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Pilot Implementation of a Community-based,
eHealth-enabled Service Delivery Model for
Newborn Hearing Screening and Intervention
in the Philippines
Abegail Jayne P. Amoranto, MSc,1,2 Philip B. Fullante, MD,3 Talitha Karisse L. Yarza, MclinAud,3
Abby Dariel F. Santos, RN,1 Mark Lenon O. Tulisana, RN,1 Monica B. Sunga,1 Cayleen C. Capco,1
Janielle T. Domingo,1 Marco Antonio F. Racal,1 James P. Marcin, MD, MPH,4 Luis G. Sison, PhD,5
Charloe M. Chiong, MD, PhD2,3 and Pora Grace F. Marcelo, MD, MPH1,2
1National Telehealth Center, National Institutes of Health, University of the Philippines Manila
2College of Medicine, University of the Philippines Manila
3Philippine National Ear Institute, National Institutes of Health, University of the Philippines Manila
4Department of Pediatrics, University of California Davis School of Medicine
5Electrical and Electronics Engineering Institute, College of Engineering, University of the Philippines Diliman
ABSTRACT
Objecves. This study explores the potenal of the HeLe Service Delivery Model, a community-based newborn
hearing screening (NHS) program supported by a web-based referral system, in improving provision of hearing
care services.
Methods. This prospecve observaonal study evaluated the HeLe Service Delivery Model based on records review
and user perspecves. We collected system usage logs from July to October 2018 and data on paent outcomes.
Semi-structured interviews and review of eld reports were conducted to idenfy implementaon challenges and
facilitang factors. Descripve stascs and content analysis were used to analyze quantave and qualitave
data, respecvely.
Results. Six hundred ninety-two (692) babies were screened: 110 in the RHUs and 582 in the Category A NHS
hospital. Mean age at screening was 1.4±1.05 months for those screened in the RHU and 0.46±0.74 month for those
in the Category A site. 47.3% of babies screened at the RHU were ≤1 month old in contrast to 86.6% in the Category
A hospital. A total of 10 babies (1.4%) received a posive NHS result. Eight of these ten paents were referred via the
NHS Appointment and Referral System; seven were conrmed to have bilateral profound hearing loss, while one paent
missed his conrmatory tesng appointment. The average wait me between screening and conrmatory tesng was
17.1±14.5 days. Facilitang factors for NHS implementaon include the presence of champions, early technology
adopters, legislaons, and capacity-building programs. Challenges idened include perceived inconvenience in using
informaon systems, cost concerns for the paents,
costly hearing screening equipment, and unstable
internet connecvity. The lack of nearby facilies
providing NHS diagnosc and intervenon services
remains a major block in ensuring early diagnosis and
management of hearing loss in the community.
Conclusion. The eHealth-enabled HeLe Service Delivery
Model for NHS is promising. It addresses the challenges
and needs of community-based NHS by establishing
a healthcare provider network for NHS in the locale,
providing a capacity-building program to train NHS
screeners, and deploying health informaon systems
that allows for documentaon, web-based referral and
tracking of NHS paents. The model has the potenal
eISSN 2094-9278 (Online)
Published: September 28, 2023
hps://doi.org/10.47895/amp.v57i9.5332
Corresponding author: Abegail Jayne P. Amoranto, MSc
Naonal Telehealth Center
3rd Floor IT Center, Joaquin Gonzalez Compound,
University of the Philippines Manila
Padre Faura St., Ermita, Manila 1000, Philippines
Email: apamoranto@up.edu.ph
ORCiD: hps://orcid.org/0000-0002-0613-0231
VOL. 57 NO. 9 2023 73
ORIGINAL ARTICLE
to be implemented on a larger scale — a deliberate step
towards universal hearing health for all Filipinos.
Keywords: newborn screening, hearing loss, health
informaon systems, community healthcare, healthcare
delivery
INTRODUCTION
e prevalence of permanent bilateral hearing loss
detected at birth is about 0.13% in the Philippines.1 If
undetected and not treated early, this results in permanent
bilateral hearing loss and serious delay in speech, which
can adversely aect intellectual and emotional development
of the child. is can cost a family about PhP 4.3 million
for special care, special education as well as account for lost
income during adulthood.2
Newborn hearing screening (NHS) can eectively
promote the diagnosis and management of hearing loss during
the rst 6 months, ensuring better outcomes for children.2-6 In
the Philippines, the Universal Newborn Hearing Screening
and Intervention (UNHSI) Act of 2009 (Republic Act 9709)
mandates that all newborns must be screened for hearing
loss and if present, receive early intervention.7 e Newborn
Hearing Screening Reference Center (NHSRC) led this
advocacy. It reports, however, poor NHS coverage in the
country with less than 10% of Filipino newborns screened
in 2020.8 is translates to approximately 1.5 million
newborns unscreened or unreported. Furthermore, around
73% to 92% of babies that required rescreening or second
testing after a “REFER” NHS result were lost to follow
up.2,8 To improve the coverage and delivery of NHS in the
country, one objective set by the UNHSI Act is to “develop
models which ensure eective screening, referral and linkage
with appropriate diagnostic, medical and qualied early
intervention services, providers, and programs within the
community”.7 In line with this objective, the Hearing for
Life (HeLe) Project proposed a service delivery model for
UNHSI, which capitalizes on the promises of information
and communications technology in health and the benets
of a community-based approach in the provision of hearing
healthcare services.9 e University of the Philippines (UP)
and the University of California (UC) led this initiative.
The HeLe Service Delivery Model
e HeLe Service Delivery Model proposes a
community-based NHS program supported by electronic
health information systems for care documentation and
referral management. It connects primary care and specialty
care providers within a service delivery network (SDN) in
the locale through an electronic referral system.
Currently, NHS is usually performed in hospitals and
specialist centers, certied by NHSRC as a Category A NHS
Center, while conrmatory and intervention services are
provided in Categories B to D. In the HeLe model (Figure
1), the Rural Health Unit (RHU) serves as the screening
facility for newborns in their catchment area. Within a
municipality, the RHU typically serves as the birthing center,
and will receive referrals of parturient mothers from Barangay
Health Stations (BHS) where oftentimes mothers receive
their prenatal care.10 e HeLe research program opted
for enabling the RHU as a Category A Hearing Screening
Center as a step towards democratizing access to the NHS.
e RHU is where most babies are born, geographically
and culturally closer to their families and homes. With the
RHU as the screening facility, parents of newborns born
in the RHU or within the community will be informed of
the NHS service their child is entitled to. Newborns will
be assessed for hearing defects within a day to 90 days after
delivery, as part of their routine newborn care.11 is service
will be recorded in the patient’s electronic medical record in
the RHU.
Children with positive hearing screening results will then
be referred from the RHU to their preferred conrmatory
testing center through the NHS Referral and Appointment
System, a web-based tele-referral system hosted in the
National Telehealth System (NTS). e NHS Referral and
Appointment System allows patients to automatically set their
appointments for hearing diagnostic testing. eir primary
care, in this case, the RHU, receives feedback on the results
of the testing. is allows them to track the hearing status
of their referred patient and refer them to available nancial,
rehabilitation, and education services in the community.
In this paper, we sought to explore the potential of
the HeLe Service Delivery Model, a community-based
NHS program supported by a web-based referral system
in improving provision of hearing care services, specically
screening and conrmatory testing. First, we identied the
existing model of care for NHS and program implementation
challenges in the study sites. Second, we described the
interventions designed to address the identied challenges
in the implementation of the HeLe Service Delivery Model.
And lastly, we presented the outcomes of the pilot, including
patient outcomes, system usage, and user perspectives on
barriers and facilitating factors to implementation.
MATERIALS AND METHODS
is prospective observational study was divided into
three phases: (1) situational analysis of NHS implementation
in the study sites; (2) pilot implementation of the HeLe
service delivery model; and (3) evaluation of the model
based on records review and user perspectives. Baseline data
was collected from October to December 2017 while pilot
implementation and evaluation data (e.g., system usage logs
and user perspectives) were gathered from July to October
2018. We received ethical clearance from the ethics review
board of the University of the Philippines Manila.
To identify potential study sites, we conducted a
mapping of NHSRC-certied Category A to D facilities
VOL. 57 NO. 9 202374
Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
in the country, and Rural Health Units (RHUs) that
adopted the Community Health Information and Tracking
System - Electronic Medical Record (CHITS-EMR)12
and had previous experience implementing telemedicine.
We identied Region VI - Western Visayas as the site for
setting up an NHS SDN. Four RHUs, one Category A
NHS facility, and one Category B NHS facility participated
in Region VI. We also engaged three RHUs from Romblon
to test the model in a setting where there were no certied
NHS facilities. Situational analysis through key informant
interviews and site visits was done to determine the NHS
implementation and referral ow in the communities, and to
assess challenges relating to the provision of NHS services.
Together with key stakeholders from partner communities,
we identied interventions to address perceived barriers to
implementation of the HeLe Service Delivery Model. ese
were presented to the sites and a Memorandum of Agreement
was signed prior to deployment. Healthcare providers (HCPs)
from the study sites underwent a blended-learning program,
which involved a computer-based training course, a three-
day face-to-face training session and onsite coaching. e
last day of the course involves a screener certication process
conducted by the NHSRC.
To test the system, a newborn hearing screening day
was organized by participating RHUs. It sought to increase
awareness among the community on the importance of the
NHS and that the service would be available in the RHU.
e event was also designed as a practice for the HCP who
partook in the HeLe capacity building program.
Children aged 0-3 months, who have yet to undergo
NHS, were recruited. Babies beyond three months of age
presented to the clinic for NHS were also included. Informed
consent was obtained from all parents of these infants.
NHS was done using a commercially available Otoacoustic
Emission (OAE) device. Healthcare providers, who received
HeLe training and passed the certication process, conducted
the NHS and documented the screening done in the CHITS
- Newborn Hearing Screening Module. During the NHS
Figure 1. The HeLe Service Delivery Model.
Abbreviaons/Legend: RHU, Rural Health Unit; NHS, Newborn Hearing Screening; NTS, Naonal Telehealth System; Categories of Newborn Hearing
Centers: A, Category A Newborn Hearing Screening Center; B, Category B Newborn Hearing Diagnosc Center; C, Category C Newborn Hearing
Diagnosc and Intervenon Center; D, Category D Newborn Hearing Diagnosc, Intervenon, Surgical, and Rehabilitaon Center.
VOL. 57 NO. 9 2023 75
Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
day in the communities, the HeLe research team – composed
of ENTs, clinical audiologist, and telehealth trainers – were
present on site to provide guidance on NHS and use of the
deployed information systems. For patients who presented
with “REFER” hearing screening results, the nal hearing
screening test was done by the HeLe audiologist or ENT
for conrmation. In both RHU and Category A pilot sites,
NHS data of babies, whose parents consented to have their
data captured in the system, were included in the study.
Screening data were entered into the CHITS - Newborn
Hearing Screening Module. Patients with “REFER” NHS
results were then referred by the physician to the patient’s
preferred conrmatory testing center via the NHS Referral
and Appointment System. e patient and the referring
facility received notications once results were available.
From July to October 2018, the researchers collected system
usage logs, specically the total number of babies screened
and entered in the system, the number of babies with
“REFER” NHS results, the number of referrals booked, the
screening and conrmatory testing results, the number of
missed appointments, and the duration between screening
and conrmatory testing. Semi-structured interviews and
review of eld reports were conducted to identify challenges
and facilitating factors in the implementation of the HeLe
service delivery model. Descriptive statistics and content
analysis were used to analyze quantitative and qualitative data,
respectively. e Human, Organization and Technology-t
(HOT-Fit) Model13 was used to examine the enablers of
and challenges to the ICT-enabled HeLe UNHSI Service
Delivery Model. We used this framework to evaluate three
components for successful implementation of information
systems, namely: (1) human component, which includes user
attitude and user satisfaction; (2) organization component,
which includes leadership, organizational support, and
environment; and (3) technology component, which involves
system, information, and service quality.13
RESULTS
Characteriscs of Study Sites
Seven RHUs (R1 to R7) and one tertiary hospital
(Category A) served as hearing screening centers in the study.
Five pilot sites (i.e., R1 - R4, Category A) were in Western
Visayas Region and three (i.e., R5 - R7) were in the province
of Romblon. All study sites, except the Category A hospital,
had implemented telehealth projects in their communities
and had been using CHITS as their electronic medical record.
Table 1 reects the community demographics, the coverage
of NHS in the community, and the status of NHS in their
area at the time of the study.
Each RHU catered to an average of 34 barangays and
these seven RHU serve about 304,000 individuals. ree
of these RHU study sites provide healthcare services to
geographically isolated and disadvantaged areas (GIDAs).
e existing Category A NHS site serves the whole region,
serving a population of about 2.6 million, who live in 32 local
Table 1. Characteriscs of Study Sites
Western Visayas Romblon
R1 R2 R3 R4 CAT. A R5 R6 R7
Health facility type RHU RHU RHU RHU Hospital RHU RHU RHU
Health facility level Primary Primary Primary Primary Terary Primary Primary Primary
Coverage Municipal Municipal Municipal Municipal Regional Municipal Municipal Municipal
Total populaon covered 92,128 64,826 33,086 22,208 2.6 million 50,619 22,265 18,244
No. of barangays covered 37 52 46 48 662 25 15 12
Esmated no. of live births / year 235 117 170 252 7,200 772 336 266
With GIDA No No Ye s Ye s Yes Ye s No Yes
% of children born in the facility who
underwent NBS
100% 95% 100% 100% Not reported 100% 75% 100%
% of children who underwent NHS 0% 0% 0% 0% Not reported 0% 0% 0%
Implements the NHS program? No No No No Ye s No No No
No. of NHS device 0000 1000
No. of HCPs trained on NHS 0000 3000
With a referral process for management
of children with hearing loss
Yes No No No Ye s Yes Yes Ye s
Distance (travel me) to the nearest
screening facility A
9.4 km
(18mB)
19.9 km
(28mB)
41.5 km
(1h 5mB)
35.6 km
(1hB)
N/A 800 m
(3mB)
53.3 km
(1h 30mB)
27.9 km
(45mB)
Distance (travel me) to the nearest
diagnosc facility A
10.8 km
(19mB)
21.3 km
(30mB)
42.9 km
(1h 8mB)
38.4 km
(1h 3mB)
136 km
(3h 47mC)
357 km
(2h 43mD)
404 km
(2h 57mD)
385 km
(2h 18mD)
NHS, newborn hearing screening; HCPs, healthcare providers; NBS, newborn metabolic screening; GIDA, geographically isolated and disadvantaged
areas
A esmated using Google Maps; B travel by land; C travel by land and sea; D land and air
VOL. 57 NO. 9 202376
Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
government units (19 municipalities and 13 cities, further
subdivided into 662 barangays). On average, 307 babies were
born each year per RHU and around 7,200 were born in the
Category A facility. All RHUs did not oer newborn hearing
screening as part of their healthcare services. Of seven,
only four reported on having an existing referral process
for children with impaired hearing. On the other hand, the
Category A hospital had been implementing NHS, and was
one of the certied hearing screening centers in the region.
Exisng service delivery models for NHS in the
Philippines
Figure 2 shows four dierent models of hearing care
service delivery in the communities based on interviews
with pilot sites. We categorized these service delivery models
as Model A to Model D. In Model A, the RHU refers the
patient to the nearest Level 3 hospital (e.g., regional hospital)
for hearing screening, diagnosis, and/or management. R1
and R2 often use this model as their communities are near
the city center where Level 3 hospitals are located. In Model
Figure 2. Models of hearing care service delivery in Philippine communies.
VOL. 57 NO. 9 2023 77
Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
B, the RHU refers the patient to the nearest Level 1 or 2
hospital (e.g., district/provincial hospital) or private clinics for
hearing screening and/or diagnosis, which then refers patients
conrmed to have hearing loss to a Level 3 or specialty
hospital for management. R3 and R4 use this model. In Model
C, the RHU hosts an ENT (otorhinolaryngology surgeon)
or a specialist team to perform hearing screening and/or
diagnostics in the community. Identied patients are referred
to general or specialty hospitals for hearing loss management.
is model is not commonly used and is often an initiative
from specialist teams or non-governmental organizations
(NGOs). In Model D, the RHU refers the patient to the
nearest Level 3 hospital for screening and diagnosis, and
then refers the patient to another tertiary hospital (often
outside the region or in the capital) for cochlear implantation.
is is the case for Romblon pilot sites (i.e., R5-R7) where
patients need to be referred outside the region, often to the
National Capital Region, for interventions. In the case of
the Category A NHS facility, it follows Model D, wherein
patients go to the facility for screening and then referred to
another Level 3 hospital or specialty clinic for diagnostics
and/or intervention.
is paper is premised on challenges of these current
models and the intent to demonstrate a complementary
and even an alternative community-based model to improve
access to NHS and early intervention.
Idened implementaon barriers and
Intervenon design
As part of pre-deployment preparation, key stakeholders
were interviewed on the existing and potential barriers to the
implementation of the HeLe model. Interventions to address
these barriers were designed to support the implementation
of the community-based NHS program and the use of the
Health Information Systems (HIS) (Table 2).
NHS Pilot Implementaon Results
A total of 692 babies were screened and had their data
entered into the CHITS-EMR NHS Module. Table 3
reects the age distribution of babies screened in the RHUs
compared to those from the Cat. A facility. In the RHUs,
the mean age at screening was 41.9 days old (SD = 31.5) or
1.4 months (SD = 1.05). 47.3% were screened by 1 month of
age (≤30 days), 28.2% between 1-2 months (31-60 days) old,
13.6% between 2-3 months (61-90 days) old, and 10.9% were
older than 3 months (91 days and above). In the Category A
NHS facility, the mean age at screening was 13.7 days (22.3)
or 0.46 month (SD = 0.74); 86.6% were screened by 1 month
of age, 6.7% were 1-2 months old, 4.3% were 2-3 months
old, and 2.4% were older than 3 months. From this 692, ten
babies (1.4%) received a “REFER” hearing screening result
(Table 4): 60% Male, 40% Female, mean age of screening at
2.2 months, and 30% with risk factors for hearing loss. Five
out of these 10 children (50%) were screened at the RHUs
while the other half were from the Category A NHS facility.
In the RHUs, 4.5% (5/110) of babies received a positive
hearing screening result compared to 0.9% (5/582) in the
Category A NHS facility.
Of the ten, eight (80%) were referred through the web-
based NHS Referral and Appointment System. And, among
these eight referrals, seven babies (87.5%) were conrmed to
have bilateral profound hearing loss while one patient (12.5%)
missed his conrmatory testing appointment and was lost
to follow up. We found that 1.8% of babies screened in the
RHU and 0.9% of those screened in the Category A NHS
facility had bilateral profound hearing loss. e mean wait
time, or the time elapsed between screening and conrmatory
testing, was 17.1 days (SD = 14.5). Babies screened in the
RHU were diagnosed with hearing loss within 14 days (SD
= 2.8), while those from the Category A site were conrmed
to have hearing loss by 18.4 days (SD = 17.5).
Families of two patients (from R7) with suspected
hearing loss were not referred through the system. e nearest
conrmatory center for Romblon was in Metro Manila,
which required the patients to travel by plane, and other costs
that were burdensome. Instead, these patients were referred
to a local ENT providing conrmatory testing services in
the island. Of note, however, the Province of Romblon does
not have certied hearing conrmatory centers based on the
ocial list for the Philippines maintained by the NHSRC. e
local ENT specialist had no xed schedule for conrmatory
testing since the service appears to depend on the number
of patients to be tested. us, conrmatory testing of these
two patients was not done even after four weeks after NHS,
within the HeLe research period.
Facilitang factors and challenges in implemenng
the HeLe UNHSI service delivery model
Table 5 reects the human, organizational, and technical
facilitating factors, and challenges in implementing the
HeLe UNHSI service delivery model. Under human
factors, the positive attitude of HCPs to implement NHS,
their familiarity with HIS, and being a certied Category
A NHS screener facilitate NHS implementation in their
locale. e presence of legislations, executive leadership and
champions, partner facilities for diagnostics/intervention,
and capacity-building programs support the NHS program
at the organizational level.
Challenges identied to NHS implementation include
the HCPs’ need for condence building to perform NHS,
perceived inconvenience in using HIS, cost concerns for the
patients, and lack of readiness of the local health system to
shoulder the cost. At the organizational level, the lack of
facilities providing NHS diagnostic and intervention services
remains a major block in ensuring early diagnosis and
management of hearing loss in the community. e costly
hearing screening equipment, equipment failures exaggerated
by delays in repairs, and unstable internet connectivity
were identied as technical challenges in implementing the
HeLe UNHSI service delivery model.
VOL. 57 NO. 9 202378
Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
DISCUSSION
Our ndings provide proof of the potential of a
community-based NHS program supported by ICT-enabled
HIS in improving coverage and provision of UNHSI services
in the country. We have identied enablers, barriers, and
lessons in the implementation of the HeLe service delivery
model, which can be used to design interventions for a
large-scale deployment.
e poor awareness among HCPs and lack of local
policy supporting community-based NHS and about the
UNHSI program were identied as the main barriers to the
implementation of the Law in the communities. is was
apparent in our study where only four of the seven RHUs
Table 2. Intervenons Designed to Address Perceived Barriers in the Implementaon of the Community-based NHS Program and
Use of Health Informaon Systems
Barriers Idened Intervenon to address these barriers
Human Factors
Poor awareness of NHS, especially
among HCPs
• Orientaon of HCPs on the NHS program and the UNHSI Act
• Engagement of the Municipal Health Ocer (MHO) as a champion to iniate and support NHS
awareness campaigns in the community
Lack of trained / cered NHS screeners • Orientaon of HCPs on the NHS program and the UNHSI Act
• Engagement of at least 3 HCPs to undergo training on NHS and the new systems
• Development and deployment of a computer-based training course on NHS and teleaudiology to
introduce new concepts / skills
• Conduct of a 3-day face-to-face training course, which includes the NHS Personnel Cerfying
Course
• Onsite coaching of HCPs during the NHS day
HCP atude on the use of health
informaon systems
• Engagement of known early technology adopters during the HeLe pilot implementaon
• Engagement of MHOs with posive atude on electronic HIS adopon
• Development of the NHS Referral and Appointment System that can be integrated into the users’
current workow
Organizaon Factors
No local policy supporng NHS
implementaon in the community
• Engagement of the Local Government Unit (LGU) through the Mayor.
• Signing of a Memorandum of Agreement between the University and the LGU to approve and
support the pilot implementaon of the program
• Engagement of the MHO as a champion to introduce and support a new health program or NHS-
related policies
Lack of specic arrangements organizing
the UNHSI SDN within the locale
• Engagement of Category A to D NHS facilies within a locale / region to organize a UNHSI SDN
Lack of appropriate room / environment
to conduct hearing screening in the RHU
• MHOs were engaged to idenfy potenal areas in the RHU (or municipality) where hearing
screening can be conducted
• Specic scheduling of NHS service was also considered as a potenal strategy to eciently manage
resources. RHUs can set a specic day per week / month to conduct NHS, similar to other public
health programs/ services
Poor tracking of children with posive
NHS results and those with conrmed
hearing loss
• Development of an EMR module for NHS documentaon
• Development of the NHS Referral and Appointment System that allows the referring physician to
receive referral feedback on the hearing status of the paent
Technology Factors
Lack of hearing screening equipment • Provision of a hearing screening equipment to the community during the HeLe pilot implementaon
• Introducon of cered hearing screening device distributors in the country to the RHU
• Introducon of the HeLe research program and approach to UNHSI to cered hearing screening
device distributors in the country (ergo, another potenal business model or distribuon channel)
Lack of equipment / updated equipment
to support the use of HIS
• Provision of new desktops and servers to study sites
• Provision of NHS equipment
Unstable internet connecon • Development of a system that allows HCPs to input paent data even oine, and only requires
internet connecon when an eReferral needs to be sent
Table 3. Age Distribuon of Babies Screened in the RHUs and
the Cat. A NHS Facility
Age at
Screening
(days old)
Babies screened in
the RHU (n = 110)
Babies screened in
the Cat. A NHS facility
(n = 582)
≤30 52 (47.3%) 504 (86.6%)
31-60 31 (28.2%) 39 (6.7%)
61-90 15 (13.6%) 25 (4.3%)
≥91 12 (10.9%) 14 (2.4%)
Mean age (SD) 41.9 days (31.5) or
1.4 month (1.05)
13.7 days (22.3) or
0.46 month (0.74)
VOL. 57 NO. 9 2023 79
Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
Table 4. NHS Results in HeLe Pilot Implementaon Sites
Facility Total number of
babies screened
Babies with “REFER”
NHS results (%)
Babies referred via NHS Referral
and Appointment System (%)
Babies conrmed to
have hearing loss (%)
No Show A
(%)
Mean Wait
Time B (SD)
R1 11 1 (9.1) 1 (100) 1 (9.1) 0 (0.0) 12 days
R2 14 1 (7.1) 1 (100) 1 (7.1) 0 (0.0) 16 days
R3 21 1 (4.8) 1 (100) - 1 (100) -
R4 17 0 (0.0) N/A N/A N/A N/A
R5 20 (0.0) N/A N/A N/A N/A
R6 50 (0.0) N/A N/A N/A N/A
R7 40 2 (5.0) 0 (0) - - -
Cat. A 582 (84.1) 5 (0.9) 5 (100) 5 (0.9) 0 (0.0) 18.4 (17.5)
All RHUs 110 (15.9) 5 (4.5) 3 (60) 2 (1.8) 1 (20) 14.0 (2.8)
Total 692 (100) 10 (1.4) 8 (80) 7 (70) 1 (10) 17.1 (14.5)
ANo Show: number of paents who missed their appointment schedule
BMean Wait Time (MWT): average duraon (number of days) from hearing screening to conrmatory tesng; computed by geng the total wait me
(in days) for all babies from a specic facility who completed conrmatory tesng (as documented on the NHS Referral and Appointment System)
divided by the number of babies from the said facility who completed conrmatory tesng.
Acronyms: NHS, newborn hearing screening; SD, standard deviaon; N/A: not applicable (since the baby had a “PASS” NHS result and thus, did not
require a referral for conrmatory tesng)
Table 5. Human, Organizaonal, and Technical Facilitang Factors and Challenges in Implemenng the HeLe UNHSI Service
Delivery Model
Facilitang Factors Supporng statements, observaons and/or reports
Human Factors
1. Posive atude and interest to
implement a community-based
NHS program and use HIS
“We’re excited to implement this (NHS). It’s great that we have an opportunity to pilot NHS in our communies.”
HCPs involved were early technology adopters. They have previously implemented several telehealth
projects in their communies.
2. Familiarity with the HIS deployed;
previous experience with HIS use
“The new (health informaon) system is easy to learn since we’ve been using CHITS for years.”
3. Trained and NHSRC-cered local
HCP as screener for hearing loss
All HCPs trained under the HeLe capacity building program passed the NHS Category A Screener
cercaon course.
Aer the blended learning program, HCPs expressed condence and excitement in being able to
implement NHS in their communies.
Organizaon Factors
1. Presence of a legislaon that
mandates and supports NHS
implementaon
“I think the presence of the (NHS) law will make it easier to implement this program and gather support from
the LGU.”
The Department of Health (DOH) Technical Working Group for UNHSI was a partner of the HeLe
research program, supporng the intent of model-building a community-based UNHSI SDN.
2. Engaged execuve leadership;
presence of a champion or a leader
that supports new iniaves /
policies
“Having the Mayor onboard with this (iniave) makes it easier to implement and get support.” Mayors
readily supported the HeLe research program implementaon, through MOA signing.
MHOs served as champions in the implementaon. Two of the MHOs engaged in the project took
the iniave to look into procuring their own hearing screening device. All MHOs idened sta that
can be trained to do NHS, alloed an area/room for screening, and looked for resources to facilitate
conrmatory tesng of children with posive NHS results.
3. HeLe UNHSI Blended Training
program
The blended learning strategy for the HeLe Capacity building program supported knowledge and skills
building, supported the predisposion and value by the HCP for NHS services for their constuents. It:
• Enabled HCP of RHU and Category A NHC to pracce NHS, with guidance by experts, and allowed
cercaon as a newborn hearing screener by the NHSRC
• Supported predisposion, desire and posive atudes of HCP towards providing NHS to their
constuents
• Reinforced stature as innovators or early adopters of ICT for health
4. Accessible care; presence of a
conrmatory tesng center within
the province
We observed that paents referred from nearby study sites (usually less than one hour from the
conrmatory tesng center) were able to go to their appointments.
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Table 5. Human, Organizaonal, and Technical Facilitang Factors and Challenges in Implemenng the HeLe UNHSI Service
Delivery Model (connued)
have a known referral process for pediatric hearing screening
and management. HCPs, including MHOs, in participating
sites were unfamiliar with NHS. is observation is consistent
with another local study, which reported lack of knowledge
on the rationale and implementation of the UNHSI
program among healthcare practitioners.14
ese ndings are not surprising. Whilst the DOH
(and the NHSRC) through its regional oces, might have
campaigned for the UNHSI program, these RHUs were not
enabled with capacity for NHS (no investments in training
screeners, absence of NHS equipment). us, the practice
and implementation of the UNHSI program is far from
the consciousness of both the local government leadership
and the local health departments. e lack of local policy
in support of the Law is not unexpected in this context.
us, the capacity building and policy advocacy of the
HeLe research program arms that these organizational
arrangements and policy investments are foundations of the
envisioned community-based NHS model that can permeate
throughout the country.
In our situational analysis, we found that the RHU
implementation of national health programs has been
successful with reported coverages at 95.7% for newborn
metabolic screening and 89.8% for infant immunization. e
information is encouraging, that given sucient resources
and a local policy framework in place to set up the UNHSI
SDN, NHS can also be implemented successfully in RHUs.
e HeLe demonstrated successfully that infants identied
needing conrmatory diagnostic services would also be
brought by their parents for appropriate care if the conditions
are enabling, as what the HeLe initiated.
e rate of babies born in the RHUs, who underwent
NHS in the nearest screening facility, was reported to be
unknown. at is, the MHOs verbalized that they no longer
tracked the status of babies referred for NHS. RHUs reported
that they often get to know their patients’ hearing status
Challenges Supporng statements, observaons and/or reports
Human Factors
1. Need for condence building in
performing NHS through pracce
and coaching on NHS
“Though we have received training on newborn hearing screening, I think more experience and guidance is
sll needed... especially in using the OAE.”
2. Perceived inconvenience in using
the HeLe systems (me-consuming,
addional workload)
“Only 1 or 2 of us are on duty every day. We do the screening, and we have other tasks as well... so usually
we do the encoding in CHITS when there’s free me or before our duty ends. But for cases which need to be
referred, we encode them on the same day since the parents would need to know the tesng schedule.”
3. Cost concerns for the paent-
families and the lack of readiness
of the local health system to
shoulder costs
Since conrmatory tesng centers are limited, paents who live far from these conrmatory tesng
centers will need to shoulder addional travel expenses. For example, paents from the Cat. A pilot
site needed to travel by land and sea to go to the nearest conrmatory center in the next province.
The esmated cost of travel is Php 300-500 (not including meals), which is the minimum wage per day
in the country.
Conrmatory tesng is yet to be shouldered by PhilHealth.
“Cost of the hearing tests can be a challenge. Right now, HeLe shoulders the conrmatory tesng and even the
travel expenses of the paent… without that, it might be dicult for the parents to bring their child for tesng.”
Organizaonal Factors
1. Lack of
• physical access
• cered conrmatory tesng
facilies within the province /
island
• regular conrmatory tesng
services
Romblon has no cered NHS conrmatory center. Thus, any paent with a “REFER” hearing screening
result would need to travel to Manila or to another region to get conrmatory tesng.
Two paents from R7 were not referred via NTS because of paent preference or incapacity to access
services from the nearest cered conrmatory center in Manila.
“For conrmatory tesng, we learned that a local ENT conducts conrmatory tesng in the area (one of the
sites in Romblon). However, the schedule of the tesng varies depending on the availability of the physician,
the device (which is transported from Manila), and the number of paents.”
Technical Factors
1. Expensive equipment (costly hearing
screening device)
Cost of the hearing screening device ranges from Php 20,000 - 50,000.
2. Equipment failure or defects, delay
in prompt repairs
During the 3-month implementaon in the Cat. A pilot site, the sta reported issues in their hearing
screening device, which took more than 1 month to x. During this period, no NHS was done.
3. Unstable internet connecon “Somemes, sending the referral (via NTS) takes a while, especially when the internet connecon is not
stable. We need to wait a few minutes and try again.”
NHS, newborn hearing screening; NHC, Newborn Hearing Center; HCP, healthcare providers; HIS, health informaon systems
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Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
when the parents come to get a referral for special education
services for their children. Poor case tracking was reported
due to lack of feedback from the patient and/or the specialist.
e use of the HeLe’s module in the CHITS-EMR and the
HeLe NHS Referral and Appointment System have addressed,
in a large part, this concern. Tracking has become the health
institution's responsibility rather than that of the patient’s
task to inform her/his primary care physician. at is, the
patient’s status is known to the relevant health providers
involved in her/his care in the HeLe service delivery network
through its attendant electronic health information and
telehealth systems. And with available information, this
lends stronger accountability for the health sector to mobilize
resources, enact policy to support the community, including
persons with disabilities.
For participating RHUs, we noted the presence of at least
one public hearing screening center within their province.
On average, the nearest hearing screening facilities from the
community study sites were 26.9 kilometers (8.5 to 45.3 km)
away or 44 minutes (14 to 74 minutes) away by land travel.
is translates to around PhP 85.9 (PhP 28.8 to PhP 142.9)
in terms of bus fare for two people (mother and companion),
and about PhP 395 in daily minimum wage lost to seek care.
However, despite the presence of an NHS facility relatively
near the communities, babies requiring NHS still came
during the ‘NHS Day’ that the RHU conducted with the
HeLe research team. In the current set-up, the prohibitive
costs of travel outside their municipality and more so, outside
of the province for continuity of care remains to be a limiting
factor.
e need for a community-based NHS is clear. In the
one-day ‘NHS Day’ conducted by the RHU, 110 newborns
and infants were screened. is accounts for around 5% of the
estimated annual live births in the seven RHU sites. Mean
age at screening was 1.4 months (41.9 days); 47.3% were
screened at one month old or younger, and more than half are
past the ideal age of one month for NHS. Among 582 infants
screened in the Category A NHS facility, the mean age was
0.46 month (13.7 days) or less than two weeks of age; the
large majority (86.6%) were screened by one month of age.
Compared to our hospital study site, babies screened
at the RHU were older by about a month. Around 10.9%
of babies screened were older than three months - the ideal
age for conrmatory testing. Babies screened at the Category
A NHS hospital were more likely to be younger (within 30
days old) than those from the RHUs because they underwent
NHS or was scheduled for NHS prior to discharge as part
of the hospital protocols. Babies screened at the RHUs
during the NHS day were mostly those born at the RHUs or
community lying in clinics, which had no hearing screening
equipment or capability to provide NHS services. We also
observed a higher percentage of babies with positive NHS
results in the RHUs at 4.5% (5 out of 110 screened) in
contrast to the 0.9% rate in the Category A pilot site. ough
only two of the ve babies with positive NHS result from
the RHUs underwent conrmatory testing, the percentage
of babies with bilateral profound hearing loss screened in the
RHUs was at least 1.8% (or two out of 110 screened), which
was at least two times higher than that of the hospital study
site (0.9%, ve out of 582 infants screened). Were it not for
the RHU-based NHS, these 110 babies from the seven rural
towns would not have been screened, and ve with probable
bilateral hearing loss would not have been identied and
referred for conrmatory diagnosis. Further, two infants
would not have been referred for denitive management for
laboratory-conrmed bilateral profound hearing loss.
All babies screened during the pilot implementation
period were entered in the CHITS-NHS Module. Of the
692 babies screened, a total of 10 babies (1.4% of infants
screened) received a positive NHS result. Eight of these
ten patients (80%) were referred via the web-based NHS
Referral and Appointment System; seven were conrmed
to have bilateral profound hearing loss while one patient
missed his conrmatory testing appointment. e average
wait time between screening and conrmatory testing was
17.1 days (2.6 to 31.6 days). Patients screened in the RHU
were diagnosed with hearing loss within 14 days (SD = 2.8),
while those from the Category A site were conrmed to have
hearing loss by 18.4 days (SD = 17.5). In terms of age of
the infant at conrmatory diagnosis, this translates to about
seven weeks and ve days, and ve weeks and four days, for
those screened at the RHU and hospital, respectively. ese
fall within the three months or 12 weeks recommended age
for conrmatory testing.
Of note, those who were screened in the hospital took
(on average) four days longer to seek conrmatory testing,
than those screened at the RHU. For the former, the period
of conrmatory testing falls within a wider range of days (0.9
to 35.9 days) compared to those who sought NHS at the
RHU (11.2 to 16.8 days). Patients born in the Category A
NHS facility - a large regional hospital - would hail from
various parts of the island, and presumably have a broader
variety of life circumstances that can aect continuity of
care. Furthermore, the lack of a conrmatory testing within
the island required patients from the Category A NHS
facility to travel by land and sea just to go to the nearest
diagnostic facility. For those screened at the RHU, parents
sought more immediate action, and perhaps within a more
predictable time due to better accessibility to conrmatory
services (e.g., the conrmatory center is within 30 minutes
away by land travel). Furthermore, the RHUs assisted the
families by reminding them of their child’s appointment
and at times, providing transportation to the testing facility.
is provides an opportunity to weave in stronger and more
specic LGU support to facilitate conrmatory diagnosis.
ese circumstances may explain the dierences in the mean
wait time from screening to conrmatory testing between
those screened at the selected RHUs and the Category A
NHS facility. However, we also note that these dierences
may have simply arisen by chance due to our limited samples.
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A larger sample size is required to determine whether
this dierences in mean wait times between facilities are
statistically signicant.
Regardless, it is strategic that both approaches -
community-based and hospital-based - must be embarked on to
achieve universal newborn hearing screening. e Philippines
has 929 private hospitals, 458 government hospitals, 662
inrmaries, 2366 birthing homes, 2590 city primary care
health centers and RHUs.10,15 e share of households,
who are mostly from low-income groups, “who sought care
in public hospital facilities and providers is almost twice
as high (7 percent) than those who used private providers
(4 percent)”.16,17
In 2020, the NHSRC listed 1099 hearing screening,
diagnostic, and intervention facilities across the country.
Of these, 1072 (97.5%) are Category A Newborn Hearing
Centers (NHCs), 13 (1.2%) Category B NHCs, 5 (0.5%)
Category C NHCs, and 9 (0.8%) Category D NHCs. e
accredited centers include both public and privately-owned
facilities, varying from primary care centers, i.e., RHUs
and birthing homes, to tertiary and specialized hospitals,
as well as stand-alone service providers. A proportion of
private facilities is stand-alone that operates by establishing
partnership agreements with several public and private
DOH-recognized health facilities. ough the NHSRC has
noted an increase in the number of NHS facilities in the
country, these facilities are mostly located in the NCR and
other urban cities.
Two patients from Romblon were not referred through
NTS because the nearest conrmatory center was in Manila.
e patients were referred to a local ENT providing diagnostic
services in the island. However, since the ENT had no xed
schedule for the test, conrmatory testing of the two patients
was not done even after a four-week follow up within the
HeLe research period. ese infants would at least be 11
weeks and ve days: almost the cut-o age where conrmatory
testing is best done. is model of NHS is service delivery
Model C and remains to be problematic. ese two cases
reect a worrisome gap in the UNHSI program and arms
that the lack of a regular and predictable conrmatory testing
service within the area severely delays care, especially early
intervention for hearing loss.
Republic Act No. 11223, the Universal Health Care
Law, promises to institute substantial health sector reforms
to achieve better equity in health, including newborn hearing
screening and hearing loss interventions. Chapters IV and
V of the Law cite health care provider networks (HCPN)
organized and contracted throughout the province- or city-
wide health systems to deliver health services to all Filipinos.
An HCPN is dened as “two or more organizations that, in
the eyes of the client, are responsible for the provision of a
connected overall service experience”.18 For the Pan American
Health Organization (PAHO), an integrated health service
delivery network or HCPN operationalizes Primary Health
Care (PHC)-based systems that lead to services that are
“more accessible, equitable, ecient, of higher technical
quality, and that better fulll citizens’ expectations”.18 HCPN
makes several of the most “essential elements of PHC-based
health systems a reality such as universal coverage and access,
rst contact, comprehensive, integrated and continuous care,
appropriate care, optimal organization and management,
family and community orientation, and intersectoral action,
among others”.18 Best practices can be seen in countries like
Brazil, Canada, Chile, Costa Rica, and Cuba, which have
long-standing support for such networks.
Lessons from these PAHO countries underpinned
the HeLe research program. HCPN can be public, private
or mixed. is study introduced a community-based mixed
public-private HCPN for UNHSI. at is, the Category B
newborn hearing conrmatory centers are privately owned
and receive referrals from government RHU and hospital-
based Category A newborn hearing screening centers
involved in this study.
Incorporating the use of eHealth and telehealth in
HCPN is/are also demonstrated in countries under the
PAHO and European Regional Oce18,19, and in the US20.
Public policy instruments and institutional mechanisms
are necessary foundations.18-20 Institutional arrangements
are clinical and non-clinical guidelines and actions that are
implemented in health service management. Telemedicine/
telehealth is identied as a clinical and institutional
mechanism in an HCPN. Likewise, three measures shown
to contribute to an eective telehealth-enabled HCPN are a
single electronic clinical record, referral and counter-referral
guidelines, duly supported and compensated health and allied
professionals are also institutional clinical mechanisms to
ensure coordinated care.20 ese elements were put in place
in the HeLe. e UNHSI is enshrined in law and dened
the referral and counter-referral guidelines.
Other policy and organizational enablers in HeLe are
as follows: rst, there was participatory governance. ere
was demonstration of clear leadership among institutions
involved in the HCPN, the multi-sectoral governance and
implementation teams (leadership of the RHUs, Category
A, B to D facilities, and local chief executives, and the
HeLe research team), a memorandum of agreement (a
‘contract’) bound the institutions. Second, there is a sound,
scientic clinical policy, or basis for innovative mode of care
delivery. e HeLe embedded the standard clinical practice
guidelines of newborn hearing screening in the telereferral
rules. ere was investment for change management; that
is, the HeLe - with partners - supported organizational and
operational changes within the health system (participating
RHU, Category A, and B to D NHC). Specically, HeLe
dened organizational processes and workow of these
medical institutions including integration of the electronic
/ telereferral, as well as documentation of these changes
and spelling these out in the HCPN clinical (NHS) HeLe
manual. ese processes embedded provisions for the Data
Privacy Act. HeLe engaged and retooled the health care
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Pilot Implementaon of an eHealth-enabled Service Delivery Model for NHS
providers . Participatory measures meant partnership building
and training the health workforce on the rationale and the
organizational rules governing the use of NHS machines,
the CHITS-NHS module, and the HeLe telehealth systems
(referral and appointment), as well as building skills on these
innovative eHealth technologies.
CONCLUSION
As research, the eHealth-enabled HeLe Service
Delivery Model for UNHSI was able to excite and engage
stakeholders with the demonstrated clinical and health
system’s ecacy. It has assured the parents of 582 infants of
their hearing health, identied those with probable hearing
loss, promptly referred these for conrmatory diagnosis,
veried bilateral hearing loss in specic patients, and again,
promptly referred these for denitive management. Since
HeLe was implemented in health facilities that continue to
provide services, the project already created demand for NHS
in participating communities. At the conclusion of the study,
the RHU already expressed trepidation for the (potential)
costly maintenance (or acquisition) of the NHS machine.
Likewise, sustainability of the institutional agreements for
UNHSI and ensuring training of new NHS screeners are
but two concerns that must be supported across time.
Nevertheless, the HeLe Service Delivery Model for
UNHSI is promising. It addresses the challenges and needs of
community-based NHS by establishing a healthcare provider
network for NHS in the locale, providing a capacity-building
program to train NHS screeners, and deploying health
information systems that allows for documentation, web-
based referral, and tracking of NHS patients. e model has
the potential to be implemented on a larger scale – a deliberate
step towards universal hearing health for all Filipinos.
Statement of Authorship
All authors certied fulllment of ICMJE authorship
criteria.
Author Disclosure
All authors declared no conicts of interest.
Funding Source
is research was funded by the Commission on Higher
Education (CHED)-Philippine-California Advanced
Research Institutes (PCARI).
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