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AMIA Annu Symp Proc. 2005; 2005: 311–315. | PMCID: PMC1560490 |
Copyright This is an Open Access article: verbatim copying and redistribution of
this article are permitted in all media for any purpose Linking Primary Care Information Systems and Public Health Vertical Programs
in the Philippines: An Open-source Experience Herman Tolentino, MD,A Alvin Marcelo, MD,A Portia Marcelo, MD, MPH,B and Inocencio Maramba, MD, MScA A Medical Informatics Unit, University of the Philippines Manila College of Medicine, Manila, Philippines B Department of Family and Community Medicine, University of the Philippines Manila College of Medicine, Manila, Philippines Community-based primary care information systems are one of the building
blocks for national health information systems. In the Philippines, after
the devolution of health care to local governments, we observed “health
information system islands” connected to national
vertical programs being implemented in devolved health units. These
structures lead to a huge amount of “information work” in
the transformation of health information at the community level. This
paper describes work done to develop and implement the open-source
Community Based Health Information Tracking System (CHITS) Project, which
was implemented to address this information management problem
and its outcomes. Several lessons learned from the field as well as software
development strategies are highlighted in building community level
information systems that link to national level health information
systems. Keywords: Public health informatics, information management, primary health care, community networks The delivery of health care services in the Philippines was devolved to
local government units in 1998 under the Health Sector Reform Agenda (HSRA) carried
out by the Department of Health [ 1]. In the course of the devolution, there was not enough time to
cede health information management functions to local government units (LGUs) for
them to carry out data collection, integration and presentation
in a seamless, distributed and coordinated manner. National vertical
health programs remained in place, however, each with its own complement
of logbooks, and reporting forms and protocols, and sometimes
personnel. The Philippine vertical programs include among others, Child
Care and Development, Maternal Care, the National TB Program, Family
Planning, and the Expanded Program for Immunization. In busy community
health centers, data entry of patient information over several logbooks
can be inefficient and is characterized by redundant and inaccurate
entries. As early as 1995, a case study of Philippine public health
information systems by Jayasuria revealed proliferation of reports consuming 40% of
the time of field personnel, high levels of duplication
and delays due to manual processing [ 2], a situation that has persisted to the present. Currently, there
are no data quality control and validation procedures where paper
forms are used and community health workers generally do not get feedback
from reports that they submit. The collection of large amounts of
health data without feedback to the collectors seems to be the practice
not only in the Philippines but in other settings where national vertical
programs are used [ 3]. Vertical programs are generally useful particularly when there
is a need to urgently address a public health problem like HIV-AIDS [ 4, 5] and smallpox [ 6] because they can achieve economies of scale and focus resources
and manpower on a specific problem. To make information management
efficient and to ensure a good supply of quality information, we needed
to integrate existing interfaces to vertical programs at the community
level, as we work our way upwards for higher level integration of information
systems at level of the city health office. In addition to the information management situation above, an alarming
trend is emerging in the Philippine health care scene. As early as 2003, thousands
of physicians nationwide, including an undetermined number
of government physicians, have been retraining as nurses to become part
of the eligible health workforce migrating to developed countries [ 7, 8]. Intra- and inter-country migration of health workers potentially
compromises the quality of health service delivery by creating uneven
distributions of providers in relation to populations [ 9]. The scenario of having health centers without doctors required
that the community-based information system should be usable by community-based
or indigenous health workers. It is in this context that in 2003 we conceptualized the project and submitted
a proposal for funding to PANASIA-ICT [ 10] 1 to implement the Community Health Information Tracking System, or CHITS ( http://www.chits.info), a primary health care information system. The backdrop of this proposal
is a bigger goal to build a national health information infrastructure
within the next five years. The community-based information system
can contribute to this bigger goal by improving information management
at the community level. We deemed the following four objectives important for project success: - To design and develop a generic, reusable, open-source framework for community
health information systems used in primary health care
- To determine the feasibility of integrating vertical programs at the community
level.
- To enable and empower community health center staff to use this community
based health information system through the development of certificate
training courses for community-based data managers.
- To harness community resources for the sustainability of health information
management activities
Lorenzi enumerated four cornerstones of health informatics [ 11] and we deemed it important to embellish these to address the
objectives above as follows: Cornerstone 1: Producing structures to represent data and knowledge so
that complex relationships may be visualized To develop a generic, reusable, open-source framework for primary care
level information systems (first objective) and integrate vertical programs
at the community level (second objective), we needed to: (1) create
an information system architecture based on conceptual data models
revolving around national vertical programs and primary health care services
at the community level; (2) build software functionality around
data models directly related to health care services and vertical programs; and, (3) design
this architecture such that it protects the health
information system from extensive code and database revisions that
may arise without software modularity. Cornerstone 2: Developing methods for acquisition and presentation of data
so that overload can be avoided To carry out integration of data collection, integration and presentation
activities of the different vertical programs at the user interface
level and eliminate paper reporting (second objective), we needed to
examine all health center forms and logbooks identified with the different
vertical programs and subsequently map out intersecting and unique
data elements for each program. Cornerstone 3: Managing change among people, process and information technology
so that the use of information is optimized To empower community health center staff (third objective), we needed to: (1) determine
work motivation factors; and (2) immerse ourselves in
the milieu of health center activities for six weeks. To meet the fourth
objective, aside from building rapport and a working relationship
with the local government units, we needed to: (1) set up partnerships
with external resources to create a “bandwagon effect”; and, (2) build
external alliances around the project to create an ecosystem
of similar applications that support project objectives. Cornerstone 4: Integrating information from diverse sources to provide
more than the sum of the parts and integrating information into work processes
so that it can be acted upon when it can have the largest effect To address the first and second objective, we needed to (1) employ modular, object-oriented
software development methods and adapted open-source
software created by other developers for integration; (2) model the
application from health center workflows and consider the paper-based
forms and logbooks as our closest “competition”; and (3) design
the application to support vertical and horizontal health
information exchange, and incorporate report-generation features to make
sure community health workers can make use of the health data that
they generate at their level. To develop and implement CHITS, these methods were applied to two health
centers (Lagrosa and Malibay) each with an average coverage of 10,000 families
and located in a progressive local government unit with which
our university had established a memorandum of understanding. We describe the project outcomes below according to the objectives previously
enumerated. To design and develop a generic, reusable, open-source framework for primary
care level health information systems One of the obstacles we faced was how to deploy an information system in
three months for a nine-month long project. We had earlier developed
a modular information system architecture called the Generic Architecture
for a Modular Enterprise (GAME) Engine [ 12] that can serve as an applications development platform for other
software development projects. The GAME Engine runs on Linux, Apache
Web Server, MySQL database and the PHP Scripting Language. The GAME
Engine makes extensive use of previously published open-source code libraries
like JPGRAPH for object-oriented graph display and FPDF, a PDF-generation
engine for creating the summary reports. Using this platform, software
development was carried out, resulting in the development
of 44 software components together with lookup data libraries, including
ICD10 Diagnosis Coding. Among these modules is a Clinical Reminders
module that enables health center staff to send mobile phone short
messages (SMS), which are generated from system templates, and sent to
patients to remind them of follow-up visits and encourage compliance
with medication intake. New software modules, software upgrades and data
dictionaries are uploaded as compressed files and automatically incorporated
into the system. The CHITS application currently runs in an
intranet environment with a Pentium 4 class server and 3 scaled down Pentium 4 workstations
costing about $1,900 at 2003 hardware prices. For
the first time, submission of electronic reports has become
part of the health ministry procedures for quality accreditation. To determine the feasibility of integrating vertical programs at the end
user level To integrate the vertical program “information system islands,” we
used the incremental development approach [ 13] (), developed a single interface for vertical program modules, and integrated
report generation tools to the end-user (). shows how modules are positioned in the GAME architecture. We involved
the health center staff in interface development, and successfully streamlined
their health center workflow using CHITS. The indigenous health
workers now interface with public health vertical programs using the
CHITS interface. Most importantly, we were able to eliminate “paper
forms” by six months by working on reports generated
by each vertical program. To enable and empower health center staff to use this community based health
information system through the development of a professionalized
training course for community-based data managers We studied health center culture and social organization using a scaled
down ethnographic approach [ 14, 15] and worked with health center staff for six weeks. One of the
obstacles we faced was the lack of confidence of indigenous health workers
on their ability to use IT. We were able to build relationships
and an environment of mutual trust, enabling us to have smooth interactions
with the health center staff. We incorporated capacity building
to present a benevolent face to potential and obstinate change management
areas, such as quality-adverse data habits (). The end users became effective trainors themselves, proudly showing
off not only their certificates but also their skills. This provided us
with a possible solution to the problem of training staff from other
health centers through “on-the-job” training offered
in centers in advanced stages of training. This also enables us to develop
cohorts of technically-enabled end-users (). Except for the health center physician module, community health workers
ran most of the software modules from health center workstations. We
decided to postpone development of other modules, like the clinical
module, in lieu of the ones most needed to automate and integrate vertical
programs, to make CHITS immediately useful and alleviate health
workers of the report generation burden. To harness community resources for the sustainability of health information
management activities We were also able to create strategic alliances around CHITS to overcome
the lack of momentum in integrating health information systems and lack
of awareness about how different public health information systems
can be made to work using a collaborative approach. One example is the
Tuberculosis (TB) registry vertical program which attracted the Philippine
Coalition Against TB (PhilCAT), a well-funded implementing arm
of the WHO Directly Observed Therapy for Short-Course Strategy chemotherapy (DOTS) for
tuberculosis control. Between July and August 2004, two
demonstration sessions were conducted for the city health offices of
two neighboring local government units (the cities of Parañaque
and Marikina). These LGUs have subsequently initiated CHITS deployment
and secured their own internal and external funding. In the hardware
area, the Advanced Science and Technology Institute (ASTI, http://asti.dost.gov.ph/) of the Department of Science and Technology (ASTI, a government agency) developed
a plug-in PC card that incorporates a GSM modem which enables
CHITS to send clinical reminders and receive data by Short Messaging
System (SMS). To support and complement CHITS implementation, we proposed
two other projects to the national government: the National Telehealth
Project, called BuddyWorks, and the Philippine National Health Information Infrastructure Project, to
link health information stakeholders and enable information exchange. Both
projects were subsequently considered for funding, with BuddyWorks now in the implementation phase, through the e-government program of the
national government and actually form part of the initial activities
of the emerging Department of Information and Communications Technology. Designing community-based health information systems is a challenging task
that involves simultaneous work along technical, social, political, and
financial fronts. Chandrasekhar enumerates systemic constraints
related to a developing country’s economic status that are breeding
grounds for skepticism towards the potential of information and
communications technologies (ICTs) to have a positive impact on health
services delivery. First, an overwhelming majority is likely not to have
access to technology. Second, inadequate education would ensure people
do not have adequate levels of competence or confidence to take part
in transformational activities [ 16]. By using the rich library of open-source tools available online, by
integrating capacity building, and harnessing external, national
and local government political and funding support, we hope to have
addressed these systemic constraints. In this project, we have developed a generic, reusable, open-source framework
and a community-based health information system that integrated
vertical programs at the community level. There are three lessons we
learned from this project: First, by paying close attention to health
center culture and immersing ourselves in the end-user’s social
context, we captured an accurate model of their organizational and personal
realities, and were able to gain insight into their needs and
requirements. We then applied these insights, together with the health
center information and data model, into software code – in a
process called evolutionary software development using a modular approach with incremental introduction of change [ 13]. These insights were also applied to the design of a certificate
data management course for community health workers that brought out
their potential to be able to manage the change brought about by technology
and allowed us to “indoctrinate” them about the
importance of data quality and the bigger information ecosystem where
health center data and information belong. Second, open-source software, aside
from enabling us to decrease implementation costs, provided
an environment for software code transparency for peer-review purposes
and fostered shared learning. Traditional proprietary software development
otherwise hides internal processes as it happens in a software “blackbox.” Third, we discovered that it is important
to have a heightened awareness of the “ecosystem” in
which the health information system will function. Included in this ecosystem
are the people who will make it work (community health workers), the
people who make things possible, logistically and politically, and
the enabling environment to use the system and derive benefits from
it. In the end, implementing this system became a battle for “hearts
and minds” as we created and managed change in implementing
a community-based health information system, first, by looking at how
the people involved viewed things from their perspective, and then by
giving them the tools to manage the change. The authors wish to thank the local government unit of Pasay, the physicians
and staff of the Lagrosa and Malibay Health Centers, and the faculty
and staff of the Department of Family and Community Medicine of the
University of the Philippines for their support in implementing the
project. The authors also wish to thank PANASIA-ICT, IDRC (International
Development and Research Centre of Canada) and UNDP (United Nations
Development Programme) for funding support to implement this project
and disseminate its results. 1. Department of Health, Philippine Government. Philippine Health Sector Reform
Agenda (HSRA). URL: http://www.doh.gov.ph/ 2. Jayasuria R. Health informatics from theory to practice: lessons from a
case study in a developing country. MEDINFO95 Proceedings. Greenes et.al. (editors). IMIA 1995; pp 1603-1607. 3. Anonymous An integrated approach to communicable disease surveillance WHO Weekly Epidemiological Record (WER) Jan 7 2000. 751 page 1. 4. Kanshana S, Simonds RJ. National program for preventing mother-child HIV transmission in Thailand: successful
implementation and lessons learned AIDS 2002. May 3 167953–9. Review. [PubMed] 5. Kilmarx PH, Supawitkul S, Wankrairoj M, Uthaivoravit W, Limpakarnjanarat K, Saisorn S, Mastro TD. Explosive spread and effective control of human immunodeficiency virus
in northernmost Thailand: the epidemic in Chiang Rai province, 1988–99. AIDS. 2000 Dec 1;14(17):2731–40. [PubMed] 6. Henderson DA. Victory over smallpox: interview with Donald A. Henderson. Popul Rep L. 1986 Mar–Apr;(5):L172–3. [PubMed] 7. Fleck F. Should I stay or should I go [News]. Bulletin of the World Health Organization. 2004 Aug;82(8):634. [PubMed] 9. Bach S. Migration patterns of physicians and nurses: still the same story? Bulletin of the World Health Organization. 2004 Aug;82(8):624–625. [PubMed] 11. Lorenzi N. The cornerstones of medical informatics. Journal of the American Medical Informatics Association. 2000;7:204–205. [PubMed] 13. Heeks R. Failure, Success and Improvisation of Information Systems Projects
in Developing Countries. Institute for Development Policy and Management. Document
last viewed at URL: http://www.man.ac.uk/idpm/idpm_dp.htm#devinf_wp January 2002. 14. Friedman C. Subjectivist approaches to evaluation. In Evaluation Methods
in Medical Informatics. Springer, New York. 1997; 205–221. 15. Myers M. Investigating information systems with ethnographic research. Communications of the Association for Information Systems. 1999 Dec;2(23) 16. Chandrasekhar CP, Gosh J. Information and communications technologies and health in low income countries: the
potential and constraints. Bulletin of the World Health Organization. 2001;79(9):850–855. [PubMed] 17. Clements P [editor]. Constructing Superior Software, Software
Quality Institute Series. MacMillan Publishing, USA, 2000. Page 59.
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