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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.
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.
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.
  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].
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].
Strategy 2: “Bayanihan” concept in information work
Strategy 5: Harnessing resources for sustainability through “bandwagon effect”
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.
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.
The use of the mouse and keyboard initially appeared to be a daunting obstacle to efficient use of the system. A creative approach using computer games was employed to enable health center staff to gain proficiency in using these input devices while having fun during their free time. Hardware issues that caused end-user frustration included loose power outlets, and loose network cable connectors. Improperly installed Linux workstations can also add to end-user frustration as observed in a few instances when one (out of 3) workstation consistently failed to launch the graphical user interface (KDE desktop) and show the “unfriendly” root prompt.
Software as an Agent of Change. Change management was approached from a variety of angles. One of the creative ways this was carried out was through the principle of proactively using software as an agent of change. This concept is a complete reversal of the traditional situation where change is managed because software introduces changes (reactive). Using this method, the authors introduced, in a controlled manner, critical points of change in various aspects of health center operations created by new software modules where end users are presented with opportunities for enlightenment about certain issues. As an example, the amount of involvement of Barangay Health Workers has been traditionally minimal in health center operations. With the software introducing points of change in (1) electronic data collection and (2) proactive patient management (a known gap) that will eventually strengthen health center coverage of its constituents, but would require more BHW contribution to the effort, the health center staff eventually acknowledged that the health center information system would need BHW involvement to strengthen its programs. For another example, the reporting of prenatal home visits appeared to be “manufactured” based on need. After using the system for a few weeks the end-users themselves verbally expressed that it will be “very hard to cheat” when everything is computerized as (1) the system keeps record of who did data entry for a specific module and (2) they “do not have access” to the raw data in the database.
In this study, a generic, reusable, open-source framework for primary care level health information systems was developed and utilized. Since it is modular, CHITS can be expanded to include community based geographical information systems, a City Health Office information system and even a telemedicine module. The authors were originally leaning towards a technology-centric implementation of an information system with the SMS data collection. With deeper analysis and a clear understanding of the needs and requirements of end users, the authors were able to put technology in its place to serve the genuine needs of community health workers. A radical project re-orientation was done to reduce the huge gap between what the end-users need (comprehensive information management) and what the project initially hoped to achieve (information management of child injury surveillance data using computers and wireless technology). The majority if not all of the technology used in this project come from the Internet and are used to run the Internet in a distributed fashion. Being mature and stable open source technologies, with huge user populations, leveraging these technologies offers extreme value at the lowest cost. These technologies have been tested under extremely grueling conditions globally. By paying close attention to health center events and using purposeful immersion in the end-user's way of life (to capture an accurate model of their organizational and personal realities), the authors were able to gain immense insight into their needs and requirements and apply these insights into software code – in a process called evolutionary software development [Clements, 2000]. A modular approach and incremental introduction of change [Heeks, 2002] also enabled the authors to isolate software problems and solve them in an efficient and systematic manner, closely involving end users in the process.
The authors were able to show the feasibility of integrating vertical programs and at the end user level. The health center where CHITS was first deployed has gone paperless, a sign of victory over the competition – paper forms.
  1. Rigby M, Roberts R, Williams J, Clark J, Savill A, Lervy B, Mooney G. Integrated record keeping as an essential aspect of a primary care led health service. British Medical Journal – Information in practice, August 29, 1998, Vol 317, page 581.

    Deletions:
    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.
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.
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.
  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].
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].
Strategy 2: “Bayanihan” concept in information work
Strategy 5: Harnessing resources for sustainability through “bandwagon effect”
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.
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.
The use of the mouse and keyboard initially appeared to be a daunting obstacle to efficient use of the system. A creative approach using computer games was employed to enable health center staff to gain proficiency in using these input devices while having fun during their free time. Hardware issues that caused end-user frustration included loose power outlets, and loose network cable connectors. Improperly installed Linux workstations can also add to end-user frustration as observed in a few instances when one (out of 3) workstation consistently failed to launch the graphical user interface (KDE desktop) and show the “unfriendly” root prompt.
Software as an Agent of Change. Change management was approached from a variety of angles. One of the creative ways this was carried out was through the principle of proactively using software as an agent of change. This concept is a complete reversal of the traditional situation where change is managed because software introduces changes (reactive). Using this method, the authors introduced, in a controlled manner, critical points of change in various aspects of health center operations created by new software modules where end users are presented with opportunities for enlightenment about certain issues. As an example, the amount of involvement of Barangay Health Workers has been traditionally minimal in health center operations. With the software introducing points of change in (1) electronic data collection and (2) proactive patient management (a known gap) that will eventually strengthen health center coverage of its constituents, but would require more BHW contribution to the effort, the health center staff eventually acknowledged that the health center information system would need BHW involvement to strengthen its programs. For another example, the reporting of prenatal home visits appeared to be “manufactured” based on need. After using the system for a few weeks the end-users themselves verbally expressed that it will be “very hard to cheat” when everything is computerized as (1) the system keeps record of who did data entry for a specific module and (2) they “do not have access” to the raw data in the database.
In this study, a generic, reusable, open-source framework for primary care level health information systems was developed and utilized. Since it is modular, CHITS can be expanded to include community based geographical information systems, a City Health Office information system and even a telemedicine module. The authors were originally leaning towards a technology-centric implementation of an information system with the SMS data collection. With deeper analysis and a clear understanding of the needs and requirements of end users, the authors were able to put technology in its place to serve the genuine needs of community health workers. A radical project re-orientation was done to reduce the huge gap between what the end-users need (comprehensive information management) and what the project initially hoped to achieve (information management of child injury surveillance data using computers and wireless technology). The majority if not all of the technology used in this project come from the Internet and are used to run the Internet in a distributed fashion. Being mature and stable open source technologies, with huge user populations, leveraging these technologies offers extreme value at the lowest cost. These technologies have been tested under extremely grueling conditions globally. By paying close attention to health center events and using purposeful immersion in the end-user's way of life (to capture an accurate model of their organizational and personal realities), the authors were able to gain immense insight into their needs and requirements and apply these insights into software code – in a process called evolutionary software development [Clements, 2000]. A modular approach and incremental introduction of change [Heeks, 2002] also enabled the authors to isolate software problems and solve them in an efficient and systematic manner, closely involving end users in the process.
The authors were able to show the feasibility of integrating vertical programs and at the end user level. The health center where CHITS was first deployed has gone paperless, a sign of victory over the competition – paper forms.
  1. Rigby M, Roberts R, Williams J, Clark J, Savill A, Lervy B, Mooney G. Integrated record keeping as an essential aspect of a primary care led health service. British Medical Journal – Information in practice, August 29, 1998, Vol 317, page 581.


    Edited on 2008-06-06 12:15:09 by WikiAdmin []

    Deletions:
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