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There is a disconnect between what is happening on the ground and what those needs are compared to the policies being made in the PhilHealth headquarters. Hence, there is a tremendous need for electronic documentation of care to ensure quality care.
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INDINGS
Delivery of eHealth and Telemedicine Services to the Philippines From a Sustainability Perspective
City of Manila and Batanes Province
Philippines Summer 2009
In Partnership with University of Philippines Manila,
National Telehealth Center Supervisor Dr. Alvin Marcelo
Written By Katherine Kuan
Dept. Electrical Engineering & Computer Science Masters of Engineering Candidate 2010
mobile care: scalable imaging and
diagnosis for the developing world
2 Delivery of eHealth and Telemedicine Services to the Philippines
Table of Contents
1 Introduction
2 Project Summary
3 Community Impact
4 Personal Impact
5 Donor Recognition
6 Appendix
i. Analysis of Philippine Healthcare System
ii. Summary of eHealth Services of the National Telehealth Center
iii. Matrix of eHealth and PhilHealth initiatives
iv. Policy Proposal for PhilHealth
v. Sample Referral Forms for Workflow
vi. Usability Testing of Moca
vii. Usability Testing of OpenMRS Media Viewer
viii. Technical Support Manual for Moca
ix. Summary of Workflow in Batanes
“Catastrophic illness or ill health in general is
now widely recognized as the most powerful
poverty-converting event in an individual’s life”
- Francisco Duque III, Past President of PhilHealth
3 Delivery of eHealth and Telemedicine Services to the Philippines
Introduction
This summer, I spent six weeks working with the University of Philippines Manila,
National Telehealth Center in an effort to further the adoption of eHealth and
telemedicine in the country. In conjunction with my Masters of Engineering research, I
first assessed and increased local capacity of the Philippines to support a deployment of
Moca. This is a cell phone platform for telemedicine that provides healthcare workers in
rural communities with the expertise of medical specialists in city hospitals. Secondly, I
worked extensively on the challenge of sustainability of eHealth, so that the poor in
remote regions would still be able to access and afford these types of telemedicine
services. This work included documenting the obstacles of the healthcare system,
identifying how eHealth could provide solutions, and collaborating with key stakeholders
such as health care facilities, universities, insurance corporations, telecom companies,
and government officials. My goal was to convince PhilHealth to promote eHealth so
that it could later potentially be the “payer” of telemedicine. Hence, they would
encourage health providers to invest in telehealth infrastructure and also be able to
extend benefit packages so that members could receive such services with zero out-of-
pocket expenses.
Project Summary
The UP Manila National Telehealth Center (NThC) is an organization aimed to provide
eHealth services to the country through 3 target areas: eRecords, eLearning, and
eMedicine. eRecords is about having electronic medical records in the system. Ninety
nine percent of the Philippines is using paper-based medical records, so there is a lot of
underreporting, fraudulent reporting, or underutilization of the medical data collected in
the policy making process. eLearning is about providing continued education and
support of remote healthcare workers through online content such as web seminars,
podcasts, or other Internet resources for the latest information on medical practices.
This increases the local capacity of health workers to provide primary care for their
community members, so that they don’t need to send patients up to regional and
provincial hospitals and overcrowding is reduced. eMedicine is about providing rural
healthcare workers with the support of medical experts in distant city hospitals using
telecommunication technologies including cell phones, computers, and the Internet.
This contributes to increased access to medical experts for citizens in remote areas and
reduces the heavy cost associated with traveling to Manila for expert consultation.
During my time in the Philippines, I was able to travel to 4 provinces outside of Metro
Manila: the Batanes, Batangas, Pangasinan, and Tarlac. I spoke with doctors, nurses,
4 Delivery of eHealth and Telemedicine Services to the Philippines
midwives, and staff people in rural health units, hospitals, and provincial health offices.
From these conversations, I was able to identify the real community needs from the
standpoint of workers on the ground in remote areas. In many cases, I learned about
obstacles they faced in their existing workflow of caring for patients that needed
specialist attention. Also, reporting and documentation was time-consuming and not
done properly for the data to be useful to policy and decision makers. I wanted some
way to document my findings and conversations with these people, so I wrote up a gap
analysis on the Philippine healthcare system which explained the existing state of the
system, the ideal state of the system, and what the gap was to achieve the ideal state.
(See the appendix for the analysis). It was surprising to me that the single concept of
eHealth (eRecords, eLearning, and eMedicine) could be the answer to each challenge
in the healthcare system. It also further emphasized the need for us to engage the key
stakeholders and educate them about eHealth.
Figure 1. Meeting with the provincial health office in Basco, Batanes province (left) and Meeting a midwife in Anilao, Batanges province (right)
Laying Groundwork for a Moca Deployment in the Batanes Province
A good portion of my time was spent collecting requirements, performing usability tests
on doctors, and doing groundwork for a pilot study on Moca in the Batanes Province. I
heard many stories of how new technologies were used but then abandoned in the
health facilities because the equipment broke, the staff wasn’t properly trained, or there
was no technical support. I learned that in order to introduce a technology that would
successfully address a healthcare problem, the system must be customized and
integrated with the existing workflow. I realized which features would be useful,
uncovered software bugs, and received feedback on which parts of Moca were easy or
difficult to use. I collected the paper forms from their existing workflow and converted
them into an electronic teleradiology procedure loaded onto Moca for more accurate
usability testing.
5 Delivery of eHealth and Telemedicine Services to the Philippines
Figure 2. Workflow in Batanes with paper x-rays that need to be sent to radiologist in Manila for diagnosis of TB, turnaround time is about a couple weeks
Figure 3. Current workflow in Basco with email tele-referrals to radiologist in Manila through the National Telehealth Center, No internet in Rural Health Unit so turnaround time is 1 week
6 Delivery of eHealth and Telemedicine Services to the Philippines
Figure 4. Expected teleradiology workflow in Batanes with Moca, turnaround time is at most 24 hours
Because I would only be in the country for a short time, it was essential to train local
people on the software and hardware involved in Moca: Google Android platform,
OpenMRS electronic medical record system, G1 phone, and Moca Dispatch Server. I
delivered a presentation to the telehealth team at the NThC on OpenMRS the electronic
medical record system, its use in existing pilots across the developing world, and its
potential for a range of medical applications. This helped them begin to see how
OpenMRS could fit into their healthcare system at the hospital level of care across the
country, and this is a technology they are strongly interested in pursuing. I also worked
closely with Randy Fernandez, a research assistant in the National Telehealth Center,
to deploy a new instance of the Moca server in the Philippines and debugged the
system to upload images from the G1 phones to the server properly. One of the key
challenges we ran into was that the local telecom companies did not support Android
phones at the time, so we had to find workarounds in order to get Moca on the GPRS
network and to send large image files across the network. Out in Batanes, where the
phone would be left with the doctors, we realized that we would need local technical
support to help the doctors in case of problems with the phone. Hence, I trained the
network administrator at the provincial health officer to be our point person in case of
technical difficulties. He had no prior programming experience, so we walked through
how to download the code onto the phone, send error log reports, and debug Moca. As
a result, I came up with a technical support manual on Moca to help new users in the
future (see appendix).
7 Delivery of eHealth and Telemedicine Services to the Philippines
Recruiting Local Developers to Work on Moca
In addition to providing technical support for the existing system, it will be also crucial to
have developers working on new features and customization of Moca going into the
future. Hence, I delivered Moca recruiting talks at the University of Philippines Manila
campus as well at the Diliman campus to over 60 students. I spoke to classrooms of 4th
year computer science students interested in finding a project for their senior thesis.
Each student filled out and submitted an interest form, and I will be going through and
contacting them to figure out a work plan.
Figure 5. Moca recruiting talks at UP Manila (left) and UP Diliman (right)
Figure 6. Examples of some projects the students could get involved with in Moca
There is also a pair of Ateneo University students working on a windows version of
Moca, so we also had joint meetings to introduce them to the NThC researchers and
also align them with the work/progress of the US-based Moca team.
8 Delivery of eHealth and Telemedicine Services to the Philippines
Figure 7. Collaborating on the Windows Mobile version of Moca at Ateneo University
Ensuring Sustainability in Adoption of Telemedicine
At the beginning of my project, I performed an extensive literature review of research
papers to find out how telemedicine was being incorporated in other countries by their
governments and insurance companies (with a particular focus on Southeast Asian
countries). There were many examples of pilot studies done across the world in places
like Taiwan, Malaysia, US, Canada, Peru, Japan, Peru, and so on. However, there
weren’t many countries that had telemedicine completely integrated into their healthcare
system with full reimbursements for such services. It seemed that many countries had
difficulty getting all the important stakeholders to work together and agree upon a
standard framework for telemedicine practice and to invest properly in such
infrastructure.
Figure 8. Key stakeholders
9 Delivery of eHealth and Telemedicine Services to the Philippines
Hence, from the start, we knew that we had to engage all the stakeholders in the
adoption of telemedicine. We spoke with health service providers and health
professionals, and feedback was immensely positive. They explained the drawbacks
of the healthcare system and welcomed the potential of quality care that eRecords,
eLearning, and eMedicine could provide them. We also worked with universities as
mentioned above, as the pipeline of developers who would be supporting the
localization of the system. Since healthcare delivery and management has been
devolved to the jurisdiction of local government units (LGUs) in the Philippines, we
worked with government officials such as the Governor of Batanes to ensure that he
saw the value in putting financial resources towards this type of infrastructure. We
began to engage the telecom companies (Globe and Smart) as well because they
would be providing the cellular 3G/GPRS and internet connectivity in remote regions
like the Batanes, so their buy-in would be important. Last but not least, the support of
the insurance organizations is paramount to making it accessible by the poor, and this is
further discussed in the next section.
Figure 9. Talking about Moca in a Department of
Science and Technology (DOST) Telemedicine
Meeting with UP Manila National Telehealth
Center and UP Diliman
Figure 10. Presenting Moca at Research Triangle
Institute meeting with NThC and people from
Tarlac Province
10 Delivery of eHealth and Telemedicine Services to the Philippines
Convincing PhilHealth to Prioritize and Invest in eHealth
I worked extensively with PhilHealth, the national social insurance corporation, in the
Philippines. Although they are intended to provide everyone in the country with health
insurance, only 80% of the population is covered leaving about 18 million uninsured. For
their members they create benefit packages for diseases like malaria, TB, H1N1 and
cover fixed amounts on inpatient hospitalization. However, they come up with these
numbers without knowledge of what the actual cost of care to patients is, what services
patients need the most, benefit utilization rates of members, and other health status
information on patients (see Analysis of Philippine Healthcare System in Appendix).
There is a disconnect between what is happening on the ground and what those needs
are compared to the policies being made in the PhilHealth headquarters. Hence, there
is a tremendous need for electronic documentation of care to ensure quality care.
Figure 11. Presenting Moca and business plan for venture-backed corporation for telemedicine to
University of Philippines Manila Dean of the
College of Medicine with NThC and Moca team
member Ted Chan
Figure 12. Presenting Moca at MIT Alumni Club of the Philippines lunch at Enderun College with
Ted Chan
11 Delivery of eHealth and Telemedicine Services to the Philippines
We wanted to emphasize how their interests and goals (PhilHealth Medium Term Plan,
universal coverage by 2010, Millennium Development Goals, and disease control) were
strictly aligned with those of eHealth and the National Telehealth Center. With
eRecords, PhilHealth would be able to figure out what services were being used by
members, measure health indicators such as maternal mortality, perform disease
surveillance, ensure continuous drug supplies to health facilities, reduce fraud, and
obtain accurate reports for policy making. With eLearning, PhilHealth would be able to
ensure accredited health professionals received continued education to provide the
highest quality of care to the members of their community. eMedicine would help
PhilHealth reach its target of universal coverage because it would provide access to
specialist care for the most remote individuals.
I started off with the connections that Dr. Marcelo introduced me to at PhilHealth (Ms.
Gitch Diaz of the CorPlan Department), and from there I was referred to other
individuals in other departments who could help me. What worked well for me was to
stop by people’s offices, do informational interviews, ask for more references, and
repeat the same process. In this manner, I was able to speak with members from all the
departments integral in incorporating eHealth into PhilHealth: accreditation, health
informatics, standards and monitoring, benefit development, corporate planning, fraud,
IT, and legal. Through these meetings I was able to organize presentations where I
educated department heads and executive officers in PhilHealth on the value of
eHealth. Throughout the whole process, Dr. Marcelo and the team at the NThC
provided very valuable insight along the way on how I could communicate and engage
the interests of those who work at PhilHealth most effectively.
Individual Meetings
Ms. Gitch Diaz (CorPlan) Ms. Jennifer Enriquez (CorPlan) Dr. Israel Pargas (Accreditation) Dr. Rizza Herrera (Accreditation) Dr. Art Alcantara (Health Informatics) Mr. Arnold Quijano (Health Informatics) Dr. Giovanni Roan (Benefits Development) Dr. Ceferino Banaga (FFIED Fraud) Dr. Neri Santiago (Actuary) Attorney Pineda (Legal) Mr. Mario Matanguihan (IT) Mr. Rommel Isaac (ITRMD) Ms. Ann Marie San Andres (Physical Resources and Infra.)
Presentations
7/8 Presentation with Chief Operating Officer and Operations Grp
12 Delivery of eHealth and Telemedicine Services to the Philippines
Improving Access to Healthcare for PhilHealth Members Dr. Marcelo introduced the National Telehealth Center and its initiatives in eHealth throughout the country. Then I presented my research on how eHealth could be integrated into PhilHealth through their initiatives P4P, Capitation, and Contracting. I had a matrix that explained the spectrum of involvement in supporting telemedicine from just written policies (no cost) to continuous financial investment in building telehealth infrastructure in their facilities.
7/20 Presentation with Senior Vice President and her Quality Assurance Group
Extracting P4P from an RHU-Based Electronic Health Record At this meeting, I presented how electronic medical record systems could directly make an impact on their quality assurance of care delivered in PhilHealth accredited facilities. Then Alison Perez, lead developer/implementer of CHITS for the NThC, did a live demo of CHITS and answered specific capability questions.
7/22 Follow-up Presentation with COO and Operations Grp Operations Perspective on Using eHealth for Capacity Building in PhilHealth In this presentation, I updated the COO on her concerns and requests for more in-depth research on legal issues, policy proposals, and IT initiatives. I also emphasized how eRecords in RHUs are a good fit for the PhilHealth framework using reasons from Figure 14.
7/22 Presentation with President and Chief Executive Officer Strategic Perspective on Using eHealth for Capacity Building in PhilHealth With Dr. Marcelo and Ms. Gitch Diaz from CorPlan Dept, we presented an overview of the NThC and eHealth services to the CEO. Then I recapped the work I had done in his organization for the past 6 weeks, highlighted how eHealth fit well with PhilHealth’s operations of quality assurance monitoring, generating reports for decision making, and benefit development. Then we discussed the future actions he could take to utilize eHealth to help his members to the fullest.
7/23 Presentation with Sector on Out-Patient Benefit Package OPB Monitoring using an RHU-Based Electronic Health Record The group went over their new out-patient benefit guidelines, which included specific policies allowing RHUs to spend their funding on technology infrastructure. I presented how eRecords and CHITS could be specifically tailored to fit their information needs on monitoring the outpatient benefits’ usage. This is already an existing initiative, and the need for eRecords is very apparent, so this was the most concrete discussion with realistic short term goals among all my presentations.
13 Delivery of eHealth and Telemedicine Services to the Philippines
By speaking with so many individuals on their role in the corporation and obstacles faced by their department, I found many ways that eHealth would build capacity for the corporation. Each presentation was tailored for the target audience and focused on how eHealth could specifically integrate with existing initiatives in PhilHealth and serve to streamline efficiency in the company. First I researched about 3 new initiatives in PhilHealth and identified areas for integration: Capitation is the money that PhilHealth provides to accredited rural health units (RHUs) (as reimbursements on the premiums paid) to run their operations and upgrade their facilities. Each RHU receives 300 pesos per household that is an indigent sponsored family in their community (the poorest level in society meaning the government pays for their health insurance). Hence for 1000 indigent families, an RHU may receive 300,000 pesos to operate their facility. This money is allocated towards bonus compensation for health workers, administrative expenses, equipment, drugs and supplies, and facility upgrades. In a policy proposal (see appendix) I wrote, we recommended that the RHUs be allowed to spend their capitation on telehealth infrastructure (computers, Internet connectivity, and web conferencing equipment). We also recommended stricter requirements for the release of funds including documentation on how the capitation funds were spent in the past and electronic reporting of what services were delivered to patients. This information reported to PhilHealth would be more accurate than the current paper forms that people fill out to the minimum extent so that they can receive funds. With electronic reporting and CHITS (community health information tracking system created by the NThC for RHUs), PhilHealth would be able to directly receive real-time data on the actual patients visiting the center and which services were provided - valuable information to base benefit package policies on. Pay for performance (P4P) is a new initiative aimed at using incentives to promote certain behavioral practices in healthcare by service providers, health professionals, and patients. These incentives can come in the form of money, transportation vouchers, faster claims processing time, earlier release of funds, and etc... PhilHealth is doing a baseline study in several provinces in preparation for a P4P pilot on maternal care. They want to reward mothers when they comply with their 4 required prenatal visits, postpartum visits, and delivery of the child at a health facility instead of at home. eRecords can make a big impact in reducing maternal mortality by tracking mothers throughout the pregnancy process, figuring out baseline statistics on maternal care (exact statistics on maternal mortality are ambiguous and different between PhilHealth and the Department of Health), and monitoring for improvement in these health indicators. CHITS the RHU-based electronic medical record system already has a maternity module to keep track of a woman's health record throughout her pregnancy: risk factors, date of visits, trimester dates, vital signs, position and size of fetus, blood pressure, FPAL, GP, vaccines/services rendered, and postpartum visits (date of
14 Delivery of eHealth and Telemedicine Services to the Philippines
delivery, outcome of pregnancy, facility where mother gave birth, nutrition of child, breastfeeding) as well. Because the program rewards good performance, accurate monitoring of the patients and of the service providers is important otherwise it gives people an easy way to report false behavior to earn incentives. Contracting is another initiative still undergoing negotiations. This is a method for contracting with certain facilities for certain health services at a standard quality, price, and performance. (Currently, health facilities and doctors can charge whatever price for a service and PhilHealth will only reimburse a fixed amount). This moves towards zero out of pocket expenses for poor patients on certain outpatient diagnostic services. eRecords also plays a big role here in monitoring the health providers to ensure they are following the contract. In return, the facility will receive faster claims processing, which PhilHealth can deliver much more easily if the claims are submitted electronically. PhilHealth Fraud Department does random checks on hospitals and claims by
tracking down the patient and verifying the service was performed. To increase
operational efficiency, they are interested in a way for the hospital log book to be
electronic. In real time, they could see which patients are being served and send a
representative to check the hospital to ask the patient immediately about the services.
PhilHealth Legal Department says that there are no legal limitations in using
PhilHealth field offices as a place for teleconsultations or sending teleradiology referrals
because of the existing computer infrastructure and Internet connectivity already setup.
There are concerns about malpractice or lawsuits, but this can be addressed by (1)
requiring patients to sign an informed consent form waiving liability of the doctor, and (2)
amending PhilHealth’s warranties of accreditation for doctors and health facilities.
PhilHealth Health Informatics Department currently encodes the paper reports from the RHUs into the computer. It’s a tedious process and they are about 7 months behind on entering data. They are in charge of the analysis and summaries of claims data, so they are already telling management that they need integrated analytics software systems to make their job easier. They are also involved in new initiatives dealing with interpretation of data (geographic information system GIS, profiling of health facilities, and information auditing), where interfacing with CHITS at the RHU level would be valuable. PhilHealth Accreditation Department is in charge of accrediting health facilities and professionals (and coming up with the guidelines for it). We would work with them to define what type of accreditation or certification professionals would need to be able to perform telemedicine services. They are also involved new initiatives like contracting with service providers. PhilHealth Benefit Development Department determines the amount of coverage in benefits for members such as through benefit packages (maternity, H1N1, malaria,
15 Delivery of eHealth and Telemedicine Services to the Philippines
etc...) They have the new guidelines for what diagnostic services PhilHealth will cover for outpatient procedures. We would work with them for determining coverage of telemedicine services (which AMA codes would map to PhilHealth case codes). PhilHealth IT Department will be important in determining whether the corporation could handle electronic communication and data storage needs of the health facilities. IT capacity must be developed to support electronic billing, medical records, and reporting. The department is also currently working on some business intelligence systems for computing analytics to present to upper management.
16 Delivery of eHealth and Telemedicine Services to the Philippines
Figure 14. Excerpts from the PowerPoint presentations made for PhilHealth that highlight how PhilHealth can benefit from eHealth services
Community Impact
In the Philippines, the National Telehealth Center has already made good headway on research and development of eHealth and telemedicine systems. However, their largest need was to figure out how to scale these solutions across the country in a sustainable manner. My work helped open many doors in PhilHealth as a source for telehealth policy decisions and funding. I was able to identify for the NThC and PhilHealth where the possible departments and programs could collaborate for mutual gains (see PowerPoint slides in Figure 14). The biggest thing holding PhilHealth back from promoting and practicing telemedicine was being unaware about what telemedicine is. To make the conversations more concrete with action steps, I researched the implementation details of what would be feasible in terms of PhilHealth’s support of eHealth – benefit development, accreditation, legal issues, IT capabilities, and health informatics systems – and summarized these findings in presentations. Through 5 formal presentations as well as countless one-on-one meetings with the department heads, I was able to educate over
17 Delivery of eHealth and Telemedicine Services to the Philippines
15 key PhilHealth leaders (including the COO and CEO) about eHealth and seek tangible ways to move the effort forward.
Figure 16. Meeting with PhilHealth Head of the Corporate Planning Department
Figure 17. Presentation to the PhilHealth COO and Operations Working Group
Figure 17. Presentation for the Senior Vice President and her Quality Assurance Group
Figure 18. Follow-up Presentation for the COO and Operations Working Group
18 Delivery of eHealth and Telemedicine Services to the Philippines
The response was very positive. The Head of the Corporate Planning Department was eager to support us through continual feedback on the best way to navigate the corporation, as well as access to internal documents and help setup meetings for us with top executives. The COO and operations group also were very enthusiastic about the potential applications of eHealth and came up with many ideas we could explore – using service offices for teleconsultations and having PhilHealth donate old computers to the RHUs. The COO said that they could not afford to go further without moving forward with eHealth because they currently made decisions by looking up at the sky (there is no data to go off of). The Senior VP of the QA group assured us that the group realized the value of electronic documentation and would be committed to working towards ensuring IT systems were in health facilities. The Sector on OPB already issued new guidelines to allow RHUs to use their money from PhilHealth for technology infrastructure. In their meeting, they came to a point where they needed to discuss monitoring of the usage of the benefits and they saw CHITS (community health information tracking system designed by NThC) as something with much potential. Because 6 weeks was a short period of time to create huge changes to a big corporation, I identified 3 major action items that the NThC could work on to carry on collaboration with PhilHealth. I transitioned the NThC team members as well with all my information and introduced them to the correct points of contact at PhilHealth to begin the work immediately.
1. Introduce people from Pasay City (site with 5 years experience of using an electronic medical record system in an RHU setting) to PhilHealth OPB team to answer questions about usage of CHITS
2. Analysis of CHITS data for PhilHealth Actuary Study with VP, Deputy Chief Actuary office to study how PhilHealth can utilize the information from the rural health unit level:
• Profiling of patients (disease, gender, age)
• Utilization rate of benefits in OPB package
• % of RHU patients not covered by PhilHealth
• Services of those who are not PhilHealth members
• Most popular services for all members
• Most popular services for non PhilHealth members
3. Integration of CHITS with PhilHealth National Telehealth Center to enhance the PhilHealth module in CHITS to keep track of health indicators needed for reports/decision making by PhilHealth. Ideally, PhilHealth would like the following to be tracked by CHITS:
• OPB Labs/services
• Drugs prescribed, drugs dispensed
• Referrals (where referred, why, how) ...another module maybe?
Figure 20. Presentation for the President and CEO of PhilHealth and the Head of the Corporate
Planning Dept
Figure 19. Presentation for the Sector on Out Patient Benefit Package Monitoring
19 Delivery of eHealth and Telemedicine Services to the Philippines
• Targets from PhilHealth
To quantify the people/organizations influenced, we can look at the number of health service providers that PhilHealth accredits. From the actuary study on CHITS, if PhilHealth realizes how valuable the information from the health facilities is and will start requiring electronic health record systems, 1,531+ hospitals and 1,217+ rural health units will be affected (in addition to the other types of clinics, see below). These systems will affect the 21,143 professionals working in these facilities, so that they become technology literate to be able to use these telecommunication technologies. In addition, in the future if PhilHealth incorporates telemedicine services into their outpatient benefit package, then their members, approximately 80 million Filipinos, would experience tremendous improvements in healthcare delivery.
Figure 15. Number of PhilHealth accredited facilities from PhilHealth’s Annual Report 2007: Bridges, Reaching out for Universal Healthcare
I made sure to transition others on the project to take over my work after I left. Dr. Marcelo will primarily be taking over my work at PhilHealth. He will work as a consultant for PhilHealth for 4 months, so he will interact closely with the teams I presented/discussed eHealth with in order to ensure that they have the necessary information and policies to make smart decisions on expansion of membership and benefits in the future. I also had another teammate from Moca also go to the Philippines with me this summer. Ted Chan, who is a 2009 graduate from MIT Sloan, worked in parallel on a business plan for a venture-backed corporation aimed at implementing and scaling telehealth in the Philippines. The corporation would provide the infrastructure to scale telemedicine services across the country and the work at PhilHealth would hopefully move towards paying for such services. Overall, with valuable help from many local people especially at the National Telehealth Center, I was able to educate many people about eHealth and telemedicine both on a policy level at PhilHealth and also at a technical/implementation level at the universities to begin a base of local developers working on Moca for the potential to influence millions of people’s access to healthcare in the Philippines.
20 Delivery of eHealth and Telemedicine Services to the Philippines
Personal Impact
Being in the Philippines was more different than I ever imagined. The trip definitely
changed my perspective on things and was one of the most amazing experiences of my
life. My trip was continually filled with unexpected adventures, new friendships, and
amazing people. I found the Filipino culture to be incredibly inspiring. The people have
faced many difficult times including the long struggle for democracy in their country and
it’s frustrating to hear about all the corruption entrenched in the political system. I
walked through the streets of Manila every day to get to work. I saw poverty that I had
never witnessed firsthand before. Small children would rush up to me and walk beside
me with their hands open begging for money or food. They would be knocking on your
window in the taxi cab or coming into the restaurant and wait next to your table. It was
heartbreaking. I could feel it in the air – a heavy feeling in the atmosphere that life was
hard. Even for the people that had full-time working positions, it was a struggle to
provide a living for them and their family. I remember seeing squatters for the first time
and was floored by the idea of how many people would live in such small quarters.
Yet despite it all, the people are extremely resilient - proud of their country and culture
for what is has become. I found them to have certain fervor for life, something that
Americans do not always have. Children in the streets played with joy and the people in
general laughed with friends and had a good time. Being fully immersed in the Filipino
culture, I was able to see their strong sense of values rooted in family and religion. They
love having large, happy families and remain close-knit with the children living at home
until they get married. Even for people not related to them, Filipinos have an undeniably
warm sense of hospitality to welcome any and all guests.
21 Delivery of eHealth and Telemedicine Services to the Philippines
I had a chance to go to the Batanes for work and it was a paradise there. The views we
saw, hills we trekked, waters we swam, and beaches we rested on were absolutely
breathtaking. Every photograph I was able to take was so picturesque. I loved visiting
the provinces. There, life was simple and peaceful. It was mostly rural, where small
homes lined the one main road that passed through the entire city. People planted their
own food for eating, fished in the sea, raised chickens, or owned a small store to make
a humble living. They would gather in small groups and sit by the main road, watch their
kids play, or just talk. They helped neighbors out as if they were family with tasks like
building a house or delivering a baby. It’s quite eye-opening when I contrasted the
province lifestyle with the one in America filled with material and superficial concerns. It
felt like a different world out there in Batanes, an escape from reality where you could
just sit and reflect on life.
22 Delivery of eHealth and Telemedicine Services to the Philippines
Last semester, I worked for months on Moca but had very broad and vague ideas about
who the technology would actually help. As a result, being able to meet the healthcare
workers and patients on the ground was motivating and unforgettable. This entire
experience solidified my interest in working for technology solutions for healthcare. Had
I not gone to the Philippines to work on this project, I think I would’ve settled for any old
software job sitting in an office 40 hours a week. Now that I’m starting to look for a
career, I know that there are jobs out there like this that are engaging, rewarding, and
multidisciplinary and I’m determined to find them!
Donor Recognition
Thank you so much for the opportunity to travel to the Philippines to perform this work. This trip has opened my eyes to the harsh realities people must face in developing countries. It gave me a concrete reason to work hard every day to do any small part that would help make the lives of the people I saw every day better (those on the sides of the street, those in the hospital wards, and etc…). I feel that I’ve been sheltered for much of my life in America, but this experience (going to the Philippines, speaking to the locals, understanding what their needs were) confirmed my choice for a career path. I want to pursue mobile healthcare applications for developing countries and get very involved on the policy side of these issues. These issues need as many people working on them as possible, and I am excited to learn more about how I can take part of this in the future!
Acknowledgements
Much of my work couldn’t have been made possible without the counsel and
opportunities provided by the team at the National Telehealth Center – Dr. Alvin
Marcelo my supervisor, Dr. Alex Gavino, Dr. Raymond Sarmiento, Alison Perez, Xandra
Bernal, Randy Fernandez, and Coy Caballes. The Moca team, especially Ted Chan, Dr.
Leo Celi, and Gari Clifford, also provided me with great guidance along the journey in
terms of the focus of my work in the Philippines as well as professional growth. Thank
you all so much for everything!
23 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Analysis of Philippine Healthcare System
University of Philippines Manila, National Telehealth Center - July 8, 2009 Written by Katherine Kuan, Moca
QUALITY OF CARE
Current System Ideal System Proposed Solution Methodology
Epidemics (H1N1, malaria, dengue) spread rapidly, Policies are created after the spread has occurred
Disease tracking and immediate management of epidemics, Anticipate health events and define protocol before anything happens
Health facilities register the diagnoses of patients so that those with certain diseases can be geographically pinpointed and quarantined
eRecords
Health facilities sitting without anymore supplies/drugs for the quarter, Heavy influx of patients when drugs are delivered but rapid drop-off when they run out
Continued supply of drugs at health facilities without requiring patients to buy drugs outside, Forecast drugs required and ship them to health facilities to arrive on time when needed
Electronic management of supplies/drug logistics, Track drug usage at each facility over time
eRecords
Expensive prescription drugs with high mark-up price
Doctors should prescribe generic drugs and promote community pharmacies
Ensure doctors are prescribing generic (not branded) drugs, Electronic record keeping of prescriptions
eRecords
Patients forgo visits to doctor because of cost/distance until they become sick and require hospitalization (i.e. if not treated, TB can spread to 10 other people each year)
Preventive medicine, diagnosing sickness before it becomes a major health problem
Affordable access to specialists in a timely manner
eMedicine
Long latencies in diagnosis when patient data is physically mailed to specialist
Immediate turn-around-time in diagnosis and patient referrals, immediate start of treatment, improved health outcome of patient
Teleconsultations with specialists through email, audio/video conferencing, mobile phones
eMedicine
Possible misdiagnosis by general practitioners in remote areas when patients don’t have access to specialists
Immediate access to second opinion from network of specialists, DTTBs learn from their mistakes for future cases when specialists correct them
IT infrastructure to link health facilities through Internet or cellular network
eLearning, eMedicine
18 million Filipinos not covered by PhilHealth
Hit 2010 target of achieving universal coverage (85%) of the nation’s population
Increase service offerings with telemedicine to provide healthcare access for the poor in rural areas
eMedicine
24 Delivery of eHealth and Telemedicine Services to the Philippines
REPORTING AND MONITORING
Current System Ideal System Proposed Solution Methodology
Unsure how capitation funding is spent
PhilHealth can view breakdown of how an LGU spent its capitation and ensure it was wisely spent on long-term improvements in healthcare
Strict requirements for allocation of funds, Strict monitoring of how the funds were spent
eRecords
Lack of effective methods for PhilHealth to enforce requirements on health facilities because control of health facilities devolved to LGUs
PhilHealth can influence behavior changes through pay-for-performance and verify such performance with tangible evidence before distributing rewards
Method to monitor the actual performance of members & service providers without room for fraud
eRecords
Handwritten reports with calculation or data entry errors (1 error per midwife x 44,000 barangays= 44,000 total errors for that month)
Automatically calculated reports and statistics available at any time
Electronic medical record system customized to output health statistics and official reports as defined by the DOH
eRecords
Some facilities use spreadsheets (Excel) to keep patient records (insecure place to store data without back-up, high potential for error in spreadsheet formulas)
Secure centralized database of patient medical records with workflow customized to fit the needs of the different levels of hospitals, Fast retrieval of patient files
Open-source electronic medical record system with software development of features custom to workflow
eRecords
Quotas are much higher than the actual # of people eligible for that vaccine/service in a province
Quotas/performance indicators calculated based on local characteristics of the region
Keep up-to-date records of demographic makeup and health status of a local population
eRecords
Report false information to meet quotas
Accurate reports for feedback on how to target improvements in PhilHealth services, and for nationwide policy decision making
Eliminate manually written reports, Require computer generated reports (from medical record system) on actual number of services provided
eRecords
POLICY AND DECISION MAKING
Current System Ideal System Proposed Solution Methodology
Most recent available FHSIS/DOH health data from 2006, decision makers can’t make health policies based on data from 2-3 years ago
No need to wait for reports to trickle from the bottom up (from barangay to district hospitals to regional and provincial hospitals), Auto-generated reports available at any time
Electronic medical record system customized to output reports/statistics to DOH
eRecords
25 Delivery of eHealth and Telemedicine Services to the Philippines
Unsure about utilization rate of member benefits
Track which benefits are being used by which patients, identify successful programs and create more targeted ones for the future
Make patient data anonymous, Perform data mining on database for program feedback
eRecords
Unsure about cost of care (cost of procedure to patient, salary of doctors) because power is delegated to LGUs, Difficult to set price points for packages
Contract standard rates with service providers, No out-of-pocket expenses for patients
Electronic billing eRecords
ADMINISTRATIVE LOGISTICS
Current System Ideal System Proposed Solution Methodology
Wait for up to 6 months for reimbursement claim to be processed
Reduced overhead in processing transactions, More efficient process to verify member eligibility and benefits’ status
Electronic billing to automatically generate claims and incorporate checks for data validity
eRecords
Each health facility has own medical records, filing system, and ID numbers for patients (redundant databases w/ related info and waste of multiple ID cards)
Integrated medical record systems where patient can visit any accredited PhilHealth facility and their unique medical file will be easily retrieved for continuity of care
Electronic medical record system accessible from any health facility to make patient transfers easier
eRecords
Hospital or PhilHealth manually encodes the diagnosis of the patient, allows room for errors in misunderstanding written notes of doctors
Doctor, who actually interacts with patient, writes diagnosis and assigns ICD10 code immediately
Data validity checks on patient visit, requires doctor to assign a code before moving on
eRecords
HEALTH PERSONNEL
Current System Ideal System Proposed Solution Methodology
Training of medical professionals limited to what they learned in school years ago
Continued medical training on up-to-date practices and latest technologies, specialty training outside the formal classroom (i.e. x-ray reading)
Training sessions conducted through webcasts and video conferencing, IT infrastructure in remote locations to receive training
eLearning
Reliance of rural health professionals on books that are expensive, out-dated, and with limited information
Access to online repository of latest information and medical advances, discussion forums and communities to share information and help each other on cases
IT infrastructure in remote locations to receive this training
eLearning
26 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Summary of eHealth Services of NThC
University of Philippines National Telehealth Center Written by Katherine Kuan
Obstacles to Quality Healthcare in the Philippines
• Shortage of trained medical professionals, recruiting/retaining qualified staff
• Shortage of quality health facilities, urban areas have more and better facilities than rural areas
• Limited transportation accessibility and infrastructure
• High cost of medicine compared to other countries
• Barriers of distance, isolation of rural health practitioners
• Lack of data standards for health records
• Lack of unique national ID system
“ONeHEALTH is the flagship program of the University of Philippines’ National
Telehealth Center developed to address such obstacles. ONeHEALTH stands for “One
Network on eHEALTH.” With advanced new technologies comes much potential to
deliver quality health services to remote areas of the country.” - NThC
eRecords: electronic health records essential for quality management of patient and
treatment information, for use at all levels of health system (existing services: CHITS,
BuddyWorks, ISIS)
• Collect and integrate patient data from many remote sites, enable smooth patient transfers
• Monitor patients over long period of time, especially for those with chronic diseases
• Minimize information loss/error (i.e. from regional language differences in symptom/treatment terminology), improve data quality with guidelines/alerts if wrong data entered
• Bridge communication gaps among levels of health system
• Reduce costs with proper drug prediction, ensure uninterrupted supply of drugs
• Enable disease surveillance and rapid response (i.e. for the H1N1 virus)
• Auto-generate standard reports at any time
• Track which PhilHealth benefits are utilized by members
• Drive policy making process with systematic information and evidence
eLearning: a form of education/support for health workers - doctors, nurses, midwives
and health volunteers - through online content on community healthcare (existing
27 Delivery of eHealth and Telemedicine Services to the Philippines
services: videos for Stroke, Avian Influenza, Basic Management of Childhood
Poisoning, TB)
• Provide opportunities for barangay healthcare workers (BHWs) to acquire and utilize new knowledge
• Increase local capacity for proper patient care, decreased hospitalization time and faster recovery
• Create collaborative social network of health facilities and universities
• Empower healthcare workers through demonstrated improvements in competence, confidence, and morale
• Promote discussion and sharing of ideas among staff on site
eMedicine: draw on expertise of medical specialists far away using telecommunications
technology, telereferral services for general medicine, pediatrics, surgery, radiology,
dermatology, ophthalmology, psychiatry (existing services: BuddyWorks, SMS, MMS,
email telemedicine)
• Provide critical clinical decision support for BHWs
• Increase access to specialized care for rural citizens
• Reduce need for patient transfers, decreased travel time and cost
• Decrease cost to patients and hospitals with improved accuracy of diagnosis and quicker recovery time
28 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Matrix of PhilHealth Initiatives with eHealth
29 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Policy Proposal for PhilHealth
Policy Proposal on Improving PhilHealth Services Through eHealth Infrastructure
Katherine Kuan, UP Manila National Telehealth Center
1 Executive Summary
At no cost to PhilHealth, the Corporation can provide increased quality of healthcare to its members by
supporting the practice of eHealth services in its accredited facilities:
• eRecords: electronic medical records
• eLearning: continued education of medical professionals through online content
• eMedicine: draw on medical expertise far away using telecommunication technology
The first steps to integrate eHealth services into PhilHealth are outlined in this paper:
• Amend policy on capitation:
o Allow RHUs to spend their capitation on eHealth infrastructure
o Require RHUs to submit accurate electronic documentation/reports for full payment
• Incorporate eRecords into P4P monitoring
o Select an existing CHITS (Community Health Information Tracking) site for the P4P pilot
site
o Use CHITS data on site for baseline analysis and for progress tracking
Electronic documentation of care will vastly improve the ability of PhilHealth to track progress on its
programs and create more targeted initiatives to improve specific health indicators.
By streamlining claims processing, tracking package utilization, ensuring Bench Book standards are
followed, reducing fraud, improving drug delivery, and also providing detailed reports about health
outcomes and benefit utilization, PhilHealth will soon be able to reach its short and long-term goals
(universal coverage, Millennium Development Goals, and disease control).
2 Introduction
PhilHealth membership has been successfully increasing, but access to quality healthcare still remains a
challenge for millions of Filipinos. To figure out whether 300 pesos per indigent family is enough for
capitation, it’s important to examine how LGUs are spending their funds. In addition, questions still remain
such as: What is the utilization rate of the OPB? Does it cover the services that are really needed in
communities?
To ensure quality outpatient care is provided to PhilHealth members, there needs to be documentation on
what services were provided and what the outcome was. Electronic medical record systems (i.e. CHITS)
are the solution to a number of challenges facing PhilHealth today:
• Unsure how capitation funding is being spent, if it’s sufficient to support RHU operations
• Unsure about utilization rate of PhilHealth member benefits
• Need method to monitor performance for programs like P4P, contracting
• Fraud and calculation errors from handwritten reports
30 Delivery of eHealth and Telemedicine Services to the Philippines
• Tedious data collection process, FHSIS/DOH reports come out 2+ yrs later
• Claims reimbursement process can take long time
Instead of relying on information from claim forms, PhilHealth will be able to use electronic medical record
systems to monitor and manage the type of care being delivered on the ground. CHITS is an electronic
medical record system designed specifically to adapt to the workflow of RHUs in the Philippine healthcare
system. Implemented in 20 sites across the country over 5 years, the system is highly recommended for
obtaining electronically documented care at PhilHealth accredited facilities. As a result, PhilHealth
management will be able to base decisions on real-time data, in order to create targeted programs that hit
performance targets on health indicators for the country.
By encouraging RHUs to utilize capitation to invest in CHITS and other eHealth infrastructure (computers,
Internet connectivity, video conferencing), their capacity to provide quality care at the local level will
rapidly increase.
In summary, eHealth and telemedicine have the potential to help the Corporation in the following ways:
• Increase access to quality care (i.e. telemedicine to reach specialists) for members
• Allow service providers to submit claims electronically for faster processing
• Allow facilities to track their patients over long time, quantitatively measure performance
improvements
• Allow system to monitor supply & demand, gather empirical data for health system performance
analysis
3.1 Policy Recommendations Regarding Capitation
1 Modify disposition of PhilHealth Capitation Fund (PCF)
Current Policy Proposed Policy
80% Drugs, medical supplies/equipment,
referral fees, site improvement
20% Administrative expenses (50% for
physicians, 50% for personnel in OPB
services)
65% Operational expenses
Drugs
Medical equipment/supplies
Referral fees
Site improvement
20% Administrative expenses
Health personnel salaries
Training for workers (eLearning sessions
through video conferencing or online
resources)
10% Technological Infrastructure
Computers
Internet Connectivity
Electronic medical record system (CHITS)
Camera, video conferencing equipment
5% Telehealth services payable to National Telehealth
Center, subscription for fixed # telemedicine
referrals to specialists
31 Delivery of eHealth and Telemedicine Services to the Philippines
2 Create stricter requirements on release of PCF funds in article 2.3 PhilHealth capitation fund
Current Policy Proposed Policy
Capitation amt released with following
conditions:
Initial release within first 2 weeks of
applicable year, RHU accreditation and
payment of premiums required
Successive releases on third week of first
month of quarter, reports and payment of
premiums required
Capitation amt released with following conditions:
Required electronic submission of Monthly OPB
Report Form (if paper report submitted, deduct 10%
of capitation in successive quarters)
Required budget proposal on how capitation from last
quarter was spent (proposal subject to auditing)
Random audits by PhilHealth on the validity of
reports, phone calls to the patient, visit RHU, flag
fraudulent cases
Initial release within first 2 weeks of
applicable year, RHU accreditation and
payment of premiums required
Successive releases on third week of first
month of quarter, reports and payment of premiums
required
3 Specify details on reporting/monitoring mechanisms required at RHUs, modify article 3.1 of Reporting, Monitoring, and Evaluation
Current Policy Proposed Policy
RHU required to submit Monthly Report
Form, Transmittal Form, Patient Treatment
Summary, Tally Sheet for OPB Services
Rendered
Health Finance Policy and Services Sector,
Benefits Development Office, Accreditation
Dept, Quality Assurance Unit monitor and
evaluate the package
For information systems management, the Corporation
strongly recommends the RHU to install the CHITS
electronic medical record system (to monitor OPB
services delivered by RHU for PhilHealth)
RHU required to submit electronic Monthly Report Form,
Transmittal Form, Patient Treatment Summary, Tally
Sheet for OPB Services Rendered
Health Finance Policy and Services Sector, Benefits
Development Office, Accreditation Dept, Quality
Assurance Unit monitor and evaluate the package
4 Modify referral system to include teleradiology referrals and teleconsultations in article 2.4 Referral System
Current Policy Proposed Policy
In case of inability to take x-ray, RHU can
refer patient to another facility, paid by
capitation fund
In case of inability to take x-ray, RHU can refer patient to
another facility, paid by capitation fund
32 Delivery of eHealth and Telemedicine Services to the Philippines
In case of specialist care or higher level of
care, refer to PhilHealth accredited hospital
(hospitalization qualifies for in-patient
coverage)
In case of specialist care (including radiologist), refer to
specialist (without travel) using telemedicine
If telemedicine can’t resolve the case, refer to PhilHealth
accredited hospital
5 Extend outpatient benefits for indigent program members to include telemedicine services in article 2.1 of OPB Guidelines
Current Policy Proposed Policy
Primary consultations with GPs
Lab fees: chest x-ray, complete fecal blood
count, fecalysis, urinalysis, sputum
microscopy
Preventive services: cervical cancer
screening, BP measurement, rectal exam,
body measurements, breast exam, smoking
counseling, lifestyle change counseling
Primary consultations with GPs
Tele-consultation with specialist (with GP referral) **
Lab fees: x-rays for teleradiology referrals, chest x-rays,
complete fecal blood count, fecalysis, urinalysis, sputum
microscopy
Preventive services: cervical cancer screening, BP
measurement, rectal exam, body measurements, breast
exam, smoking counseling, lifestyle change counseling
** Must be at telemedicine certified facility, Can be out-
of-pocket expense for patient (at first) but later to be
included in standard outpatient benefit package
3.2 Pay-for-Performance Pilot Study Recommendations
3.2.1 Select a CHITS site as a P4P pilot site to facilitate monitoring of performance in order to distribute incentives. Choose from 20 existing sites:
Lagrosa Health Center, Pasay City
Malibay Health Center, Pasay City
Marikina Heights, Marikina City
Sto Nino Health Center, Marikina City Taniong Health Center, Marikina City Quezon Rural Health Unit, Quezon Province Sigma Rural Health Unit, Capiz Cuartero Rural Health Unit, Capiz Tapaz Rural Health Unit, Capiz Dumalag Rural Health Unit, Capiz
3.2.2 Require performance at pilot site to be reported using electronic medical record system to:
• Prevent fraudulent data that says performance target achieved
• Track progress of pilot sites as feedback loop on whether P4P incentives are effective
• Utilize data for statistical analysis on maternal care to provide to management for decision making
Pagsanjan Rural Health Unit, Laguna
Mendez Rural Health Unit, Cavite
Alfonso Rural Health Unit, Cavite
Orion Rural Health Unit, Bataan
Real Rural Health Unit, Quezon Province
Child Hope Foundation Inc.
Labuan Rural Health Unit, Zamboanga del Sur
One municipality in Zamboanga Sibugay
Batanes PHO , Basco, Batanes
Uyugan Rural Health Unit, Batanes
33 Delivery of eHealth and Telemedicine Services to the Philippines
3.2.3 Perform baseline analysis on the P4P site by using previous years of CHITS data for that site, will be able to show quantitative improvement directly as a result of the P4P program
3.3 Recommendations for Using PhilHealth Service Offices for
Telemedicine
PhilHealth service offices, which are widely established across the country, already have existing
telecommunication infrastructure such as computers, Internet, and perhaps video conferencing.
3.3.1 Draft up a Memorandum of Agreement between PhilHealth and LGUs
• Teleconsulation: Allow local health professionals to refer patients to
specialists using teleconsultations, to be held in the PhilHealth field office
• Store-And-Forward Telemedicine: Allow local health professionals to send
images, audio, video of the patient to a specialist for diagnosis, using
PhilHealth field office Internet connectivity
3.3.2 Draft up a Memorandum of Agreement between PhilHealth and UP Manila National
Telehealth Center (NThC), allow NThC to coordinate telereferrals and teleconsultations
between patients and appropriate specialist
3.3.3 Require all patients utilizing telemedicine services to sign an informed consent form to
waive liability from PhilHealth
3.3.4 Amend Warranties of Accreditation for Health Professionals, certify specialists to answer
telemedicine referrals
4 Roadmap on Providing eHealth Services for PhilHealth Members
34 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Sample Referral Forms for Workflow
35 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Usability Testing of Moca
Batanes Provincial Office and General Hospital Written by Katherine Kuan
Directions for Users
1. Turn on G1 phone using red button
2. Hit the gray arrow to unveil the list of applications
3. Select the Moca application by using your pointer finger to touch it on the screen
4. Perform a "Radiology examination" procedure using Moca
5. Use the patient with
ID number: 22222
First Name: Peter
Last Name: Smith
Birthdate: 01/03/1985
6. Perform a "Surgery follow-up"
Directions for Moderator
1. What is your goal in referring a patient?
2. Can you tell me what your usual procedure for seeing a patient and taking an x-ray is?
3. What problems come up with this type of workflow?
4. From scale of 1-10, Easy to use?
Batanes Provincial Health Office
Goal
• Increase quality of x-rays compared to previous status
• Clients have access to affordable, quick reading of their x-rays
• Better management of patients
Existing Workflow
36 Delivery of eHealth and Telemedicine Services to the Philippines
• Patient comes in, received by nurse at registration area
• Interviewed for general data: name, birthdate, occupation, where they live
• Nurse interviews them for chief complaint, basic symptoms, history of illness, vital signs (bp,
heart, BMI, heart rate), past family history, OBGYN history, others (alcohol use, exercise)
• Doctor asks them for history of present illness, physical exam, do other lab tests
• Give x-ray request form, go to BGH, come back
• Take picture of x-ray and send to Manila
• Take contact number, while awaiting the x-ray results
• Administer drugs, final instructions
• Signs/symptoms for immediate follow-up
• For teleradiology, don’t write a lot, just important details
• Save all replies in email
• Not yet protocol to write the reply of the email down in the patient record
• Can take up to half a day for 1-2 images to be uploaded
• Hard to use own email to store data, need to find a way to store data
• Use digital camera 3MB
Usability
• Not too hard to get used to, looks daunting, lots of tabs
• “After I went through the process of filling out data, it was quite easy. Much easier than sitting
in front of the internet and typing it all.”
• “Very user friendly for people to use this technology”
• Okay with leaving it on the table to wait for it to upload
• Doctor in Batanes also wants to learn how to read x-rays for emergency cases when can’t
wait for the image to be uploaded for a diagnosis
o Will look for old x-rays to see similar cases
o Library to compare x-rays, teaches them what to look for
o WHO donated book of expert labeled x-ray images
o See where in the x-ray are the densities/haziness
o Learning tool for the doctors in Batanes
Difficulties
• Easier if had a pen for the touch screen
• Keyboard small but okay
• Taught them to use tip of finger, not fingernail
Issues
• Not all patients have medical ID number, usually list them alphabetically based on household
head
• Slash character for birthdate should be automatic
• Verbal notes
o Clarify what the verbal notes are, who records them (patient or physician)
o Didn’t need to record a verbal note, but can leave it in
o Not all doctors used to recording their notes, more comfortable typing them
• Written comments
37 Delivery of eHealth and Telemedicine Services to the Philippines
o Daunting to see little space, think they can’t write a lot, will have to scroll down a lot
to read all the data, can only read one line at a time
o Make ½ or ¾ of the screen filled with the text box
• Didn’t really need to use the GPS coordinates
• Hard to hold it and tap it, kind of hard to use, right handed, hold it on top of the camera
• Telehealth format has chief complaint, quick history of illness, rundown of physical exam
findings, purpose of referral, what has been done to the patient, signs/symptoms
• “Why do I have to go back?” to review the pages
• Don’t have fixed number of options for the diagnosis, have a free text entry box for diagnosis
• Took about 5 mins to learn and talk through the workflow
• Send back SMS or PDF file, whichever is faster (priority is speed)
• PDF radiology report of patient for clearances, to see actual reading (most patients don’t
care)
• Will likely be sending 2 or 3 images at a time
• Personal data
o Barangay
o Municipality
o Middle name/initial (many similar first/last names)
o Date
o Gender
o Chief complaint
o Short history of present illness (1 or 2 lines) “Include all data significant to case at
hand, OBGYN, alcohol, smoking, medication taken”
o Physical findings (empty text box)
o Diagnosis (large empty text box)
Batanes General Hospital
Existing Workflow
• See patient, ask why they came, symptoms, physical exam, lab exam
• If need more diagnostic exam, may refer to telehealth
• Send to Manila
o Send x-ray plates through relatives or someone they know, just drop it off at airport to
give to radiologist (turn around time 1+ week)
o Radiologist will write findings, sometimes send back official report, relatives relay
information back
Usability
• Willing to enter data using the phone
• Cannot carry around big computers
• With computers, have to login to the net
• “It’s nice, much better than just ordinary paper” (faster)
• Prefer phone over writing it down
• Could use it to take picture of ECG print out, video recording of ultrasound, OB/GYN (Cervical
cancer), external eye exam
Issues
38 Delivery of eHealth and Telemedicine Services to the Philippines
• Couldn’t select the option “female” for gender
• Click next/prev goes too fast
• Force close during camera app
• X-ray procedure
o
o Part to be x-rayed: upper extremities, lower extremities, chest, skull, neck, cervical, back
� Upper extremities: arm, forearm, hand, shoulder, elbow, wrist
• Choose side: right or left
o Choose view: antero-posterior, lateral, postero-anterior, oblique
� Lower extremities: hip, thigh, knee, leg, ankle, foot
• Choose side: right or left
o Choose view: antero-posterior, lateral, postero-anterior, oblique
Back: thoracic, lumbar, thoracolumbar, sacrum, coccyx
39 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Usability Testing OpenMRS Media Viewer
Philippine General Hospital, National Telehealth Center, Batanes General Hospital Written by Katherine Kuan Radiologist
Usability test done on radiology oncologist (for radiation therapy for cancer patients) at Philippine General
Hospital (PGH). He is a consultant with the radiology department at PGH and teaches residents. He
voluntarily answers all teleradiology referrals for the National Telehealth Center by email.
Existing Workflow
• Uses Mac image viewer called “Preview”
• Uses Preview to modify darkness/brightness, white balance
• “Eventually we want it like this (the OpenMRS image viewer). What we do now is difficult
because I open the email, read it, etc..”
• Receive only a few films by email, 10 per week
• Willing to read up to 100 plates per day
• Problems w/ x-rays (patient is breathing), radiology technician not properly trained
• Send notification to cell phone to check the web
40 Delivery of eHealth and Telemedicine Services to the Philippines
• Will check email when get home, 1x per day, sometimes 2x
• Each takes on average 1 minute to diagnose, chest x-ray 2 mins, max 5 mins
• Slow internet at hospital
• Doing telehealth referrals for pro bono now
• 1 patient per email so don’t mix up names with images
• Takes 1 min to download the image, 2-3 minutes to diagnose
Take proper chest x-ray image (to retrain radiology technician)
• Angulated by 15 degrees
• See apex
• Top part of chest should take up 50% of the x-ray
• Female patient should remove bra
Features Needed
• Zoom magnification
• Vary contrast and brightness
• Just save original image (not modified version)
• Panel of information: symptoms, clinical diagnosis, clinical history
• View past x-rays (2 side by side, previous and latest)
• Access to older films (zoom and brightness capabilities on those images too)
• Radiologists need box for “findings/interpretation” and for “notes”
• Clinicians should be able to write diagnosis, treatment, notes (some fields can be blank)
• No drop down box for diagnosis, no fixed reading (except for “normal chest”)
• No cancel button needed, will read it then
• If not sure of diagnosis, will leave it blank or refer to someone else � put case on “hold”,
assign it to another doctor, allow both doctors to be on the case
• Output an official report, type report next to image, then go directly to an editable version
of the official report (auto populate the official report and then make it editable, preview +
edit report)
• Don’t need to annotate image, maybe a circle/arrow/pointer if clinician wants to see
lesion (dermatology cases may require annotations)
• List of on-call doctors, typically on-call all day from 7am-11pm, diff person per day, a
doctor is on-call 2-3 times per week
• Could charge 30-50 pesos per x-ray plate reading
• If bad image, disappear from queue until need it again, don’t need the bad pics
• Personal digital signature
Nurse
Difficulties
• Double click to annotate
Workflow
41 Delivery of eHealth and Telemedicine Services to the Philippines
• Clinician needs to incorporate the radiologist reading with other data from patient (ECGs,
other labs)
• Once sure about interpretation, don’t need to go back and save, only compare, won’t
return to edit it
• Clinician � rad tech � radiologist � clinician
• Time diagnosis 48 hrs
• Use Windows default image viewer
Features Needed
• Make the image DICOM compliant (Open binary file, first part is text (key value pairs in
header), parse into fields, latter part is image
• Embed in file the doctor who interpreted the data
• Click on annotation to edit again
• Zoom (enlarge it so one lung is screen width, 3-5 MP)
• Don’t need to rotate it
• Label it as “user” or “patient”
• Add doctor’s name as the one interpreting the data
• Annotation box can be fixed to a corner of the screen
• Don’t need other info from medical record of patient besides the summary
• Compare with previous x-ray films, click to see previous plates, side by side comparison
• If not sure, need to refer to another doctor (residents may be unsure about diagnosis)
• Clinician needs diagnosis, treatment, other notes box
• Clinician may not need to annotate image
• Can have another system for clinician, pull out radiology image for same visit of patient
• Change brightness, contrast, sometimes can see shadows
• Date is fine, don’t need timestamp
• Bad image quality -> comment why bad image, want another view
• Retake shot (i.e. top of chest)
• Save original ones with new images
• Drag image around, zoom to click, scroll image like Google maps
Doctors in Batanes
• Need annotations for clinicians and radiologists
• Blank spot for clinical diagnosis
• Blank spot for radiologist (i.e. there were no densities, diaphragm is intact, heart is not
enlarged)
Doctor in Manila
• Spell checking for the boxes
• Findings, diagnosis boxes
• Make sure it’s embedded in the workflow (see surgery system by National Telehealth
Center)
• Separate screen for diagnosis of patient, not in the image viewer
42 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Technical Support Manual for Moca
Batanes Provincial Health Office - July 1, 2009 Written by Katherine Kuan
1 Setup Basic Tools
1.1 Download Eclipse
From USB key, Copy Eclipse folder into Program Files folder on computer Launch eclipse.exe Hit the icon that says “Go to workbench” Install plug-ins by going to Help > Install New Software > Click “Add…” Button SVN plug-in
Help > Install New Software > Add… to add site Name: http://subclipse.tigris.org/update_1.4.x Location: http://subclipse.tigris.org/update_1.4.x Click OK Click Next, I agree to terms and conditions, Finish
Android SDK plug-in Help > Install New Software > Add… to add site
Name: http://dl-ssl.google.com/android/eclipse/ Location: http://dl-ssl.google.com/android/eclipse/ Click OK Click Next, I agree to terms and conditions, Finish
1.2 Setup the Android SDK
From USB key, copy Android folder into My Downloads folder My Computer > Right click > Properties > Advanced Settings > Environment Variables Under system variables, find “Path” > Edit > Add semicolon Find system path location of the android SDK TOOLS folder Copy this path into the Path variable
1.3 Install the Android phone device onto computer
43 Delivery of eHealth and Telemedicine Services to the Philippines
Click “No not this time” for Windows Auto Installer Driver located in Android folder directory under usb_driver, x86 folder Under Eclipse, Click Windows > Preferences > Android > Browse for the Android SDK location (select the folder that has the tools folder located inside it)
2. Download Moca Code into Eclipse 2.1 Import the Moca project into Eclipse from the server
Right click in the left hand side panel (Package Explorer) > Import Click on SVN folder > Checkout project from SVN Create new repository location Location: http://dagny.mit.edu/svn/moca/trunk/clients/moca, Click OK You’ll see the folders show up under http://dagny... Click http://dagny.mit.edu/svn/moca/trunk/clients/moca Click Next, Next, Finish
2.2 Undo changes in Eclipse and get the version from the server
Right click the file or folder > Replace with > Latest from Repository 2.3 Save changes onto the server (only commit changes that are applicable to all
deployment sites) Right click the file or folder > Team > Commit 2.4 Back up your data Go to C:\Doc and Settings\PHO Main\workspace Copy the project folders onto hard drive or something else
2.5 Update Code in Eclipse for MoCa
Right click on MoCa > Team > Update to Head
2.6 Create new procedure for the phone
Under the code branch, MoCa > res > raw Right click raw > New > File Create new xml file (ex: radiology.xml) To rename, Right click the file > Refactor > Rename Copy surgery.xml and create pages according to the doctor’s wishes (http://www.mocamobile.org/development/index.php?title=How_to_Define_Your_Own_Procedures) Add this procedure to the list of procedures by going to MoCa > src > org.moca.util > MocaUtil.java
2.7 Open Logs for Android Window > Open Perspective > DDMS (android icon next to it), Find logcat window
3 Setup Moca on Android Phone
3.1 Install Moca application
In Eclipse, Right click the folder > Run > Android Application
44 Delivery of eHealth and Telemedicine Services to the Philippines
On Phone, Hit Menu > Reload Database Menu > Settings
Moca Dispatch Server URL: http://moca.mit.edu/mds-dev Initial Packet Size: 1 kb Username: admin Password: moca!mobile Enable Upload Hack
3.2 Uninstall Moca application
Home > Settings > Applications > Manage Applications > Moca Uninstall > OK
3.3 Change APN settings on Android Phone for GPRS to work in Philippines
Go to Home > Settings > Wireless Controls > Mobile Networks > Access Point Names > Smart WAP
Correct Settings (starts automatically using your minutes): APN: internet Proxy: 10.102.61.46 Port: 8080
Incorrect Settings (to save minutes): APN: internetq Proxy: 10.102.61.46q Port: 8080
3.4 General Tips
Always need to enter an ID number (no dashes allowed)
If it crashes, hit close, and then launch the application again > Saved Procedures > continue and try to upload again
If you hit upload to server and it doesn’t go back to the main Moca home screen, then it didn’t upload. Try to upload again
4 Login to OpenMRS to Check Uploads
Access OpenMRS Electronic Medical Record System Go to URL http://moca.media.mit.edu:8080/openmrs/
Username: admin Password: ******** Click Administration > Moca > Moca Queue
45 Delivery of eHealth and Telemedicine Services to the Philippines
Appendix: Summary of Workflow in Batanes
For Singapore Lien i3 Challenge Application Written by Katherine Kuan
The governor of Batanes was very enthusiastic about Moca and said it was “very, very
applicable.” He said it was easy to use and clear to follow. He said that there are only
general practitioners in Batanes and no specialists available, so telemedicine would
provide access to specialists and quality healthcare for his community. He said that cost
wasn’t really an issue and that they want to make the investment. Also, local technical
support wasn’t an issue. He said that “Filipinos are fast learners” and that they would
work it out. In general, he is proud of the culture and heritage of the province (especially
since Batanes Day celebrations just happened) and proud to have such a healthy
community. They have KSK a local social health insurance program, and I believe all
citizens in Batanes are covered by insurance (either just PhilHealth or PhilHealth plus
KSK).
From my impression, the people in Batanes were very peaceful and hospitable. They
lead simple lives, some live in huts by the beach, and they help each other out a lot. For
example, if someone is building a house, there are no construction workers around to
hire, so they ask their neighbors to help them out. During Batanes Day celebrations you
can just walk into people’s homes when they have a party and they will feed you even if
you are a stranger. We met the governor by going to his house one night because he
had a party for his wife’s birthday, and all the neighbors, family, and friends were
invited.
Rural Health Units
For some health services, some people pay. RHU services are free for people who live
in that municipality. If you’re from outside, depending on your income class, you can pay
from 25 pesos to 100 pesos for the consultation with the doctor. At the RHU they
perform minor surgeries, a dentist comes in once a week, and other primary care
consultations. Sometimes they ask if they can pay later (sometimes they do, sometimes
they don’t). Sometimes Dr. Lariosa (municipal health officer) gets paid for services with
a chicken, fish, other food or homemade goods. That’s the culture there because the
neighbors help each other out (i.e. you can always get eggs from your neighbor if they
have chickens).
Teleradiology
When doctors don’t know how to diagnose the patient from the x-ray, they either send
the plate to Manila or sometimes refer the patient to Dr. Lariosa or Dr. Thea. This is a
46 Delivery of eHealth and Telemedicine Services to the Philippines
problem because Dr. Thea at the provincial health office isn’t really supposed to be
receiving many patients anyways. They say that the doctors (like at the Batanes
General Hospital) and staff are a little hesitant to use telereferrals. They’ve been trained
already multiple times, but they really aren’t motivated to use telemedicine. It’s mostly
Dr. Lariosa or Dr. Thea who do the telereferrals. Even with telereferrals through email, it
can be slow. In the provincial health office, internet connectivity is really slow.
Sometimes it can take up to half a day to upload an image to an email, so Dr. Thea is
definitely willing to wait until it finishes uploading (half an hour to half a day) via GPRS
with Moca. It’s not urgent that she does it right after each other, since it’s just the x-ray
plate, she can just upload one, set the phone down, and wait till it finished uploading.
Then come back later. Sometimes the x-rays are sent to Cagayuan (sp?) but it takes 1-
2 weeks before they get a reading.
Dr. Thea says that they only received basic training on radiology, but just to be sure,
they like to send the x-ray to Manila to make sure they’re reading it correctly. It’s also
practice for them because then they can see whether they read the x-ray correctly and
learn from their mistakes. Sometimes if a similar case comes up again, she will go back
and find the email from the previous case. It’s disorganized though because she has to
search her email. Once they receive the diagnosis from PGH, they just tell the patient. I
don’t think it’s officially recorded anywhere, they don’t require an official report to be
printed out. She thinks that a revenue opportunity would be if the official report was sent
by PGH so that they could charge the patient money if they want a copy.
eLearning
There’s definitely a good case for a database of expert-labeled images here to be used
as training material for them. They have some books donated by WHO (see attached
image) where they can see examples of what sample chest x-rays are and how they
were diagnosed. Books are expensive and limited in the number of examples they
provide. It’s necessary to develop this capacity at the local level because in the case of
an emergency if the patient can’t wait for a teleradiology referral or for the snail mail
way, the general practitioner has to make the call. At that time they can only use what
they know from experience and the examples of past telereferral cases to try to find a
similar image.
Insurance
In terms of insurance, there is insurance from PhilHealth, where it is mandatory for them
to pay 100 pesos per month. For the formally employed sector, they pay 100 pesos per
month for coverage of the whole family. They can avail of inpatient services, but if they
come to the clinic they cannot reimburse services/medicine. Even for inpatient services
though, PhilHealth will cover maybe 50-70% (don’t quote us on this number) of the bill
47 Delivery of eHealth and Telemedicine Services to the Philippines
depending on what the hospital charges. Basically hospitals can charge whatever they
want and PhilHealth will always reimburse up to a flat amount according to what
service/case it is. With telemedicine though, people will be able to pay less out-of-
pocket expenses for even better care.
There is an informally employed (or self-employed group). They are not mandated to be
enrolled because there is no employer giving them a salary. They are the most
vulnerable group in terms of not having insurance coverage.
The indigent program in PhilHealth is where people with income class < 14,000 pesos
per month for a family of 6 receive free healthcare coverage. Indigents receive inpatient
and outpatient benefits. For inpatient benefits, they don’t have to pay. The facility can
submit the claim straight to PhilHealth, but they can wait up to half a year to be
reimbursed. This is where eRecords can come into play and automate billing for faster
turnaround time from PhilHealth (latencies in verification of member benefits can be
done faster electronically). The money to provide indigents with PhilHealth insurance
comes from governors, mayors, congressmen, or the province itself.
There is also KSK, a local social health insurance (community-based). It’s not
mandatory, so they have to work on marketing for people to buy it. There are about
1000 households enrolled in KSK out of 3000 in Batanes. Reimbursements are quicker
because it’s only run by a couple of people in the provincial health office. KSK was
setup by a German NGO partner. The NGO did a survey to see how much people can
afford for healthcare. I think they found about 50 pesos per month to be affordable.
Another consultant pegged it at 90 pesos per month. For KSK, members pay 92 pesos
per month for coverage. They receive 5000 pesos for hospitalization per family per year,
and 500 pesos for outpatient services.
Benefits of Telemedicine
For telemedicine, we can save the amount of money it costs someone from Batanes
traveling to Manila. It’s about 16,000 pesos for airfare, 1,000 pesos per day for
board/lodging, so it comes out to be 18,000 for 1 person but usually they travel with
more than one person. If someone does actually fly out to Manila, if the illness is not an
emergency, PGH will send the patient back home and ask them to follow up in 6 months
for a surgery later. Even if the person needs an operation, they may have to come back
after 6 months to actually have the operation. Basically they have to fly in first for
advice/consultation/diagnosis and then later come for the operation. This initial
consultation can be done through teleconsultation and save lots of money!
Teleconsultations are also valuable in cases where rehab is needed or surgery follow-
up.
48 Delivery of eHealth and Telemedicine Services to the Philippines
In terms of volume, there are about 20-30 x-rays taken per day for the 3 health facilities
in Batanes. For the provincial health office, the max they requested was 4-5 x-rays per
day, but not all of these are referred to a specialist.
An officer in the Provincial Health Office in Batanes says that it’s hard to compute the
health statistics manually from all the provinces. If data looks incorrect, they have to go
track down the RHU to figure out where the error came from (simple calculation error or
misread handwriting). Hence, they made an Excel spreadsheet with formulas (but these
are also prone to error). Everything is compiled into 1 spreadsheet (where each sheet
has all the statistics for a different city/municipality – see attached picture). So one file
has statistics for each month of the year for each city/municipality and I’m not sure if it’s
backed up regularly or in a secure place (anyone can access the files if they go on that
person’s computer in the office). They really want software that can generate these
reports easily, to save time and minimize errors.