Community of Interoperability Labs: Pragmatic Approach to Achieving Interoperability.

To achieve interoperability of health data, stakeholders must overcome various socio-technical challenges. The "Mind the GAPS, Fill the GAPS" framework was created by the Asia eHealth Information Network (AeHIN) in 2017 to help countries with their challenges with interoperability. A year later, AeHIN formed the Community of Interoperability Labs (COIL), a group of labs from six countries to share knowledge and resources. Since interoperability requires data exchange between disparate entities, it is imperative to establish a trustworthy space where stakeholders can come together and solve their common problems. The networked learning approach of the COIL makes possible the potential for interoperability within and between countries contributing to national and international understanding.

Design of a Vaccine Passport Validation System Using Blockchain-based Architecture: Development Study.

BACKGROUND: COVID-19 is an ongoing global pandemic caused by SARS-CoV-2. As of June 2021, 5 emergency vaccines were available for COVID-19 prevention, and with the improvement of vaccination rates and the resumption of activities in each country, verification of vaccination has become an important issue. Currently, in most areas, vaccination and reverse transcription polymerase chain reaction (RT-PCR) test results are certified and validated on paper. This leads to the problem of counterfeit documents. Therefore, a global vaccination record is needed. OBJECTIVE: The main objective of this study is to design a vaccine passport (VP) validation system based on a general blockchain architecture for international use in a simulated environment. With decentralized characteristics, the system is expected to have the advantages of low cost, high interoperability, effectiveness, security, and verifiability through blockchain architecture. METHODS: The blockchain decentralized mechanism was used to build an open and anticounterfeiting information platform for VPs. The contents of a vaccination card are recorded according to international Fast Healthcare Interoperability Resource (FHIR) standards, and blockchain smart contracts (SCs) are used for authorization and authentication to achieve hierarchical management of various international hospitals and people receiving injections. The blockchain stores an encrypted vaccination path managed by the user who manages the private key. The blockchain uses the proof-of-authority (PoA) public chain and can access all information through the specified chain. This will achieve the goal of keeping development costs low and streamlining vaccine transit management so that countries in different economies can use them. RESULTS: The openness of the blockchain helps to create transparency and data accuracy. This blockchain architecture contains a total of 3 entities. All approvals are published on Open Ledger. Smart certificates enable authorization and authentication, and encryption and decryption mechanisms guarantee data protection. This proof of concept demonstrates the design of blockchain architecture, which can achieve accurate global VP verification at an affordable price. In this study, an actual VP case was established and demonstrated. An open blockchain, an individually approved certification mechanism, and an international standard vaccination record were introduced. CONCLUSIONS: Blockchain architecture can be used to build a viable international VP authentication process with the advantages of low cost, high interoperability, effectiveness, security, and verifiability.

Global Infectious Disease Surveillance and Case Tracking System for COVID-19: Development Study.

BACKGROUND: COVID-19 has affected more than 180 countries and is the first known pandemic to be caused by a new virus. COVID-19's emergence and rapid spread is a global public health and economic crisis. However, investigations into the disease, patient-tracking mechanisms, and case report transmissions are both labor-intensive and slow. OBJECTIVE: The pandemic has overwhelmed health care systems, forcing hospitals and medical facilities to find effective ways to share data. This study aims to design a global infectious disease surveillance and case tracking system that can facilitate the detection and control of COVID-19. METHODS: The International Patient Summary (IPS; an electronic health record that contains essential health care information about a patient) was used. The IPS was designed to support the used case scenario for unplanned cross-border care. The design, scope, utility, and potential for reuse of the IPS for unplanned cross-border care make it suitable for situations like COVID-19. The Fast Healthcare Interoperability Resources confirmed that IPS data, which includes symptoms, therapies, medications, and laboratory data, can be efficiently transferred and exchanged on the system for easy access by physicians. To protect privacy, patient data are deidentified. All systems are protected by blockchain architecture, including data encryption, validation, and exchange of records. RESULTS: To achieve worldwide COVID-19 surveillance, a global infectious disease information exchange must be enacted. The COVID-19 surveillance system was designed based on blockchain architecture. The IPS was used to exchange case study information among physicians. After being verified, physicians can upload IPS files and receive IPS data from other global cases. The system includes a daily IPS uploading and enhancement plan, which covers real-time uploading through the interoperation of the clinic system, with the module based on the Open Application Programming Interface architecture. Through the treatment of different cases, drug treatments, and the exchange of treatment results, the disease spread can be controlled, and treatment methods can be funded. In the Infectious Disease Case Tracking module, we can track the moving paths of infectious disease cases. The location information recorded in the blockchain is used to check the locations of different cases. The Case Tracking module was established for the Centers for Disease Control and Prevention to track cases and prevent disease spread. CONCLUSIONS: We created the IPS of infectious diseases for physicians treating patients with COVID-19. Our system can help health authorities respond quickly to the transmission and spread of unknown diseases, and provides a system for information retrieval on disease transmission. In addition, this system can help researchers form trials and analyze data from different countries. A common forum to facilitate the mutual sharing of experiences, best practices, therapies, useful medications, and clinical intervention outcomes from research in various countries could help control an unknown virus. This system could be an effective tool for global collaboration in evidence-based efforts to fight COVID-19.

User Acceptance of Electronic Medical Record System: Implementation at Marie Stopes International, Myanmar.

OBJECTIVE: This study assessed the technical feasibility and aimed to determine the factors influencing intention to use Electronic Medical Records (EMRs) at Marie Stopes International, Myanmar (MSI-M). METHODS: A cross-sectional survey was conducted among 112 participants who were working at the clinics and head office of MSI-M. Demographic information, type of office, technical feasibility, information communication technology knowledge, computer usage, and user acceptance towards the proposed system were obtained from the participants. RESULTS: The results indicated low health information technology usage and network availability at MSI-M clinics. Positive perception of EMRs was found among the staff members of MSI-M, which was reflected by positive responses regarding perceived usefulness (average score of 4.15), perceived ease of use (average score of 4.03), and intention to use (average score of 4.10) on a 5-point Likert scale. Statistically, staff from the head office expressed less desire to implement an EMR system (odds ratio = 0.07; 95% confidence interval, 0.01-0.97), especially when they do not perceive the usefulness of the system (odds ratio = 5.05; 95% confidence interval, 2.39-10.69). CONCLUSION: Since health information technology usage and network availability were low in MSI-M, it is important to strengthen the information and communication technology infrastructure and introduce a policy for capacity building at MSI-M. Adequate training and strong leadership support are recommended for the successful initial implementation and sustainability of an EMR system at MSI-M.

An Architecture and Management Platform for Blockchain-Based Personal Health Record Exchange: Development and Usability Study.

BACKGROUND: Personal health record (PHR) security, correctness, and protection are essential for health and medical services. Blockchain architecture can provide efficient data retrieval and security requirements. Exchangeable PHRs and the self-management of patient health can offer many benefits to traditional medical services by allowing people to manage their own health records for disease prevention, prediction, and control while reducing resource burdens on the health care infrastructure and improving population health and quality of life. OBJECTIVE: This study aimed to build a blockchain-based architecture for an international health record exchange platform to ensure health record confidentiality, integrity, and availability for health management and used Health Level 7 Fast Healthcare Interoperability Resource international standards as the data format that could allow international, cross-institutional, and patient/doctor exchanges of PHRs. METHODS: The PHR architecture in this study comprised 2 main components. The first component was the PHR management platform, on which users could upload PHRs, view their record content, authorize PHR exchanges with doctors or other medical health care providers, and check their block information. When a PHR was uploaded, the hash value of the PHR would be calculated by the SHA-256 algorithm and the PHR would be encrypted by the Rivest-Shamir-Adleman encryption mechanism before being transferred to a secure database. The second component was the blockchain exchange architecture, which was based on Ethereum to create a private chain. Proof of authority, which delivers transactions through a consensus mechanism based on identity, was used for consensus. The hash value was calculated based on the previous hash value, block content, and timestamp by a hash function. RESULTS: The PHR blockchain architecture constructed in this study is an effective method for the management and utilization of PHRs. The platform has been deployed in Southeast Asian countries via the Asia eHealth Information Network (AeHIN) and has become the first PHR management platform for cross-region medical data exchange. CONCLUSIONS: Some systems have shown that blockchain technology has great potential for electronic health record applications. This study combined different types of data storage modes to effectively solve the problems of PHR data security, storage, and transmission and proposed a hybrid blockchain and data security approach to enable effective international PHR exchange. By partnering with the AeHIN and making use of the network's regional reach and expert pool, the platform could be deployed and promoted successfully. In the future, the PHR platform could be utilized for the purpose of precision and individual medicine in a cross-country manner because of the platform's provision of a secure and efficient PHR sharing and management architecture, making it a reasonable base for future data collection sources and the data analytics needed for precision medicine.

Unique health identifiers for universal health coverage.

Identifying everyone residing in a country, especially the poor, is an indispensable part of pursuing universal health coverage (UHC). Having information on an individuals' financial protection is also imperative for measuring the progress of UHC. This paper examines different ways of instituting a system of unique health identifiers that can lead toward achieving UHC, particularly in relation to utilizing universal civil registration and national unique identification number systems. Civil registration is a fundamental function of the government that establishes a legal identity for individuals and enables them to access essential public services. National unique identification numbers assigned at birth registration can further link their vital event information with data collected in different sectors, including in finance and health. Some countries use the national unique identification number as the unique health identifier, such as is done in South Korea and Thailand. In other countries, a unique health identifier is created in addition to the national unique identification number, but the two numbers are linked; Slovenia offers an example of this arrangement. The advantages and disadvantages of the system types are discussed in the paper. In either approach, linking the health system with the civil registration and national identity management systems contributed to advancing effective and efficient UHC programs in those countries.

Developing and implementing national health identifiers in resource limited countries: why, what, who, when and how?

Many resource-limited countries are scaling up health services and health-information systems (HISs). The HIV Cascade framework aims to link treatment services and programs to improve outcomes and impact. It has been adapted to HIV prevention services, other infectious and non-communicable diseases, and programs for specific populations. Where successful, it links the use of health services by individuals across different disease categories, time and space. This allows for the development of longitudinal health records for individuals and de-identified individual level information is used to monitor and evaluate the use, cost, outcome and impact of health services. Contemporary digital technology enables countries to develop and implement integrated HIS to support person centred services, a major aim of the Sustainable Development Goals. The key to link the diverse sources of information together is a national health identifier (NHID). In a country with robust civil protections, this should be given at birth, be unique to the individual, linked to vital registration services and recorded every time that an individual uses health services anywhere in the country: it is more than just a number as it is part of a wider system. Many countries would benefit from practical guidance on developing and implementing NHIDs. Organizations such as ASTM and ISO, describe the technical requirements for the NHID system, but few countries have received little practical guidance. A WHO/UNAIDS stake-holders workshop was held in Geneva, Switzerland in July 2016, to provide a 'road map' for countries and included policy-makers, information and healthcare professionals, and members of civil society. As part of any NHID system, countries need to strengthen and secure the protection of personal health information. While often the technology is available, the solution is not just technical. It requires political will and collaboration among all stakeholders to be successful.

Satisfaction with Paper-Based Dental Records and Perception of Electronic Dental Records among Dental Professionals in Myanmar.

OBJECTIVES: To overcome challenges in the implementation of electronic dental record systems in a low-resource setting, it is crucial to know the level of users' satisfaction with the existing system of paper-based dental records and their perceptions of electronic dental records. METHODS: A cross-sectional paper-based questionnaire survey was conducted among Myanmar dental professionals who worked in one of two teaching hospitals or in private dental clinics. Descriptive data were analyzed and regression analysis was carried out to identify factors influencing perceptions of electronic dental records. RESULTS: Most dental professionals (>60%) were satisfied with just three out of six aspects of paper-based dental records (familiarity, flexibility, and portability). In addition, generalized positive perceptions were found among decision makers towards electronic dental records, and 86% of dentists indicated that they were willing to use them. Financial concerns were identified as the most important barrier to the implementation of electronic dental records among dentists who were not willing to use the proposed system. CONCLUSIONS: The first step towards implementing electronic dental records in Myanmar should be improvement of the content and structure of paper-based dental records, especially in private dental clinics. Utilization of appropriate open-source electronic dental record software in private dental clinics is recommended to address perceived issues around financial barriers. For the long term, we recommend providing further education and training in health informatics to healthcare professionals to facilitate the efficient use of electronic dental record software in Myanmar in the future.

Effectiveness of Implementation of Electronic Malaria Information System as the National Malaria Surveillance System in Thailand.

BACKGROUND: In moving toward malaria elimination, one strategy is to implement an active surveillance system for effective case management. Thailand has developed and implemented the electronic Malaria Information System (eMIS) capturing individualized electronic records of suspected or confirmed malaria cases. OBJECTIVE: The main purpose of this study was to determine how well the eMIS improves the quality of Thailand's malaria surveillance system. In particular, the focus of the study was to evaluate the effectiveness of the eMIS in terms of the system users' perception and the system outcomes (ie, quality of data) regarding the management of malaria patients. METHODS: A mixed-methods technique was used with the framework based on system effectiveness attributes: data quality, timeliness, simplicity, acceptability, flexibility, stability, and usefulness. Three methods were utilized: data records review, survey of system users, and in-depth interviews with key stakeholders. From the two highest endemic provinces, paper forms matching electronic records of 4455 noninfected and 784 malaria-infected cases were reviewed. Web-based anonymous questionnaires were distributed to all 129 eMIS data entry staff throughout Thailand, and semistructured interviews were conducted with 12 management-level officers. RESULTS: The eMIS is well accepted by system users at both management and operational levels. The data quality has enabled malaria personnel to perform more effective prevention and control activities. There is evidence of practices resulting in inconsistencies and logical errors in data reporting. Critical data elements were mostly completed, except for a few related to certain dates and area classifications. Timeliness in reporting a case to the system was acceptable with a delay of 3-4 days. The evaluation of quantitative and qualitative data confirmed that the eMIS has high levels of simplicity, acceptability, stability, and flexibility. CONCLUSIONS: Overall, the system implemented has achieved its objective. The results of the study suggested that the eMIS helps improve the quality of Thailand's malaria surveillance system. As the national malaria surveillance system, the eMIS's functionalities have provided the malaria staff working at the point of care with close-to-real-time case management data quality, covering case detection, case investigation, drug compliance, and follow-up visits. Such features has led to an improvement in the quality of the malaria control program; the government officials now have quicker access to both individual and aggregated data to promptly react to possible outbreak. The eMIS thus plays one of the key roles in moving toward the national goal of malaria elimination by the next decade.

Health-oriented electronic oral health record for health surveillance.

Public health surveillance of oral health might benefit from increased access to and analysis of electronically available data including systematic collection, analysis, interpretation, and dissemination of outcome-specific data for use in public health action to improve oral health. This study aimed to develop and evaluate a new Health-oriented Electronic Oral Health Record (Health-EOHR) that integrated new oral health status graphical user interface, the health-oriented status and intervention model to facilitate oral health surveillance. We designed an experiment using focus groups and a Delphi process to develop health-oriented status and intervention model and graphical user interface. The Health-EOHR was implemented and integrated into the existing Electronic Health Record widely used in community hospitals. The study on usefulness for oral health surveillance was conducted. Overall, the dentists were significantly satisfied with the Health-EOHR compared to the existing EOHR (p < 0.001). The dentists found it easy to use and were generally satisfied with the function and the impact on their work, oral health services and surveillance.

Impact of Thailand universal coverage scheme on the country's health information systems and health information technology.

Thailand achieved universal healthcare coverage with the implementation of the Universal Coverage Scheme (UCS) in 2001. This study employed qualitative method to explore the impact of the UCS on the country's health information systems (HIS) and health information technology (HIT) development. The results show that health insurance beneficiary registration system helps improve providers' service workflow and country vital statistics. Implementation of casemix financing tool, Thai Diagnosis-Related Groups, has stimulated health providers' HIS and HIT capacity building, data and medical record quality and the adoption of national administrative data standards. The system called "Disease Management Information Systems" aiming at reimbursement for select diseases increased the fragmentation of HIS and increase burden on data management to providers. The financial incentive of outpatient data quality improvement project enhance providers' HIS and HIT investment and also induce data fraudulence tendency. Implementation of UCS has largely brought favorable impact on the country HIS and HIT development. However, the unfavorable effects are also evident.

Impact of right ventricular pacing on right ventricular function.

BACKGROUND: The benefits of right ventricular pacing in patients with symptomatic bradycardia are well recognized. Currently, left ventricular (LV) function after cardiac pacing has already been extensively investigated. However existing data on right ventricular (RV) function in these patients is extremely limited. MATERIAL AND METHOD: To test this, records of RV and tricuspid valve function of patients with a pacemaker measured at least a year after implantation were reviewed for a prevalence of RV dysfunction. The patients were also divided into those with and without RV dysfunction. Factors affecting the two groups were evaluated. RESULTS: RV dysfunction and moderate to severe tricuspid valve regurgitation were found in approximately 4% and 21% respectively in cardiac pacing patients with mean implantation duration of 6.4 years. Compared to normal RV function, factors presumed to affect on RV dysfunction including site of pacing, pacing mode and percentage of ventricular pacing were not significantly different (p = 0.54, 0.37 and 0.12 respectively). CONCLUSION: Based on these data, the prevalence of right ventricular dysfunction appears to be infrequent and factors that were assumed as contributors to LV dysfunction failed to show significant contributions to RV dysfunction.

eHealth in Thailand: the current status.

The World Health Organization (WHO) defines eHealth as the use of information and communication technologies (ICT) for health. Thailand is one of the leading countries in emerging and developing economy that the use of ICT applications is pervasive including eHealth. However, the status of eHealth in Thailand hasn't been assessed. Employing the WHO global Observatory for eHealth development model and its instrument, this study describes the uptake of eHealth foundations and the extent of eHealth applications and services implemented in the country. A group of the nation 18 eHealth experts met and evaluated country eHealth status and provided recommendations. The results show that the development of the country's eHealth foundations is inadequate and need to be the priority for national eHealth development.

Factors influencing health information technology adoption in Thailand's community health centers: applying the UTAUT model.

BACKGROUND: One of the most important factors for the success of health information technology (IT) implementation is users' acceptance and use of that technology. Thailand has implemented the national universal healthcare program and has been restructuring the country's health IT system to support it. However, there is no national data available regarding the acceptance and use of health IT in many healthcare facilities, including community health centers (CHCs). This study employed a modified Unified Theory of Acceptance and Use of Technology (UTAUT) structural model, to understand factors that influence health IT adoption in community health centers in Thailand and to validate this extant IT adoption model in a developing country health care context. METHODS: An observational research design was employed to study CHCs' IT adoption and use. A random sample of 1607 regionally stratified CHC's from a total of 9806 CHCs was selected. Data collection was conducted using a cross-sectional survey by means of self-administered questionnaire with an 82% response rate. The research model was applied using the partial least squares (PLS) path modeling. RESULTS: The data showed that people who worked in CHCs exhibited a high degree of IT acceptance and use. The research model analyses suggest that IT acceptance is influenced by performance expectancy, effort expectancy, social influence and voluntariness. Health IT use is predicted by previous IT experiences, intention to use the system, and facilitating conditions. CONCLUSIONS: Health IT is pervasive and well adopted by CHCs in Thailand. The study results have implications for both health IT developmental efforts in Thailand and health informatics research. This study validated the UTAUT model in the field context of a developing country's healthcare system and demonstrated that the PLS path modeling works well in a field study and in exploratory research with a complex model.

Impact of prior clinical information in an EHR on care outcomes of emergency patients.

A patient's prior clinical information available electronically can be helpful during the care process, particularly in the emergency department (ED). The effect of such information on quality and efficiency of ED patient care has not been adequately studied. This study uses secondary data to investigate its impact on surrogate measures of care quality and efficiency among 6,143 congestive heart failure, diabetic, and asthmatic patients in 3 EDs. Results show that in some subgroups of chronic patients in some EDs, availability of prior clinical information in the electronic health records was associated with significantly lower hospitalization rates, shorter inpatient length of stay, and reduction in the numbers of laboratory tests and diagnostic procedures ordered during the ED visit. However, there were also contradictory effects and lack of significance in other subgroups. The effects vary by ED and disease, highlighting the possibility of contextual differences influencing the effects of such clinical information.

Creating a large database test bed with typographical errors for record linkage evaluation.

Evaluation of record linkage algorithms requires a large database test bed that is representative of the real-world data. We created such a large database that reflects the demographic distribution of a typical population and contains typographical errors commonly made during data entry. This database can be used with high confidence as a test bed to evaluate various record linkage algorithms.

Improving access to clinical information in an emergency department: a qualitative study.

We studied the information flow in an emergency department (ED) to understand how patient information was received and shared between providers and how information from a computerized ambulatory system, which was not well-integrated with the hospital information system at that time, could be used. The study was aimed at identifying possible methods that could push information from the ambulatory system to providers with minimal interference with the ED's current workflow. Using observations and interviews, the ED's information flow was mapped and a strategy for making ambulatory encounter information available was identified.

Penetration and adoption of health information technology (IT) in Thailand's community health centers (CHCs): a national survey.

A universal healthcare coverage program has been implemented in Thailand since 2001 and the Thailand Ministry of Public Health (MOPH) is restructuring its health information systems to support the management of this reform. The MOPH believes that health information technology (IT) is fundamental to the development of an effective health information system, and that users' adoption of health IT is one of the most important factors to the success of health IT implementation projects. However, there is no national data available regarding the penetration and adoption of health IT in Thai community health centers (CHCs). This cross sectional survey was designed to study the penetration and adoption of health IT in the country's community health centers. A random sample of 1,607 regionally stratified CHC's from a total of 9,806 CHCs was selected. With an 82% response rate, the data showed that people who worked in CHCs were currently heavy users of health IT. They exhibited high IT acceptance and positive attitudes toward using health IT. CHCs' staff was less resistant to adopt health IT than previously anticipated. These results are similar in all of the country's geographic regions. Health IT is pervasive in CHCs across the country and penetrates all regions.

Synthesis of a database test bed for evaluating record linkage algorithms.

Record linkage algorithm development is a challenging task requiring large databases representative of a target population. As part of an evaluation of a health information exchange project we had the need for a linking algorithm that would not pass protected health information among organizations. We synthesized a test bed for this purpose employing a randomization process and incorporating conditions that represent the study population and possible error generating conditions in real world electronic record systems.

Linking patients' records across organizations while maintaining anonymity.

In an health information exchange (HIE) project, linking patients' health records across organizations while maintaining appropriate patients anonymity is essential. Anonymous identifiers created from various combinations of personal identifiers using one way encryption function were evaluated for linkage quality between two synthesized databases. Preliminary results show that such anonymous identifiers (IDs) based on date of birth, zip code and last name or first name can link records with high specificity and sensitivity.