Content uploaded by Alvin Marcelo
Author content
All content in this area was uploaded by Alvin Marcelo on Mar 04, 2015
Content may be subject to copyright.
Linking Primary Care Information
Systems and Public Health Information
Networks: Lessons from the Philippines
Herman Tolentino
a,c,
Alvin Marcelo
a,c,
, Portia Marcelo
a,b
, Inocencio Maramba
a,c
a
University of the Philippines Manila College of Medicine
b
Department of Family and Community Medicine
c
Medical Informatics Unit
Abstract
Community-based primary care information systems are one of the building blocks
for national health information systems. In the Philippines, after the devolution of
health care to local governments, we observed “health information system islands”
connected to national vertical programs being implemented in devolved health units.
These structures lead to a huge amount of “information work” in the transformation
of health information at the community level. This paper describes work done to
develop and implement the open-source Community Based Health Information
Tracking System (CHITS) Project, which was implemented to address this
information management problem and its outcomes. Several lessons learned from
the field as well as software development strategies are highlighted in building
community level information systems that link to national level health information
systems.
Keywords:
Public health informatics; Information management; Primary health care, Community networks
1. Introduction
The delivery of health care services in the Philippines was devolved to local government
units in 1998 under the Health Sector Reform Agenda (HSRA) carried out by the
Department of Health [1]. In the course of the devolution, there was not enough time to
cede health information management functions to local government units (LGUs) for them
to carry out data collection, integration and presentation in a seamless, distributed and
coordinated manner. National vertical health programs remained in place, however, each
with its own complement of logbooks, and reporting forms and protocols, and sometimes
personnel. The Philippine vertical programs include among others, Child Care and
Development, Maternal Care, the National TB Program, Family Planning, and the
Expanded Program for Immunization. In busy community health centers, data entry of
patient information over several logbooks can be inefficient and is characterized by
redundant and inaccurate entries. As early as 1995, a case study of Philippine public health
information systems by Jayasuria revealed proliferation of reports consuming 40% of the
time of field personnel, high levels of duplication and delays due to manual processing [2],
a situation that seems to have persisted for the last decade. Currently, there are no data
quality control and validation procedures where paper forms are used and community
health workers generally do not get feedback from reports that they submit. The collection
of large amounts of health data without feedback to the collectors seems to be the practice
Connecting Medical Informatics and Bio-Informatics
R. Engelbrecht et al. (Eds.)
ENMI, 2005
955
Section 13: Public Health Informatics, Clinical Trials
not only in the Philippines but in other settings where national vertical programs of this
type are used [3]. Vertical programs are generally useful particularly when there is a need
to urgently address a public health problem like HIV-AIDS [4, 5] and smallpox [6] because
they can achieve economies of scale and focus resources and manpower on a specific
problem. In this particular situation, to make information management efficient and to
ensure a good supply of quality information, we needed to integrate existing interfaces to
vertical programs at the community level, as we work our way upwards for higher level
integration of information systems to the level of the city health office. In addition to the
information management situation above, an alarming trend is emerging in the Philippine
health care scene. As early as 2003, thousands of physicians nationwide, including an
undetermined number of government physicians, have been retraining as nurses to become
part of the eligible health workforce migrating to developed countries [7, 8]. Intra- and
inter-country migration of health workers potentially compromises the quality of health
service delivery by creating uneven distributions of providers in relation to populations [9].
The scenario of having health centers without doctors required that the community-based
information system should be usable by community-based or indigenous health workers.
It is in this context that in 2003 we conceptualized the project and submitted a proposal for
funding to PANASIA-ICT [10] to implement the Community Health Information Tracking
System, or CHITS (http://www.chits.info), a primary health care information system. The
backdrop of this proposal is a bigger goal to build a national health information
infrastructure within the next five years. The community-based information system can
contribute to this bigger goal by improving health information management at the
community level.
We deemed the following four objectives important for project success:
1. To design and develop a generic, reusable, open-source framework for community
level health information systems for primary health care services
2. To determine the feasibility of integrating vertical programs at the community level.
3. To enable and empower community health center staff to use this community based
health information system through the development of certificate training courses
for community-based data managers.
4. To harness community resources for the sustainability of health information
management activities
2. Methodology
Lorenzi enumerated four cornerstones of health informatics [11] and we deemed it
important to embellish these to address the objectives above as follows:
Cornerstone 1: Producing structures to represent data and knowledge so that complex
relationships may be visualized. To develop a generic, reusable, open-source framework for
primary care level information systems (first objective) and integrate vertical programs at
the community level (second objective), we needed to: (1) create an information system
architecture based on conceptual data models revolving around national vertical programs
and primary health care services at the community level; (2) build software functionality
around data models directly related to health care services and vertical programs; and, (3)
design this architecture such that it protects the health information system from extensive
code and database revisions that may arise without software modularity.
Cornerstone 2: Developing methods for acquisition and presentation of data so that
overload can be avoided. To carry out integration of data collection, integration and
presentation activities of the different vertical programs at the user interface level and
eliminate paper reporting (second objective), we needed to examine all health center forms
and logbooks identified with the different vertical programs and subsequently map out
intersecting and unique data elements for each program.
Cornerstone 3: Managing change among people, process and information technology so
that the use of information is optimized. To empower community health center staff (third
Connecting Medical Informatics and Bio-Informatics
R. Engelbrecht et al. (Eds.)
ENMI, 2005
956
Section 13: Public Health Informatics, Clinical Trials
objective), we needed to: (1) determine work motivation factors; and (2) immerse ourselves
in the milieu of health center activities for six weeks. To meet the fourth objective, aside
from building rapport and a working relationship with the local government units, we
needed to: (1) set up partnerships with external resources to create a “bandwagon effect”;
and, (2) build external alliances around the project to create an ecosystem of similar
applications that support project objectives.
LAGROSA
HEALTH CENTER
MALIBAY
HEALTH CENTER
MANILA INTERNATIONAL
AIRPORT
1 km
N
MAP OF PASAY CITY
Figure 1 - Map of Pasay City showing the location of the two health centers in the study
Cornerstone 4: Integrating information from diverse sources to provide more than the
sum of the parts and integrating information into work processes so that it can be acted
upon when it can have the largest effect. To address the first and second objective, we
needed to (1) employ modular, object-oriented software development methods and adapted
open-source software created by other developers for integration; (2) model the application
from health center workflows and consider the paper-based forms and logbooks as our
closest “competition”; and (3) design the application to support vertical and horizontal
health information exchange, and incorporate report-generation features to make sure
community health workers can make use of the health data that they generate at their level.
To develop and implement CHITS, these methods were applied to two health centers
(Lagrosa and Malibay), each with an average coverage of 10,000 families and located in a
progressive local government unit with which our university had established a
memorandum of understanding for student deployments in community health centers.
Figure 1 shows the map of the local government unit of Pasay City where the two health
centers are located.
3. Results
We describe the project outcome below according to the objectives previously enumerated.
To design and develop a generic, reusable, open-source framework for primary care level
health information systems. We had earlier developed a modular information system
architecture called the Generic Architecture for a Modular Enterprise (GAME) Engine [12]
that can serve as an applications development platform for other software development
projects. This software engine runs on Linux, Apache Web Server, MySQL database and
the PHP Scripting Language. GAME makes extensive use of previously published open-
source code libraries like JPGRAPH for object-oriented graph display and FPDF, a PDF-
generation engine for creating the summary reports. Using this platform, software
development was carried out, resulting in the development of 44 software components
Connecting Medical Informatics and Bio-Informatics
R. Engelbrecht et al. (Eds.)
ENMI, 2005
957
Section 13: Public Health Informatics, Clinical Trials
together with lookup data libraries, including ICD10 Diagnosis Coding. Among these
modules is a Clinical Reminders module that enables health center staff to send mobile
phone Short Messaging System (SMS) messages, which are generated from system
templates, and sent to patients to remind them of follow-up visits and encourage
compliance with medication intake, particularly for tuberculosis treatment. New software
modules, software upgrades and data dictionaries are uploaded as compressed files and
automatically incorporated into the system. The CHITS application currently runs in an
intranet environment with a Pentium 4 class server and 3 scaled down Pentium 4
workstations costing about $1,900 at 2003 hardware prices. For the first time since CHITS
became operational in one health center, submission of electronic reports has become part
of the health ministry procedures for quality accreditation.
To determine the feasibility of integrating vertical programs at the end user level. To
integrate the vertical program “information system islands,” we used the incremental
development approach [13] (Figure 2), developed a single interface for vertical program
modules, and integrated report generation tools for the end-user. Figure 3 shows how
modules are positioned in CHITS. We involved the health center staff in interface
development, and successfully streamlined their workflow as far as vertical programs are
concerned. Most importantly, we were able to eliminate “paper forms” by six months.
Figure 2 - Modular and incremental software development. Modules built incrementally and tested
in a live environment over time, the red arrows indicating incremental buildup of each module
(adapted from Heeks [13]).
To enable and empower health center staff to use this community based health information
system through the development of a professionalized training course for community-based
data managers. We studied health center culture and social organization using a scaled
down ethnographic approach [14, 15] and worked with health center staff for six weeks.
We were able to build relationships and an environment of mutual trust, enabling us to have
smooth interactions with the health center staff. We incorporated capacity building to
present a benevolent face to potential and obstinate change management areas, such as
quality-adverse data habits. The end users became effective trainors themselves, proudly
showing off not only their certificates but also their skills. This provided us with a possible
solution to the problem of training staff from other health centers through “on-the-job”
training. This also enables us to develop cohorts of technically-enabled end-users. Except
for the health center physician module, community health workers operated most of the
software modules from health center workstations.
To harness community resources for the sustainability of health information management
activities. We were also able to create strategic alliances around CHITS. One example is
the Tuberculosis (TB) registry vertical program which attracted the Philippine Coalition
Against TB (PhilCAT), a well-funded implementing arm of the WHO Directly Observed
Therapy for Short-Course Strategy chemotherapy (DOTS) for tuberculosis control.
Between July and August 2004, two demonstration sessions were conducted for the city
health offices of two neighboring local government units (the cities of Parañaque and
Marikina). These LGUs have subsequently initiated CHITS deployment and secured their
own internal and external funding. In the hardware area, the Advanced Science and
Technology Institute (ASTI, http://asti.dost.gov.ph/) of the Department of Science and
ONE MODULE AT A TIME
Incremental changes
Modules
Connecting Medical Informatics and Bio-Informatics
R. Engelbrecht et al. (Eds.)
ENMI, 2005
958
Section 13: Public Health Informatics, Clinical Trials
Technology (ASTI, a government agency) developed a plug-in PC card that incorporates a
GSM modem which enables CHITS to send clinical reminders and receive data by SMS.
To support and complement CHITS implementation, we proposed two other projects to the
national government: the National Telehealth Project, called BuddyWorks, and the
Philippine National Health Information Infrastructure Project, to link health information
stakeholders and enable information exchange. Both projects were subsequently funded
through the e-government program of the national government and actually form part of the
initial activities of the emerging Department of Information and Communications
Technology. These projects provide a primary care and public health informatics
environment where CHITS becomes an integral component.
Figure 3 - Flow of information from user interface, processing within modules and reorganization
of information to health ministry vertical programs in CHITS. Only selected modules and vertical
programs are shown here.
4. Discussion
Designing community-based health information systems is a challenging task that involves
simultaneous work along technical, social, political, and financial fronts. Chandrasekhar
enumerates systemic constraints related to a developing country’s economic status that are
breeding grounds for skepticism towards the potential of information and communications
technologies (ICTs) to have a positive impact on health services delivery. First, an
overwhelming majority is likely not to have access to technology. Second, inadequate
education would ensure people do not have adequate levels of competence or confidence to
take part in transformational activities [16]. By using the rich library of open-source tools
available online, by integrating capacity building, and harnessing external, national and
local government political and funding support, we hope to have addressed these systemic
constraints.
In this project, we have developed a generic, reusable, open-source framework and a
community-based health information system that integrated vertical programs at the
community level. There are three lessons we learned from this project: First, by paying
close attention to health center culture and immersing ourselves in the end-user's social
context, we captured an accurate model of their organizational and personal realities, and
were able to gain insight into their needs and requirements. We then applied these insights,
together with the health center information and data model, into software code – in a
process called evolutionary software development using a modular approach with
incremental introduction of change [13]. These insights were also applied to the design of a
certificate data management course for community health workers that brought out their
Family
Barangay
Patient
DEMOGRAPHICS
CONSULTS TODAY
CHITS
CONSULTS TODAY
CHITS
Notifiable Diseases
Immunization
Maternal Care
Immunization
Child Care
DOTS
PhilHealth
Maternal Care
Immunization
Child Care
DOTS
PhilHealth
MODULES
USER
INTERFACE
VERTICAL
PROGRAMS
Maternal and
Child Health
Immunization
Notifiable
Diseases
REPORTS
CORE MODULES
Connecting Medical Informatics and Bio-Informatics
R. Engelbrecht et al. (Eds.)
ENMI, 2005
959
Section 13: Public Health Informatics, Clinical Trials
potential to be able to manage the change brought about by technology and allowed us to
“indoctrinate” them about the importance of data quality and the bigger information
ecosystem where health center data and information belong. Second, open-source software,
aside from enabling us to decrease implementation costs, provided an environment for
software code transparency for peer-review purposes and fostered shared learning.
Traditional proprietary software development otherwise hides internal processes as it
happens in a software “blackbox.” Third, we discovered that it is important to have a
heightened awareness of the “ecosystem” in which the health information system will
function. Included in this ecosystem are the people who will make it work (community
health workers), the people who make things possible, logistically and politically, and the
enabling environment to use the system and derive benefits from it.
In the end, implementing this system became a battle for “hearts and minds” as we created
and managed change in implementing a community-based health information system, first,
by looking at how the people involved viewed things from their perspective, and then by
giving them the software and knowledge tools to manage the change.
5. Acknowledgements
The authors wish to thank the local government unit of Pasay, the physicians and staff of the Lagrosa and
Malibay Health Centers, and the faculty and staff of the Department of Family and Community Medicine for
their support in implementing the project. The authors also wish to thank PANASIA-ICT, IDRC
(International Development and Research Centre of Canada) and UNDP (United Nations Development
Programme) for funding support to implement this project. Herman thanks Michael McNeill of the Centers
for Disease Control and Prevention for providing insight into the menagerie of words that can be used to
express the collaborative nature of the project.
6. References
[1] Department of Health, Philippine Government. Philippine Health Sector Reform Agenda (HSRA). URL:
http://www.doh.gov.ph/.
[2] Jayasuria R. Health informatics from theory to practice: lessons from a case study in a developing country.
MEDINFO95 Proceedings. Greenes et.al. (editors). IMIA 1995; pp 1603-1607.
[3] Anonymous. An integrated approach to communicable disease surveillance. WHO Weekly Epidemiological Record
(WER), Jan 7 2000, 75:1, page 1.
[4] Kanshana S, Simonds RJ. National program for preventing mother-child HIV transmission in Thailand: successful
implementation and lessons learned. AIDS. 2002 May 3;16(7):953-9. Review.
[5] Kilmarx PH, Supawitkul S, Wankrairoj M, Uthaivoravit W, Limpakarnjanarat K, Saisorn S, Mastro TD. Explosive
spread and effective control of human immunodeficiency virus in northernmost Thailand: the epidemic in Chiang
Rai province, 1988-99. AIDS. 2000 Dec 1;14(17):2731-40.
[6] Henderson DA. Victory over smallpox: interview with Donald A. Henderson. Popul Rep L. 1986 Mar-Apr(5):L172-
3.
[7] Fleck F. Should I stay or should I go [News]. Bulletin of the World Health Organization. August 2004; 82(8):634.
[8] Jaymalin M. DOLE chief sees silver lining in exodus of doctors, nurses abroad. URL:
http://www.newsflash.org/2004/02/hl/hl101202.htm. Last accessed: 3/14/2005.
[9] Bach S. Migration patterns of physicians and nurses: still the same story? Bulletin of the World Health
Organization. August 2004; 82(8): 624-625.
[10] PANASIA-ICT web site. URL: http://web.idrc.ca/en/ev-51764-201-1-DO_TOPIC.html. See also URL:
http://web.idrc.ca/en/ev-51764-201-1-DO_TOPIC.html.
[11] Lorenzi N. The cornerstones of medical informatics. Journal of the American Medical Informatics Association.
2000; 7:204-205.
[12] GAME Engine Sourceforge Web Site http://www.sourceforge.org/game-engine/.
[13] Heeks R. Failure, Success and Improvisation of Information Systems Projects in Developing Countries. Institute for
Development Policy and Management. Document last viewed at URL:
http://www.man.ac.uk/idpm/idpm_dp.htm#devinf_wp. January 2002.
[14] Friedman C. Subjectivist approaches to evaluation. In Evaluation Methods in Medical Informatics. Springer, New
York. 1997; 205-221.
[15] Myers M. Investigating information systems with ethnographic research. Communications of the Association for
Information Systems. December 1999; 2(23).
[16] Chandrasekhar CP, Gosh J. Information and communications technologies and health in low income countries: the
potential and constraints. Bulletin of the World Health Organization. 2001; 79(9): 850-855.
[17] Clements P [editor]. Constructing Superior Software, Software Quality Institute Series. MacMillan Publishing,
USA, 2000. Page 59.
Address for Correspondence:
Herman D. Tolentino, MD, Medical Informatics Unit, University of the Philippines, College of Medicine, 547
Pedro Gil Street, Manila, Philippines 1000, Email: herman.tolentino@gmail.com
Connecting Medical Informatics and Bio-Informatics
R. Engelbrecht et al. (Eds.)
ENMI, 2005
960
Section 13: Public Health Informatics, Clinical Trials
