “What’s in it for me?”

But in the end, realize that you can’t please everyone. Which is why we should know who the decision makers are, who the influencers are, who the engaged stakeholders are – the inner circle of people who matter and who will make things happen.

Slide 9
What system do I use?
Should I get best of breed or an integrated enterprise system?

Whatever works, whatever fits. But do know where your system fits into the national system structure. Know the standards and have interconnection capabilities.

For our purposes, its use would be communicating with government agencies such as PhilHealth and DOH. Functionalities that I would be most interested in then would be – to improve process flow, record keeping and business optimization.

Be the lone wolf and you can’t interconnect.

Slide 10
In summary, I addressed the following issues as presented by the WHO manual on EHR:
2. Resistance to computer technology and lack of computer literacy
3. Resistance to change
11. Involvement of clinicians and hospital administrators

References:

  • Electronic Health Records, Manual for Developing
    Countries, World Health Organization
  • Health Information Systems: Failure, success and
    improvisation, Richard Heeks
  • Beyond Change Management, Linda Ackerson
  • Electronic Health Records for Public Health, Gordon
    Cressman
  • Making IT Happen: Strategies for Implementing the EMR –
    EHR, Health Information and Management Systems Society

Status: It’s Complicated

“If you can’t explain it simply, you don’t understand it well enough.”   -Albert Einstein

“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?”

Just like relationships, sometimes it’s not the more the merrier. Not really knowing how and why things went wrong, we end up saying – it’s complicated.

Set aside the problem of finding the funds to finance a national health information system, we are left with people, processes and the technology it requires. With lots of people doing their own thing, talking their own language, expect chaos. That’s the current assessment of our health information system structure – inadequate and fragmented. There’s  a lot of data that can be used towards improving health outcomes for Filipinos but it comes from several sources, most of the time not compatible with each other.

Perhaps it’s time to be on blinders on mode, similar to a greyhound which sees only its prey and chases it on a single track. Except we shouldn’t be going round and round in circles but instead know the direction we are headed, recognize what we want to accomplish and finally decide how we are going to get there.

If we were part of government leadership, what can we do? First, we’ll have to understand how data is created from the grassroots level and address what Heeks describes as the “design-reality gap”.  Perhaps it is best to look at the project from several perspectives from the start of its conceptualization – technological, organizational, financial, social. Government  will need to come up with a strategy, and with this, long-term goals and a plan of action. Part of this strategy should include the use of an architectural approach, having a framework from which to build on to ensure judicious use of scarce resources. Multi-sectoral involvement is necessary. One way we can work on stakeholder engagement is including them in discussions when government sets up standards.  Capacity building then follows conforming to the set framework and standards. After government has set the goal, the framework, the standards and the parameters where private enterprise can work in, big business will recognize the needs, see the opportunities and fill in the gaps with their products and services.

With the vision set, action plans done, government will have to continue the process thru regular monitoring and evaluation. Methods must be put in place to measure if we are on track with our plan and assess the quality and impact of the work that has been accomplished.  Without impact, we may just be going through the motions, doing lots of things but actually achieving nothing.

National Health Information Sytem

Reference:

1. Alvin Marcelo, MD. History and Evolution of the Philippine eHealth Strategic Framework and Plan. Accessed thru: https://ehealth.atlassian.net/wiki/display/ESCT/The+Philippine+eHealth+Strategic+Framework+and+Plan%3A+the+Story+of+its+Evolution

“What’s in it for me?”

“In the Philippines, are free market forces, unfettered by government intervention or regulation adequate for providing deployment of the national information infrastructure in support of health and health care?”

Whenever we talk of free market forces, we talk of supply, demand and competition. With more hospitals  being built to meet up with the needs of a growing population, I expect an increasing demand for health information systems.  Each hospital though, or maybe even each department in a hospital has its own information system resulting in a fragmented network, unable to connect with each other. More than ever, more data is being collected with the introduction of electronic health records. However, there is no set national standard.

On the supply side, increasing demand brings about a resultant increase in the IT workforce, hopefully with a health informatics background. Competition results as more choices are available for services and products. This is the reason free markets are important – there reaches a point where the same service and the same product is offered by several competitors and price is the only differentiating factor.

WIIFM

There are several stakeholders in the healthcare industry. In the formulation of a national information infrastructure for health and health care, all these stakeholders must be taken in to formulate the blueprint – one vision, one strategy, one framework. Inevitably, “big business” is bound to ask – “What’s in it for me?” The bottom line for “big business” has always been profit. However, we now see companies practicing “social responsibility” willing to leave their mark and participate in nation building. Maybe it is time to appeal to them to partner with government to attain this vision.

What then are the roles of government and business?  Full government regulation has usually been reserved for basic commodities and some service industries for the protection of consumers. In this case, government intervention is best left to setting the parameters and standards then let business and market forces do the rest. Big business will always find ways to maintain the viability of their ventures. Big business, free market forces could not build a national information infrastructure for healthcare by itself if government does not provide direction. Investors may just pursue their own personal agenda and protect their self-interests. Government should stay at the helm, spearhead efforts by providing the framework, build partnerships with the private sector and practice eHealth governance.

National Information Infractructure

Reference:

1. Shortliffe EH et al. The federal role in the health information infrastructure: a debate of  the pros and cons of government intervention. Accessed thru: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC116307/

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

Building the foundation for sustainability

In my previous blog, I talked of people, the economy, technology and structures. I think those same factors address the problem of sustainability of a health information system in a developing country such as the Phillipines.

Sustainability

“What are the challenges of sustainability for health information in developing countries?”

Sustainability of a health information system in the country faces several challenges. Change from the status quo is difficult for most people, this is so with leaders who are reluctant to embrace new ideas, new technology as well as end users who are resistant to anything that alters their daily routine.  More people who are trained in IT are needed to diffuse their knowledge to more people as well as augment the meager IT workforce in health informatics that we presently have. The  problem could be further compounded by the “brain drain” which may happen with ASEAN integration.

The economy of the Philippines has been on the upswing for several years and this bodes well for the IT industry and health information services in particular. This provides a better environment for new technologies to prosper and enables more opportunities for the gains of this growth to trickle down to branches of government, businesses and eventually to ordinary people. At present, only 4 percent of GDP is allocated to health care. Since the Department of Health is spearheading the move for a unified health information system for the country, more sources of funding would be needed. An assessment of the current state of the various health information systems, noted to be fragmented, has already been done and moves have been initiated to improve on its capabilities.

In order to sustain the shift towards a unified health information system for the country, a solid foundation must be built. This can only happen if we have a single road map to track to, a single blue print to follow which eHealth governance for IT espouses. All capacity building that ensues must look to this blueprint for strategic alignment, IT value delivery as well as resource and performance management. We must also have leaders who are enablers working with vision, passion and commitment. However, it should not be only one group or one department of government working for this goal, it should be all the stakeholders in the health and IT industry. Multiple sectors must be involved and have a claim to ownership of this blueprint for sustainability. Widespread acceptance ensures alignment with strategy, a consensus of IT processes needed, the steps necessary for its implementation and desired outcome.

Reference:

1. Kimaro HC & Nhampossa JL. The challenges 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 http://www.jhidc.org/index.php/jhidc/article/viewFile/6/34

Gear Up for Change!

“Success at transformation is determined largely by an organization’s capacity for change.” – themanager.org

What are the factors affecting the advancement of the field of health informatics in the Philippines?

Important factors that I see for health informatics to take off in the Philippines are people, the economy, technology as well as having systems in place. Simply put, for change to occur, there must be leaders with vision, passion and commitment, a favorable economic environment with increased demand for the products or services that health informatics offers as well as tools and systems needed for its advancement.

I am limited by my abilities to come up with a cool infographic – either the available templates were not adaptable for what I had in mind or the program I wanted to use had a steep learning curve which did not allow me to be proficient given the time that I had. But I wanted to come up with facts culled from research and statistics that would allow the viewer to think for himself – “Is this an enabling factor or is it a hindrance to our efforts to advance the field of informatics?” I hope my effort for a thought provoking infographic requires little explanation.

 

Gear Up for Change.001

What do the numbers say?

  • GDP growth is forecast at 6.4% in 2014 and 6.7% in 2015.
    Source: Asian Development Bank. Asian Development Outlook 2014. Webpage Article.
  • The Philippines’ ranking in the World Bank’s Doing Business Survey jumped by 30 places to 108th of 189 economies in 2013.
    Source: Asian Development Bank. Asian Development Outlook 2014. Webpage article.
  • Healthcare outsourcing Road Map 2016: $1 billion in revenues and 100,000 full-time employees. Industry has gone a long way from the relatively simpler medical-transcription services to higher-valued services, such as case management and health-care analytics.
    Source: The Philippine Star. Webpage Article. November 2012.
  • Registered the slowest Internet speed of 2 megabits per second (mbps) on average. It ranked 158th of the 190 countries surveyed worldwide.
    Source: Sun Star. Webpage Article. June 2014.
  • The Philippines global rank in IDI (Information & Communications Technology Development Index) was 98 out of 157 countries.
    Source: National Statistical Coordinating Board. Webpage Article. February 2014.
  • Ranked 95th in fixed broadband Internet tariffs – not only one of the most expensive in the world, but also one of the most expensive in ASEAN region.
    Source: An Analysis of the Current State of Philippine ICT. Diana Jane Gonzales. PPT presentation. September 2013.
  • Philippine Health Information System: Review and Assessment 2007. Health Information System resources – Present but not adequate: 48% score, ICT not maximized, poor ICT infrastructure.
    Source: Philippine Health Information System: Review and Assessment. The Philippine Health Information Network, Department of Health. July 2007; Philippines – Impact and Lessons Learned in Strengthening HIS. Portia Fernandez-Marcelo. National Telehealth Center, University of the Philippines. PPT presentation for Asia eHealth Information Network conference.
  • Health Information Management sector’s workforce count rose 47%, from 44,849 in 2012 to 65,895 in 2013.
    Source: Full Speed Ahead! Philippine Organizations Team Up for the Success of the Healthcare Industry. TeleDevelopment Webpage. Webpage Article. May 2014.
  • Fifty two percent of Filipinos have a computer with high speed internet at home. 24% access the Internet on a daily basis via a mobile phone. 56% intend to access the Internet via a mobile phone in the next 12 months.
    Source: National Statistical Coordinating Board. Webpage Article. February 2014.
  • Placed 32nd among 61 countries on the first ever Web Index. The country scored 58.95 points in the index’s social impact category, placing 26th. The social impact category includes impact of the Internet on access to basic services, social networking sites, teacher training via the Web, the use of virtual social networks, and Web use for public health. The Philippines had 7 points, the same score as Australia’s, on the issue on what extent information and technology enable access for citizens to basic services such as health, education, financial services in the country.
    Source: ABS-CBN News. Webpage Article. September 2012.

What do you think? Are we up to the challenge of ASEAN integration by 2015?

Reference:

1. Marcelo A. Health Informatics in the Philippines. APAMI/MIST 2006 yearbook.