Telehealth – How Can It Change the Landscape of Health Care Delivery in the Philippines?

It’s the second to the last blog before the end of the semester. This week’s topic is all about telehealth. The question we were asked was…

How can telehealth support healthcare delivery in the Philippines?

To help answer this question, we were tasked to read and evaluate the Telehealth Act of 2014, and to suggest revisions, if any.

Telehealth, according to the Center for Connected Health Policy (n.d.) is “a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies.” It is not a specific service but a term that describes the variety of technology and tactics to deliver virtual medical, health, and education services.

The practice of the use of telehealth services is more common in developed countries such as the US. In the Philippines, however, it is not as popular. Quite frankly, I finished nursing school and medical school without encountering a lecture on what it is and how it can be applied to our setting.

The Philippines is an archipelago composed of more than 7,600 islands. Our geography, while it has blessed us with incredible sights and natural wonders, has also made it more difficult for healthcare to be accessed and delivered. It is the same geography that constitutes the physical factors that characterize geographically isolated and disadvantaged areas or GIDAs. GIDAs are communities with marginalized population that are physically and socio-economically separated from mainstream society. They physical factors are mainly to geography and also includes difficult access due to weather conditions. Socio-economic factors, on the other hand, include high poverty incidence, presence of vulnerable sector, communities in or recovering from situation of crisis or armed conflict (Department of Health, n.d.).

With telehealth, the population that could potentially most benefit are those residing in GIDAs. The idea is that since they have difficulty access to healthcare, healthcare will be brought to them. This is one of the objectives of the Telehealth Act of 2014.

House Bill No. 4199, also known as the Telehealth Act of 2014, declares that “the State shall protect and promote right to health of the people and instill health consciousness among them. Henceforth, it is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with health provider. Telehealth or Telemedicine shall not be construed to alter the scope of practice of medicine or any health care provider or authorize delivery of health care services in a setting or in a manner not otherwise authorized by law.”

Aside from the objective I mentioned above, other objectives of this Bill are to reduce the costs, set standards and establish regulations regarding the field, and strengthen the health system and infrastructure.

There are 20 sections to this Act. I have chosen the following to evaluate.

Section 9. Database. – All telehealth center and originating sites shall coordinate with DOH for consolidation of pertinent databases. DOH shall maintain and manage a national database for consults on clinical cases as well as health and medical education exchanges. Considering how important documentation is especially for something like this, I feel as if this section is severely lacking.

Having read the comprehensive IRR of the Data Privacy Act of 2012 in the previous blog, this, to me, needs further details. At the very least, the basic contents of the database should be enumerated. I would like to know if there are other types of data that should be gathered/documented when a consultation is done via telehealth.

Section 16. Standard of care. – The standard of care is the same as regardless whether a health care provider provides health care services in person or by telemedicine. Telehealth or telemedicine shall not be construed to alter the scope of practice of medicine or any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law. Telehealth shall not replace health care providers or relegate them less important role in the delivery of health care. The fundamental health care provider-patient can not only be preserved, but also augmented and enhanced. While I agree that the standard of care should be the same whether the consult is done in person or via telehealth, I think the Bill fails to capture the limitations on this type of service. Granted that the scope of medicine (or allied medical services) will not change in terms of what a doctor can do, it should also acknowledge that that the things a doctor cannot do. There  is a science to the practice of medicine (and other disciplines) that simply cannot be done via a video call or similar means. Section 5. Scope can be elaborated further to include limitations. Or limitations could be in a whole new section together, and in that section include what can and cannot be penalized. The way I see this Bill so far is that it is not healthcare provider-friendly. The providers are not protected the same way the patients are.

Overall, a good portion of the Bill, in my opinion, needs further refinement apart from the 2 sections I stated above. But the fact that it exists is promising, as this legitimizes the practice of telehealth (or telemedicine). This field will open up a lot of opportunities especially for patients and will help in positively changing the landscape of healthcare delivery to the Filipinos.

Have you read the Telehealth Act of 2014? What do you think? How open are you to the idea of using telehealth services? How do you think will that impact the way we practice medicine in the Philippines? Let me know in the comments below.

XO,
Eve


References

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Personal Health Records – The Patient Tool

We’re more than halfway through the semester and I can honestly say that this course has been very enlightening so far. Over the first half of the semester, my preconceived notions about health informatics especially in the Philippines was basically shattered, and I am discovering that there is so much more to learn from this course than what I initially thought.

That being said, let us now dive into this week’s topic – personal health records.

The question we were asked was…

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

In last week’s blog, I discussed electronic health records (EHR). In researching for that topic, it was only then that I realized that EHRs are not synonymous with electronic medical records (EMRs). I also learned that automated health records (AHRs) and computer-based patient records (CPRs) are also different. Now we will be adding patient health records (PHRs) to the mix.

According to HealthIT.gov, a personal health record or PHR is an “electronic application used by patients to maintain and manage their health information in private, secure and confidential environment.” The key phrase here is “used by patients”, since that is the main distinguishing feature of the EHR from the AHR, CPR, or EMR (Ideally in EHRs, there should be a component where patients can manage their data as well). Through PHRs, a patient can be more involved or proactive in the management of his own health since it allows him to enter, view and modify health data into the application. Aside from being a static repository of data, the more advanced PHRs have decision-support capabilities that assist patients in managing their conditions. They have the potential for to help analyze a patient’s health profile, identify health threats or deviation from normal at an earlier time which leads to prevention or early intervention, or provide improvement opportunities based on analysis of drug interactions, gaps in current medical care, and identification of medication errors. When the PHR is also made accessible to the clinician or health care provider, it facilitates communication between provider and patient for continuous exchange of health data.

With the rapid developments in technology also come numerous attempts at personal health record softwares or systems. However, PHRs have not received the same attention as EHRs and EMRs. There are several issues that arise when it comes to its adoption, and I believe that the two main issues are:

  • Quality of data – Since in PHRs patients are mostly the ones who enter the data, then how accurate are the data? Are they entered using medical or laymen terminology? Are the diagnoses accurate? Are the medications accurate? What about the laboratory and diagnostic results? Are they entered correctly? Abundant but poor-quality data defeats the purpose of the PHR.
  • Security and privacy of data – Most PHRs are web-based or mobile applications that were developed for commercial distribution and use. Unlike EHRs and EMRs with more robust security features since they are usually linked to bigger institutions, PHRs are, as mentioned, often web- or mobile-based. Data contained in a mobile app, for example, may only stored in the mobile device. If there is an option to store it elsewhere, it usually in a cloud-based storage (which is often another application not primarily intended to store medical data). Or the data could be exported as a PDF or Excel or Comma Separated Values file, and then sent to an intended user (ex. physician) via email. The transfer is usually not encrypted and therefore vulnerable to breach or exposure.

What, then, are the criteria for a good personal health record system or application? Kim and Johnson (2002), in their paper Personal Health Records: Evaluation of Function and Utility, reviewed and evaluated several web-based PHRs that were available the time based on several criteria. Under function, they evaluated the website application in terms of access, medical conditions, medications, laboratory test, diagnostic tests, and immunization. As for utility, they assessed whether the application could incorporate data to manage conditions at a basic and more comprehensive level of representation. The overall conclusion of the study was that the PHRs available then had limited functionality and therefore had limited ability to serve as adequate representations of medical information for use in clinical practice.

Basing on Kim and Johnson’s paper, the identified barriers to adoption and on my personal experience as well, I developed a scoring system for the evaluation of PHRs. This, in a way, also helps answer the driving question for this week “What features are considered critical or most useful by users of Personal Health Records?”

screen-shot-2016-10-06-at-8-37-14-am

Each criterion is will be scored from 1 to 5, with 1 being the lowest and 5 the highest. The rating per category will be averaged at the end, and the overall score will serve as basis if the app will be recommended or not. PHRs that scored 5/5 will be highly recommended, 3-⅘ as recommended, and 1-⅖ as not recommended.

To explain further the scoring system I created, I signed up for personal health record. I was not able to find a PHR that was made or based in the Philippines. I settled for the top hit in Google, which is the application My Medical.

See slide presentation below for my review of the application.

I, personally, am very interested in PHRs because aside from the fact that I am a neat freak and I want to keep things organized, I am also a patient (under the care of multiple health care providers). I actually have a big binder at home documenting my health since 2007. It is a pain to carry it around whenever I have to visit my doctors, and after 9 years, the method is just not efficient anymore. The app I reviewed above will work for me because it appears more to be a static repository of data, which I prefer. However, non-medical personnel or laymen who want to use this to gaina more proactive role in the management of their health might find some of the features lacking, because it has limited decision-support capabilities and the means for communicating the health data contained in the app to a health care provider is also limited.
Disclaimer: The application is not sponsored and I paid for the app with my own money.
And that is it for this week’s blog! Do you agree with the scoring system I made? Are there other features you are looking for in a personal health record that were not part of my criteria? Given the features I showed above, is the app something you would consider using as well? Or have you tried other PHR applications?
As always, let me know in the comments below. Your input will be very much appreciated.
XO,
Eve

References:

Health Informatics in the Philippines – How Do We Move Forward?

It’s another week in our Health Informatics 201 class, ergo another blog post is due. For this week, we were tasked to answer the question…

How can we advance the field of health informatics in the Philippines?

Before we can move forward, a review of the current status of HI in the Philippines is imperative. Below is an infographic to help illustrate the rest of the contents of this blog.

HI 201 - W3 - Infographic

One of the earlier papers published that described the HI in the Philippines is by Dr. Marcelo in 2006. In his paper “Health Informatics in the Philippines”, he recounted the practice of biomedical informatics in the Philippines from the early 1980s and later on briefly told about how the Medical Informatics Unit of UP Manila was established. He then discussed infancy of health information system projects until the creation of this course. He considered the Masters of Science in Health Informatics as being at the center stage in HI in the Philippines. The paper was a decade old and gave the impression that while the field may be young, it held much promise in terms of healthcare in the years to come.

I remember thinking that the paper was written at the time when the first Nokia phones were gaining popularity both locally and globally. The same way that mobile phones have significantly evolved since then, the field of HI has had many milestones as well. In the following paragraphs are brief descriptions of some of those advances.

UP Manila is currently on its 11th batch of students for the MSHI program. Even though it is still the only program of its kind in the country (i.e. a masters degree), a similar course which offers certifications is now being offered by De La Salle University – Manila, in partnership with Electronic Health Records Philippines – Inc. They offer an online health informatics course that has two tracks – one for health professionals and another for IT professionals.

CHITS, which is short for Community Health Information Tracking System. It is a free and open source software electronic health record for the local government health centers in the Philippines. It is being managed by the UP Manila – National Telehealth Center and has been present since 2004. This software was integrated into RxBox, which is an ICT innovation designed to support DOH’s call for universal health care. The RxBox is a described as a telemedicine device capable of capturing medical signals, storing data in an electronic medical record or EMR, and transmitting health information via internet. The target areas for the this device were the rural health units/local health centers in geographically isolated and disadvantaged areas. Currently, the devices are deployed in 143 sites scattered throughout the Philippines.

On the other hand, eHealth Philippines is a community resource catering to health enthusiasts, experts, and researchers. They provide resources such as articles for their members, and conduct discussions and/or fora on various health-related topics. Meanwhile, HealthXPh is collaborative effort by healthcare stakeholders to discuss and use emerging technologies and social media to positively impact the Philippine health landscape. Like eHealth Philippines, they regularly conduct discussions through Twitter and Google Hangout Air that aim to educate all healthcare stakeholders and encourage collaboration and application of emerging technologies to improve the delivery of healthcare. In 2015, they pioneered the Healthcare Social Media Summit in Cebu and brought together different stakeholders to discuss the role of social media in healthcare.

Speaking of summits, another one is the eHealth Summit organized by the DOST-through PCHRD and DOH, the first of which was conducted in 2014. Similar to the aforementioned summit by HealthXPh, this is a venue for the different stakeholders to come together and discusses the many aspects and developments in terms of eHealth in the country.

Another advancement is in the field of HI is the presence of Health Research and Development Information Network (HERDIN). Gone are the days of manually looking through books, publications and whatnots for health-related data since HERDIN’s database provides access to both published and unpublished Philippine journals, conference proceedings, international databases, thesis and dissertations to name a few.

Finally, there’s the nationwide emergency hotline number – 911. This, to me, is one of the more impressive achievements of the Duterte administration, considering he has only been president for less than 2 months. Prior to the launch of 911, emergency services in the Philippines were decentralized. So far, I’ve read some feedback that the 911 system actually works and has helped not only address medical emergency but safety concerns as well.

Although no longer included in the infographic, “eHealth” has also been more used in private institutions in several ways. For example, St. Luke’s Medical Center in Quezon City and Bonifacio Global City offers a lot of online features for their clients. Patients can view their laboratory and diagnostic results online, as well as avail of other services like room booking and scheduling an appointment. They have also been electronically archiving their patient charts, and are moving towards the use of electronic medical records. Similar offerings can be found in other institutions such as Makati Medical Center (another private hospital), or Hi-Precision Diagnostics (a chain of private clinics). Even companies that are not healthcare facilities per se like Chevron Holdings, Inc., a private multinational company in the oil and energy industry, is employing the use electronic medical records as part of their clinic management system.

I’m sure that there were many other advances in the field of HI that I was not able to tackle, but I hope that what I’ve written above so far has given you more or less a better picture of how HI has progressed in the Philippines.

Going back to the driving question, how then can we advance the field of HI in the Philippines?

I have listed 9 different but interrelated aspects which I feel should be focused on.

First is the investment in the education of future stakeholders. We are currently in a digital age but the integration of healthcare seems to be lagging behind. The mere fact that there is only one masters program offering HI reflects a shortage in the opportunities for learning. As a physician in particular, I would love for health informatics to be incorporated in the doctor of medicine curriculum across all the medical schools, so that our future physicians will be more equipped not just with clinical knowledge or the digital savviness but also with at least an awareness of how they can contribute to the advancement of the field of HI. Nursing informatics is already being taught in nursing schools, and the medical schools definitely need to catch up. IT professionals should also be more given more opportunities to specialize in the field of or learn more about health informatics, as they will be key to the development of healthcare technologies.

Second is the training and enhancement of the knowledge and skills of the current workforce. Since health informatics is a relatively young field in the country, many healthcare professionals (HCPs) do not have a clear picture of what it is. In contrast to millennials and the younger generation who can easily navigate new technologies, the older population of HCPs (ex. doctors, nurses, barangay health workers in urban and rural areas) who are not as tech savvy may find it difficult to implement the new changes that are being introduced, such as the switch to electronic medical records from paper charts. This can lead to resistance to change or an impediment to the diffusion of an innovation, as discussed by Cain and Mittman in their iHealth Report entitled the Diffusion of Innovation in Health Care.

Third is the collaboration with key players. I’m using the term key players to loosely refer to anyone who has a say in the decision-making for any innovation that in the healthcare field. They can be the businessmen who will invest in the technology, researchers and developers, administrators of hospitals, legislators, etc. The field of healthcare in general has always been dynamic and technological advances are rapid. Communication channels should always be open so that there could be opportunities to collaborate and innovate.

Fourth, since a lot of the features of successful delivery of eHealth is done via the internet, our network infrastructure should also be improved. The Philippines is notorious for having one of the slowest and most expensive internet connectivities in the world. For HI to advance, our internet connection has to be significantly improved as well. Introduction of foreign telecommunication companies to increase local competition hopefully can drive our current providers to provide better and cheaper services.

As of 2016, 44.5M of the Philippine population uses the internet, translating to around 43.5% penetration rate. Globally, we account for 1.3% of the share of world internet users. In particular, Rappler reported that our mobile phone subscription has a 117% penetration rate. An average PH internet user spends 3.2 hours per day on his/her mobile phone and 5.2 hours on the desktop or tablet. The top online activity is engaging in social media (47%), followed by watching videos (19%) and playing online and mobile games (15%). HI should capitalize on these data. Mobile applications as means to deliver healthcare should further be explored. A strong social media presence would also be an advantage, because it has more potential to reach a wider audience. For example, health awareness initiatives may be best promoted via social media campaigns. Any type of information could easily be at the fingertips of the Filipinos as long as they own a mobile phone and have access to internet. We have to make sure that health-related information will be included in the list of those that they can easily have access to.

Next, creation and amendment of eHealth legislations should also be prioritized. Legislations play a significant role in the implementation of programs and in their funding. For example, if there was a law mandating all schools to incorporate health informatics in their curriculum, learning about HI will no longer be an elective or an option but something standard across all the schools offering that course. A law or bill mandating an initiative like RxBox would also affect the budget allocation of the government agency  responsible for said initiative.

Lastly is centralization. The proposed Philippine Health Information Exchange, for example, was planned to be rolled in late 2014 but has not been implemented until now. That would have allowed establishment of a centralized system for health registries and linkage systems. One of its planned features was the ability to store basic medical records of patient admitted in government health centers to ease the decision-making of professionals. Consequently, referral system would be improved as well as continuity of care. It is something that I feel would significantly benefit the public health sector in particular, but unfortunately it is still not being implemented. Meanwhile, at present, a number of private institutions already use electronic medical records or have in some way or form electronic databases. But since these were developed specifically for a particular company/institution, the systems they use are different from one another. It would be ideal if we can start with having a centralized healthcare system at least for the public sector first, and then we could explore linking it to the existing systems of private institutions. The idea seems grandiose and will probably be painstakingly hard, but ultimately the Filipinos will benefit from a more organized and efficient national healthcare system.

That is it for this week’s apple! To be honest, what I learned when I researched about the current health status of HI in the Philippines surprised me because I was so immersed in the private health sector that I did not know there were already a number of advances in the field led by the government agencies.

My questions for you this week are…

What are the some examples of health programs or campaigns that you were made aware of through social media?

Comments, suggestions and discussions are very much welcome on my blog. Leave a comment down below and let’s discuss and learn together.

XO,
Eve


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