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Introduction

The University of the Philippines Manila National Telemedicine Center was established in 1998 to investigate the use of information and communications technology (ICT) to improve health care delivery for all Filipinos. The Center is based at the Philippine General Hospital. It manages referrals from more than 40 doctors in remote areas around the country, connecting them to more than 600 experts at the Philippine General Hospital. In implementing e-health and telemedicine, the National Telemedicine Center chose an approach based on community involvement as well as technology. Three different case studies are described below that demonstrate different aspects of this strategy. The case studies are CHITS, the E-Learning for Health Project and the SMS Telemedicine Project.

The approach to implementation consisted of three distinct steps:

1. The human experience: start from where the people are.
   
   
2. The technological opportunity: identify appropriate, available, accessible and culturally acceptable technologies.
   
   
3. The sustenance factor: embed the technology into the local fabric.

The human experience

Although technology offers benefits in terms of applying new processes and approaches to problem-solving, the fact is that most health interventions are only as effective as their ability to become embedded in routine activity. This means that if e-health implementations are approached from a purely technical standpoint it will invariably fail to realize their full potential.

The essence of the human experience is communication and interaction. The National Telemedicine Center has observed that the benefits for communities of e-health and telemedicine occur when the technology presents itself (a) as an enhancement to existing human relationships that have been established through conventional routes or (b) as a solution to a long-felt community need. In either case, the Center’s experience has shown that technology has higher chances of sustaining itself in areas where mature human relationships and interactions already exist.

My experience with the Community Health Information Tracking System¹ (CHITS) has allowed me to observe a highly technical training programme evolving into one that is less technology based and more community oriented and dialectical. During the initial CHITS training, much time was wasted in teaching elderly health workers how to use a mouse and to type on a keyboard. At the end of the training sessions, participants still appeared to be afraid of accidentally damaging the computer. Post-training interviews revealed that the health workers never became comfortable with the technologies that were being introduced (the PC and the electronic medical record application).

Community Health Information Tracking System

CHITS was funded in 2004 by the International Development Research Centre of Canada and subsequently by the United Nations Development Programme (UNDP). The aim was to develop an integrated disease surveillance system. CHITS was developed in close consultation with village health workers to best identify their needs. The result was an open-source application for the village health centre that combined the features of an electronic health record and clinic appointment system while also integrating modules for national health programmes.

CHITS was a starting point for the integration of information systems. Through CHITS, community-based health information was made available not only to public health agencies requiring community level information but also to the community that generated the information. It enabled the community to use this information for local decision-making.

Currently, CHITS is in use in 12 health centres in two cities and two provinces in the Philippines. It has made the work of village health workers easier, since information is entered only once during a patient consultation and can then be used to generate the different reports that need to be submitted to the Department of Health. Since data are stored electronically, it is now easier to access and consolidate information, and there is less risk of data loss. More timely reports allow community leaders to make better decisions for their people.

There are approximately 100 000 transaction records from the 12 health centres presently using CHITS. The information is stored in databases using simple data elements patterned after the Department of Health. Access is limited to authorized personnel, who undergo a two-day electronic health record training prior to using the system. In this training programme, the ethics of health information management are taught with special attention to the responsibility and security required for digital data. All data are owned by the relevant health centre, which also controls access. The data can be extracted using open-source software tools.

In the light of early experience, revisions in the training programme were made. Foremost among the changes was the shift from a highly structured training programme on how to use the keyboard and mouse to a less strict, more fun approach to using the interfaces by allowing the health workers to play games on the computer. The trainers discovered that health workers were often afraid of the new ‘formal’ skills that they needed to acquire, but were more relaxed (albeit sometimes fiercely competitive) when asked to beat each other in a game of solitaire. So, instead of coercing the participants into a strict regimen of clicking and copy-pasting, they are given time to develop confidence in the use of the keyboard and the mouse through simple games. The game orientation removes the fear that they have to perform well in a short period of time. This is what is meant by starting from where the people are. A recognition of the cultural aspects of community life is important in starting them off into a new direction such as computerization and automation.

In 2006, CHITS was chosen as one of the key e-government projects by the APEC Digital Opportunity Center in Taiwan.² It was also a finalist in the 2006 Stockholm Challenge.³

The technological opportunity

The process of understanding local cultures and processes, respecting the local experts, and analyzing their thought processes can often be frustrating. However, it is essential if external technology is to be embedded into the community’s way of life. Once the community has been understood, the technologies that are available and appropriate can be determined. The National Telemedicine Center’s experience with its E-Learning for Health Project has demonstrated the importance of this step.

E-Learning for Health Project

The migration of health professionals from rural areas in the Philippines has progressed to the point that many municipalities are unable to provide regular training to community health care volunteers. Many of these under-served communities are also in hard-to-reach, remote areas, and travel costs can be high. With support from USAID, the National Telemedicine Center developed four video modules about common topics relevant to the management of disease in the community:

• community management of accidental childhood poisoning
  
  
• community management of stroke
  
  
• community management of tuberculosis
  
  
• community introduction to the avian influenza threat.

These video modules last 7–10 minutes each and are narrated in the vernacular with English subtitles. The audiences are community health care volunteers in remote communities. After the video showing, an interactive question and answer session is established between the expert in Manila and the volunteers using the best available technology (ranging from videoconferencing to mobile phone calls). Various telecommunication media have been employed for the educational sessions which are held in various locations (Figure 3.1):

• childhood poisoning between Manila and Basak Pardo, Cebu, using broadband Internet (Figure 3.2)

Figure 3.1 Locations of educational sessions

Figure 3.2 An expert participating in a health worker’s meeting via videoconferencing

• stroke between Manila and Nueva Vizcaya, using cellphones
  
  
• avian influenza and tuberculosis between Manila and Roxas City and Tapaz, Capiz Province, using Internet videoconferencing.

One reason for the success of this teaching model was the familiarity of the audience with the lecture format. We were able to elicit participation from the audience by providing them with access to an expert in Manila. There were several benefits. First, there were cost and time savings from travel by not having to transport the expert to a remote area. Second, the expert could serve several communities in a single session. The audience were able to receive updates using a novel method that did not require them to establish new skills. In all cases, the local participants were given the opportunity to participate and ask questions directly of the expert using the vernacular.

In the Philippines, massive migration of doctors and nurses has resulted in a lack of trainers in the public health sector. Even where there are many community health volunteers, there are not enough trainers and leaders to provide them with the requisite knowledge.

Visiting the under-served communities has made the staff of the Center aware of what technologies are available. Televisions and video CD players can be found in almost all communities. In populated areas, there is invariably mobile phone coverage, so that voice calls and/or a short-message service (SMS) are also available.

The E-Learning for Health Project has shown that, by using locally available technology and the best available bandwidth, it is possible to establish interaction between a group of health care volunteers (in a remote community) and an expert (in an urban area). Voice calls were found to be most effective, although participants also appreciated videoconferencing. The community members were keen to accept the new modality, because it employed technologies that were already familiar to them. Pretests and post-tests given to participants revealed that they were able to gain knowledge from the e-learning activity.

The sustenance factor

Stand-alone, intermittent, expert-driven events (such as the E-Learning for Health Project and CHITS) are easy to implement, but are they sustainable? In order to achieve permanence, e-health and telemedicine applications must be embedded into the local fabric of the community.

How, then, do we overlay the technologies (step 2) over the local issues (step 1) to ensure that the technical solution finds a home in the heart of the community? E-health should be considered as another community activity that will need to involve discussions, arguments and deliberations. E-health should thus become the vehicle for more rapid and more structured community development through enhanced communications and process documentation. This becomes more apparent with the use of mobile phones for health-related concerns such as announcements for community meetings, reminders for vaccinations and prenatal check-ups. It also involves gathering the health volunteers and workers regularly to attend e-learning sessions on community health development.

In one high-profile government-funded project, the BuddyWorks Community Partnership in Delivering Telemedicine Services, remote sites were provided with workstations and broadband Internet connections to allow them to refer difficult cases to experts in a central facility. A total of 10 facilities in four provinces was involved. However, despite the substantial investment, referrals from the remote sites did not occur. Analysis revealed a workflow that prevented the users from assimilating desktop Internet technologies for communicating clinical dilemmas. In the proposed system, the remote physician needed to log on to a computer with Internet access, go to the agreed website portal, enter the relevant clinical data and wait for the response of an expert – who would probably be busy with his or her own patients at the time. The process had so many steps that the risk of a failed transaction was very high.

SMS Telemedicine Project

In response, the workflow was revised to allow the doctors to communicate via SMS. Most doctors already owned a mobile phone. Using SMS, they were able to communicate more effectively. It was then decided to supplement the existing network by providing modest prepaid SMS allowances to the doctors and offering them free conference call services for voice-based referrals. This system has proved to be sustainable and effective. During a 6-month period, over 300 referrals were received from 44 doctors in remote areas.

Conclusion

It is widely accepted that all societies, especially those of developing countries, can build more cohesive communities through the primary health care approach. Telemedicine and e-health have a great potential to facilitate service delivery in primary care. For example, rural health workers commonly suffer from inefficient, paper-based recording systems. CHITS, based on free and/or open source software and SMS, provided a more effective alternative.

At the core of any telemedicine service is an electronic health record. This is how CHITS plays a role in telemedicine – by providing a consistent view of the patient’s records. The current telemedicine services in the Philippines are simple enhancements to existing trust structures. By using SMS and mobile phones, the National Telemedicine Center is able to provide access to experts for patients who would not otherwise have been able to consult them. The use of SMS technology has increased the area of coverage of the Center.

The challenges that plague the Philippine system are the continuing loss of health professionals from internal and external migration. As more and more health workers seek work in other countries and rural physicians move from rural to urban practices, the number of municipalities without doctors will increase. Establishment of an efficient and effective referral network, based on mobile phone technology, is a key component in mitigating the effects of this migration. The faster the trust relationships between the remote doctors and physicians are established, the quicker telemedicine services can take hold in the relevant communities.

Further reading

International Medical Informatics Association. IMIA Code of Ethics for Health Information Professionals. Available at: www.imia.org/ethics.lasso.

Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, 6–12 September 1978. Available at: www.who.int/hpr/NPH/docs/declaration_almaata.pdf.

Heeks R, Mundy D, Salazar A. Why Health Care Information Systems Succeed or Fail. Institute for Development Policy and Management, 1999. Available at: unpan1.un.org/intradoc/groups/public/documents/NISPAcee/UNPAN015482.pdf.

University of Texas Medical Branch Web Education Courses. Telemedicine 101: Basic Principles of Telemedicine. Available at: www.utmb.edu/teletraining/th101/index.html.

World Health Organization. Executive Board. eHealth: Proposed Tools and Services. Available at: www.who.int/gb/ebwha/pdf_files/EB117/B117_15-en.pdf.

References

¹ Tolentino H, Marcelo A, Marcelo P, Maramba I. Linking primary care information systems and public health information networks: lessons from the Philippines. Stud Health Technol Inform 2005; 116: 955–60.

² APEC Digital Opportunity Center. Available at: www.apecdoc.org.

³ Stockholm Challenge. Available at: www.stockholmchallenge.se.

Document(s) 5 of 31