Abstract

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

Health informatics, information management, public health, primary care, vertical programs

Background

The Project Setting. Pasay City is a major local government unit in Metro Manila situated near Manila Bay. It has a population of 435,000 and includes 201 barangays, which are provided free public health service coverage by 13 health centers. The Pasay City Health Office is a multi-awarded city known for its capacity as partner to several foreign and locally funded health programs. The University of the Philippines Manila, through a memorandum of agreement provides ground level education to its College of Medicine students through community based learning experiences in Pasay City. This includes, but is not limited to, sending medical students and faculty to the different communities and health centers of the local government unit in the context of its community-oriented medical education program.

The Medical Informatics Unit (MIU) is an academic unit of the College of the Medicine tasked with promoting and advancing education and research in health informatics in the Philippines. Since the College of Medicine was working with SafeKids International on an injury surveillance project, the Medical Informatics Unit conceptualized the Child Injury Surveillance Project using Global System for Mobile Telecommunications Short Messaging System (GSM-SMS) for rapid data collection of injury data. This was submitted as a proposal to PANASIA ICT and was granted funding for a 9-month implementation period [PANASIA]. The proposal covered the installation of an mobile telephony-based child injury surveillance system to be used by Barangay Health Workers (BHWs) in Pasay City.

About 70-80% of information systems projects worldwide end up as failures [Heeks, 2002]. Facing the possibility of implementing a project that looks feasible and innovative on paper but will never be used, the authors decided to address each problem above from the health informatics perspective. The radical decision of expanding project scope to include not only the development of a child injury surveillance system had to be done and this had to include the conversion of paper-based vertical programs into a rationalized and unified information system through horizontal integration.

Systems Analysis. During systems analysis and development it became apparent that the project as proposed would not realistically address the needs of end-users and decision-makers on the ground and would be a candidate for failure. The following key findings provided the rationale for the actual design and implementation of CHITS:

1. Incomplete devolution of health care services. The delivery of health care in the Philippines was devolved to local government units sometime in 1998 under the Health Sector Reform Agenda carried out by the Department of Health [HSRA].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. This led to the deterioration of data collection, information processing activities, data quality and reliability at different levels of the health system, particularly at the grassroots. As a result, local government units were left to implement their own health information systems. In Pasay City, there have been a number of attempts to create electronic health information systems but none of these have been institutionalized. From these previous attempts, the authors anticipated a possible “information systems implementation fatigue.” Because of this, the authors chose to implement the incremental approach (see below) to systems development with the intention of creating success with each small step taken.

2. Vertical health programs. Because of the need to create efficient methods of collecting and analyzing data to generate measures of performance, national vertical health programs, each with its own set of logbooks, and reporting forms and protocols are created and implemented at different levels of the public health system nationwide. The vertical programs, which include among others, Child Care and Development, Maternal Care, the National TB Program, Family Planning, and the Expanded Program for Immunization, receive aggregated data for analysis, most often in paper format from lower level organizational units using the largely paper-based Department of Health Field Health Surveillance and Information System. At the health center level, vertical programs utilize numerous log books as data collection tools. Depending on the number of vertical programs present, the number of logbooks to be filled by health center staff will vary but the time-consuming task of filling out the logbooks with repeating information can take an enormous amount of time, sometimes half a day (depending on the patient load of the health center), that can otherwise be devoted to delivering health care services. In addition, the health workers are also required to submit weekly, monthly, quarterly and annual reports derived from the vertical program logbooks, a repetitive task than can be delegated to automated information systems. 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 [Jayasuria, ], a situation that has persisted to the present.

If the authors implemented the original project as proposed, the data processing activities that vertical health programs required in this setting can potentially overshadow and overwhelm the activities required to carry out SMS data collection. An article in the WHO Weekly Epidemiological Record describes the similar practice of using national vertical programs in other countries [WER, 2000]. Vertical programs are not entirely undesirable particularly when there is a need to urgently address a public health problem like HIV-AIDS [Kanshana, 2002; Kilmarx, 2000]. Smallpox was eradicated from the face of the earth with a well-designed vertical program [Henderson]. The information management problem the authors observed with vertical programs at the health center level is probably a lingering adverse effect never before viewed from a health informatics lens.

The authors subsequently gathered from interaction with the health workers that “data manufacturing” has become an option to satisfy higher level reporting requirements. This situation has likewise been observed by the authors in other areas of the country. This practice leads to loss of data integrity, particularly since no subsequent and intrinsic validation is done by using the data for decision making at that level.

With this data quality scenario, the authors selected as a strategy the adoption of capacity enhancing measures to build up data quality consciousness among health workers. Elsewhere in the bigger health system, this mistrust of health data is manifested as low availability of national level health information from designated authorities and low intensity regional data exchange activities with neighboring countries.

In addition, the collection of huge amounts of health data without feedback to the collectors seems to be the practice not only in the Philippines but in other settings as well, where there are vertical programs [WER, 2000]. With this in mind, the authors emphasized the formulation of appropriate information management strategies, which put emphasis on data utilization at the level of generation.

3. Health workforce export. Concomitant to the situation above, a more alarming systemic scenario is emerging, not only in Pasay City but in the whole country. A number of Pasay City health center physicians, together with about 2,000 other government physicians (as of 2004) nationwide have been undergoing training as nurses with the end in mind of migrating to foreign shores (mainly US, UK and Australia). This form of labor export apparently plagues not only the Philippines but also a number of developing countries in Asia and Africa which have a highly skilled health sector workforce. The desire to work abroad seems to be a pervasive theme during lunch time conversations conducted by the authors with health center staff. Health worker migration to foreign shores potentially compromises the quality of health service delivery including data processing and decision-making. With this challenging backdrop, the authors decided that the health information system to be designed should be usable by health center staff who possess minimal technical skills, and these include barangay health workers, midwives, and nurses.

Significance of the study. There are four areas where this study can make impact:

1. Establishment of a electronic longitudinal health record for local communities. The establishment of an electronic medical record containing all of the patient’s data that also allows for extraction of anonymous population-based epidemiologic studies has remained elusive [Rashbass, 2001].
2. Coordination of care at different levels of service delivery towards quality health care [IOM, 2003]
3. Integration into public health information systems;
4. Estbalishment of a locus for population-based data repositories for public health and primary care research.

Objectives

General Objective. To develop a prototype community-based primary care information system in an urban setting

Specific Objectives:

1. To design and develop a generic, reusable, open-source framework for primary care level health information systems
2. To determine the feasibility of integrating vertical programs and at the end user level.
3. 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.
4. To harness community resources for the sustainability of health information management activities

Methods

According to the British Medical Informatics Society, the terms 'medical informatics' and 'health informatics' have been variously defined, but can be best understood as meaning the understanding, skills and tools that enable the sharing and use of information to deliver healthcare and promote health. 'Health informatics' is now tending to replace the previously commoner term 'medical informatics', reflecting a widespread concern to define an information agenda for health services which recognises the role of citizens as agents in theirown care, as well as the major information-handling roles of the non-medical healthcare professions. Primary care is considered one of the fields of health informatics and has been described in terms of the following: first-contact care, longitudinality, comprehensive services, and coordination. Lusignan defines primary care informatics as “the scientific study of data, information and knowledge and how they can be modeled, processed or harnessed to promote health and develop patient-centered primary medical care.” He further states that “its methods reflect the biopsychosocial (as opposed to biomedical) model of primary healthcare and the longitudinal relationships between patients and professionals” and that “its context is one in which patients present with unstructured problems to specially trained primary care professionals who adopt a heuristic approach to decision making within the consultation” [Lusignan, 2003].

Health Informatics Strategies. Nancy Lorenzi enumerated four cornerstones of medical informatics : (1) producing structures to represent data and knowledge so that complex relationships may be visualized, i.e., modeling; (2) developing methods for acquisition and presentation of data so that overload can be avoided; (3) managing change among people, process and information technology so that the use of information is optimized; and (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 [Lorenzi, 2000]. Using these 4 cornerstones as guideposts, the authors identified key strategies to be used in the development and implementation of CHITS:

Results and Analysis

For this project, two health centers in the Pasay City local government unit were selected: (1) the Malibay Health Center, a very busy health center or with a heavy patient load, and (2) the Lagrosa Health Center, with light to moderate patient load. The four cornerstones and the corresponding strategies used and their outcomes are briefly described below.

1. Information Architecture designed to match primary care environment
The Medical Informatics Unit had earlier developed a modular information architecture implementation called the GAME Engine [sourceforge], short for Generic Architecture for a Modular Enterprise, that allows the reuse of software code in other software development projects . The GAME Engine entailed the use of the application's data model as the foundation for creation of software modules. Essentially, two types of data models are used: the GAME Engine internal data model and the health center (CHITS) data model. Figure 1 partially shows the GAME Engine internal data model for the module class.

Using the GAME Engine, software development was carried out on a modular basis (see below), avoiding global and potentially catastrophic and time-consuming changes to monolithic code and database structure, and strictly enforced both module independence and dependence, and system security and authentication. This approach also enabled implementation of completed modules without waiting for the rest of the application to be completed.

The Child Injury Surveillance System, now renamed Community Health Information Tracking Systems, or CHITS, is currently composed of close to 40 software components together with lookup data libraries. It includes ICD10 Diagnosis Coding with its own search engine, and the majority of modules was developed within a span of 3 months of intense software development activity. A separate research is being carried out to map reasons for encounter to ICPC-2 . The Child Injury Surveillance Module is now part of the this bigger application and is appropriately integrated into the “big picture” at the community level. This change in the project specification also effectively increased the contribution of the Medical Informatics Unit and the University of the Philippines when converted to financial value, in the overall funding picture. The original SMS portion of the project has been expanded to include clinical reminders which serves several modules. The module, Clinical Reminders, enables health center staff to send SMS messages generated from system templates to patients for follow-up and medication intake reminders. This appears to have the greatest use in three modules: Child Care for vaccination follow-ups, Maternal Care for prenatal follow-ups and anti-tetanus vaccinations and the National TB Program for the DOTS treatment protocol. The original proposal called for an SMS-based data collection system.

The GAME Engine specifications are listed in Table 2. The modules are both functionally designed to be self-contained and reusable in other applications with very minimal modifications. Since the GAME Engine is web-based, hardware requirements are modest. Modules, software upgrades and data dictionaries are uploaded as files and automatically incorporated into the system. The modules are distributed in compressed format (GZIP) so that they can be easily passed around in 3.5” floppy disks. The CHITS application currently runs in an intranet environment with a Pentium 4 class server and 3 scaled down Pentium 4 workstations. Although it runs in an intranet environment, it has also been designed with stubs to incorporate source code for running in a distributed network (to link health centers together) to enable data interchange between health centers using ordinary dial-up connections and XML-based web services using SOAP . The design for the portable primary care record is still under development.

2. Elimination of Data Overload
This project presented an opportunity to solve the “dis-integration” of vertical programs' paper-based information systems at the community level (health center). The vertical programs, after analysis by the authors, revealed thoughtful and logical implementation on paper representing with fidelity their individual data models, purely and possibly from numerous iterations during actual implementation. However, their individual data models disregarded the existence of the other vertical programs and created “information system islands” (Figure 2) The approach taken here was to integrate the different data models into one and present a unified interface and report generation tools to the end-user.

The original Filipino custom called “bayanihan” involves sharing the workload in a given task such that village folk can move a whole “bamboo and nipa” house by carrying the house together (Figure 3). To avoid creating a physician-centric health information system, the authors created a system that enables all staff members in the health center to contribute to building up the database and maintaining the information system in a distributed manner. In the first pilot health center, a nurse readily serves as a system administrator and creates accounts and assigns permissions for the rest of the staff. He also teaches the staff how to log in and use the different modules of the system (effectively duplicating what the health center physician can do). The concept of doing information work collectively silently bore fruit as the health center staff saw their database growing in size.

3. Change Management
The authors anticipated difficulty in ascertaining the actual information culture at the health center from interviews alone. Using an ethnographic approach [Friedman, 1997], the primary investigator spent 6 weeks of working with the health center staff to acculturate him with the health center information and social culture. It also allowed the building of relationships and an environment of mutual trust, which enabled the primary author to extract more information from the health center workers and from key health center processes, not just in terms of information system processes, but also in terms of attitudes and culturally bound practices. An insight into the aspirations of health center staff allowed the authors to carefully craft a multi-level curriculum for capacity building geared towards empowerment and building of self-esteem. Lunch time (group) and individualized encounters of the authors with the health center staff also provided a non-threatening environment and teachable moments for health center staff to absorb nuggets of informatics knowledge and principles. Sjoberg and others describe participatory information systems development being used in a primary care setting [Sjoberg, 1998].