Knowing the security risks

Scenario:

You are part of a group practice that has decided to implement an electronic solution for clinical documentation. However, you have come across many horror stories regarding health information security that have led to failed clinical information system implementations. How would you prevent this from happening to your group practice?

When it comes to healthcare, the overall service to the people that comes with it may be the most important role. However, protection of the patient’s privacy and confidentiality plays vital. Maintaining privacy and confidentiality helps to protect participants from potential harms including psychological harm such as embarrassment or distress; social harms such as loss of employment or damage to one‘s financial standing; and criminal or civil liability.¹ The importance of this domain is sometimes neglected due to the unforeseeable hazards that it impose. However, in this environment where change is constant, personal data can be an attack point of malicious people that might lead to enormous damage not only to the patient but to the institutions as well.  In line, the value of personal data restrictions became a subject of fortification in the medical world especially on health IT.

Going back to the case, the integration of an electronic solution for documentation may be the best or most beneficial intervention the institution to improve their services or eradicate the issues of good quality data. However, this might pose issues on certain grounds that might garner negative or positive outcomes. Overall, the solution will provide a lot of pores that the group might want to cover. Aside from the workflow integration, security is the next topic that the group should focus to in order to address the threats to patients’ privacy and confidentiality. To repulse the threats that the solution might get, I formulated some steps that can help counteract these issues before acquiring the product that will be used as an intervention.

   

Establishment of the security baseline

Implementing a decision that might affect the workflow of a medical institution through incorporating/ altering the normal scenarios requires a validation not only from the top-level decision makers but also from the workers as well. A technical working group (TWG) might be essential to gather all the necessary consensus and issues. All the departments should be engaged and represented. A part of the group will be the lead on data security (Data Security team) and should be responsible in consolidating the security baseline from all the members by using these guide questions:

1. If your department/ group manual operations will be converted to electronic, what is the most effective security that you can suggest?

2. What would be your suggested methods for optimum data security?

After consolidation, the Data Security team will summarize the results and present it on the TWG. The TWG will then vote for the most appropriate data security method. Through this the whole institution will agree and support the method since it is a consensus. Shooting two birds with one bullet, the baseline was also established.

Imposing the baseline while selecting the best product

From the baseline, the security criteria can be set and should be satisfied to the software development team or the vendor. Upon inquiry for possible companies that will sell their products or development services, the group may ask the following:

1. Does/Can your product meet the security requirements the TWG is suggesting?

2. If not, what other plausible methods that can replace the features set by the TWG?

From here the developers or vendor will design the most effective security providing the framework, network structure, levels of protection and additional security features. The criteria should match the output of the TWG. All of the changes should be consulted to the technical working group before giving the “GO” signal to the developer or vendor. Selection of the best product that can cater all the needs (aside from security) will commence.

Using the product

By providing risk assessment and analysis, potential threats can be counteracted. Risk analysis is the process of identifying the risks to system security and determining the likelihood of occurrence, the resulting impact, and the additional safeguards that mitigate this impact. Parts of risk management are synonymous with risk assessment.

A. Server and Network Infrastructure- The server is the main brain of any electronic solution (i.e EMR, EHR, PHR, etc.). May it be a localhost, cloud server or in-house server, the set-up may still be breached.

1. What are the protection methods in place? (i.e. Firewall, decryption, antimalware, antivirus, intensive authentications)

2. Who will be authorized to access the server? (i.e. upgrades, archiving, release of patient data)

3. Who are given the authority to access administrative access? (i.e. generation of reports, adding/ removing user accounts, checking data duplicates, etc.)

4. Are security questions available for changing username/ passwords?

5. Is the server accessible through a public LAN or WAN?

6. Who will be providing maintenance to the server?

7. Where will be the server placed? In what section or department?

B. Hardware and software- can be a vital part of any information system. As discussed, the terminals, units or lines can be vantage point of an attacker or a person with malicious intent.

1. What will be the operating system of the server? of terminals or relay stations?

2. Does the operating system have internal security/ protection? Is the OS vulnerable to malware/ virus/ adware attacks?

3. Will terminals have an OS log-in for added protection?

4. What are the accessories allowed to be attached in the terminals?

  

C. Health workers- are the primary users of the product and should be given extensive precautions.

1. Who will be the primary users of the software in each department?  

2. Will a regular account be given to visiting physicians/ health workers?

  

3. Who will provide technical support in case of issues or technical problems?

4. Are users in the department allowed to give personal data of clients to requestors such as the police, other regulatory authority or the patients themselves? If not, who are allowed?

D. Policies- Policies will give a strong foundation for the standard operating procedures that may strengthen the protection of patient’s personal data.

1. Does frequent password change occur?

2. Are the users allowed to share their account details such as username or password?

3. Will an encoder be allowed for computer illiterate health workers?

4. Is insertion of flash disks allowed in the terminals?

5. What are the steps needed by patients or authorities in acquiring personal data?  

6. Who will be the person liable in case of breaches? What are the actions/ penalties that will be imposed?

Note: The above questions were just formulated. One may add or remove queries accordingly to suit their needs.  

1           "Privacy and Confidentiality." Privacy and Confidentiality. Web. 20 Mar. 2016. <http://www.research.uci.edu/compliance/human-research-protections/researchers/privacy-and-confidentiality.html>.

Penetrating the Barriers

The Department of Health is one of the leading offices that advocate the eHealth perspective. Through the establishment of the eHealth Steering Committee, the government seriously took the challenge of implementing innovations such as electronic medical records, mobile health applications and the like. Though this national strategy proved to be effective, barriers and hurdles are still imminent.  

Change process is difficult to measure however creates a significant impact. This barrier includes components such as organizational structure and behavior. Getting the organization/ facility on board will certainly be a dilemma. Resistance may be imminent for some especially those entities who are not amenable on drastic changes in management and operations. However, getting the top level management's (leader/ steering committee) buy-in may resolve the crisis. In an institution or facility, a leader or a champion (usually physicians) can be a driving force for adoption and positive behavior towards the use of any product or technology that changes their norm or work environment. In an article, it was stated that Physicians’ adoption or avoidance of the EHR impacts hospitals both in financial sector and quality of care. Physicians, especially those in private practice, perform a pivotal role in directing where their patients go for treatment. If a physician decides to renounce his privileges related to an EHR mandate, the hospital may experience a drop in revenue.¹    

For the behavior component, laggards² who comprise the 16% of the population (health staff) may not consider the use of technology during the first encounter and will take time to accept the system. In connection, age and experience may be considered a major factor in this area. These factors affect the performance expectancy, effort expectancy, and social influence and facilitating conditions as stated in the Unified Theory of Acceptance and Use of Technology (UTAUT) framework.³ To mitigate this, the development of the software should always include the champions and end-users. Engaging and preparing them early, may warrant a more rapid acceptance by the system users. To summarize, change management/ process should be mainly considered, once this barrier is handled, seamless integration and implementation will follow.        

Another barrier that plagues the continuous deployment of these systems is the financial aspect. Let us admit that “money’ enables the movement of the project timeline. The high cost of start-up, deployment and maintenance is seen as a hindrance to sustainability. A cost estimate made by www.healthit.gov for Software as a Service (SaaS) type of deployment in the US shows an average $8000 dollars as yearly cost. A deployment combined with a long term support may cost up to $58,000, 38% more expensive.⁴ From this cost study alone, one can figure out the enormous amount of money to be disbursed. The government can provide all the necessary expenses, however in some instances, it may be limited or not enough. Expect that the resources may not be channelled accordingly as prioritization may affect technology related projects.      

One of the many financial factors is the staggered and long process of materials procurement. This factor directly and indirectly affects the project foundations, development, implementation and support. An article from the Senate Economic Planning Office recognized these as a problem by stating this in their August 2008 Policy Brief, stated that government procurement time has an average of 7 months.⁵ Provided this situation, a project may suffer and returns a domino effect and again, the timeline is usually at stake. It may then leads to lower quality of software development (including the planning and design) then the apparently may affect the entire operation.

Lastly, technical will be one of my topmost barriers to consider as these elements may predict the success/ failure of the EMR in the facility. Having a quick rundown, this barrier listed these factors:

End-users’ computer skills, complexity of the system, physical hardware and software concerns, connectivity, lack of infrastructure and technical support.

First and foremost, infrastructure should be evaluated because this will the backbone of the EHR/EMR. It should be laid down before anything else. In the 791 Philippine public hospitals⁶ , there is a big possibility of encountering facilities with “less to no” ICT infrastructure. From here, proper resource allocations, policy making (governance) or technical assistance (last option) may aid as countermeasures. The idea is that the foundation should be in place before the software will be utilized.    

Technical and organizational factors, including support, are widely acknowledged as important for successful implementation and promotion of Health Systems effective use of Health Information Technology (HIT).⁷ This domain will always be an enabling mechanism of sustainability and maintenance aside from the upgrades and preventive services. That is why it is crucial that technical support should be planned ahead, even during the inception phase.

Erasing the age factor, the usability of the EMR will always depend on the skills of its end-users. As an implementer, the project team is responsible to assess the computer competency and assess a viable training plan. Complexity should be eliminated by creating simple user interface (UI) that is integrated in their manual-based workflow. User Interface is one early attempt to achieve some uniformity among health IT UI by collecting empirically validated designs with descriptions of their qualities and applicable contexts. Continuing and building on this type of work will allow for the development of intuitive, adaptive displays with the capacity to effectively support the evolving role of EHRs in clinical practice.⁸ However, technology should always be just an aid to their daily operations; it should not replace their accustomed system. Connected to the human barrier, the skills should be enhanced. Short courses for healthcare professionals and continuous medical education programs should be provided on the subjects of EMRs and health information management⁹ during implementation.

       

References:

1          Luchetski, J. R. (2009, December). Physician Champion Role in an Electronic Health Record Implementation, a Case History. Retrieved February 25, 2016, from http://digitalcommons.hsc.unt.edu/cgi/viewcontent.cgi?article=1093&context=theses

2          Diffusion of Innovation Theory. (n.d.). Retrieved February 25, 2016, from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models4.html

3          Phichitchaisopa, N., & Naenna, T. (n.d.). Original article: FACTORS AFFECTING THE ADOPTION OF HEALTHCARE TECHNOLOGY.Retrieved February 24, 2016, from http://www.excli.de/vol12/Naenna_13052013_proof.pdf

4          Retrieved from: https://www.healthit.gov/providers-professionals/faqs/how-much-going-cost-me. How much is this going to cost me?. Accessed 2/24/2016.

5          G.H. Ambat and Renard Kayne Ycasiano. Policy Brief: Plugging the Loopholes of the Philippine Procurement System. August 2008. Retrieved from https://www.senate.gov.ph/publications/PB%202008-05%20-%20Plugging%20the%20Loopholes.pdf.

6          Health Service Delivery Profile – Philippines (2012). (n.d.). Retrieved February 25, 2016, from http://www.wpro.who.int/health_services/service_delivery_profile_philippines.pdf

               

7          Khalifa, M. (2013). Barriers to Health Information Systems and Electronic Medical Records Implementation. A Field Study of Saudi Arabian Hospitals. Procedia Computer Science, 21, 335-342.

8          Shachak, A., Montgomery, C., Dow, R., Barnsley, J., Tu, K., Jadad, A. R., & Lemieux-Charles, L. (2013). End-user support for primary care electronic medical records: A qualitative case study of users’ needs, expectations, and realities. Health Systems Health Syst, 2(3), 198-212. Retrieved January 25, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/26225209

9          Electronic Health Record Usability:Interface Design Considerations. October 2009. Retrieved from https://healthit.ahrq.gov/sites/default/files/docs/citation/09-10-0091-2-EF.pdf

                

Factors affecting EMR Adoption, Use and Data Quality

Article: 

Physician user satisfaction with an electronic medical records system in primary healthcare centres in Al Ain: A qualitative study

Alawi, S. A., Dhaheri, A. A., Baloushi, D. A., Dhaheri, M. A., & Prinsloo, E. A.

1. What are the key points of the article? 

The article discusses the strengths and weaknesses of an Electronic Medical Record (EMR) called Cerner which is deployed on rural areas of a highly developed country in the United Arab Emirates. Cerner Solutions is a medical software company based on Australia. It has a range of applications from critical care to primary care among others.  

(1)Cerner® solutions enable physicians, nurses, and other authorized users to share data and streamline processes across an entire organisation. An online “digital chart” displays up-to-date patient information in real time, complete with decision-support tools for physicians and nurses. Simple prompts allow swift and accurate ordering, documentation, and billing.

The company was awarded by Al Ain, Abu Dhabi as their EMR and was implemented last 2008.  A complete suite (patient-centered modules, labs, referral and reports) was implemented in these Primary Health Centres. 

In this study, the satisfaction of the physicians interviewed were gathered and summarized into themes, mainly: 1) Physician-dependent factors, 2) Patient-related outcomes, 3) System-dependent factors and 4) Suggestions. The themes were further specified and dissected in this table (2):

Physician- dependent factors

The table provided us a bird’s eye view to extract the advantages and disadvantages of having paperless / less-paper systems. Based on the Physicians’ answers, adopting the system in the beginning is difficult. Computer skills aspect was a major setback especially with aged doctors (but not all) experience technology gap. However their perception of the system’s usefulness reflected in the study.

Patient-related outcomes

The doctor- patient relationship was affected since the eye to eye contact was decreased. Waiting time for the patient has lengthened according to the responses. This is an opposite of what an electronic method is promising. However, patient acceptance was noted by the physicians.

System-dependent factors

This factor was the bulk of the responses. Important factors were considered here like:

Positive themes

a. Good quality documentation (inserting the Good Quality Data as identified by the WHO)

b. Prescription is much better

c. Decreased errors especially on medications

d. More organized orders and results

e. Referral system is easy

Negative themes

a. Complexity of the system affects use

b. Compatibility of the system with the facility’s operations

c. Takes (Time on encoding is longer, loading spinners)

d. Confidentiality of patient is at risk.

2. What lessons learned does it describe?

Four (4) key points to describe the lessons that I’ve learned from the article

Systems strive hard to achieve perfection

There is no such thing as a perfect system. Even though Cerner is an established company and there are a hundred to a thousand dedicated developers, however, it cannot fully determine how the system behaves based on some factors. There are very minor loopholes which can create massive damages when given the opportunity.

Integrate with the facility’s workflow

Workflow integration is crucial. This will dictate the usability of the system, it’s ease of use and how will it be adopted.  When deploying a system to a facility, consult and develop the system together with the health workers who will use it.  

    

Satisfy your customers

End-user suggestions are very important. The lessons learned in the first implementation combined with user experience are a good precursor of a better system. Additionally, provide optimum user support. Health workers, though others can be tech savvy, have many responsibilities aside from encoding data in the system. Technical support is an enabling factor to consider when it comes to usability.

Protect your patients

The local or the cloud database can be compromised at times. Always consider the threats for patient confidentiality and privacy to alleviate the need for legal countermeasures and patient and user distrust.     

3. How can this relate to the local setting in the Philippines?

There are similarities between the case of Al-Ain and the Philippines. First, like Al-Ain in 2008, the Philippines is now into manual to electronic-based transition. The difference however, given the challenges of our geography and dialects make, we have a lot EMR’s who are already deployed unless all are amenable to have a sole EMR that will be used nationwide. The problem will manifest when the Government decides to unify all health records and I think we are a bit late on this. To mitigate this, the country launched its advocacy for interoperability (PHIE) however a great deal of time is needed to settle the issues. A lot of aspects should be considered: Connectivity, Electricity and budgetary problems for the recipients while business, politics and legacy for the implementers.

Second similarity would be the technology adoption. Age may not be a factor for some but for me, it does matter. As an EMR implementer myself, I’ve encountered a lot of aged health workers who are laggards when it comes to technology adoption or are having difficulties in using devices (computers, mobile phones, etc.). A thorough and intensive training is required to alleviate this problem. Another measure would be  to select a champion in a form of the facility’s manager/leader, who will steer his/her staff to use the system. A robust end-support should also be established to counteract the problems with ease of use and system usability.

System implementers should be visionaries. They should always think 2 steps forward. Risk management while still on the conceptualization stage would greatly benefit the deployment. From the workflow design to hardware specifications, identification of the possible issues and their corresponding interventions is important. In this way, problems about confidentiality and workflow compatibility are lessened. Sometimes the government lacks these traits, making them vulnerable to conduct unpolished systems. In the end, user and patient satisfaction will mainly suffer as a consequence. 

Sources:

(1)   http://www.cerner.com/solutions/Hospitals_and_Health_Systems/.Accessed January 27, 2016,

(2)   Alawi, S. A., Dhaheri, A. A., Baloushi, D. A., Dhaheri, M. A., & Prinsloo, E. A. (2014). Physician user satisfaction with an electronic medical records system in primary healthcare centres in Al Ain: A qualitative study. BMJ Open, 4(11). Retrieved from http://bmjopen.bmj.com/content/4/11/e005569/T2.expansion.html

     

The HI 201 End of Semester Report

The first semester of the Masters of Science in Health Informatics (MSHI) course was a very memorable and exciting experience for me. It was a mixture of happiness and anxiety as I was about to enter school again after years of stagnation. One thing more that made me nervous is that it is my first time to work and study at the same time and I do not know if I will be able to cope up with the changes.

Week 1

http://wheresthesausage.typepad.com/my_weblog

          

I’ve enrolled as a part time student and one of the subjects that the course required was to take the core, HI 201- Health Informatics. During the first day of our class, the subject deliverables were explained and was tackled one by one. The professors were also named ahead. I was astonished by the roster, having great names to teach us the foundations of Health Informatics like Dr. Iris Isip-Tan, Dr. Alvin Marcelo, Dr. Mike Muin and the latest addition to the field Sir Isidor Cardenas will be such an honor. As I browse the components of the subject in UVLE, I know my knowledge in the field will be enriched and the questions that I was looking forward to be satisfied will be answered. To start the course, we were asked to express our expectations through writing and blogging. This is like setting the expectations in hardcore mode. After many years of being in front of the computer and using social media, it was my first time to have and man a blog.

http://www.health.wa.gov.au/snapshots/wachs_kimberley_ehealth.cfm

Week 2

We were asked to answer the relevance of Global Health and eHealth through a concept map. Constructing a concept map is difficult because first of all, it was my first time constructing one and I do not know what tool to use for this. I looked samples in the internet and asked my higher batch for this. Luckily, they were kind enough to show me what they did for the same subject. The theme, explain the linkages between Global Health, Informatics and eHealth. Learnings from this assignment took me back to my roots, community health. I’ve engaged Informatics as an integral part of Global Health by means of its nature of creating innovative ways to make the domain easier to understand and provide solutions to known problems. I’ve described Informatics as the bridge that binds the two fields. The role of eHealth (Health through the form of informatics) is one path of achieving optimal global health.

Week 3

http://bachelordegreelink.com/how-earn-bachelor-health-informatics-degree#formPage_1

What are the factors that hinder the advancement of Health Informatics in the Philippines? This the driving question for this week’s assignment. It should be expressed using an infographic. It was my first time to create one. It looks simple but the task ws difficult. First of all you need to find the right infographic tool for the job, I’ve came across three potential tools and none of them met my expectations. First  of all, they are not that easy to use and secondly, you need o have a professional account just to use all the images and styles. So I decide to go old school and used MS Powerpoint instead. It is a bit limiting but I was able to pull it off and answer the driving question. During the presentation of our work, we enumerated various factors that affects or may be crucial reasons of bottlenecks of Health Informatics in the Philippines; we went very deep and neglected the academe part of HI. In the end, our Professor, Dr. Iris Isip-Tan reiterated the importance of the academe to the Health Informatics world.  We learned a lot with her words of wisdom and were enlightened about the broad array of the course.

  

http://www.mindmapart.com/3d-thinking-mind-map-paul-forema/

Week 4

Mind mapping is one the things that HI 201 taught me. Through the mind map I was able to think aloud and transcribe it into writing, share my thoughts to my co-students and fix my scattered ideas into meaningful map. This activity allowed us to think about the HIS sustainability in developing countries like the Philippines. We identified the factors affecting sustainability and dig further with the idea. The idea became sporadic until we were satisfied and were able to answer the driving question. Each factor grew into array of problems and possible solutions. It was a good experience for me since it was again my first time to encounter this. It is one great tool to explain the things and ideas inside an individual’s mind especially during project presentations or even just expressing your thoughts.   

http://venitism.blogspot.com/2013/09/the-american-economy-is-not-free-market.html

Week 5

Week 5 was a bit of challenge. We were asked to research on free market forces and explain if it is essential in building a National Health Infrastructure that can support the eHealth Strategic Framework being planned by the government. My stand for this driving question is that our country has too much to learn and we really need aid from the private sector in terms of infrastructure. The possible venue of a private-public partnership (PPP) should be reconsidered but terms should be introduced to avoid total private sector domination. The Government should be the initiator and the one to maintain sustainability. It should act accordingly by establishing laws and rules. This assignment was difficult in a sense that I recognized that we cannot fetter what the private sector has established and that building the government’s own will make it more complicated, meaning that our status will stand back to zero.

https://www.shrs.pitt.edu/mshis

/

Week 6

The Driving Question is: If a hospital information system in one facility is a complex process by itself, how much more complex will a national health information system be? How can government manage this complexity? An information system is complex in the sense that every implementor has many factors to consider. The establishment of an IS (information system) takes a lot hardships along the way. The honest to goodness objective is not enough to properly instate a system that may change people’s lives for the better. Having an initiative is not adequate. Proper dissemination of goals and end-benefits, building a structure communication infrastructure and hand-in-hand cooperation between the private sector, government, end-users and recipients are the essentials of removing the complexity of the National Health System. Planning the early stages using frameworks that suit our country’s status will make the work easier. The most important thing is sustainability planning. We should not be satisfied of just deploying the National Health Information System, we should maintain and upgrade it for the end-users and recipients to continually utilize the system. At the end of the day, our customers, who are the health workers and patients, will matter.   

http://deadlinesandducttape.com/blog/2011/02/17/keep-enterprise-architecture-under-the-hood/

Week 7

This week’s task is to evaluate the 4 frameworks: Zachman, TOGAF, FEA and COBIT5. For me, this the most complicated but very exciting and intriguing week. I believe that the bottleneck of assignments was initiated by this area. One framework will take you 3 to 4 days to study and understand. It took me week to decide that TOGAF was I think the suitable framework for the Philippines. The flexibility nature of this framework made me decide that t can adapt to every aspect of the Philippine eHealth Strategic plan.  TOGAF brings a variety of plans that involve almost all of the agencies connected to the plan. I’ve learned a lot from this assignment, although we were forced to embed these four frameworks in our minds, I am happy to say that the basics were well absorbed and we are ready to be certified and aid in the Philippine eHealth Strategic plan even in our little ways.

http://ihealthtran.com/wordpress/2014/06

Week 8

This was Dr. Mike Muin’s week. The driving question was changed to a series of inquiries depending on the field we are currently working with. I chose the Primary Care Setting for I am part of an Information System deployment team who caters the health centers in Geographically Isolated and Disadvantaged Area’s (GiDA’s). The question: What are the issues and challenges in implementing an electronic health record in the Primary Care Setting? The guide questions were provided and were answered in a presentation slide. Then it was posted in the Basecamp account of Dr. Muin. He commented to each post hoping to ignite the exchange of views between the students and him. It was very fruitful, I’ve learned in the assignment that the preparations we are doing in engaging the stakeholders of the IS lacks certain components to make it more successful. I’ve also learned that sustainability is the key in implementing a successful project for these areas. Additionally, technical support is vital in maintenance and sustainability.     

Week 9

http://cheyenneregional.org/sites/

Shifting from the Global and National Health Perspective down to the specifics was a relief. On this week, the students were asked to evaluate a Personal Health Record existing on the web or in mobile market. I’ve decided to evaluate Clarus PHR, a mobile PHR designed to be portable and complete to suit the user’s need. I utilized the star rating, a common scale used for rating product and service satisfaction. I’ve based the facts from the references provided with some modifications for the rating. Overall, I’ve rated the application to have 3 stars for some of the important features such as security and patient confidentiality are lacking in the application. From this assignment, I learned how to dissect an application b means of evaluating. I’ve also learned that no application for health records is perfect and that security and privacy are the areas mostly neglected. The completeness of the application should always play second to these areas.

http://rdn-consulting.com/blog/2013/07/28/interoperability-arrested-progress/

Week 10

Week 10 was Dr. Mike Muin’s week once again. For this assignment, we were asked to choose from different scenarios and answer its underlying questions. The scenario I chose was of course on the primary health care setting data flow to the national registry. We were asked how the data from the grassroots using different systems can be passed to the national level. We were also asked the role of each system and identify the triggering factor of each information flow. Additionally, we were asked to identify the ways these facilities will communicate to each other through the use of standards and interoperability. I’ve learned a lot from this activity. I was able to lay out the interoperability of the said facilities using my knowledge in EA, Standards and interoperability that were previously tackled in this subject. Fruitful conversations between Dr. Mike Muin and some of my co-MSHI students provided me some insights that I do not usually encounter in the field. I’ve also learned that everyone has unique methodologies in attacking this domain of interoperability.

Week 11

https://one.telehealth.ph/beta/nthc-events/seminarstrainings/chits/

This is my favorite part of the subject. We were asked to evaluate a Clinical Decision Support component of the Community Health Information Tracking System (CHITS). This information system is close to my heart for the reason that this is a project component of the program our institution currently deploys. CHITS has evolved from basic modules to the different vertical programs of the Department of Health. Alongside with the evolution are clinical decision support components that can aid healthcare professionals deliver optimum care to their patients. It continues to improve to help in achieving better clinical outcomes. The most recent addition to the system is its inventory and appointment system that can aid critically to a community health center decision making. Its automatic computation of BMI, ratios, Expected date of confinement, AOG and Maternal complication risks are just some of the added features compared to the lower versions. Clinical decision support system is one important section an information system should have. It is a great help in making the lives of the health professionals and patients easier and more efficient in terms of providing interventions like treatment, counseling and referral.

http://blog.piratelufi.com/2012/08/data-privacy-act-is-finally-signed-by-aquino/

Weeks 13 and 14

The Data Privacy Act of 2012 has been existing for 2 years and yet it was not yet well implemented. In this assignment, MSHI students were asked to evaluate its adequacy as a law. As per my personal views, it is adequate for it is a customer-centered act. It penalizes mainly the controllers of data which should be the real case. Upon my review of the law, it will benefit everyone’s health data including those whose data are being processed here in the Philippines. The idea of protecting health data is critical given that we do not have adequate protection of these here in our country. The data privacy act enforces everyone to secure the data under their jurisdiction which in return has a great impact on the economic state of the Philippines. As for my insights in this case, I’ve learned how to dissect an act essential to the health informatics world, together with the Cybercrime law, this act will give patients the edge in making sure that their personal health records are safe from persons with malicious intent. For me, I am glad these laws are enacted upon. This means we are slowly gearing up to long term plans of going electronic and be interoperable.

http://www.naccho.org.au/telehealthinfo/home/

Week 15

The task is to pick and evaluate two sections of the proposed Telehealth Bill. The bill was initiated in congress by Congressman Joseph Emilio Abaya, an advocate of the initiation of telemedicine in the country. Together with lead agencies like the Department of Health, the bill was pushed further to Congressional hearings. After years of struggle, it slowly faded away. MSHI students were asked to review the bill and suggest revisions if there are any. As the reports are being presented, we have noticed that the flaw in building the National Telehealth Board and its functions and roles. During the Monday reporting, almost all noticed that the National Telehealth Board part has missing components and members and its responsibilities exceeded what a Board should really do. Learning from the week’s task, we suggested possible revisions on the act. Health informaticists should be aware of the existing laws and acts. He/she should always be vigilant and an advocate of these laws. The review of bills and acts connected to Health Informatics is a good exercise of one’s freedom and professional advocacy, for in the long run, it will not only benefit the patients and users but also profession.

PHC eTriage mock up

Week 16

The assignment for this week was very exciting. We were tasked to propose a mHealth application that does not exist in the market. It should not duplicate any idea that is out in the mobile application stores. Given the chance to propose an application that, I focused on finding a solution on a RHU’s lifelong, problem patient queuing and triaging. I’ve created a mock up to further explain my application’s functionalities.  How is it unique to other triage application? It is patterned to a Philippine Health Center standard workflow. This is definitely a new experience for me, designing and proposing an application was never my forte. Hi 201 provided me this opportunity to showcase my talent in designing and conceptualizing. This assignment was retweeted by a Doctor in Ireland. I was surprised that my blog was followed by the international community, thanks to the network PMIS and UP MSHI provided me.  

Taken from Brain Doctor game

Week 17

The last topic was about gamification for health. This was handled by Sir Isidor Cardenas, one of the recent MSHI graduate and an expert on games related to health. His “Gobbles” became the template of MSHI students who are into programming and developing serious gaming (health). On this assignment, he asked us to evaluate an existing health game application in the market. The driving question, “Can games improve health?” should also be answered. I came across a kid’s game on brain treatment and surgery called “Brain Doctor”, its target users are children aspiring to become doctors someday or individuals who just like to have a feel of doing medical activities in the brain. It is a “Clinical Training Labs” type of game. At the end of the game, it can open awareness to kids and influence them to pursue their medical dreams by means of doing similar to real activities.      

Overall, the entire HI 201 experience provided me with tools for the job and basic but critical knowledge of the course. That is why it called the “Core”, the very foundation of everything. These ideas, tools, learnings and insights will be my armament in continuing the course and even after I graduate and become a full-pledge Health Informatics professional.  Each week’s 3 hour class was worth it. We get to mingle with our co-students, exchange views and created camaraderie. We were taught not to be afraid of the Social Media, not afraid of comments and bashes. Another thing that HI 201 taught us is that we should not be afraid to cross unchartered waters and learn how to swim in our own when our boat sinks.  With the guidance of our Professors, we were able to develop the knowledge required by the course. We managed to increase our level of HI understanding and comprehension as time flies and the semester come to an end.                                   

Gamification: One of the Best Platforms for Improving Health

Week 17: Gamification for Health

Driving Question:

Can games improve health?

Assignment:

Evaluate a health-related mobile game app.

I can say that I’ve been in “gaming” industry for more than 15 years now (Yes! I’ve started during my high school years, sad to say). From the stretch, I have encountered a lot of games with different genres and types. These games influenced my interests in computers and consoles that somewhat lead me to become technically savvy (sometimes, you do everything in your power to find ways to troubleshoot the console or the PC unit you are using in order to continuously play). I’ve seen the evolution of games from 2D to 3D, from big/fat to slim consoles, from slow to powerful RAM’s (Random Access Memory). Platforms are continually tested, from consoles, to PC units to mobile devices, virtual reality glasses (e.g. oculus) to smart glasses (e.g. Google glass). Games are limitless given the fast paced technology.

Gamification is the concept of applying game mechanics and game design techniques to engage and motivate people to achieve their goals. Gamification taps into the basic desires and needs of the users impulses which revolve around the idea of Status and Achievement.[1] The key element to a success of a gamification business is finding the right target audience or users. They are the ones who will use the application or even make it sensational and popular. That is why every gaming company has its business models whether they are tagged to be free of charge or paid. Gamification has also a wide area span, from just mere entertainment to the serious domains like healthcare.

 Healthcare professionals recognizes the use of games in controlling or preventing disorders, for example VR classrooms are stimulated in Oculus Rift consoles to test children with ADHD and monitor how well they can pay attention. Some of doctors recommend playing “Candy Crush” or “Bejeweled” to prevent Alzheimer’s disease.[2]  Harnessing the power of games to ward off diseases can be the smart choice. The world is moving in to digital age and it is inevitable.

In health informatics, the development of technology is a very good tool to explore. The trend of smart phones and gadgets should be a kindling point of establishing a healthy world. Combining the mobile health applications and games can be a powerful tool that can help healthcare professionals and patients achieve these goals and objectives.  It can also increase its value sense of purpose. For example [3]:

a. Games that help modify user behavior – basing on the target audience, these games can increase health awareness that may trigger users change their views on their behavior. For example, an application sends daily prompts to help remind patients, and then patients are required to check in every day to record their behaviors. They are assigned small activities, games and surveys and rewarded for positive changes (Core Drive #2, Development & Accomplishment). Over time, these behaviors turn into new lifestyle habits which help patients make better progress and develop more autonomy in terms of their health.[4]

b. Games that train wellness behaviors – achieving wellness through mental or physical exercises. For example, pedometer applications count the number of steps taken by the user and prompt them if they’ve achieved the target number of steps that are transcribed to a quest. The interactive quests’ level of difficulty increases, making the users comply with the activities, without them realizing that they are actually exercising.            

c. Clinical learning labs- Simulated activities transcribed in an application that can be used in training healthcare professionals and even normal users. A good example is an Emergency Response simulated in a virtual reality platform. This can be utilized to train emergency medical team or even the normal users who may likely encounter these situations, on applying basic life support activities. To add, good examples of these are games that mimic the real-life medical procedures like surgery and treatments. For medical practitioners, the cases rendered on these games may provide review on the domain they’ve chosen.  On non-medical practitioners, these may increase the level of awareness on these procedures making them more careful on their health or make them vigilant whenever a similar thing happens to them.          

    

Evaluating a health-related mobile game app

Keywords: Health games, Health and fitness, healthy games

Upon hitting these keywords in Apple’s App Store and Google play, I’ve found a variety of games that spark my interests. From the calorie counting to stride counters, Gym and exercise guides, PHR’s and Clinical Decision Support, etc. But the gamer in me focused on games that are interactive in nature, has cool graphics, near to the real thing and simply “FUN”.

The Content

I’ve picked the “Brain Doctor” developed by GameiMax to evaluate. Its target users are kids or children who aspire to be brain surgeons or doctors one day. It is about doing procedures in the brain using tools somewhat similar to real-life surgery or treatment. What interests me, is that this game is has medium maturity content, meaning that this Application in this category may include sexual references; intense fantasy or realistic violence; profanity or crude humor; references to drug, alcohol and tobacco use; social features and simulated gambling according to support.google.com.

Taken from "Brain Doctor" game

From the features, it has really some gross stuff like the innings of the brain, blood, blood vessels, bacteria, etc. But the developer made it too cartoony and colorful so that children may appreciate the content and enjoy the gameplay. The procedures are similar to what we expect during a brain treatment but the game lacks facts which should make it more educational. For example, the game should define the common bacteria that attack the brain (e.g. Meningitis) or define the procedures that are being done (e.g. draining).

It has also impossible procedures such as applying plaster bandages inside the brain and vacuuming the brain. These are just fine, they were just exaggerated so that it will suit the taste of the target audience, which are kids. But more facts and figures should be added to the procedures to make the game more informative.

Taken from "Brain Doctor" game

The gameplay

The game is not that user- friendly for first timers (even for me). It does not have walkthroughs that may help in knowing the exact activity per user interface. It is simply, “Yes! Go on, do what you have to do”. It does have tips and hints but are not that helpful on the game itself. The user will wonder what to click or what tool should be used first. In the end, it will be a trial and error just to proceed.

   

The intended-users may appreciate the application. For aspiring medical practitioners, it may give them the feel of doing treatments and interventions on such young ages. I’ve let my 10 year old sister use the application. At first she does not know exactly what to do, but upon guiding her on the gameplay and explaining every procedure we meet. She slowly grasped the idea. She was having fun doing playing the game. The game becomes more informative and knowledge based when an entity who knows the procedures guide the target users.     

To summarize the application, the game covered the Clinical Learning Labs type of game. Training the young minds at an early stage initiates an avenue of choices and learning.   The informative value that this game gives to the intended users was replaced by fun and excitement. The colorful ambience of the game helped in making the boring world of medicine interesting. The interactive nature provided the misunderstood procedures easier to comprehend. Even though some parts did not pass my standards it will definitely give kids the idea of pursuing their dream medical vocations. For sure, my sister who used the application and dreams to be a doctor someday appreciated the application. She started asking me what kind of doctor cures the brain. Maybe, the lacking features were intended for human guidance and for these kids to still have social interactions.  

References:

1. “Gamification” Source: http://badgeville.com/wiki/Gamification

2. “Playing for Prevention: Alzheimer's and Keeping the Mind Sharp” Source: http://www.huffingtonpost.com/cat-del-valle-castellanos/alzheimers-prevention_b_4262586.html

3. “Market Driven Patient Portal: Gamification and Serious Games” Source: http://blogs.perficient.com/healthcare/blog/tag/gamification/

4. “Top Ten Gamified Healthcare Games that will extend your Life” Source: http://www.yukaichou.com/gamification-examples/top-ten-gamification-healthcare-games/#.VI5u4NKUe3s

5. "Brain Doctor- A kid's game"Source: https://play.google.com/store/apps/details?id=com.gameimax.braindoctor&hl=en

PHC eTriage: An application to aid a vital Primary Health Care area

Week 16: mHealth

Driving Question:

How can mobile applications be useful in primary care?

Assignment:

Propose an app idea for a primary health care scenario. Your app idea must not duplicate any app already available in the market.

Definition of Primary Health Care

The WHO defines Primary Health Care an essential health care made universally acceptable to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and country and afford at every stage of development.

In the Philippines, key elements of Primary Health Care were identified to better define or isolate the services rendered by the healthcare type.

The following are the eight (8) essential elements of primary health care:

1. Education for Health

This is one of the potent methodologies for information dissemination. It promotes the partnership of both the family members and health workers in the promotion of health as well as prevention of illness.

2. Locally Endemic Disease Control

The control of endemic disease focuses on the prevention of its occurrence to reduce morbidity rate. Example Malaria control and Schistosomiasis control

3. Expanded Program on Immunization

This program exists to control the occurrence of preventable illnesses especially of children below 6 years old. Immunizations on poliomyelitis, measles, tetanus, diphtheria and other preventable disease are given for free by the government and ongoing program of the DOH

4. Maternal and Child Health and Family Planning

The mother and child are the most delicate members of the community. So the protection of the mother and child to illness and other risks would ensure good health for the community. The goal of Family Planning includes spacing of children and responsible parenthood.

5. Environmental Sanitation and Promotion of Safe Water Supply

Environmental Sanitation is defined as the study of all factors in the man’s environment, which exercise or may exercise deleterious effect on his well-being and survival. Water is a basic need for life and one factor in man’s environment. Water is necessary for the maintenance of healthy lifestyle. Safe Water and Sanitation is necessary for basic promotion of health.

6. Nutrition and Promotion of Adequate Food Supply

One basic need of the family is food. And if food is properly prepared then one may be assured healthy family. There are many food resources found in the communities but because of faulty preparation and lack of knowledge regarding proper food planning, Malnutrition is one of the problems that we have in the country.

7. Treatment of Communicable Diseases and Common Illness

The diseases spread through direct contact pose a great risk to those who can be infected. Tuberculosis is one of the communicable diseases continuously occupies the top ten causes of death. Most communicable diseases are also preventable. The Government focuses on the prevention, control and treatment of these illnesses.

8. Supply of Essential Drugs

This focuses on the information campaign on the utilization and acquisition of drugs. In response to this campaign, the GENERIC ACT of the Philippines is enacted. It includes the following drugs: Cotrimoxazole, Paracetamol, Amoxycillin, Oresol, Nifedipine, Rifampicin, INH (isoniazid) and Pyrazinamide,Ethambutol, Streptomycin,Albendazole,Quinine

Facilities

The facilities involved in rendering primary care services includes Outpatient, dental and laboratory services that specializes on TB, Malaria, Dengue, etc. Health centres, Primary care hospital, Clinics and provider network Hospitals. Basically these facilities do not have the capacity to perform major activities, such as most of minor and all major surgeries, deliveries of complicated pregnancies and in depth diagnostics such as CT scans and EEG’s.

The Health Centers are the government’s armaments to penetrate and serve every point of the Philippines.  In total there are 2376 Rural Health Units and 101 City Health Offices. These facilities are ready to accommodate every single Filipino who seeks primary care consultations. They are also included on the provider registry network of public and private health facilities with referral or escalation protocols from primary to tertiary level of care.

Working in an Institution that prioritizes the community, I’ve been through many Health Centers that serve as the main health hub of people especially those who are in isolated islands or landlocks. Within these facilities, I’ve encountered health worker runts and problems when it comes to their workflow. For health centers with a large catchment area, the primary issue is patient load. And it does have an impact on processes and management in the area.

Before the deployment of any system, workflow and situational analysis are conducted. We found out that every health center has a standard workflow. What makes them unique is that they make adjustments and revisions to cope up with the number of staff and type of staff.  Here are some of the examples:

Figure 2 RHU 2 General Workflow

Basing on the figures above, we identified the number of personnel manning each station (swim lanes) and identified their tasks. We’ve noticed that the admission section has the heavy load when it comes to consultations. Here are their tasks:

Figure 1 RHU 1 General Workflow

a. Acquire patient’s demographics

b. Search for the patient’s folder if archived; make a new folder in the case of first visits

c. Make an individual treatment plan (ITR)

d. Get anthropometric measurements (Height and Weight) then write down in ITR

e. Get vital signs then write down in the ITR

f. Gather complaints then write down in the ITR

g. Give number to patient for queuing

h. Triage patients to services 

The Problem

Usually the staffs assigned to this area are encoders, nurse casuals, midwives or NDP’s (Nurse Deployment Program). In some RHU’s, they have a rotation to prevent personnel burnout, some assign 2 or more people to cater the influx of patients, some permanently designate HW’s in the area because of understaffing problems.

The admission area sometimes causes the bottleneck of an RHU workflow. The other stations are not fully maximized in the sense that few are served, however pooling of patients in the area is evident. The quality of service declines as the other service stations (Physicians, Midwives, etc.) adjust to accommodate the influx of patients. The peak of this problem is customer discontentment. The cumbersome waiting time and the low quality service give toll to patient’s satisfaction. As a result some patients have decreased trust and confidence on Health Center workers.         

Even though the admission section is a minor section of the facility in terms of depth of service (not totally medical), it is the most important part of the facility. It supposed to act as the reception or secretariat. It has vital duties and roles when it comes to keeping the workflow intact.

The Solution

The problem could be resolved easier by integrating an electronic process in the workflow. An application similar to the standard workflow of health center can be an answer to efficiency problems of the admission processes. The use of the present mobile technology is a perfect environment for this application. Here are some of the reasons:

a. It is portable and light

b. It is not direct power dependent

c. It has features that can be harnessed for other things such as video conferencing, email, etc.

d. It has developer options (Android)

e. Mobile applications are light

f. Its expandable memory provides multiple applications in just one device

g. It can be updated from time to time (via Playstore for example)

h. It can be integrated to a personal PC application

i. Technology adoption is not an issue (most health workers use smartphones)

Introducing the PHC eTriage (Primary Health Care eTriage)

It is designed to improve the admission triaging processes. The manual based operations of RHU admission were converted to electronic to improve time management and efficiency of the area.        

1. Users

a. Admission area

b. Dentist

c. Physician

d. Nurse

e. Midwives

2. Proposed Network layout

Layout 1

Narrative:

Standalone mode

A gateway is installed in a laptop or desktop. This will serve as the consolidator of data taken from PHC eTriage peripherals. The gateway is connected to a wireless router to broadcast an access for the peripherals to use. The users will manually save the IP address of the gateway before using the application.

Integrate to EMR

Integration to EMR is also possible given that the identifiers, registry type, dictionaries and functionalities are similar to the application. The consolidated data of the gateway can be synched to the EMR server via cloud or local server. Or in the future, it can be the portable admission application of the EMR.

Layout 2

Narrative:

The mother app will be installed on a administrator smartphone, this will be held by the staff in the admission area as he/she will be the moderator. The admin will set up a hotspot on her device so that other users can connect. The application will use the hotspot or wireless access emitted by the mother application to exchange data and communicate.  

Key features:
1. The application is made in accordance to Philippines' health center settings and workflow.
2. The application has a dashboard isolated per service to monitor the patient queue of health center specific areas effortlessly.
3. The application can save patient demographics for admission and service references.
4. Can be integrated to an EMR

For full specifications, you may check this link:
https://www.slideshare.net/secret/iFpoXeehBKb4IO

References:

• http://www.wpro.who.int/health_services/service_delivery_profile_philippines.pdf
• http://nurseslabs.com/primary-health-care/
• http://nhfr.doh.gov.ph/Philippine_health_facility_statuslist.php
• http://www.who.int/publications/almaata_declaration_en.pdf