CHN 2

Chapter 20

eHealth in the community setting

Arturo M. Ongkeko, Abby Dariel Santos, Isidor F. Cardenas, Melissa J. Pedreña

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to do the following:

 Differentiate eHealth, digital health and information and communications

technology for health.
 Describe the national eHealth vision and its components. Discuss
examples of public information management systems.
 Enumerate the different applications of eHealth in the community.
 Explain the importance of eHealth in the community.

Digital health

In the advent of Information Communication Technology (ICT), the current

healthcare industry is undertaking a significant transformation. Since the goal of
the health system is to provide quality, affordable, accessible, equitable, and
efficient health for all, majority of the health systems are challenged to improve
the quality of care while decreasing cost and establish an administrative and
medical process with the use of ICT such as digital health.

Digital health, also known as information and communication technology (ICT) in

the health system, is the field of theory and practice associated with any aspect
of adopting digital technologies to improve health from its conceptualization to
application or operation (World Health Organization [WHO], 2019; Ghebreyesus,
2017). Digital health involves the use of different healthcare technologies in
administering healthcare services to improve patients’ health and well-being
(Mellodge and Vendetti, 2011; Kostkova, 2015; Baumann, 2015; Sonnier, 2016).

Digital health versus eHealth

Often digital health is used interchangeably with eHealth. But digital health is
broader and focuses also on smart devices, huge data storage and big data
analytics (WHO, 2019). Moreover, since the face of digital health is dynamic,
terms-eHealth, medical informatics, health informatics, telemedicine, telehealth,
and mHealth-have been used over the last decades, depending on the available
advancements of technologies and their respective local environments (WHO,
2019; Wootton et al., 2009). All these terms were attempts to describe the
application of ICT to health sectors, health systems, and well-being (WHO,
2019). However, digital health goes beyond its simple meaning as it reflects the
integration of concepts while allowing flexibility for diverse purposes to
understand various categories, functions, and policy needs (WHO, 2019). The
terms digital health and eHealth will be used interchangeably in this chapter
depending on the context within which a particular term is being discussed.

Uses of digital health interventions

The ultimate objective of digital health is to enable a health system to use ICT to
improve achievement of health and wellness, in line with the national health
strategies and plans as well as with the global objectives such as Universal
Health Coverage (UHC) and Sustainable Development Goals (SDGs) (Marcelo et
al., 2018; WHO, 2018). In many countries, digital health is utilized to improve
gaps in health systems such as:

1. Digital disease surveillance systems

2. Electronic medical records

3. Social health insurance payment processes and;

4. Health education and interventions

With this objective, digital health has been acknowledged by the World Health
Organization (WHO) as an important building block for Universal Health
Coverage and health related Sustainable Development Goals (SDGs) (WHO,
2019; WHO, 2018). The Seventy-first World Health Assembly also recognized its
potential to advance the SDGs particularly in supporting health systems in all
countries for health promotion and disease prevention by improving quality,
accessibility, affordability of health services (WHO, 2018). Digital health
overcomes geographic barriers and supports the delivery of healthcare and
health-related information to communities situated in remote, isolated,
resource-constrained, and physically insecure conflict-affected areas.

The nature and scope of digital health in the Philippines

Digital health in the country can be traced back to the 1960s. During this time,
the use of telephones. is increasingly becoming more prevalent and at the same
era, using telephones, resident physicians in the country sought consultations
and medical advice from senior clinicians regarding the management of
hospitalized patients (Fernandez-Marcelo et al., 2012). In 1998, the National
Telehealth Center in the University of the Philippines Manila was established.
(National Telehealth Center [NTHC), 2019). As a primary research unit of UP
Manila for ICT, the NTHC initiated the design and development of ICT cost-
effective tools especially for the remote, rural and underserved communities in
the Philippines. (NTHC, 2019). In 2004 to 2008, the NTHC had its first
breakthrough when it conducted a telemedicine research and service in remote
and underserved areas in the Philippines through a partnership with the
Commission on Information and Communications Technology (precursor of the
Department of Information and Communications Technology) and Department of
Science and Technology Philippine Council for Health Research and
Development (NTHC, 2019; Marcelo, 2009).

In 2009, the WHO conducted a global survey on eHealth (WHO, 2011, pp. 182-
183) with self-reports from a selected group of digital health expert informants
as the basis. It revealed that in the country, ICT training both formal and non-
degree courses for students and health professionals alike can be used to build
the digital health capacity of the workforce (Fernandez-Marcelo et al., 2012). In
addition, in 2011-2016, with goals to develop user- friendly ICT solutions in order
to accelerate the gathering and processing of health and related information for
policy making, and to deliver quality healthcare services, the National Unified
Health Research Agenda (NUHRA) recognized ICT in the health sector as a
priority regnized focus (Fernandez-Marcelo et al., 2012).

Vision, components, strategic phases

In 2013, the Philippine eHealth Strategic Framework and Plan (PeHSFP) for 2014-
2020 was released (see Table 20.1). It was the first official document that serves
as the roadmap on how the country will use IT to support health care service
delivery. The eHealth national vision is stated as:

By 2020 eHealth will enable widespread access to health care services, health
information, and securely share and exchange patients' information in support
to a safer, quality health care, more equitable and responsive to health systems
for all the Filipino people by transforming the way information is used to plan,
manage, deliver and monitor health services.

The implementation strategies to roll out the National eHealth Program are
generally divided into three phases:

1. Standardize and connect the key focus is on the establishment of governance

and foundations and provide basic connections to start information sharing
across the health sector. This phase started in 2014 and was concluded in 2016.

2. Transform-involves continuing innovations to develop and implement defined

national eHealth solutions. This phase started in 2016 and is expected to
conclude in 2019 and beyond.

3. Maintain and measure-e Health is expected to be established at this point and

there is a need to maintain, sustain, continuously measure in terms of
performance, and ongoing innovations and updates need to be managed. This
phase is set to commence in 2020. Supporting policies to ensure continuous
funding and support services were also issued to ensure sustainability and
scale. Some of these issuances were jointly released by key stakeholders such
as the DOH, DOST, Department of Budget and Management (DBM), PhilHealth,
and National Economic and Development Authority (NEDA). Table 20.2describes
the relevant policies governing the eHealth implementation in the Philippines
(see Fig. 20.1).

TABLE 20.1 & 20.2

FIGURE 20.1

The Philippine health information exchange

Health information exchange (HIE) is a process of sharing patient-level

electronic health information across different health facilities, practitioners, and
organizations (Adler-Milstein and Dixon, 2016; Khumalo, 2017; Vest and Gamm,
2010). Health Information exchange not only addresses the portability of the
patient data information to health care providers and government agencies such
as health insurance providers, but the integration of different health information
systems (HIS) addresses the need for better information for decision making
(Bates and Bitton, 2010). Through this, the gaps in management of health care
delivery networks, health care delivery, and social determinants on health can
be analyzed and eventually addressed. This leads to a sound evidence-based
health policy which is catered by different government agencies that supports
public health (himss.org) (Fig. 20.2).

The power of data and information

Nurses are knowledge managers. They constantly process raw patient data into
valuable information to deliver evidence-based and individualized care. Data are
the fundamental elements of cognition (Gudea, 2005), and are defined as
unanalyzed raw facts that do not imply meaning. When meaning is attributed to
data and when data are processed and analyzed, then data become
information. Consider, for instance, the number 39. It can be an age, house
number, jersey number, etc. This is data. The school nurse noted that it was
written on the respiratory rate field of the record of Grade 5 student Rosemarie.
Number 39 now has a meaning to the nurse and has become information. Based
on the nurse’s knowledge that Rosemarie’s respiratory rate is above normal and
considering other findings, the nurse concludes that she is hyperventilating. The
nurse gave Rosemarie a brown paper bag heavily on accurate recording of
obtained data.

Paper-based methods may bring inconvenience especially when it comes to

integration of health services, information backup, and instant data access. A
number of bigger problems may also emerge such as:

1. Continuity and interoperability of care stops in the unlikely event that a

record gets misplaced. If the patient suffers from a chronic condition,
previous findings supporting this diagnosis, drug allergies, pre- existing
conditions, or even past accounts of the patient’s previous visits may no
 longer be accessed unless the health providers have made several copies
of the same record. The patient may also need to recount his/her
condition for every transfer of care.
2. Illegible handwriting results to misinterpretation of data. A direct
observational study of medication administration found opportunities for
errors associated with incomplete or illegible prescriptions (Tissot et al.,
2003)
3. Patient privacy is compromised. Traditional, paper-based patient records
are vulnerable to unauthorized viewing since there is no audit trail of the
usage of the chart. The disclosure of highly private information arising
from such incident can lead to loss of trust in the health facility or even
legal risks (Patdu and Tenorio, 2016).
4. Data are difficult to aggregate. Manual data recording and tallying
significantly delays implementation of interventions and targeted health
programs. Health care monitoring is compromised as information is not
readily available and up to date on a daily basis.
5. Actual time for patient care gets limited. Time spent by the community
health worker searching for a paper-based record is time lost for actual
care. According to one study on Philippine public health information
system, health workers consume about 40% of their time in processing
reports (Jayasuriya, 1995).

Likewise, for both clinical and community settings, the overall impact of
the problems related to manual/traditional data-gathering is articulated
(Englebardt, S. P., & Nelson, R. (2002) as follows:

1. The ability to manipulate large amounts of data.

2. The ability to relate data to cohorts of people who share similar
health problems.
3. The ability to link to genomic data.
In contrast, having a well-managed patient information system can have
the following benefits:

1. Data are readily mapped, enabling more targeted interventions and

feedback. Through a system that delivers real-time and accurate
patient and community information, health care providers are able to
deliver patient- centered care and targeted disease prevention and
management programs. The facility and staff are also provided
feedback on their performance through computer alerts, enabling them
to continually comply with standard guidelines and monitor monthly,
quarterly, or yearly health targets. From the societal public health
perspective, adhering to these guidelines keeps individuals healthy and
lowers the risk of disease outbreaks in communities (Menachemi and
 Collum, 2011). Health professionals can also track the frequency and
locale of diseases in real time through an EMR and Geographic
Information System (GIS) like the Philippine Health Atlas of the
Department of Health (DOH, 2012a). GIS technology enables detailed
maps to be generated with relative speed and ease. In turn, this
provides public health practitioners with the ability to provide quick
responses to questions or concerns raised in a community meeting
(Richards et al., 1999). GIS is not the complete solution to
understanding the distribution of disease and the problems of public
health but is an important way to better understand how humans
interact with their environment to create or deter health (Ricketts,
2003).

2. Data can be easily retrieved and recovered. In the event of force

majeure, retrieval of patient information is not a problem since data are
automatically backed-up periodically in a secure server.

3. Redundancy of data is minimized. Patient data that are frequently

required in various health forms such as unique identifying information
(e.g.. name, birthday, age. Gender) need to be recorded only once.
These can be linked and organized automatically into related record
types through a database. Allowing a better record management and
ease-of-use.

4. Data for clinical research becomes more available. The potential impact
of health research in the country is often hindered by the lack of quality
data. Whenever data is gathered, it is often not communicated to the
rest of the research community. Having quality data stored in
databases provides faster and more reliable research outputs that may
eventually be translated to health care innovations and actual
interventions.

5. Resources are used efficiently. By making patient information more

readily available, EMRS reduce costs related to chart pulls as well as
supplies needed to maintain paper charts. Studies have also shown
that having an EMR as opposed to a paper file can result in reduced
transcription costs through point- of-care documentation and other
structured documentation procedures (Menachemi and Collum, 2011).
In developing countries, health care information systems have been
driven mainly by the need to report aggregate statistics for
government or funding agencies. Improvements in drug supply
management using medication data from EMR systems can offer the
most measurable cost benefits at present; a well-managed drug supply
also improves availability and quality of patient care (Fraser et al.,
2005).

Characteristics of good quality data

The nursing process begins with obtaining data through assessing the
patient's signs and symptoms. These data are interpreted by the health
care professional into useful information to formulate a diagnosis. This
is then followed by necessary interventions and ends with obtaining
new data from evaluating the results. Without data, it will be difficult
for a health professional to assist the patient. Human error, computer
viruses, software bugs, and hardware issues pose a great threat to the
integrity of data. ICT can help decrease these errors by putting
safeguards in place, such as backing up files on a routine basis and
error detection Mcgonigle, D., & Kg, M. (2003). In order for information
to be valuable, data must have the following characteristics (Abdelhak
et al., 2014):

1. Accuracy. This ensures that documentation reflects the event as it

happened. All values should be correct and valid. In a computerized
system, a computer can be instructed to check specific fields for
validity and alert the user to a potential data collection error (WHO,
2003). In electronic systems, format requirements must be followed
(e.g., if date required is mm-dd-yyyy, then it should be presented as
03-24-1989).

2. Accessibility. This is a data characteristic which ascertains data

availability should the patient or any member of the health care staff
needs it. An example is readily available reports or statistics when
needed by decision makers.

3. Comprehensiveness. Data encoded should be complete. This is done

by making sure that all required fields in the patient's record are
properly filled up.

4. Consistency/Reliability. Having no discrepancies in data recorded

makes it consistent. This means that when John Lloyd Dela Cruz is
written on the first page of the patient record, it should not be Jon Loyd
Dela Cruz in the next. This potential error is reduced through error
detection and alerts by the computer.
5. Currency. All data must be up-to-date and timely. This is exemplified
when the community health nurse records data at the point-of-care or
when it happened.

6. Operational Definition. Data should be clearly defined. For example,

36 is just an ordinary number unless it is labeled as an age of a person.

Electronic medical record systems (EMRS)

EMRs are automated systems that stores patient demographic, clinical

and administrative data. Some documented advantages of EMR use
are:
1. Easily retrieve patient data especially on their follow-up visits.
2. Track patient progress over time.
3. Monitor and improve overall quality of care. The pioneering
community based EMR in the country is the Community Health
Information Tracking System or CHITS (Ongkeko et al., 2016). It was
developed in 2004 by Dr. Herman Tolentino of the University of the
Philippines Manila (UP Manila) Medical Informatics Unit (MIU). At
present, it is being used in 179 health centers nationwide particularly
in Quezon City, Taguig, Pasay City, and other selected cities and
municipalities in Visayas and Mindanao (NTHC, n.d.a). The Integrated
Clinic Information System or iClinicSys-a homegrown EMR of the DOH
developed in 2013-is the widely used community-based EMR. It is
currently deployed to more than 1,200 health centers and barangay
health stations nationwide.

The year 2012 is a breakthrough year for EMRs in the Philippines. The
DOH included in the National Objectives for Health (NOH) 2011-2016
the use of eHealth as a key strategy to address the problems to poor
access to good quality data, fragmentation and persistent delays in
health information systems. The NOH 2011-2016 accelerated
development and adoption of various EMR Solution especially on
several priority areas such as non- communicable diseases, infectious
disease and surveillance, procurement logistics and financial
managements de chains) management and electronic claims (e-
Claims) for health insurance payments.

Universal health care and EMR use

The Universal Healthcare Law of 2019 or Republic Act 11223 calls for
the full adoption of information systems which “include but are not
limited to enterprise resource planning. Human resource information
systems, electronic medical record and electronic prescription logs”.
The law also mandates regular uploading of data through interoperable
systems (Republic Act 11223, 2019, p.25).
PhilHealth is mandated to ensure financial risk protection to all Filipinos
by developing service packages. Most common service packages
available in community health centers, lying-in clinics and primary
hospitals arìe the primary care benefit (PCB) packages, maternal and
newborn care packages, outpatient TB-DOTS benefit package and HIV
and AIDS benefit packages among others.

Today, EMRs are largely used as tools by PhilHealth (or the Per Family
Paynsurance payments as usually referred to by PhilHealth in their
official documents) for the by community health the services provided
Phil Health certifies complies Since 2016, providers to national
mpliance of EMR standards. Table 20.3 describes the relevant policy
issuances that detail the responsibilities of the EMR providers and the
operational guidelines for EMR adoption.

Challenges to EMR implementation

There is high interest to implement EMRs but the necessary

infrastructure for a seamless exchange of information, technology
support, costs and expertise remain to be inadequate (Ongkeko et al.,
2016). Managing resistance to change is crucial and full integration of
EMRs in the clinical workflow may take time (Ash and Bates, 2005;
DesRoches et al., 2008; Hakes, 2008). Continuous capacity building
through regular training sessions and coaching can help change or at
least modify present behavior and attitudes (Cresswell et al., 2016;
Ongkeko et al., 2016). The three most common challenges encountered
in a healthcare facility when implementing an EMR are the following:
1. Double charting-as the facility transition to fully electronic, health
workers tend to record patient data on both paper and electronic
charts (Hakes, 2008). This phenomenon of double charting
frequently caused frustration among the users and forces them to
revert back to paper charts. To address this, EMRs should be
designed based on users' needs and context through regular
feedback sessions to facilitate easier workflow integration.

2. Interference with face-to-face patient care-since the use of EMR

involves frequent typing and requires a substantial amount of screen-
time, health workers feel that they compromise a level of attention
they could devote to patients. As a workaround, health workers divide
 attention between patient and computer or delay any data entry after
the consultation which results in extended overall work hours.

3. The perception that EMR is just a simple replacement of the paper

record. This perception will only duplicate the weakness inherent to
paper-based records.

4. Managing data privacy and confidentiality. Health workers face a

new set of ethical and legal dilemma as they use eHealth solutions
(Cresswell et al., 2016; Kleinpeter, 2017). Existing policies such as
Republic Act 10173- Data Privacy Act of 2012 must be monitored
regularly for strict compliance (Patdu and Tenorio, 2016).

Public health information management systems

Table 20.4 enumerates the most common electronic health information systems
that you will encounter in a typical community health center. As the
infrastructure for eHealth continues to thrive, more organizations are developing
new systems and are offering more ways to be efficient and effective. A list of
government certified EMR and eClaims provider can be found on this link:
https://www.philhealth.gov.ph/partners/csp/The webpage is periodically updated
as new EMR providers are added.

eHealth utilization in public health

We can broadly classify the use of eHealth in the public health sector in three
ways:

(1) to improve access to health information and services,

(2) improve public health surveillance for data-informed decision-making, and

to

(3) support health promotion efforts.

Improve access to health and service delivery

Another key strategy in the PeHSFP is the use of Telehealth to improve access to
quality healthcare services. The WHO defines telehealth as, “the use of
telecommunications and virtual technology to deliver health care outside of
traditional health-care facilities.”

One example of a telehealth solution is project RxBox. It is a biomedical device

with sensors to collect patient’s blood pressure, peripheral capillary oxygen,
electrocardiogram data, and temperature. The device is also built with a fetal
heart monitor and a maternal tocometer to monitor pregnant women during
labor (Lontoc, 2017). Data collected by this device are stored in CHITS and
accessible to authorized health professionals (NTHC, n.d.). In cases that the
community physician needs a specialist opinion, these data can be
electronically transmitted to a clinical specialist in tertiary care facilities such as
regional hospitals and medical centers and the Philippine General Hospital.

The private sector is also thriving with digital health solutions. KonsultaMD, is a
24/7 health hotline service offered by Globe Telecom. Upon subscription, callers
can talk to a licensed physician to access a range of medical information which
includes maternity and pediatrics for primary conditions like fever, rashes, and
allergies. The MyDocNow app is another similar telemedicine platform that
offers video consultations, comprehensive patient education and remote
monitoring in selected metropolitan areas. MyDocNow has an existing
partnership with Lifeline Rescue - an emergency response service provider – to
manage the coordination and continuity of services from primary care to
specialized care services.

Improve public health surveillance and evidence-based decision-

making

The data or information from EMRs are best appreciated and useful for the
decision. Makers if they are summarized, aggregated and visualized. One of the
popular open source software for visualization is the District Health Information
System version 2 (DHIS2) developed by the University of Oslo in 2006. The
platform has an easy-to-use report with charts and tables for selected indicators
and summary reports, an analytics module such as geographic information
systems (GIS), Pivot Tables, and Data Visualizer among others.

In the Philippines, UP Manila customized the CHITS Local Government Unit (LGU
Dashboard) using the DHIS2 software. The LGU Dashboard focuses on selected
maternal and child health indicators and was deployed in selected municipalities
in Mindanao with high rates of maternal and child deaths. The Ateneo de Manila
University also developed a similar visualization tool called eHaMBinGG or the
eHatid LGU Morbidity Boards in Geospatial Graphs. It focuses on morbidity cases
and fever patterns for possible infectious diseases such as Dengue.

In terms of disaster risk reduction and management, ‘eBayanihan’ is a web-

mobile disaster management platform (e.g., Project Agos by Rappler, Inc.) that
crowd sources disaster- related information as part of preparedness and
mitigation. The system captures data from citizens through the use of
standardized social media hashtags (e.g., #FloodPH, #RescuePH, #ReliefPH).
Flash reports of initial damage needs assessment and different requests for
assistance are consolidated. These layers of information are then visualized on a
map.

Enhance health promotion efforts

Empowerment is said to be one of the key components of health promotion
(Korp. 2006). One way to empower citizens and communities is to provide timely
and understandable them access to is a low-cost tool which can provide two-
way Communication between the patient and the health care provider (Abaza
and eat and the 2017; Custodio et al., 2018). The common use case for SMS-
based solution is the appointment reminder system. This feature is available in
most of the EMRs that are already implemented in the country especially to
remind mothers in the community of their prenatal check-up and immunization
appointments.

The SMS-based reminder system was also tested to be useful among patients
with Diabetes Mellitus (Abaza and Marschollek, 2017; Adikusuma and Qiyaam,
2017). In a documented local study in 2013, an SMS was sent to patient 3 times
a week for a period of 6 months to remind them of complying with proper diet
and exercise. The results proved the program to be effective as they found
patients with a better diet and exercise compliance during 3 rd and 6th month of
project implementation. The glycosylated hemoglobin (HbA1c) levels of the
participants in the study were found to have decreased significantly (Tamban,
Isip-Tan, and Jimeno, 2013; Tamban et al., 2014), providing evidence that
mHealth may be instrumental in improving patient outcomes.

Summary

Digital health is a means to an end and not a panacea for health inequities. It is
capable of accelerating efficiencies in the health care system provided that it is
appropriately implemented based on context and identified need.