Real-time regular routine reporting for health (R4Health): Lessons from the implementation of a large scale mobile health system for routine health services in the Philippines

BACKGROUND: The Philippine government aims for a modern information system to enhance data quality and provide more rational evidence to support timely and efficient delivery of health care, management of health systems, programs and policy. Hence, the Real-time Regular Routine Reporting for Health (R4Health) mHealth application was developed and field tested in 246 isolated and disadvantaged municipalities to support the campaign for Universal Health Care and the achievement of the Millennium Development Goals. The R4Health collected point-of-care-specific data on services routinely provided at the rural health facilities, aggregated them and presented in a dashboard for use by program managers and policy makers. OBJECTIVE: This paper describes the use of R4Health, a mobile technology-based health reporting system. It will discuss the context of the R4Health implementation, its development and deployment to 246 municipalities in the Philippines. Furthermore, the paper sought to determine enablers and challenges to the adoption of R4Health in routine health care. METHODS: Data was collected through surveys, focus group discussions, participant-observation and review of project reports. Quantitative data was summarized using descriptive statistical methods; qualitative data underwent content analysis.    RESULTS AND CONCLUSION: A total of 515,855 R4Health reports equivalent to 48,856 patient transactions were received from 246 municipalities within a nine-month observation period, supporting the viability of the R4Health as an alternative option to the existing manual and paper based health information management to improve the quality of data. R4Health utilizes a tool that everyone is familiar with, can easily be incorporated in their workflow, can be brought and used anywhere and has an application that is clear, understandable, and easy to learn and use. R4Health data elements, however, have overlaps with other government health reporting systems and is already misconstrued to further duplicate work. More discussions are warranted to coordinate and integrate systems. Given the general positive perspectives, integration of this alternative system to the RHU workflow, an improved R4Health, has a high potential of being accepted and adopted by the first-line health workers across the country. 

Community health information and tracking system (CHITS): Lessons from eight years implementation of a pioneer electronic medical record system in the Philippines

The CHITS (Community Health Information and Tracking System), the first electronic medical record system in the Philippines that is used widely, has persevered through time and slowly extended its geographic footprint, even without a national policy. This study describes the process of CHITS development, its enabling factors and challenges affecting its adoption, and its continuing use and expansion through eight years of implementation (2004 to 2012) using the HOT-fit model. This paper used a case study approach. CHITS was developed through a collaborative and participative user-centric strategies. Increased efficiency, improved data quality, streamlined records management and improved morale among government health workers are benefits attributed to CHITS. Its longevity and expansion through peer and local policy adoption speaks of an eHealth technology built for and by the people. While computerization has been adapted by an increasing number of local governments, needs of end-users, program managers and policy-makers continue to evolve. Challenges in keeping CHITS technically robust, up-to-date and scalable are already encountered. Lack of standards hampers meaningful data exchange and use across different information systems. Infrastructure for electricity and connectivity especially in the countryside must be established more urgently to meet over-all development goals specially. Policy and operational gaps identified in this study have to be addressed using people-centric perspective and participatory strategies with the urgency to achieve universal health care. Further rigorous research studies need be done to evaluate CHITS' effects on public health program management, and on clinical outcomes.

Formulating the national policy on telehealth for the Philippines through stakeholders' involvement and partnership

The Philippine Department of Health (DOH) recognized the potentials of information and communication technology (ICT) as a valuable aid to achieve Kalusugan Pangkalahatan (KP) or Universal Health Care for all Filipinos. In 2011, the Development of the National Telehealth Service Program (NTSP) in the DOH Project was proposed and implemented as a collaborative and developmental project of the DOH, with the University of the Philippines-Manila through the National Telehealth Center. The Project defined operational and policy issues critical in incorporating telehealth as a standard program, service delivery and information management mode in the DOH. To sustain this beyond the current Project financing and political leadership, as well as to provide a policy framework to guide the implementation of telehealth in the country, a DOH administrative order (AO) was proposed. Stakeholder feedback was sought to surface views and concerns to ensure better relevance and effective policy implementation. Four public fora were held from 2012 to 2014 participated in by 241 individuals from the national agencies and local governments, project implementers, academe, and the private sector. General comments centered on governance and ensuring representation by patient advocate groups and the local governments. Capacity building and financing of telehealth, and regulation especially with regards to ethical use and protection of patients' privacy were prominent concerns. Participants affirm the preference for the poor and marginalized, although envision that telehealth and digital health information systems should be standard components of health care in the country. Other comments were specific to telemedicine and using mobile phones to report on health services from the frontline clinics. Recommendations are presented.

Elaborating and discoursing the ethics in eHealth in the Philippines: Recommendations for health care practice and research

OBJECTIVES: The objectives of the research study were to determine ethical guidelines and principles applicable in the practice and research of eHealth and telehealth in the Philippines, how these are applicable to the Philippines, and to differentiate between the ethical issues in research and in clinical practice of eHealth. METHODS: This research study used: 1) review of ethics manuscripts, guidelines and literature; 2) focused group discussion and key informant interviews of experts; and 3) triangulation. The information sought for the review were- 1) relevant policies, guidelines in eHealth that are pertinent to the discussion of eHealth ethics in the Philippines; 2) components of ethics in eHealth research; and 3) components of ethics in eHealth practice. The framework of the consultation with experts was to identify mechanisms and strategies in incorporating ethics in both eHealthpractice and eHealth research within the following- 1) in reference to existing laws, policies, and guidelines on ethics in medicine and health; and 2) in the context of the Philippine setting. RESULTS: Based on the review, there are pertinent codes of ethics, applicable laws, policies and guidelines in eHealth, both in the international and local settings. The focus group discussion and key informant interview with experts yielded significant and deeper understanding on how to address the gaps and lapses of ethics applied to eHealth in the country. These recommendations were given which distinguish between the ethics in clinical practice and ethics in the planning and implementation of eHealth systems. There is also a need to resolve the problem of whose primary responsibility the patient is- the referring, commonly referred to as the attending physician in the local community, or the specialist from the center. The proposed resolution was also presented. CONCLUSION: The study has shown how important eHealth in potentially promoting timely and improved health care access. However, there are still lapses and gaps in the implementation of policies and guidelines on and relating to eHealth in the Philippines as shown by the data culled from the review and the focus group discussions with the experts. With more specific ethical guidelines and relevant policies, the development and practice of eHealth and telehealth will be on its way in bridging the gap and aiding in health systems development in the Philippines, especially with the support of the national government and collaboration of various agencies and stakeholders.

The Philippine policy context for eHealth

BACKGROUND: eHealth in the Philippines is poised to take off but adoption of eHealth applications in the country's public health sector is limited in scale. OBJECTIVE: This paper examines the context and status of eHealth policy in the Philippines. The aim is to lay out the domains of policy issues that should be addressed for the successful implementation of eHealth in the Philippines. METHODS: The themes and issues of policies on eHealth cited by Khoja, Durrani, Nayani and Fahim (2012) were used to describe and analyze the status of eHealth policy context in the Philippines. These are: (1) networked care, (2) interjurisdictional practice, (3) diffusion of eHealth/digital divide, (4) eHealth integration with existing systems, (5) response to new initiatives, (6) goal-setting for eHealth policy, (7) evaluation and research, (8) investment, and (9) ethics in eHealth. Documents and policies in the form of enacted laws, memoranda, implementing rules and regulations were retrieved and reviewed to answer whether or not policy themes and issues are addressed currently. RESULTS AND CONCLUSION: Current policies in the status quo do not adequately address the issues that enable effective implementation of eHealth in the Philippines. While preconditions for eHealth to flourish such as strategic frameworks for ICT and eHealth have been established, they are inadequate in addressing licensing, diffusion of innovation, handling innovation, evaluation and research, and investment.